Physicians in Taiwan Face up to Severe Sepsis: Should We Be Surprised?* Timothy H. Rainer, MD Accident and Emergency Medicine Academic Unit Chinese University of Hong Kong Shatin, New Territories, Hong Kong
include these factors in a regression model. However, two other factors—urbanization and Charlson score—which, on the initial univariate analysis, were not statistically significant were also included in the regression models. It is not clear why the authors elected to do this. n the United States, the healthcare sector employs more The strengths of this study lie in its relatively large sampeople than any other industry ( 1 ) and its employees are ple size, in which approximately 60,000 subjects or 0.3% of not without significant risk (2). Yet, few studies have inves- Taiwan's 23.34 million population were recruited; its comtigated relative mortality and morbidity risks in physicians. It prehensiveness, drawn from all over Taiwan which has one may have been the special effects of severe acute respiratory of the largest and most comprehensive health databases in syndrome in 2003 in Taiwan (3), and its particular affect on the world; the reassurance it may give to certified male phyhealthcare workers (4, 5), or there may be other unknown sicians below 65 years, that they are more likely to recover reasons, but our professional colleagues in Taiwan have taken from sepsis than the nonmedical population; and finally, the some initiative in assessing relative health risks in physicians. In potential for improved outcomes in nonmedical persons, 2005, they noted a lower morbidity and disease risk in Chinese assuming that education and awareness are significant and medicine physicians compared with the general population relevant factors. (6). With this in mind, one wonders whether western medicine However, it is important not to overinterpret these findings. physicians have similar outcomes, and to what degree this findIn their abstract, Shen et al (10) conclude that "These findings ing translates into other more specific healthcare settings. support the hypothesis that physicians are less likely than conSepsis is a common condition in patients admitted to ICUs, trols to develop or die of severe sepsis, implying that mediand severe sepsis has a high mortality (7-9). Although phycal knowledge, higher disease awareness, and easier healthcare sicians have significant contact with such cases, there are no access in physicians may help reduce their risk of severe sepsis studies that specifically investigate the risk of severe sepsis in and associated mortality." It is clear from the raw and adjusted physicians. The linked article by Shen et al (10) in this issue data analysis that male physicians especially those under 65 of Critical Care Medicine takes some steps to investigate such years are less likely than controls to develop or die of severe risk. In a large, matched cohort study, all physicians in Taiwan sepsis. However, whether "medical knowledge, higher diswere compared with a similar nonmedical group, which were ease awareness, and easier healthcare access" improve a phymatched demographically, socioeconomically, and by age and sician's self-awareness, self-diagnosis, and determination to gender. Subjects were followed for 9 years except in cases of seek help is highly speculative. Although doctors learn from death or withdrawal from the study to determine the relabeing patients, they often live in denial prior to such experitive risk of severe sepsis and of subsequent 90-day mortality. ence (11). Intuitively it is reasonable to assume that physiPhysicians were 24% less likely to acquire severe sepsis than cians have greater medical knowledge, disease awareness, and nonmedical personnel, and after adjustments, they were also true healthcare access, but it is quite another issue whether less likely to die. However, this was most marked in physicians they really apply such knowledge to themselves in ways that below 65 years. improve their health. Shen et al note four factors that are worthy of comment Why did the authors choose to divide age above and below that were statistically significant and which differentiated phy65 years for their analysis? Was it chosen because traditionsicians from the nonmedical community. They are age, income ally the age of retirement in many countries is set at 65 years level, level of medical center, and geographical distribution. To or because there is a perception that physiology deteriorates adjust for confounders and variable interaction, the authors in the 60s? The cutoff is interesting because below 65 years, male physicians appear to have a much lower relative risk of developing severe sepsis and of dying, whereas above 65 years there is little if any difference between physicians and the non'Seealsop. 816. medical population. In fact there appears to be little "biologiKeywords: mortality; occupational risk; physicians; severe sepsis; Taiwan cal justification for separating the elderly from the rest of the Dr. Rainer provided expert testimony for solicitors, lectured for Hospital adult human race" (12). Could there be more of a deteriorating Authority, has a patent through university institution, has stock options trend across the continuum of the whole age spectrum rather (private, nonhealthcare related), and received support for travel to conthan a 65-year-old cutoff? The authors do this for mortality ferences. His institution received grant support from government grants. but not for severe sepsis. Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins Although the article is limited in generalizability, especially DOI: 10.1097/CCM.0000000000000090 as other nations may have a much higher proportion of female
I
Critical Care Medicine
www.ccmjournal.org
981
Editorials
doctors than in this study, nevertheless the authors note that there are similarities to other work for the United States (13). They also highlight that there is no obvious physiological reason why doctors should fair better than the general population. The fact that they do so implies that better outcomes from severe sepsis may be possible for the general population at least in Taiwan. Others have noted that physicians' health practices strongly influence patients (14, 15), so there is good reason to believe from this study that patient outcomes can be improved. It initially appears that physicians in lower income brackets are at much higher risk of severe sepsis than their equivalents in the nonmedical population. As the authors do not present a multivariate analysis of these data, we do not know whether this is a real factor or due to confounding. It is understandable that doctors target medical centers rather than regional or district hospitals as these appear to be larger tertiary centers. Nevertheless, this may be due to geography rather than personal selection. It is also understandable that there is geographical variation as very few countries boast equal care across all jurisdictions. The authors have a large database and one wonders whether more could not be gleaned from the data. In their article, Shen et al (10) identify factors associated with 90-day mortality for the group as a whole. However, as physicians have different outcomes from the nonmedical population, then what are the specific factors that differentiate physician survivors from physicians nonsurvivors and also from nonmedical survivors and nonmedical deaths, especially for the younger, under 65-yearold, male physician subgroup? Whatever the answer to these questions, this issue of Critical Care Medicine provides some good news for adult male physicians under 65 years in Taiwan.
982
vwwv.ccmjournal.org
REFERENCES 1. Udasin IG: Health care workers. Prim Care 2000; 27:1079-1102 2. Dorevitch S, Forst L: The occupational hazards of emergency physicians. Am J Emerg Med 2000; 18:300-311 3. Chen KT, Twu SJ, Chang HL, et al; Taiwan SARS Response Team: SARS in Taiwan: An overview and lessons learned. Int J Infect Dis 2005; 9:77-85 4. Lee N, Hui D, Wu A, et al: A major outbreak of severe acute respiratory syndrome in Hong Kong. N EngI J Med 2003; 348:1986-1994 5. Rainer TH, Cameron PA, Smit D, et al: Evaluation of WHO criteria for identifying patients with severe acute respiratory syndrome out of hospital: Prospective observational study BMJ 2003; 326:1354-1358 6. Liu SH, Li TH, Lin YL, et al: Lower morbidity and disease risk among the Chinese medicine physicians in Taiwan. Tohoku J Exp Med 2009; 219:207-214 7 Bernard GR, Wheeler AP, Russell JA, et al: The effects of ibuprofen on the physiology and survival of patients with sepsis. The Ibuprofen in Sepsis Study Group. N EngI J Med 1997; 336:912-918 8. Rice TW, Wheeler AP, Thompson BT, et al; NIH NHLBI Acute Respiratory Distress Syndrome Network of Investigators: NHLBI ARDS Clinical Trials Network: Enterai omega-3 fatty acid, gammalinolenic acid, and antioxidant supplementation in acute lung injury. JAMA 2011:306:1574-1581 9. Sivayoham N, Rhodes A, Jaiganesh T, et al: Outcomes from implementing early goal-directed therapy for severe sepsis and septic shock: A 4-year observational cohort study. Eur J Emerg Med 2012; 19:235-240 10. Shen H-N, Lu C-L, Li C-Y: Do Physicians Have Lower Risk of Severe Sepsis and Associated Mortality? A Matched Cohort Study. Crit Care Med 2014: 42:816-823 11. Parker-Pope T: When doctors become patients. Available at: http://well. blogs.nytimes.com/2008/02/08/when-doctors-become-patients/?_r=0. Accessed October 28, 2013. 12. Caird FL, Evans JG: Chapter 31. Medicine in old age. In: Oxford Textbook of Medicine. 3rd Edition. Weatherall DJ, Ledingham JGG, Warrell DA (Eds). Oxford, UK: Oxford University Press, 1996, p 4331 13. Frank E, Biola H, Burnett CA: Mortality rates and causes among U.S. physicians. Am J Prev Med 2000; 19:155-159 14. Frank E, Dresner Y, Shani M, et al: The association between physicians' and patients' preventive health practices. CMAJ 2013; 185:649-653 15. Oberg EB, Frank E: Physicians' health practices strongly influence patient health practices. J R Coll Physicians Edinb 2009; 39:290-291
April 2014 • Volume 42 • Number 4
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
include these factors in a regression model. However, two other factors—urbanization and Charlson score—which, on the initial univariate analysis, were not statistically significant were also included in the regression models. It is not clear why the authors elected to do this. n the United States, the healthcare sector employs more The strengths of this study lie in its relatively large sampeople than any other industry ( 1 ) and its employees are ple size, in which approximately 60,000 subjects or 0.3% of not without significant risk (2). Yet, few studies have inves- Taiwan's 23.34 million population were recruited; its comtigated relative mortality and morbidity risks in physicians. It prehensiveness, drawn from all over Taiwan which has one may have been the special effects of severe acute respiratory of the largest and most comprehensive health databases in syndrome in 2003 in Taiwan (3), and its particular affect on the world; the reassurance it may give to certified male phyhealthcare workers (4, 5), or there may be other unknown sicians below 65 years, that they are more likely to recover reasons, but our professional colleagues in Taiwan have taken from sepsis than the nonmedical population; and finally, the some initiative in assessing relative health risks in physicians. In potential for improved outcomes in nonmedical persons, 2005, they noted a lower morbidity and disease risk in Chinese assuming that education and awareness are significant and medicine physicians compared with the general population relevant factors. (6). With this in mind, one wonders whether western medicine However, it is important not to overinterpret these findings. physicians have similar outcomes, and to what degree this findIn their abstract, Shen et al (10) conclude that "These findings ing translates into other more specific healthcare settings. support the hypothesis that physicians are less likely than conSepsis is a common condition in patients admitted to ICUs, trols to develop or die of severe sepsis, implying that mediand severe sepsis has a high mortality (7-9). Although phycal knowledge, higher disease awareness, and easier healthcare sicians have significant contact with such cases, there are no access in physicians may help reduce their risk of severe sepsis studies that specifically investigate the risk of severe sepsis in and associated mortality." It is clear from the raw and adjusted physicians. The linked article by Shen et al (10) in this issue data analysis that male physicians especially those under 65 of Critical Care Medicine takes some steps to investigate such years are less likely than controls to develop or die of severe risk. In a large, matched cohort study, all physicians in Taiwan sepsis. However, whether "medical knowledge, higher diswere compared with a similar nonmedical group, which were ease awareness, and easier healthcare access" improve a phymatched demographically, socioeconomically, and by age and sician's self-awareness, self-diagnosis, and determination to gender. Subjects were followed for 9 years except in cases of seek help is highly speculative. Although doctors learn from death or withdrawal from the study to determine the relabeing patients, they often live in denial prior to such experitive risk of severe sepsis and of subsequent 90-day mortality. ence (11). Intuitively it is reasonable to assume that physiPhysicians were 24% less likely to acquire severe sepsis than cians have greater medical knowledge, disease awareness, and nonmedical personnel, and after adjustments, they were also true healthcare access, but it is quite another issue whether less likely to die. However, this was most marked in physicians they really apply such knowledge to themselves in ways that below 65 years. improve their health. Shen et al note four factors that are worthy of comment Why did the authors choose to divide age above and below that were statistically significant and which differentiated phy65 years for their analysis? Was it chosen because traditionsicians from the nonmedical community. They are age, income ally the age of retirement in many countries is set at 65 years level, level of medical center, and geographical distribution. To or because there is a perception that physiology deteriorates adjust for confounders and variable interaction, the authors in the 60s? The cutoff is interesting because below 65 years, male physicians appear to have a much lower relative risk of developing severe sepsis and of dying, whereas above 65 years there is little if any difference between physicians and the non'Seealsop. 816. medical population. In fact there appears to be little "biologiKeywords: mortality; occupational risk; physicians; severe sepsis; Taiwan cal justification for separating the elderly from the rest of the Dr. Rainer provided expert testimony for solicitors, lectured for Hospital adult human race" (12). Could there be more of a deteriorating Authority, has a patent through university institution, has stock options trend across the continuum of the whole age spectrum rather (private, nonhealthcare related), and received support for travel to conthan a 65-year-old cutoff? The authors do this for mortality ferences. His institution received grant support from government grants. but not for severe sepsis. Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins Although the article is limited in generalizability, especially DOI: 10.1097/CCM.0000000000000090 as other nations may have a much higher proportion of female
I
Critical Care Medicine
www.ccmjournal.org
981
Editorials
doctors than in this study, nevertheless the authors note that there are similarities to other work for the United States (13). They also highlight that there is no obvious physiological reason why doctors should fair better than the general population. The fact that they do so implies that better outcomes from severe sepsis may be possible for the general population at least in Taiwan. Others have noted that physicians' health practices strongly influence patients (14, 15), so there is good reason to believe from this study that patient outcomes can be improved. It initially appears that physicians in lower income brackets are at much higher risk of severe sepsis than their equivalents in the nonmedical population. As the authors do not present a multivariate analysis of these data, we do not know whether this is a real factor or due to confounding. It is understandable that doctors target medical centers rather than regional or district hospitals as these appear to be larger tertiary centers. Nevertheless, this may be due to geography rather than personal selection. It is also understandable that there is geographical variation as very few countries boast equal care across all jurisdictions. The authors have a large database and one wonders whether more could not be gleaned from the data. In their article, Shen et al (10) identify factors associated with 90-day mortality for the group as a whole. However, as physicians have different outcomes from the nonmedical population, then what are the specific factors that differentiate physician survivors from physicians nonsurvivors and also from nonmedical survivors and nonmedical deaths, especially for the younger, under 65-yearold, male physician subgroup? Whatever the answer to these questions, this issue of Critical Care Medicine provides some good news for adult male physicians under 65 years in Taiwan.
982
vwwv.ccmjournal.org
REFERENCES 1. Udasin IG: Health care workers. Prim Care 2000; 27:1079-1102 2. Dorevitch S, Forst L: The occupational hazards of emergency physicians. Am J Emerg Med 2000; 18:300-311 3. Chen KT, Twu SJ, Chang HL, et al; Taiwan SARS Response Team: SARS in Taiwan: An overview and lessons learned. Int J Infect Dis 2005; 9:77-85 4. Lee N, Hui D, Wu A, et al: A major outbreak of severe acute respiratory syndrome in Hong Kong. N EngI J Med 2003; 348:1986-1994 5. Rainer TH, Cameron PA, Smit D, et al: Evaluation of WHO criteria for identifying patients with severe acute respiratory syndrome out of hospital: Prospective observational study BMJ 2003; 326:1354-1358 6. Liu SH, Li TH, Lin YL, et al: Lower morbidity and disease risk among the Chinese medicine physicians in Taiwan. Tohoku J Exp Med 2009; 219:207-214 7 Bernard GR, Wheeler AP, Russell JA, et al: The effects of ibuprofen on the physiology and survival of patients with sepsis. The Ibuprofen in Sepsis Study Group. N EngI J Med 1997; 336:912-918 8. Rice TW, Wheeler AP, Thompson BT, et al; NIH NHLBI Acute Respiratory Distress Syndrome Network of Investigators: NHLBI ARDS Clinical Trials Network: Enterai omega-3 fatty acid, gammalinolenic acid, and antioxidant supplementation in acute lung injury. JAMA 2011:306:1574-1581 9. Sivayoham N, Rhodes A, Jaiganesh T, et al: Outcomes from implementing early goal-directed therapy for severe sepsis and septic shock: A 4-year observational cohort study. Eur J Emerg Med 2012; 19:235-240 10. Shen H-N, Lu C-L, Li C-Y: Do Physicians Have Lower Risk of Severe Sepsis and Associated Mortality? A Matched Cohort Study. Crit Care Med 2014: 42:816-823 11. Parker-Pope T: When doctors become patients. Available at: http://well. blogs.nytimes.com/2008/02/08/when-doctors-become-patients/?_r=0. Accessed October 28, 2013. 12. Caird FL, Evans JG: Chapter 31. Medicine in old age. In: Oxford Textbook of Medicine. 3rd Edition. Weatherall DJ, Ledingham JGG, Warrell DA (Eds). Oxford, UK: Oxford University Press, 1996, p 4331 13. Frank E, Biola H, Burnett CA: Mortality rates and causes among U.S. physicians. Am J Prev Med 2000; 19:155-159 14. Frank E, Dresner Y, Shani M, et al: The association between physicians' and patients' preventive health practices. CMAJ 2013; 185:649-653 15. Oberg EB, Frank E: Physicians' health practices strongly influence patient health practices. J R Coll Physicians Edinb 2009; 39:290-291
April 2014 • Volume 42 • Number 4
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
