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Thursday, June 23, 2016

Medical blogger attacks respected cancer doctor

When it comes to explaining medical science and exposing dangerous medical scams and practices, the Science-Based Medicine blog is tops (full disclosure: I was one of the early bloggers at the site and I'm personally a fan). The team of bloggers are well-recognized doctors, researchers and communicators, many from top institutions. Dr. David Gorski, the managing editor, is a highly respected breast cancer surgeon and researcher at Karmanos Cancer Center, a nationally recognized NIH Comprehensive Cancer Center. Steve Novella, the founder of the blog, is a Yale neurologist, well-known for helping educate the public and other doctors about science and medicine.

Naturally, this puts these folks in the crosshairs from time to time. I'm not nearly as prolific as either of them, and I receive a respectable volume of hate mail. I've had critics try to pad online doctor rating sites with negative reviews. But I'm busy, I'm well-respected, and I'm good at what I do. And, importantly, I'm in private practice, which gives me a great deal of freedom to say what I want.

While I've had some pretty unpleasant run-ins with some pretty crazy people, nothing compares to what Dr. David Gorski appears to be going through. One of Gorski's frequent targets of criticism is a guy named Mike Adams who fancies himself some sort of “Health Ranger.” I don't know what that means, exactly, but his website Natural News, which calls itself “the world's top news source on natural health,” is a cesspit of conspiracy theories and very bad health advice. Beyond the fact that it promotes unproven and often dangerous medical practices, Adams's tone is so paranoid and abrasive, he makes Ted Cruz seem like a teddy bear.

I hate the site. I don't know the guy behind the site, but I'm beginning to take on a strong dislike of him as well, not just because he promotes dangerous and frankly idiotic medical ideas, but because he takes on his critics with vicious personal attacks, threatening their livelihoods, their feeling of safety and their careers.

Just this week, Adams published a piece titled, ”Karmanos cancer surgeon Dr. David Gorski linked to “skeptics” kingpin James Randi caught on tape soliciting bl*w job from young man—source.” The really scary thing here is that the headline is the least inflammatory part of the article.

Let's put aside the fact that the headline seems to imply that Gorski was the one doing the soliciting. Further reading shows that he simply knows the man who Adams is accusing of sexual improprieties. That sort of cowardly, defamatory garbage is just the lede. The real attacks come in the body of the blog. Here's the point-by-point breakdown of Adams's lies, dishonest allegations and defamatory (at least in my lay opinion) accusations.

First, there is a non-existent FBI investigation: Dr. David Gorski—already the subject of a Natural News investigation that has submitted numerous allegations to the Federal Bureau of Investigation …

If you read carefully and follow the links, you see that Dr. Gorski is not the subject of any investigation but the 1 in Mike Adams's own head. Adams's writes that he himself has pestered the FBI to look into Dr. Gorski for … “reasons”? Making it seem as if a well-respected surgeon is the subject of a federal investigation is a dangerous road to go down.

Next, is alleged “racketeering”: Dr. David Gorski … is the mentally deranged leader of an online hate group calling themselves “skeptics.” An ongoing Natural News investigation has revealed that Gorski is just one of several co-conspirators who engage in online racketeering, identity deceptions and alleged cyber crimes to commit scientific fraud while destroying their targeted enemies in the holistic health realm.

Much of this is simply deranged opinion, but to state as fact that someone is “mentally deranged” and “leader of an online hate group” is dangerously close to making harmful, knowingly false statements about someone. And to state as fact that someone is engaged in a racketeering scheme seems to go well beyond “opinion.”

Third, is guilt by association: David Gorski's colleague was just convicted of massive medical fraud and sentenced to 45 years in federal prison

This is as far as I can read without actually vomiting. Here in the Detroit area, a cancer doctor named Farid Fata was sentenced to prison for crimes that, for doctors like David Gorski and me, are so horrific as to be nearly indescribable. Dr. Fata told people they had cancer and gave them chemotherapy even when they were perfectly healthy. He did this at great profit. He violated the most important trust, that your doctor is in this for you, the patient, and that he would rather give up his career than harm a single person.

Dr. Fata and Dr. Gorski were “colleagues” in about the same way as me and Josef Mengele: Yeah, we're both doctors, so “colleagues,” I guess, except 1 of us was a pathological torturer and murderer (hint: not me). Dr. Fata was affiliated with an institution which was affiliated with an institution that Dr. Gorski is part of. So, yeah, they were colleagues maybe in some sort of twisted definition. The only conceivable reason to write this is to imply that Dr. Gorski is guilty of the same horrific crimes by association.

Nothing could be further from the truth. David, who I am proud to call a friend and colleague, has spoken out against Fata and other dangerous doctors for years. He has made it a mission to help reveal to the world how quacks do what they do, and how to watch out for them. In addition to fighting cancer in the lab and in the operating room, he fights with the written word against dangerous and deceptive medical practices.

Dr. David Gorski is a quiet medical hero. OK, he's not quiet online, but he's a soft-spoken, gentle, brilliant guy. I can live with the accusations that imply that he is involved in online “racketeering” or is friends with someone who may have asked someone for a BJ (and really, is that all that rare?) but to associate him with a criminal of the worst sort, a doctor who intentionally harms patients for profit, is the worst sort of attack.

I'm a good doctor, but I'm no lawyer. I have no idea whether Mike Adams has crossed the defamation line, and even if he has, whether Dr. Gorski would dignify Adams's idiocy with any sort of legal response. But let's hope that those of us who benefit from Dr. Gorski's work (which is just about everyone who wants to improve the quality of medical care) will not let some nut job tossing around hateful allegations silence people like Dave.

Mike Adams has opinions that are distasteful and dangerous. That is my opinion. He also has every right to state them, as long as he doesn't harm others in a way our legal system recognizes. Dr. Gorski's employers, funding sources and colleagues, if they bother to notice Adams at all, should thank David for being willing to stand on the front line, defending what we all care about most–helping others.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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Wednesday, June 22, 2016

How expertise dies: of character, credentials, and crap

Perhaps no topic better illustrates the enormous gap between knowledge and ignorance, and its profound importance to the ambient understanding of all humanity vital to advancement at the most basic level, than evolution. The story of evolution by natural selection is, effectively, written, in vivid detail, in the language of molecular genetics. If you can read this language, the tale it tells is clear, decisive, and irrefutable; the facts presented about as prone to denial as sunrise.

Nor need you be literate in molecular genetics per se, any more than you need learn Russian to read Crime and Punishment. There are highly proficient translators in both cases. A bounty of books on evolutionary biology have been written by the unassailably erudite for the decidedly less so among us. Complex science has been translated into the lingua franca.

What, then, is the basis for denial in all its shades of gray, from intelligent design, to young earth creationism? In a word, ignorance. But not ignorance of the traditional “I really wish I knew, but alas, I don't” variety. Rather, this is generally ignorance of the “my eyes are covered and my ears are plugged, so you must be wrong” variety.

The only way to dispute the evidence for evolution is never to look at it in the first place. The fossil record is itself almost astonishingly replete, given what is required to preserve the faint impressions of fleeting life in dust and mud over millions of years. But the fossil record is all but irrelevant, mere icing on the cake. The cake is baked of our DNA, which provides an encyclopedic account of life's recipe.

So, permit me to reiterate: the only way to dispute so incontrovertible a case is to ignore it. Now, of course, you cannot ignore the content of an entire domain and achieve any recognition by peers, credentials, expertise, or even rudimentary understanding. Ignoring leads only to ignorance. Actual experts can and do, of course, disagree in their interpretations. But those interpretations require knowledge and understanding. Knowing is prerequisite to interpreting. Disagreements born of expertise are interesting, and resolving such tensions is in the service of progress.

Not so the dissent of non-experts. Asserting the deficiencies of a field one has never mastered is tantamount to the claim that any language you don't speak is just gibberish.

The problem is indeed acute for evolutionary biology, but by no means unique to it. In every field, from evolutionary biology, to biomedicine, to political science, the cries of non-experts populate cyberspace: listen to us, too! We've only ever read what we already decided to believe—if we've read anything at all—but listen to us just the same.

The long-standing tendency to repudiate understanding not on the basis of alternative understanding, but on utter lack of understanding and, for that matter, never attempting to learn, is massively amplified by the Internet, the ultimate leveler. Nobel laureates, and consummate nincompoops, have recourse to the same megaphone. This is where expertise goes to die.

But how does it die? There is famous concern about ending with a whimper rather than a bang. Sadly, we are well into the realm of a demise more tiresome still.

Non-experts routinely assert their opinions to refute the views of experts they simply don't like (this may refer to the views, the experts, or both). If challenged for want of expertise, they label it an attempt at character assassination. They allege that their legitimate, alternative view is being suppressed. In other words, they whine, 140 characters at a time.

But credentials are not character; that's a load of crap. Credentials, whether formal or informal, are the price of entry into any legitimate debate. Expert debate actually requires expertise on both sides. Two literary scholars might differ in their interpretations of Crime and Punishment, or War and Peace, and an interested audience might benefit from the exchange. But the audience is forgiven for restricting its interest to debaters who have actually read the works in question. Participation in the vein of, “I never read it, but I know it stinks,” would be reliably less illuminating.

Confront the pretenders for what they are, and you find yourself in the morass where credentials are conflated with character. They may also charge at you under an anti-elitist banner, implying that expertise is really just prissy privilege in disguise. But that campaign reeks of hypocrisy. Find me the anti-elitist willing to let any untrained, highly opinionated stooge perform neurosurgery on their child, and I will give up my day job for hula dancing.

So, yes, our culture seems tolerant to the substitution of fatuous hearsay for genuine knowledge, earned the hard way (is there any other?). Yes, our culture is implicated in the death of expertise.

It dies neither with a bang, nor a whimper. It dies silently, drowned in the endless echoes of incessant cyberspatial whining by those conspiring, ignorantly, to kill it.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Tuesday, June 21, 2016

Is there a pill to make you live longer? The HOPE-3 trial and the hype that will surely follow

Today in the New England Journal of Medicine an article has appeared reporting the results of the Heart Outcomes Prevention Evaluation-3 (HOPE-3)trial. Exciting simplifications are sure to follow in the news. If you would like to stop reading now, the answer to the question posed in the title is probably no.

The question:
For many years researchers have discussed the possibility of a creating a pill that might contain several kinds of medication that would reduce people's risk of dying of cardiovascular disease. It is an attractive thought. Since cardiovascular disease is the major cause of death globally, reducing that risk has the potential to vastly reduce death and disability. Originally we thought that a suitable “polypill” might contain something to lower the blood pressure, something to lower cholesterol and something to reduce the risk of blood clots. Many studies have looked at the mortality benefits of various blood pressure pills, cholesterol lowering strategies and anti-clotting drugs and we have found that some of them help some people to some extent and some cause some people problems. Drat. So complex.

The history:
The original HOPE trial looked at a blood pressure pill (ramipril) which was added to whatever other medication a group of people at high risk of cardiovascular disease were taking. It lowered the risk of heart attack, stroke and death significantly enough that the study was stopped early and drugs in the ramipril class (ACE inhibitors) were aggressively prescribed, especially for patients with diabetes, probably to good effect.

The HOPE-2 trial looked at using vitamins to reduce homocysteine levels, which appeared to be a significant risk factor for heart attack and stroke. The studied doses of vitamin B6, B12 and folate did not reduce any of the outcomes they looked at. HOPE-2 was dashed.

In 2007 HOPE-3 began, looking at a combination of blood pressure medication and cholesterol medication, specifically to reduce death from heart attack or stroke, new heart failure, cardiac arrest or non-fatal heart attack or angina. The study was performed in academic medical centers all over the world, including the U.S., Europe, China and India, South Africa and Southeast Asia. Over 14,000 patients were enrolled, limited to men 55 and over and women 65 and over with intermediate cardiovascular risk (calculated at about 1% per year). Women 60-65 years of age were eligible if they had one of several specific risk factors, including glucose intolerance, smoking and high waist to hip ratios. These were people who had never had heart problems or strokes.

Drug company involvement:
Astra Zeneca helped fund this study along with the Canadian Institutes of Health Research. The cholesterol and blood pressure medication used in the study was on patent and sold by Astra Zeneca. The cholesterol pill was rosuvastatin (Crestor) and the blood pressure medication was candesartan/hydrochlorothiazide (Atacand/HCT). There were many drugs to choose from in the categories of effective blood pressure reducers and statin cholesterol medication, some of which would have been cheap and generic. The drugs they did choose are now generic but not yet cheap. I suspect Astra Zeneca hoped the study would have ended in time for them to reap financial benefits as their particular drug proved miraculously effective, or that the combination of the drugs could be made into a new formulation that would extend their market share.

So what happened? Getting to the point.
First there was a run-in phase. The 14,000+ patients were given the study drugs and about 2000 of them dropped out because they didn't tolerate them or didn't want to participate anymore. 12,000 patients were left. Of these about 3000 took placebo pills, 3000 took the blood pressure pills only, 3000 took the cholesterol pill only and 3000 took both blood pressure and cholesterol medication. After about 5.5 years, the patients taking blood pressure medication did not have a significantly lower risk of death, heart attack or stroke or the other cardiovascular outcomes. The patients taking cholesterol medication did have a reduced risk of death and cardiovascular outcomes. Taking both blood pressure medication and cholesterol medication was no better than just taking the cholesterol medication.

How big was the effect and how much does this cost?
The article quotes a hazard ratio of 0.71 for patients taking the combination medication, meaning that the medicated patient has 7 tenths the risk of a bad outcome of the unmedicated patient. The raw numbers are way more interesting. After about five and a half years of taking the combination of drugs or placebo, 163 patients in the active drug group had died and 178 of the placebo group had died, a difference of 15. At the present cost of these drugs, about $280 per month, it would cost about $3.7 million per life saved, which is pretty steep. Just taking the cholesterol medication, which is really the only one that had a positive effect, would cost about $2.6 million per life saved. If there were drugs on a $4 a month plan that did the same thing we might get down to a very reasonable cost of $53,000, assuming no other associated costs like doctor visits or lab testing (which is not a fair assumption.) Death is not the only thing we care about, of course, but other differences, such as numbers of hospitalizations, were not much more impressive when I reviewed the supplemental data.

How about side effects?
To begin with, 2,000 of 14,000 patients did not like or tolerate the study drugs, so some of them probably had intolerable side effects. During the study, however, there weren't many important side effects except a bit more dizziness in the patients on blood pressure medication, which apparently didn't do them much good anyway. There was some muscle pain, but patients on placebo also had that. The dose of the cholesterol pill was very low, which might have explained the pretty awesome side effect profile. Also the patients most bothered by side effects probably dropped out in the run-in period. By the end of the study only about 70% of patients were still taking the prescribed drugs, so there may have been intolerance that was not reported. There was no excess of development of diabetes, perhaps because of the very low statin dose. Good studies have shown more development of diabetes in statin users, but doses are often significantly higher.

Other interesting findings from the supplemental data:
I was very pleased that the NEJM published a well written summary of data that didn't get discussed in the article. There were some really weird things that showed up.
1. South Asians and to some extent Chinese subjects did not have near as much benefit from the study drugs as did subjects of European descent.
2. Stroke risk was actually higher for patients with borderline high blood pressure when they were treated with the blood pressure lowering drugs, though reduced for patients with higher and lower blood pressures.
3. Patients with the highest cholesterol levels (LDL greater than 141, mean of 166) did not benefit from treatment with cholesterol lowering drugs. That's really strange and counterintuitive.

Bottom line?
We have not discovered a pill yet that will make everyone live longer. Taking a statin drug which lowers cholesterol (who knows if that's the important effect) may lower your risk of cardiovascular disease or death, but you need to take it a long time to make a small difference and we aren't sure which one is most effective. Most people who take statin drugs (Lipitor, Crestor/rosuvastatin etc.) for primary prevention (meaning they haven't had heart attacks or strokes) will not benefit from them. Low doses of Crestor/rosuvastatin usually have a low risk of side effects. Treating normal or slightly high blood pressure with low dose candesartan/HCTZ doesn't reduce the risk of heart attacks, strokes or cardiovascular death. Navigating the pros and cons of all of these pills and potions is neither obvious nor simple and is best done with a doctor who you know and trust.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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What is shingles?

Thanks to my patient for allowing me to use her photo to talk about a common condition known as shingles. The medical name is herpes zoster and it is caused by the re-activation of the chickenpox virus (varicella zoster). This crazy virus lays dormant in the nerves and something causes it to flare up years or decades later.

This patient noticed a small rash behind her right ear and thought it was insect bites after a camping trip. She had some tingling (a common sign) and swollen and tender lymph nodes. Two days later when I saw her, the rash had spread down her neck and shoulder and she definitely had lymph node swelling at the neck and above the clavicle (nuchal and supraclavicular nodes). She had no fever but felt a little down.

Most shingles occurs in older people but it is not uncommon in younger folks too, like this patient. The rash takes about a week to develop and can last about 2 weeks with varying degrees of pain and annoying tingling. Some patients have pain that lasts in the nerves long after the rash has resolved.

We treat shingles with antiviral medication (valcyclovir ) and pain control. People over the age of 60 are recommended to get Zostavax vaccine to help prevent an outbreak. It reduces the chances of shingles by 51% and even higher reduction of post-herpetic neuralgia pain.

No special tests are needed to make the diagnosis. This is another reason everyone should have a primary care physician who can make the diagnosis and get the patient started on treatment.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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