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September 24th, 2017

Need a Positive Test for Something, Anything? We’ve Got You Covered!

(Inspired by various unvalidated, non-FDA approved lab tests.)

Fatigued? Achey? Having difficulty concentrating?

Don’t have quite the “zip” you used to have when you were young?

If you suffer from any of these symptoms and are frustrated by unrevealing medical work-ups and negative blood tests, you’ve come to the right place.

For at DNA-Dx, we’ll find that positive test result — we guarantee it or your money back!

Using novel antibody tests with in-house interpretive criteria, home-brew PCR assays and in situ hybridization, imaginative culture techniques, and other proprietary amplification tests, we dial up the sensitivity of our testing so that no stray molecule of infection passes by us undetected.

Not sure what test to order? No problem! Just order our special Pathogen Discovery Panel ($1299.99), which rigorously evaluates blood, urine, and stool specimens for literally thousands of microorganisms, leaving no stone unturned.

It’s available now for a special introductory price of only $999.99. And once you get that positive test result — whatever it is — you’ll agree it’s worth every penny.

Not only that, but if you order now, you get a free canvas tote bag with the DNA-Dx logo. Great for picnics, trips to the beach, or just shopping.

About Us

DNA-Dx is a company founded by Dr. Melvin Smoot, a chiropractor with over 20 years experience in spine manipulation and core alignment. Based on his patients’ histories, he was convinced that many of them with negative work-ups for fatigue and aches were in fact suffering from an undiagnosed infection. Working with Scientific Director Virginia Gleeper, Ph.D. (an honors graduate of Eastern Slovenia Polytechnic Dietary Institute), Dr. Smoot opened his first lab in the food court of an abandoned shopping mall. By redeploying some leftover equipment (in particular from Sbarro and Panda Express), they were able to offer an increasingly broad range of diagnostic studies.

Today, the company has over 100 employees, with offices and labs in most communities with high median incomes.

Frequently Asked Questions

  • Q:  What do you use for negative controls?
    A:  We at DNA-Dx do not believe in negative controls. Even our negatives are positive, provided you test them the right way.
  • Q:  Can you refer me to any scientific validation of your results?
    A:  The best data supporting the validity of our tests are the numerous patient and client testimonials praising our work. We have literally thousands of letters, emails, and cashed checks that endorse what we do.
  • Q:  What is your most common positive test?
    A:  Our expansive stool analysis routinely returns positive for hundreds of different microbes.
  • Q:  What techniques do you use for testing for tick-related infections?
    A:  At DNA-Dx, we are very concerned about the rising incidence of tick-related infections. As a result, we feel it is our responsibility to do as many different tests as possible. We won’t stop until one is positive.
  • Q:  One of my tests was positive — what do I do now?
    A:  If you click here, you can book a free consultation with one of our trained providers. They will guide you through our selection of a wide range of natural therapies and supplements, each proven* to help restore you to vigorous health. (Credit card required.)
  • Q:  Do you take insurance?
    A:  No.

*Disclaimer:  DNA-Dx is a registered trademark of DNA-Dx, Corp., and may not be reproduced, reprinted, or repurposed without the express written consent of DNA-Dx. Tests offered by DNA-Dx were developed and its performance characteristics determined by DNA-Dx. Tests and therapies have not been cleared or approved by the U.S. Food and Drug Administration to diagnose or treat any condition. 

 

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September 17th, 2017

Inactivated Zoster Vaccine Soon to Be Approved — Should Patients Wait for It?

Man with herpes zoster, 1893. National Library of Medicine.

For the last year or so, conversations with patients about getting the zoster vaccine have gone something like this:

Patient: So should I get the shingles vaccine? I saw an ad for it on TV.
Me:  Well, yes … and no.
Patient (confused — he/she has never heard me say anything but an enthusiastic “Yes!” to vaccines):  What does that mean?
Me:  There’s a better shingles vaccine coming soon, likely within a year. So I’d wait.

Now it looks like that wait is almost over.

This past week, an FDA advisory panel voted unanimously that the investigational inactivated zoster vaccine is safe and effective for adults older than 50. The materials the panel reviewed are here.

FDA approval should follow soon — potentially next month — along with the critical review and recommendations from the Advisory Committee on Immunization Practices (ACIP).

The expert advisory panel based their decision on two pivotal randomized trials, ZOE-50 and ZOE-70, which compared the vaccine (administered as two doses) to placebo in people aged 50 and older or 70 and older, respectively. The studies enrolled nearly 30,000 subjects.

Vaccine efficacy was 97% in the first study, 89% in the second. The incidence of post-herpetic neuralgia was also reduced.

Importantly, adverse events were more common in vaccine recipients, but most were of mild severity. There was no significant difference in the incidence of severe side effects, deaths, or autoimmune processes.

Though these studies were not a direct comparison with the currently available live-attenuated zoster vaccine (Zostavax), remember that the efficacy of that vaccine is only around 50%.

Plus, it has been around long enough that we now know its efficacy wanes substantially over time.

That Zostavax is a live-virus vaccine creates additional difficulties. There is understandable concern — and confusion — about giving it to people with defects in cell-mediated immunity, for whom it’s contraindicated, and their household contacts, for whom it isn’t.

Finally, there are the practical difficulties of storing it before administration. Even clinics that do lots of immunizations — ours, for example — don’t have the required stand-alone freezer for storage of this vaccine. Many patients currently need to go to a pharmacy to get it, which adds an additional required step.

So this inactivated zoster vaccine won’t be just a “me-too” approval, but a real advance in prevention of what can be a truly debilitating condition. With the caveat that we lack safety data in very large patient populations — that should come after licensing — I’m not surprised the advisory panel voted the way they did.

It was exciting enough that I felt inspired to relay the following:

Which just goes to show that I can’t count.

 

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September 4th, 2017

Meropenem-Vaborbactam, Zika Cases Decline, Gas Station Nachos, and More — An End-of-Summer ID Link-o-Rama

Labor Day amusement, 1940.

There’s so much interesting ID material out there.

The only solution — an ID Link-o-Rama, especially curated for the long Labor Day weekend.

(Actually, not really, but that sounded good.)

Off we go!

And now, a non-ID section, some medically related, some not:

For Steely Dan fans out there, a personal favorite, this relatively obscure track:

 

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August 27th, 2017

Who’s Most Likely to Leave an Out-of-Office Message While on Service?

Once upon a time, I used being on service as a convenient excuse for not writing very much — or certainly, not writing very much of importance — on this site.

The on-service time also allowed me to poke gentle fun at my colleagues, several of whom always turn on an “out-of-office” message when they attend on the inpatient ID consultation service.

I’m talking about this thing that responds instantly when you email them:

I am currently attending on the inpatient consult service. During this busy time, I may not be able to respond to email in a timely fashion. If you need to reach me urgently, please page me by calling xxx-xxx-xxxx, or leave a non-urgent message here and I will respond shortly.
Thank you,
Rudolph

Reminding me of this post, my friend Carlos Del Rio sent me this email earlier this year:

Going on service April 1st. Should I put my “Rudolph” message up?

I’d advised Carlos to check Emory’s Policies and Procedures — am sure it’s in there somewhere.

Now, having just completed a couple of weeks doing inpatient ID consults — and falling behind on emails — I thought it time to add a few additional observations about this practice:

  1. Who is most likely to do it? Let’s call people who do this “OOODS.” (Pronounced like the first syllable of “noodle,” and standing for “out-of-office during service” types.) My anecdotal impression is that OOODS are predominantly academic physicians, people who know patient care is important but don’t do it on a day-to-day basis. Hence they want to “clear the decks” of other pressing responsibilities. A minority might be full-time outpatient clinicians who only rarely do inpatient work.
  2. When not on service, they are generally very responsive to email. OOODS are often “inbox zero” types who wouldn’t think of allowing the sun to set on a critical research or administrative query. So when busy consult days happen, and the long hours on the wards make it impossible for them to keep up, they want to reassure their colleagues and friends that they haven’t suddenly decided to abandon academic medicine for more frivolous activities. Imagine the speculation!

    “Hey, I emailed Dr. Smith 12 hours ago, and he hasn’t  gotten back to me yet — that’s weird, he’s usually so quick to respond. Plus, no out-office-message.”

    “Yes, that’s weird. But he’s a pretty big Phish Phan — maybe seeing all their summer concerts?”

  3. They’re generally pretty important. Many exceptions to this rule, but the academic rank and productivity of OOODS is impressive. One study found that the number of citations for papers published by OOODS was significantly higher than non-OOODS, even when controlling for total RVUs generated on the consult service. NIH grant dollars and the impact factor of their published papers were also significantly higher. If you don’t believe me, the published paper can be found here.
  4. One person who inspired the original post identified herself almost immediately. Shortly after I wrote it, I received this email:

    Hey, I’m Rudolph aren’t I??? Is that a bad thing?

First, let the record show that this OOODS person who emailed me was only one of several people who sent me a similar query, as I adapted the sample out-of-office message from a bunch of different ones used by friends and colleagues.

Second, it is by no means a bad thing — it’s just a thing some people choose to do; others don’t (I don’t) — as evidenced by the fact that this particular OOODS person was most deservedly just appointed an extremely important leadership position.

Congratulations, Rochelle!

 

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August 20th, 2017

Two Quick Thoughts Inspired by Inpatient ID Consults, and An Inspirational Baseball Poster

Mount Ararat, original source of daptomycin.

A couple of quick thoughts for those of us doing inpatient care these days:

Thought One:  Is daptomycin now preferred over vancomycin in most clinical settings? 

It’s taken a while, but we’re getting there — close to that Gladwelllian “tipping point”.  Allow this recap of vancomycin’s problems:

  • The growing recognition that higher drug levels — the levels we want — bring with them more side effects.
  • The extraordinary hassle and imprecision of monitoring vancomycin levels.
  • The enormous variability in dosing due to differences in clearance from patient-to-patient.
  • The lengthy vancomycin infusion time (at least 60 minutes/dose) which, if you have a patient on every 8 hour dosing, means they are spending many of their waking hours receiving vancomycin.

If you add to these issues the substantial decrease in daptomycin’s cost since it went generic, it’s hard to justify using vancomycin over daptomycin for many non-pneumonia indications these days.

Daptomycin is far from perfect, but if it replaces vancomycin there will be few tears shed on its behalf — vancomycin isn’t such a great drug either. Beta lactams are preferred over both of them for susceptible organisms.

And for the next time there’s a lull in the conversation with your friends, here are some fun facts about daptomycin, including how it was discovered on Mount Ararat in Turkey.

Thought Two: Outpatient parenteral antimicrobial therapy (OPAT) should be avoided whenever possible.

Two recent studies highlight the hazards associated with sending patients out of the hospital with intravenous lines to complete antibiotic therapy:

  1. Out of 339 patients prospectively studied from two academic medical centers, 18% experienced a significant adverse drug event, most commonly during the first two weeks after discharge. Note that most retrospective analyses have even higher rates, probably because many are discharged without being in an organized OPAT program.
  2. In people who inject drugs — a particularly challenging patient population who increasingly have “indications” for OPAT — a whopping 61% failed their OPAT course.

Aside from the medical challenges of OPAT, there’s also the clinical service side — which is dismal. Since payers typically do not reimburse providers for monitoring OPAT, this gives us ID doctors two terrible choices — provide the service for free because it’s good for patients or, alternatively, refuse to do it and document (leverage) the suboptimal care to get institutional funding.

The former is an example of our being “too nice”; the latter just makes me uncomfortable, but is increasingly required.

Bottom line:  we should strive to give oral over IV antibiotics at discharge for all patients, except when the data strongly support parenteral therapy. Oral treatment is safer, cheaper, and usually just as effective.

Finally, given the current political climate, isn’t this poster just awesome?

It’s a subway poster from 1950, published by the Institute for American Democracy.

And as a baseball-crazy ID doctor, of course I love it!

 

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August 13th, 2017

Dog-Related Infectious Diseases as an Excuse to Show Pictures of Dogs

For proof that we’re not like other human members of the planet, when ID doctors think of dogs, it sometimes brings to mind one or more of following associations:

  • Gastroenteritis due to Campylobacter jejuni. No, there’s nothing cuter in the world than a puppy — but remember that these little critters are particularly predisposed to symptomatic (and asymptomatic) campylobacter infection, and, given our inability to resist picking up puppies and cuddling them, not surprisingly can be the source of human infection as well. Older dogs are less susceptible, so probably best to keep the puppies out of the elder care facilities.
  • The wonderfully named bacterium Capnocytophaga canimorsus. This is a rare cause of sepsis after dog bites — in particular in people without spleens, those who consume too much alcohol, and the immunocompromised. A good trivia question for parties is to ask someone the bug’s original name, which was “DF-2”, standing for “Dysgonic fermenter.” Then ask them what “dysgonic” means. Then ask the difference between “DF-2” and “DF-1”. That will make you the life of the party. (For the record, I have no idea what “DF-1” is.)
  • echinococcus_lifecycleDogs are the “definitive host” of Echinococcus granulosus. This parasitic infection (which can cause nasty cystic lesions in the liver, lungs, and brain) is most common in people who raise sheep, which like humans act as intermediate hosts. But dogs are required to complete the life cycle, and they get infected when they eat discarded meat and internal organs from echinococcus-infected sheep. That might be yuck to us, but it’s no doubt yum to them. Here’s the CDC-approved life cycle diagram, if you don’t believe me.
  • Rabies. (Cue scary music here.) Even though there hasn’t been a human case of rabies linked to a dog bite sustained within the USA in decades, every ID doctor frequently receives calls about dog bites and the risk of rabies. That’s not surprising since 1) dog bites still account for over 90% of human cases world-wide; 2) rabies is nearly 100% fatal, and; 3) there are anti-vaccine crackpots who have spread their nonsense to their dogs. Couldn’t make this stuff up.

Of course that’s hardly the full list — there’s Dipylidium caninum (dog tapeworm), Ancylostoma caninum (dog hookworm), Microsporum canis (ringworm), Brucella canis (transmitted to humans when infected pregnant dogs have spontaneous abortions), and Ehrlichia canis (the cause of ehrlichiosis), just to list those that have the Latin root for dog in their name.

And we could on with several other infections that, in various settings, have been linked to dogs. A true potpourri of zoonoses! There’s giardiasis, Yersinia pestis (yes, that’s the plague), leptospirosis, Pasteurella multocida (though cats really deserve most of the blame for this one) — even MRSA!

Which brings me to the real reason for this post, which is to show three pictures of dogs that struck me as particularly fetching, infectious risks of owning these beasts notwithstanding. First, my friends just got an adorable puppy named Elijah — and here he is.

Second, and just so someone close to me won’t get jealous, here’s a recent picture of a very vigilant Louie, who has clearly spotted some danger in the distance (or maybe just a squirrel).

Third, I happen to work with Francisco Marty, who is not only a remarkable clinician and clinical researcher, but also one extraordinary photographer. And below is proof, entitled “DUMBO’s Dachshund!”

Woof!

DUMBO's Dachshund! by Francisco Marty on 500px.com

 

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August 6th, 2017

Have We Reached the End of HCV Drug Development?

Rabbit or duck?

Two new HCV regimens gained FDA approval recently, bringing us closer to the end of this extraordinary phase of drug development.

Think about it — has there ever been a more spectacularly rapid improvement in treatment of anything? If so, please let me know what that is. Remember, as recently as early 2013, highly toxic interferon-based therapy (with ribavirin and telaprevir or boceprevir) was still standard-of-care.

The recent approvals:  Sofosbuvir-velpatasvir-voxilaprevir (Vosevi) on July 18, indicated for patients who have failed prior treatment with either sofosbuvir or an NS5A inhibitor. Twelve weeks of treatment (one pill daily) will cure 95–96% of patients, and pretreatment presence of NS5A, NS3, or NS5B resistance mutations does not reduce response. A month of sof-vel-vox — which will only be used as a salvage therapy — is priced at $24,900.

Then, glecaprevir-pibrentasvir (Mavyret) was approved on August 3rd. A pan-genotypic regimen that includes both an HCV protease inhibitor and an NS5A inhibitor, “G/P” is 3 pills daily, requiring only 8 weeks of therapy in treatment-naive individuals without cirrhosis. Clinical trial results show cure rates in the high 90s, with a low incidence of treatment-related adverse events requiring drug cessation.

Glecaprevir-pibrentasvir can also be used in patients with renal impairment (including dialysis), prior treatment failure of genotype 1 with either an NS5A inhibitor or PI (but not both), and in compensated cirrhosis. Treatment duration should be increased to 12 weeks in those with prior treatment or cirrhosis.

So where does that leave us in terms of “unmet needs” in HCV therapy?

Let’s review what we currently have:

  • Nearly 100% of those who get treated are cured.
  • Most regimens are one pill daily.
  • Ribavirin is rarely required for treatment-naive patients.
  • Side effects leading to drug discontinuation are exceedingly uncommon.
  • Treatment duration is only 8–12 weeks.
  • Drug interactions are mostly manageable; if not, HCV treatment is so short that temporary discontinuation of the conflicting drug is usually fine.
  • Several pan-genotypic options are available.
  • Certain therapies are also effective for treatment-experienced patients with resistance.
  • Some regimens are safe and effective for those with moderate-severe renal disease — even hemodialysis.

From a medical perspective, this doesn’t leave out a whole lot, does it? Treatment of HCV is so easy there’s a strong push in some circles to move it to front-line providers in primary care — and of course outcomes in their hands are as good as with hepatologists and ID specialists.

Yes, cost of and access to HCV therapy remains an issue, especially in certain regions.

But things have vastly improved in this area too. With prices way down from the crazy days of early 2014 (when the non-FDA approved “sim-sof” regimen was > $100,000/cure), we should anticipate that more payers will stop medically unjustified policies such as fibrosis criteria, negative toxicology screens, and limiting prescribing of HCV therapy to specialists.

And market forces are doing something — note that the wholesale price of G/P is $13,200 per month, very close to the negotiated discounted price for LDV/SOF with the VA and certain state Medicaid programs.

Which brings me back to the title of this post — Have We Reached the End of HCV Drug Development?

If we’re not there yet, we’re certainly close.

Here’s a poll about where we should go with HCV research — please vote!

What is the most important remaining challenge in HCV research?

View Results

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July 30th, 2017

Really Rapid Review — Paris IAS 2017

Last week, the International AIDS Society meeting returned to Paris for the first time since 2003.

Yes, you and I are that old. Jeeze.

Here’s a Really Rapid Review® of some of the conference highlights, roughly ordered by “cure”, prevention, treatment, and complications.

As always, feel free to use the comments section for notable studies I might have missed — thank you!

Now for a few non-scientific observations:

  • Paris Street; Rainy Day. Gustave Caillebotte, 1877. Art Institute of Chicago.

    The weather was mostly, cool, cloudy, and intermittently wet. Regardless, Paris is among the most beautiful and lively cities in the world. (Not such an original opinion, I know.)

  • A bike race visited Paris at the same time. Lots of excitement.
  • What a weird conference center. Numerous escalators, winding hallways, and a disorienting layout made getting around tricky. At least the session halls for the slide sessions were very comfortable (though some over-crowded).
  • Why can’t we have a subway system like that? The Paris Metro seems to get better all the time — fast, clean, reliable, inexpensive. I’m sure it’s not perfect, but is there a better urban rapid transit system in a large city anywhere else?
  • Although per capita cigarette consumption is roughly the same in France and the USA, it sure doesn’t seem that way. I’ll anecdotally say that lots of professionals (even doctors, gasp) and other well-to-do people smoke in France — you don’t see that much in the USA anymore.
  • Next year’s conference is in Amsterdam. July 23-27.

Speaking of bicycling around Paris …

 

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July 19th, 2017

Mystifying Cochrane Library Review on HCV Therapy Elicits Strong Response from IDSA

Last month, the Cochrane Review published a controversial paper on HCV therapy that left many ID doctors and hepatologists perplexed.

After reviewing 138 randomized clinical trials using directly acting, non-interferon based therapies, they came to the following conclusions:

  • The use of sustained virologic response (“SVR”) — or “cure”, if you want to use plain English — as a valid endpoint for predicting clinical outcomes is questionable.
  • There is currently insufficient evidence that treatment with DAA-based regimens improves clinical outcome.
  • The studies reviewed were at high risk of bias, so tended to overestimate benefits and minimize harm.
  • More randomized clinical trials are needed.

Anyone — clinician, researcher, or patient — who has experienced the miraculous advances in HCV therapy that started in 2014 could easily be scratching their heads at these conclusions.

The FDA might be surprised as well, since they have allowed SVR as an appropriate “surrogate” marker of the effectiveness of HCV therapy for some time.

Fortunately, we now have a focused, persuasive response by the IDSA, just published in Clinical Infectious Diseases.

I strongly encourage anyone who doubts the clinical benefits of curing HCV to read the full paper, but in essence the argument goes like this:

  1. The review was overly selective in the papers it included. Remember, many HCV trials could not include a control group since DAA therapies were so rapidly effective and well tolerated it would have been unethical. These non-controlled studies were not included in the review.
  2. HCV cure as an appropriate marker for treatment efficacy was established during the years of interferon-based therapy. Liver inflammation (as measured by biopsy or serial LFTs), fibrosis, portal hypertension, splenomegaly, even cirrhosis improved in those with SVR. And I would add that some surrogate markers are more intuitively obvious than others — and you can’t really get more obvious than curing the very infection that’s causing the disease. HCV RNA is not an obscure, indirect tumor marker (oncology), or a change in lipids (cardiology). It’s analogous to HIV RNA in HIV therapy, only better. And is there any plausible biologic reason why HCV cure with DAAs might be less effective in improving clinical outcomes than using interferon?
  3. The time horizon to see the full clinical benefit for HCV cure will take many years. We’ve only had these therapies widely available since 2015 — hardly enough time to see reductions in the incidence of long-term complications such as cirrhosis or hepatocellular carcinoma. Note that we’ve already seen benefits in HCV transmission from treatment in a clinical cohort of MSM from Europe.
  4. Despite this short time period of DAA availability, clinical benefits have already been observed with HCV cure. These include resolution of vasculitis, spontaneous remission of non-Hodgkin lymphoma, and — perhaps most remarkably — stabilization or improvement in those with the most advanced forms of HCV liver disease.

I will note that this isn’t the first time a “systematic review” of an Infectious Disease treatment under the Cochrane name ended up with a surprising conclusion.

Remember this one on HIV treatment with TDF/FTC/efavirenz? The one which stated there was insufficient evidence to support its use, despite numerous randomized clinical trials documenting its efficacy? And its widespread adoption in clinical guidelines?

It may be hard to find today, since it was later withdrawn.

 

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July 9th, 2017

Should You Answer Medical Questions from Clinicians You Don’t Know About Patients You’ve Never Seen?

This email popped into my inbox the other day from a person I’ve never met:

Hi Dr. Sax,
I do mostly hospital-based ID in Pennsylvania, and was consulted on a newly diagnosed HIV patient with CD4 10, viral load 210,000, and lymphoma. I started him on Truvada and dolutegravir, which is going well so far. Because he complained of blurred vision, he had an ophtho evaluation yesterday which showed CMV retinitis. My drug-interaction checker says I can’t use valganciclovir with either tenofovir or abacavir, and if I replace the Truvada with a boosted PI, it will interact with his chemotherapy. What should I do for his ART?
Thanks so much.
Marie

There are two issues with this email worth discussing.

The easy part first — the medical question. Here’s my response:

Hi Marie,
There is no significant interaction between ganciclovir and tenofovir alafenamide, and even the interaction with tenofovir DF is theoretical, not an absolute contraindication. No interaction with abacavir either, so not sure where you are getting your information! (Use this site, it’s awesome:  www.hiv-druginteractions.org.) So switch the Truvada to Descovy (tenofovir alafenamide/emtricitabine), that’s all you need to do. Safer for kidneys and bones, too.
Regards,
Paul

The second item to cover is whether we should be answering questions like this at all. Remember, this is from a person I don’t know, asking about a patient I’ve never seen.

Though I obviously responded to the query, there are a few reasons not to answer questions from clinicians you’ve never met about patients you haven’t seen.

The medical information might not be correct, or complete enough, to make a good recommendation. If you make the wrong suggestion, or your recommendation is misquoted, there’s the potential for patient harm. Even worse: if your name is in the chart, there’s a medicolegal risk — especially if you review patient data sent to you. The risk may be small, but who wants to take that chance?

And if you ask an economist, they would say it definitely makes no sense to answer these questions — not only are you being paid nothing, but there’s little chance of downstream revenues, and it takes time away from other remunerative tasks and opportunities.

But economists can be short-sighted, and this is one of those times. Obviously I thought it was better to answer the question than to ignore it for a bunch of reasons.

  1. Answering helps the patient. Sometimes cliches are true: helping people remains the primary reason most of us went to medical school to begin with.
  2. Answering helps the clinician. When I see a difficult case of coccidioidomycosis, I of course call an expert in this tricky fungal infection; cases of cocci are rare in Boston. And I’m so grateful when John Galgiani responds, given his voluminous experience. Ditto various cases over the years involving rapidly growing mycobacteria (Richard Wallace), bartonella (Jane Koehler), toxoplasmosis (Jose Montoya), Mycobacterium avium complex (Chuck Daley, Gwen Huitt), cytomegalovirus (Richard Whitley), and many others. Thank you!
  3. It was a straightforward, focused question, presented clearly. I didn’t quote the whole email, which included numerous other details about the chemotherapy regimen, but those were thoughtfully placed at the bottom of the communication.
  4. The person asking was polite. No dreaded Red Exclamation Point indicating that this was of the utmost urgency. (Here’s a thought — let’s ban that particular means of communication.) No “Thanks in advance for your rapid reply.” (Ugh.)
  5. It’s flattering when someone asks you questions in your area of expertise. Gosh, Marie chose to ask me about her patient’s HIV therapy? When there are so many other people she could have asked? Hey, maybe I should be thanking her! (Of course she might have sent the same email to 20 others, but … who’s to know?)

The bottom line is that I think we should be helping out other clinicians when we can — it’s just the right thing to do.

 

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.