Gallant is Answering Your HIV Questions and Zuger Writes About the Tough Practice of "Doing Nothing"

June 17th, 2013

Gallant is Answering Your HIV Questions and Zuger Writes About the Tough Practice of “Doing Nothing”

Two highly recommended products from a couple of my friends in the HIV/ID world:

First, the inimitable Joel Gallant — long time of Johns Hopkins, soon to be of Santa Fe — has resuscitated his terrific Patient Q & A Forum here. He used to answer patients’ questions regularly on www.hopkins-aids.edu, but that whole site appears to be gone — either truly gone, or Harvard Medical School controls our web searches, nixing anything having to do with a top rival.

(Nope — truly gone. Here’s a little archived material.)

The questions on the new forum are far-ranging in topic — though risk of transmission seems to be a recurring theme — and, not surprisingly with Joel’s writing the answers, the responses are always authoritative, and often very funny.

Fortunately, he’s populated his site with some of his favorites from the Hopkins days:

Is the actual risk of female-to-male transmission greater than the .0001 per contact that I am always hearing? If this is actually the case, it would seem that a policy of promiscuity would actually reduce risk, at least from a male perspective.

I’ve read your question several times now, and each time I read it my jaw drops lower. First, numbers like these are fairly meaningless because they don’t take into account the woman’s viral load, the nature of the sexual contact, the presence or absence of blood or genital ulcers, etc.

But unless I missed something in high school math, any number greater than zero means promiscuity is a bad idea. Engaging more frequently in an activity that has an identifiable risk, however low, cannot reduce the risk of infection. Granted, I took my last math class decades ago. Maybe there have been new developments in the field that I’m not aware of. If you are using an alternative form of mathematics that makes promiscuity not only safe but advisable, please enlighten us! I’m sure there would be great interest!

This one pretty much crystalizes what’s great about his Forum (and, come to think about it, Joel in general) — he can be academic and racy at the same time!

Meanwhile, over at the New York Times, there’s a superb piece by ID/HIV Specialist, Times staff writer, and Journal Watch editor Abbie Zuger.

It’s about how challenging it can be in clinical medicine sometimes to … do … nothing. Citing the example of one of her patents who has persistent and multiple complaints over a decade of care despite innumerable blood tests, scans, treatments, and referrals to specialists, Abbie realizes that what’s best for her is sometimes taking this passive but difficult approach:

That meant not treating her terrible sinus attacks, not investigating her continuing abdominal pain, not medicating her headaches and her crampy hands, not addressing her depression, her itch, her nausea … To really do nothing, all shamanic trappings must be abandoned: stethoscope, prescription pad, weighty pronouncements, the works. And yet — and this is key — doing nothing is also quite different from saying, “There’s nothing I can do for you; goodbye.” Most doctors are masters of this final nothing. But keeping a therapeutic relationship afloat without the usual tools, tricks or enticements — that is a rare achievement, and surely harder than the hardest microsurgery.

I kept nodding my head in recognition during the article; perhaps this is the best line of all: “In fact, one might hazard that doing nothing is the most subversive activity in all of modern medicine, undermining as it does the agendas of all doctors, all patients and all interested corporate parties.”

Maybe it’s no surprise that the reader comments on her piece drew wildly divergent opinions — some wondered how Abbie could bill for her services if she’s “doing nothing”; some accused her of saying that her patient was faking the symptoms (she never said that at all).

Fortunately a significant proportion of commenters realized just how accurate — and important — this practice for “doing nothing” sometimes is in modern medicine. Certainly it’s a whole lot safer than prescribing unnecessary medications or ordering low-yield, expensive, and potentially harmful tests.

Jerry Seinfeld would be proud.

HIV and ID Observations

An ongoing dialogue on HIV/AIDS, infectious diseases,
all matters medical, and some not so medical.

June 17th, 2013