Diagnostic Conundrums

By Dr. Jim Ferguson

It’s hard for me to just be a concerned father when your beloved daughter is sick. There are three types of people in the world: children, adults and parents. I will always be the father of my kids. This sacred relationship transcends any post-modern notions of equality. We all want to be cared for. And studies have shown that children want the boundaries their parents establish – at least until they are teenagers.

So, how can a doctor take off his medical hat and replace it with the concerned father’s hat? How can the alpha male in me stay within my boundaries, and allow others to care for my beloved? It’s easier to hold my tongue when things are going well, but harder when my girl founders within the dysfunctional medical system.

I’ll admit that I have more of the Mr. Spock persona in me than the warm, fuzzy Dr. McCoy. I’ve explained this to people by asking them whether they would rather my wife, Becky, answer our telephone or me. Invariably, they all smile knowingly, choosing Becky’s warmth rather than my logic. Years ago a cousin of my daughter was ill. She sought answers to her problem, and though I sat at the table, she turned to Becky and asked her what she thought was wrong with her.

Becky is my social conscience. Many times she has corrected my phone persona. I’ll admit I’m more like Sergeant Friday during a 2:30 am medical consultation. By comparison, I’ve observed Becky in late night non-medical phone calls where her warmth is the same as during the daytime.

You can be right and yet be wrong. Because I’m more direct, I’ve been seen as wrong because I was insensitive to the emotional side of the human equation. In the Myers-Briggs typology, I am an ISTJ (Google it if you need background information because I’ve previously written about this useful psychometric tool). My strong suits are observation, reason and decision making. However, by knowing my strengths I can become aware of my secondary, less developed traits and work on them to hopefully become a more rounded and better person.

I can now be calmer and more reflective because my daughter has finally received the correct diagnosis and the appropriate treatment is working. I’ll admit it was hard to be in a supportive role during the diagnostic drama. My family knows my heart is in the right place, even though they have had to endure my railing about similar medical scenarios that unfortunately are all too common. My only justification is my advocacy for patients, especially my daughter. During her illness, I was as calm as a father-M.D. could be.

The complaint of a sore throat is a common medical problem. Most of the time sore throats are due to viral infections, post nasal drainage, mouth breathing or allergies, but can be associated with bacteria such as streptococci – ie. strep throat. A typical strep throat infection causes a sore throat, tender lymph glands, fever, headache and exudates on the throat or tonsillar area. Obviously, the greater number of these symptoms and exposure to someone with a strep throat increases the likelihood of the diagnosis. However, studies have shown that doctors using clinical criteria make the correct diagnosis of a strep infection only 50% of the time.

The gold standard of strep throat is the isolation of this bacteria on a throat culture. Unfortunately, a throat culture takes several days, so doctors often utilize a throat swab to test for the streptococcal protein. If a patient manifests the above clinical criteria and their strep screen test is positive, a doctor can be reasonably certain of the diagnosis and treat with an antibiotic. However, rapid strep tests may be falsely positive in kids up to 21% of the time due to simple colonization and negative in up to 30% of true strep infections. You might be surprised that the major reason to find and treat strep throat is not to just relieve suffering, but to avoid complications of strep infection such as rheumatic fever or nephritis.

Bacteria have been on earth much longer than humans. Thankfully, our skin and immune system usually keep us safe, but can be overwhelmed by the multitudes of germs around us. There are other bacterial causes of a sore throat including streptococcal variants and even gonorrhea. And strep variants (Beta strep) in the genital tract are now routinely sought and treated to prevent puerperal sepsis in a laboring mother or her newborn child.

Numerous viruses can cause pharyngitis, nasal congestion and low grade fever. Since most of these viral infections have no available treatment, doctors focus on bacterial causes. However,  viral influenza and herpes can cause a sore throat and anti-viral agents can be helpful.

Another cause of viral pharyngitis is mononucleosis commonly referred to as mono. This herpes family virus usually infects children, often without recognizable symptoms. Primary infection becomes increasingly symptomatic after childhood. Since the virus is shed in saliva, teenage infection has acquired the moniker “kissing disease” for obvious reasons. And  2% of mono occurs in adults where fatigue and malaise often persist beyond the acute phase symptoms of sore throat, tender lymph nodes, enlarged spleen and hepatitis.

It often takes considerable diagnostic skill to evaluate a patient and institute proper treatment. In straightforward situations a nurse practitioner, a physician assistant, military corpsmen or even less well trained individuals can arrive at the correct diagnosis and Google a treatment. However, in the atypical or complicated patient a doctor is required; sometimes even specialists are stumped.

So, how do you know if your sore throat or belly ache is a straightforward issue or portentous of something more sinister? That’s the “sixty-four dollar question” and I don’t have a ready answer. How do you know if your doctor (I bristle at the label, healthcare provider) is competent? I know that judgement is required. A physician must recognize his/her limitations. Perhaps you can sense that he/she cares about you. But does your doctor spend adequate time with you and listen, a necessity to avoid mistakes? And lastly, I believe a doctor must have a sense of responsibility for his patient, and this can’t be legislated or mandated. It comes from the heart, not from Washington, insurance companies, or bonus checks from the HMO for efficiency.

The Master understood what is needed in a healer, “It’s not the healthy who need a doctor, but the sick” (Luke 5:31). Prevention is fine, but not at the expense of resources diverted to unproven “wellness exams” and to a system where doctors are relegated to only supervisory roles.

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