Tuesday, July 7, 2015

We need to rethink professionalism

A new study in JAMA Pediatrics (free full text here) should make hospital epidemiologists and infection preventionists cringe. All physicians and advanced practice providers at Children's Hospital of Philadelphia were sent a survey on presenteeism. Of the 929 providers surveyed, 58% responded.

The big findings were as follows:
  • 95% felt that working while sick puts patients at risk
  • 16% would come to work with fever 
  • 30% would come to work with diarrhea
  • 5% would come to work with vomiting
  • 56% would come to work with acute onset of respiratory tract symptoms
  • Asked several ways, >90% stated they would come to work while sick out of a sense of professional obligation
What I find most interesting about this paper is not how often sick healthcare workers come to work (though it's a big problem), but why they do so. And once again, professionalism rears its ugly head. Professionalism revolves around expectations and norms set by the profession. It seems to me that if we viewed this more through the lens of humanism rather than professionalism, we'd be better off. From a humanistic standpoint, which holds a universal rather than parochial view, all would agree that individuals who are ill with potentially contagious illnesses should not come to work (doesn't matter whether you're a doctor, a teacher or a plumber). Similarly, in the white coat debate, professionalism drives the argument that physicians should wear a white coat. Humanism would dictate that attire should be practical, comfortable, safe, and personally desirable. Several years ago, Judah Goldberg wrote a great essay in Academic Medicine that I often quote and recently re-read on the conflict between humanism and professionalism. It really crystallized for me the differences between the two philosophies, which are often in conflict, and once the differences are made clear, it's easy to see the corrupting influence of professionalism. It's worth a read.

Friday, July 3, 2015

The white coat debate continues on and on and on and on...

I couldn’t resist blogging in response to Eli’s recent post regarding doctors’ attire. I guess this debate continues on with some new warriors from the University of Michigan. They plan to do a bigger, worldwide study of patient preference for physician attire. We really do need another meaningless study on this topic, don’t you think? While they’re at it, I think they should ask patients their favorite color, favorite flower, and favorite season of the year, because it would have the same impact.

I have blogged on this topic many times (see here, here, here, here, and here) and I won’t rehash all the arguments in this post. But these are the most important arguments, I believe:
  1. I think we need to act consistently about the role of clothing in infection control. That is, if you believe that contaminated clothing plays no role in transmission of infection, then be consistent and eliminate contact precautions. If you do believe that clothing may transmit pathogens, ditch the white coat and employ bare below the elbows or contact precautions, or some combination of the two. Or if you believe that the white coat magically resists contamination by pathogens, disclose that as well and those of us who believe in the germ theory and other scientific concepts like global warming can move on.
  2. If you think that we need more data about patient preference then put the issue of physician attire into context in your survey or test your hypothesis with a clinical trial. Both types of studies have been done. And the results are clear: when placed into context, patients find physician attire to not be very important (not really surprising—most patients would rather have a kind physician who wears scrubs than a mannequin in a white coat) and when formally tested in clinical trials, attire had no impact on patient satisfaction with their care (see here and here).
  3. The white coat is all about the doctor, more specifically the doctor’s ego. It’s truly about professionalism in the most negative sense of that concept (physicians judging other physicians to “protect the profession”).
In my current job as Chief Quality Officer at an academic medical center, I am able to separate my time fairly cleanly into clinical time and administrative time. When I am seeing patients, I wear scrubs, have done so for the past 6 years, and have never had a complaint. Interestingly, when my CEO sees me in scrubs, he always points to the scrubs and comments, “that’s a good look!” I also don’t consistently introduce myself as “Doctor,” particularly in situations where I am likely to follow a patient over a long period of time, and in cases where the patient’s status is tenuous and they need to be able to reach me quickly, I give them my cell phone number. Call my crazy, but this approach to patient care works well for me. When I’m working in my administrative role, I frequently wear a tie, though not always, rarely wear a sports jacket, and almost never a suit. Most physicians have enough common sense to dress appropriately for work, so very few need to be told how to dress. And I respect the fact that each of us has our own style. How you dress is a personal decision, a reflection of who you are. By the same token, there are some patients who prefer their doctor to dress more casually. There is no one size fits all.

So to our colleagues in Michigan, a challenge: in your new survey ask patients the following question: which is more important to you—that your physician be dressed in a white coat or that your physician gives you his/her cell phone number? I can’t wait to see the results.

Thursday, July 2, 2015

The limitations of patient-centered infection control

"You can't just ask customers what they want and then try to give that to them. By the time you get it built, they'll want something new." - Steve Jobs

I woke up to Vineet Chopra and Sanjay Saint's editorial advocating for a patient-centered approach to selecting clinician attire. In the editorial they point out that in the 21 of 30 papers they reviewed "patients had strong preferences about what physicians wore. And it looks like patients more often prefer for their doctors to wear formal clothing and white lab coats than not." They also reference the SHEA guidance document on healthcare attire and state there is little evidence "that germs on male doctors’ neckties, long sleeves, or white coats actually spread infections in a nonsurgical setting. So bans on such garments, such as those in place in some countries, may go too far."

So how can we decide what the safest attire is for our patients? I would recommend epidemiological studies that track bacteria spreading in hospitals and attempt to determine if those same strains are contaminating clinician attire using whole genome sequencing.  In fact, CDC released a SHEPheRD Task Order 2015-006 last month that seeks to do just that and more. I very much look forward to the results.

Drs. Chopra and Saint recommend a different patient-centered approach as they "plan to survey thousands of patients from the US, Italy, Switzerland and Japan" and "will specifically assess how factors such as age or how often a person interacts with the health system shape patient opinions." Is this a rigorous or unbiased method? Will the surveyed patients know that a quarter of white coats are coated with invisible S. aureus or MRSA and that they are rarely washed? Will they understand that a lack of data supporting transmission from white coat or long sleeve or neck tie is because no one has ever funded such studies? Will they understand that the circumstantial evidence supporting bare below the elbows is as strong as that supporting a clean environment in hospitals? Will their next editorial say that bleach is stinky and irritating to patients, so we shouldn't use it in hospitals unless supported by a patient-centered survey?

Thus, there are several potential limitations to patient-centered infection control and the planned physician attire survey, which I hope they will consider before collecting data and selling the findings. I'm all for patient-centered healthcare where applicable and data are fairly presented to patients and I support evidence-based medicine when we fairly rate the science based on what studies have been funded or will ever be funded. I'm not sure any patients "feelings" about the dirty white coat are worth the increased risk of MRSA or Acinetobacter infection, but we can disagree. All I would ask is that if we do patient-centered research, it's with properly informed patients.

Oh, and if we're going to require evidence before making physician attire recommendations, how can the authors write that "scrubs do not belong outside the hospital environment. Especially not in the grocery store." Where is the study that scrubs spread bacteria outside of hospitals and that there is any risk to population health in grocery stores? Clearly the bacteria on cantaloupes are riskier than those on scrubs! And surely the immobile ICU patient with central venous and urinary catheters is at greater infection risk when you wipe your MRSA-contaminated white coat on their catheter than when you brush up against a healthy grocery store patron with your scrubs? Scrubs are at least washed daily - white coat laundering occurs somewhere between every two weeks and... never.

Additional thought, I am not aware that the US, Italy, Switzerland and Japan have mandatory bare-below elbows policies. It might be important to add Scotland or England to the survey since they have had BBE policies for some time and patients may have adjusted their preferences for physician attire.

Thursday, June 25, 2015

When antibiotics don't work any more: Maryn McKenna's TED Talk

Maryn McKenna is a public health journalist whose stories, books and posts have been important for explaining antibiotic resistance to those not already immersed in its study. Her TED talk from last spring just became available - well worth the listen. If you want to read more, head over to her 'new' blog at National Geographic: Phenomena: Germination.

Thursday, June 18, 2015

The role of weather, season and climate in HAI

The recent attention given to climate change served as a backdrop to this talk (slides posted below) that I just gave at ICPIC in Geneva. ICPIC has been a wonderful conference and it was a nice forum for discussing the larger, international issues hindering HAI control. I look forward to seeing everyone again in two years.

Tuesday, June 9, 2015

MERS in S. Korea and Infection Control

I've been thinking about this all week, and came to the conclusion that I don't have much of a take on the latest outbreak. Surprising, I know, given how we are the number one "therapeutically abrasive blog"* on the interweb. With that said, I want to counter a meme I've seen emerging.

In Nature News today there was an article and a quote from David Heymann, chair of Public Health England, that I found a bit concerning. He said, “The focus on South Korea would be better directed towards Saudi Arabia.” It appears to me that the article and he are suggesting that it's more important to study episodic animal-to-human transmission than to focus on human-to-human infection control. I think this is a poor choice (or perhaps a poor choice of words) for a number of reasons. First, it is unlikely that prevention activities in Asia compete for research dollars with epidemiological investigations in the Middle East - we can and should do both! Second, in the case of MERS, CDC has estimated that more than 90% of cases could be linked to health care exposures. So, if we care about preventing incident human cases, public health authorities must still focus on understanding and halting nosocomial transmission. Finally, in a recent article in Time, the CDC's Tom Frieden said “Hospitals can become amplification points...It’s the case in measles, it’s the case for drug-resistant tuberculosis, it’s the case for MERS and SARS and Ebola. That’s where sick people go and that’s where vulnerable people are. It really emphasizes the importance of good infection control in the health care system.”

And if I can extend what Dr. Frieden said - we don't actually know how to achieve good infection control for MERS and the other pathogens he mentioned. If only we invested in studies to understand how to best implement PPE in these settings. One could imagine improved PPE technology, refined PPE donning and doffing algorithms and enhanced environmental cleaning as potential targets for future studies examining optimal protection from MERS. Not coincidentally, many of these are the same targets that Mike, Dan and I mentioned in our Ebola+PPE editorial several years months ago. If we invest in infection prevention technology and implementation research, our health care system will be safer regardless of the pathogen du jour.

For those interested in reading more about infection control for MERS, I suggest a recent review by Westyn Branch-Elliman, Connie Savor Price, Alison McGeer and Trish Perl in the March 2015 ICHE. ICHE has graciously made the review "free access" for the month, so download the PDF now. Of note, this group has first hand experience with MERS infection control in Saudi Arabia. Additionally, CID just published an invited review on MERS for clinicians that is also free access. Finally, for a recent update on the S. Korean outbreak I suggest this excellent article by Julia Belluz in Vox.

*I found "therapeutically abrasive" quite funny and think it could be very useful in preventing C. difficile

Saturday, June 6, 2015

This study is boring, and we need more just like it

What is there to say about a study that compares the treatment of an infection with X versus Y days of antibiotics? The recently published STOP-IT trial didn’t reveal groundbreaking new approaches to treatment or prevention, or provide keen insights into pathogenesis or transmission. The investigators simply compared two antibiotic treatment durations for abdominal sepsis: a short course after source control (~4 days), versus a more standard course that continued until fever, elevated white cell count and ileus had resolved for 2 days or so (to a maximum of 10 days). The verdict? No difference in outcomes (a composite of surgical site infection, recurrent intraabdominal infection, or death within 30 days). Our own Mike Edmond and Dick Wenzel penned the excellent accompanying editorial, to which I refer you for more detailed commentary.

I like this study, and we clearly need more studies that test our current approaches to antimicrobial treatment of common infections. “How long do we need to treat this infection?” is one of the most frequent questions we get as ID consultants, and it’s amazing how scant the evidence base is regarding duration of therapy. Studies like this one, and this oft-cited study that helped reduce our duration of treatment for ventilator-associated pneumonia, have the potential to markedly reduce unnecessary antimicrobial therapy, thereby reducing risk for C. difficile and antimicrobial resistance emergence, among other adverse effects of antimicrobial overuse.

Also of note, this study was published just in time for the White House Antimicrobial Stewardship Forum!