Category Archives: Confessions of a Microbiologist

“Going on leave…or not?”

When an “Out of office autoreply” is received into your inbox, it is increasingly common to get something like this…

“Please note I am on annual leave for the next two weeks. I will only be checking my emails intermittently.”

Hmmm….

There are two reasons why this “halfway house” is a bad idea, regardless of your responsibilities or seniority. Firstly, by checking your emails at all, you are not getting away from work completely. By checking your emails, you will never get work out of your mind, the things in the laboratory which were stressing you will still be stressing you, defeating the purpose of leave in the first place. Time is a great healer…

And secondly, by checking emails whilst on leave, you are giving the perception of distrust for those colleagues who are covering for you. Leave them to it. They are more than capable.

There is not much that cannot wait in the microbiology laboratory. And anything that cannot wait, should never be sent by email.

With smartphones, the temptation to keep in touch with work whilst on leave is almost overwhelming. Don’t do it! Switch the notifications off. Even better disconnect the email app from the server. Remove yourself from temptation, you will still have a job to go back to when you return, and people won’t think any less of you because you have been totally incommunicado during your holidays. In fact they may well have a grudging respect….

Enjoy your holidays, spend quality time with your family, and forget all about work for a while. You will likely come back rejuvenated, and ready to provide value to your microbiology laboratory.

Trust me, the sky will not fall because you are not there.

So the next time you are on leave, put something like the following on your out of office autoreply.

“I am on leave until date X. Person Y is covering for me. If necessary I will get back to you on my return.”

Take leave like you mean it!

Michael

p.s. Worried about that mountain of emails that awaits you on your return? Don’t be. Give yourself 1 hour exactly to clear the bulk of your inbox. Be brutal, ruthless and without remorse. Many of the email topics will have been sorted, or forgotten about. You will soon work out which emails are actually important, which in reality is about 1%!

“Susceptibility to Influenza”

If you live in the Northern Hemisphere you may have found that your laboratory was swamped by incoming influenza tests this season?

You would not be alone.

Influenza is an unpredictable beast. In my own neck of the woods, New Zealand, the 2015 season was busier than usual, the 2016 season was almost non-existent, and the 2017 season was very average.

Nobody knows what will happen with influenza during 2018.. (Note that as NZ is in the Southern Hemisphere, our winter is June, July , August, right in the middle of the year).

Often you will see Influenza “experts” on TV making predictions about how severe the forthcoming influenza season will be. However such predictions come with huge pinches of salt. You might well be better off predicting the stock market…

The truth is that we don’t really know how bad the forthcoming influenza season is going to be, whether you are an expert or just an interested bystander.

And as a result we have no idea how much each influenza season is going to cost a diagnostic laboratory that performs influenza testing.

Let’s say a bog standard Influenza/RSV PCR costs approximately $30. In a quiet season 1000 tests might get performed in a medium sized hospital. However in a busy season 5000 tests might be required, with an excess cost of $120000. This would of course cause the laboratory manager some sleepless nights!

I am glad I am not a laboratory manager..

And then there might be an influenza pandemic…

The same goes for Public Health Laboratories. The numbers of samples coming in for antigenic sub-typing will be closely related to the severity of the influenza season.

Contracts that laboratory providers have with healthcare funders need to take this unpredictability into account. Some sort of clause like “The diagnostic laboratory will perform up to X Influenza PCRs during the Influenza season. If this number is exceeded, further funding will be negotiated”. Unfortunately this is often not the case. Often laboratory providers will be so desperate to get the contract signed and sealed that they will accept these risks, and manage such problems reactively.

From a financial point of view, microbiology laboratories are very susceptible to influenza test volumes, just like they are susceptible to emerging diseases and MDROs, cohorts where “unexpected testing” may need to take place.

There will of course be some laboratories who are reimbursed per test performed (fee for service). Those places of course would be hoping for a pandemic every year!, but such laboratories/funding arrangements are getting less and less common. The funders are not daft!

I hope for a quiet influenza season this year, and that is nothing to do with my personal risk! (I look forward to receiving the quadrivalent vaccine in the next couple of months).

Michael

“Back pocket antibiotic prescriptions: Good or Bad?”

Whenever my children get taken to the GP for a suspected chest/ear/throat/sinus infection, more often than not we are given a “back pocket”/delayed antibiotic prescription to be used only if the child does not improve over the next couple of days.

Is this a good policy?

My analytical way of thinking deduces the following assertions from the decision to prescribe a “back pocket” antibiotic prescription.

  • The doctor has decided that based on the current clinical presentation, the patient doe not require an antibiotic immediately.
  • The patient/guardian now has the primary responsibility as to whether the antibiotic is actually given or not. Is this really a good thing?

Studies have shown that back pocket prescriptions are acted upon about half the time, maybe a bit less than that. Whether or not a back pocket policy reduces antibiotic prescribing depends entirely on what you are comparing it against. If you say that all these patients would otherwise have received an antibiotic straightaway, then of course you can demonstrate a reduction! (Lies, damned lies and statistics…)

So what seems like a good idea may in reality may not be so perfect after all.

Given that only a small minority of such infections ever really need an antibiotic I prefer an educational approach (check out this leaflet), along with advice to come back if not settling in a couple of days’ time for clinical reassessment.

I remain to be convinced that back pocket prescriptions are a truly effective means of antimicrobial stewardship. To me it is more a way of the GP showing that they are doing something for the patient, a bit of a halfway house as such. It may even give out the completely wrong message to the patient. i.e. “I am not interested in seeing you again.”

If we are really serious about antimicrobial stewardship, then I think we need to review the back pocket policy. I think antibiotic prescribing for minor infections needs much tighter regulation. I also think including the clinical indication for the antibiotic on the prescription should be mandatory.

So the antibiotic prescription in my back pocket hardly ever comes out, and my gut feeling is that it shouldn’t even be there in the first place…

Michael

Here is an article with a bit more detail on this debate.