For many residents, hospitalists and other physicians, vancomycin and piperacillin-tazobactam has approached reflex status.  The patient has a fever, looks sick (perhaps even septic) and has no obvious infection so we start vanc and pip/tazo.

For yours this combination bothered me, because it implied the lack of a careful thought process.  If we just write vanc and pip/tazo, then we need not think further.  If we are lucky, some culture will turn positive and we can de-escalate.  I dislike the absence of thinking.

For a few years, I thought this reflex was unique to our training program, but visiting professor status has taught me of the universal status that vanc & pip/tazo occupy.

BTW, pip/tazo has the tradename Zosyn (but I prefer to think in generic drug terms).

More recently, we have learned that this combination has a major adverse impact – increased acute kidney injury.   This article – Risk of Acute Kidney Injury in Patients on Concomitant Vancomycin and Piperacillin–Tazobactam Compared to Those on Vancomycin and Cefepime

This study shows clearly that vanc & pip/tazo have a negative synergistic impact on the kidney.  The most interesting point in the article (to me) is that vanc trough levels predict AKI in vanc/cefepime but NOT in vanc/pip-tazo.

So in 2017 I fear vanc/pip-tazo.  Patients on this combination had a length of stay averaging 2 days longer!

The housestaff with whom I work know my fear, and work hard to avoid the combination.  Perhaps they are actually being more thoughtful about antibiotic choices.  That would be good for our patients.

Why you should read the Undoing Project

The Undoing Project, the new Michael Lewis book (Big Short, Blindside, Moneyball), tells the story of Kahneman and Tversky – 2 Israeli psychologists who challenged assumptions of rationality and decision making.  I first heard Tversky at a Society of Medical Decision Making meeting.  He presented their work and emphasized the concepts of heuristics and biases.  Over the past 35 years, I read their papers, and when Kahneman’s book – Thinking Fast and Slow – appeared I read it carefully.

Lewis takes us to the beginning of their collaboration.   He paints a picture of two very different men, from different backgrounds, different personalities and both absolutely brilliant thinkers.  He tells of their intellectual bromance, and explains how their mutual respect and challenging natures led to work so important that Kahneman eventually won the only Nobel Prize (in Economics) ever won by a psychologist.  Unfortunately, Tversky died young and could not win that award.

If you already know their work, this book gives you great insight into how they developed their theories and research.

If you do not know their work, this book provides a great introduction to their work.  Moreover, Lewis does a wonderful job of showing how their work has influenced other researchers in many fields, including medicine.

Lewis tells captivating stories.  He develops the protagonists’ characters so that you know that you recognize them.  He takes their complex work, and gives understandable examples to make their findings practical and accessible.

This stuff is important.  We, who practice clinical reasoning, must understand these concepts.  We physicians make these mistakes.  Experts in diagnostic error believe that understanding these reasoning shortcuts (heuristics) that can hamper diagnostic accuracy may decrease those errors.

The book took me around 4-5 hours to read.  I learned things despite having already spent significant time studying this field.

If you would like to read excerpts, I know of 2 great ones:

Bias in the ER

HOW TWO TRAILBLAZING PSYCHOLOGISTS TURNED THE WORLD OF DECISION SCIENCE UPSIDE DOWN

An insight on the challenge of changing behavior ( h/t @gretchinrubin )

Veteran readers know that I had a major behavior change in 2013 – becoming an exercise addict and improving my eating habits.  I lost approximately 35-40 pounds, and have kept that weight off for almost 3 years now.  The big question that my friends and acquaintances ask me is how did I do it.  My stock answer really is too simple – exercise more and eat less.  I had some idea of why I had success, but did not really understand why what worked so well for me might now work for others.

Last week I heard a wonderful interview with Gretchin Rubin (the podcast was Run to the Top).  She talked about the four tendencies, and her explanation struck home.

Your response to expectations may sound slightly obscure, but it turns out to be very, very important:
Upholders respond readily to outer and inner expectations (I’m an Upholder, 100%)
Questioners question all expectations; they’ll meet an expectation if they think it makes sense–essentially, they make all expectations into inner expectations
Obligers meet outer expectations, but struggle to meet expectations they impose on themselves
Rebels resist all expectations, outer and inner alike

In taking her quiz, I confirmed that I am a questioner.  For a long time I had thought about weight loss, yet had not mentally committed to that expectation.  Something clicked internally (suggestions from others had no great impact), and then I developed an internal strategy.  It would not have worked if I had not made this a major inner expectation.

I like having a BMI between 24 & 25.  I like the continued comments about my weight loss (3 years later).  I loved giving away my old clothes to charity and buying all new clothes.

But my strategy would not work for everyone.  Obligers and Rebels would not respond internally.  Upholders likely would have already lost the weight.

Rubin’s quiz is quick and easy.  As a physician, her explanation of the 4 tendencies helps me understand patients, and their challenges at behavior change.

Some patients – both upholders and obligers – will try hard to meet our expectations.  Questioners need to absorb information, and perhaps argue a bit about our conclusions.  Only when they are convinced that our recommendations are correct and worthwhile will we have a chance for them to adhere.  Rebels – just cannot do much with rebels.

We physicians know many rebels.  I never knew what to call them, but I recognize the personality type.

I once had a patient who had multiple medical problems.  She was an extremely intelligent rebel.  She recognized the wisdom of my recommendations, but admitted that she would do exactly as she pleased.  She never tried to fool me.  She died too young.

So I recommend that you read the link about the 4 tendencies and perhaps take the quiz.

I believe that I will use these concepts clinically to decrease my frustration with those who do respond to outer expectations.  After all, I am one of them.

Meet your exercise goals, not others’

Over the past 2 days I listened to a wonderful podcast – Life at the Back of the Pack: The positive spirit of the Sub-30 Club; Ted Spiker on leading from the back.

Ted Spiker writes a wonderful blog – the Big Guy Blog.  Several years ago, he had a goal of breaking 30 minutes for a 5k.  He wrote about it, and invited readers to join him in a support group.  Now the sub-30 club has over 4000 members.  They have custom T-shirts, meet ups, and new traditions.  They often have scheduled partying in the middle of the race.

The subbers (as they call themselves) have an overarching principle – support each member towards that member achieving their goal.  As I listened to the podcast about the subbers, I related their stories to my own exercise journey.

Readers know that I love OTF (Orange Theory Fitness).  One implicit principle at OTF is that we are all working to improve our fitness.  Having taken numerous classes at several different studios, I have seen participants in outstanding fitness shape and beginners.  At times we all compare ourselves to others in the class; but more often we compare ourselves to our previous accomplishments.

The best exercisers respect everyone’s accomplishments.  They have the attitude that anyone showing improvement is doing great.

Speaking of sub-30, when I started running 3 years ago, sub-30 was exactly my goal.  Having achieved that goal, I set new goals.  I remember the thrill of meeting the sub-30 goal.  Now I have accomplished some new goals.  OTF has peak performance measures twice a year.  I improved my 1 mile time and my 24 minute distance.  Of course I have set new goals for a 5k and for the next OTF peak performance.

The subbers now include members with various goals.  They support each members striving for their own personal goal.

Some runners and exercisers strive to win races.  But races and goals have different meanings to the average participant.  We should all follow the subbers philosophy.  We should all celebrate everyone’s efforts and personal successes.  We should all be philosophical subbers.