Career Exploration: So You Want To Be A Hospital Epidemiologist? Flashback from 2009

Wow! 

So you want to be a Hospital Epidemiologist? Featured in Career Exploration in the Richmond Times Dispatch in 2009....recovered from the dustbin today during an office clean out.

I am not so sure if this really worked out is a recruitment tool....

Humans: A Brief History of How We F****! It All Up

Kudos to Tom Phillips for a masterful book, one that is is equal parts an academic history lesson with a perfect blend of wit and comedy.

I particularly enjoyed the chapters on science and the age of discovery. To quote the author:

“Confirmation bias is our annoying habit of zeroing in like a laser-guided missile on any scrap of evidence that supports what we already believe, and blithely ignoring the possibly much, much larger piles of evidence that suggest we might have been completely misguided.”

Spot on.

This book is well worth reading.

The Kardashian Index For Scientists

Figure 1 from Hall, N. (2014). Genome biology, 15(7), 424

It is true that a journal's Twitter following is strongly linked to its impact factor and citations,  suggesting that higher quality research receives more mainstream attention.  This perspective is neatly summarized here.

However, just in case you were unaware, the Kardashian (K) Index (referenced here), is a measure of discrepancy between social media profile and publication record for scientists.

Although high quality scientific publications, particularly if newsworthy, are associated with increased Twitter activity, not all scientists with large Twitter profiles produce high quality scientific work.

Much like scientific inquiry, Twitter should be approached critically.

Merry Christmas.

Justinianic Plague: Beware of Scholarship From Untested Hypotheses

Source: Ancient-Origins.net

Every now and then, in my literary meanderings, I come across a truly intriguing read.

This paper, published in the Proceedings of the National Academy of Science, beautifully researches the socioeconomic impact of the Justinianic (Bubonic) Plague (circa 541 to 750 CE), an epidemic which presumably precipitated the Dark Ages.

The scholars reviewed papyri, inscriptions, coins (currency), pollen, Yersinia pestis DNA  and burials concluding that no convincing evidence exists to support the assertion that the Justinianic Plague reduced the population of Europe by one third.

No doubt, the Justinianic plague, also known at the "First Pandemic, was significant, yet not nearly as much as the Second Pandemic and the Black Death.

To quote the authors- "More broadly,  the scholarly treatment of the JP demonstrates the dangers of uncritical multidisciplinary." Bravo.

Beware the dangers of scholarship from untested hypotheses.

I Am a Specialist But I Seek Range

Yes, I am an infectious diseases specialist, however, I seek range, especially after reading the book Range by David Epstein.  A spectacular read.

There is an inherent danger to specialization, particularly too early in the process of development- whether you are an athlete, musician or even a physician.

Specialization has a limiting effect. Analogical reasoning comes from a diversity of learning experiences. This results in greater creativity and problem solving skills.

Stay curious.

Physician Burnout and Healthcare Epidemiology: Dual Implications Worthy of Greater Scrutiny

Physician burnout is a hot topic of discussion.

We explore the topic of physician burnout in hospital epidemiology, a nuanced subject worthy of greater scrutiny. Our research brief was just published in Infection Control and Hospital Epidemiology, available here (PubMed Indexed here).

Hospital epidemiologists face different pressures than front-line physicians, these may drive burnout. On the flip side, our demands for infection prevention standardization, checklists, time-outs, audits and feedback may drive burnout in colleagues, by way of a perceived erosion of autonomy.

Further studies are needed. 

Single Occupancy Rooms Required for Contact Precautions and ESBL? Maybe Not

Once again, a paradigm is challenged.

This time, it is the use of single occupancy rooms for  contact precautions and the control of ESBL pathogens. The study was published in The Lancet Infectious Diseases and employed a 16 hospital cluster randomized strategy for contact precautions in single bed room versus contact precautions with multiple-bed rooms for patients with ESBL-producing Enterobacteriaceae cultured from routine clinical samples.Transmission risk assessment was judged by rectal carriage of ESBL-producing Enterobacteriaceae  in at least one wardmate.

Multiple-bed room contact precautions for ESBL-producing Enterobacteriaceae  was not inferior to contact isolation in a single occupancy room.

This provides valuable information for a more pragmatic approach to the use of contact precautions for the control of multidrug resistant organisms, particularly when a scarcity of single occupancy rooms exists. A very Satisfice approach to infection prevention.

Quality and Safety in Healthcare: What Defines a Struggling Organization? Time for Reflection

Source: PeaceLabs.org

It is typically more common for publications to identify what is required for select positive outcomes.  

I like this alternative approach, a publication which defines the characteristics of organizations that struggle with quality and safety.   The paper is PubMed indexed here.

Although the results may not be Earth shattering the findings are important.  The five domains consistently reported by struggling organizations include:

1.  Poor organizational culture
2.  Inadequate infrastructure
3.  Lack of a cohesive mission and vision
4.  System shocks- such as high level personnel turnover, particularly in leadership
5.  Dysfunctional external relations

Although no prescriptive plan is offered, these domains provide a comparative reference and a reflective focus point for organizations struggling to meet safety and quality goals.

All change starts with self (organizational) reflection.

2019 Delaware Communicable Diseases Summit

Thank you to the 2019 Delaware Communicable Diseases Summit organizers for a hugely successful event.  The meeting was held at the Christiana Care Health System.The turnout was spectacular, standing room only.

My colleagues, including Drs. Karyl Rattay, Gary Marshall, Karen Ravin, Deborah Kahal and Karen Lopez, expertly covered a lot of ground on vaccine hesitancy, emerging ID threats, infectious diseases and the opioid epidemic and One Health.

It was an honor to give the lecture on the prevention of healthcare associated infections and to participate in the panel discussion.

As always, I learn more than I contribute.

Sympathy for the Drummer: Why Charlie Watts Matters

I am off topic yet again, no medical writing today, rather music, or drumming to be more specific.

Sympathy for the Drummer: Why Charlie Watts Matters, by Mike Edison, is a book that resonates with those who are rhythmically inclined. Charlie Watts, the legendary Rolling Stones drummer, is a jazz virtuoso turned great rock drummer for The Greatest Rock Band in the World. Once I started reading this book I could scarcely put it down.

Charlie putts the 'roll' in rock and roll, with a minimalist drum set, amazing beats, fills and grooves that both push and pull the rhythm of a song. No need to be flashy, just consistently unique. The Stones need Charlie Watts more than Charlie Watts needs the Stones.

If you think it is easy, try playing along to a Rolling Stones song, beat by beat.

I am in Wilmington, Delaware for the 2019 Communicable Diseases Health Summit tomorrow (12/9/2019). Very much looking forward to it.

Stay tuned.

Re- visiting the panculture and other thoughts

I really enjoyed this clever article titled Re- Visiting the Panculture, available here. The authors, Valerie Vaughn and Vineet Choprak, highlight the waste associated with reflexive panculturing of febrile patients. The call for a more 'mindful' approach to the evaluation of fever  is spot on.

The above concept is applicable to this more recent publication titled Knowledge and practices of physicians and nurses related to urine cultures in catheterized patients: An assessment of adherence to IDSA Guidelines.

So, can we be more mindful when assessing a febrile patient?  

Yes, but education and feedback to  providers only goes so far in my experience. This must be coupled with electronic medical record decision support mechanisms which prompt physicians to practice more guideline concordant care. Sometimes, forcing functions are needed, such as an electronic medical record hard stop on Clostridium difficile test ordering for patients with diarrhea and on laxatives.

Erosion of  provider autonomy is not inconsequential, and should employed selectively at most,  such as when patient safety and resource stewardship is on the line.

Ethical Implications of Recruiting Universal Stool Donors for Fecal Transplants

Source: Yale Global Health Review

Although I have performed multiple fecal transplants for recurrent Clostridium difficile

infections, with donor stool coming from OpenBiome, I have not given much thought to the ethical implications of recruiting universal stool donors. My focus has been on the risk/benefit of the procedure to the patient.

Kudos to my colleague Dr. Susy Hota and her collaborators on this truly unique prospective on the ethical implications of recruiting universal stool donors, published in Lancet Infectious Diseases.

For example, informed consent for stool donors should take into consideration that the microbiome may convey sensitive personal information such as travel history, past exposures and sexual practices and may act as a pressure on various aspect of a donor's lifestyle. The intestinal microbiota is also a source of health information that may guide clinical decision-making in the future. Mechanisms to deal with these issues should be developed. Further consideration should be given on what is appropriate compensation for stool donors.

The role of universal stool donor is not as simple as it appears.

UVC Light Disinfection: Our Experience in BMT and Oncology

Let me be clear, UVC terminal  disinfection of hospital rooms is no panacea, especially when it comes to the prevention of Clostridium difficile infections.

Our biggest impact on reducing Clostridium difficile at VCU Health comes from minimizing over testing through electronic medical record decision support. This includes hard stops on  Clostridium difficile test orders for patients receiving laxatives.

Our experience with UVC light terminal room disinfection, particularly in bone marrow transplant and oncology populations was recently published, PubMed indexed here. Using an interrupted time series analysis, we observed a significant decrease in Clostridium difficile infection rates following the deployment of UVC light disinfection in these specific wards.

The next frontier in Clostridium difficile reduction is class restriction of antibiotics.  This is only feasible with expansion of antimicrobial stewardship programs to 7 days a week coverage.

Stay tuned.