Exploring Clinical Dilemmas in Infectious Diseases

Paul Sax: [00:00:12] Hi everyone. This is Paul Sax, the editor in chief of Clinical Infectious Diseases. And welcome to the Let's Talk ID podcast. Today, I'm delighted to be joined by doctors Daniel Minter and Varun Phadke. Two of them are ID doctors and they are clinical teachers extraordinaire at UCSF and Emory, respectively. And they've just started an exciting new series at CID called, "Clinical Dilemmas in Infectious Diseases." We'll be talking more about that series in a moment. But let's start us off by just having the two of you tell us a little about yourself. I know that's a very open-ended question. Take it wherever you want. And, Varun, why don't you start us off?

Varun Phadke: [00:00:50] Absolutely. Thanks, Paul, for inviting us to be part of this series. So, as you mentioned, I'm a faculty member here at Emory in the infectious Diseases division. I'm actually also the program director of our ID fellowship program as of this last year. I do both general infectious disease and transplant infectious disease. My passion, above all, is medical education, and I have the great privilege of getting to teach medical students in our medical school about microbiology. I teach in the residency program and have a lot of roles in our didactics for our fellows. In addition to being an ID doctor, I'm a husband and a dad to a six-year-old, which are my two parallel passions.

Paul Sax: [00:01:33] Terrific. Thank you. And Daniel?

Daniel Minter: [00:01:36] Awesome. Well, thanks so much again for having us. I'm really excited to be here as well. I am an assistant professor at UCSF in San Francisco, which weather wise, is doing better than different parts of the US right now in terms of our cold winters. Similar to Varun, I also mainly see folks on the transplant ID service. I do some general ID time as well. I attend on the medicine teaching service where I get to interact with the residents, which is a blast. And then I see patients in the infectious disease clinic. Also similar to Varun, very passionate about medical education and specifically how clinical reasoning can interact with our specialty as an infectious disease doctors. I have a teaching role in the School of Medicine, sort of reinforcing the foundational sciences for med students during their clinical years, and then give talks to the residents and fellows in terms of outside of work sort of stuff. My wife and I just recently adopted a puppy that is named Rocephin or Rosie for short, and she's been taking up a lot of our time and has been just a total bundle of fun.

Paul Sax: [00:02:33] So yeah, for trivia folks out there, Rocephin was the brand name of a very widely used third generation cephalosporin called ceftriaxone. Anyway, thanks to both of you. You know, Daniel, maybe you could start us off by telling us how the two of you ended up working together?

Daniel Minter: [00:02:52] Well, I really think it's kind of a success story of the IDSA and its committees. I met Varun initially when I was a fellow member on the Medical Education Community of Practice, Teaching and Learning Resources Committee. I had heard a lot about Varun from mentors at my institution who were well aware of his role in medical education and interest in clinical reasoning, which I've been interested in for a while. So I got to learn from Varun on that Teaching and Learning Resources committee, working on a couple of projects with him. And then after our stints, both sort of came to an end on that committee. We met at IDWeek and just kind of compared notes about things that we were interested in working on, and that was really the genesis of this idea for the Clinical Dilemmas in Infectious Diseases series.

Paul Sax: [00:03:35] And Varun, what specifically inspired it? Did you have other models?

Varun Phadke: [00:03:40] Yeah, that's a great question, Paul. So Dan and I, one of our shared passions is surfacing the way that we think about cases and way the way infectious disease doctors think about cases. I think we are uniquely positioned in the hospital and our role in the hospital is often to make sense of challenging scenarios and come up with a causal sequence of events that led to the patient's current state and kind of reason through the different strategies to get them out of that state. Looking around, we recognize that there was an opportunity to create a series that would showcase those thinking skills more explicitly through the Clinical Dilemmas in Infectious Disease series. Some of the inspiration was existing series in general medicine journals, like the Clinical Problem Solving series in the New England Journal of Medicine, or Exercises in Clinical Reasoning in the Journal of General Internal Medicine, and there are other series in other journals too, like the Journal of Hospital Medicine and Neurology. And we saw a space for this in our very cognitive specialty to highlight and showcase the very unique thinking that we do.

Paul Sax: [00:04:53] And, you know, I think it's great that you had those inspirations. Did anyone come forward to help you out from any of those journals?

Varun Phadke: [00:05:01] When we were brainstorming the model for this series, we had the great fortune to communicate with the lead editor at the New England Journal in charge of the clinical problem solving series. We also engaged with editors who are our friends and colleagues at the Journal of General Internal Medicine, who run the Exercises in Clinical Reasoning series and learned from them in terms of pearls and pitfalls, to launching a sort of case-based series focused on clinical reasoning, and adopted a lot of their wisdom as we design this.

Paul Sax: [00:05:32] Great. Great. So, Daniel, and by the way, I happen to be friends with that lead author of the New England Journal of Medicine. So I feel if I can get like a tiny bit of credit for introducing you by email, that would be great. Daniel, take us through the primary goals for the readers of these cases. If people pick these up or just, you know, look online and start reading. What do you want them to get out of it?

Daniel Minter: [00:05:55] Before I get into that, I'll just say again, thank you, Paul, for putting us in contact with Dr. Karen Solomon. That was, you know, like meeting a celebrity. Certainly having grown up on the New England Journal cases. But, you know, our goals for this series and maybe just to explain kind of the format is these are cases that are presented to a blinded discussant and sort of evolve over distinct aliquots of information. So there will be like a bolded two paragraph aliquot of information, and then the discussant will respond with their contemporaneous thoughts about what they would do in that clinical scenario or diagnostically, what steps they would take or therapeutically what they would do. And, you know, between probably like 4 to 7 aliquots of information, they'll journey through that case and, you know, tackle a lot of the uncertainty, tackle a lot of the sort of diagnostic management challenges and ultimately reach a conclusion. And in doing so, our goals for this series are really to highlight what infectious disease doctors do best. You know, we reason through cases. This is a cognitive specialty. This is our procedure. I think it's the reason that I personally came into infectious diseases, and I think a lot of folks are attracted to this specialty, is those cognitive challenges that we're able to face. Like Varun was saying, we didn't see a clear spot that celebrated that for our specialty in our literature prior to this. And we're really excited that you and CID have given us the opportunity to sort of create that space.

Paul Sax: [00:07:16] Happy to do it. We were thrilled when you approached us. I think part of it's going to be how you communicate to potential contributors what you're interested in. So, Varun, take us through how you do that, because that's not a small task.

Varun Phadke: [00:07:29] As Dan pointed out, this is sort of a new area for our specialty, and I think it will require some development of submitting authors and reviewers of this series for understanding the types of cases we're looking for and the kind of discussion we're looking for after each case. The language of diagnostic reasoning and management reasoning hasn't percolated as deeply into the ID literature as it has into a lot of the general medicine literature. And so as we were brainstorming ideas for cases, we wanted to make sure that we got the entire spectrum of infectious diseases, including outpatient cases, inpatient cases, the many different niches within infectious diseases like transplant ID and travel medicine, general ID, HIV medicine, and so on. And to make sure that we explore not only the diagnostic reasoning aspect of ID, which we excel at and I think are celebrated for in the hospital. But really the management reasoning as well, which I think is something that a lot of the inspiration for this series has not explored as much, and something I think we as ID physicians do really well in terms of thinking through the nuance of the different management options. Communicating that nuance to our colleagues because we are consultants and have to engage in a lot of negotiation and persuasion tactics to get our nuanced plans in place. In order to invite authors to participate in this conversation, we have created a pre-submission enquiry form that provides a lot of explicit guidance to authors about the kinds of cases we're looking for, the kinds of clinical reasoning commentary that would be high yield, and the first case will be accompanied as well by an editorial by the two of us, with further guidance for submitting authors.

Paul Sax: [00:09:27] Good, good. Yes. You know, and not surprisingly, I've read the editorial and it's really excellent. And I encourage anyone who wants to submit one of these pieces to CID, to read the editorial, to read the instructions for authors, and to give it a shot with the pre-submission enquiry. So we've got a case about to go, it’s already appeared in preliminary form on the CID site as an accepted draft. But, Daniel, tell us about this first case. It's called Rewriting the Script.

Daniel Minter: [00:09:57] Yeah, I'm really, really excited about this case just because this is a new format Varun and I have been working pretty closely with authors on the first series of cases to more or less develop them internally and make sure the format is what we what we're hoping to aim for the rest of the series. So this is actually a case from colleagues of mine here at UCSF about a patient who has end stage liver disease and develops a classic ID problem of MRSA bacteremia.

Paul Sax: [00:10:23] Oh, that's so uncommon. That's a very exotic problem. What are you talking about?

Daniel Minter: [00:10:27] Yeah, we're working on esoterica in this series here, for sure. But, you know, I think that's one of the great things that we're trying to highlight in this. This case is like, this is a clinical scenario that any ID doctor on an inpatient service could see. And yet, despite the fact that we see this more than any other condition, we still get tripped up. And there's all these challenging decision points. So this is a really fun case that highlights a lot of those decision points. And it is, as you could expect, maybe not a routine run of the mill MRSA bacteremia case. There's, you know, twists and turns, relapse, you know, sort of surprising lab findings and accompanying that a really, really masterful discussion by the discussant. I think one of the other reasons I really am excited about this case is that it highlights a lot of these different sort of management reasoning themes that we're hoping to touch on throughout this series. Specifically, how do you develop your sort of playbook or management script for a common scenario? How do you evolve that management script for areas where you're sort of pushing the bounds of evidence or, you know typical clinical practice, and how do you go back to basics and kind of think through these management decisions to ultimately help, uh, help care for these patients. So I'm really, really excited to see it out there.

Paul Sax: [00:11:39] Yeah. No, I think I think it's a terrific example of what we're hoping to see more of, and it's a really good start. But speaking of the start, you know, you've got a lot of energy to get going and everything seems so fresh and new. So how are you going to sustain that? Varun, what are your plans to keep it lively? And how often how often are they going to appear?

Varun Phadke: [00:12:01] To answer that second question first, we initially planned to have our cases appear quarterly in CID, and we actually already have several submissions in the pipeline for the next several quarters in a row after this first case that Daniel described. As we think about building the series, Dan and I have been thinking really carefully about the different kinds of readers who will be excited by this series. Speaking from our own experiences, we know that those in any area of education will find this series interesting and useful in their own teaching to provide learners with example cases and how expert discussants think through real dilemmas and navigate gray areas where there is no evidence. So we want to be mindful of inviting cases that for which there is no clear right answer, where reasonable people will disagree, where we ourselves may disagree with what the authors may have described happened in their case. Another important readership will be clinicians who find joy in reading cases where they may have done something different and get to challenge themselves as they read along each aliquot. I think what's been really fun for the two of us, as we've met regularly about this series, is as we come off service or come out of clinic, we think to ourselves, oh man, that's such a good dilemma. You know, one that we'd love to highlight. Let's hunt for a case. Let's invite cases that will really reflect authentically the kinds of challenges that we face, and I think that is how we want to keep it fresh. We want every case to highlight real dilemmas, real challenges, and give our readers the opportunity to test their own sort of wisdom and intuitions and against another clinician.

Paul Sax: [00:14:01] We have other pieces like this in CID, and I'm thinking of our state of the art reviews, which you're probably aware of, but also there are, you know, IDSA and elsewhere we publish treatment guidelines, Daniel, distinguish this series from those two in particular, treatment guidelines I think is one to focus on, because that's not what you're after.

Daniel Minter: [00:14:25] It would come as no surprise to any ID clinicians that not every patient fits nicely within the scope of these guidelines. I go back to the guidelines constantly, have them bookmarked on my computer, but I think any of us can think of a hundred scenarios where like, oh, that didn't totally fit within the guidelines. What do I do now? And that in itself is a reasoning challenge. I think the state-of-the-art review series, I'm obsessed with, by the way. I absolutely devour those. And I think that that builds off of the guidelines in a really interesting way that sort of navigates like areas where there's less certainty or the evidence is lacking. So we're really trying to take even a step further off of that of, you know, this evidence base that exists or doesn't exist out there for a condition. How does an individual clinician apply that to an individual patient scenario? And navigating the questions or the uncertainties that could arise in those patient care scenarios? And it's not that, you know, Varun and I just don't want there to be any discussion of evidence for these cases. We certainly welcome that. But it's really more about like what's going on in that clinician's head as they sort of think through these problems.

Paul Sax: [00:15:29] You must have some ideas for promotion. I know that you have have appeared on some other ID podcasts. Any thoughts? Do you want, maybe for the individual ones?

Varun Phadke: [00:15:39] You, Paul, individually, and all of the staff that at CID and IDSA have been incredibly supportive of us as we've developed this series. To promote individual cases, I think there's a lot of different avenues. Promotion on social media through CID, as well as through our individual social media presence, through parallel educational podcasts that have a specific focus in clinical reasoning that Dan and I intersect with. We have also engaged with the medical education community of practice through IDSA. And our colleagues there, including Michael Millea and Darcy Wooten, have been fantastic at sort of including us in some of the events that they have, and sharing this opportunity with members of that group who we know will be excited about potentially submitting and reviewing for us.

Paul Sax: [00:16:31] Okay, great. Great. So I'm going to ask you some questions outside of the series, which, and by the way, thank you for the compliment about CID's handling of this. And I will send you the $20 check, which I promised you after asking you to say that.

Daniel Minter: [00:16:46] [laughs]

Paul Sax: [00:16:47] Ha, ha. I'm going to ask the two of you something that comes up a lot when we're interviewing potential ID fellows, which is many of them say that they want to spend a significant proportion of their time in their career in clinical teaching. And both the two of you seem to have successfully done that. What advice do you give to residents and fellows out there who want to do this? Because obviously not everyone can do it. And, uh, but what do you say? So let's start with you, Dan.

Daniel Minter: [00:17:19] This is an area that is coming up more and more with fellows, and certainly was on my mind as I applied to fellowship and pretty early in my career still. But the thing that I've really taken away with is or taken away is that, um, you know, if you want to be a clinician educator and make that your passion, make that your life, like, don't have that be the backup plan. Like, don't think that you're going to do attempt a research career and this is your backup if you end up not wanting to pursue that later on, I'd say, you know, if you really want to do this, make that, you know, plan number one, your first plan and do what you can to make that happen. And the corollary to that too, is, you know, you're not alone. You're part of a community of educators within the IDSA. And certainly, as you know, I got to meet Varun through some of the IDSA working groups and the medical education community of practice. There's a ton of people out there. There's people who have similar ideas to you or complementary ideas. And, you know, IDSA is just such a wonderful community of clinicians and like-minded folks that, you know, that's a really great thing that you could tap into and get some ideas about how to make that career happen.

Paul Sax: [00:18:20] Great, great. And, Varun, any responses to this query?

Varun Phadke: [00:18:24] Yeah. So this is a question I am tackling often in my role as program leadership for our fellowship program. It's important to approach a career as a teacher and clinician educator, as one where you want to build a niche and an expertise in it, just like you would in a research career or any other career. We in our training are asked to teach a lot, right? As residents and fellows. And it becomes sort of a natural skill set that we build over time and we enjoy it and want to continue it in our faculty time. But I think we sometimes forget that there are different domains within education where we can focus our energies and really build a particular muscle or skill set, whether that is in assessment, large group teaching, small group teaching, in our case a clinical reasoning, many others. And I encourage those interested in these types of careers to explore different niches, different learner populations that they may want to work with, whether that's undergraduate medical education, graduate medical education, finding that niche and really being intentional about seeking feedback on your skills, building those skills in a thoughtful way, seeking out a network, going to a professional meetings to meet like-minded individuals that is helps you as you grow into this field and become someone others go to for their expertise.

Paul Sax: [00:19:52] Okay, great inspiring words. All right. So lightning round of questions. Ready? Favorite wintertime vacation spot?

Daniel Minter: [00:20:00] I'll say, uh, Lake Tahoe is our local winter spot here in California. My folks just retired there, too, so that makes it easier.

Paul Sax: [00:20:07] I got it. So a skier in the winter?

Daniel Minter: [00:20:10] Yep.

Paul Sax: [00:20:11] All right. Varun?

Varun Phadke: [00:20:12] I'm jealous, Dan. For me, it's, uh, going back to New York City to visit my brother and my family. And New York City at Christmas time is a magical place.

Paul Sax: [00:20:22] It is. It's wonderful. And it usually involves some great restaurant meals.

Varun Phadke: [00:20:27] Absolutely.

Paul Sax: [00:20:28] Okay, um, how about a hidden talent that few others know that you have? No matter how trivial. Varun?

Varun Phadke: [00:20:36] So I love to solve puzzles and love to engage and create scavenger hunts. That's actually how I proposed to my wife.

Paul Sax: [00:20:45] One day on another podcast. We'll go into that in more detail. Dan?

Daniel Minter: [00:20:49] I'm not sure if it's a talent yet, but I'm hoping someday I could develop this into a talent. But you know, post training, I'm trying to have hobbies and I'm getting into fly fishing, which is a nice way to get outside. And I can't say I'm particularly good yet, but hopefully someday.

Paul Sax: [00:21:02] One of my very good friends is a passionate fly fisher, and he took a landmark birthday and decided that that he would go to South America, to Patagonia, where they have some of the best fly fishing in the world.

Daniel Minter: [00:21:15] Oh, wow.

Paul Sax: [00:21:16] All right. Last one is an ID related question. Most remarkable animal related infection you've ever seen. Dan?

Daniel Minter: [00:21:25] So this is a patient I saw long after they actually experienced this infection. But it was a person from South America who had a brain abscess with a Brucella species found only in marine mammals. And the thought was that apparently there's some local delicacy of that's no longer eaten very frequently, but it was like dolphin fin tartare or something like that. So presumably that's where they got it from. And he's doing well now.

Paul Sax: [00:21:53] All right. Good one, good one. And Varun?

Varun Phadke: [00:21:56] So I'm going to answer this question in two ways. The first is the best animal related question that I got to ask a patient, which was a patient I saw who had a soft tissue injury of his arm. And I asked him, how did this happen? And he said, well, I was cut on an alligator. And I had to ask him, was the alligator alive or dead when you incurred this injury? So that's the question. Turned out to be a staph aureus infection.

Paul Sax: [00:22:24] Okay. Yes. Well.

Varun Phadke: [00:22:24] But the best infection? One of my colleagues presented a case a couple of years ago of a Pasteurella peritonitis related to a cat biting their ambulatory peritoneal dialysis tubing.

Paul Sax: [00:22:38] Gosh, those cats, those cats. I mean, I have to say, my wife loves cats. We had cats for years. I am much happier with our dog. That's all I can say. Listen. Thank you. Uh, Daniel and Varun. I've been talking with Dr. Daniel Minter and Varun. They are the editors of our new series, Clinical Dilemmas in Infectious Diseases that appears in CID. And you can read right now both the first of these pieces, plus their accompanying editorial. And we encourage you to submit. Dan and Varun, thanks so much for joining us.

Daniel and Varun: [00:23:12] Thanks so much.