Newman's Notions | April 2015 | FREE
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Quattro formaggi

Working in the hospital can be a cheesy experience.

Working in the hospital can be a cheesy experience, as the following examples show.

Who moved my cheese?

Illustration by David Rosenman
Illustration by David Rosenman

In the business fable “Who Moved My Cheese?” written by Spencer Johnson, MD, in 1998, 2 mice and 2 diminutive humans are trapped in a maze in search of cheese. It's an allegory for adapting to change. The mice, Sniff and Scurry, are ready to run the maze in search of cheese. They don't overthink the issue; they do what needs to be done.

The humans, Hem and Haw, are slow to adapt to change. When the cheese supply dries up, they are caught unaware. They blame, they dither, they wait for the cheese to come back. Eventually one of them sets forth in the maze, to eventually be rewarded by cheese and by the insight that to be successful, you must embrace the hunt for cheese, or change.

Remember these lessons: They keep moving the cheese. Smell it often so you know when it's getting old. Be ready to let go of old cheese, and savor the adventure of chasing cheese, because again, they keep on moving it.

What's the lesson for hospitalists? We are in a rapidly evolving field, with rapid growth and constant change. Just when you learn the quality guidelines, they change them. When you finally understand the 2-midnight rule, it gets updated and a certification statement is no longer needed. We are functioning in a regulatory environment that is constantly shifting. Expecting our job to be static or not being willing to embrace changes in medicine will leave us cheese-less, and clueless.

The Swiss cheese model

Anyone who has attended a lecture or read about medical error has seen an image of Swiss cheese. The Swiss cheese model originated in James Reason's 1990 book, “Human Error.” When the holes in multiple pieces of Swiss cheese are not aligned, nothing can flow through. But when the 4 slices are laid on top of each other and the holes line up, error slips though.

The hospital is filled with Swiss cheese. We all have heard of or managed patients who experienced sentinel events or near misses because of a domino effect of minor errors that led to the big, bad outcome. Safety is a top priority for hospitalists. The Swiss cheese error model runs neck and neck with the cover of the 1999 Institute of Medicine report, “To Err is Human: Building a Safer Health System,” for PowerPoint dominance in medical error talks.

Swiss cheese, aka Emmental, is filled with “eyes.” (Hole-less cheese is actually called “blind.”) These holes are provided courtesy of bacteria: Streptococcus salivarius, Lactobacillus helveticus, and Propionibacterium. The Propionibacterium releases gas, making the cavities. Eye size is a function of pH, temperature, and time. Of course the USDA has a say in it, too: Hole size is regulated to be between 3/8 and 13/16 of an inch in diameter. The government has its eye on Swiss cheese. And anyone who works in the hospital knows the importance of both regulations and good bacteria.

Cheese diseases

The Urban Dictionary defines cheese disease as the GI disturbance that results from massive ingestion of string cheese after significant inhaled exposure to tetrahydrocannabinol. Of a more historic and medically significant nature is caseous or “cheese-like” necrosis. This was first described by the Austrian pathologist Rudolf Virchow in 1863 in relation to granulomas in tuberculosis. This type of caseating granuloma can also be seen in sarcoidosis, histoplasmosis, and other fungal diseases. The term “caseous” comes from its white and tan cheesy appearance on autopsy. Cheese has also been at the core of several epidemics. In 1947, F. W. Fabian summed up 60 years of cheese-borne illness in the American Journal of Public Health, finding 1,389 cases, 16 epidemics, and 47 deaths, mostly attributed to bacterial infection from unpasteurized cheese.

The cutting of cheese

No discussion of the hospital and cheese would be complete without the cutting thereof. When managing postoperative patients, the passage of flatus is a consistent topic on daily rounds. In the hospitalized postoperative patient, the gaseous emission is a post-ileus thing of joy (unless it occurs on the elevator). Perhaps the most comprehensive and flatulent work on this topic is Jim Dawson's “Who Cut the Cheese? A Cultural History of the Fart.” However, Aristophanes, Shakespeare, and William Blake also did not hesitate to make use of this literary passage. The expression “cutting the cheese” comes from the odiferous nature of a newly sliced piece of cheese.


So before you head (and head cheese is not a cheese at all) to the hospital today, think about the cheesy experience of being a hospitalist. On the way in, play Jimmy Buffett's “Cheeseburger in Paradise,” pull out your camera, and take a selfie. But don't forget to “say cheese!”