HIV and ID Observations

Let’s rewind the clock a bit — OK, a lot. Ancient history.

It’s winter, 1986. An interview day for medical residency at Brigham and Women’s Hospital. A bunch of us nervous medical students sit in a conference room, wearing our interview suits, while Dr. Marshall Wolf tells us what to expect that day.

Amazingly, Marshall knows all our names already — which he proves by saying them out loud while handing us each folders.

The folders have our schedule for the day, including our interviews with faculty. One of my interviews is with Dr. Burton “Bud” Rose.

No exaggeration — he was already legendary among medical students. We all had his book, “Clinical Physiology of Acid-Base and Electrolyte Disorders,” which described this complex topic with astonishing clarity.

One of my medical school classmates, a brilliant guy but sometimes a bit of a bull in a china shop, described  using this book during his medicine rotation:

His book gave me a rich and logical foundation in the field, along with a silly level of cockiness. The chief resident during my medicine clerkship asked why people with DKA develop hyperkalemia. I responded, confidently, “insulin deficiency and hyperosmolar solvent drag.” She said, “No it is cation exchange.” I replied, “You are wrong.” It went back and forth for awhile, and then I brought her the book next day. I was right, but it did not help my evaluation.

Not surprisingly, I’m awestruck to have an interview with Bud Rose. Even more nervous than before, if that’s possible.

But meeting Bud was great — he couldn’t have been more welcoming. And it was memorable, too — memorable for the precise sentences that made up his conversation (no surprise), and for one particular exchange indelibly imprinted in my memory:

Bud:  What area of medicine interests you the most?

Me:  Infectious diseases.

Bud:  That’s my least favorite. Too much memorization. I prefer areas of medicine where you arrive at diagnoses by understanding basic physiology. (Smiling.) Like nephrology, for example.

Me:  Can I change my answer?

Bud (laughing, fortunately):  Too late. So convince me — why should someone like ID?

Me:  Maybe because I was an English major in college — I like stories. And ID cases often have great stories — like the patient I saw who developed a knee infection from Pasturella multocida because his German shepherd licked between his toes every night. People often think of cats with pasturella, but dogs have it too.

Bud:  That is a good story — it’s disgusting, but it’s a good story. But you had to memorize that dogs have pasturella, didn’t you? See, I’m right about ID. Too much memorization.

The conversation then went to his college major, which was History — he liked stories too — and how he ended up in medical school, why he loved teaching, how Boston differs from New York, why I should start playing tennis, and how Brigham medical residents supported each other.

It was a wonderful, far-ranging, and bidirectional conversation. Not intimidating at all.

Not once did he ask me about my less-than-stellar preclinical medical school transcript — relief — and to this day I’m grateful to have matched at the Brigham, no doubt due in some small part to my interview with the legendary Bud Rose.

During residency, he regularly stopped by our intensive care unit to review cases of renal failure and electrolyte abnormalities with us. He’d ask only for the numbers — the electrolytes, renal function, and glucose on a given patient — along with a list of the patient’s medications, and the primary reason for admission to the ICU. That’s it.

From these bare-bones presentations, he’d narrow down the possibilities for each of these cases to the two or three most likely diagnoses — sometimes the only diagnosis. It was a clinical reasoning tour-de-force, the likes of which to this day amazes me.

Let’s now fast forward from 1986 to, roughly, 1993. Yes, still ancient history — still long before the days of high-speed internet.

I’d been gone for a few years doing my ID fellowship, but now I’m back at the Brigham for an ID faculty position. Soon after returning, I get a call from Bud Rose — he wants me to come meet with him to discuss a project he’s working on.

He’s still in the same tucked-away office we had our interview in in 1986, but there’s something new in the room — a small computer on its own little table, barely bigger than the computer itself. I believe it was a Macintosh SE, with a tiny screen and two floppy disk drives.

Here’s our dialogue this time:

Bud:  Imagine you’re seeing a patient, and she has hyponatremia. What are the first questions that come to mind?

Me:  Hey, I’m an ID doctor — not a nephrologist, remember?

Bud (smiling):  I haven’t forgotten that! But this works for anyone who does patient care. What comes to mind?

Me:  Hyponatremia — what’s causing it? How serious is it? How do I treat it?

Bud:  Exactly! Now if you were planning to manage this patient, you’d want the answers to your questions — normally you’d go to a medical textbook, and find the index, then the chapter on hyponatremia, and then scan for causes and prognosis and management. But what if you could leap right to the answers? And those answers could be updated rapidly with the latest research? Let me show you something.

He heads over to the computer, and launches a program called Hypercard — and writes in the search box, “causes of hyponatremia.” Instantly a paragraph appears on the topic. On the computer screen, I recognize Bud’s clear and well-organized writing, adapted from his textbook.

Bud (continuing):  Now look at this — here’s some highlighted text.  He moves his mouse over the word “hyperkalemia.” If you click on this word, it takes you to the card on that topic. I call them cards because they represent cards on a particular question, or problem, from my card file.

He points to a meticulously organized card file on which he’s summarized a staggering array of nephrology papers.

Me: Wow, that’s amazing!

Bud:  Now I’ve just done this for nephrology. I would like to expand to all of medicine. Are you interested?

Me:  Even ID? I thought you hated ID.

Bud:  Not if you include the stories.

Of course I’m interested — how cool is that little machine! What he’s showing me in this meeting, of course, is a very early version of UpToDate — the preeminent “point of care” medical reference that has over time all but obliterated traditional medical textbooks.

Bud’s key insight is that what we clinicians want, first and foremost, is authoritative advice on how to manage our patients — and that advice stems from common clinical questions. The background information on pathophysiology, the basic research, the details of clinical trials, the epidemiology should only serve as foundations to this primary goal, answering these questions.

And it must be updated in real-time — no delays for publication of new editions. It isn’t called “UpToDate” for nothing. It anticipated the fast pace of biomedical research long before any other medical resource.

That the original program was distributed on floppy discs makes its success all the more remarkable. He couldn’t have anticipated the ubiquity of high-speed internet, or smart phones, or electronic medical records, but each of these has further solidified UpToDate’s leadership in this medical education space.

Google for medicine, but smarter and based on evidence. What a great analogy.

Bud told me many years ago his two favorite things in the world were taking walks with his wife and kids on a beautiful day, and playing tennis. After that, it was hearing from a clinician that UpToDate had helped improve patient care.

I don’t know how many family walks he took and tennis games he played — but no doubt thousands and thousands have benefited from that project he started on his small computer.

Bud Rose died April 24 2020 of Alzheimer’s disease and COVID-19.