This email popped 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 CD4 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 CMV retinitis. My drug-interaction checker says I can't use valganciclovir 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?
Thanks so much.
There are two issues with this email worth discussing.
The easy part first -- the medical question. Here's my response:
There 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: www.hiv-druginteractions.org.) So switch the Truvada to Descovy (tenofovir alafenamide/emtricitabine), that's all you need to do. Safer for kidneys and bones, too.
The second item to cover is whether we should be answering questions like this at all. Remember, this is from a person I don't know, asking about a patient I've never seen.
Though I obviously responded to the query, there are a few reasons not to answer questions from clinicians you've never met about patients you haven't seen.
The medical information might not be correct, 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 your name is in the chart, there's a medicolegal risk -- especially if you review patient data sent to you. The risk may be small, but who wants to take that chance?
And if you ask an economist, they would say it definitely makes no sense to answer these questions -- not only are you being paid nothing, but there's little chance of downstream revenues, and it takes time away from other remunerative tasks and opportunities.
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.
- Answering helps the patient. Sometimes cliches are true: helping people remains the primary reason most of us went to medical school to begin with.
- Answering helps the clinician. 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 when John Galgiani responds, given his voluminous experience. Ditto various cases over the years involving rapidly growing mycobacteria (Richard Wallace), bartonella (Jane Koehler), toxoplasmosis (Jose Montoya), Mycobacterium avium complex (Chuck Daley, Gwen Huitt), cytomegalovirus (Richard Whitley), and many others. Thank you!
- It was a straightforward, focused question, presented clearly. 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.
- The person asking was polite. 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.) No "Thanks in advance for your rapid reply." (Ugh.)
- It's flattering when someone asks you questions in your area of expertise. Gosh, Marie chose to ask me 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?)
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.