Spiraling Empiricism: When in Doubt Put on Blindfold and Shoot

microscopes.JPGOne of the reasons I went into infectious diseases as a sub-specialty of medicine was that I enjoyed the notion of being a sleuth at the bedside, of seeing someone with pneumonia and examining their sputum by personally carting it to the "wet lab" adjacent  to the hospital ward, then smearing a tiny sample on a slide and then, using a time-honored method of staining bacteria called the Gram stain, coming up with the exact cause of the pneumonia and thereby beginning appropriate treatment. 

A better example, and a memorable one from my training days, was seeing a patient with HIV (in the first days of AIDS when we did not know the viral cause) and watching as his fever raged on despite our efforts. One morning, I spotted some unusual skin lesions on his forehead. I scraped one with a needle and put the material on a slide. In the wet lab under the microscope, I saw tons of small budding yeast: this was cryptococcus, a fungus that affects persons with HIV.

There are so many instances in infectious diseases where a rapid and precise diagnosis can be made by directly examining sputum, wound drainage, blood smears, skin lesions and the like. Over two decades I can still remember those "Eureka" moments; it made all the difference in the care of the patient by finding precisely what was causing the problem, short circuiting what was otherwise blind therapy with many drugs, hoping one was treating the cause of the infection. Diagnosis matters--surely that's something we can all agree on.

Perhaps not. Some years ago, OSHA closed down our wet labs."These historic rooms--where interns and residents in the night or at any time could look at urine, use a Gram stain to look for bacteria in various specimens, and do other simple tests--were gone. Admittedly, they were messy rooms, and I suppose there was some potential for exposure to unsafe pathogens. But it was also the place where a generation of interns and residents learned bread and butter tricks that made them better diagnosticians. We lost that battle.

Once the wet labs closed, the choice was then to walk over to the microbiology department. Well, I got used to that, and in many ways this worked well, as the lab had more resources, better microscopes, and you could also look at the culture plates with the microbiologist and see what was brewing. Though I was willing to make the walk--microbiology is integral to my specialty-- for busy interns and residents, the walk made it less likely they would drop by the lab.

But then, many hospitals (including some where I see patients) went one further and have farmed or moved their microbiology labs off site, miles away! (I kid you not.) Say I happen to see a patient without a spleen who has come in with fever and shock, someone in whom I might make a diagnosis in minutes by quickly examining the buffy coat of blood (because such patients are prone to overwhelming infection so that their body fluids will be teeming with organisms);  now all I can do is helplessly watch as the specimen is transported away, with inevitable delay. And what is worse, more and more, no one seems to be too bothered. No one seems too worried about what exactly is causing the infection, but rather people are content instead to empirically add antibiotic after antibiotic, to "cover" the patient. And if the fever persists and the patient is worse, well then the answer is to keep "broadening" the antibiotic coverage. It's kind of like flushing out a sniper who is terrorizing your own city by bombing the city  to rubble in the hopes of silencing the sniper. Diagnosis matters.

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Abraham Verghese is an author, physician and med school professor. He is the author of Cutting for Stone and his writing has appeared in many major publications. More

Abraham Verghese is a physician and writer. His third book and first novel, Cutting for Stone, was published by Knopf in 2009. He is also known for two acclaimed non-fiction works, My Own Country, which was based on his experiences working with persons living with HIV in Johnson City, Tennessee; that book was a finalist for the National Book Critics Circle award and was made into a movie. He followed that with The Tennis Partner, also a New York Times notable book and a national bestseller. His writing has appeared in The Atlantic, The New Yorker, The New York Times , The New York Times Magazine, Sports Illustrated, and The Wall Street Journal as well as many medical journals. Verghese is board-certified in internal medicine, pulmonary medicine and infectious diseases. He attended the Iowa Writers Workshop at the University of Iowa where he earned his MFA. He currently practices and teaches at Stanford University School of Medicine where he is a tenured Professor and Senior Associate Chair for the Theory and Practice of Medicine in the Department of Internal Medicine.

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