Medical Paradoxes in Clinic, Lab Should Encourage Physicians to Reappraise Ideas about Health and Disease

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Wash your hands. This most basic tenet of proper hygiene has been drummed into our heads for years. It’s an obvious infection prevention activity, yet for years, compliance among physicians and other caregivers has been lackluster. To rectify this matter, regulatory agencies began auditing hospital staff adherence to this axiom of infection prevention. Not only can the financial penalties be steep for failure to comply, but the embarrassment of scoring poorly would sink a hospital’s reputation; the carefully cultivated image of top-tier medical care would flow down the drain.

Paradoxically, it is exactly these two items—the sink and the drain—that can actually transform the cleansing act of hand washing into a potentially hazardous activity.¹ The strategy of placing sinks near the bedside seems like a great idea—their close proximity to the patient would serve as a visual reminder for staff to wash. Right? However, it turns out that those U-shaped bends in the pipes that drain sinks are ideal locations for bacteria to aggregate and form vast colonies known as biofilms. Studies suggest that these colonies may be capable of retrograde movement, allowing bacteria to find their way back into the sink basin where water pouring out of a faucet can splash these bugs onto the hands of an unsuspecting washer.

This scenario may seem preposterous, but indirect evidence supports it. A retrospective study conducted in an intensive care unit in The Netherlands observed that following the removal of sinks from patient rooms and the introduction of “water-free patient care,” a significant reduction of colonization of multi-drug-resistant gram-negative bacteria in patients occurred.² The longer the admission, the more likely that this effect was observed. Who knew?

The Medical Paradox in Clinical Practice

The paradoxical event can be fortuitous and haunting, striking out of nowhere like a bolt of lightning. Consider the patient whose cancer is seemingly cured only to succumb to a massive pulmonary embolism. In other scenarios, the paradox may arise as a considerable nuisance, such as an outbreak of psoriasis in a patient successfully treated with tumor necrosis factor blockade, an attack of podagra after a patient begins urate-lowering therapy or weight loss in a patient following the use of corticosteroid therapy. These are unexpected outcomes that fly in the face of logic.

Consider the odd relationship between smoking, among the worst personal habits that adversely impact one’s health, and ulcerative colitis (UC). Several studies have observed that UC is less prevalent in smokers than nonsmokers, whose odds ratio for developing the disease is 0.4. In fact, current smokers with UC are more likely to exhibit milder disease than former smokers and nonsmokers.³ These findings can make the plea for smoking cessation in this population a nettlesome conversation.

Paradoxical developments arising in the clinic or in the lab should not be viewed as nuisances or obstacles impeding the path of medical progress. They should serve as intellectual challenges or warning signals that dare us to return & reappraise our preconceived notions about health, disease & human biology.

A similar predicament may arise with some forms of heart disease. Prior studies have found that smokers undergoing thrombolytic therapy for ST-segment elevation myocardial infarction have lower in-hospital mortality than nonsmokers, a phenomenon called smoker’s paradox. Recent data extended this smoking benefit to patients with an ST-segment elevation myocardial infarction who required primary percutaneous coronary intervention.⁴ They, too, achieved more favorable outcomes than nonsmokers. The results of this study were not merely a statistical anomaly caused by smokers with coronary artery disease being younger than nonsmokers.