When summer heat evaporates, cooler air blows in, bringing with it a familiar adversary: Group A Streptococcus. Experts estimate that several million cases of non-invasive Group A streptococcus, which include pharyngitis, scarlet fever, and impetigo, occur annually in the U.S. This foe is so well known to medical professionals that one might feel an internal sense of ease when a throat swab yields a positive strep result. This is medicine in its most basic form. Step one, make the right diagnosis. Step two, initiate the correct treatment. Step three, the patient improves. If only it were that simple. Patients, especially children, often return with group A streptococcus throat infection. Are treatments failing because resistance is emerging, or has the patient been reinfected? Did the patient receive the necessary aftercare? Today, like everything else in medicine, numerous things prevent this from being an easy one, two, three.
I glance at the visit history for my next patient, a 6-year-old whose chief complaint is, “My throat hurts bad.” It reveals a recent visit for fever, vomiting, and sore throat. Further review indicates a rapid strep test at their primary care physician’s office was positive, and the patient was treated with 10 days of amoxicillin. Today, my patient tells me they felt better quickly after starting antibiotics, but the sore throat returned abruptly the previous night. This morning, it not only hurts to swallow, but they are also experiencing abdominal pain and a headache. The patient’s mother reports that her child completed 9.5 of 10 days of antibiotics, missing only one dose. On examination, I find enlarged tonsils, petechiae on the roof of the mouth, and swollen anterior cervical lymph nodes. My patient has no cough, nasal congestion, or conjunctival injection. A molecular strep test is positive for Group A streptococcus.
Strep throat causes an estimated 5.2 million outpatient visits yearly among people younger than 65. These visits result in 2.8 million antibiotic prescriptions each year. Group A streptococcus is the primary bacterial cause of sore throat, responsible for 20%-30% of sore throats in children and 5%-15% in adults. I returned and shared the results with the patient’s mother. She was surprised by the positive test and immediately asked if the antibiotic they were given did not work. This is where the seemingly simple in-and-out visit takes a turn. I ask a few additional questions. Is anyone else in the household sick? No. Has the patient had frequent antibiotic use? No. I counsel the family on routine strep care, sharing that antibiotics can reduce the duration and severity of symptoms, the likelihood that infection will spread to others, and, more importantly, the risk of complications. I share that children may return to school when they are generally feeling better and after they have been fever-free on antibiotics for at least 24 hours. I instruct the parent to call their doctor if there is no improvement after taking antibiotics for 48 hours. To prevent household spread, I remind the family to sterilize shared utensils and clean commonly touched surfaces. After instructing the family to err on the side of caution and change the toothbrush again after two to three days on antibiotics, the patient’s mother looked at me puzzled. “I didn’t know I was supposed to do any of that,” she responds. “No one told me.”
The Latin root of the word doctor is “docere,” meaning “to teach.” Arguably the most straightforward part of a physician’s job, teaching, or providing instruction, may also be the most important. When patients receive relevant information about their condition, they are more likely to take ownership of their health by taking medications correctly and making necessary lifestyle changes. This leads to lower readmission or return visit rates, lower health care costs, and better health outcomes. In an age of rapidly growing antibiotic resistance, appropriate patient education can also be seen as a meaningful component of antibiotic stewardship, preventing unnecessary retreatment or escalation to broader spectrum medications. Yet even for the most complex patients at the highest level of care, findings suggest that significant gaps occur in what patients understand after visiting us. Addressing the six key discharge communication domains (medication changes, appointments, disease self-management, red flags, question solicitation, and teach-back) is increasingly difficult. Discharge information and related tasks are often delegated to support staff. Instructions are frequently printed and provided to the family. Indeed, it is the responsibility of the patient to read and follow this guidance, but verbal instruction is a crucial accompaniment to printouts to ensure compliance.
The ability to read, analyze, and comprehend written medical information also varies widely. Only 12% of the U.S. population is health literate enough to efficiently navigate the health care system. The structure of our health care system is such that face-to-face visit time is becoming shorter and shorter. Patient expectations no longer match the time clinicians are afforded for care. In a recent public opinion survey of patients, the top three most important characteristics of a good doctor were the ability to treat the whole person, not just the specific medical condition: to listen, take time to answer questions, and have up-to-date medical knowledge. In previous years, characteristics like being board-certified and having a good bedside manner were higher up on the list of desirable attributes. Similarly, most clinicians agree having less time to spend with patients is a source of professional discontentment.
So, was my young patient a case of Group A streptococcus reinfection, a carrier state, or an antibiotic failure? Confident that this child is sick, I ruled out a carrier state. With no evidence of a widespread failure of amoxicillin occurring, it is more likely that my patient, with an infrequent history of antibiotic use and who completed an entire course of a first-line antibiotic, has reinfected themself.
Getting the diagnosis correct is challenging enough. Ensuring the patient is given the diagnosis and understands the proper aftercare instructions is something we, the collective health care team, can do. To improve patient understanding, adherence, and outcomes, even for the most seemingly simple diagnosis like strep throat, we can utilize tools such as the teach-back method. The teach-back method is an easy way of opening dialogues with our patients, and it has been proven to result in better immediate recall and comprehension of discharge information.
After giving care instructions, have the patient explain it back to you in their own words. Put patients at ease by framing this activity as a way to ensure you explained it well, rather than a quiz they can pass or fail. The teach-back method can help identify cognitive, cultural, language, or health literacy barriers that might be causing miscommunication. It can also lead to higher patient satisfaction scores, all while improving the informed consent process by facilitating shared decision-making.
Step one, make an accurate diagnosis. Step two, initiate the correct treatment. Step three, make sure the patient understands their diagnosis and the necessary aftercare. Then, the patient improves. While we cannot oversee the patient’s actions after they leave us or control every outcome, we can lean into our role as teachers. Educating our patients by sharing best practices as we understand them empowers patients for optimal health.
What are some ways you educate your patients about their aftercare? Share in the comments!
Dr. Nicole Hight is a practicing pediatrician in the Atlanta area and a multi-year recipient of the Top Doctor and Parent Magazine parent choice awards. She earned her undergraduate and medical degrees from Emory University and served as Chief Resident at Levine Children’s Hospital. She believes a listening ear and an encouraging word change lives. You can reach her at www.linkedin.com/in/nicolebhightmd@yourtrustedpediatrician on Instagram @doctorhight on TikTok. Dr. Hight is a 2024–2025 Doximity Op-Med Fellow.
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