Thursday, June 19, 2014

Interview with Associate Professor Tom Gottlieb about infectious diseases, antimicrobial stewardship and one awesome Aussie shepherd

Associate Professor Tom Gottlieb with Jamaica.
This week we were fortunate enough to catch a cuppa with Associate Professor Tom Gottlieb, a senior specialist in microbiology and infectious diseases at Concord Hospital, past president of the Australasian Society for InfectiousDiseases, current president of the Australian Society for Antimicrobials and owner or cohabiter with Jamaica, an affable Australian Shepherd who prefers that no one expresses her anal glands thank you very much.

I’m always excited when I meet our medical counterparts. What kind of cases do they see? Do they catch diseases from their patients? Do they love their dogs as much as we do? So many questions. If you’re as curious as I am you might want to head on up to the ASID Zoonoses Conference in Brisbane next month.

How did you get involved working with infectious diseases? Do you have any favourite infectious diseases?

Like most things in medicine you stumble into it. It all makes sense looking backwards but somehow going forwards its just random choices you make. As a trainee I worked in New Guinea and in New Guinea it was all infectious disease and in my time it was all TB.

My favourite diagnosis is TB because it presents in so many different ways, each patient is a surprise in some way even though the management is very guideline driven.

In infectious diseases the hardest cases are the silly little old ulcers in elderly people because they are so hard to manage whereas exotic diseases like TB and typhoid are not that difficult to manage but people think they are. So there is glory in managing some of those exotic diseases but far less glory, and often much harder to manage the mundane things.

Once you start in infectious diseases you realise that it is centered around antibiotic management, so in the last 10-20 years the big interest has been antibiotic use and antibiotic resistance because they go hand in hand.

In your role in ASID you’ve been integral in organising a symposium on zoonoses. Why should veterinarians and doctors learn about zoonotic disease together?

When I was training we had a wonderful workshop at the zoo one day with vets and doctors and it hit me that a lot of the common infections we talked about we had seen in patients but vets had had themselves – contracted from their patients.

And I realised there was a lot of commonality. We tackle infections often slightly differently. Some things I suspect veterinarians have cottoned onto earlier and got onto the right approach and in some areas doctors might have stumbled onto faster than vets. For example, I think one area that doctors do well (or better now than they used to) is infection control and antibiotic management, partly because we have been forced down that line through regulation. Regulation is the most effective form of control, sadly, because we are not easily pulled into line unless forced to. I suspect vets are the same and I think in these two areas we’ve been laggards in - or vets need to do catch up on?

We organised a summit about antibiotic resistance in 2011 where we tried to pull all common groups together and we realised there was a way to go with antibiotic resistance in veterinary or zoonotic infections as well. At the same time the concept of “one health” was taking off (which is the new black) and we thought it was a great opportunity to bring us all together. We organised the zoonoses meeting partly out of subliminal intent to set up a dialogue about antibiotic use in animals.

When the meeting happened I was surprised at how much common interest and how much fun we have learning about each other’s strands of medicine. It was such a success that just like any good party, we wanted to do it again.

I've always wondered if infectious disease physicians are more likely to catch infectious diseases due to a higher risk of exposure to infectious diseases. Is there any truth in this?

No, I don’t think so. I don’t know anyone who has had any more infections than anyone else. And partly - and unlike vets – this may be because we have referred patients from GPs or the emergency department and so there is an expectation by the time the patient comes, to know which way the wind is blowing. You can anticipate things in referred patients, but you cannot anticipate left field things, new events and diseases like SARS. When that came long nobody was prepared. The point about SARS is we stopped thinking and we admitted patients with respiratory infections and we didn’t protect ourselves from respiratory droplets when common sense tells you that you should be protected. SARS caught us unawares because infection control wasn’t up to it. But in a day to day experience we can anticipate the risks fairly easily and therefore I don’t think it is a major issue.

The other thing is that most infectious disease aren’t contagious - they are caused by microorganism that are often unique to that person and you have to try very hard, by whatever exposure such as sexual  contact or insect bite, to get it. That’s unlikely to happen in my office.

It’s when we’re unprepared and we don’t set up systems to deal with risks we should have anticipated, that’s where we get caught. Hence the point about the first meeting with vets. The doctors at the meeting talked about patients with psittacosis, while just about every vet in the room had had it. It comes back to the issue of infection control and thinking through systems to make sure these are well covered to prevent infection of the vet or transmission of drug resistant organisms.

How did you meet your Jamaica?

Our other dog had died and we felt utterly relieved to be dog free. We could travel without guilt. Bring on Italy, Spain. A few months after the deat, we went to Fox Studios for a dog owners’ day, which was mostly people bringing their own pets for a walk around. But there were a couple there with two Aussie shepherds and their litter. We got smitten in that very moment and we bought the runt of the litter.

And our only regret is we didn’t buy two runts. Great error of judgement, that was. The runt of the litter turned out to be a wonderful dog with a fantastic personality which keeps us honest. (The previous dog was thoroughly loved and died of old age).

Jamaica takes the fam for a walk.
How would you describe your relationship with Jamaica?

Intimate. Your animals become your children, particularly when your children leave home or give you grief, suddenly the dog is seen as being much easier to manage and deal with and so much cheaper to run.

How do you spend time together?

In idle moments we sit on the lounge and we peer deep into each other’s eyes. At other times we walk because I am the designated walker on weekends. She is slowing down a bit as she is not as partial to hills anymore, and nor am I, so we’re slowing down together or maybe she is moulding herself to me.

We talk. Well, I am sure she is talking to me, and at times out of desperation I talk to her. When does madness creep in? When you start answering or writing letters? But talking is okay isn't it?

Jamaica is easy company and has a circuit of friends who are happy to take her in for walks and stays and she is always looked after. Your life revolves around having your dog catered to because the guilt is too much! So any non-dog holidays are anticipated by dog organisation moments.

How could you not love this dog???
Does your infectious disease knowledge inform the way you relate to Jamaica?

Does infectious disease knowledge inform the way I deal with my children? Its often through benign neglect and often to the consternation of my dear wife who felt I was never there for the major illnesses and never took them seriously when I was there. And sadly I have a similar attitude to Jamaica which is a “she’ll be right” approach. That said its held out fairly well.

You learn to be a little bit - not blasé, but not to get panicked by illness - because you have to deal with it every day. That probably informs how you deal with family medical stresses, you don’t push the panic button so fast - til you really do need to.

What do you think Jamaica thinks about veterinarians?

The only major setback Jamaica has was when both Frances and I were away and so imposed on our friendly vet friend to do a home visit. At which point he did something to Jamaica that she has never forgiven him for [expressed her anal glands] and now she starts barking when he is within a 5km radius of our house. That’s an exaggeration. Probably 1km. He comes to the door and she growls, she eventually settles down but she doesn’t growl at anyone else. I have learnt. Dogs or Jamaica, don’t forget indignities like that.

Is that a halo?
How has living with Jamaica changed you as a human being?

I wish things would change me as a human being but I suspect I am immutable. A few people have commented on that, and mentioned they wish there was a way.

I have learned to appreciate certain things in life. Poor Jamaica gets two chicken wings a day and has had that for last ten years on instigation of the same vet. And every night when she gets two chicken wings has unbridled enthusiasm and joy for the same bloody chicken wings.

It makes you realise that you can get sheer exultation out of simple things - you don’t have to look too far beyond what is under your nose, so to speak.

Dogs also teach you unconditional love, and that’s why we seek those animals.

Me and my brother grew up in a very fastidious house as my mother obsessed by cleanliness and didn’t have animals even though she was brought up on a farm. Funnily enough when we both left home we got animals immediately. Girlfriends and dogs, can’t remember which came first nor which were bigger priorities. . Having an animal in your house changes the dynamic…and its fantastic.

You get too preoccupied if there are only humans. The animal needs and relationship adds an extra dimension to your household life and I think we’re all better for it. When our first dog died, we said we didn’t want another dog. Now we could travel. And now Jamaica is getting older we think the same – when she goes we will travel and not worry about the dog. But I cannot help but think there will be another dog around the corner. They force you to walk and not focus on yourself and talk about doggy issues.

As an addendum I’ve been asked for photos and realised I should do more selfies with the dog. A selfie with Jamaica in Centennial park to compete with selfies with Wife in Italy or Spain. That could be a new resolution.

Thank you Tom! Clearly, behind every good infectious diseases physician there is a great dog. Meantime if you need even more encouragement to attend the ASID conference, its also a chance to meet Nobel Prize laureate (and veterinarian) Peter Doherty. You can read his message for vets here.