RIP, Combined IM/EM Residency that Molded My Career

In my last emergency department (ED) shift, at my hometown community hospital in which I do a couple of casual ED shifts a month, a cardiologist said to me “I have a question for you: why do you work in the ER.” It was probably a puzzling question to him given that he knows I am primarily an infectious disease and critical care physician and don't "need" to work in the ED. My reply, “it can be so much fun.” The reply was true but there is much more to the story than just fun.

When someone decides they want to be a physician my experience is that they have some pull towards one of the specialties and/or subspecialties of medicine. So it was for me. Though in my case I was pulled in myriad directions that in my mind, and now easily seen in retrospect based on my career path, were obviously integrated. I knew immediately that I wanted to be an infectious disease physician dealing with the puzzles, the problem solving, the societal import, and the national security implications of these endlessly fascinating infections. But, I loved the action of the ED in which medicine was hyperacute, results were often immediate, and you never knew what you might see next – including the next pandemic, a novel emerging infectious disease, or the first hints of a bioterrorist attack. So it was natural that I would pursue a double residency in Internal Medicine (internal medicine is the gateway specialty to infectious disease) and Emergency Medicine (IM/EM).

But did such a career pathway even exist? I can vividly remember looking on the internet (dial-up) for such programs in the mid-1990s as a pre-medical student and seeing about 9 pop up. As I perused the list, I became ecstatic when I saw that one was in Pittsburgh at Allegheny General Hospital (AGH). I noted that it took two residents per year and that it interviewed quite a number more than that. At that moment, I mentally committed and fixated on that residency as the goal I would achieve.

As I went through medical school and progressed through my rotations, my commitment to dual IM/EM training at AGH only grew as my classmates constantly changes which specialties they were interested in. Once on a whim, I got in touch with a chief resident of the program years before I was even able to apply just to ask him about the program. Though I have never met him in person what he said to the precocious nagging medical student that I was at that time still echoes in my brain: “With this residency, you will be ready for anything.” That is exactly the type of doctor I wanted to be and though I may not have lived up to that aspiration, it is the ideal that I strove--and still strive--for. What this resident, who is now at a major medical center, was keying in on was the fact, as was put in an 1987 letter advocating dual training, that IM/EM dual-trained physicians are able to experience a “depth in pathophysiology," acquire "an unusual breadth of medical knowledge," and develop "a firm understanding of the natural history of disease.”

I eventually matched at AGH -- which I naturally ranked #1 -- and was graciously welcomed into the ranks of the residency that I had imagined myself entering for so long. I progressed through my 5 years of residency and through that time made lifetime friends and really learned to be a physician. My last year of residency I served, as all combined IM/EM residents do, as chief resident and had the ability to steer the program, interview prospective applicants, and ruffle feathers when I believed IM/EM residents were being undervalued.

Yesterday I heard that AGH has decided to close the combined residency and not take new residents. This news induced some sadness in me because that residency program is a core element of who I am as a physician. It was something you expected always to be there -- almost like one's elementary school. It is how I became a physician and spent a lot of my young adulthood. My co-residents (and those that came before and after me), who I believe to be an elite group of physicians, took a special interest in making sure each of us excelled because we were a unique group of hybrids almost on a special mission. As such, IM/EM residents were a special breed at AGH and, because we were there for five years, grew to know almost everyone in the hospital from the CEO – who utilized us for committees – to the mysterious night shift cafeteria worker whose eyes one would never meet (our own Boo Radley). When several IM/EM residents were rotating in the ICU together they were colloquially known as “a dream team” because of the heightened skills and knowledge that they were thought to possess. One resident was known as “Dead On Davis” because of her unrivalled ability to see a cryptic diagnosis before anyone else.

I cannot do the program the justice it deserves in this blog post but I am grateful for the opportunity it afforded me (and continues to afford me).  I am reluctant to speculate on why the program suffered this fate but, if I were to venture a guess, I think that it was a combination of diminished interest among medical students coupled to lack of full commitment to and leadership for the program – something we often noted as we were constantly being balkanized between two departments without having a home of our own in the hospital -- in the financially beleaguered status of the sponsoring health system.

A future project of mine is to collate the names of all the graduates (and the current residents finishing the program) so that this program and the impact of these physicians – many who have excelled to a level unheard of from our counterparts from the categorical internal and emergency medicine programs (a fact borne out in two studies) -- who saw and pursued a synergy that others were unable to see will not be forgotten. I only hope the still existing IM/EM (and IM/EM/CCM) programs do not suffer the same fate.

The Consequences of a DMV Approach to Infectious Disease

One of the recurrent themes I reiterate when it comes to whatever infectious disease emergency the world is faced with is that much of the expertise of responding to these ever evolving threats resides in public health agencies. These agencies range in depth and expertise from the CDC at one end of the spectrum to a local health department at the other. While infectious disease management is really the raison d'etre of public health and are their core and original function, recent decades have seen public health agency's exhibit mission creep. Now public health agencies often balance the demands for developing a plan for tackling obesity with one for preventing the spread of tuberculosis. Such, in my view, distractions from their fundamental role deprioritize infectious disease in a risky manner. Last night, I gained another piece of data I added to support my position.

As someone who also trained in emergency medicine -- in addition to infectious disease and critical care medicine -- I try to keep my hand in the field with a few casual shift in my hometown hospital's emergency department. Being an infectious disease physician, however, I am always on the lookout for interesting infectious disease cases that I can pluck from amongst the myriad complaints that bring people to the ED.

Yesterday, I had that opportunity when I saw a patient recently returned from a Zika-laden area of the world who had symptoms entirely consistent with Zika. The case was uncomplicated and likely will be self-limited, as most Zika cases are. But, ever conscious of the epidemiological importance of diagnosing certain infectious diseases, I believed the patient merited confirmatory testing. Such testing is largely the province of the state department of health (though commercial tests are available) and, because of that, requires consultation to arrange for testing to occur.

Because it was after hours (infectious diseases are regularly not just 9-5 pathogens) , I was predictably frustrated with the state department's health response as it took some time to reach a person who could "authorize" the test, which was being performed almost exclusively for public health purposes as my treatment of the patient would not be impacted by the result of the test. Needless to say, an after hours inquiry in which one must navigate and bounce between telephone numbers with recorded messages and an answering service unable to effectively understand or triage the needs of a caller are the opposite of the nimble response needed to adeptly manage infectious disease emergencies. It is what one expects of the DMV.

To its credit, I did receive the information needed from professional and knowledgeable health department personnel but I would say that the trouble I incurred trying to obtain this information is likely something many physicians would not endure-- a dangerous situation that limits the ability to have full situational awareness of infectious diseases circulating. I am an unequivocal supporter of reporting infectious diseases with requisite import and can only imagine how many healthcare providers understandly do not wish to wade through the bureaucratic processes needed to ensure that appropriate testing and notification occurs. So, suffice it to say, the Zika case reports in the US are likely an underestimate. 

I'd like to think that this phenomenon would not occur so readily if the original focus of the department remained intact and their resources were not scattered so far afield from their original infectious disease mission.

Truth is Stranger than Fiction: Designated Survivor, Bioterrorism, and Elections

The bioterrorism scenario on last night's episode of ABC's Designated Survivor involved an attack with ricin specifically aimed at poll workers in an effort to derail Congressional election. While people who are not steeped in the history of bioterrorism may think this was just a far-fetched Hollywood fairytale, it was not. 

Over 20 years ago a similar plot was enacted successfully not in some banana republic but in the United States. The setting was a 1984 election in Oregon in which one of the issues was how a locality would handle a religious cult's (Rajneeshee) land holdings. In order to diminish voter turnout, salmonella was spread on restaurant salad bars sickening hundreds. 

It was not obvious that this represented a biological attack as poor food handling practices were how the event was initially described. Remeber that salmonella outbreaks are ubiquitous. Only after cultists eventually confessed was the actual etiology of the event uncovered -- underscoring how hard it can be to tell the difference between a natural and an intentional outbreak.

It would make a good movie.

 

The US: A 5.4%er in Infectious Disease Mortality

As nations civilize and become rife with sanitation, vaccines, health care providers that causes of death of the population will change. In this transition, infectious diseases became less substantial components of overall mortality as heart disease, cancer, strokes, and other conditions -- typically associated with longer life spans -- begin to became the major causes of death. Such has been the case in the US for quite some time. Indeed, the decline of infectious diseases after the advent of penicillin is what first gave rise to the need for a distinct group of physicians to develop specialized knowledge of what had become relatively rare illnesses.

A new paper. published in JAMA, attempts to quantify what proportion of deaths in the US can be attributed to an infectious cause. The verdict is that between 1980 and 2014 infectious diseases comprised 5.4% of the causes of mortality of the US. While the 5.4% number may seem relatively small there are a couple of important aspects of this statistic that merit consideration:

  • The revolutionary impact of antiretroviral treatment on survival rates of those infected with HIV
  • The rise of deaths from infections such as Clostridium difficile and West Nile Virus
  • The relative plateauing of deaths from pneumonia and influenza
  • The decline death rate from vaccine preventable illnesses

I wonder, however, if 5.4% is the true number as it was ascertained from death certificates which I have found to be pseudo-random in what is listed as a cause of death. Additionally, sepsis -- a final common pathway to death for many infections -- is clearly a major contributor to deaths, accounting for half of all hospital deaths. It is debatable whether sepsis, as a non-specific non-pathogen centric diagnosis, should be included however, strictly speaking, it is infectious disease-related.

Another important aspect of this research is understanding how low we can get with infectious disease mortality. There are several avenues for this and it is unclear from where the highest yield will emerge.  One strategy that come to my mind includes attacking the pneumonia/influenza death rate -- which comprises 40% of infectious disease deaths-- through a better influenza vaccine coupled to higher uptake of influenza and pneumococcal vaccines.

I think it is long since time the US aim for, join, and found the 1% club for infectious disease mortality. 

Multitudes R Us: A Review of Ed Yong's I Contain Multitudes

If I were to break the history of infectious diseases medicine into periods I would say that infectious disease has moved into the period of the microbiome. This period, I believe, will be characterized by major discoveries regarding the role of the microbiome not only in health and disease but also establishing the role of the microbiome and its constituent microbes in various physiological functions in virtually every living organism on the planet. 

I have found no better way to understand the full implications of the microbiome than the masterful science journalist's Ed Yong's I Contain Multitudes: The Microbes Within Us and A Grander View of Life

This book, which is almost impossible to encapsulate because of the plethora of valuable information it contains, is a tour of the world of life with special attention and focus devoted to the role that microbes play in every organism's life. While the role of the microbiome is very well-established with certain human infections such as Clostridium difficile, Yong moves much further than these topics and explores the role of the microbiome in life more generally moving deftly from humans to corals to frogs. Some of the aspects of the book that I found exceptionally fascinating were his detailing of the various roles of the Wolbachia genus of bacteria as well as that of Sodalis.  

After finishing Yong's book, I am increasingly thinking that maybe we should stop discussing genomes and microbiomes and move to discussing the holobiome instead for understanding the "multitudes" and how they interact with us and other organisms likely holds many keys to unraveling the myriad mysteries of biology that remain to be solved