{"id":8412,"date":"2017-07-09T17:13:14","date_gmt":"2017-07-09T21:13:14","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8412"},"modified":"2017-07-12T13:20:33","modified_gmt":"2017-07-12T17:20:33","slug":"answer-medical-questions-clinicians-dont-know-patients-youve-never-seen","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/answer-medical-questions-clinicians-dont-know-patients-youve-never-seen\/2017\/07\/09\/","title":{"rendered":"Should You Answer Medical Questions from Clinicians You Don’t Know About Patients You’ve Never Seen?"},"content":{"rendered":"

\"\"<\/a>This email\u00a0popped into my inbox the other day from a person I’ve never met:<\/p>\n

Hi Dr. Sax,
\nI do mostly hospital-based ID in Pennsylvania, and was consulted on a newly diagnosed HIV patient with\u00a0CD4 10, viral load 210,000, and lymphoma. I started him on Truvada and dolutegravir, which is going well so far. Because he complained of blurred vision, he had an ophtho evaluation yesterday which showed\u00a0CMV retinitis. My drug-interaction checker says I can’t use\u00a0valganciclovir with either tenofovir or abacavir, and if I replace the Truvada with a boosted PI, it will interact with his chemotherapy. What should I do for his ART?
\nThanks so much.
\nMarie<\/p>\n

There are two issues with this email worth discussing.<\/p>\n

The easy part first —\u00a0the medical question. Here’s my response:<\/p>\n

Hi Marie,
\nThere is no significant interaction between ganciclovir and tenofovir alafenamide, and even the interaction with tenofovir DF is theoretical, not an absolute contraindication. No interaction with abacavir either, so not sure where you are getting your information! (Use this site, it’s awesome: \u00a0www.hiv-druginteractions.org<\/a>.) So switch the Truvada to Descovy (tenofovir alafenamide\/emtricitabine), that’s all you need to do. Safer for kidneys and bones, too.
\nRegards,
\nPaul<\/p>\n

The second item\u00a0to cover\u00a0is whether we\u00a0should be answering\u00a0questions like this at all. Remember, this is from a person I\u00a0don’t know, asking about a patient I’ve never seen.<\/p>\n

Though I obviously responded to the query, there are a few\u00a0reasons not<\/em> to answer questions from clinicians you’ve never met about patients you haven’t seen.<\/p>\n

The\u00a0medical information might not be\u00a0correct, or complete enough, to make a good recommendation. If you make the wrong suggestion, or your recommendation is misquoted, there’s the potential for patient harm. Even worse: if\u00a0your name is in the chart, there’s a medicolegal\u00a0risk — especially if you review patient data sent to you. The risk\u00a0may be small, but who wants to take that chance?<\/p>\n

And if you ask an economist, they would say it definitely<\/em> makes no sense to answer these questions — not only are you being paid nothing, but\u00a0there’s little\u00a0chance of downstream revenues,\u00a0and it takes time away from other remunerative tasks and opportunities.<\/p>\n

But economists can be short-sighted, and this is one of those times. Obviously I thought it was better to answer the question than to ignore it for a bunch of reasons.<\/p>\n

    \n
  1. Answering helps the patient.<\/strong>\u00a0Sometimes cliches are true: helping people remains the primary reason most of us went to medical school to begin with.<\/li>\n
  2. Answering helps the clinician.<\/strong> When I see a difficult case of coccidioidomycosis, I of course call an expert in this tricky fungal infection; cases of cocci are rare in Boston. And I’m so grateful<\/em> when John Galgiani<\/a>\u00a0responds, given his voluminous experience. Ditto various cases over the years involving\u00a0rapidly growing mycobacteria (Richard Wallace<\/a>), bartonella (Jane Koehler<\/a>), toxoplasmosis (Jose Montoya<\/a>), Mycobacterium avium<\/em> complex (Chuck Daley<\/a>, Gwen Huitt<\/a>), cytomegalovirus (Richard Whitley<\/a>), and many others. Thank you!<\/li>\n
  3. It was a straightforward, focused question, presented clearly.\u00a0<\/strong>I didn’t quote the whole email, which included numerous other details about the chemotherapy regimen, but those were thoughtfully placed at the bottom of the communication.<\/li>\n
  4. The person asking was polite.<\/strong> No dreaded Red Exclamation Point indicating that this was of the utmost urgency. (Here’s a thought — let’s ban that particular means of communication<\/a><\/strong>.) No “Thanks in advance for your rapid reply.” (Ugh.)<\/li>\n
  5. It’s flattering when someone asks you\u00a0questions in your area of expertise.<\/strong>\u00a0Gosh, Marie chose to ask me<\/em> about her patient’s HIV therapy? When there are so many other people she could have asked? Hey, maybe I should be thanking her! (Of course she might have sent the same email to 20 others, but … who’s to know?)<\/li>\n<\/ol>\n

    The bottom line is that I think we should be helping out other clinicians when we can — it’s just the right thing to do.<\/p>\n

     <\/p>\n

    \"Register<\/a><\/p>\n

    Save<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

    This email\u00a0popped into my inbox the other day from a person I’ve never met: Hi Dr. Sax, I do mostly hospital-based ID in Pennsylvania, and was consulted on a newly diagnosed HIV patient with\u00a0CD4 10, viral load 210,000, and lymphoma. I started him on Truvada and dolutegravir, which is going well so far. Because he […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,8,9],"tags":[],"class_list":["post-8412","post","type-post","status-publish","format-standard","hentry","category-health-care","category-infectious-diseases","category-patient-care","category-policy"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8412","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=8412"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8412\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=8412"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=8412"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=8412"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}