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.
It is probably of no surprise to anyone who has read my blog entries, I am a proponent of vaccines. They give the most bang for the infection prevention buck, and many of the childhood illnesses covered by the vaccine are now so rare that many physicians, even in Infectious Diseases, have never taken care of cases of measles or mumps or German measles, etc. It is a remarkable triumph of modern medicine. Of course, the decline of infectious diseases is always multifactorial: good nutrition, understanding of diseases epidemiology, and good hygiene all have contributed to the decline of many diseases, vaccine preventable or not, The application of science has resulted in an almost inconceivable decline in contagions that have killed and injured millions.
It is always better to prevent an illness than to have to treat it. An ounce of prevention is worth a pound of cure. Even those who erroneously believe that standard vaccines are not effective and/or dangerous understand that it is better to prevent illness with some sort vaccine. But rather than use an effective vaccine, they choose, instead, other options. Like homeopathic vaccines. (more…)
I have been involved in infection control and in what is now called quality for my career. Since infection control issues can occur in any department, my job involves being on numerous quality related committees (Medical Executive, Pharmacy and Therapeutics, etc) where I have witnessed or participated in what seems to be innumerable quality initiatives.
It always gripes my cookies when someone says “Get your own house in order,” because that is a person who evidently is arguing from ignorance. Since To Err is Human was published at the turn of the century, the hospital systems in Portland and across the country have invested significant time and money into quality improvement. Do a Pubmed on ‘Hand Hygiene Compliance’ in the last decade; there are over 400 references. Or ‘deep venous thrombosis prophylaxis’ — over 5,000 references. Or ‘ventilator associated pneumonia prevention’ — over 750 references. Pick a topic related to safety and quality and search the literature, and you will find a remarkable amount of research into the best ways to decrease morbidity and mortality in the hospital.
Hospitals, at least those in my city, take safety and quality very seriously, and by applying the results of these studies, there has been a marked decrease in mortality and morbidity in my institutions. Compared to historical controls, we estimate we have, in the last 2 years, prevented about 600 hospital acquired infections and over 200 deaths. (more…)
In the last post on acupuncture, I noted that the University of Maryland offered reflexology along with other supplements, and complementary and alternative medicine (SCAMs). I was uncertain as to the particulars of this SCAM, and this post is a result of those investigations.
Although messy in reality, science is a tool that gives us an idea as to how the real world functions. People will observe some aspect of nature, often for a lifetime, and from those observations discover a pattern in the data. Tycho Brahe spent a life carefully measuring the orbits of the planets; the data was used later by Kepler to determine that the planets orbit in an ellipse with the sun at one of the foci. If you have knowledge of the history of science, you realize what an amazing feat this represents, both in the measurement of the orbits and the analysis of the data. Careful observation, analysis of the data, then conclusions.
This is in contrast to SCAMs, where so many of the interventions are discovered by revelation, and then developed independently of data and observation. Palmer and chiropractic, von Peczely and iridology, Usui and reiki are examples. These geniuses discovered aspects of existence unseen by anyone before or after.
The bar on this blog is set high. The entries are often complete, with no turn left unstoned. Yet, not every topic needs the full monty with every post. The blog has extensive evaluations on many topics, and new medical literature doesn’t require another complete analysis. Many new articles add incrementally to the literature and their conclusions need to be inserted into the conversation of this blog, like a car sliding into heavy traffic. My eldest son just received his driver’s license, and car metaphors are on my mind. As are crash metaphors and insurance metaphors.
So in response to this need, a need only recognized by me, I give you Short Attention Span SCAM. Occasionally I will summarize a few recent studies and their key points as they relate to prior posts at SBM.
Humans love to find patterns in the world. Sometimes patterns exist, sometimes they are imaginary. Sometimes you can see a pattern that may be interesting and ignore its significance. As a resident I used to say that anyone who smokes three packs of cigarettes a day has to be schizophrenic, it was meant more as a joke, when, in fact, it was later discovered that tobacco helps ameliorate the symptoms of schizophrenia. I need to pay more attention.
Part of my job is to look for patterns as a key to the patients diagnosis. Diseases and pathogens tend to (more or less) cause reproducible signs and symptoms and looking for that pattern is often the most helpful clue towards finding the diagnosis. Of course things are never as easy as one would like, as you have to consider whether you are seeing common manifestations of a common disease, uncommon manifestations of a common disease, common manifestations of a uncommon disease and, the hardest, uncommon manifestations of an uncommon disease. When I have a complex or uncertain cause, I explicitly run through that, and other, litanies so I do not miss a unusual diagnosis.
Chronic Fatigue Syndrome (CFS) has, at least to my way of thinking, two patterns. I see the occasional CFS patient in clinic and, I hope, pay attention to their disease patterns. I keep in mind I may be seeing a pattern that does not exist, but looking for disease patterns is what doctors are trained to do.