WORM
00:00:09.440 – 00:00:11.200
Ciao. My name is Worm.

GERM
00:00:11.440 – 00:00:12.400
I’m Germ.

WORM
00:00:12.560 – 00:00:28.710
Welcome to episode 103 of the Germ and Worm Travel Health Podcast, Tales from Dr. Pottinger’s Post Travel Infectious Disease Clinic.

I’m Dr. Chris Sanford, also known as Worm, Associate professor in the Departments of Family Medicine and Global Health at the University of Washington.

GERM
00:00:28.870 – 00:00:35.990
And I’m Dr. Paul Pottinger. You could also call me Germ. I’m a Professor of Infectious Diseases at the University of Washington in Seattle.

WORM
00:00:36.310 – 00:02:58.930
Today, instead of our usual potpourri of medical topics, I’m going to be interviewing Paul concerning his experiences at his post travel clinic at the University of Washington. Here are some of the questions we’ll consider today. Just how did Paul get into studying and and treating people with infectious diseases?

Within the field of infectious diseases, how did Paul get into travel health? What illnesses have people returned to the US with? And knowing what he knows now, having seen what he’s seen, what does he do differently before and during travel?

First, a reminder to our listeners, please contact us with your travel health questions, stories, tip for success, or requests for clarifications about something we say here on the podcast. Just Visit our website germandworm.com or email us at germandworm@gmail.com.

Before we jump in today, here is our medical disclaimer.Our podcast is designed to inform, inspire and entertain. However, you should not use this podcast as clinical care before you travel. Please see a qualified healthcare professional for recommendations specific to you and your itinerary.

First, before I start asking questions, let me give a little intro, a little background information on the erudite, silver-tongued and clever, charismatic Paul Pottinger, M.D.

Paul was a history and literature major at Harvard as an undergraduate, a medical student at Yale and then a medicine and chief resident at the University of Colorado. He came out to Washington State for his infectious disease fellowship and decided he liked it.

And he stayed and he’s now professor in the Division of Allergy and Infectious Diseases, where he sees a lot of patients, teaches students, residents and fellows. He directed the fellowship here in infectious disease for 14 years.

A particular focus of his within medicine is antimicrobial stewardship, which means giving the right antibiotic for the right reason, but not too much, and not giving it when you don’t need it. He’s also incoming Chair of the ID Week at the National Meeting for ID Doctors.

A particular passion of his, as you’ve heard on this podcast, is climbing really tall mountains. So first, Paul, welcome to the German Worm Travel Health Podcast and let me ask you this Just how did you get into.

Out of all the different specialties you learned about in medical school, how did you decide upon infectious diseases?

GERM
00:03:15.570 – 00:07:43.500
Well, first of all, that. How fun to have you do the boilerplate at the beginning. Like I think it takes us 103 episodes to switch it up. So we should do this every other time.

I’m liking it, just sitting here. Erudite, silver tongued and charismatic. I know I have silver hair. I didn’t know the tongue was silver. Is there a DSM code for the disorder of the silver tongue? Silver stools is definitely a thing. I gotta look in the mirror and see what my tongue is doing.

It sounds evil, whatever it is, but thank you for super kind intro for sure. I think our listeners have probably gotten sick of hearing from me already. But that was nice of you to say. You asked about infectious diseases.

I mean the bigger question is why choose medicine? I was an undergrad thinking about becoming a filmmaker or novelist. I’m born from two lawyers, my folks, I’m not sure they know what DNA stands for.

I mean I had no science background really. So for me that was a big change. I got into medicine because I just loved it so much.

I was trained as a wilderness EMT when I was an undergrad guiding incoming college freshman in the wilderness of the northeast. And that training came in handy with some unfortunate, unexpected emergencies. I liked having the skill.

Put your hands on someone, know what you’re doing, make them better. That emergency medicine approach. And actually that ethos still sticks with me to this day, being in the mountains and such.

But I really came to medical school thinking about emergency medicine, thinking about surgery, something with my hands I like, you know, being hands on guy. That’s just my, my way. And so it’s funny that I chose infectious diseases, right? Which is. It’s the one, one of the few specialties.

We call them the cognitive specialties. It’s real insult to the other specialties, like they’re not thinking at all. But we call ourselves the cognitive specialist because we don’.

I don’t know. My procedure is the history and physical. I may be looking at a gram state.

Like I don’t actually cut people except to cut out a maggot or a lance, a boil or something. I don’t do a lot of operations and such, but. So why did I choose infectious diseases within?

Well, first of all, I chose internal medicine because it was so broad. I didn’t want to narrow myself too much medicine. I felt like I could see.

Well, it’s not quite like you, Chris, where you do the entire lifespan, but it’s close to that. But then I chose infectious diseases during medicine residency at Colorado. It was partially a cognitive, intentional, academic thing.

You know, I wanted to be. I didn’t want to ever get bored, and I thought the human body might be too boring. Just one species.

Maybe I should have been a veterinarian with all these different species coming in, so all the different microbes that you see in infectious diseases, all the germs, each with its own biology, its own vibe, its own personality. I wanted that diversity, and I wanted to do something that would keep me seeing patients regardless of where they were coming from, who they are.

Everybody is dealing with, you know, we’re all covered with germs. Sometimes they infect us, sometimes they don’t. But every part of the body is involved with infections.

Every phase of the human lifespan has an infectious disease risk. So I liked that generalism of id. So. And I decided, yeah, this will be fun to do.

But it was more of at least as much an emotional calling, because I just loved it. I just loved these cases. I kept resisting it. I want to do something where I stick a scope in somebody or I cut something out. No.

The greatest cases, the greatest patients, and by far the greatest attendings, the colleagues, the people who are my role models, they were all id, And I just could not resist it. I remember in medical school, we had a patient who had a case of meningoencephalitis, and we couldn’t figure out what the diagnosis was.

We suspected tuberculosis. And back in those days, in the 1990s, it was difficult to make that diagnosis. Well, it remains difficult today.

We did not have as much molecular diagnostics, so we had to send her to the operating room and get a leptomeningeal biopsy, which confirmed the diagnosis of tb. Anyway, I remember walking out of the operating room, I was the student on the ID rotation. I went in to catch the hunk of brain.

It was my idea, so I might as well take the tissue to the lab. And the neurosurgeon said, oh, I see, you’re going to do id. And I said, oh, I don’t think so. I want to be a surgeon.

She’s like, no, I think you’re going to do id. You clearly love this. And I said, nosipo. This was Nosipo Marere, who’s the very eminent neurosurgeon and author, by the way.

And I really admired her a lot. It’s like, nosopo. No, I’m going to be. I’m going to be some kind of surgeon. She’s like, you’re going to do id. She was right.

I just couldn’t help myself but choose this specialty and no regrets. To answer your next question, I do not regret going into id.

In spite of all the challenges and shortcomings and problems, I cannot imagine doing anything else differently.

WORM
00:07:43.900 – 00:07:48.940
So it sounds like to some extent this was an emotional decision, like you had found your tribe.

GERM
00:07:49.580 – 00:08:33.560
The tribe was there and I just loved hanging with those people, talking to them about cases and learning. So much learning every day. It’s just this endless fire hose of information about the microbiology, epidemiology.

You know, in any different area of medicine, you can have a public health impact. That’s true in cardiovascular medicine, whatever. But in id, there’s always that question, where did this infection come from?

Who did this person give it to? Is it from people? Is it from the environment? That public health piece really called to me.

I don’t know why, I just think it’s super interesting and I’ve always admired public health workers as well. I’m not a public health person myself, not officially, but I think all good ID docs should aspire to be good public health citizens as well.

WORM
00:08:33.960 – 00:08:46.270
And most infectious disease doctors primarily see infections from their own country. And you have this subspecialty of both travel and tropical medicine. How did you get into those?

GERM
00:08:46.910 – 00:10:39.670
To be clear, most of the infections I deal with are indeed acquired in the United States, and that’s where I live and work. And so those are the infections I typically deal with. But I do have this interest in both travel and tropical.

So I, I think I just enjoy travel so much. I just love to see the world. I was lucky to grow up in a household where travel was something that the family did. My dad would take us on vacations.

My mom was very interested in travel as well. And so I’ve just always been a travel minded person. And then to think about all the issues related to health that come with travel.

I actually came to this mostly through the tropical side. What’s the difference between travel medicine and tropical medicine?

You know, travel medicine is folks who are living, for example, in the United States, go overseas and then come home with an issue or problem. That’s good. That’s what we talk about here on the podcast. Tropical medicine is different.

That’s people who are living in these areas of higher endemicity in the tropics and they live there. And so you’re trying to not just deal with someone who’s Traveling temporarily, but to serve the people who live in these communities.

And I’m inspired by that. I was so interested in this. Actually, it was during medicine residency at Colorado.

Yeah, I spent some time in London at the London School of Hygiene Tropical Medicine. Got my diploma in tropmed and hygiene. Hygiene is the British word for public health. That was in the year 2000, 2001.

And that was exciting to me because I was just learning this entirely different discipline within medicine.

And it was just really inspiring to think that I could use some knowledge to help people who really need help to know what to do for folks who are dealing with arcane, strange, rare conditions, to have that knowledge, learn from these people in communities overseas and be able to serve them. To me, that was just a great calling. I was excited about that and that has just stuck with me ever since.

WORM
00:10:40.590 – 00:10:50.830
And Paul, let’s get into specifics. You’ve been a doc for a long time. Can you tell us a little bit about some of the cases and some of the illnesses you’ve seen people return to the US with?

GERM
00:10:51.150 – 00:12:55.550
You know, I have a rarefied and strange perspective because we know that when people travel overseas, they’re going to get sick. I mean, this happens. We’ve all been there before. The leading issue is respiratory infections.

The number two issue, or GI infections, traveler’s diarrhea issues. These happen to people a lot and usually they’re self limited and benign. And those folks do not come to see me in my clinic.

I have a very rarefied perspective. If you want to get in to see me, it has to be something that, well, number one, lasts longer than a week. It just takes a while to get in to see me.

And then number two, usually it’s something that other qualified healthcare physicians, healthcare providers, just haven’t been able to figure out or they think they know what it is, they just can’t make it better. So yeah, for me, Chris, it’s not the run of the mill. I like the mill. I like running the mill.

Mills are good, but we’re talking about the more exotic things that come to see us. And so, yes, I do see folks who acquire respiratory. GI skin issues overseas, sexually transmitted infections, flare of a urinary tract infection.

This is all within the practice, but our practice is enriched for things that are less common as well. For example, cutaneous leishmaniasis, which is a parasitic infection people tend to catch in my practice when they go to Latin America.

Especially exciting times in the jungle at a yoga retreat, botanists and animal biologists, people spending time in the forest who come back with boils and sores on their skin that don’t heal. I’m thinking about cutaneous leishmaniasis. That’s somebody I want to see as soon as possible. Malaria is another example.

We’ve talked about malaria in one of our recent episodes right here in the month of May, where people go overseas and then come home with, you know, a fever, an undifferentiated fever that could be a case of malaria, I would say, Chris, to answer your question, one of the leading things that triggers a call or a consult in our clinic would be fever. Someone who comes home from being overseas with fever and the fever won’t break and we can’t figure out exactly where it’s coming from.

That’s pretty typical.

WORM
00:12:56.350 – 00:13:21.290
And suppose now. Well, let me contrast this.

When I see someone with fever, if they have not left the United States, I think about pneumonia or maybe pyelonephritis, which is kidney infection and a variety of other things. You see someone coming back from the tropics and they have a fever and they feel like hell. What are some of the first sort of.

Even before you ask questions, what are the thoughts for likely diagnoses coming to your mind?

GERM
00:13:21.770 – 00:17:50.763
Yeah, so causes of fever in the returning traveler.

Malaria is at the top of the list, not because it’s the most common, although it is common, but because it’s one of the few that is dangerous when we miss it. So any number of things can cause fever. And folks, fever, we really want to be, you know, above 38.3 degrees centigrade.

If you’re a 37 degree person and you say this is a fever for me, that may not be true. We’ll talk about that when you come to see me. But for a true fever, you know, there’s a list of things that do this.

Malaria is at the top of that list. Viral infections are on that list as well. That could be a case of dengue fever or chikungunya, which we’ve talked about here.

And depending where someone has traveled, could be other viral infections. Infections, too. We always worry about other bacterial infections. So malaria is a parasite infection.

Viral infections can do this, but so can bacterial infections and typhoid or paratyphoid fever. Both those are pretty typical. Also, they’re things that we worry about. These are all acquired in slightly different ways, right?

Sometimes it’s through the bite of a female Anophelene mosquito. Sometimes it’s through fecal oral contamination. Sometimes they can be transmitted through.

Through sexual contact or through consuming Food that is befouled. Sometimes it’s just taking a dip in a river or a waterfall.

So one of the things that I want to get to in a moment, honestly, and we’ve talked about this before. How can people be a great patient when they come to see me? Now, I’ve interviewed you, Chris, on the topic of a pre travel visit.

We gave advice in that episode for how people can be great patients when they see you before they travel. And I hope our listeners will go back and check that. If they missed that episode, go back and listen to. It’s a great conversation with you.

The same question comes up here, doesn’t it? How can people be great patients when they see me? Let’s say they’re returning with a fever.

And you know, honestly, I would say that great patients are great communicators. What I’m looking for in my patients, I’m sure you’ll feel the same.

I just want people to feel comfortable telling me the truth and recognizing that truth themselves. What do I mean by telling me the truth? I need the details. I really need to know exactly what happened on that trip.

The itinerary, by dates and location, but also by activity. And that includes, yeah, what did you eat? Who did you hang out with? Who did you have sex with? What activities did you do?

And these questions may, they may feel very personal because they are. These are the most personal conversations that you will have with a medical doctor.

If you cannot talk about these things with your doctor, then when can you talk about them? Everything that we discuss in medicine is confidential.

We do not talk about this with anyone else except with the blessing and permission of the, of the patient. So I just want to prepare people that if you come back sick, please be willing to tell the truth and be comprehensive.

When I get frustrated with patients, it’s when they’re very quiet. They just say that they’ve gone to this or that place and they won’t, they won’t give me that information. So I’m a skillful doctor.

I’m good at pulling information out of people. I know you are too, Chris. Sometimes it’s like pulling teeth. Try to get this information from folks, and that’s just a little bit exhausting.

Sometimes people don’t take this seriously.

One of the questions that I was recommended to ask by a colleague was, if you’re dealing with someone like this who’s very taciturn, and I’ve done this before, I’ll say, tell me the stupidest thing you did when you traveled, like, I want to Know what’s the dumbest thing? And that sort of shakes people awake, like, oh, did I possibly do something stupid?

You get all kinds of crazy answers, like, I bought a chunk of the rainforest or I went gambling, or, you know, had some sort of racing experience on the back of an ostrich. I mean, you get all these crazy answers and that, number one, it’s entertaining for you.

Number two, it’s a signal to the patient that you need to tell us what you’ve done, because each activity comes with its own potential for acquiring an infection or some other disorder. And I won’t have that opportunity unless I know about it.

Give you an example patient of mine who came back from a trip to Hawaii with a constellation of very, very concerning, alarming central nervous system issues, including the periodic inability to speak, double vision, difficulty with balance, very concerning and serious illness after Hawaii. If she had not told me that she was a guest in a friend’s home and consumed a fresh salad during that trip, it would not have been as clear that, yeah, this is going to be neuroangiostrongyliasis, also called rat lungworm disease. Rat lungworm disease we get when we consume slugs or snails blended into salads. And so she had no idea she’d eaten a snail, but she did.

And that’s how the worm got into her system and went through her very living brain. So with that history eating the salad in Hawaii, we were able to make that diagnosis faster.

WORM
00:18:14.300 – 00:18:31.410
Now, speaking of the least wise decision people ever made, you mentioned sexually transmitted diseases. Suppose someone goes abroad, has a new partner, doesn’t use a condom, has symptoms, comes and sees you.

What are some of the sexually transmitted things that you’ve seen in your clinic?

GERM
00:18:31.890 – 00:20:14.670
Oh, yeah, thanks. You know, any sexually transmitted infection, STI, they’re also called STDs. STD, sexually transmitted diseases, it’s the same thing.

So any number of the infections that you can catch through sexual contact here in the contiguous US that they are also possible to catch elsewhere in the world, the prevalence, meaning the absolute risk of catching an STD overseas might be higher, might be lower. It’s partially based on the location where you go. That’s true.

I think it’s much more to do with the activity level and the risk that someone is willing to undergo when they’re overseas. STDs are cosmopolitan. They’re where the people are.

And so, you know, if someone has a number of new partners and they don’t know the STI status of those partners, and there’s no intervention practice in place yet. That’s a high risk situation.

This is why it’s so helpful for people to come and see us before they travel, because we have all kinds of great technology. You mentioned condoms. That’s one way to reduce the risk of a number of STDs.

But so too with pre exposure prophylaxis against HIV infection, post exposure prophylaxis using doxycycline against chlamydia, gonorrhea and syphilis. So those are the big ones that I’m worried about with these cases would be, you know, HIV infection, syphilis, gonorrhea, chlamydia.

But there are others which are less common in our contiguous US Context, which may be more common elsewhere, including certain variants of chlamydia, certain bacterial infections that are more prevalent elsewhere in the world. We need to really be able to hear from our patients what they experienced.

They also need to let us do a careful exam and testing so we can get on this right away and make a difference for those people.

WORM
00:20:15.380 – 00:20:31.780
Now you mentioned traveler’s diarrhea as being one of the more common things that cause infections in travelers. Can you give some guidelines? Suppose someone gets diarrhea in a low income country.

When do they not need to see a doctor and when should they see a doctor after returned?

GERM
00:20:32.020 – 00:22:51.420
Yeah, if you’re going to go to these fun places like my friend here, Chris Sanford says, that’s you’re going to get diarrhea. I mean, as I’d say it, shit happens. The way Chris says it is, you know, this is a low tax for visiting highly interesting places.

So if you develop diarrhea that’s not totally unexpected. Most cases of traveler’s diarrhea should resolve, if not completely, mostly within seven days. These are typically very short term episodes.

I’m thinking about enterotoxigenic E Coli, right, Chris? Good old E tech, goes by a lot of vulgar names and it’s present around the world.

Those people can feel sick as hell and within a week they should be back to where they were. Most people will lose some weight because they’ve had a lot of diarrhea, some anorexia.

But then they get hungry again, they start eating, the appetite returns, the belly settles. Now, at seven days, I would not expect someone to feel completely better.

There may be something we call post infectious irritable bowel, where you’re a little bit sensitive to lactose products, for example, or your poop pattern. Your bowel pattern may not be back to normal, but people at the end of a week should know either I’m getting better or I’m not.

Because if you’re not, you need to come in and get checked. You know, I’m thinking about a patient of mine, young woman who got sick. As it happens, I think it was Cancun was with a group of other travelers.

She was the only one who got sick. This is just how it goes. And man, she did not get better. Or a couple of her other travel mates actually did get sick, but they all improved.

She did not.

And even two weeks after coming home to the US Was still having profuse, difficult to control explosive diarrhea, not irritable bowel, but active infection. And so, you know, testing of the stool itself is the easy way to make this diagnosis. This is a condition called cryptosporidium infection.

And cryptosporidium, look, it’s a parasite that you catch from drinking contaminated water or potentially food. It’s usually the water, I think, that does this. It’s kind of like malaria for your gut. That’s the way, this is the way the parasite works.

It’s very similar to malaria, but instead of going to the bloodstream goes to your intestines and people can feel very, very sick indeed. We do have a treatment, it’s called nidozoxanide. It’s not great, but it’s okay and it can help.

And in this person’s case, actually we treated and that person got dramatically better and was grateful that they came in to be seen.

WORM
00:22:52.060 – 00:23:01.260
And when it comes to skin, people don’t like it when they come back with a new rash. What are some things involving the skin that you’ve seen in your post travel clinic?

GERM
00:23:01.500 – 00:24:41.770
Skin is such a. It just gets brutalized when people are traveling to areas of high humidity, high ultraviolet light, and scratched and bitten.

And you know, skin is our, that’s our barrier. So it’s very typical for people to get skin issues.

There’s so many things that can go wrong with the skin, from sunburn to bacterial infections to parasitic infections. So when should somebody come and see us?

Look, if you come home and you have a skin disorder that’s not improving, obviously I want to see that person. I would have that person honestly start with their primary care physician, before dermatology, before infectious disease.

See your primary care to decide whether this is something that needs to be made wet, made dry, receive steroids, or receive antibiotics. I mean, those are the big dividing lines when it comes to simple things with the skin.

I am happy to see people who have a bacterial infection, you know, it’s infected if there’s pus. Right. That pus needs to be drained.

If you have a wound, let’s say you were exposed to water, fresh or otherwise, you had a puncture wound with a sea urchin spine or something, that area is not looking right. You can come straight to Infectious Diseases, but if you can’t get in with me, you see your doctor right away.

Because these puncture wounds, water exposed wounds, they can be nasty, they can be relatively difficult to treat with antibiotics. And so those are things I want to see right away. And finally, if you see a maggot down under your skin, I can help remove that.

So bot fly infections we see a lot of in our practice. And happy to help you remove that maggot. They’re not dangerous, but they sure are unpleasant.

People don’t like seeing maggots crawling through their flesh. So I can, I can help with that too.

WORM
00:24:42.570 – 00:24:52.250
Oh, imagine that. And Paul, over your years of being a doc, what are some things you’ve learned and how have you become essentially a better doctor every year?

GERM
00:24:53.050 – 00:28:09.430
Well, I. That’s fascinating. I hadn’t heard that I was getting better every year. I’m trying. So you’ve heard the reputation that that’s happening.

I’m delighted to hear it. As medical doctors, we always strive to improve. Right, Chris? This is what we do. We call it the practice of medicine. We’re always practicing.

So what I have found. Yeah, I’ll share a few tips. We talked about how to be a great patient, see us early and often, and be a great communicator.

Those are true characteristics of physicians as well. We should be willing to see our patients. We should be good communicators with them as well.

But for me as a specialist, I got to tell you, one thing I have found is that I need to step outside my specialty. So when I see a patient with an unknown diagnosis, we don’t know what they have, but they’re ill.

I try to force myself every time to not think about infectious diseases first because it’s so seductive, it’s so interesting. It’s what I do, that’s my specialty. They are there to see me for infectious diseases, but it may not be an infection.

So I just want to say that the differential diagnosis, the list of possibilities of what’s making somebody sick, I really try to start with the other stuff first because if I go down the rosy primrose, the golden brick road of id, I may have been on the wrong path the whole time.

What if someone has familial Mediterranean fever, or they’re having a flare of their rheumatoid arthritis, or their, their Crohn’s disease is getting worse. There are other things that can give a fever or belly pain or shortness of breath. This is part of the fundamental practice of medicine.

It’s not specific to travel, it’s not specific to id, but I really do try to do that. I’m sure at least a handful of our listeners out there are physicians, also qualified healthcare providers.

I hope you’ll agree that it’s important to keep that broad differential.

And furthermore, if I’ve gone through that process and I feel that I’ve eliminated these non infectious causes of symptoms, that I’m willing to go back to see that person again, examine them again, interview them again, again, reconsider my differential diagnosis. The times when I’ve been burned is when I get fixated on one particular diagnosis.

Maybe because it’s interesting, maybe there’s something I haven’t seen before and I think, oh, I’m going to see the first case of this or that.

Yes, to our listeners, yes, we doctors love what we do and we get excited about adding to our, our punch list, you know, the things that we’re interested in learning about that we want to add to our, our list of great cases that can be a seduction and of course that can be a dangerous thing to do because we may miss the fundamental underlying things.

So for me, it’s all about spending time with these patients, talking to them, having a genuine two way conversation, doing the testing and then, you know, discussing the results with them. Those are the fundamental things that’s true in any practice.

True for you as well, I’m sure, But for me, I just want to make sure that people know that they’re coming to see me because they’re worried about an infection, which they may have, they may not at all have an infection or not one that I can diagnose or treat. And sometimes that is a sore spot for our patients. Chris, they really want an answer and they really want to be reassured. That’s what I want to do.

That’s why I go to work. I cannot always deliver that.

So for me, the other part to your question, setting expectations, really making sure that the conversation will be fruitful so that people know what I’m worried about and what I can and cannot provide based on current technology.

WORM
00:28:10.390 – 00:28:59.180
You know, I’ve heard that whole process of keeping an open mind and not coming to a decision too soon expressed in the dictum that we teach to medical students and Residents avoid premature diagnostic closure because as soon as you narrow it down to a certain category, you may be excluding something that, in fact is what’s going on.

There’s a TV show, a good TV show called House, and House can shake your hand and in seconds state the exact correct rare disease that you have, which is really satisfying and it makes for great drama. But that’s Hollywood. That doesn’t happen in the real world. As you say, Paul, you generate this differential diagnosis, which is statistical.

You go through your long process as you get more info, you update and you change and you reorder your differential diagnosis. I’m glad you raised that point.

GERM
00:28:59.740 – 00:29:45.980
House is one of my favorite shows. Not realistic in any way. I get that all the time. What do you think of House? I think it’s great acting, great writing.

It is not medicine, but it sure is quite entertaining. The other thing to say is that we have this old saying, occam’s razor. Sir William of Ockham, who said, you know, the.

The answer that explains everything is probably the one that is. That is most likely. So we. We do that a lot in medicine, don’t we, Chris? Occam’s Razor. Well, in. In the tropics, Occam’s razor gets really rusty.

I like Hickam’s dick, which is patient can have as many diseases as they damn well pleases. And so that’s really true that people who have infections tend to get more infections. People who have STIs tend to get more STIs.

We really do need to think about the idea that the may be more than one thing happening in these complicated patients with a complicated itinerary.

WORM
00:29:57.500 – 00:30:28.300
Well, everyone, that’s a wrap for episode 103 of the Germ and Worm Travel Health podcast. As always, we welcome your questions on travel health. Please send us questions, tips for travel success, or suggested corrections.

Just email us: germandworm@gmail.com or visit our website, germandworm.com if you enjoyed this episode, please subscribe, rate us favorably on your device and spread the word with friends, family and on social media. Those are totally free ways to support the pod. I’m Worm.

GERM
00:30:28.540 – 00:30:31.260
I’m Germ. It’s a big planet. See it in good health.

WORM
00:30:31.830 – 00:30:55.110
We’ll see you next time. This podcast is designed to inform, inspire, and entertain.

However, this podcast does not establish a doctor patient relationship and it should not replace your conversation with a qualified healthcare professional. Please see one before your next adventure. The opinions in this podcast are Dr. Sanford’s and Pottinger’s.

Alone and do not necessarily represent the opinions of the University of Washington or UW Medicine.