Hospitals Are Ground Zero

The MERS coronavirus has now spread from the Middle East to home town USA.

Since both US victims of this resurgent respiratory virus - one in Indiana and another in Florida - are healthcare workers, all eyes have turned to nosocomial transmission. In some locales nosocomial transmission has outpaced the former frontrunner for the MERS transmission prize: camel spit.

Proper infection control, therefore, is hugely important. The CDC recommends special airborne infection rooms, masks, eye protection, gowns and gloves. I remember taking these precautions when the SARS epidemic came through town. In some cases, patients were incredibly sick and it was scary; other times folks with SARS had the sniffles and we made a big deal over very little. Let's hope that as we learn more about MERS, the early reports of 30% case fatality will turn into less sobering statistics. 

Along the way, it's good that the macho culture of medicine has been changing. When I was in training, it was common and even admirable for doctors to work sick. I remember idolizing a medicine resident who did morning rounds with an IV pole at his side. Yet now we know - how could we not have clued in then?!  - that this risks spread of infectious diseases to our fragile patients.

In a nice story just out today titled "Second MERS Case Shows Hospitals Are Ground Zero for MERS," Maggie Fox of CBS News quoted me and others about MERS infection control. 

A Positive Partnership

In a new blog post at the HIV-related web site The Body, I recall the last few years with an HIV-positive patient, Steve. Steve and I started out with the treatment of sexually transmitted diseases and delicate discussions of safer sex. Now, Steve is on effective HIV treatment and we talked most recently about his honeymoon plans. It has been really fun to watch Steve grow, and change, and thrive.

A Watchful Eye in Hospitals

DESPITE the intensely personal moments that happen in hospitals, patient privacy can be elusive. Hospitals are multimillion-dollar corporations that look like shopping malls and function like factories. Doctors knock on exam room doors to signal they are about to enter — not to ask permission. The curtain that encircles the hospital bed always lets in a crack of light.

Yet we do expect some degree of privacy in hospitals. We trust doctors with our secrets in part because they take a 2,000-year-old Hippocratic oath to respect our privacy, an oath enforced by laws like the Health Insurance Portability and Accountability Act. But sometimes, doctors have to weigh patients’ privacy against their health and safety, and that’s when things get complicated.

My hospital, where I am chairman of the bioethics committee, recently wrestled with the question of where patient and family privacy ends. Nurses in the neonatal intensive care unit (N.I.C.U.) worried that a premature infant, whom I’ll call Rickie to protect his identity, was being harmed by his parents.

Read my full op ed at The New York Times. 

Changing the Water in Which We Swim

As the lights in the auditorium go down, just before I flick on my microphone, I remember what media critic Marshall McLuhan once said about culture: We live “in an electric information environment that is quite as imperceptible to us as water is to fish.”

As a leader of my institution’s curriculum redesign effort, I often speak with departments and even the whole faculty about our plans for the new curriculum. These experiences have made me acutely aware of how well McLuhan’s quote applies to what has been called the “hidden curriculum” in medical education. Medical education, and the culture of medicine in which it occurs, influence personal identity and perception so pervasively that it can be a challenge to talk clearly about how to change the hidden curriculum.

Read the rest of my blog at Health Affairs. It is a response to a very nice article by Liao et al in the January issue of that same journal.

This just in: how HIV kills

New findings by researchers at the Gladstone Institute of Virology at the University of California at San Francisco (UCSF) have upended how we understand the pathogenesis of the acquired immunodeficiency syndrome (AIDS). 

Enter Warner Greene, a dapper white-haired professor of medicine at UCSF and its Gladstone Institute of Virology. In a feat of scientific hutzpah sure to trigger fits of envy among other scientific heavy-hitters, Greene shattered the existing model of AIDS pathogenesis in two simultaneous groundbreaking articles in the prestigious journals Science and Nature in late December 2013.

Greene’s team made multiple seminal observations. Their key findings were ...

Read my new post at Scientific American guest blogs to learn more

Protect Thy Neighbor

We are now deep into flu season. Forty states are reporting widespread influenza, and the number of deaths is greater thane expected.

Hospitalized patients are among the most vulnerable people in flu season. Immune systems already weakened by kidney failure or another major illness, hospitalized patients contract influenza from loved ones and - most ironically - from hospital workers. From doctors to nurses and beyond, a coughing caregivers can be the worst kind of medicine for vulnerable hospitalized patients.

Should hospital employees be obligated to get a flu shot to protect vulnerable hospitalized patients? Some hospitals - including mine - require employees to get flu shots or else suffer consequences such as mandatory masks, furlough and firing. Is this an unjustified infringement on personal liberty, or a thoughtful way to protect the health of our most vulnerable? 

Ethicist Bill Nelson and I explore this controversial issue in a recent issue of Healthcare Executive.

Toward fewer demons

My New Year's resolution 2014: fewer demons.

There were a lot of demons in 2013. Some like Typhoon Haiyan were faceless, and not of our making. Most demons, though, were human, and their demonism was a false and human creation. 

2013 saw many people treated like demons: Ted Cruz, Barack Obama, Justine Sacco, Miley Cyrus, gays, the GOP, Paula Deen, Pope Francis. The list goes on*. I revere some of these demonized people, and others I don't. But inarguably these people and many others like them have fallen prey to our abbreviated, stereotyped, uncharitable understanding of the Other. The Other is, like us, flawed. Capable of great sin, even. But when we sit in judgment of them, dispassionately, unforgivingly, we commit a second sin of our own. 

My trip to the United States Holocaust Memorial Museum was a powerful reminder of how this kind of polarization and demonization can lead to evil. One large portion of the determination it took to build that institution came from one of my favorite Georgetown professors, Michael Berenbaum. Berenbaum was an inspirational teacher at Georgetown, and in between classes he flew frequently to Europe to collect artifacts for the Holocaust Memorial Museum. A student once asked Berenbaum how he accomplished so much. Berenbaum paused at the front of the class, silent for a moment with his tie torn in honor of his recently deceased father. He had bags under his eyes from a recent transatlantic flight. "You know how you doubt yourself?" he asked, "You spend time asking, 'Can I do this?' or saying to yourself, 'I'm not smart enough?'" He said he used the time most spend on self-doubt to accomplish a little more of his life mission. In his case that mission was to help avert future evil through the remembrance of the Shoah, but whatever your mission, that there is sound advice.

So: in 2014, I will debate the issues, perhaps even loudly, but I will try my best to be civil and respectful and not to make a demon out of anyone. This is especially important precept to follow amid strong disagreement. Along the way, as much as I can, I will keep my focus on achieving my mission and not on how great or poorly I am looking along the way. 

In a related vein, critic Frank Bruni had a timely message recently: Tweet less, read more. Bruni argues that in the Age of Twitter we are too apt to make snap judgments without letting the full complexity of the situation "steep" in the way it may when we take time to ponder. As we do when reading fiction. Amen, I say, amen! Hallelujah! 

Prohibitions like these - don't hate, don't fear - are good, but they don't fill me up. As a result, I will keep this photograph in mind as well. 

Taken from the Year in Pictures at The New York Times, this is an Afghan schoolgirl, reading. Considering how hard-won the freedom to read a few words of text can be in towns like hers, this powerful reminder of the preciousness of learning and education will be one guide for me through the challenges of 2014.

Gratitude, too, will guide me. I am grateful for the connections I made in 2014: my wonderful patients, an inspiring troupe of medical educators, our vibrant hospital ethics committee, and a motley cast of Twitter characters. I cannot imagine better company in 2014.

Happy New Year!

* PS Shortly after I posted this article, I was pained to see a crowd of science writers whom I respect sit in rather snarky judgment of another excellent writer (and my former editor), Bora Zivkovic.

Way back in 2013, Zivkovic had apologized (imperfectly) when accused of sexual harassment by more than one female science writer. As New Year's Day unfolded, Zivkovic's story looked like a hunk of red meat amid a pack of wolves. Much as it had in fall 2013.

There were many reasonable-sounding justifications for the public flogging: sexual harassment must be stomped out, Zivkovic appeared to want to make a fresh start without making enough apologies to satisfy everyone, this was a pattern that exemplifies the male power structure in science, etc etc.

What reasonable person would argue these points? What emerging science writer would dare raise his or her voice amid all that certainty, and blood? Such a person risks being lumped with perpetrators, surely.

Yet silence is not always golden. What was lost amid the din was the idea that there are more effective and more humane ways of rectifying such wrongs than a Twitter hanging. Some writers wrote they were done hearing from not only Zivkovic but a friend who supported him. "They're dead to me," that writer and her supporters seemed to say. Others, most of them not at least publicly victims of the behavior of which Zivkovic is accused, critiqued whether his apology felt ... apologetic enough.

For all involved, I hope this private problem can have a private fix. I just don't see how this public excoriation helps anybody. Certainly decrying sexual harassment in public can do good: it may well discourage other perpetrators and help define what is and what is not harassment. This is the core story to which the public dialog should hew. But this public mastication and remastication of one man's sin went beyond PSA - it looked to me like bloodlust and distracted from the main story.

Instead, private apologies and a private plan for prevention seem the way to salvage some good from this story. Most importantly, any victims (identified in public or not) should have the opportunity to hear an apology and some assurances that harassment will not recur. I get the sense from Zivkovic's writing that he is willing to make such amends and hope this indeed occurs at least to some degree of satisfaction of those he harmed.

What should the rest of us do with our typing fingers while such things occur in private? Get a PSA out there, for sure. Learn. Listen. Consider if we could commit that same sin and how we might avoid it. Most of this can occur with mouths shut and fingers still. (See Bruni, above.) And then: we move forward. 

When identifying a sin such as Zivkovic's, it is too easy to think of him as equivalent to and nothing more than the sin itself. Without considering the full scope of his humanity and his personhood, we essentially commit a second sin. It's an easy sin - we make a joke, we pass judgment, we block a Twitter account. No one of these acts is a major problem. But I worry about a society build on such a foundation.

Some would say such protestations enable the original sin itself. That whatever is done in the defense of those wronged women is fair game. This is the game of empowered white men, goes the screed. They should be quiet and take their licks. It is the turn of the downtrodden to rise up and take the stage.

I disagree. Unless we are simply trading bad power for bad power, we who think of ourselves as good should be able to think with nuance, and to hold two ideas in our heads at once. A sinner can be wronged. A victim can do wrong. (Not to imply this has occurred; I'm saying we should be able to think in more than black and white.) It'd be great if the world were divided into good and evil but the truth is most of us fall somewhere in between. Sinners and pundits look quite a lot alike, it turns out. Perhaps it is the similarity that motivates the pundits to make a starker distinction than really exists? Or perhaps we forget our own troubles for a while when we decry someone else's?

I can only hope the virtual community erected on Twitter and on blogs can learn from the mistakes made in the corporeal society that preceded it. Yes, there are invidious power structures here and we should fight them. We too need justice. But, a system of justice build on vengeance and demonization will ultimately be the downfall of all our lofty ideals. We aren't being soft on crime - we are trying not to compound the original crime with a new one.

The way forward? The original victims should expect reparation. Absolutely. But those looking on from their typewriters, from their comfortable seats at the edge of the town square, should behave as gently and as humanely in their responses to this sinner - this man - as they would hope to be treated when they too walk out into the middle of the square with their sin in full view. We all have our day. What kind of people are we? Are we vengeful, or are we just? 

The ethics of research in low and middle income countries

Many developed world academic institutions are forming international partnerships to improve clinical care, education and research in developing countries. This is a great development, and one I hope will last even when it is no longer trendy. But, particularly the conduct of research in developing world countries brings with it ethical complexities: it's cross-cultural, there are power gradients, and sometimes researchers are motivated more by pecuniary gain than true altruism. To help manage these risks, so our outreach can be most effective and least undermined by such factors, I wrote a review of the history and approach to the ethics of research in low and middle income countries. 

HIV doesn't happen here

The rural state of New Hampshire has some of the lowest HIV incidence and prevalence rates in the United States. That's great news, but it comes with a price. 

Many at risk people in New Hampshire think HIV is a third world or city problem and not something they need to worry about personally. That means they are less likely to take precautions against HIV. 

At the same time, people who have been diagnosed with HIV in New Hampshire face stigma from neighbors and friends who may be less familiar with HIV than people living in urban areas where the disease is more prevalent. Geography adds to those challenges: the ~650 people cared for at Dartmouth-Hitchcock HIV Program come from a much wider geographic area than patients in similarly sized clinics in metropolitan areas. That translates to longer travel times and more complicated access to care.

Not surprisingly, HIV patients living in rural areas have been shown by Sam Bozzette and others to receive substandard care, probably because HIV experts are not sufficiently accessible.

In formal analyses at the Dartmouth-Hitchcock HIV Program, our HIV expert providers  delivered outstanding care equivalently to rural and urban patients  But despite this my colleagues and I showed that our rural patients have higher rates of depression and even higher mortality. New Hampshire might be a lovely place to live, but living with HIV infection anywhere is no walk in the park. 

Todd Bookman of NHPR touches on these and other issues in nice  radio story in which I was quoted. There are still plenty of battles remaining in the war against HIV in New Hampshire.

Glad to Add a Modest Contribution to "The Fist Bump Manifesto"

How should we protect patients from infections in our hospitals? Although hand washing is the most important intervention, James Hamblin of The Atlantic wrote a great article about the use of the fist bump to prevent infections. I was honored to be interviewed and to contribute some thoughts about hygiene and hipness.

Check out the article at The Atlantic.