Paul Sax, MD

Paul Sax is an infectious disease physician who blogs HIV and ID Observations, a part of NEJM Journal Watch.

An infectious disease doctor answers your COVID-19 and coronavirus questions

Paul Sax, MD

Conditions

March 5, 2020

Being a specialist in infectious diseases right now is an interesting experience. Added to the usual challenges of our everyday practice — caring for people receiving transplants or chemotherapy, those with HIV, surgical infections, tropical diseases, and others — we now must manage a deluge of coronavirus-related questions from friends, family, and colleagues.

Here are a few recent examples in bold, along with my responses.

Frequently asked questions

My baby …

When should physicians read the House of God?

Paul Sax, MD

Physician

August 2, 2019

Many consider the novel the House of God, written by Samuel Shem (pen name for Stephen Bergman), to be a must-read for any physician or soon-to-be physician. A fictionalized account of his internship year, the book details how the accumulated stress, fatigue, and powerlessness of being a first-year doctor inexorably accumulates during that year — with sometimes hilarious, and but also disastrous, results.

The survival strategies of the interns in …

Should we write that patients are “pleasant” in medical notes?

Paul Sax, MD

Physician

May 17, 2019

When writing medical notes, some clinicians include an appreciation of their patient’s personality and disposition in their opening line (the “chief complaint”), or when they’re wrapping up (in the “assessment and plan”), or in both locations.

You know — it goes like this:

“CC: Ms. Smith is a very pleasant 62-year-old woman admitted with …”

or:

“A/P: To summarize, Mr. Jones is a delightful 89-year-old man presenting with …”

or:

“CC: This lovely 74-year-old retired school teacher was in her usual state of health …

Why this physician chose to specialize in infectious disease

Paul Sax, MD

Physician

April 16, 2019

Forgive the autobiographical nature of this post, but here’s a recap on how I started down the path to becoming an infectious disease (ID) doctor.

To begin, understand that my first year of medical school was rough going.

In hindsight, this wasn’t surprising. After majoring in English during college (with a minor in the Harvard Lampoon to develop good study habits, ha ha ha), then spending a year abroad teaching, I found medical school’s unrelenting …

Why do we still use CD-ROMs for radiology images?

Paul Sax, MD

Physician

November 21, 2018

In the United States, any person who has tried getting their own (or their patient’s) radiology images from another hospital or practice will find the practice painful.

Here are several obvious reasons why the CD-ROM — briefly the darling of large data transfer — is a truly terrible way to share radiology images in 2018:

They require physical transfer. Remember the term “snail mail”? Do people still say that?

They are slow. When you bring a …

This infectious disease physician still finds HIV care rewarding. Here’s why.

Paul Sax, MD

Physician

August 20, 2018

Earlier this year, I wrote a piece about friends and colleagues of mine who have left HIV clinical practice. Something about it touched a nerve.

Admittedly, it was kind of a downer — but it might have been slightly misinterpreted. A lot of the problems my friends cited could have easily applied to almost any area of clinical practice; these challenges were by no means limited to HIV care.

They mentioned the …

It would be disastrous if we reverse our impressive vaccine progress

Paul Sax, MD

Meds

January 30, 2017

As an infectious diseases specialist married to a pediatrician, I am going to propose, in most unhumble fashion, that I have the ideal perspective to assess the worthiness of vaccines.

So when Robert F. Kennedy Jr., a notorious anti-vaccine crusader, announced that he was under consideration to head a government commission on vaccine safety and scientific integrity, and is planning to step away from his environmental job to take that post, I …

The relatively low compensation of infectious disease specialists

Paul Sax, MD

Physician

May 9, 2014

MD-Compensation-Report

Now a median of $174,000 per year is hardly chump change, so I don’t expect much in the way of sympathy on these data. On the other hand, someone has to to be last, and note that our income hasn’t increased a bit since the last time I commented on this survey three years ago.

So it’s worth taking a few moments listing …

Baby cured of HIV: What’s the real story?

Paul Sax, MD

Conditions

March 25, 2013

As undoubtedly you’ve heard by now, there’s another person cured of HIV out there — this time, it’s a baby born to an HIV-infected mother.

Here’s the story: The mother didn’t know she was HIV positive until delivery, and the baby was found to be infected by both HIV DNA and RNA right at birth. The doctors started combination antiretroviral therapy approximately one day later, essentially as soon as the results …

HIV screening and the USPSTF: Better late than never

Paul Sax, MD

Conditions

December 10, 2012

A flurry of coverage recently appeared about the U.S. Preventive Services Task Force’s recommendation for one-time HIV screening for all Americans, ages 15-64.

Some might wonder why this is news — um, hasn’t this been recommended now for years? — and I think I’ve figured it out.

Let me start by relaying that every ID/HIV specialists can tell some version of the following sad story, which is still repeated on a regular basis …

What is your case conference personality?

Paul Sax, MD

Physician

March 4, 2012

We specialists in infectious diseases love case conferences — especially those where the case is presented as an “unknown,” and we try to figure out the diagnosis from the history.

I suppose this isn’t very surprising, since ID cases in general are already among the most interesting in all of medicine. Those that are case-conference-worthy are particularly prime.

“Funny bug in a funny place,” was how one of my colleagues characterized these …

The specialty that makes doctors rich and happy

Paul Sax, MD

Physician

September 8, 2011

A long time ago, I was very close to becoming a cardiologist. Really.

Even though my fascination with ID and microbiology started in medical school — and believe me, not much fascinated me in medical school — the fact that all the top residents in my program were going into cardiology made me feel that somehow I should be doing this too. Plus, the guy who was Chief …

How switching from brand name drugs to generics is sometimes absurd

Paul Sax, MD

Meds

June 16, 2011

I had an interesting exchange with one of our nurses recently about a long-term patient of ours.

The e-mails went something like this:

Got a fax from —-’s insurance that his Lipitor won’t be covered anymore. They will cover simvastatin, lovastatin, and pravastatin. Let me know what you want to do.
Charlie

He’s on darunavir, and all three of those statins are contraindicated because of drug-drug interactions. Rosuvastatin?
Paul

Checked with them — rosuvastatin needs …

Read more…

How switching from brand name drugs to generics is sometimes absurd

How an EMR can be shockingly inconvenient for prescription refills

Paul Sax, MD

Tech

March 31, 2011

Let me start by confessing I’m something of a gadget freak. I was an early Palm Pilot adoptor, loved the iPod from the get-go, and need to avoid CNET, Engadget, Gizmodo, and David Pogue’s columns for the New York Times when deadlines loom.

Not surprisingly, I embraced the shift to electronic medical records (EMRs) enthusiastically. While I acknowledge that sometimes EMRs …

Adherence to HIV treatment in Africa

Paul Sax, MD

Patient

January 24, 2011

There has been an irresistible urge for people — doctors, public health officers, politicians, journalists, the usual pundits — to compare adherence to HIV treatment in resource-rich vs. resource-limited setting.

I suspect this is because the whole issue got off to a famously bad start in 2001, when then-head of the U.S. Agency for International Development (USAID) Andrew Natsios said in an interview with the Boston Globe that Africans,

don’t know what Western time …

Read more…

Adherence to HIV treatment in Africa

Pregabalin for HIV related distal sensory peripheral neuropathy

Paul Sax, MD

Meds

November 24, 2010

Published earlier this year in the journal Neurology – not typically on my radar screen — is this remarkable study comparing pregabalin to placebo for HIV-related distal sensory peripheral neuropathy.

Here are the results:

At endpoint, pregabalin and placebo showed substantial reductions in mean Numeric Pain Rating Scale (NPRS) score from baseline: -2.88 vs -2.63, p = 0.3941 …

… Individuals with HIV-associated neuropathy achieved NPRS treatment effect size similar to those in …

Read more…

Pregabalin for HIV related distal sensory peripheral neuropathy

Why specialists don’t do more curbside consults

Paul Sax, MD

Physician

October 6, 2010

One of the simultaneously most enjoyable and exasperating aspects of being an infectious disease specialist is the large volume of “curbside” consultations we get from colleagues.

For example, here’s this week’s tally — and it’s only Tuesday — done from memory and without systematically keeping track of emails, pages, phone calls, etc.:

Duration of antibiotics after urosepsis, organism resistant to TMP/SMX and quinolones
Need for repeat immunizations in splenectomized adults (got that one …
Read more…

Why specialists don’t do more curbside consults

Empiric antibiotics in the ICU

Paul Sax, MD

Meds

August 31, 2010

Last year, I commented on the ironic sameness of ICU infectious diseases — that incredibly sick, complex patients entered the ICU with vastly different problems, then over time, seemed to converge, presenting similar kinds of clinical issues and management challenges for the ID doc.

Or, as a visiting medical student said to me, “My ICU attending said that every patient in the ICU should be on vancomycin and Zosyn.”

Which brings up …

Read more…

Empiric antibiotics in the ICU

Notes in the chart are helping patients less

Paul Sax, MD

Physician

August 4, 2010

What is the purpose of the note in the patient chart?

Depends who you’re asking.

The best guidance I ever received on how to write a good note came from my residency program director, who told us that a note needn’t be encyclopedic to be excellent; in fact, he urged us to get away from the “second-year medical student” style, which typically includes absolutely everything.

Instead, he urged us to write, as concisely …

Anal cancer screening in HIV+ men

Paul Sax, MD

Conditions

July 4, 2010

In Journal Watch AIDS Clinical Care, we published a simple case: Clinically stable HIV+ gay man, on HIV treatment; anal pap comes back with “atypical squamous cells of undetermined significance” (ASCUS).

What to do with this result? Two experts weighed in, Howard Libman and Joel Gallant. In Howard’s thoughtful response, he acknowledges the limitations of the data thus far, but said he would refer the patient for high-resolution anoscopy (HRA) and …

Read more…

Anal cancer screening in HIV+ men

Paul Sax, MD

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