Dan: 0:00

Boghuma Titanji is an ID doctor. ID stands for infectious disease.

Dr. Titanji: 0:07

I really enjoy the first moment when I walk into a patient's room, particularly when it's a case where nobody knows what's going on and I introduce myself and I say I'm with ID and I'm here to help figure out what's going on with you and I'm going to ask you some really unusual questions. Are you okay if I do that?

Dan: 0:33

She's often trying to solve medical cases that other doctors couldn't crack.

Dr. Titanji: 0:38

We always say you really know it is an exotic case when you get the call and they tell you oncology and rheumatology are already seeing this patient and now we are consulting infectious diseases because it usually tells you this is a case that no one really knows what's going on.

Dan: 0:59

And her primary tool is not blood work or imaging, it's conversation with the patient.

Dr. Titanji: 1:06

We are generally known for our ability to take really, really thorough histories and get in-depth information, which usually helps make the diagnosis in challenging cases.

Dan: 1:19

So you're almost like a diagnoser of last resort or something.

Dr. Titanji: 1:24

Yeah. I would say that, you know, we like to describe ourselves as detectives of sort.

Dan: 1:31

And like any detective, she's got questions.

Dr. Titanji: 1:34

Our main tool as infectious diseases physicians is actually speaking to the patient and examining them and trying to piece together the pieces of the puzzle. How does this thing that they just told me fit into what I'm worried they might actually have as a disease process?

Dan: 2:05

I'm Dan Heath and this is What It's Like to Be. In every episode, we walk in the shoes of someone from a different profession. A forensic accountant, a hospice nurse, a conductor. We want to know what they do all day at work. Today, we'll ask Dr. Titanji what it's like to be an infectious disease doctor. We'll talk about the wildest cases she's encountered, what's absurd about the TV character, Dr. House, and the time she encountered a suspected case of Ebola. Stay with us.

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Dan: 3:17

To get a feel for doctor Titanji's work, let's take an example. A patient, middle aged, is admitted to the hospital.

Dr. Titanji: 3:25

They've been having a fever for three weeks. They've just returned from travel from Asia, and they have been on antibiotics and nothing is better, they have a rash. Can you come help us figure out what's going on? Now that's a case where I'm going in with no idea of what's actually happening with the patient. All I have is maybe their age, where they traveled to, and the fact that they have a fever and a rash. Now if you were to put those cluster of symptoms or clues into a Google search, it would probably generate a 100 differential diagnosis.

Dan: 4:05

So a differential diagnosis is basically every plausible thing this particular ailment could be. It's almost like a list of suspects, and she's gotta start crossing suspects off the list. And the early focus isn't so much on finding the highest probability suspect, it's more like eliminating the highest danger options. The ones you can't afford to miss. And the ID doctor's key tool is the patient history.

Dr. Titanji: 4:35

Really, what we are focusing on when we take the history is things like what the patient's hobbies are, where they've been, where they've traveled, who is at home with them, what they've been exposed to. And we do that in a manner that is quite systematic and methodical, which is usually why we're able to catch things that others may not have caught even though they would have spoken to the patient. Sometimes even multiple teams have seen the patient before infectious diseases comes in. I'll give you a specific example.

Dan: 5:12

Yeah.

Dr. Titanji: 5:13

It's very common when, I'm thinking about, tuberculosis being part of the differential. What I see is sometimes people don't go far back enough. You might have a patient who is an octogenarian, and no one thinks to ask them, when you were a little child, do you recall living in a house with someone who was being treated for TB, or do you recall a grandparent who was away, say for instance in a sanitarium receiving treatment for TB? So that's a lot more specific than asking them very vaguely, do you have any TB exposures? Because for something like tuberculosis, an exposure that you had forty years ago because it's a bacteria that can hide in the body and get reactivated or active many decades later, the exposure may have happened decades before the person is presenting with that infection.

Dan: 6:11

Wow. So it can just sort of stay dormant for for decades at a time.

Dr. Titanji: 6:16

Absolutely.

Dan: 6:18

She often gets oddly specific with her questions. So she won't just ask, have you traveled to a foreign country recently? If they have, she'll follow-up with...

Dr. Titanji: 6:28

Did you go into a a cave? Are you a a bat fanatic? Did you go exploring bats? You know? Did you, swim in any local lakes and eat any of the local foods? Was any of that partially cooked or raw? If you went on a retreat and were in a shaman retreat, what sorts of concoctions were you ingesting during your time there? And these are just things that people don't really delve as deeply into. And if you don't ask these specific questions, sometimes the only thing that jogs that person's memory is to be asked the question.

Dan: 7:09

Dr. Titanji had a case where a patient came in with a fever. No one could figure out why. The patient seemed to be doing okay with the fever, but the person was immunocompromised, which raised the stakes. So the medical team had reached out to Dr. Titanji for a consultation.

Dr. Titanji: 7:27

And I go to see this person, and in taking the history, one of the things that I had noted about their lab work was that they had changes in their blood work that's usually indicative of a mild inflammation of the pancreas, which we call pancreatitis. And sometimes one of the very rare causes of this is being bitten by a scorpion. So I walk into the room, and I'm talking to this patient, and I specifically ask them, have you been bitten by a scorpion recently? And they immediately said, yes. That happened about two days before I came into the hospital.

Dan: 8:06

Oh, wow.

Dr. Titanji: 8:07

I crushed it, and I actually have a picture. And they pull out their their phone, and they show me a picture of the scorpion. So I walk out of the room, and I tell the team, I don't think this is an infection. I think this is scorpion bite related pancreatitis. And you all are doing the right thing. Supportive care is enough. And my colleagues asked me, why on earth would you ask someone specifically if they've been bitten by a scorpion? And, you know, so we had this very fun exchange where I think there was some frustration on their part that they had not asked the question. And the patient had been asked if they've had any insect bites recently.

Dan: 8:50

Oh.

Dr. Titanji: 8:50

But people don't always think about a scorpion as an insect. It's kind of, like, a lot more specific. It's its own thing. Right? And it took asking the specific question to be able to elicit the history that ultimately clinched the case and the diagnosis for this individual.

Dan: 9:09

That must be such a kind of rush of pride to be the one in in in a facility full of very smart people. I mean, all these MDs have been, you know, schooled and had experience for years, if not decades, and you're the one who cracks the case. I imagine that's one of the payoffs of the job.

Dr. Titanji: 9:28

Absolutely. You know, you come out riding basically, like, with an invisible cape when you're able to make some of these very, very rare diagnoses and make some of these connections between a nugget of history that ultimately reveals what was causing the process. But, you know, while those moments happen and happen a lot more frequently if you're an ID physician, there are also moments where we don't know what's going on and we're not able to crack the case. And I think that some of the more challenging cases keep us humble and honest, and we have a really healthy respect for the breadth and depth of potential diagnoses that are out there.

Dan: 10:13

So with with the scorpion example, I'm curious whether your ability to pattern match to that, is that something that is just sort of inevitably built up over time with experience? Like, you kind of just acquire one weird case after another, or is that something that is possible to learn more systematically? Like, is there a class during your infectious disease residency on, you know, the consequences of scorpion bites?

Dr. Titanji: 10:43

Yeah. I would say that to be a good infectious diseases physician, fifty percent will be what you read in textbooks and the other fifty percent will just be experience and pattern recognition and seeing enough cases to be able to piece together what combination of clues actually is consistent with which diagnosis most of the time. And I think also the art of asking the right question

Dan: 11:14

Yeah.

Dr. Titanji: 11:14

Is something that you cannot learn by reading a textbook. You only refine that by doing it over and over again and knowing exactly what are the questions to ask.

Dan: 11:29

One counterintuitive thing about infectious disease doctors is that they see an awful lot of people who don't actually have an infectious disease. For example, an infectious disease can cause a fever, but

Dr. Titanji: 11:42

It's not only infections that cause fever. If you have cancer, cancer can manifest as a fever.

Dan: 11:49

Mm.

Dr. Titanji: 11:50

If you have a rheumatologic condition, it can manifest as a fever. Sometimes a drug reaction to a drug that you're taking that has nothing to do with an infectious disease process, that can cause a fever. So we tend to have to have a broad knowledge of things that are non infectious processes as well as the infections that we are called upon to treat.

Dan: 12:17

What's one of your your favorite cases looking back on, just where you're proud of the detective work you did?

Dr. Titanji: 12:24

I think one of the ones that I'm really proud of was it was actually quite early on in my specialty training when I was still a fellow learning how to become an infectious diseases physician. And we had had this consult case, so we were called upon to see this individual who had come into the hospital with a very severe pulmonary infection, what looked like a pulmonary infection.

Dan: 12:51

A pulmonary infection means an infection of the lungs. The ICU team was treating the patient, but she wasn't getting better. And the team wanted to make sure they weren't missing something.

Dr. Titanji: 13:03

So I go to see this person, and they had their family with them. And I'm again rehashing the history and taking a very detailed history and asking about their exposures. And I I specifically asked because of the way in their lung imaging looked, I asked them if they had pets at home, and they said no. I said, have you ever kept any birds? And they said no. And, you know, again, I was I asked, have you lived on a farm? Are you exposed to chickens? And the patient's daughter immediately piped in, we've not been able to talk her out of getting rid of the chickens.

Dan: 13:49

Mhmm.

Dr. Titanji: 13:49

And they live in the basement.

Dan: 13:51

The chickens in the basement.

Dr. Titanji: 13:53

In the basement. She had two pet chickens that she was keeping in the basement and had been keeping for three years.

Dan: 14:01

And and the pet question and the bird question didn't trigger that.

Dr. Titanji: 14:05

It did not trigger that. Because for some reason, people don't always think of chickens as birds. When you ask them if they have a bird for a pet, they're thinking maybe a cockatoo or a parrot or an exotic bird.

Dan: 14:19

Right.

Dr. Titanji: 14:19

They're not necessarily making the connection that, yeah, I have chickens. And in the end, we were able to recommend specific testing for this particular bacteria that is common in birds, including chickens, called psittacosis. And we were able to get the right samples, send it to that particular test, and it came back positive.

Dan: 14:43

That's so interesting.

Dr. Titanji: 14:45

So that was really memorable because as an infectious disease fellow at the time, that was also my first case of actually culture proven psittacosis that matched with the history that I had been provided by the patient and their family.

Dan: 15:03

Well, that that's such a great example. I mean, one theme of what you're saying is the case history is everything, and you're a facility with knowing what to ask and how deeply to probe. And, you know, here in this example, you had to get past pets, past birds into asking about chickens specifically. I'm curious, what have you learned over the years about interviewing people? If you were training, you know, a new fellow today, like, how would you coach them on getting the right answers?

Dr. Titanji: 15:36

I think one of the things I've learned is listen more than you speak. Watch out for the pauses and go back and probe those pauses, learning when to change direction of questioning, also learning to create an environment where the patient is able to really trust you with information that they may not have told anyone else before.

Dan: 16:01

Mhmm.

Dr. Titanji: 16:02

I think that that is usually the biggest challenge that I see young trainees or doctors in training who are rotating through our service where they come and they make a presentation to me, and then I go and I speak to the patient, and I get 20 additional clues that they did not find. Right?

Dan: 16:20

Right.

Dr. Titanji: 16:20

And they're like, well, I was in the patient's room for an hour. How come they didn't tell me that? Well, did you approach it with a checklist and asking yes and no questions? Or did you pause and really allow them to speak? Sometimes to get more information about a person's pet, for example, when I ask people, do you have a pet? And they might say, yes. I have a dog. I always ask, what type of dog is it, and what is it called? And do you have a picture of the dog? Can I see it? Because people are always very willing to share pictures of their pets, and usually they're, quote, unquote, babies, and they want to be able to share that with you. For one, it breaks the ice. And for for second, by asking that question, I've been sometimes able to find out that, oh, guess what? My dog just had a litter of puppies. Oh, okay. You're coming in with a fever. Have any of those puppies been having diarrhea? Because there's specific infections that are linked to puppies having diarrhea that can manifest as an infection in a pet owner who has underlying immunocompromise.

Dan: 17:35

After the break, Dr. Titanji sees a patient who may be infected with Ebola. Stay with us.

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Dan: 18:14

I think people are gonna listen to this episode and think about, the House TV show, you know, the kind of, detective work. And and, of course, House was a famously cantankerous character, but but isn't that kind of exactly the wrong personality for this? I mean, don't you have to have that good bedside manner that elicits the right information?

Dr. Titanji: 18:38

Absolutely. And that is actually one of my pet peeves about watching House because this fictional character, he is board certified in infectious diseases and in renal medicine, even in the show. So they did get the aspect of him being a diagnostician and doing detective work with the ID part, but the character itself is so far removed from what the average ID doctor is. Like, you know, I I think that our specialty really draws people who, for one, loves talking to patients and usually have some of the most amazing bedside manner that there is. And I think that even if you come in to train as an ID physician and your bedside manner isn't at its best, usually by the time that you're done with training, because gaining that trust and being able to get people to trust you with their information and being okay with this total stranger I just met five seconds ago asking me to tell them my entire family tree and, you know, all of that, you have to be someone who comes across as not callous and who has compassion and who is able to be someone that, you know, the patient would look at and say, you know what? I really can trust this person with my information.

Dan: 20:05

You know, it's interesting just talking to you. We can't see each other right now, but there's a warmth to your voice. There's almost like a smile in your voice where I can hear, you know, a little bit of that bedside manner that you're talking about. And and it makes me curious, like, how did you know you had that ability? And and if you did, was that part of what steered you to this specialty?

Dr. Titanji: 20:30

Well, I think that ID found me as opposed to me finding ID.

Dan: 20:36

Mhmm.

Dr. Titanji: 20:36

When I went into medical school, I initially thought that I was going to pursue a surgical specialty. And when I did my rotations in surgery, I just felt that that was not my tribe because it didn't really tie together what I felt were my biggest strengths. I'm someone who enjoys talking to people, finding out about people. Surgery has a silent component to it where the most of the time you're operating on a patient, you're not talking to them because they're under anesthesia.

Dan: 21:09

Yeah.

Dr. Titanji: 21:09

And I really missed that. I felt like, yeah. This is not my tribe. I really respect what you do, but these are not my people. And then when I had the opportunity to spend time with, infectious diseases and encounter infectious diseases, first of all, it was actually a specialty that enjoyed talking to people and wanting to know more about them.

Dan: 21:35

Some infectious diseases must be taken much more seriously than others, even when their presence is only suspected. Like one time, she was asked by an ICU doctor to authorize a test for a particular patient. It was a test only an ID doctor is supposed to authorize. And so she asked for a bit more information from the ICU doc.

Dr. Titanji: 21:58

And the the ICU physician who was calling said, well, it's this person who was found down, brought in overnight. All we know is they arrived from X Country ten days ago, and they came in with a fever.

Dan: 22:12

Mm.

Dr. Titanji: 22:12

X country being a country that was experiencing an ongoing Ebola outbreak when that happened.

Dan: 22:19

Oh dear.

Dr. Titanji: 22:20

Yes. And so I said immediately, actually, I do want to see this patient before I authorize this particular test because you've just made mention of things that make me, consider other questions. Not wanting to to be alarmist on the phone. I did not say the words Ebola.

Dan: 22:42

Oh, so they didn't know they hadn't made that connection. Okay.

Dr. Titanji: 22:45

They had not made the connection. This was several years ago, and there was an ongoing outbreak. I knew because I follow outbreaks of infectious diseases. So I go in to see the the individual in the ICU. I I wear on my my gown and my mask, and I go in and I do an exam on this person who was on life support at the time because they were found unconscious where they were brought in to the to the hospital.

Dan: 23:11

Mhmm.

Dr. Titanji: 23:12

And when I left the room, I had to make a decision if I was going to pull the trigger to basically shut down that ICU until we had more information.

Dan: 23:24

So Dr. Titanji makes the call to shut down the ICU.

Dr. Titanji: 23:29

And that immediately triggered sealing off that ICU, notifying the leadership of that hospital, and tracking down the patient specimens from the ER to all the labs because it had become basically bio containment level four samples.

Dan: 23:49

So everyone who was in that patient's room is asked to quarantine at home until further notice. Meanwhile, hospital leadership starts making plans for how they're gonna handle it if the patient comes back positive for Ebola, and Dr. Titanji is coordinating with the key players.

Dr. Titanji: 24:06

Basically, I was on a call with hospital leadership and my a bunch of my senior ID colleagues within an hour of making that call.

Dan: 24:16

Yeah.

Dr. Titanji: 24:17

And this was now an emergency response meeting. The health department had to be notified. CDC had to be notified. Not that there was a confirmed case, but that there was a case with reasonable suspicion of what could be a high consequence pathogen in a particular local hospital.

Dan: 24:38

It wasn't long before they got their answer.

Dr. Titanji: 24:41

Thankfully, we were able to collect blood samples that were sent to, CDC for testing, and within less than eight hours, we had negative tests ruling out that as a diagnosis. You know? And when I went home, later that evening, I was processing for myself the fact that I had walked into this person's room

Dan: 25:04

Yeah.

Dr. Titanji: 25:04

And examined them. Granted, I I I wore my my personal protective equipment, but there's still a part of your brain that's thinking, oh my god. If this comes back as confirmed

Dan: 25:16

Yeah.

Dr. Titanji: 25:16

Am I now entering quarantine to make sure I don't develop symptoms?

Dan: 25:20

Right. But you you cannot afford to think about a very serious high consequence diagnosis and not act on it. And sometimes you're going to inconvenience a lot of people, and most of the time, it's going to be overkill. But think about the consequences of having a true case and then not acting on it. So, Boghuma, we always end our episodes with a quick lightning round of questions. Here we go. What is a word or phrase that only someone from your profession would be likely to know, and what does it mean?

Dr. Titanji: 25:56

Source control.

Dan: 25:57

Source control. Okay.

Dr. Titanji: 26:00

Going back to infectious disease physicians being detectives, when you tell me there's an infection, I want to know the source. Because if you don't control the source, you don't control the infection. So you would hear us say a lot of times, this is not an antibiotic problem. It is a source control problem. And that's usually an indication that we sometimes need help from our colleagues that perform procedures to help us control the source. If it is an abscess, maybe my surgeon colleague needs to help me drain that abscess before I can help you out with antibiotics. So source control is the one that comes to mind.

Dan: 26:40

What phrase or sentence strikes fear in the heart of an infectious disease doctor?

Dr. Titanji: 26:47

Oh, the blood culture is positive for staphylococcus aureus.

Dan: 26:52

Oh.

Dr. Titanji: 26:53

Yes. Yes. When you start your training as an infectious diseases physician, I think one of the biggest lessons you learn, the first lesson you learn, is to respect staph. And staph infections are common, very common, and but the thing about staph infections is that it's a particularly virulent organism. And when you see it in the blood, it doesn't only mean that that person has a bloodstream infection. It means really that you have to look for where else the infection has gone because it is a bacteria that tends to stick to things and go places. So when I go see someone, a patient who has staph aureus in their blood, I'm asking myself, where else has the bacteria gone? And oftentimes, the infectious diseases consult will reveal that, oh, it's also in their knee joint. It's also in their spine. They also have an abscess in the liver that's caused by the bacteria, and sometimes they're having strokes because the bacteria has caused abscesses in the brain. So staph is very virulent and can present in a very large variety of ways when it is in the blood. And in order to treat it and treat it properly, you have to be absolutely sure that it's only in the blood and it's not hiding somewhere else.

Dan: 28:20

What's a sound specific to your profession that you're likely to hear?

Dr. Titanji: 28:25

You know, I think when it comes to infectious diseases, it's not so much the sound that we like to hear. I like to say it's the smell. Infectious diseases physicians can sometimes use their sense of smell to be able to help us narrow a diagnosis. Really? Because there are particular infections that have a characteristic smell. If you've ever been in the room of a patient who is having diarrhea caused by Clostridium difficile, c diff diarrhea, it has a characteristic smell. If you have a patient who has a wound infection with a bacteria we call Pseudomonas, it has a sweet grape like smell that you can smell the moment you you unwrap the wound. So, you you know, sometimes I go and examine a patient, and just walking into the room, I can smell the wound, and I immediately start thinking, I think this Pseudomonas may be involved in this infection because it's so characteristic that if you smell it once, you're like, yep. That smells like Pseudomonas.

Dan: 29:35

That's so interesting. It makes you wonder why why is there not, like, a tag team of a doctor and a dog that could be, like, superheroes in the profession. You know what I mean?

Dr. Titanji: 29:47

Yes. And and you you know that, dogs have been used for their sense of smell to help with the diagnosis of TB by smelling sputum

Dan: 29:56

Really?

Dr. Titanji: 29:57

Collected yes. Dogs and certain types of, giant African rats are well trained to smell the sample collected, the sputum sample collected from patients with TB and they are really good at identifying particular samples that are positive.

Dan: 30:16

How does doing this work shape your view of the world?

Dr. Titanji: 30:21

I think that one of the things that ID has done for me has really impressed on me the interconnectedness of the world and how much pathogens can make that interconnectedness very obvious. You know, having an outbreak that's happening in what may feel like a geographic location very far off from you doesn't mean that that outbreak doesn't impact you because all it takes is for an individual who is carrying a particular infection to get on a flight, and they may land in an emergency department near you. And your ID doctor in Atlanta or in New York or in Chicago, may be the one responding to that initial case of that particular infection in The United States.

Dan: 31:21

ID doctors are at the front lines of fighting new and exotic diseases like COVID or Hantavirus that killed three people on a cruise ship in spring 2026.

Dr. Titanji: 31:33

To understand the mindset of an ID doctor, I was not in the least surprised when the WHO announced that the crew of experts that had gone on the ship when they were still trying to figure out where the ship was going to dock included two infectious diseases doctors.

Dan: 31:52

Mhmm.

Dr. Titanji: 31:52

Because I think that that really encapsulates what we do. We are usually the first people to get into a room where there's concern that an infectious process may be ongoing, where people may be worried about going into that room because they don't know what to do. You know, when the pandemic hit health systems around the world, when you think about your hospital and who was helping make protocols on how to keep our surgical team safe in the operating room if they had to operate on a patient with COVID, how to make sure that we had isolation protocols in place so that we didn't have nurses and technicians and other doctors getting sick. All of those questions and decisions as well as some of the initial treatment protocols were all developed by teams of infectious diseases physicians in hospitals across the country and across the world. And mind you, this was a pathogen that no one had seen before.

Dan: 32:55

Mhmm.

Dr. Titanji: 32:56

But our training really affords us the the upper edge to be the go to individuals in a health care system for the unknown where infections are concerned.

Dan: 33:12

Dr. Boghuma Titanji is an infectious disease doctor and professor of medicine at Emory University. Remember what doctor Titanji said about how when she worked in surgery, she realized this is not my tribe? And then she discovers infectious disease and realizes this is it. These are my people. It reminded me of a moment from my interview a while back with our turnaround consultant, Jeff Vogelsang, where some of his mentors steered him toward his people.

Jeff: 33:46

I reached out to three people and all three of them said, you should go be a turnaround consultant. Your personality is well suited for it. Now, personality is well suited for it may not have been the term that they all used, but, you know, we won't use the term that they referred to me as on this podcast.

Dan: 34:06

Jeff's friends are telling him, given the way you are, here's where to find your people. And there's something important in that. What makes you good at a job is skill, which is learned, and experience, which is earned. But there's another layer, disposition. Dr. Titanji loves talking to people, and in infectious disease, that's the heart of the job. About 18 episodes ago, I talked with the dog groomer Aaron Williams. Remember, he's the guy who doesn't think he's ever used his car horn, and his exquisite patience was the perfect fit for his work. Some jobs make use of what you know. Others also make use of who you are. And that's when you know you've found not a job, but a career. Digging deep into patient histories, asking about caves, chickens, and scorpions, making high stakes calls before you know you're right, walking into rooms others are afraid to enter. Folks, that's what it's like to be an infectious disease doctor. A shout out to Sheila Racinez who suggested we talk to Dr. Titanji. Thank you, Sheila. And if you know someone who would be good for the show, reach out to us. Or even better, encourage someone you know to reach out and leave us a voicemail. That number is always in the show notes. A shout out to recent Apple podcast reviewers, CellenCooks, Matt ST, Ski Bird, and The Good Samaritan. This episode was produced by Matt Purdy. I'm Dan Heath. See you next time.