I like to read. I read a lot. I am retired and have time to read. And I like to tell others about the books I have read. (My teachers made me write a lot of book reports in high school and I guess the habit stuck.) As a result, I seem to have become the designated book reviewer for SBM. But I have been derelict in my duties. I read Mark Crislip’s book Puswhisperer: A Year in the Life of an Infectious Disease Doctor a long time ago and intended to review it, but I never got around to it. Finally, I got a round TUIT.
But not before I learned he had written another book, Flies in the Ointment: Essays on Supplements, Complementary and Alternative Medicine (SCAM). And after I read that, I discovered he had written a sequel to the first book, Puswhisperer II: Another Year of Pus.
Mark, slow down! You’re writing books faster than I can review them! So here’s a triple-header.
Mark’s first contribution to SBM was in January, 2008: the classic “Alternative Flight,” and he continued to contribute regularly until his retirement in June, 2017. He is known for his ceaseless promotion of science in many venues, for his criticism of SCAM (Supplements, Complementary and Alternative Medicine), for his irrepressible sense of humor (he can hardly open his mouth without something funny coming out), for his annual flu season tirade about the “dumbasses” who refuse flu vaccines, and for his numerous errors and typos (dyslexia?). He describes his job as an infectious disease specialist as “Me find bug. Me kill bug. Me go home.” I miss his puns and his snark.
The first book: Puswhisperer
Puswhisperer is a collection of blog entries from the first year of his blog Rubor, Calor, Dolor, Tumor (Redness, heat, pain, and swelling are the four signs of inflammation). He describes the blog as “a mostly qod [every other day] account of days [sic] events, a cool ID case, a referenced pearl, and a minimum of 1 horrible, yet ultimately feeble, attempt at humor.” It reminds me a bit of internship and residency, as if I were following a particularly good attending physician around the wards and learning from him. Although none of the attendings I had were anywhere near as entertaining.
The book provides a unique insight into the experiences, diagnostic reasoning, and thought processes of an infectious disease doctor. It’s full of things I didn’t know. It shows how much science doesn’t know and how doctors must act on incomplete knowledge, for instance in treating patients empirically before the cultures results are available. It shows how hard it is even to determine whether an infection is present, and whether it needs to be treated (sometimes it’s better not to treat).
Doctors who understand the limits of science-based medicine are humble. Crislip says, “Every year I know more and more… and each year I seem increasingly unsure about what is going on with my patients… knowledge breeds uncertainty…I seem to know less and less about more and more until one day I will know nothing about everything.” At the end of every entry, he provides citations from medical literature to support what he has said. But he lists them under the heading “Rationalization.”
The job
The job of an infectious disease doc is to answer three questions:
- What is the bug?
- How best to kill it?
- How did it get there? – often the most interesting question.
Crislip’s love of his job is evident, and what he loves most is figuring things out. Like Sherlock Holmes, he searches for clues and makes clever deductions. In one case, the species of microbe allowed him to astound the patient by telling her exactly where she had spent her last vacation. In another case, he was sure the patient had contracted an infection from a cat, but the patient insisted he had no pets. On further questioning, he finally determined that the patient’s roommate had cats. The patient had not thought to mention that!
Clinical wisdom
He says,
…the three important parts to making a diagnosis are history, history, and history. Cultures, labs, and X-rays should only confirm what you figured out after talking to the patient.
I am far more often wrong than I am right, and it is always annoying how often reality gets in the way of a good diagnosis. I wish I were an alternative medicine provider and did not have to worry about reality.
Good docs are not those who are initially right, but those who do not stick to the initial ideas when they are wrong.
Patients do not read the textbooks before coming into the hospital and so do not know how to manifest their diseases properly.
Doctors are often accused of automatically prescribing drugs; not true. Crislip’s expert knowledge allows him not to treat when not treating is the best course.
I am the only doctor who can stop an antibiotic. I am the only doctor who can ignore cultures.
The intern says don’t just stand there, do something. The attending says don’t just do something, stand there.
There is Occam’s razor, but there is also Hickam’s Dictum: “Patients can have as many diseases as they damn well please.”
…serologies are unreliable. Patients may make antibody that you cannot measure. Patients may not make antibody to the infection. Patients may have a positive test. But it is cross-reacting to another organism, resulting in a false positive test.
He attacks quackery like live blood analysis and labs that do tests that have not been validated or approved by the FDA.
Little-known facts
Did you know there is an ICD billing code for being bitten by a duck? Did you know that the pneumococcal vaccine for children has resulted in a decrease in antibiotic-resistant strains in adults?
The number of bacteria in you and on you vastly outnumbers your human cells. “You are a sentient transport system for bacteria.”
“Google searches are a good early warning system for disease activity.” Searches for flu, muscle aches, and fever go up dramatically when flu is circulating in the community.
If a patient has a Hispanic surname and seizures, he is almost certain to have cysticercosis (pork tapeworm with cysts in the brain).
The most infectious organism is Norwalk virus: a single particle has a 50% chance of causing an infection. Shigella takes 10 organisms to cause disease, and other organisms typically take many more.
Transmission of herpes from contact during wrestling: over a five-year period, 39 of the 700 Sumo wrestlers in Japan got a new variant of herpes and two died.
Only 1% of bacteria can be cultured. Genomic techniques can find the other 99%.
“It has been estimated that more than half of everyone who has ever died has died of a mosquito-borne illness.” Malaria, etc.
People worry about getting AIDS from a needle stick. The risk for HIV is only 0.3%. The one to worry about is hepatitis B where the risk is 1-40%,
Humor
His writing is filled with clever and often atrocious puns. He calls the exams “Medicine Boreds.” After mentioning myelocytes and metamyelocytes he says “I have never metamyelocyte I liked.”
He once got a call from the ER with an unusual question. A performer at a strip club was lactating. When she spun, the patient got milk in his eye: did he need HIV protection? Crislip was almost laughing too hard to answer.
He includes an article about zombies and even a recipe for waffles.
Horror stories
A case of necrotizing fasciitis in a young man “required removal of most of the soft tissue of his thighs and abdomen, including his scrotum. His testicles were resting on a damp towel.”
Crislip once examined a lady whose pneumococcal eye infection ruptured during the exam.
In describing infections transmitted from animals to humans, he recounts his own experience with his children’s one and only pet. The hamster bit him, then fell down a heating duct and died there, spreading the odor of roasting, rotting hamster throughout the house. It cost $400 to fix.
Infection control
Crislip has long been in responsible for infection control in several hospitals. Bacteria can be cultured from ties, stethoscopes, beepers, etc. Handwashing is the best prevention. “Best practice bundles have almost wiped out hospital-acquired infections at all my institutions.”
Crislip is horrified by acupuncturists who don’t use gloves: “In my career I have seen several infections, including joint infection, due to acupuncture.”
Puswhisperer II: Another Year of Pus
Year II is more of the same, with the addition of POLL RESULTS after many entries. Example:
I worry most about:
- Kuru from a zombie 12%
- Hepatitis C from a vampire 21%
- Chilblains from a ghost 3%
- Rabies from a werewolf 0%
- Tomato stains from the Flying Spaghetti Monster 52%
- Other Answers 12%
- Black lung from Santa Claus
- Being eaten last by Cthulhu
- Consults from a homeopath
More horror stories
- A compulsive nose picker (rhinotillexomania) who picked his entire nasal septum away.
- A patient with cranial osteomyelitis (bone infection of the skull) from picking off a section of scalp down to bone about the size of a small plate.
- People who are allergic to penicillin can get allergic reactions from just having sex with a partner who is taking penicillin.
- A violently psychotic patient had a teratoma with ectopic brain tissue; the tumor produced antibodies that attacked her brain. Cut out the tumor, cure the psychosis.
More philosophy
- “I let others use new antibiotics and see if widespread use kills people.”
- “Much of medicine treats first world problems – complications of not dying from infections and poor nutrition.”
- “Often I get asked to do a consult with a question that has no answer, or at least not an answer that I can get without doing the patient some serious harm….Is it better to treat a disease that may not be there or not treat a disease that may be there?”
- When he doesn’t end up with an answer, most of the time it’s because the answer doesn’t matter: most infections improve with little or no medical intervention. Some diseases get better and we don’t have a diagnosis.
- “I hate getting tests that will make no difference in patient care, as much as my curiosity itch needs scratching.”
- “There is the acute illness of the patient and then there is the underlying disease that leads to the acute illness. There is the tree, and the dirt in which it grows.”
More humor
- “I am not a fan of seeing dermatology patients. I hate making rash decisions.”
- “…no abscess or phlegmon (sounds so Jamaican. Where is the phleg, mon?)”
- “Google to the fescue, since I hope to lawn something.”
More interesting facts
- “…iron deficiency protects against many infectious diseases such as malaria, plague, and tuberculosis.”
- If you have been infected with herpes simplex virus, you are probably shedding bits of HSV all the time. When you get sick, shedding increases. When you have a test as sensitive as PCR, you get positive results. Is HSV causing disease? Tough question.”
The third book: Flies in the Ointment: Essays on Supplements, Complementary and Alternative Medicine (SCAM)
This one is a carefully selected and edited compendium of the best of his blog posts from ScienceBasedMedicine.org. Yes, you could read them in the SBM archives, but you won’t. The book is conveniently packaged and organized into sections:
- What’s the harm? Why SCAM is bad for people, animals, and the environment.
- Alt-Facts: Why Scientific Thinking is Hard: Why our powers of logic are often powerless against SCAM.
- Counting to Ten: Statistics for the Rest of Us: Why interpreting the literature is difficult even for clinicians.
- Realm of the Possible: supplements, probiotics, etc.
- Eliminate the Impossible: Chiropractic, homeopathy, acupuncture, miscellaneous quack remedies.
- Vaccines and flu woo: The fallacies behind anti-vaccination beliefs, and why you should always get your flu shot.
There is a wide range of information, a wealth of humor, and a deep wisdom in these articles. Here are a few tidbits:
- “Human nature predisposes us to believe SCAM. You can’t change human nature but you can be aware of its flaws and compensate.”
- “Often getting the right diagnosis and therapy is less about what you know and more about being rigorous about understanding how you know. Only when you are conscious of your ability to think poorly, can you compensate. In the era of Google, any knowledge gap is a search engine away, but you have to be aware of the knowledge gap first.”
- “Don’t believe everything you think.”
- “If a product provides support and is not an undergarment, it is a crock.”
- “The ‘best’ way to make the body more alkaline is to go to a high altitude and develop acute mountain sickness. I don’t recommend this as a cure for cancer.”
- “Much of alternative medicine where it overlaps with real medicine is the art of making therapeutic mountains out of clinical molehills.”
- “What they call boosting or increasing immune health, I call inflammation.”
- “Licensed and certified magic is no more effective than unlicensed and uncertified magic.”
- “Adults have the right to be stupid; it is what makes American great.”
- “It is getting increasingly difficult to keep track of all the miracle cures I am supposed to keep secret.”
And I love his quotation from David Letterman: “Lose weight without diet or exercise? I guess that leaves cancer.”
There is more, so much more! I have read every post on SBM since its inception, but I had forgotten a lot. I was delighted to revisit Mark’s incisive wisdom and wit.
His writings are filled with typos, but it’s still easy to understand what he means. The errors of language don’t detract from his message except for those of us who are sticklers and grammar police. I am one of those, but I give Mark a pass because what he has to say is so clear and so important. I do wish he would get help from a proofreader; in fact, I would be happy to proofread his work for free.
Conclusion: Laugh and learn
These three books by Mark Crislip are all very worthwhile. The Puswhispererbooks will be particularly interesting for medical professionals, but the medically naïve can skim over some of the more esoteric details and enjoy the message and the humor. The SBM posts in Flies in the Ointment may appeal more to the general reader. There is much to learn from these books, and much to enjoy and to laugh about. The pieces are short enough to be perfect reading for the bathroom or the waiting room. Although the other people in the waiting room or the next stall may wonder why you are laughing out loud.
Mark, we miss you! I’m hoping you will become bored enough in your retirement to eventually grace the pages of SBM again with an occasional contribution.
This article was originally published in the Science-Based Medicine Blog.
