Columns Oct 26, 2011 at 4:00 am

Can Bacteria Forget How to be Resistant?


Again "Dr." Golobs position as an physician is allowing him to spread dangerous and inaccurate information. For example, "in fact, for most bacteria (aside from some key exceptions), just about any antibiotic will kill them off". That is simply not true. Infectious disease specialists train for 6 years (and more) AFTER medical school to learn to judiciously select the best antibiotic regimen for certain infections. As someone who works with them all the time, I can tell you that there are far more that "some key exceptions". In fact, for each and every infection/bacteria there is a limited number of antibiotic regimens that can effectively treat it. In addition, some antibiotics do not kill bacteria at all. These "bacteriostatic" antibiotics only halt bacterial growth, and usually need to be used in combination with "bacteriocidal" (killing) antibiotics. I AM MENTIONING THIS BECAUSE WHEN "DOCTOR" GOLOB WRITES STUFF LIKE THIS, IT MAKES PEOPLE USE OLD ANTIBIOTICS THAT THEY HAVE LYING AROUND AT HOME. I have had many patients tell me that they never saw a doctor for their pneumonia because they found some old antibiotic prescription that they never used and they figured that any antibiotic would work. Jonathan, you might want to remember the mantra "first do no harm" (although that phrase is not explicitly stated in the hippocratic oath, I find it useful). USING YOUR MD TO SPREAD INACCURATE INFORMATION ABOUT ANTIBIOTICS IS HARMFUL.
Jonathan also neglects to mention another important point - the majority of antibiotic resistance is not due to the use of these drugs in health care. Actually, according to some agricultural experts, the majority of antibiotic resistant bugs is due to widespread use in the cattle industry. I mention this because physicians get blamed all the time for "being the problem". While I do believe that we as physicians need to careful about how we use antibiotics, I think the truth is that most of the problem is NOT coming from us.
You can come at Jonathan for oversimplifying, but he's not wrong. Most bacteria are killed off easily by "first line" broad-spectrum antibiotics. It happens that resistant bacteria are not anywhere near as common as the run of the mill pathogens which are less common than non-pathogenic bacteria.

As for "majority of resistance" issues, you are pretty off-base there, too. The most widespread use of drugs in agriculture are feed-additive, sub-therapeutic antibiotics. They are generally classes of drugs that aren't used in human medicine. Ionophores, which are the most common class of feed additive antimicrobials, have no current bacterial target in human medicine. They aren't even administered to reduce bacterial burdens in feed animals, they are to reduce protozoal parasite burdens. Most of the actual antibiotics used in feed are long since abandoned as human drugs, but they still work fine as growth enhancers, lightening the burden on an animal's immune system so they can put energy into production. Drug classes useful for human pathogens are much more tightly regulated and are generally not feed additives. Places that have banned using feed-additive antibiotics (I think Denmark was one, but I'd have to check) end up with sicker animals, more severe infections, higher doses required to treat them, and more advanced drug classes. Basically more drugs are used, more animals are sick, and more drugs that are important to humans end up being used in veterinary applications, increasing the likelihood of breeding resistance to antibiotics that we actually use.

Yes, the public needs to be more concerned about making sure that the infection they have is treated by an effective dose of the right drug for a sufficient duration. However, that wasn't the question, and his answer did not propone using any old antibiotics lying around the house.

I would point out that recently there has been some change in the idea that most resistance is particularly energy intensive. Studies are finding that many resistance genes are persisting much longer in populations than would be predicted for traits that are mildly deleterious (as is expected when energy is wasted). Not a good thing.
@Kaliann, I would be interested in seeing how many of your patients (I am assuming that you are a doctor?) have acted inappropriately because they have heard a doctor, such as Jonathan claims to be, say that "just about any antibiotic" will work. I can tell you that for the patient populations that I have treated, this number is far from zero, and I have had to do some extensive re-teaching of patients who were misinformed by someone that they believe was qualified. No doctor would ever propone using any old antibiotic around the house. But as we know (again, assuming that you practice medicine), how patients interpret statements is variable. This is why I think it is the social responsibility of doctors to be as accurate with their statements as possible. Just because you did not interpret his article that way does not mean that others won't.

Jonathan did not say that most bacteria are "killed off by first line, broad spectrum antibiotics" (quoting you). He said, and I quote, that "for most bacteria, just about any antibiotic would kill them off". The two are very different statements. Now, if he said that as "Bill the janitor", that is one thing. But stating that as "Jonathan the doctor" is another. In fact, I have allowed several of my fellow physician colleagues read this article, and they also agree with me that it sends a somewhat dangerous message.

Re: my comments about resistance, I was simply quoting the views of people who are recognized experts in this area. If you can demonstrate that you are an expert in this, I will be happy to quote you as well. Until then, I would rather stick with the people I know than the people I don't. In any case, my main point was that physicians get a lot of blame for something that is not really their fault.
I'm in pathology, so while a doctor, I don't talk to patients for my job. Infectious diseases are rather a focus of my specialty, and not to get too specific, zoonotic pathogens are particularly relevant to my program. Hence my commentary on resistance. Most people are wildly uninformed about the use of feed antimicrobials and results thereof. Unfortunately, at the densities current agricultural practices keep food animals, feed additives are better than the alternative of only treating the sick animals. Better still would be reducing densities of animals, but this is not currently economically feasible for producers or tolerated by consumers. Don't take my word for it, though, I encourage you to look up the research on it. There are definitely some drugs that should not be used in animal feeds (avoparcin is linked to vancomycin resistance in enterococci), but there are others that do not have any evidence of promotion of resistance relevant to human disease (e.g. ionophores, which are dosed at coccidiostatic levels).

Physicians using correct drugs for treatable bacterial conditions shouldn't get the blame. There is a lot of resistance that comes from patient non-compliance. (Srsly, take all the meds! Even if you are feeling better! Please, for the love of MRSA, take the meds.) However, you know there are GPs out there who will empirically treat with Abx when a patient has a viral infection. That needs to be decreased. Your statement that "[i]nfectious disease specialists train for 6 years (and more) AFTER medical school to learn to judiciously select the best antibiotic regimen for certain infections" is a bit disingenuous when you know that most Abx are not administered by them, they are prescribed by GPs. Yeah, experts do train for a really long time, and in outbreaks of public health concern, hopefully they are calling the shots. They aren't the ones blowing through Augmentin and Cipro like they are candy, though, and I'm pretty sure you know that.

One of the larger problems with the development of resistance is that we take our sickest people with the nastiest bugs and put them in environments surrounded by other sick, vulnerable people. Hospitals. Nosocomial infections are a huge issue that needs a multifactorial approach to reduce in-hospital duration, improved access to smaller clinics, better social coordination for in-home care, and improvement of tele-medicine, among other things. It'd be nice if we had a health care system where people could be seen by a GP for their common infectious diseases rather than walking into an emergency room every time they need to be treated. (Sorry, that was a bit of a tangent.)

Back to the issue at hand, I can understand your concern. The article doesn't make a real distinction between "most bacteria" and "most infections". While doctors intuitively understand the difference, a doctor saying "most bacteria can be killed off by just about any antibiotic" can easily be misconstrued by a patient to mean "most infections can be treated by any antibiotic", which is, of course, a dangerous misunderstanding. An infection must be diagnosed and treated by a doctor with an appropriate medication for a duration sufficient to ensure complete clearance of all of the pathogens targeted.

I think this point could have been clarified without the use of caps, scare quotes, and melodramatic exhortations to "first, do no harm".
Interesting points you make about resistance, although, as I said, I was merely citing others, who are also quite qualified. As with any field in science, there is sure to be disagreement. However, I have done some reading on it, and there are certainly those who disagree with you. I would love to elaborate, except that the debate of how much agriculture plays a role was certainly not the point of my original response.

Actually, my comment about how long infectious disease specialists and how long they train is not being disingenuous at all. I was simply pointing out that antibiotic choice is not a simple as Jonathan was making it out to be. In fact, GPs get it wrong all the time.

Thank you for acknowledging my main point- that it is important that we as physicians are clear and appropriate when we make public statements. As for the "caps and scare quotes" - I should just point out that this is not the only article that Jonathan has used his title as an "actual doctor" inappropriately. If my tone seems harsh, it is because I am calling him out. Now, I may agree with him on many of his other articles, but I do not think that it is ever acceptable for any physician to say "I am a doctor so I believe in (insert political view here)." As I hope you would agree, being a doctor is an honor, not a means to lend credence to public opinions on many topics, some of which have nothing to do with medicine.

Finally, re: your reference to "first do no harm" as "melodramatic exhortation" - pathology was clearly the best choice for you. Some of the finest, most dedicated physicians I know use this phrase on a daily basis, in matter of fact conversation. The reason for this is that when you are dealing with patients, it is actually incredibly easy to forget this mantra. How many times do we get a CT scan reflexively because we haven't thought about the patient enough? How often do was draw some extra blood for a lab we do not need? How often do we get sloppy with our medical jargon, or confuse our patients? This is not melodramatic exhortation. This is something that we need to remind ourselves every day, because it is so easy for us to harm our patients. I respect pathologists, I really do, but if you were directly involved in patient care you would never refer that phrase as melodramatic.
Let me be clear, while I am not currently involved in clinical medicine and direct patient care, do not assume that I never was. Also, as you well know, any doctor will have absolutely every friend or family member asking them about medical problems, procedures, test interpretations, and physiology constantly. I see the results of patients confused by their GPs all the time, and I have the luxury of a little more time to unpack the concerns and explain their doctor's positions to them. I've comforted many people by demystifying medicine for them.

Your presumption that I'm in pathology because I lack due reverence for the principle of "first, do no harm" is insulting and inaccurate. I don't have an issue with the idea, I simply think your use of it in your tirade was melodramatic. Your point would have been better made by clarifying the issue at hand, without implying that Golob, your colleague, has a basic deficit in understanding the primacy of non-harm.

A patient reading your rant is likely reading it because they already like "Dear Science"; they are a group self-selected to like Dr. Golob. If you want to educate them on a point you felt was dangerously unclear, you can do that convincingly without producing what appears to be a textual tantrum. You diminish your credibility with histrionics. If your concern is, as you claim, patient education, then take the opportunity of these comments to educate on something relevant to the article (as part of your comment attempted to do), and leave out the entirely unprofessional all-caps shouting.
If the point of my comments were to educate people, I would agree with you. I do not pretend that a comments section beneath an article is a realistic forum by which to educate people. These comments sections are usually either to direct a message at the author, or to prompt discussion, both of which I did effectively, apparently.

On reading my initial comments, I hardly find that that they were a tirade or a rant. It appears that you took offense to my use of caps and scare quotes. I hardly think that putting caps is unreasonable, given that the font size of the comments section is miniscule compared to the main article, and I am not sure which of my quotes was scary to you.

You also seem to make alot of assumptions about what I am trying to say, although I never said it. I never stated, or even implied, that Jonathan has a deficit in understanding non harm. If you read my comments, I told him that he might want to "remember" that. If that implies anything, it is that he DOES (pardon the caps, I know it offends you) understand non-harm.

I also never assumed you were never involved in patient care. In fact, to my knowledge, it is actually impossible to be a pathologist without doing so. However, as most doctors I know will be the first to admit, lack of continued involvement in patients does make one forget the challenges of patient management, especially clinic visit management.

Finally, I made no suggestion that you are in pathology because you lack reverence for the principle of non-harm. I said it is a good thing you chose pathology. However, by referring to my use of it as "melodramatic", my impression is that you certainly do lack reverence for it. My point was that using that phrase is never melodramatic, and that most doctors I know would agree with me, especially the ones who trained me. In any case, I certainly was not trying to be melodramatic when I was using it.

I understand that you de-mystify medicine for people, or clarify test results etc. I applaud you for it, but let me ask you: in your daily activity, when do you have the opportunity to harm a patient? By this, I mean that other than making a medical error, how often to you make a decision that involves putting patient through more suffering, or exposes them to risk? Do you order the biopsy? or the CT scan? or the extra blood? I was simply stating that if you were in a position to harm patients 20 times a day, perhaps the "first do not harm" mantra would not be so melodramatic to you. I am telling you, it is ridiculously easy to forget this. I see doctors, including myself, do it all the time.

One more point - you seem to agree with me that at least part of Jonathan's comments could lead to dangerous misunderstanding. So, is it not fair to say that he forgot to "first do not harm" in his original article?
First do no harm is never melodramatic? Really? If you had used "Do unto others as you would have them do unto you" or or any of a number of well-known aphorisms in an intermittently caps-shouted diatribe, I'd have called those melodramatic too. It's not because I lack respect for what I consider to be a moral cornerstone (the Golden Rule), it's that you don't get to pretend that my critiquing your usage and context is the same as my having diminished reverence for the concept.
It is interesting that you begin by claiming that you never suggested I lack reverence for non-harm, but follow it up with oops, actually I do, for daring to call your usage melodramatic.

I'm not entirely sure why it is important to the conversation that you are in a position to harm patients directly more frequently than I am, but you can win that contest. (Though it is convenient that you exclude "medical error", allowing you to basically claim that you "ordering an unnecessary blood test" is much more valid than my "if I give the wrong diagnosis the patient loses a limb, goes through unneeded chemo, or dies because I thought it was benign.")
I'm sure you are not implying that pathologists (or me specifically) are less able to be concerned about harming patients simply because we physically interact with them less.

As to whether or not Golob forgot FNDH in the original article, no, I don't believe that his memory has a problem. He was unclear in a way that, as you pointed out, might contribute to a lack of understanding on a very important subject. I agree there, but accusing him of forgetting a fundamental tenet of medical ethics is excessive.

Also, putting the title of Doctor in scare quotes is rather unprofessional. You seem to be unclear on what I'm referring to, so allow me to clarify:…

Actually, yes, I am implying that you seem less concerned about harming patient because you physically interact with them less. I would not extend that to other pathologists, of which I know many who I believe are excellent doctors and do not think that "first do no harm" is ever melodramatic. In fact, "first do no harm" was first taught to me years ago by a pathologist who had a profound influence on my career, who emphasized how easy this is to forget, and told me never to forget it, and to be sure to remind all my colleagues never to forget it. He would never refer to it as melodrama. Since at this point I am pretty sure that he is a more respected pathologist than you (try not to take offense - he is more respected than anyone I know in all of medicine, which is saying something), I would be inclined to follow his lead rather than yours.

I should also point out that the majority of articles written by Jonathan were done when he had not earned his MD, so actually, the lack of professionalism is in pretending that he had reached a stage of training that he had not reached. I actually think the scare quotes are going pretty easy on him.

The fact that you seem to express more concern about my professional conduct and less concern about his negligence (which, by the way, you agree with) only goes to explain why the public seems to view doctors as a group that defend each other, rather than public safety.

Re: your comment that you don't believe Golob "has a memory problem", again you completely ignored what I wrote - I said that ALL doctors, including myself, have a memory problem when it comes to FDNH (my god, that was in all caps, I'm sorry). I was not trying to single out Jonathan at all. Rather, I was trying to teach, much in the same way that my pathologist mentor taught me.
@Kaliann I was reading all of your comments over again. Lets summarize them so far:

Jonathan's statement that you acknowledge is potentially dangerously misleading: Jonathan was "oversimplifying". No further comment.

My use of scare quotes and caps: "unprofessional" and criticized multiple times.

Way to keep your eye on the ball, doctor. Perhaps I might give your comments more credibility if you at least acknowledged that Jonathan was being irresponsible. Apparently, in your world, the use of scare quotes is a greater crime than a physician who misleads.
I did not write in to berate Golub or convince you that he was perfect, I wrote to point out that the article was not factually incorrect but easily misunderstood. And then I a) clarified the parts of his article that were easy to misinterpret, b) addressed the parts of your comment that were also rather oversimplified and misleading regarding resistance associated with feed additives, and c) brought up a more recent issue on how resistance may not be as energy intensive as once thought, indicating that persistence of resistant genes is a problem we should all be concerned about. My original comment was primarily focused on education and clarification, due to my concern for public health and knowledge. I also felt that your approach detracted from the information, and so I tried to provide a more reasonable voice for potential patients. I expanded on and agreed with some of your points and disagreed with others, but did so without implying basic moral failings on your part.

You missed an opportunity to clarify the article in your rush to paint him as an irresponsible quack. An admonishment to point out how the oversimplification would be easily misinterpreted would have been much more effective at actually educating the public.

You admit that you have had trouble with remembering non-harm in the past, but I assume you still expect people to refer to you as doctor. That courtesy does not extend to others, it seems. This article was written by a doctor. Previous articles are not at issue. Scare quotes are unnecessary.

You seem determined to misconstrue my critique of your approach, which has been rather histrionic from the start, as insufficient reverence for a time-honored tenet of medicine. Citing "first do no harm" does not make you invulnerable to criticism, and your continued harping on my supposed lack of respect for patient well-being is misguided.

You had a perfect opportunity to clarify the issue in a convincing and reasonable way, which would be more likely to actually correct potential misunderstandings and improve the knowledge of the general public. Instead, your comment made you sound emotionally unbalanced and discredited both your point, which had merit, and your profession, where patients expect doctors to be rational and knowledgeable.

Apparently, in your world, the use of scare quotes is a greater crime than a physician who misleads.

Your straw men do not help your credibility. People are more likely to be receptive to your recommendations if you can present your arguments while sounding objective, responsible, rational, and thoughtful. It's extra nice if you can actually be those things. Don't let your demeanor convince people to dismiss your advice simply because you sound over-emotional or hostile. It does a disservice to your training as a physician.

It appears that I have been debating with another pretend "doctor". @kaliann: you might want to consider that the practice of human medicine and veterinary medicine are, you know, different? I mention this because you seem to comment on how physicians should act, or how people should be treated. Yet, you are certainly not qualified in any way to do so, at least in no way more than anyone else who does not practice human medicine.

I am sure that you are very proud of your profession, but apparently not proud enough to state upfront that you are a veterinarian. Instead, you refer to yourself as a pathologist (which you certainly are), but perhaps by not being totally honest you are covering up some insecurity? Or, you just wanted to spout off about my behavior as a physician and trying to claim some credibility by pretending to be my peer? I do not recognize you as a peer, no more than you would recognize me as yours if I called you unprofessional, melodramatic, and disingenuous.

Now, at this point I imagine that you are plotting some diatribe about how veterinary medicine is just as worthwhile as human medicine, and that the two are really the same. Fair enough, so long as you answer the following question. If you had to choose between saving your child, and saving your dog (assuming that you have both), which would you choose? I know what my choice would be. If you can honestly answer that you would sacrifice your child to save your dog, then I would be delighted to put your profession on equal footing with mine. But if you think that human life is more important than animal life (which most people do), then I would suggest that we should hold irresponsible physicians, such as Jonathan, to a higher standard, don't you think?

No doubt you are going to call me arrogant, harsh and mean. After all, given that my scare quotes and caps led you into such a tizzy, I would imagine that this comment is making you fume right now. Please bear in mind that I just received a professional ethics lecture from someone who has never once saved someone from the consequences of Jonathan’s negligence, as well as the negligence of other physicians. The child who is not vaccinated because a physician says it causes autism, the mother who does not feed her child because a physician wrote that fatty foods cause cancer, the physician who simplifies antibiotic use.

Suppose that there was an article about an animal shelter that mistreated animals, you express your outrage, and then I, under the pretense of being a veterinarian, told you that you were being melodramatic? Purely hypothetical, of course, because I would never be unethical enough to pretend to be something I am not. You, “doctor”, are a CHARLATAN.
Such outrage! I am a doctor, a pathologist, and a medical professional and never claimed to be a human physician. While I considered specifying my veterinary origin, I considered it orthogonal to the subject at hand. I admit that I left your assumption unchallenged, focusing on common ground, and here you are calling me a pretend doctor and a charlatan to justify my point. My expertise in pathology was the original purpose of entering into this conversation on antibiotics and resistance, and my education and credentials on that subject are likely as good or better than yours, particularly when it comes to zoonotic pathogens and resistance. This article was not about canine physiology, which would be out of your expertise, it was about antibiotics and resistance, in which you, Golub, and I are all trained professionals.

I commented on how doctors should comport themselves (reasonably), how the public should be educated (clearly and thoroughly), and how non-harm of patients is a vital medical tenet. I have been calm, measured, and educational. Meanwhile, you have consistently been insulting and dismissive of any attempts to temper your demeanor. Yes, you did just get a professionalism lecture from a veterinarian, and your response was "but you aren't even a real doctor". If you can't meet the standards of public and professional discourse set by a lowly veterinarian, how do you expect people to respect your medical recommendations?

Consider this: your initial comment, and many of the ones that followed, served mostly to make you sound volatile and unreliable, and to denigrate another doctor. You managed to damage both his credibility and your own. You could have focused on addressing the shortcomings of the article in a meaningful and convincing way, which would also have impressed upon Dr. Golob as to why he has a responsibility to be careful and clear in his explanations. This would have been to the betterment of both public health understanding and Golob as a doctor, but instead you managed to make it less likely that people will trust either of you. And therein lies the harm.

On further reflection, I do owe you an apology. It was disingenuous of me to allow and encourage you to consider me a human practitioner. I can see that this has upset you, and I am sorry for that as well.

While I don't believe my field detracts from my arguments, it has prevented you from considering them on their merits. I can only hope that someone with suitable credentials can offer you a critique that you will eventually hear and improve yourself with.
If you had simply left your comments to the science, perhaps you would have been better heard.

You constantly make the assumption that I was attempting a public education statement. I was not. I was reprimanding and educating a fellow physician. If you were a physician yourself, you would not think my language was melodramatic, unprofessional, histrionic or any other myriad of adjectives that you used to describe it. You would have recognized it as the socratic method by which most senior physicians address junior ones when the latter have acted irresponsibly. While you might not like my language, I am reasonably certain than Jonathan, as with most other physicians in training, hears far worse on a daily basis.

Whether you agree with the subculture of human medical practice or not, the fact is that it exists. The criticism is doled out, and accepted, between physicians, because we understand that human health, rather than our personal feelings, is of the highest priority. I agree with you that the interactions can be harsh, but in our field it often results in the most rapid learning, and I am fairly certain that Jonathan will be more considerate of the accuracy of his statements in the future.

Physicians accept harsh criticism because we have all had to deal with consequences of another acting irresponsibly, and we feel that we cannot improve unless we are willing to be blunt, critical, and honest. Case in point - Jonathan did not try to challenge my criticisms. Like most well-intentioned physicians-in- training, he likely went with the assumption that he did not act as appropriately as he could have, that he deserved to be criticized, and that he could improve his conduct. This is exactly how it should be.

While physicians will often give and receive such socratic criticisms between each other, we typically do not do so from outside forces. I was willing to accept, at least in part, criticism from you when I thought you were physician, because I assumed that as part of our subculture you have accepted criticisms from other physicians in the past.

I realized that you might not be a human practicioner because you kept insisting that "first do no harm" was melodramatic. Physicians remind each other of this so many times during training, I simply could not understand how another physician could take offense to my use of that phrase.

Your being a veterinarian does not discredit the science behind your comments, but it completely removes your right to lecture me on professional conduct towards a colleague. Hence, my outrage.

I appreciate that you are now conversing in a much more diplomatic fashion.
I understand that you are unable to accept my critique as you would a member of your in-group; perhaps I can offer a different perspective.

Please bear in mind some points, if not from a physician, at least from an educated professional and member of the public:
1) You did not make your comment in the forum of the medical in-group - this is not a hospital or training facility wherein harsh comments between doctors, especially mentors and trainees, are indeed par for the course. You, an anonymous person claiming to be a doctor, launched a very aggressive statement in the public forum at a named and known individual who is a doctor. It was not even phrased as being directed to him (other than 2 sentences), but rather about him. While Golob would undoubtedly read it, you were virtually guaranteed that your audience would be primarily non-medical. As a person outside your in-group, perhaps I am even better situated to inform you that your "reprimand" came across as intemperate to a degree that damaged your credibility within that wider context and diminished the efficacy of any attempt at clarification. If you really believed that your comment was genuinely useful to him and the tone appropriate between doctors, then you should have kept it between doctors by emailing him directly and identifying yourself. I sincerely believe that you could have corrected the fault you noted in the column - publicly calm or privately irate - without damaging the credibility of the medical profession by presenting yourself so belligerently in an open forum. I think a rational clarification would also have been beneficial to the public, which was one of my original purposes in commenting. It's interesting that apparently I have been more concerned with correcting the problem - by actually educating the public while reinforcing the importance of being clear and rational in public discourse - than you have.

2. The Socratic method relies on using questions and debate to allow the student to arrive at an understanding of the subject at hand through defense of their position and logical progression of dialogue. You, however, declared Golob's credentials invalid and shouted at and about him with no attempt to engage in productive dialogue with him. You set yourself up as a disapproving authority, expecting and even remarking on how appropriate it was that he accept your dressing down unchallenged (even though it would be hasty to assume anything of his opinion based on his silence). Reliance on appeals to emotion and authority are exactly the sort of logical fallacies that the Socratic method endeavors to avoid.

I was willing to accept, at least in part, criticism from you when I thought you were physician...

3. Demonstrably false. Even when you believed me a physician, you never once indicated that you considered my critique of your conduct valid, so your supposed openness to correction by members of your subculture is deeply suspect. The fact that you believe anyone not in your subset of medical science has no standing to expect you to behave in a professional manner in a public forum is further evidence that you are not nearly so open to betterment through criticism as you claim. These behaviors serve to reinforce the unfortunate, though untrue in many cases, stereotype of arrogant doctors unable to admit to their mistakes or accept criticism from the outside world.
I will address each of your points in turn

1) I could care less about whether I appear credible to you. If there is one thing that I have learned in the practice of medicine, it is that you can not please everyone. There are people who need to respect you, and there are people who don't. I focus on those who are in need, and in advocating for them I will invariably offend someone else. You act as if my tone and criticism is a reflection of being a poor physician, when in fact I use that exact same tone to defend the rights of my patients to insurance companies, and protect their health from a system that has many flaws. I am very comfortable with my credibility with my patients, and with my colleagues. In fact, during residency, I was selected by my peers and superiors to deliver a public lecture to both physicians and patients about what it means to be a physician, and how to be a good one. The tone I used during that lecture was very much the same one that you find so offensive. During that lecture, I asked each physician in the room to remember their capacity to do harm, and to always ask themselves how they can be better. I also lectured in no uncertain terms what bad doctoring was. I have been told it was the most passionate, inspirational lecture that they have ever heard.

The only time I would care about my credibility with you is if your life (I repeat, your life) depended on it. In the meanwhile, I could care less about your opinion. It is not because you are a vet, it is because you are clearly outside my relationship with the people I treat or the people I work with. My tone that offended you so much is the exact one that my patients respect, because they know that I put their safety above protecting the feelings of the irresponsible. I'm not saying that you should agree with them. I'm simply asking you: why should I care about your respect, when I have theirs?

2. Dr. Golobs credentials ARE invalid. He is an intern. In many parts of the country, he is not even recognized as a physician. His current position does not allow him to practice medicine without supervision. I would argue that his articles, which I would imagine are not reviewed by any real expert in the field, are not supervised either. In our litigious society, anyone who suffers an adverse event by following his advice could easily take action against him (I am not saying they would win, but they could take action). So, as far as I am concerned, I am doing him a favor.

3. Again this goes back to "1." Even when I believed you a physician, I considered what you said and other than being perplexed by it I responded in a reasonable way. Now, I understand that you did not find me reasonable. I am sure your friends/colleagues/other fans of Jonathan will agree with you. My friends/colleagues agree with me. Clearly, your opinion about my tone is subjective. More importantly, it is irrelevant. But just remember, between the two of us, only one of us could be accused of falsifying their occupation. I did not come close to pretending that I was your colleague so that I could criticize your conduct. It was the other way around.
P.S. I did not tell Dr. Golob not to debate. But, as I give him credit for being a well intentioned physician in training, he probably realizes that his first statement was not accurate, and potentially dangerous, and that he could have done better.
I should add (only because this is fun for me) that when Andrew Wakefield came up with the vaccine/autism fiasco, the comments sections beneath those articles were FILLED by physicians who used language that attacking Wakefield, by any measure, make mine look gentle. In fact, physicians attacked him without abandon in truly public forums as well. Now, I am not saying that Jonathan is a Wakefield. I am just saying that if you think that I am an atypical physician when it comes to my use of comments boxes below a medically misleading article, think again.
"I think a rational clarification would also have been beneficial to the public, which was one of my original purposes in commenting. It's interesting that apparently I have been more concerned with correcting the problem - by actually educating the public while reinforcing the importance of being clear and rational in public discourse - than you have."

Why are you so pretentious?

Perhaps you have not noticed, Kaliann, the average number of commenters for jonathan's articles are <10, at least as of late. I get more comments on my facebook posts. Stop pretending, as I never did, that this is a public forum by which to educate people. The fact that you think of it as such and I do not does not mean you care about educating the public more than I do. It only allows you to pretend to, much in the same way that you pretended to be a physician. Just because I choose to educate the public outside of the forum of the "hallowed realm of the Stranger comments section" does not mean that I do not care about educating the public.

Thanks for all the fodder, by the way. I'm on call and needing the entertainment.
MuDPhuD, I'm not a doctor of anything and I find Kaliann's perspective to be much more helpful here. Why doesn't "first, do not harm" apply to the credibility of a colleague?
@22 please permit me to elaborate here. The simple answer is because it describes the treatment of a patient by a doctor. "First do no harm" does not ask doctors to be perfect and not make mistakes. Instead, it asks physicians to recognize that every action, no how matter well intentioned, may have negative consequences if they are not well thought out. What Kaliann so casually describes as melodramatic is actually an incredibly difficult concept to learn. Her accusation that I used "first do no harm" as melodrama was actually offensive.

Let me give an example which I hope will not bore you. Suppose a patient comes into the hospital with abdominal pain, loss of appetite, vomiting and the classic findings of appendicitis. You order a CT scan to try to make the diagnosis. Where can be the harm in that? Appendicitis is potentially fatal. Surely, making a rapid diagnosis could not possibly hurt the patient, right?

The problem is, as many doctors will tell you, appendicitis is a clinical diagnosis. In other words, it is based on physical exam and history. If a patient has all the classic findings of appendicitis, a CT scan is not necessary. You take the patient to surgery right away. The rationale is pretty simple - if the CT scan shows appendicitis, then the patient has it. If it does not, the patient STILL probably has it. In other words, the results of the CT scan are not useful, and in obtaining one we would have exposed the patient to a significant amount of radiation.

As you can see, what appears to be a slam dunk medical decision, that many doctors make (incorrectly) every day, actually does harm. It is very easy to see why: we are naturally well intentioned, and are therefore blinded to the potential harmful consequences of our actions.

I did not accuse Jonathan of not meaning well. However, his good intentions of educating the public are problematic for several reasons. First, he is not a fully trained physician, and certainly not fully trained in many of the medical issues that he addresses. As a result, many of his medical statements are either inaccurate, incomplete, or outright biased. I draw your attention to a previous article that he wrote that claimed that marijuana was not an effective medicine, or something to that effect. Many physicians commented on that article with more anger than I ever exhibited.

Now, why would I not try to educate the public of the dangers of listening to poorly clarified internet medicine? The answer is I do. I just do not believe that the comments column in the stranger is the forum to do it. In fact, I frequently re-educate patients who "read on the internet" something totally wrong. I have also written in hospital newletters, etc. items for patient education. However, when I do so, I am very clear about language, and I think frequently about how patients interpret that information, and might also misinterpet it. If Jonathan wrote what he wrote after thinking about it, then he is an idiot. I do not think that he is an idiot. Therefore, I assume that he did not think about what he wrote too carefully, and did not realize that his position as an MD would give him a position of trust, that quite frankly he abused a little.

Going back to your original question: Physicians are under no obligation to protect each other from being irresponsible. Cases in point - the near universal admonishment of physicians such as Wakefield and Conrad Murray, by other physicians.

Please feel free to ask me to clarify anything that would help you understand my perspective better. However, also understand that I am simply addressing you here, and in no way attempting to be helpful or educate the public. I do not think that being helpful should be an expectation or requirement of posting a comment. My comments directed towards Kaliann were only meant to irritate and offend, something which I am sure you would agree I did quite effectively.

Before you side with Kaliann further, I ask you to consider: what would you want from your doctor? Someone who cares about protecting you, or someone who cares about protecting other doctors? Although I did not mean to educate the public with my initial comment, I am certain that Jonathan will be more careful in future. Therefore, I have certainly done the public a service.
Since we're all about doing each other services, can I just pop in with the following advice for you, MuDPhuD. Ignore it or take it --it's meant as a service. Here on the internet, many of us aren't who we pretend to be. Routinely people assume oposite genders, different races, different professions. Based on your handle, you might indeed be a "doc-squared" or you might be some guy living in his Mom's basement, sitting in his underwear and flaming on the intertubes. So, from the point of view of the readers here, reasonable is as reasonable writes. When you start putting people's professional titles in scare quotes, and typing in all caps, especially in your first two or three posts as a registered SLOGer, people will assume you're a flaming asshole troll, even if in real life you're Alexander Fleming, and they will discount everything you say. Here on SLOG we don't know Fleming, and we don't know his internet style, but we do know a lot of trolls, and at least initially, your style was their style. In pointing this out to you, Kaliann has done _you_ a service. If you take his advice, build up some credibility, and later say something on the SLOG that helps someone else, then Kaliann's service will have had a higher-order beneficial effect.

As for this quote: "I was willing to accept, at least in part, criticism from you when I thought you were physician." I take back my original concern. Not even the most expert troll could have faked that fatuous a statement. You are most definitely an M.D.!
@Eric from Boulder: Thanks for acknowledging that I am an MD. Of course, whether anyone other than Jonathan believes I am an MD or not means very little to me. In fact, whether Jonathan believes it is not important, as long as he recognizes my criticism as valid.

However, you and I both know I am not an "a$#hole troll", as you put it - people do not waste as much time as you and Kaliann (especially) did on a$#hole trolls. Between a Fleming and a troll, you are both concerned that I might be closer to the former. I'm sorry you feel that way: it must be irritating to dislike someone who might actually do really noble work.
Seems like my advice fell on deaf ears.
Unsolicited advice usually does - you and Kaliann might find this useful:…

I prefer condescension and confrontation. As you would have to agree, that does not usually fall on deaf ears.
Golob wrote:
"for most bacteria (aside from some key exceptions), just about any antibiotic will kill them off"

He did not say "human disease-causing bacteria", he just said "most bacteria", and I don't think context suggests the former interpretation. Do you think the bacteria in the bottom of the ocean, in yogurt, and in the forest floor's soil are all antibiotic-resistant? I would think those bacteria far outnumber the few in us humans.
Golob wrote:
"for most bacteria (aside from some key exceptions), just about any antibiotic will kill them off"

He did not say "human disease-causing bacteria", he just said "most bacteria", and I don't think context suggests the former interpretation. Do you think the bacteria in the bottom of the ocean, in yogurt, and in the forest floor's soil are all antibiotic-resistant? I would think those bacteria far outnumber the few in us humans.
@28 and 29 please take a look at the original question in italics (which actually is a brilliant question from "Future Nobel Prize Winner"). The article was a response to that question, so I would argue it was referring to 'human disease causing bacteria".

Otherwise, you raise an interesting question, that I am sure Kaliann could answer for you.
So if i keep gettig the clap, eventually pennicilin will not get rid of sick dick?
I'm VERY glad that MuDPhuD is not my physician. I will; however, take Kaliann as a veterinary pathologist any day. Hell, I'd probably take her as a primary care provider over MuDPhuD any day.
Remember the Mos Eisley cantina scene in Star Wars? There were two aliens, apparently scientists, having what seemed like a very focused, intricate argument. Those were my favorite aliens, and I am hearing now in my head the strange sound of their language as they conversed intently with each other.
While I feel this article was intended well, the information was reduced down to oversimplified inaccuracies.

While it is true most bacteria can be taken care of with a course of broad-spectrum antibiotics, this is not what you want to happen. You really only want to target those bacteria, which are harmful to the host and cause disease. Many of these harmful or pathogenic bacteria have acquired resistances to many of the commonly used antibiotics.

Simply not using this antibiotics for awhile might possibly make them effective again in the future, for a very short time. Once the population of bacteria have developed a resistance mechanism to an antibiotic it is not something they generally lose, so even if the population as a whole is now sensitive (or treatable) by this antibiotic, all it would take is a few organisms to have retained the resistance mechanism and you will not be able to treat the infection with that antibiotic. Being resistant to an antibiotic isn't that much of an energy waste in all cases. Sometimes it is the simple modification of an already used protein, that makes binding of the antibiotic impossible. This costs the cell no extra energy to produce the modified protein.

A lot of the science within the field of Microbiology is focusing on the 'good bacteria'. These organisms live in your gut and help breakdown food. They are finding that variations in these populations due to antibiotic usage, and even diet can lead to higher susceptibility to bacterial infections. So general broad spectrum antibiotics, which target these cells as well can lead to more harm than good. So as the MD/PhD from above suggest it is a good thing to utilize a more specific antibiotic to target the disease-causing agent a little more carefully.

Also, the nonsense about Staphylococcus aureus changing its cell walls to become resistant to antibiotics is very inaccurate. The emergence of the dreaded MRSA (Methicillin-resistant Staphylococcus aureus) is due the acquisition a gene called mecA, which allows the cell to express a different receptor on the surface that no longer binds methicillin. This mechanism of resistance has been seen in many bacteria since the discovery of the first known antibiotic, penicillin, as well as many of the derivatives including methicillin. The cells have not drastically changed their cell walls to become impervious to the antibiotic but it can no longer bind to them. The good news in the case of MRSA, is that the antibiotic Vancomycin is still highly effective for use against MRSA infections. And some labs have reported that the target of Vancomycin is along an alternative pathway for methicillin resistance. Meaning that resistance to one, makes them vulnerable to the other.
"Propone"? Seriously?
@35 - to be clear, Fistique, I completely agree with you. it was Kaliann who used that ridiculous word first. I only used it to quote her.

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