More on tick infections, a case presentation, and a cliffhanger. Latest: paulsaxmd.substack.com/p/the-diagno...
The Diagnosis Was Obvious. The Mistake Came Next.
A two-part story about medicine under pressure.
paulsaxmd.substack.com
Paul Sax
@paulsaxmd.bsky.social
Harvard/Brigham Infectious Diseases doctor, writer, educator. Editor of Clinical Infectious Diseases. Prefer baseball to football, pizza to sushi, dogs to cats, Beatles to Stones. https://blogs.jwatch.org/hiv-id-observations/
So much we need to learn about tick-related infections, so this effort by HHS is welcome. But I worry deeply about the company they keep in their announcement. More here: #IDSky #Medsky voices.nejm.org/doi/full/10....
Lyme Disease Deserves Better — But Better Starts with Better Evidence
A recent federal announcement to combat tick-borne disease has a promising premise but deserves scrutiny.
voices.nejm.org
Who doesn't have a love-hate relationship with email? Impossible. open.substack.com/pub/paulsaxm...
You’ve Got Mail. And Mail. And More Mail.
Part #2 of my Love-Hate Series: Email -- the miracle that connects us, buries us, and sends a “gentle reminder.”
open.substack.com
It took 6+ years, but will likely soon have a preventive strategy for Covid that actually works. Full story here: | NEJM Voices #IDSky #Medsky voices.nejm.org/doi/full/10....
An Oral Preventive Strategy for Covid-19 that Actually Works
Ensitrelvir reduced Covid-19 incidence 67% in household contacts of active cases.
voices.nejm.org
Two weeks on ID consults → some highlights: • Staph aureus from the urinary tract (yes, really) • “Explosive pleuritis” (still a great name) • Sinus fungal balls that aren’t so scary • Poor CD4 recovery in HIV • And why strep taxonomy = chaos And an A+ team! @nejm.org voices.nejm.org/doi/full/10....
ID Link-o-Rama: On Service Edition
Staph aureus in an unexpected place, sinus fungal balls, “explosive pleuritis”, and other lessons from 2 weeks on the consult service
voices.nejm.org
One of the most commonly used words in my house growing up was "ambivalence." Which might explain why I had no trouble coming up with a list of things in infectious diseases that I both love and hate. New post here, with bonus @idsainfo.bsky.social podcast. open.substack.com/pub/paulsaxm...
Loving and Hating the Same Thing
Antibiotics, diagnostics, and other sources of professional ambivalence.
open.substack.com
Don't miss the two -- count 'em! -- free videos! Rabies, Tuberculosis, and Other Cheerful Spring Topics open.substack.com/pub/paulsaxm...
Rabies, Tuberculosis, and Other Cheerful Spring Topics
Including a video making its big premiere, plus a few other entertaining subjects of note.
open.substack.com
Box #1 is the BEST. We do everything we can to help people get out of Box #4.
Alainna J. Jamal@alainnajj.bsky.social · 4mo agoThe Four States of Clinical Medicine, courtesy of @paulsaxmd.bsky.social. We live in box 4 a lot in ID (and it can be unsettling wondering if you missed a crucial piece of the hx, a key investigation, a key rx, etc. - a good time to call more seasoned friends for help) blogs.nejm.org/hiv-id-obser...
One-month treatment for latent tuberculosis. Why aren't we using it? (Hint: We should.) voices.nejm.org/doi/full/10....
One-Month Treatment for Latent Tuberculosis
Why aren’t we using it?
voices.nejm.org
Latest for @nejm.org, an attempt to bring much-needed attention to these challenging ID cases that for some reason receive so little attention -- NTM. #IDSky Nontuberculous Mycobacteria: The Common Infections You’ve Possibly Never Heard Of | NEJM Voices voices.nejm.org/doi/full/10....
Nontuberculous Mycobacteria: The Common Infections You’ve Possibly Never Heard Of
Twenty facts about a surprisingly common group of infections.
voices.nejm.org
How Much Do You Really Want To Know About Your Doctor's Political Views? I tend to keep these discussions short. Here's why. open.substack.com/pub/paulsaxm...
How Much Do You Really Want To Know About Your Doctor's Political Views?
My guess: not much, as long as they’re taking good care of you.
open.substack.com
Some highlights from CROI2026, with commentary. Enjoy. (Free to read.) #IDSky voices.nejm.org/doi/full/10....
Really Rapid Review: Conference on Retroviruses and Opportunistic Infections 2026
Dr. Paul Sax rounds up key takeaways from CROI 2026, the leading HIV research conference.
voices.nejm.org
In this @nejm.org Voices post, I take on one of the more annoying and pointless rituals of hospital work -- the annual N95 fit test. As one of the respected infection control specialists told me, it's not their fault. And I totally believe them. #idsky #medsky voices.nejm.org/doi/full/10....
Requiring Annual N95 Mask Fit Testing Is a Waste of Time and Money
Is it time to replace annual N95 mask fit testing with a less expensive, evidence-based policy?
voices.nejm.org
My friend John shared this story with me. I promise, it has an ID theme. You'll see. open.substack.com/pub/paulsaxm...
Raccoon Bites
This isn't really about raccoon bites.
open.substack.com
CROI is quirky and selective. It meets in very cold cities. And it remains the best meeting in HIV medicine. Reflections from this year’s gathering blogs.nejm.org/hiv-id-obser...
Some Ruminations on CROI — Still the Best HIV Meeting
CROI, which just wrapped up in Denver, is not like other scientific meetings — it’s quirky. Let me count the ways. There’s the name — the Conference on Retroviruses and Opportunistic Infections — coin...
blogs.nejm.org
Two things can be true: 1. FDA’s handling of Moderna’s mRNA flu vaccine review raises process questions 2. The data themselves were underwhelming Here's my take, finishing up with perhaps the biggest disappointment -- it's a hit on pandemic preparedness. blogs.nejm.org/hiv-id-obser...
Two Things Can Be True: The FDA Process Was Inconsistent, and the mRNA Vaccine Data Were Disappointing
Share Tweet Pin Mail SMS Any time I write about vaccines, especially mRNA vaccines, things get dicey. Any negative comments might fuel attacks from ...
blogs.nejm.org
Learning how to teach in the year before medical school. Truly on-the-job training. open.substack.com/pub/paulsaxm...
A Teacher Who Needed Teaching
Learning how to teach, forty minutes at a time.
open.substack.com
AI is terrific for quickly summarizing what guidelines say. Here are 3 places clinicians can get input from actual human beings instead, one old-fashioned, a couple newer: blogs.nejm.org/hiv-id-obser...
Sometimes You Just Need to Get Input from a Real Human Being
Share Tweet Pin Mail SMS If you’re not using AI in clinical medicine yet, allow me to strongly recommend you start — soon. Like ...
blogs.nejm.org
What did you do the year before medical school? I taught in an English "public school", and for the first few days, I was desperately trying to fit in. open.substack.com/pub/paulsaxm...
The Year Before Medical School
Or, how I ended up teaching at a boarding school instead of pipetting in a research lab.
open.substack.com
Now "free to read" -- great progress! One remaining barrier in Massachusetts: HIV testing of people unable to give verbal consent. Especially relevant when caused by critical illness, or a patient is the source of an occupational exposure. open.substack.com/pub/paulsaxm...
Another Thing That's Undeniably Improved in Medicine: Getting an HIV Test
A Happy Birthday to a landmark policy change.
open.substack.com
Paul Sax@paulsaxmd.bsky.social · 6mo agoGetting an HIV test used to involve a convoluted series of steps that ended up discouraging testing. It was bad for patients. All that changed (finally) in 2006 -- real progress! #IDSky #Medsky open.substack.com/pub/sensible...
Used to really enjoy watching football. Now, not so much. Actually, not at all. A week before the big game, I decided to document what changed, with the 100% understanding that this is an unpopular perspective. (I'm ok with that!) open.substack.com/pub/paulsaxm...
Not Watching Football
A personal exploration of an unpopular view.
open.substack.com
Getting an HIV test used to involve a convoluted series of steps that ended up discouraging testing. It was bad for patients. All that changed (finally) in 2006 -- real progress! #IDSky #Medsky open.substack.com/pub/sensible...
Another Thing That's Undeniably Improved in Medicine: Getting an HIV Test
A Happy Birthday to a landmark policy change
open.substack.com
Rabies is undoubtedly terrifying. Three recent case reports highlight both the clinical severity and the importance of prevention. But how broadly should we apply prevention when the risk for so many exposures is very, very low? #IDsky #Medsky blogs.nejm.org/hiv-id-obser...
Rabies Is Terrifying -- and the Challenge of Managing the Low Risk of a Dreadful Disease
Three case reports of human rabies recently appeared in the MMWR. Reading each one served as a reminder of just how horrifying this infection is when it strikes — which very fortunately is quite rare ...
blogs.nejm.org
Revisiting "How to Figure Out the Length of Antibiotic Therapy", and how it came to be. Sobering that my greatest claim to writing fame is now over 15 years old, implying a subsequent lack of inspiration. 🤷♂️ #IDsky #medsky paulsaxmd.substack.com/p/the-story-...
The Story Behind My Most Famous Blog Post
The origins of "How to Figure Out the Length of Antibiotic Therapy"
paulsaxmd.substack.com
One of the most honest answers in medicine remains: “We just don’t know.” Especially true for the flu -- timing, transmission, vaccines, all still full of surprises. Five questions, five reflections on why the flu keeps humbling us. #IDsky #Medsky blogs.nejm.org/hiv-id-obser...
Influenza -- So Familiar, Still So Mysterious
In what feels like the fastest-peaking influenza season in quite some time, I find myself returning to a familiar answer when asked questions about this miserable virus: “We just don’t know.” At least...
blogs.nejm.org
Interesting poll results! (Still time to vote.) paulsaxmd.substack.com/p/dear-reade...
Dear Readers: Who Are You?
Checking in at the three-month point in this writing journey.
paulsaxmd.substack.com
Azithromycin: once a pharmacologic breakthrough, now a textbook case of overuse. Part 2 explores resistance, muddled diagnoses, and the cases where it's still arguably the drug of choice. #IDSky #Medsky blogs.nejm.org/hiv-id-obser...
How the Z-Pak Took Over Outpatient Medicine, Part 2: The Reckoning
Share Tweet Pin Mail SMS Part 1 of this azithromycin series explained how the drug became ubiquitous. In Part 2, we’ll explore why many ...
blogs.nejm.org
How fortunate that two of the things I love the most in life are associated with prolonged survival. Plus, a very important "recent" paper. Happy New Year! #IDsky #Medsky open.substack.com/pub/paulsaxm...
Two Things that Prolong Life and a Great Recent Paper
A Happy New Year gift to me and everyone who shares one or both of these enthusiasms.
open.substack.com
How did a five-day antibiotic course become a cultural phenomenon? A brief (ha ha, ID docs can't be brief) but riveting history of how the Z-Pak took over outpatient antibiotic prescribing. Part 2 (the problems) coming soon. #IDSky #Medsky blogs.nejm.org/hiv-id-obser...
How the Z-Pak Took Over Outpatient Medicine
Chances are, across this great land of ours, right at this very moment, someone is coughing, or sneezing, or struggling with a sore throat, or some combination of the above, and taking the antibiotic ...
blogs.nejm.org
Some things really are MUCH better than they used to be. Zero nostalgia for the old days when it comes to reviewing radiology images! paulsaxmd.substack.com/p/one-thing-...
One Thing That’s Undeniably Better in Medicine
Looking at radiology images, then and now.
paulsaxmd.substack.com