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This article originally started as an Email question about Sore Throats, Tonsillitis and how to find medical treatment that you can trust. The answer became so all encompasing and of such universal interest that it begged to become a Tonsillitis article. The questions that a reader in the Phillipines were asking reminded me of the dillema faced by most of us when life situations get to the point that we can't make sense out of it and begin mistrusting things that we already thought we knew. After a book by a similar name, I call the articles: The 'Hitchkikers Guide' to Sore Throats!

QUESTION: I have a 3 year old son that often gets tonsillitis (I believe), but his pediatrician always tells me this is an indication of typhoid fever…which I doubt…If it is typhoid fever, I believe she should ask my son be confined, right? What I believe he is having is tonsillitis…what concerns me is that he often gets it every 2 or 3 months and I’m worried with a lot of antibiotic he is taking…not just Amoxil, but much stronger like Cefixime, Klaricid, etc…How can I prevent him from having tonsillitis?... Laennec J-A

MY FIRST RESPONSE: The question seemed so "odd" that I had to request further clarification. If he was in the US, there just Had to be a problem with communication either in what the doctor said or what was "heard" by the patient. I asked him where (in the world) he was living; and, because he had used the term "pediatrician" (probably erroneously, because in the US it means a licensed physician who has undergone three additional years of specialty training and passed the National Board examination in Pediatrics) I asked the training of the doctor he had seen.

Additionally, I requested a little bit more description of his child's episodes of illness? What happens to him, and what HE sees before he takes him to the doctor? Also, what the doctor sees and how he confirms the diagnosis (i.e. lab tests, cultures, etc.) and if there were any other medical problems associated with the 'sore throat.'"

HIS REPLY: I am from the Philippines… What I mean for pediatrician is a licensed doctor for the young/kids... There isn’t any laboratory tests my doctor do to my son…she just looked at his throat and have him lie down, press a little his stomach. I am wondering whether her diagnosis of always typhoid fever is correct for my son. If the water we are drinking or using in taking a bath is not clean, I assume that there will be an epidemic of typhoid in our area. She advised me to boil the water my son is drinking and I did…but still he still encounters symptoms of typhoid per my doctor…which I think is only tonsillitis…My question is that is there a way that we can prevent tonsillitis? I am very concerned that he is always taking antibiotics and if you look at the dosage since my son is a little bit big it is much higher than the ordinary 3 year old kids? Can chocolates really cause tonsillitis?... Laennec J-A

Wow... ok... I'm going to try and tackle the issues raised by this letter; because, despite being from another country, it raises many very important concerns for you all in trying to obtain good, accurate - and helpful - medical care. The questions I "hear" in his letter are: 1) "Have I selected the right doctor"? 2) "Is my doctor giving me correct advice"? 3) "Which of us is correct - is it Tonsillitis or Typhoid"? 4) "What is the difference between: Sore Throat, Tonsillitis and Typhoid"? 5) "Will having 'tonsillitis' every 2 or 3 months hurt my child"? 6) "Is my child taking too much antibiotics and will they hurt him"? 7) "Can sore throats be prevented"? and, 8) "Does chocolate cause sore throats"! First let's tackle one of the easy ones...

8) Can Chocolates really cause tonsillitis? No... I have never heard of such a correlation, nor is there any mention of it in my recent search of the medical literature. I'm not sure where he heard that it does— I hope, actually, that it was from a relative or neighbor, who you might expect could be wrong. I hope that it wasn't from the same person who tells him that his son's sore throats are from Typhoid— one is less understanding when your "doctor" tells you things like that! (See below)

Now... for the more difficult to answer questions, requiring me, first, to set some background.

"International" differences in medicine You must know, that I have never "practiced" medicine in the Philippines which puts me at a definite disadvantage in answering his specific question. Not only is the language different, but, sometimes, physicians even see diseases completely different!

For example, while doing my residency training in California, I (of course) saw many children with ear infections; and, if I do say so myself, became quite skilled in obtaining a thorough exam before the child started crying. I would treat them, present their cases in rounds and discuss them with colleagues; THEN, attend national meetings and read literature and be highly confused. It was as though these other people were discussing a different disease!

They talked about: seeing children back multiple times, doing needle cultures, switching antibiotics and going frequently to surgery. What on earth were they talking about? Most all of OUR kids got better, with the first treatment!

Little did I know that, when I moved into the US Mountain Time Zone, the tables would be turned and it would be like I had never learned medicine- kids didn't get better. They kept coming back, took weeks or months to heal, had different germs and needed much more antibiotics and surgery than I had experienced near the coast! It WAS a different disease... with the same name; And... that was just a few miles away, in the same country.

And, there are more differences that that. Californian's don't usually get Rocky Mountain Spotted Fever or Lyme disease, like Utahan's and New Yorker's- no tick vectors; but, they get the Valley Fever (Coccydiomysosis) that the other's don't. And on, and on. So, what goes into a physicians (or countries) decision on how to diagnose and treat an illness like "sore throat"?

The background for Medical "Recommendations" We call them "recommendations" because "book learning" sometimes doesn't always apply to a specific patient who is sitting in front you with a problem. The scientific information MUST be augmented with a physicians experience. That is why, although a "kid doctor" (right out of medical school) will often have the latest clinical knowledge; the "old guy" is not infrequently of more use to his/her patients in understanding them, and treating their illnesses. There, of course, is a place for both.

But, not only does a physician use his observation of the way hundreds of "sick throats" look, there are the thousands of throat cultures taken by the doctors in his community. A local profile of the "bugs" that are commonly attacking the children of the area is developed and, most importantly, what will "kill them"! (the bugs that is) A large part of a doctors ability to know "what's going around" (in the US at least) comes from when he is standing around the hospital sink scrubbing his hands with the other doctors in the community. If your colleague says: "I saw my first case of meningitis this year" - it means that you, too, had better be very suspicious of any sore throat which has petechiae (tiny ruptured capillaries which produce a miniscule, "sliver-like bruise" on the skin): because, it may culture to be "Nisseria Meningititis."

Choosing the training of your physician Dentists have learned that there are some procedures, like cleaning teeth, which can be performed by their companions (dental hygienists) who have had much less training than they have. Plumbers use apprentices, mechanics hire assistants- it seems like everyone, including morticians, does it. There are even different levels of "physician's assistants" working with physicians.

We know that "common things happen commonly," therefore many of the illnesses which attack children, like colds and possibly an infected tonsil, are what we would call "minor" and can, everything going well, be diagnosed by a knowledgeable person with some, but limited, training. And maybe even treated..

And, even the most skilled physician, can sometimes be caught off guard by a deadly problem masquerading as a "common illness." It depends upon: – How much you know (training); – How much you've seen (experience); – How honest you are (professional integrity); and, – How much you care (attention to detail in spite of personal convenience and remuneration, i.e. lack of laziness)

Wow, did I say that about my own profession? Yep, doctors are human too; and we are not immune to the same personal faults, pride and avarice found in other professions. So... when choosing a physician for your child, or evaluating the advice she/he gives, you must also consider things like: training and background, apparent thoroughness, communication ability (does it make sense intuitively) and even remunerative bias (does it make them more money).

"Baby doctor" versus Pediatrician The terms are NOT the same, and you should understand this, if you are going to make the appropriate evaluation that I have been talking about. The term "baby doctor" is a lay-term for 'anyone who provides medical care to a child." This could, and often does, include ANY amount of training from office assistant, to nurse, to physicians assistant, general practitioner, family practice certified and actual Pediatrician. Even a Medical Doctor (MD) who sees your child- but is either a General or Family Practitioner- is NOT considered a Pediatrician.

Even a Medical Doctor (MD) who sees your child- but is a General or Family Practitioner- is NOT considered a Pediatrician.

Only because I want you to understand the concept of levels of training, I'll mention the relative education intensities of the categories I listed above as "baby doctors." (In the US system) Most have completed at least four years of college- the office assistant probably has not. Nurse and Physicians assistants might have some additional education after their college degree. However, General and Family Practioners and Pediatricians have undergone a selection process for Medical School which attempts to only accept the "top" 15 - 20% of those who actually apply for it, into post-graduate school. Then, after graduating from Medical School, both the Family Practioner and Pediatrician have completed even more sub-specialty training, for at least three years. However, of that sub-specialty training, probably less than 15 - 20% of it is on children, for the Family Practitioner; for the Pediatrician, it is full-time, 100%.

Ask questions in order to choose your doctor wisely It is very appropriate for a parent to inquire about the training of someone who they are considering to become the medical care-giver for their child. In fact, you SHOULD do it, always. Nurses and Office personel should be READILY able to tell you what training and degree their doctor has attained— and even show you the diploma. If they can't, then ask the doctor directly who should happily tell you how much of his life he has spent learning his trade and where. If you sense any hesitancy or embarassment, or if they seemed to feel challanged by your questions then its best to reconsider your affiliation with them as patient. You can also check with the local medical association or hospital credentialing office to verify their training.

1) "Have I selected the right doctor"? It doesn't seem so, to me. Based upon what you have told me, I have some serious doubts about the correctness of the advice you have been given (see next article). It would make sense initially to select a doctor who has the most experience and training on children. Of course some localities don't have board certified pediatricians; but, select the highest trained and experienced individual possible in your area.

Then, personality factors and other "person skills" should be considered. Does he/she communicate well with you, so you can understand and follow their instructions? Do they listen to you, seem 'interested' in the child, and appear to be thorough in their examination and treatment? Do they take the time to explain what they are doing and why; and, do they make you feel like you are a partner in the decision and care? Do they seek follow up for their treatment and spend enough time to get to know the child when they are well? Do they offer parenting and other advice, not just treat illness? Are they available to you, or do you feel like you have to run the gauntlet of hurdles in order to speak to them making you feel like you are 'intruding' on their time? Are they your doctor, or do you only get to see their partners and/or assistants? Do they seem like they have done this so much that they are 'going by a script,' or do you feel like they are individualizing their care to your child?

Also very important is whether or not your doctor makes you feel comfortable enough that you can ask questions and provide him/her feedback on how you feel about what they are saying or doing. Do you feel like you would be able to tell them that you disagree with a treatment, diagnosis or specific advice? How do you think they would handle such a question or disagreement? Would you be able to discuss it with them? If the answer to any of these questions is "NO," then you probably should look further to find a physician for your child- (that is, of course, if you have any other options in your area. Another article will deal with what you can do when you have no other choice.)

If you have found a doctor which you feel comfortable with— good for you. That is the first step in obtaining any medical care, for any problem. The next article will expand further on what to do when you think your child is having too many sore throats and/or are considering a tonsillectomy.