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The Hard Sell

Louie, Ted MD

Infectious Diseases in Clinical Practice: September 2006 - Volume 14 - Issue 5 - p 254
doi: 10.1097/01.idc.0000227710.96259.4d
Reflections of an ID Specialist

University of Medicine and Dentistry of New Jersey, New Brunswick, NJ.

Address correspondence and reprint requests to Ted Louie, MD, 579A Cranbury Road, East Brunswick, NJ 08816. E-mail:

Infectious disease doctors, in general, seem to get along very well with housestaff. This happy situation probably occurs for a variety of reasons. First of all, infectious disease specialists tend to work long and sometimes unpredictable hours in the hospital. Those cases of pneumococcal meningitis or necrotizing fasciitis always seem to happen on a weekend. Thus, stressed out interns getting anxiety attacks because they think they are the only doctors left in the entire hospital often find themselves toiling alongside a weary infectious disease physician at some odd hour. This tends to breed great camaraderie.

Secondly, we serve a very useful function in the hospital. Our bread and butter, of course, is sepsis and fevers. Seeing a patient with high fever and rigors in the bed in front of you can, of course, test the fortitude of any physician, young or old, and I think that when we dispense our practical advice to housestaff either in person or over the telephone, it is often very reassuring.

Thirdly, infectious disease physicians as a group are generally quite motivated to teach. Many in our ranks are chiefs of internal medicine or deans. And those who are not often slip in a remark or two about the "postantibiotic effect of aminoglycosides" or a pearl about daptomycin in our daily conversations with housestaff.

I myself feel quite close to our residents. I am in the habit of asking the residents what career choice they have made, and I often hear "cardiology" or "pulmonary." To my chagrin, it is all too infrequently that I hear "infectious diseases."

So I stayed up several nights brainstorming: What analogy could I use to impress these supple young minds, express to them the inner feelings and passions of practicing the art of infectious disease medicine? And the answer dawned on me: football, of course.

I practiced on my wife first.

"Hut, hut" I barked. "ID is just like football. The microbes are on offense, and you have to plan the defense. Some bacteria, like coagulase negative staphylococci, are plodders. They run the ball and can often be stopped quite easily. But sometimes, as in the case of a prosthetic valve infection, they keep coming, and coming, and coming, and if you're not aggressive and stack up the line, they can chew up a lot of yards.

"Other bacteria, such as many of the Gram negatives, have quick strike capabilities. You may have to double cover them to prevent a long bomb. You don't want to let their speedy receivers get behind you, because if you give up some quick scores, you'll have to play catch up with the patient. If you can't defend the pass, then you can't defend the run either, and you'll wind up in shock, with multiorgan failure.

Oh, the enemy is cunning. These microbes will try to disguise their formations. When the play starts developing, you have to read what they're doing, and if you're to be successful, you have to anticipate their next step. You have to be thinking ahead, cover the MRSA, cover the Pseudomonas, cover the fungus. You have to know their tendencies. You also cannot cover everything at once."

My wife was not buying any of this and showed some small skepticism.

I thought fast.

"How about cooking?" I asked.

"Yes, I'm starving," she said. "How about some pasta?"

"No, no, a culinary analogy. When choosing antibiotics, one must plan carefully, as in planning a meal. Certain flavors go together: soy sauce, ginger, and black beans in Cantonese cuisine; olive oil, garlic, and oregano in Italian cuisine. Yet you wouldn't use, say, capers, soy sauce, and cumin together. The same concept holds in ID. Ampicillin and gentamicin, yes, for the Enterococcus. Penicillin and aztreonam, not too tasty a combination.

"The duration of antibiotics, like cooking time, is important. You certainly don't want to undercook or overcook. Of course, it depends on what you are treating (or cooking). You may want to treat your uncomplicated bacteremia with precisely 14 days antibiotics, like a well-timed steak, or you may wind up treating a deep osteomyelitis more like soup. Four weeks? Six weeks? When exactly do you turn off the stove?"

My wife clearly thought I was bonkers.

"Philosophy, perhaps?" I asked. I was clearly on a roll now. "These questions are unanswerable: What is the sound of a tree falling in the woods? Is fever harmful or helpful? Why is it that antibiotics can both help eliminate fever and yet also cause fever?"

But my wife sent me right back to the drawing board. And the next time a medical student asked me why I chose infectious diseases as a vocation, I had to resist the urge to bring up sports or cooking. But if I could not wax philosophical, perhaps I could use the romantic approach.

"Do you crave adventure?" I began. "Have you ever heard the heroic exploits of a young physician named Walter Reed? Down in the teeming, mosquito-infested jungles of…"

© 2006 Lippincott Williams & Wilkins, Inc.