Wednesday, December 7, 2016

Shakespearean Syphilis, The Libertine and the Ravages of a New World Disease on European Society

Here is an article that highlights the astute observations on syphilis in the many works of William Shakespeare. The article was published in Pharos, by the Alpha Omega Alpha society.

The Libertine, starring Johnny Depp, is about a 16th Century English nobleman (John Wilmot, The 2nd Earl of Rochester) who was notably afflicted by syphilis, among other ailments of debauchery.   

Both the works of Shakespeare and The Libertine document syphilitic manifestations in Europeans following the disease's introduction from the New World. These included gummas, alopecia, extremely painful osteitis, neuropathy and dementia.

Although we still see a lot of syphilis the cases are much less severe.  This is likely due to more rapid diagnosis and early, effective treatment.  Regardless, I have to suspect that reinfection (particularly in the brothels) and general poor health and nutrition likely played a significant role in disease progression. How could it not?      

History of medicine via literature and film! 


Friday, December 2, 2016

The Digital Doctor Is In!

I am not a luddite! I believe in medical technology but as with many things, there is a force and counterforce, a yin and yang of sorts.

There is no doubt that the electronic medical record (EMR)has led us to new heights, such as immediacy of access and retrievability of data, images etc.  

There is a dark side, however. We spend more time tapping on our PCs, minimizing contact with our patients, the so called iPatient phenomenon, as explored in this New England Journal of Medicine article by Dr. Anthony Verghese. Also, the EMR minimizes the need for doctor-doctor in person consultations. Who makes radiology rounds anymore? This may not be a good thing.

Much of this is summarized in the Digital Doctor, by Dr. David Wachter, a book which I found quite enlightening.

I am back on the VCU Wenzel Academic ID Consult Service this weekend, will attempt to focus on the patients...and not the EMR.

Monday, November 28, 2016

Good Read: Sapiens- A Brief History of Humanind

I spent the last week plowing through Sapiens, A Brief History of Humankind by Yuval Noah Harari

This 500 page book is anything but a tome, rather, it is a gripping account of our history through the lens of the cognitive, agricultural, scientific and industrial revolutions that defines much of human history. 

As we further change the world for our purpose (environment, genetic engineering etc) we are left with the scary and challenging question of what do we want (or want to become)?

Now back to more mundane matters, such as my job in the hospital and getting people to wash their hands.

Friday, November 25, 2016

Quantity and /or Quality? The Importance of Publishing Many Papers

I have heard the comment that the quality of papers published is more important than the quantity. Who really knows?

I found this paper in PLOS ONE which aimed to answer the above question with a formal correlation analysis of author publications,citations and impact factor. The greater the number of publications (productivity) the greater the number of citations and the greater the impact factor.  

Like in many aspects of life, success begets success.

Recognizing that 'major impact publications' or scientific breakthroughs are rare events, perhaps the best strategy is to press on at a steady and consistent pace. This should ultimately result in a decent and reasonable contribution to the literature, an academic slow burn of sorts.

Back to it....

Tuesday, November 22, 2016

System Failure, Accountability and High Reliability in Infection Prevention- Striking the Right Balance

I am going to limit this commentary exclusively to hospital infection prevention. We are searching for high reliability in infection prevention, this means that evidence based risk reduction practices are implemented in a systematic and consistent way.    

To succeed, we need to standardize, educate, implement (this includes providing the materials and infrastructure to support the intended behavior) assess performance and provide non-punitive feedback (particularly when errors occur).

These efforts, without a doubt, improve practice and minimize system failure, but they only go so far.  The last critical step is accountability. Poor performers and recalcitrant outliers must be held accountable by institutional leadership for non-adherence to evidence based, reasonable infection prevention expectations. 

Low reliability infection prevention cannot habitually default to the 'system failure' excuse.

To borrow a quote: The culture of any organization is shaped by the worst behavior that a leader is willing to tolerate.

Monday, November 21, 2016

Satisfice! Let It Be So in Infection Prevention.

Herbert Simon- Nobel Laureate
Lately I have been obsessed with implementation science, heightened safety, infection prevention and high reliability. Those close to me have heard me talk repeatedly about solutions that 'satisfice', a term coined by the late Nobel Laureate, Herbert Simon

Satisfice comes from the fusion of two words, satisfy and suffice. Satisficing is a decision making strategy that seeks solutions that are 'good enough'- satisfactory and sufficient for a more realistic world.

We continue to implement many evidence based strategies in infection prevention- hand hygiene, chlorhexidine patient bathing, automated urinary catheter discontinuation orders, central line checklists, and deployment of UVC touchless cleaning technologies. How certain are we that the measures are implemented?

We are unable to ideally observe, document, feedback and cross-check implementation of all strategies as it is physically and logistically not feasible.

Using designated staff and /or electronic data mining, we are able to generate reasonable, automated and scheduled point prevalence reports on nearly all process of care measures and technology deployments. Assessment drives performance and leads to improvement in practice. All of our patient centered infection control outcomes continue to improve.

Infection prevention science must play out in the real world. 

Real life challenges require solutions that satisfice.

Wednesday, November 16, 2016

VCU Antimicrobial Guide- Coming to a (VCU) Smartphone Near You

We developed an institution specific (using our own antibiogram) online guide for antimicrobial use at VCU Health. 

This point of care guide is available as a link within our electronic medical record. Since its  launch, it has been accessed > 10,000 times over the past year. The project was spearheaded by Dr. Michael Stevens and 3rd year epidemiology fellow Dr. Dan Markley.

We formally assessed the need for transitioning this online guide to a point of care smartphone app, for all VCU providers. The manuscript is now in press at American Journal of Infection Control, available here (PDF).

The VCU antimicrobial smartphone app will launch in 2017.

The goal is to enhance antimicrobial stewardship through point of care, portable guidance, driven by the stewardship program and by the hospital's own antibiogram.

This is no ivory tower academic exercise.