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January 13th, 2019

Are We ID Doctors Really So Unhappy Outside of Work?

Must be a rheumatologist or otolaryngologist. (Source: National Library of Congress.)

Medscape released their 2019 Physician Lifestyle & Happiness Report, and the results aren’t pretty for a certain cognitive specialty, one commonly abbreviated “ID.”

Out of 29 medical and surgical specialties, infectious diseases physicians ranked second to last when responding to a 7-point scale rating on their happiness. Only neurologists were gloomier than we were during their off-hours.

Rheumatologists and otolaryngologists finished first and second, smiling all the way.

The news was even worse for ID docs in “self-esteem,” where we ranked last, right behind oncology and internal medicine. Meanwhile, the plastic surgeons, urologists, and ophthalmologists scored highest on this measure.

Some of my ID colleagues have commented about possible methodologic issues with the survey, as the results don’t correlate with our own happy non-work lives.

For example, Dr. Dan McQuillen weighed in with this critique:

I have a query into Medscape to get more information about these concerns, and they’ve kindly agreed to get back to me. For example, I don’t understand how the 7-point happiness scale translated into the percentages shown in the linked figure.

More importantly, what were the demographics of these 150 ID respondents, and how do they compare with ID practitioners as a whole?

Methodology notwithstanding, it’s worth postulating at least a few reasons why indeed we might be somewhat less happy outside work than other doctors right now. So here goes:

1. The current political climate. It’s no secret that ID doctors skew strongly to the left when it comes to politics. I can’t be the only ID doctor who, on a certain Wednesday in early November 2016, went to work and encountered several colleagues and trainees literally in tears.

(Or maybe you were in tears yourself. It’s OK to admit that to other ID docs.)

I’ve discussed this issue before, postulating that the “safety net” and inclusive ethos of ID doctors was more in line with one particular party than the other. Some even choose ID as a specialty because of these political leanings. Here again are the facts, which could very well contribute to a lower happiness score during the recent survey period:

How about today, two-plus years later? Decent chance that the fraction who have registered red is even smaller.

2. Salaries, debts, and money concerns in general. During a time when certain government workers are sadly not being paid at all (see #1, above), it seems petty to complain about ID doctor salaries — which, in this latest comprehensive salary report, aren’t really that bad:

In general, full-time ID physicians in private practice (n = 366) reported higher incomes, with a median annual salary of $260 000, than respondents employed by hospitals, clinics, or academic medical centers (median salaries of $237 500 and $181 500, respectively).

But context is everything, and here are some important considerations. Students graduate from medical school with on average nearly $200,000 in medical school debt, a hefty sum to pay down with these ID salaries.

Furthermore, ID doctors are often paid less than hospitalists and primary care physicians — doctors who have spent less time training, and frequently work fewer hours, than ID doctors. And all of us cognitive clinicians can only dream of accumulating the RVUs (and hence revenues) of a plastic surgeon, urologist, or ophthalmologist.

Hey! Those are the docs who just happen to lead in the “self-esteem” metric! Hmmm.

3. We’re by nature big-time worriers. Obsessive to a fault, we ID doctors take the most detailed histories, frequently contact the outside labs, march down to the radiologists or ECHO room or microbiology lab to review primary data, write the longest (too long) notes, and still — we live in terror of missing something.

Could it be that this personality trait doesn’t translate into happiness? Maybe the sensation that our work is never done translates into non-work “worry hours” that cloud the responses to a happiness survey.

Imagine the thought bubble of some of us as we head home from work:

How can I be happy at home when that patient with Staph aureus on a urine culture may have bacteremia? Or that other patient with a positive IGRA could develop active tuberculosis when starting etanercept? Or that person being discharged on IV antibiotics won’t have close follow-up? Or that guy who missed his HIV follow-up appointment might have stopped ART? Or that patient getting blasted with immunosuppression for graft-versus-host disease might have an undiagnosed fungal infection? Or that person …

You get the idea.

4. Our work lives are so interesting, rewarding, and wonderful that everything else pales by comparison. This must be the explanation, right? For example, look what I accomplished at work just this last week — how could anything beat that?

So, what do you think? Is the Medscape survey valid?

January 6th, 2019

Rabies After Trip to India, Aortic Dissections with Quinolones, a Vaccine for Candida, Koala Bites, and More: A Welcome-to-2019 ID Link-o-Rama

From the Library of Congress, government shutdown notwithstanding.

As 2018 tips over into 2019, here are a bunch of ID- and HIV-related studies that, for one reason or another, haven’t made their way to this site yet — but still yearn for your attention:

Have you written 2018 on a form or check yet?

Of course you have. Happy New Year!

And just 18 million views for this video (and counting):

January 2nd, 2019

How Did Our Medical Notes Become So Useless?

Dot Phrase, by Grace Farris, MD

Among the many complaints about electronic medical records (EMRs), the death of the useful medical note ranks very high.

Notes are too long, too complex, and filled with unhelpful words. It’s often impossible to glean what the clinician thinks is going on, or what’s planned.

Ever get a note from an urgent care clinic on a patient who went there with a viral syndrome? Or a discharge summary? The note contains pages of indecipherable gobbledygook, ICD10 codes, irrelevant review of systems, stock phrases — the medical words are there, but where is the content? Give a click on this note for a particularly egregious example (all identifying information removed). Then come on back here. I’ll wait.*

(*Good chance these notes are faxed to your office, then scanned into your EMR’s “media manager,” or whatever your EMR calls it. My wife, a primary care pediatrician, calls this part of the EMR “the place where information goes to die.” Yep.)

It hasn’t always been this way. I’ve worked with EMRs of various sorts for decades. One of them, designed for outpatient care, had two ways to file notes — the clinician either dictated a narrative (for complex cases) or, more often, wrote a brief handwritten note in a 3-line section that was immediately typed in by clerical staff.

Both types of notes were infinitely more useful than today’s behemoths. The long dictated notes told a logical story, the short ones highlighted only the most relevant information. Example of the latter:

New painful rash on back. PE: vesicles in T10 dermatome on L, otherwise neg. Dx zoster, Rx Valacylovir 1 gm TID for 7d. Discussed possible complications, reasons to return or call for f/u.

That’s it! Today, this would be unimaginable. In a paper published in the Annals of Internal Medicine, three experts in EMR optimization compared the length of notes in the USA vs other countries:

In other countries, [a note] tends to be far briefer, containing only essential clinical information; it omits much of the compliance and reimbursement documentation that commonly bloats the American clinical note. In fact, across this same EHR, clinical notes in the United States are nearly 4 times longer on average than those in other countries

So how did we get here? What caused the note to shift from being the primary means of communicating medical information to this gargantuan beast? Three primary reasons:

1. Money. Some might call this “billing” or “regulatory” or “compliance,” but let’s call it by its root source — money. Based on quirks of our strange American healthcare system, certain words or phrases or diagnoses yield higher reimbursement than others. This hierarchy has nothing to do with delivering good patient care or communicating with other clinicians.

It’s not just individual words — entire sections of notes owe their very existence to maximizing revenue from clinical services. Dr. Mark Reid, author of the entertaining Medical Axioms, complained last week about being forced to include certain words in his notes.

He received this painful response from a Cardiology fellow, who recently had his notes reviewed by a “Cardiology Coder”:

Not only did poor Dr. Azeem include a Review of Systems to satisfy the Insatiable Billing Monster, but someone reviewed his Review of Symptoms to ensure he used the correct words! Could there be a better example of what’s wrong with medical documentation than this anecdote?*

(*And could you imagine having that reviewer’s job? Shudder.)

2. Copy/paste. Some EMRs have a feature where you can highlight only the original — not the copied or imported — content of a note. If you do this, you instantly understand why “ID consulted, awaiting input” appears several days after you’ve done your consult and have been communicating regularly with the primary team. They’re not ignoring your beautiful consult, they just haven’t gone back to update the text.

Other symptoms of copy/paste madness are the gobs of laboratory and radiology data appearing in every note, copied from the actual reports and then pasted into the “Results” section, or imported via macros (see #3 below).

How bad is the copy/paste phenomenon in medical documentation? Researchers at UCSF reviewed the source of text from medical notes over an 8-month period, and their findings were not pretty:

We analyzed 23, 630 notes written by 460 clinicians. In a typical note, 18% of the text was manually entered; 46%, copied; and 36%, imported.

3. Text expanders. Call them what you like — “smart text” or “auto text” or “templates” or “dot phrases” — but these tricks of the trade, once mastered, are simply irresistible to most of us, for better or worse. Dr. Grace Farris captures our ambivalent relationship with this strategy perfectly in the cartoon that led off this post.

It works like this — we enter a magic little short string of characters, press return, and voila! Everything from a complex (but commonly used) sentence to a full medical note appears on the screen. Take a bow and admire your work!

From a Reddit thread on this strategy:

.NICU: As a peds resident, I made this dot phrase. Took me about 2 full days of work to get it together, but I basically created it to pull all the info I needed to preround on a patient. All the numbers from all systems, weight change, ecmo/ventilator settings, even the number of desaturations they had overnight. Approximately 6-8 pages worth of data, arranged in order of systems that we would present on rounds.

Impressive! But do we clinicians really learn, or interpret, material that “autopopulates” a note? And how can these one-size-fits-all notes apply to the infinite diversity of patient care?

Full disclosure: After once receiving feedback that my notes didn’t have sufficient documentation about the time spent on counseling and patient education, how did I respond? By creating “.saxcounsel”, of course — which when typed, expanded into a thorough description of time spent on counseling and patient education! That will show them!

So is there any hope for the medical note?

I do think there is a way to improve them, at least a bit, that won’t require a complete overhaul of billing regulations — but that will be a topic for a different post. In the meantime, I very much welcome your suggestions in the comments!

December 16th, 2018

ID Doctors Are Lousy Golfers, and Time to Pick Your Favorite Cartoon Caption

Some might wonder how people who take care of patients, who deal with illness and suffering on a regular basis, can find humor in medicine.

Alternatively, one could take the opposite perspective — with so much misery around all the time, how could we survive without humor?

Clearly the folks at The BMJ are in the latter camp, as each year they bring us some high-quality chuckles with their annual Christmas issue.

Take this recently published paper on golf habits among doctors, a leisure activity apparently quite unpopular among us ID physicians (my explanation below):

Note that there was also a strong inverse correlation between the percentage of golfers in a given specialty and their average golf handicap (whatever that is). I’m pretty sure this means that we stink at it.

Now it’s time to add to the holiday fun by offering you the chance to vote on your favorite caption from our last contest.

As always, we used a rigorously tested algorithm to come up with the finalists. This fully automated process harnesses the full computing power of the NEJM Journal Watch servers, slowing other publishing activities to a crawl.

First the cartoon (thank you again, Anne Sax), then your vote, please.

Which is the funniest cartoon caption?

View Results

December 12th, 2018

Two Weeks of Attending on the ID Consult Service, with One-A-Day ID Learning Units

Ellis Island, Contagious Disease Hospital Isolation Ward I; Library of Congress

For those of us who don’t do inpatient medicine all the time, the “blocks” doing inpatient Infectious Diseases consults are a stark reminder of just how complex and challenging the case material can be.

Think about it — if a hospitalized patient has a straightforward ID problem, we are not getting involved. No one consults ID for cellulitis that rapidly improves, for community-acquired pneumonia responsive to antibiotics, or for the post-op infectious complication easily amenable to incision and drainage.

I’ve said it before — you know that randomized study of short-course antibiotic therapy for abdominal fluid collections? The one where the entry criteria included “adequate source control”?

We’re never consulted on those cases. Just these.

That’s why it was no surprise to read this recent paper, which showed that among 2.5 million patients in Canada, those seen by ID ranked second in complexity among all the sub-specialists. We trailed only nephrology — who, by taking care of all those people on dialysis, certainly have their hefty share of complex patients.

In order to provide some structure to this on-service experience, I try to find at least one item daily to for us to learn.

My “criteria” for inclusion:

  1. Has to be related to a case.
  2. Has to have a reference.
  3. Has to be interesting.
  4. Has to have no patient confidentiality issues.

Unlike previous rotations, this time I did it on the fly (so to speak) using Twitter. While some stay away from Twitter since it is (to certain individuals) an irresistible way to say something stupid, medical Twitter can also elicit fascinating responses and dialogue from an incredibly diverse group of clinicians. Thank you for that!

So here are the daily ID Learning Units from two weeks on service — a truly enjoyable time spent with an outstanding first-year fellow and a great second-year medical resident, someone I’m hoping will one day go into ID!

 

December 2nd, 2018

As A Strategy for HIV Prevention, Disabling the CCR5 Gene in Embryos Implanted in HIV-Negative Mothers Makes Zero Sense

The CRISPR Way to Identify Proteins Essential to HIV-1 Infection. From N Engl J Med 2017; 376:1290-1291.

One of the great joys of being an ID/HIV specialist is looking back at how far we’ve come in HIV prevention and treatment since the beginning of the epidemic.

Here are a bunch of things we know about HIV prevention, listed roughly in order of when we learned them — and forgive me if this is an oversimplification for this sophisticated readership:

  • Condoms work very well in preventing HIV transmission.
  • Taking a brief course of HIV therapy soon after exposure reduces the risk of HIV acquisition.
  • Babies born to HIV-positive mothers do not contract HIV if the moms take suppressive HIV therapy.
  • Male circumcision reduces the risk of these men acquiring HIV.
  • People do not contract HIV from their HIV-positive partners if the person with HIV takes suppressive HIV therapy.
  • People taking pre-exposure prophylaxis markedly reduce their risk for HIV acquisition.

You’ll note that nowhere on this list is anything about preventing HIV in babies born to women who don’t have the virus to begin with — because the babies are not at risk, even if the mother’s male sexual partner has HIV.

Just typing that sentence felt a little strange, it’s so obvious. However, it seems that He Jiankui may not understand this basic fact.

He’s the scientist who startled the world by releasing news that he and his research team had used CRISPR–Cas9 genome-editing to alter the embryos of two babies. The editing disabled the CCR5 gene, which means the babies lack a key co-receptor that HIV uses to infect cells.

However, as noted at 1:53 in the above-linked video, it’s the father who has HIV. Indeed, reports indicate that eight serodiscordant couples have participated in his studies — all with the fathers having HIV.

I’ll let others with far greater knowledge of genetics, embryology, and medical ethics comment on just how reckless this experiment was — here’s a good take (there have been many).

But from an HIV prevention perspective, it’s easy to judge — it makes zero sense to do this since the babies aren’t at risk of getting HIV to begin with. For them and their families, the genome-editing was all risk and no reward.

Let’s hope the mothers understood this before they agreed to participate in this disturbing experiment.

November 25th, 2018

Does Experiencing Childhood Illness Make Someone Stronger? How One Person Turned Adversity into Remarkable Success

Source: CDC (1990).

Many people growing up with chronic illness become resilient.

Whether it’s Crohn’s Disease, or cystic fibrosis, or diabetes, or the sequelae of an accident, or whatever condition they have, they impressively live their life just like the rest of us — occasionally regressing or slowing down only during a flare of the illness.

But then there’s an extreme version of this resilience — people born with or acquiring severe illness as a child, and somehow not just surviving, but thriving.

Their medical problems are just a small bump in the road as they go from one success to another, each achievement more remarkable given what they’ve had to go through to make this success happen.

The easy interpretation is that all the hardships they’ve endured make them stronger — but it must go beyond that, since most of us mere mortals would respond in no such way.

Dr. Eric Winer, who runs the breast cancer program at Dana-Farber Cancer Institute, is an example of this remarkable group. He kindly agreed to tell his story for a podcast on Open Forum Infectious Disease.

(It’s also available on iTunes, and Overcast; we’re working on Stitcher.)

He talks about growing up with hemophilia, and HIV, and hepatitis C, and how this influenced his career and family life. (Quick answer — both hardly at all, and more than most could possibly understand. That’s a theme here.)

The medical and personal details are fascinating, and not just to ID and hematology-oncology doctors.

Has he been extraordinarily lucky, or terribly unlucky?

The answer, again, is both — listen and find out.

November 18th, 2018

HIV and HCV Treatment, Shorter Antibiotic Courses, Malaria-Sniffing Dogs, and Other ID and HIV Reasons to Be Grateful, 2018 Edition

As noted here before, I’m a big fan of Thanksgiving, a great excuse to get together with family and friends, and to eat a gargantuan amount of food.*

(*On this last point, non-U.S. citizens will wonder how this differs from any other time we “Americans” get together. Indeed, we are the Land of Giant Portions. Ever eat at a Cheesecake Factory? Yeesh.)

But the primary purpose of Thanksgiving is expressing gratitude, a very healthy impulse that makes everyone happier. And since this is an ID blog, here are bunch of things ID and HIV specialists can be thankful for over the past year:

  • HIV treatment continues to improve. In the past year, we’ve seen approvals of bictegravir/FTC/TAF, darunavir/c/FTC/TAF, doravirine and doravirine/3TC/TDF, and ibalizumab. If that’s not enough, generic 3TC/TDF and EFV/3TC/TDF also gained FDA approval. Treatment now is so good with bictegravir and dolutegravir-based regimens that essentially 100% of patients taking these simple, well-tolerated regimens achieve viral suppression, and the IAS-USA Guidelines responded by making them the preferred treatments. Starting HIV treatment on the same day of diagnosis has moved from an interesting idea to a practical reality (especially with bictegravir/FTC/TAF and darunavir/c/FTC/TAF). Finally, the remarkably good results of the two-drug dolutegravir plus 3TC regimen in the GEMINI studies suggest that therapy can be even safer — and cheaper — than it is now.
  • When it comes to the duration of antibiotic therapy, less is almost always better than more. A barrage of studies have shown that almost regardless of the condition, a shorter course of antibiotic treatment is the right choice. Shorter is better than longer both in the hospital and in the outpatient office. The take-home message from these data should be that clinicians can use their clinical judgment to decide how long to treat someone, not relying on some arbitrarily chosen treatment course — and yes, I mean even a treatment course defined by an ID doctor.
  • It is becoming increasingly clear that oral antibiotics can substitute for intravenous in almost every situation. In the much-discussed POET study, stable patients with endocarditis who completed treatment with oral therapy did just as well as those who completed treatment with IVs. (And here’s a big thank you to Dr. Grace Farris for allowing us to use her wonderful journal club cartoon.) In another study, linezolid — price dropping rapidly — was a fine option for completing treatment in uncomplicated Staph aureus bacteremia. OVIVA study, where are you?

    POET Study, by Grace Farris, MD (click to enlarge).

  • Hepatitis C treatment has become staggeringly simple. I’m going to estimate that 99.156% (approximately) of treatment-naive patients could be successfully treated with either 1) sofosbuvir/velpatasvir, one pill daily for 12 weeks or, 2) glecaprevir/pibrentasvir, three pills daily for 8 weeks (sometimes 12). Go ahead and abbreviate SOF/VEL and GLE/PIB, if you find saying them a mouthful. Both are pan-genotypic, safe, well tolerated, and incredibly effective, and the price has dropped dramatically since the crazy days of 2014. In other words, these are the “must know” HCV treatments; the rest are optional. Here are a couple of slides I’ve made to describe a few of the medical issues in the choice between them — it’s a very short lecture — since most of the time, either one will do.
  • Undetectable = Untransmittable, even in the highest-risk patients. The first publication of the PARTNER study of “condomless sex” among HIV serodiscordant couples didn’t have enough MSM couples to make a confident statement about the risk in this population. No longer — in a follow-up presentation this summer in Amsterdam, 783 MSM couples contributed data including 1596 couple-years of follow-up, and 76,991 (impressive precision!) condomless sexual encounters — and there were still zero transmissions. Giving this U=U message to our patients never gets old.
  • Treatment of African trypanosomiasis will very soon be safer, easier, and more effective. Current treatment for this life-threatening parasitic infection — better known as “African sleeping sickness” — involves a complicated infusions with the drug eflornithine (administered in a hospital) along with nifurtimox. By contrast, fexinidazole (just approved) is given as one pill daily for 10 days and is both more effective and less toxic. Thanks to several European countries, the Bill and Melinda Gates Foundation, Doctors Without Borders, and other donors for funding the study that led to its approval, which was coordinated by the Drugs for Neglected Diseases Initiative.
  • Preventive therapy for latent TB is getting shorter. In a large randomized study, a 4-month rifampin regimen was just as effective as 9 months of INH, and was both less toxic and more likely to be completed. In people with HIV, 1 month of daily rifapentine/INH prevented TB as well as 9 months of daily INH. The latter study hasn’t yet been published — and included some “high risk” patients who lacked positive skin testing or IGRA studies — but one is hopeful that the favorable results would translate to people without HIV as well.
  • There continue to be ID-related studies that test the diagnostic skills of dogs. I guess they can’t reliably sniff out C. diff after all, but they did pretty well identifying malaria from the socks of children. (Yes, that’s what they were asked to do. Dogs will sniff anything.) I don’t actually think any of these dog diagnostic strategies will ever become standard-of-care (alas), but the videos and pictures released with each study sure are cute.

What are you grateful for this Thanksgiving?

November 12th, 2018

Sharing Radiology Images Across EMRs Is Frustratingly Terrible — and It Doesn’t Have to Be This Way

In the United States, any person who has tried getting their own (or their patient’s) radiology images from another hospital or practice will find this brief anecdote painful:

Here are several obvious reasons why the CD-ROM — briefly the darling of large-data transfer — is a truly terrible way to share radiology images in 2018:

  • They require physical transfer. Remember the term “snail mail”? Do people still say that?
  • They are slow. When you bring a CD-ROM down to your friendly radiologist to review the scans, also bring a good book — you will be waiting awhile for the images to load. Zzzzz …
  • There’s no universal software to read them. Watching even the most tech-savvy radiologist trying to extract images from these disks is proof enough that this is a horribly outdated technology.
  • The blank disks are disappearing. When was the last time you purchased a “spool” of these things? Back when Napster was a thing?
  • The drives are disappearing from computers. They’ve been gone from most laptops for years. Desktop computers, especially the mass-market, small-form ones used in hospitals, often lack them as well.
  • Hospitals spend significant time and money transferring images from CD-ROMs into their EMRs. It works like this: you walk the disk down to wherever the uploading machine is located. You fill out some forms. You hand the disk over. It goes into queue with other disks. Later — hard to predict exactly when, could be later that day, or tomorrow, or next week, but never during your patient’s office visit — you can view the images in your patient’s medical record. However, sometimes (and this has happened more times than I can count), the disk is unreadable, or doesn’t even have images at all — only the radiology report, and not the actual images. Gak.
  • No one knows whether CD-ROM disks should be spelled “disk” or “disc.” Discuss among yourselves — I’m going with “disk.”

Non-clinicians might wonder, what’s the big deal if you can get the radiology report? Isn’t that what “Care Everywhere©™” does?

Xray of active tuberculosis, 1939; National Library of Congress

Sure, having the report is better than nothing. But in complex cases, and when making difficult diagnostic or therapeutic decisions, it is always better to review the actual images — preferably with a radiologist specially trained in the involved anatomic region.*

(*ID doctors do a lot of this kind of thing. This probably explains why getting ID consults on complicated cases is associated with better outcomes. And it definitely contributes to why we’re typically bottom-feeders in an RVU, procedure-based world. How do you bill for time spent chasing down images and reviewing them with radiology?)

Of course it doesn’t have to be this CD-ROM way. If there ever were an irrefutable argument for the benefits of digitizing medical information, the switch from hard copy “films” to digital images would have to be right near the top. Think of how far we’ve come from the days of searching for x-ray films that, not surprisingly, would disappear in direct proportion to how interesting the case, or how sick the patient.

That’s why the current CD-ROM strategy is so frustrating. Never mind that a faster and more reliable technology (the USB flash drive) has been available for years. Though cheap and ubiquitous, and better than CD-ROMs, USB flash drives would also require physical transfer.

The solution, of course, is to put the images on the web — which is apparently what many non-U.S. hospitals have been doing for years:

So here’s what I recommend we do, starting now:

  1. Patients scheduled for imaging fill out a form while they are waiting asking if they want their images available for review by the clinicians caring for them.
  2. If the answer is Yes — and I imagine it would be for all but the most paranoid individuals — then after the scan is done, they are provided a secure link. It can be communicated by email, text, a post-procedure print out, or all of the above.
  3. In order to make the link work, they need to click on it and verify that it can be accessed by others.
  4. They then get to choose the variety of ways others can access it — secure password? Two-step verification?
  5. The patients can then share the link with whomever they like.

There, wasn’t that easy?

November 4th, 2018

Your Next ID Cartoon Caption Contest — Yearning for Your Submission

The nice people who write our hospital’s newsletter interviewed me recently about this blog, and we covered a whole lot of territory.

How it got started … inspirations … popular posts … fax machines … why an ID doctor from Mexico asked me about my dog Louie.

There was, however, a grave omission — nowhere in this otherwise comprehensive review of highlights did I mention our ID Cartoon Caption Contests.

Appalling, I know — especially since these are easily the most commented-upon posts in the 10-plus year history of this thing. If you add up posted comments here and on Twitter, we must have something like a gazillion so far.

A collaboration with my sister Anne, these contests are the product of a now- patented creative process, which goes something like this (all by email/texting):

Me:  Hey, Anne. How about we do another cartoon?
Anne:  Sure! Any ideas?
Me:  Let’s do one that shows a doctor examining a patient with a highly obvious abnormality — something so absurd you can’t miss it.
Anne:  How’s this?
Me:  Yikes. Too scary.
Anne:  How about this? Or this?
Me: I’m partial to dogs [OBVIOUSLY] — but dolphin man might be better.
Anne:  Really? How bout getting rid of the animals altogether? Take a look at this.
Me: Perfect! Umbrella head!
Anne: Wonder how your brilliant readers will come up with an ID-themed caption.
Me:  They’ll think of something.

Here, then, without further ado, is the latest cartoon, desperate for your clever caption. You’ll see it’s a common cartoon theme, but with a medical twist. And just in time for the cold weather.

As always, write your proposed caption in the comments section, or post it on my Twitter feed. Have fun, and be safe out there!

And given the obvious inspiration for this whole exercise, here’s a highly relevant video.

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.