Why Don’t They Listen?- ID Consults and Recommendations

At times I am vexed after spending a fair amount of time on an infectious diseases consults only to have the recommendations either ignored or partially heeded by the primary team.

Here is an article (free full text) in Clinical Infectious Diseases on adherence to recommendations of infectious diseases consults.

The authors reviewed 465 consultations at 2 academic institutions. The overall adherence was 80%, with 85% adherence to crucial recommendations. Using multivariate analysis, adherence to ID recommendations was highest for therapeutic recommendations instead of diagnostic recommendations, when they related to a specific clinical question, and when recommendations were deemed crucial by the ID service. Not surprisingly,  adherence was greater if the primary service was medicine.

I have always felt that for a consult to be meaningful it must be focused, answer the clinical question(s) in a prioritized fashion, and, be succinct. In a busy hospital, no one has the time or inclination to read an overly verbose consult.

Brevity is key.

Final Day- 2012 Infectious Diseases Board Review Course

Today is the final day of the 2012 Infectious Diseases Board Review Course. 

Apart from (re)learning a lot, I had the pleasure of catching with with Drs. Johanna Brown and Kiren Mitruka, fellow infectious diseases trainees at Cornell University, 10 years ago!

The Blogger with Dr. Brown (L) and Dr. Mitruka (R)

It is hard to believe that 10 years have elapsed since our days of training together.

Pubic Lice- Infectious Diseases Factoid!

Source: Wikipedia

I am on day four of the 2012 Infectious Diseases Board review Course in Tyson's Corner, Virginia. This morning, the lectures covered sexually transmitted infections.

Today's interesting fact: one can get pubic lice in the eyebrows, particularly after oral sex.

Ah......knowledge.

Physician Specialty Re-Certification: Improvement in Patient Outcomes?

Zzzzzzzz.....sleeping at the ID Board Review Course

I am currently in Tyson's Corner, Virginia, at the 2012 Infectious Diseases Board Review course. I am due to re-certify in infectious diseases this October. The Board Review Course days are long with nearly 9 hours of lecture, a veritable test of attention span and mental fortitude.

The rational is that re-certification ensures an up-to-date physician. This is logical, but what is the evidence that re-certification results in better patient outcomes?

Here is a review exploring the association between specialty board certification and published in Academic Medicine. 

The bottom line: although it may be reasonable to require re-certification in specialty boards, there is no robust measure or association between (re)certification and improved patient outcomes.

Back to the books.

Noise Induced Hearing Loss at Rock Concerts

Scene of the crime: ringing in my ears after a Duran Duran concert
Portsmouth, Virginia, August 22, 2012

The other night I attended a rock concert. The next morning, while rounding on patients in the hospital, my ears were still ringing!

Here is an article in the Canadian Journal of Public Health on noise induced hearing loss in attendees of rock concerts. The survey respondents, concert goers at a Toronto rock and roll venue, reported tinnitus (ringing) and other hearing disturbances by 84.7% and 37.8%, respectively.

Okay, we had excellent seats and were only several rows from the stage, so it was worth it, but, I should have know better. I will carry ear plugs next time. 

Rock on!

Tropical Diseases Are Exclusively of Developing Countries: Think Again

Source: NY Times

Tropical diseases are associated with poverty and seen only in developing countries, or so the thinking goes. Here is contrary perspective written by Dr. Peter Hotez, the Dean of the National School of Tropical Medicine at Baylor College of Medicine.

Of note, tropical diseases disproportionately affect Americans living in poverty, and  thrive in the warm climate of the south. Contact with mosquitos and other insects, poor sanitation and lack of access to healthcare all heavily burden the poor.  

This is not exclusively a Third World phenomenon.

Communication of Risk to Patients: Context Matters

The internet can be tremendous resource and can minimize information asymmetry, particularly between doctor and patient. Unfortunately, there is a lot of medical misinformation out on the web as much of it is not subject to medical peer review and written by advocacy groups.  A challenge facing physicians is how to effectively communicate information and opinion about risk so that informed decision making between doctor and patient genuinely occurs.

Here is an article, on explaining risks to patients, that was brought to my attention by my colleague Dr. Michael Stevens. Two important points I would like to mention:

First, the authors suggest that using information about relative risk without reference to absolute risk should be avoided. Here is an example:

• Treatment X can reduce the risk of Outcome Y by 50% (this is a relative risk reduction) when compared to no treatment. However the absolute risk (risk without treatment) of Outcome Y is 1 in 1,000,000.  Thus, the relative risk reduction with Treatment X is from 1 to 0.5 per 1,000,000.  The overall impact of the Treatment X is very small given the already very low risk of the Outcome Y. Framing the discussion exclusively in terms of relative risk reduction (50% in this example) is misleading.

Second, the authors suggest that visual representations of risk may be effective for informing patients. As an infectious diseases physician, I am vexed when patients refuse vaccination on the grounds that thimerosol (a mercury containing preservative) will cause them toxicity and harm. These fears abound despite no convincing evidence of harm caused by low doses of thimerosol in vaccines. So here is a visual aid for those who fear thimerosol, many of whom, however, eat fish because of presumed health benefits.

A picture is worth a thousand words.