There is germaphobia, the fear of germs. Or Germans. One of the two. Oddly, I do not fear most germs, despite my daily reminders as to how destructive these wee beasties can be. I recognize their limits and my immunologic strengths and know I have more to fear from cars or unsaturated fats than E. coli or influenza.
There is also a fear of vaccines, the too many too soon that is said to be at the heart, or maybe the left atrial appendage, of one of the imaginary problems with vaccines. There are, by my counting, 5 live attenuated viruses and 21 different antigens in the vaccine schedule by age 6, for a total of 26 or twice thirteen. Some fear those antigens and viruses, making it a triskaidekaphobia times two (1).
From my perspective the paltry quantity of antigens children receive with the vaccine schedule are, when compared to the enormity of antigens in the environment, a rounding error. We are awash in bacteria, fungi, viruses and an enormous number of environmental organisms. I think of each of us like Pig-Pen, but instead of dirt, we are in a cloud of micro-organisms.
Our immune systems, contrary to the opinions of the unimaginative who direct scorn and derision at Dr. Offit, can cope. As discussed, we have a ability to stave off the phenomenal number of organisms that would just as soon use us as the ultimate supersized meal. Of course, it is not all the immune system that keeps the wee beasties away. Being warmer than ambient temperature helps. Understanding disease epidemiology, hygiene and the prn malum q 24 h also keeps the doctor away. (more…)
There are sources of information I inclined to accept with minimal questioning. I do not have time to examine everything in excruciating detail, and like most people, use intellectual short cuts to get through the day. If it comes from Clinical Infectious Diseases or the NEJM, I am inclined to accept the conclusions without a great deal of analysis, especially for non-infectious disease articles. Infectious disease publications I have to read more closely; its part of passing as an expert.
Outside of medicine, I am predisposed to accepting at face value many of the articles in Skeptic and Skeptical Inquirer. They are trusted sources. Some topics, like haunted house or Big Foot investigations, I barely skim. After all these years, I doubt there will be any new insights into the subject. Other topics, depending on my interest, I may read more carefully.
I often read longer articles many times. First a quick skim to see if it offers anything of interest. If it does, then I may read it carefully.
This months Skeptical Inquirer had an article called Seven Deadly Medical Hypotheses by Reynold Spector. Just seeing the title and knowing the magazine, I was primed to accept the content at face value. I enjoy a well reasoned, thoughtful rant. I relish a clever diatribe, even if I do not agree with the topic. So I gave it a quick skim. I was discomfited. My first gut check was ick. But I was uncertain why. So I read it slowly and carefully, and still ick. But why? (more…)
I was interviewed for Birmingham Skeptics and you can hear the result at
It is bad enough listening to myself as I correct my podcasts, so I have no idea how good the interview is; it was fun at the time. And the picture makes me look fatter than I am. Oh well.
For those who are new to the blog, I am nobody from nowhere. I am a clinician, taking care of patients with infectious diseases at several hospitals in the Portland area. I am not part of an academic center (although we are affiliated with OHSU and have a medicine residency program). I have not done any research since I was a fellow, 20 years ago. I was an excellent example of the Peter Principal; there was no bench experiment that I could not screw up.
My principal weapon in patient care is the medical literature, accessed throughout the day thanks to Google and PubMed. The medical literature is enormous. There are more than 21,000,000 articles referenced on Pubmed, over a million if the search term ‘infection’ is used, with 45,000 last year.
I probably read as much of the ID literature as any specialist. Preparing for my Puscast podcast, I skim several hundred titles every two weeks, usually select around 80 references of interest and read most of them with varying degrees of depth. Yet I am still sipping at a fire hose of information
The old definition of a specialist is someone who knows more and more about less and less until they everything about nothing. I often feel I know less and less about more and more until someday I will know nothing about everything. Yet I am considered knowledgeable by the American Board of Internal Medicine (ABIM), who wasted huge amounts of my time, a serious chunk of my cash, and who have declared, after years of testing, that I am recertified in my specialty. I am still Board Certified, but the nearly pointless exercise has left me certified bored. But I can rant for hours on Bored Certification and how out of touch with the practice of medicine the ABIM is.
It always somewhat surprises me how some interventions never seem to die. Theophylline seems to have disappeared in the medical pantheon, but what comes around, goes around. I predict a resurgence of theophylline this century. Despite the recent study that shows, yet again, echinacea has no effect on colds, I predict the study will neither decrease the sales of echinacea nor prevent further funds being spent on clinical trials on its efficacy. Hear that JREF? I made predictions. I will await my million dollar check. Make it out to Mark Crislip.
Another therapy that refuses to be put to rest, or even to be clarified, is the use of cranberry juice for urinary tract infections. Pubmed references go back to 1962, and there are over 100 references. Firm conclusions are still lacking.
There is a reasonable, but incomplete, basic science behind the use of the cranberry juice for urinary tract infections. (more…)
I have been in Infectious Diseases for almost 25 years. I have two major jobs: I see inpatient consults and I chair the Infection Control program. I have been involved in quality improvement, especially as it relates to hospital acquired infections, for my entire career. It has been an interesting quarter century. Year after year we have driven down infection rates and other kinds of mortality and morbidity in hospitalized patients. Everyone recognizes that medicine is difficult and dangerous and its biggest problem is medicine is practiced by humans, who, I would venture to observe, are prone to mistakes and any number of cognitive errors.
It has not been a easy journey. People hate change and there has not always been certainty as to the best options to choose to solve a problem, a problem that continues today. For example, how best to treat a patient with potential methicillin resistant Staphylococcus aureus colonization (MRSA). Should we screen everyone? Screen high risk patients? Surgical patients? Do we decolonize, with the long term consequence of accelerating antibiotic resistance? Do we place everyone with MRSA in isolation, with the known decrease in care that patients in isolation may have? Everything we do has potential downsides and unintended consequences. No good deed ever goes unpunished.
I gave a lecture last fall on The Vaccine Pseudocontrovery for Oregonians for Science and Reason. There are evidently Oregonians against Science and Reason, hence the title. My Dad went and said it was a good talk. You going to argue with Dad? I think not.
Someone with a handheld camera recorded it, edited it, and put it up on the YouTubes in four parts. The first part is here:
It was also Quackcast #45 as well, so you may have heard it all before.
If you can’t be self-aggrandizing, what’s the point of having a blog?
I keep half an eye on the medicine displays in stores when I shop, and this year is the first time I have seen Oscillococcinum being sold. Airborne as been a standard for years, but Airborne has been joined by Oscillococcinum on the shelves. Dumb and dumber. It may be a bad case of confirmation bias, but it seems I am seeing more iocane powder, I mean oscillococcinum, at the stores.
On a recent podcast I was listening to one of the hosts suggested a homeopathic remedy for flu symptoms, and then specifically suggested osillococcinum. This is a technology podcast, the 404, and the hosts are certainly bright, educated people. Why would he suggest osillococcinum? Probably because he unaware of how oh so silly the product is.
The worst part of flying is the take off and landing. Not that I am nervous about those parts of the trip, it is that I am all electronic. Once I have to turn off my electronic devices, all I am left with is my own thoughts or what is in the seat pocket in front of me. Since there is nothing to be gained from quiet introspection, I am stuck with either the in-flight magazine or SkyMall. I usually choose the latter. SkyMall, for those of you who do not fly, is a collection of catalogs bound in one volume. I have occasionally purchased products found in SkyMall and thumb through it with mild interest.
This time one product caught my eye, the Aculife home acupuncture/acupressure device. I had never noticed the ‘health’-related products in SkyMall before, usually looking for electronic gadgets that I really do not need. I was curious. How many other products besides Aculife are in the catalogue? According to the interwebs, about 100,000,000 Americans fly every year and well over half a billion people world wide. A lot of people can potentially look at SkyMall, including the occasional skeptic.
Life and medicine generate facts and experiences that require conceptual frameworks that aid in understanding. It is no good have a pile of facts if they cannot be understood within a broader understanding.
The practice of Infectious Diseases, while certainly aided by understanding anatomy, physiology, microbiology, chemistry and the other sciences that form the core of medicine (referred to in Medical School as the basic sciences), gains a broader appreciation from the concepts of evolution. Infectious Diseases, at its most fundamental level, is applied evolution, and understanding evolution often adds greater insight into infectious diseases. Me find bug, me kill bug, me go home may be my motto, but it is meant in jest.
There have been papers or books that have added conceptual frameworks to my understanding of the natural world and medicine. Besides evolution, there was Observations on Spiraling Empiricism a classic that all health care providers should read, as it outlines the cognitive errors we all make in prescribing medications; I have discussed this article before.
There is The Drunkard’s Walk: How Randomness Rules Our Lives by Leonard Mlodinow. So often the explanation of why something happens is a shrug of the shoulders; feces occurs. The book formalized my understanding that much of what happens is random and without cause. The challenge in medicine is trying find a pattern in the randomness of life upon which to base a diagnosis. It is equally important to recognize when patterns are not there. All too often what is seen as a pattern is our imposing structure on what are random events. Or maybe that really is a bunny in the clouds. Clinical study results often occur by chance and having a significant ‘P’ value may still be due to randomness if the study is measuring nonsense.