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Saturday, October 31, 2009

The vaccine that went away.

You could almost think of it as part of the positive publication bias that almost all conference session are about things we do have, whether they're diseases, drugs, or dilemmas.

The IDSA session "Why is there no vaccine for Lyme disease?" bucked that trend. Experts reviewed why the Lymerix vaccine (on the market from 98-02) didn't work out. Problems included that the vaccine wasn't approved for kids, who are one of the highest risk groups, and it required multiple shots to acheive good (80%) effectiveness. Because of these factors (and others), the CDC gave it an underwhelming recommendation and uptake was limited. Protest, on the other hand, was serious and involved class action lawsuits claiming an association with arthritis that was never proven by the evidence.

Therefore, it's not surprising that no manufacturer has come up with a new vaccine, the experts said, but it is a "public health disaster" according to Stanley Plotkin, MD. Parts of the U.S. (like the Northeast) have a high prevalence of Lyme disease and residents who could benefit from a vaccine. Some are so eager for a vaccine that they've asked vets to give them the USDA-approved dog vaccine, Greg Poland reported.

Yet the only work on a Lyme disease vaccine (which hasn't gotten as far as human testing yet) is being done in Europe by Baxter. Europeans are less hostile to the concept and public attitude is really the factor that will determine whether the U.S. ever gets a vaccine, the experts concluded. "At least with Lyme disease, the advocacy groups are a lot more influential than we are," said CDC's C. Ben Beard. "Without their support, it's doubtful that vaccination would be successful."

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Friday, October 30, 2009

Infectious tidbits

More hot stuff in infectious disease, this time from Bennett Lorber, MD. Dr. Lorber reviewed an array of recent research yesterday at IDSA. Here's the super-condensed version of his conclusions:

It's pretty clear that acid-suppressive medications are increasing the risk of pneumonia, and thereby causing excess hospital deaths, so they should not be prescribed so broadly. "We need to tell our medicine and hospital colleagues that acid-suppression should be a carefully considered decision," Dr. Lorber told the infectious disease docs.

Prescribing prophylactic antibiotics before catheter removal, on the other hand, is supported by new evidence. A recent trial found a NNT of 6 to prevent symptomatic infection. "We don't like this idea, but it's a pretty good study," Dr. Lorber said.

However, if you're trying to prevent infections after cardiac surgery, there's not enough evidence to justify putting patients on a statin before the procedure. A recent cohort study found that statins weren't associated with reduced post-op infections.

And finally, if you suspect a prosthetic joint infection, tell the lab to hold on to the specimen for at least 2 weeks, because a recent study showed that about a quarter of bacteria grown in cultures didn't show up until after a week had passed.

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It's a party! Bring your own alcohol (gel).

I learned about a new holiday today at IDSA. The WHO has declared May 5 to be hand-hygiene day. I'd suggest that we all celebrate by washing our hands, but apparently the point is that health care workers should be cleaning their hands all the time--specifically at 5 moments in the patient encounter. (See, 5 moments for the cinco de Mayo.)

This international effort is trying to make hand hygiene "easy, convenient and even sexy," according to Didier Pittet, MD. The project is very country-specific--in some developing countries, they're teaching how to make your own hand gel, while in others the focus is on humorous education to improve compliance. The importance of localizing humor was made clear by a French cartoon of a germ on a couch that Dr. Pittet presented. "Dr. Freud, in this hospital, it's become impossible to cause infections anymore," the germ said. It sure wouldn't win the ACP Internist/Hospitalist cartoon caption contest.

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QD: News Every Day--the Halloween edition

Doctors who are ghostwriting has recently come to the fore recently, so now we're writing about ghosts for our doctors. Enjoy ACP Internist's Halloween edition of QD: News Every Day.

First, physicians are looking at near-death experiences and trying to come up with answers about them--the bright light at the end of the tunnel, for example. It may have a neurological cause, but why do so many people all report a common experience? If a near-death experience has left you terrified, then it's not entirely a myth that your hair could turn white overnight.

For those of you trying to stave off death one more day through exercise, here's one fitness trainer's fun idea: use pumpkins for your workout instead of for pies. This one is worth the click-through just for the photos (putrid pushups, devilish diagonal chops and more).

Next on this haunted tour, Dr. Justina Ford, the first black woman to practice west of the Mississippi, is said to still haunt her office and home. Further west and further back in time comes this folklore about a physician who gets help from beyond the grave in making the correct diagnosis.

Coming back into a more modern concern, A Happy Hospitalist writes about spooky contact lenses being commonly available, even though they require a prescription. Finally, hospitalist Jamie Newman, FACP, tells his tale of working the graveyard shift at locum tenens facility that's off the beaten path.

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Thursday, October 29, 2009

The fact that it is almost Halloween is purely coincidental.

At an IDSA session on "What's hot in infectious disease," John Bartlett, MD, updated us on the risks of bat bites. Apparently (surprising as this sounds), it's easy to be bitten by a bat without noticing, and a fair number of bats are rabid.

Therefore, standard protocol (at least in Canada, I'm not sure if this also applies to the U.S.) was "If you wake up and see a bat in the bedroom, you should be considered for rabies prophylaxis." Some Canadian researchers were suspicious of the cost-effectiveness of this recommendation, so they did a study of 36,000 people. They asked how many of them had either had contact with a bat or seen one in a bedroom, and then calculated the cost of providing rabies prophylaxis.

Turns out that just the therapy--not even counting clinician time--would cost $2 billion per rabies case prevented if you treated all the bedroom encounters, and $48 million each if you treated just the people who had contact. Canadian policy was revised based on these calculations, and the results appear to confirm the projections, Dr. Bartlett said. "The epidemic of rabies has not been found."

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Get your darn flu shot!

The press conference I attended today at the Infectious Disease Society of America's annual meeting had a clear message and it was pretty much a more polite version of this post's title.

Researchers presented data showing that flu vaccination of pregnant women (seasonal, not pandemic, by the way) makes their babies less likely to be premature, small or admitted to the hospital for flu early in their lives. So, such vaccinations would solve the problem of not having a vaccination for newborns and achieve the cost-effectiveness of protecting two people with one shot. The scientists expressed hope that their findings would increase the currently "dismal" rates of expectant-mother vaccination. "If they're not doing it for themselves, maybe they'll do it for their babies," said Marietta Vasquez, MD.

I wouldn't count on it, based on the results presented about vaccination attitudes among hospital workers. The one-hospital survey found that plenty of health care workers, and even some physicians, believe that flu vaccines aren't safe and could give you the flu. In addition, many of them were not aware that one can transmit the flu without having symptoms. Depressing.

On the bright side, even though vaccine expert Paul Offit, MD, termed his part of the press conference a "mini-rant," he actually had some positive news to offer. "The pendulum is starting to swing the other way," he said. Concerns from parents of immunocompromised kids and the refusal by some docs to see unvaccinated children, among other factors, are putting the anti-vaccine troops on the defense, he thinks.

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QD: News Every Day--public option in da House!

ACP Internist's daily digest of news and events covers how health care reform is being reconciled in Congress, how the primary care shortage impacts local emergency rooms, and how community doctors in Bermuda are reacting to the introduction of hospitalists.

Health care reform
While the Senate stares down a threatened filibuster of legislation that includes a public option, the House introduced its version, which includes it. As the House and Senate reconcile their respective bills into one per each chamber,
Cecil B. Wilson, MACP, who is also the American Medical Association's president-elect, told Floridians at a union-sponsored rally that the majority of Americans, including physicians and AMA members, want reform. (Washington Post, Miami Herald)

Primary care shortage
A column in The Olympian (Olympia, Wash.) points out that the community already has universal health care. Unfortunately, it's the local emergency room. In Palm Beach, Fla., county commissioners are considering whether to build a public hospital for just that purpose. Jose Arrascue, ACP Member, representing the Palm Beach County Medical Society, told commissioners, "We believe the health care delivery system in Palm Beach County is in critical condition. We have escalating numbers of uninsured, diminished access to care, an aging physician population and a lack of specialty care." (Palm Beach Post)

University of Pennsylvania bioethicist Arthur Caplan told an audience in Bakersfield, Calif., that one way to alleviate the primary care shortage is to forgive medical school loans. (Bakersfield.com)

H1N1 influenza
Now, there's an app for that. Harvard Medical School has launched an iPhone application that includes information on the pandemic's spread, practical steps people can take to mitigate their risk of infection, key symptoms to watch for, and what to do in case of infection. The application includes text, video and links to government databases. It also provides information to businesses for managing through the pandemic. People need all the help they can get. Richard Wenzel, MACP, reports that half of all outpatient H1N1 influenza cases don't develop a fever, so the patients don't take precautions. Even among hospitalized patients, 15% don't get a fever. (Minnesota Public Radio)

In case you missed it ...
Family doctors claim that the switch to hospitalists has shut them out of their community hospital ... in Bermuda. The chief of staff at King Edward VII Memorial Hospital feared being hanged in effigy outside his office after general practitioners lost their hospital privileges and communication suffered between community and hospital doctors. But, the chief said outcomes have improved and the move is needed as his facility moves from being a rural provider to a modern metropolitan facility. (Bermuda Sun)

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Wednesday, October 28, 2009

Trick or treat!

Just in time for Halloween, we've got some spooky and disgusting medical news.

First, from the annals of how machines are out to get us (or the Journal of Craniofacial Surgery), a study of young healthy men who wear their cell phones on their hips found that pelvic bone density was slightly reduced on the side where they usually wear their phones. Apparently the phone holster was subjecting these men to not only ridicule by fashionistas, but electromagnetic fields. Based on the findings, researchers recommend keeping your phone "as far as possible" from your body, HealthDay reports.

And now, from the plastic surgeons' annual meeting, an image grosser than the bowl of brains at your neighborhood haunted house. A group of 50 women had fat liposuctioned from their thighs, bellies or "other areas" and injected into their breasts, according to HealthDay. The good news is that the procedure didn't impair cancer detection and took only slightly longer than a lunch hour. (Alternate fat reduction strategy: see some photos of this procedure and develop sudden motivation to skip lunch.)

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QD: News Every Day--public option unsettles Senators

ACP Internist's daily digest of news and events wraps up how the public option has shifted the balance of opinion in the Senate, how the public itself has shifted on H1N1 vaccination, and the economic impact of a rural physician.

Health care reform
The introduction of a public option has precariously shifted Senators' support. Democrats are divided. What bi-partisan support there was has evaporated. Liberals are happy, but that won't carry the day. (AP, Los Angeles Times, Boston Globe)

H1N1 influenza
Some hospitals are seeing their emergency department patient volumes double from H1N1 influenza as doctors are being recruited as the flu police, trying to prioritize who gets vaccinated. To ease the crunch, more than 22 million doses of H1N1 flu vaccine are now available now, and health officials are still saying better late than never. (USA Today, New York Times, AP/MSBNC.com)

Data produced by a supercomputer shows that there could be a third wave of the H1N1 virus in the spring. The University of Texas is using
the "Ranger" supercomputer to make its predictions. (KXAN-TV)

Handshaking was out, and now so is the simple fist bump. Here's some humorous ways to greet people. (NPR)

In case you missed it ...
Doctors' economic contributions are as important to rural communities as their medical ones. The National Center for Rural Health Works estimates that a rural hospital loses $236,565 from clinic visits and $451,169 net revenue for every half-a-physician they are short. When extrapolated to include services purchased by the physician, the clinic and employees, the shortage translates to 13.8 jobs and $533,493 in income. (Iowa Independent)

Irving Harper, ACP Member, discusses how he handles his patients with e-mail, cell phone and video chat. Ahhh, but it's good to practice in Hawaii. (U.S. News & World Report).

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Tuesday, October 27, 2009

QD: News Every Day--the need for health reform

ACP Internist's daily digest of news and events continues with more on how the need for health care reform plays out across the country, as well as the uneven distribution of H1N1 vaccines.

Health care reform
Sen. Reid's announcement of a public option in Senate legislation follows statements by legislators who said they'd oppose any bill without it. He still doesn't have 60 Senators on board to prevent filibuster. (AP/The Washington Post)

ACP Fellows continue to vent about the need for health care reform. In the latest op-ed, Rod Hochman, FACP, CEO of Swedish Medical Center in Seattle, talks about how the patient-centered medical home plays out in what he calls "the other Washington." (The Seattle Times)

The largest private group practice in Kansas City, Mo. has stopped accepting walk-in Medicare patients. At Kansas City Internal Medicine, 65% of its nearly 70,000 active patients are 65 or older. Keith Jantz, ACP Member, says that it's a harbinger of things to come if Medicare reimbursement is cut by 21%. (CNN) It's a situation that one patient experienced in Grand Junction, Colo. (KJCT8.com )

A Thomson Reuters piles on the blame, finding the health care system wastes between $505 billion and $850 billion every year, about a third of the overall bill. (Reuters)
--antibiotic overuse and lab tests to protect against malpractice are 37% of the wasteful spending, or $200 to $300 billion a year,
--fraud is 22% of waste,
--administrative inefficiency and redundant paperwork are 18%, and
--mistakes are 11%.

H1N1 influenza
Despite shortages and some tales of uneven or nonsensical distribution, the vaccine is worth getting late rather than never, said Health and Human Services Secretary Kathleen Sebelius. (ABC News; Los Angeles Times; GetBetterhealth.com; AP/The Washington Times) Also, USA Today breaks down H1N1 flu incidence by region.

In case you missed it ...
One medical student prefers primary care, despite the financial shortfalls he'll face. His profile is here. (Minneapolis Star Tribune)

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Monday, October 26, 2009

QD: News Every Day--H1N1 'emergency' and vaccine shortage

ACP Internist's daily digest of news and events continues with H1N1 updates, and physicians speaking out about health care reform.

H1N1 influenza
The weekend's health news had one theme: President Obama declared a national emergency, coupled together with pictures of long lines of people waiting for vaccines. Lines formed despite the large numbers of people refusing to get inoculated. (Half of all Canadians!)

Health insurance
Health care reform may have to start at the (medical) home. Eleven percent of health care workers are uninsured. Ambulatory care workers are three times as likely as hospital employees to not have insurance; residential care workers are four times as likely; and service workers are 50% more likely to be uninsured than those involved in treatment. Meanwhile, Blue Cross Blue Shield of Florida, that state's largest insurer, is moving its 5,000 employees to a high-deductible insurance plan linked to health savings accounts.

In case you missed it ...
Internist Randy Silverstine, MD, turned his solo office into a concierge practice but only charges $600 a year, a fraction of what others have charged. He joins the ranks of the 12% of internists who no longer accept health insurance. "This was the only way I knew how to keep practicing the kind of medicine I loved," he told the Sarasota, Fla. Herald-Tribune.

ACP Fellows are sounding off about health care reform. Charles M. Fischman, FACP, spells out how the possibility of a 21% cut in Medicare reimbursement would play out in Florida--with a mass exodus, he predicts. Paul Dolinsky, FACP, says there's plenty of blame to spread around for rising costs.

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Medical News of the Obvious

In our special migraine edition ...

Rats do like Guiness beer by adria.richards via Flickr.comMigraine sufferers may be more prone to hangovers. A rat study at Thomas Jefferson University found that rats with migraines experienced more pain four to six hours after drinking alcohol than the control rats. But researchers ruled out dehydration or impurities in the alcohol. (What's the rodent equivalent of "Beer then liquor, never sicker?")

Another cause of migraines is bad air quality. The Santiago Province of Chile is densely populated and surrounded mountains, so researchers found increased hospital admissions for migraines, as well as tension and cluster headaches, on days of heavy pollution. Hmmm, people who live in big cities get headaches ...

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Friday, October 23, 2009

QD: News Every Day--slow start for H1N1 vaccine

ACP Internist's daily digest of news and events continues with the answer to the age-old question: Which came in first, H1N1 influenza or its egg-based vaccine?

Twenty percent of U.S. children had a flu-like illness earlier in October, and most of them likely H1N1 flu. And 7% of the surveyed adults said they'd had a flu-like illness in the past week, according to a household survey of more than 10,000 adults done in the first 11 days of October. Now, an already slow process of using chicken eggs is now burdened by vaccine-makers trying to make diseases for seasonal and H1N1 strains. Also, the virus on which the swine flu vaccine is based reproduces very slowly in eggs, moreso than seasonal flu.

New York City is seeing fewer cases than expected, but Philadelphia's childrens' hospitals are already hunkering down from ER cases that probably could have been treated at home. Both cities had been suggested to have acquired a "herd immunity" from having been hit so hard in the spring.

Leave it to Moody's to break it down into investment advice. Hospitals usually see some positive cash flow during flu season, but H1N1 could muddle the picture.

And, don't miss the H1N1 robotic simulator.

Health care reform
Senators met with White House officials Thursday evening to discuss how to merge the two health care reform bills in the Senate. Politico reported negotiators are contemplating a national government health plan, but allowing states to opt out. But then it's not a national plan ...

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Denied health insurance

One difficult part about being a doctor is the realization that I am part of a corrupt industry that I cannot influence. Such strong words about American medicine? Well, I have encountered yet another patient who is denied health insurance for underwriting reasons that are just plain unfair.

Maryanne has run out of COBRA, the temporary continuation of health insurance that is guaranteed when a person loses their job. It only lasts 18 months and, in case you didn't know it ... we are in a hell of a recession and there are a lot of people who are unemployed.

Maryanne, age 41, was turned down by Blue Shield of California after submitting all of her health records because she (and I quote) "did not meet the underwriting acceptance criteria:
--migraines treated with Imitrex, Aleve, seen in emergency department once 2009
--thyroid adenoma treated with Synthroid
--deaf"

This is pretty outrageous. One migraine headache that required an over-the-counter pain killer and a recognized pill that works for migraine is hardly a rare health condition. Some 30 million Americans have migraine headaches.

She is deaf since childhood and functions completely normally by lip reading. Of course, being profoundly deaf does affect her ability to get just any old job in this economy, doesn't it?

She does have a thyroid enlargement that will likely need further investigation. These are easy to work up but, without insurance, the cost can be exorbitant and probably more than an unemployed person can comfortably pay.

Another one has joined the 47 million uninsured. There is no safety net for Maryanne or millions of others who are living with the anxiety of being uninsured.

Toni Brayer, 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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Thursday, October 22, 2009

QD: News Every Day--health care reform and H1N1

ACP Internist's daily digest of news and events continues with health care reform, H1N1 influenza and how primary care shortage issues play out regionally.

Health care reform
Halts to the annual cuts to physician reimbursement under Medicare died in the Senate because legislators objected to $247 billion in unfunded costs over the next decade. Enough legislators from both parties objected to an effort to freeze reimbursement for 10 years while Congress found an alternative to the sustainable growth rate formula. ACP President Joseph W. Stubbs, FACP, said, "Although many [legislators] will claim that their vote against cloture was a vote for fiscal responsibility, there is nothing fiscally responsible about pretending that Medicare will save money, from cuts that Congress has no intention to let go into effect, in order to make it seem like Medicare will spend less than it really will."

Meanwhile, some versions of health care reform legislation in the U.S. House would raise the rate of medical spending, not lower it, reports the Office of the Actuary, an independent arm of the Centers for Medicare and Medicaid Services. Spending would increase by 2.1% over 10 years, or $750 billion, because 34 million more people would have health coverage, according to the report. (Wonks can read it here.)

A lesson can be taken from Massachusetts physicians, who support their health care reform laws by a 5-to-1 margin, albeit with some desired changes, reported the Boston Globe. That's slightly higher than in the rest of the public, according to the most recent general poll by Robert Wood Johnson Foundation and Blue Cross Blue Shield of Massachusetts Foundation. Highlights include:
--Two-thirds of doctors say the law has not diminished the quality of care;
--19 percent say it has improved quality;
--62% say the law has not affected the amount of time they spend with their patients; and
--Nearly 80% say the law had no negative impact on their practice overall or had a positive impact.

The original study was published in the New England Journal of Medicine. Health care reform can expand access but not reduce costs, if lessons from Massachusetts teach us anything, reports The Christian Science Monitor.

H1N1 influenza
Production of a vaccine for swine flu virus is behind schedule, said Anne Schuchat, FACP, director of CDC's National Center for Immunization and Respiratory Diseases. Officials expect "widespread availability" by mid-November.

Meanwhile, public radio presents more on "presenteeism" and how a lack of sick days forces some sick workers to show up.

Primary care shortage
ACP's governor of its Connecticut Chapter addresses why so much money is spent on some health care items, such as prescription drugs, medical scans and durable medical equipment, and not on more important areas such as public health education and training medical students. The consequences are dire, as this profile of the Sacramento, Calif. area shows. California has 59 primary-care physicians per 100,000 citizens, whereas 60-80 considered sufficient.

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Wednesday, October 21, 2009

The future is now.

Yesterday morning, I still thought the patient-centered medical home (PCMH) was the abstract future of primary care. But to hear Edwina Rogers, of the Patient-Centered Primary Care Collaborative, talk, the future is already here.

She reported that there are 27 multi-stakeholder (as in more than one insurer) pilots of the PCMH being conducted in 18 states. In all, 44 states and DC have some kind of PCMH activity underway, and one of the laggards, Nevada, promises to be up and running very soon. The details of all these programs are available in a new report that came out today, in conjunction with the PCPCCC's annual summit in DC.

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Is the evidence piling up everywhere or just around me?

First, there was the session advising primary care docs to start making money off MRIs. Then, there was a big TIME magazine article about the success of the Geisinger model. Now, today I attended a seminar on coordinated diabetes care, and heard over and over again--from docs and other experts--that the reason doctors don't do more care coordination is because they're not getting paid specifically for it.

One alternative to motivate coordination is to pay for outcomes, but of course, that brings up concerns about gaming the system and general fairness (as Zeke Emanuel put it, the reverse-Lake-Wobegone effect, where everyone thinks their patients are sicker than average).

It's beginning to seem more likely, to me at least, that doctors may have to be provided the same incentives that the rest of us are. Why do I write obits and answer phone calls from PR people instead of just crafting snide blog posts all day? Because it's my job and I'm paid a--here comes the dirty word--salary to do it. I know, the loss of independence and entrepreneurship and all that, but when more and more medical students are deciding that they don't want to get involved in the primary care business, maybe it's time to change the model.

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So that's what that slide does.

The disclosure slide has become a standard feature of medical lectures. A good percentage of the time speakers disclose nothing, or something silly like their love of the Yankees.

But yesterday, at the ACR meeting, I saw a disclosure slide that even the speaker himself described as "very conflicted." This doctor was there to offer his expertise on osteoporosis drugs so it's not exactly shocking that's he worked with a long list of pharma companies.

Even so, his potential conflicts stuck in my mind, popping up when he expressed suspicion about the effectiveness of generics or pooh-poohed concerns about side effects. For example, "there have been more papers written about osteonecrosis of the jaw associated with bisphosphonates than there have been cases."

Of course, there's no way to know if an interested expert is actually conflicted, but I do now have the anecdotal proof that those disclosure slides serve as more than just an opening for the speaker's warm-up joke.

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QD: News Every Day--SGR cuts stalled

ACP Internist's daily digest of news and events continues with more on SGR cuts, and one physician who reformed health care in Oregon from the inside, as a legislator and later as governor.

SGR cuts
Legislation to permanently fix the annual threat of sustainable growth rate (SGR) cuts to Medicare physician payment formula has stalled. Some legislators balked on voting for it because the $247 billion price tag over 10 years wasn't offset elsewhere. Permanently ending annual SGR cuts were part of a quid pro quo deal between doctor's groups and Senate Majority Leader Harry Reid; eliminate the SGR in exchange for supporting overall health reform. The money would hold reimbursement where it is until Congress can create a better way to reimburse for Medicare.

Since political debate involves a lot of name-calling, one legislator compared the American Medical Association's position to prostitution for its support. The AMA promptly got all dolled up and released 22 "patient access hot spots" nationwide that the organization claims highlights the impact of Medicare cuts. The AMA analyzed state-level data on five access measures and declared hot spots are based on their ranking in the top 15 of at least two of five measures of access:
-- practicing physicians per 1,000 Medicare beneficiaries,
-- Medicare beneficiaries below 150% of the federal poverty level,
-- estimated underserved population living in primary care health professional shortage areas,
-- hospital emergency room visits per 1,000 population, and
-- percentage who hadn't seen a doctor in the past 12 months because of cost.

In case you missed it ...
A physician enacted health care reform in Oregon, first as president of the state's Senate and then as its Governor. The Oregon Health Plan prioritized medical services by value and the number of services covered was determined by how much money the legislature appropriated. It was radical and it worked. Kaiser Health News profiles the physician.

Meanwhile, ACP governors from Nebraska and North Dakota and a member from Green Bay, Wisc. chimed in their support for health care reform.

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Tuesday, October 20, 2009

QD: News Every Day--Senate considers SGR overhaul

ACP Internist's daily digest of news and events continues with the tantalizing prospect of permanently ending the annual SGR cuts, changing public support over health care reform, and Maine's effort to recruit medical students to its rural areas.

SGR cuts
The Senate considers today closing debate and proceeding to vote on a way to permanently end annual SGR cuts. This year, a 21% reduction is on the line, which would prompt primary care doctors to stop seeing Medicare patients. Democrats and Republicans had put off the procedural step, called a cloture vote, to allow time for consensus on the issue instead. ACP reports what doctors can do ahead of this key vote. The separation of SGR cuts from health care reform was done in exchange for physician support for both items.

Health care reform
The Robert Wood Johnson Foundation found that about one-third of Americans worry about losing health care coverage, a slight increase from last month. The number of Americans who worry about losing coverage in the next year has increased by 11% points since the spring. Young adults are the most often concerned (40%), followed by middle-aged (38%) and then seniors (29%) even though they have Medicare.

The Washington Post reports 57% of all Americans now favor some form of a public insurance option while 40% oppose it. More specifically, 45% of Americans favor current outlines in Congress, and 48% are opposed.

H1N1 influenza
H1N1 influenza--"swine flu"--has finally been confirmed in pigs. The agriculture department confirmed that a pig exhibited at the Minnesota State Fair was infected, and that the infection was unrelated to teenagers there who later became sick. But, three other piglets may have become ill after being handled by humans.

In case you missed it ...
Tufts University School of Medicine in Boston and the State of Maine will offer all Maine-based students half-tuition scholarships for those who agree to clinical practice in rural Maine. The students will spend most of the first two years in Boston studying at Tufts’ main campus, then get immediate hands-on experience traveling around rural locations in the state. Maine used Recovery Act stimulus package funds and private sources for the scholarships and hopes in return to retain 75% of students as doctors after graduation.

Also, Illinois' largest insurer is launching a patient-centered medical home pilot. The Chicago Tribune spells out how it might work.

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Narrowing the focus on fibromyalgia

If attendees at the Association of Rheumatology Health Professionals' fibromyalgia debate were expecting strident disagreement, they were likely disappointed. There were some points of disagreement, but a fair number of accord as well.

Anthony Russell, MD, of the University of Alberta, who took the anti-fibromyalgia position, listed off the long history of trendy, unexplained fibromyalgia-like illnesses and pointed out the common incidence of such symptoms. (See ACP Internist's Q&A with Frederick Wolfe for more in this vein.) Physicians shouldn't reinforce patients' perceptions that they are sick, he argued.

Leslie Crofford, MD, of the University of Kentucky, didn't disagree that fibromyalgia is only the latest name for what has been a persistent, inexplicable patient complaint. But she argued that patients benefit from having their problem labeled as fibromyalgia. A diagnosis makes patients less likely to consume additional time and resources looking for an explanation, she said, and more able to move on the managing their condition.

She also offered a suggestion to decrease the likelihood of having a similar debate about whatever disease is in style five years from now: "We will all do better if we stop the foolishness of changing the name."

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A rheumatology study for primary care

Researchers are usually calling on docs to follow guidelines, but a study presented yesterday revealed that ignoring a certain guideline for gout therapy could actually improve results. The study experimented with increasing gout patients' doses of allopurinol over recommended levels. "The problem with the dosing guidelines is that many patients fail to reach target serum uric acid levels," explained study author Lisa Stamp. "We are effectively undertreating."

The study increased the drug dose to try to get patients to the target serum uric acid level of 6 mg/dL, in some cases exceeding recommendations by as much as 400 mg/day. A few of the patients (3 of 45) developed rashes at the higher doses, but 86% of the participants hit the target.

The findings are particularly important for primary care physicians, who may be following the guidelines more rigidly than are doctors who have more experience with the medication. "I think this is going to support what rheumatologists are doing anyway," said Dr. Stamp.

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Monday, October 19, 2009

The ACR's got milk...and lemonade and water.

The point of the rheumatologic press conference I attended this afternoon was probably supposed to be the results of the research presented, but what I found most interesting were the ways that researchers found to collect and torment their subjects.

First up, a study that investigated the possibility that skim milk consumption can lower serum uric acid concentrations, thereby reduced the risk of gout or gout attacks. They found that cow milk--but not soy--did decrease levels when it was consumed in 80 gram servings by healthy young men. The author helpfully explained how much milk that is for us measurement-challenged listeners--5 to 7 glasses at a sitting. And all that milk was drunk by guys who weren't even sick! Hope they at least went back home and challenged their buddies to the gallon challenge.

If you don't like milk, perhaps you would have preferred to join the Coke-sponsored osteoarthritis trial which asked participants to drink two bottles of diet lemonade (spiked with either glucosamine or placebo) every day in a single sitting. The bad news for them was that all that lemonade-chugging had no apparent effect on their knees.

Beverages seemed to be the theme of the day, although the lucky participants in the next trial didn't have to change their consumption, just monitor it. The interesting thing about them is that they were recruited through a Google ad. The ad recruited gout sufferers across the country to report all kinds of data about their behavior when they are and aren't having gout attacks. Turns out that not drinking water seems to increase the risk of a gout attack.

The data led one astute reporter to wonder whether the milk-drinkers would have done just as well chugging water. It's an issue for further study, admitted the researcher. But where's the fun in that?

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QD: News Every Day--the H1N1 fist bump

ACP Internist's daily digest of news and events continues with ways to avoid spreading the flu (and how it's making us rude), Michigan's proposed doctor tax, and a review of evidence-based medicine.

H1N1 influenza
A feature story profiles how ways to avoid spreading disease are making society less civil (fist bumps instead of handshakes) Thomas Fekete, FACP, says that it's only reducing risk by 1%-2%.

Primary care shortage
Michigan is considering taxing physicians. They propose a 3% physician tax to offset Medicaid cuts to hospitals. The measure could generate $300 million, which would recoup another $525 million in matching federal money. Michigan's hospitals, nursing homes and health plans already pay a physician tax, as do 44 other states. The Michigan State Medical Society Michigan Osteopathic Association oppose it, saying it will exacerbate the primary care shortage and shortchange specialists, but the Michigan College of Emergency Physicians supports it, saying the tax would fund increased reimbursement for Medicaid, which in turn would encourage more primary care doctors to accept those patients.

On the plus side of the balance sheet, Pikeville College will expand its School of Osteopathic Medicine to reduce the primary care shortage in eastern Kentucky. The $4.5 million expansion may eventually increase each year's class from 75 to 125 students. Of course, once they're students, they're overwhelmed by the pace and the scope of school loans, as profiles in northwest Indiana relate.

Evidence-based medicine
One doctor relates the dangers of trying to apply rigorous reviews to individual patients, in this case, his own mother. Another caveat to evidence-based medicine is who's providing the evidence base. Online health sites that allow patients to directly compare (sometimes unapproved) treatments and outcomes are cropping up more rapidly--nearly 500 by now. These sites combine social media with aspects of wiki-style medical references and evidence-based medicine. Patients are turning to them for H1N1, for example. ACP Internist profiled one such site and the controversy it generated a year ago.

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Medical News of the Obvious

People who are cognitively active, socially engaged and physically active may fend off cognitive impairments, according to the Archives of Neurology. The article concludes: "In the most optimistic view, dementia could be delayed or even prevented by these interventions. At worst, people will improve their overall health, especially their cardiovascular health, and enjoy a more cognitively and socially engaging life."

People can be shamed into washing their hands in public restrooms. Researchers from the London School of Hygiene And Tropical Medicine team used LED screens to flsash messages such as "Water doesn't kill germs, soap does" and "Don't be a dirty soap dodger," at the entrance of the toilets. They measured results among 250,000 people via sensors at the toilets, then the soap dispensers. The message "Is the person next to you washing with soap?" boosted rates of hand-washing with soap by 11% in women and 12% in men, suggesting people were most sensitive to the idea that others were watching their behaviour. (Or maybe it's that they were being tracked while in the bathroom.)

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Friday, October 16, 2009

QD: News Every Day--One stolen laptop threatens all doctors' personal data

ACP Internist's daily digest of news and events continues with a stolen laptop's threat to physician's personal info, plus the Senate voting and voting and voting on physician payments, and the reasons why the public is so divided on the way they view public health issues.

Almost all U.S. physicians, 800,000 total, have been warned that a stolen laptop had their names, addresses social security numbers and provider identification numbers on it. An employee of the trade group representing Blue Cross insurance plans moved information to a personal laptop that was then stolen, which leave as many as 20% of all doctors vulnerable to identity theft.

H1N1 influenza
The World Health Organization urged prompt antiviral treatments in people with suspected H1N1 flu because it can lead to pneumonia so quickly in young, otherwise healthy people.

Physician payments
A bill that would increase Medicare payments to physicians will require three votes by the Senate--needing 60 votes each time--before the Senate can take a fourth vote. Greatest legislative body in the world, indeed. Oh, and the Congressional Budget Office estimated the $240 billion bill will actually cost $247 billion over 10 years.

Primary care shortage
A blog post explaining the reasons why there is a primary care shortage doesn't offer any new insight so much as it puts all the reasons in one easy-to-read place. These aren't esoteric issues; they play out in real life all across the country, as this profile explains what's happening in Omaha.

In case you missed it ...
Much of the disconnect on health care reform can be explained by political beliefs, researchers reported in the American Journal of Public Health. They tested a news article describing how a lack of sidewalks and presence of fast food were linked to type 2 diabetes. Republicans were less likely to believe junk food led to a diabetes epidemic than Democrats. Researchers told ABC News that the same message has to be framed differently to the two audiences to garner support.

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Patient uses Twitter as he undergoes appendectomy

Today, live, patient Marc Needham is tweeting his hospital visit, which he just learned will result in an appendectomy. He's Scripps Health's Corporate Director of Web Technology. Also today, live, Henry Ford Hospital is again using Twitter to "broadcast" a surgery, in this case a kidney transplant. The first surgery was "tweeted" this morning, and the recipient surgery will follow this afternoon.

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Rheumatology: Ill-advised session titles

Another conference, another edition of Ill-advised Session Titles. The American College of Rheumatology is meeting in Philadelphia next week and we will bring you some serious news from there. But first, some semi-funny titles. (Not to start a turf war or anything, but rheumatologists just don't seem to be as creative as the medical group managers.)

We've got some metaphors: "Getting a Grip on Arthritis" and "Tip-Toeing Around Arthritis and Foot Pain" and one movie reference: "Something's Gotta Give: Couples Coping with Chronic Pain." I know, not very hilarious.

The sad thing is that rheumatology has lots of potential. Take this session, for example: "The Effect of an Iyengar Yoga Program to Minimize Falls and Build Balance Confidence, Postural Stability and Improved Gait in Women Between Ages 60 and 75." How much more likely would you be to attend if it were called "Downward dog for dowagers" or "Say 'Om,' Grandma"?

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Thursday, October 15, 2009

QD: News Every Day--legislative tricks, treat the underserved and banning sick kids ... from hospitals

ACP Internist's daily digest of internal medicine in the news continues with a look at legislative tricks for health legislation, a medical school that sends students into poor neighborhoods as part of their training, and hospitals that are enacting bans on minor visitors to avoid spreading H1N1.

Health care reform
Senates are seeking a bill that increases Medicare fees by $247 billion in the next decade. Because it will raise the deficit, Senators are trying a two-bill approach, a bit of legislative sleight-of-hand, to let them claim that health care reform won't cost more. At stake is a 21% reduction in Medicare reimbursement that was is scheduled to take effect in January.

In another bit of having one's cake while eating it, too, seniors will pay more for Medicare Advantage when costs increase from an average of $32 to $39 per month next year. Insurers are cutting plans that have no premiums--a federal requirement. Also being scrutinized are the free perks meant to entice traditional Medicare patients into private Medicare Advantage policies. But free to patients means paid for by the government--or sometimes hidden as higher co-pays and additional fees.

Investor's Business Daily points out a looming fight between primary care and specialty medicine. Legislation in the Senate gives primary care doctors a 10% bonus if they work in a Health Professional Shortage Area and 60% of their services are primary care. Half of the funding for the bonus comes from across-the-board cuts for specialists, who are refusing support.

Primary care shortage
Federally qualified clinics could treat more than 20 million patients this year, 2 million more than last year, the AP reports. The increase comes at a time that states are cutting their health care budgets.

To serve this need, Florida International University curriculum will send medical students to poor neighborhoods as part of their training. TIME profiles the program (and quotes ACP president Joseph W. Stubbs, FACP in the process.)

Finally, an emergency room doctor wrote an open letter to President Obama, making the points that:
--people without health care head to ER for treatment,
--medical training is expensive and causes primary care shortages, and
--legislators would discuss the space program without involving astrophysicists, so it's time to get doctors involved in health care reform.

These are all familiar points, but the letter is worth a read.

In case you missed it ...
To avoid spreading H1N1 influenza, hospitals have begun banning visitors less than 18 years old. These are children's' hospitals, too. M.D. Anderson followed suit, as well.

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Wednesday, October 14, 2009

I feel your difficulty being empathetic.

During his speech this morning, Cleveland Clinic CEO Toby Cosgrove, MD, was remarkably willing to admit his own flaws. He talked about the clinic's less than stellar levels of employee engagement and told one negative story on himself. When he spoke to a Harvard Business School class, one of the students asked him about his reputation for a lack of empathy. The question really made him think, he said, about how empathy is something of importance to patients that he hadn't focused on.

And then he launched into a slide show of all the recent improvements to patient experience made by the Cleveland Clinic--more windows, free wifi, greeters at the door, sofa beds for visiting family, hospital gowns designed by Diane Von Furstenburg. It struck me that those are all great patient-centered innovations, but they do nothing to make clinicians more empathetic to patients--the b-school student's actual concern.

Dr. Cosgrove's struggles with empathy reappeared during the Q&A. One questioner asked how small and midsize practices (where most of the MGMA attendees work) could provide high-quality coordinated care without the integration and resources of a big health system. Dr. Cosgrove responded by saying that he thinks the trend in health care is definitely away from small practices and toward big employed systems. In other words, you can't do it, so you'll be gone soon. Ouch.

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Jargon of the day

The term "patient-centric" may have only recently appeared on many clinicians' radar, but it's already headed for obsolescence. Kaiser Permanente is working on being more "consumer-centric" and "member-centric" to capture potential, in addition to actual, patients. "We can no longer wait for the patient to show up in our exam rooms," said medical director William Wright.

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Out of the mouths of executives

They weren't the "futurists" who have been popular features of conferences lately, but I'd still put some faith in the predictions offered by the speakers I heard this morning. An MGMA panel included Toby Cosgrove, MD, Gary Kaplan, MD, and William Wright, MD, chief executives at the Cleveland Clinic, Virginia Mason and Permanente Colorado, respectively.

They had a lot of miscellaneous information to offer (strategies for improving quality, maintaining employee satisfaction, etc.) but I found a couple of points on health reform particularly interesting.

All three have electronic medical record systems, and while they think that the technology will have beneficial impact on quality, they say the government's focus on EMRs as cost savers is misguided. "I do not think we've saved a penny so far and we've shucked out hundreds of millions," said Dr. Cosgrove. Dr. Wright also made the point that EMRs will make no difference in quality, either, unless they're used to improve other aspects of care.

So how will health care reform manage to save money? Bundled payments. All of the execs think that bundled payments for episodes of care and outcomes are coming and that they will have a major impact on the way money is distributed within health care. Dr. Kaplan thinks they'll even create downward pressure on proceduralists, when various specialties have to divide the pot. They're so certain about the impending changes that one of the docs described physician-owned hospitals as an effort "to take the gains for the few remaining years left."

Another prediction that might displease physicians was the experts' certainty that minute clinics are here to stay. They advised providers to either embrace the trend or partner with it (Cleveland has a partnership with CVS).

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QD: News Every Day--The disconnect of health reform

ACP Internist's daily digest of internal medicine in the news continues with the disconnect on health care reform, a larger analysis of who was hospitalized for H1N1, and more on the primary care shortage.

Health care reform
Americans want health care reform to change, but they don't want to pay for it.

Meanwhile, the Economic Policy Institute, a think tank focused low- and middle-income Americans, points out that Medicaid and the SCHIP held in check the number of children who would have gone without health between 2000 to 2008. Children without insurance dropped 1.7% between 2000 and 2008, while adults less than 65 without insurance rose 3.1%. By contrast, children with public coverage grew 8.8%, compared to a 3.5% increase for the adult population under 65.

H1N1 influenza
Health officials now say that 46% of 1,400 adults hospitalized with H1N1 influenza did not have a chronic underlying condition, according to the largest analysis to date. The study looked at adults and children hospitalized from April through August in 10 states at medical centers participating in a special disease surveillance network. Anne Schuchat, FACP, who heads the CDC's National Center for Immunization and Respiratory Diseases, said the larger analysis looked at underlying conditions not previously examined. Among adults, 26% had asthma, 10% had diabetes, 8% had some other chronic lung disease, 8% had weakened immune systems and 6% were pregnant.

Primary care shortage
A financial advisor chimes in with his analysis of why primary care doesn't pay, including input from his own internist. The doctor says, "The average income of a primary care doctor in Massachusetts is about $86,000. Why do I do it? Because I love it."

The medical home
Profiles of practices trying the patient-centered medical home include Greenhouse Internists in Mt. Airy, Pa. and the Adirondack Regional Medical Home Pilot, which also an effort to stop the loss of primary care practitioners in the region. And for a lighter note, don't miss ACP Internist's own Stacey Butterfield's report from the MGMA meeting in Denver.

In case you missed it ...
In Minnesota, the Vitality Project prompted one town to build sidewalks and bike trails; restaurants, groceries and schools to push healthier foods; and employers to give workers time to exercise. The experiment added an average 3.1 years to the longevity of about 2,300 residents who calculated their lifespans by answering 36 lifestyle questions.

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Tuesday, October 13, 2009

The annual point when the biz of medicine gets me down.

Now that T.R. Reid and Ezekiel Emanuel and I have hung out (OK, so they lectured and I listened along with 2,000 other people), I like to imagine that I understand a little bit about how they think.

And I imagine they would have been just as depressed as I was with yesterday's session on how primary care practices can make money by going into the imaging business. There were so many wrong incentives involved, it's hard to even count. You can begin with the fact that the lecturer predicts continuing growth in the imaging industry because tort laws (or at least perceptions of them, I would argue) appear likely to continue encouraging defensive medicine.

Then there were the obstacles you would face, most notably the Stark laws. But a good health care attorney can find lots of ways to work around these, the speaker said. Take the example case offered in the session. The anti-kickback statutes prevented this practice from actually providing any imaging, so they decided to go into business buying imaging from the hospital. In other words, as best I can understand, the only thing that changed was that the primary care practice would now send all of their patients to the hospital for imaging, pay the hospital for the service, bill insurers and take a cut off the top.

The story is in some ways an argument for the effectiveness of government-run health care. The setup wouldn't fly with CMS, so it only applies to private payers.

I don't mean to necessarily condemn practices that do this (they're only being good capitalists after all), but when you think about where their profit comes from, it makes clear the defects in our system. The practice's slice must either being coming out of the non-profit hospital's pockets or the insurer's (and thereby all of their premium payers) and represents no actual goods or services.

And despite all the talk of cost-cutting, this isn't an issue that health care reform will probably tackle. Proposals like bundled payments and the medical home could even make such arrangements more convenient, the speaker concluded.

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Improve your patient satisfaction scores for free!

I was going to call this post "ways to be nicer to patients" but we all know nicety is not nearly as compelling a motivation as a bump in pat sat.

So, some quick tips from Meryl Luallin, a consultant and secret-shopper patient who spoke today:

Don't put up a sign at the front desk instructing patients to sign themselves in and wait to be called. It's unfriendly. "If you're short-staffed, short the staff somewhere else," she said.

When you enter the exam room, don't say "What brings you in today?" "How can I help you today?" gets the same answer but sounds nicer.

And lastly, when a patient phones to talk to a physician, staff shouldn't say "He's with a patient right now" because the patient will assume that the doc will call back as soon as he is done with that patient. Instead, try "The doctor usually returns phone calls at the end of the day. Is there something I can help you with in the meantime?"

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Overheard at MGMA

I spend most of my time at conferences attending sessions and (obviously) updating the blog with what I've learned. For reasons I've never understood, most of the other reporters spend their time interviewing vendors of electronic health records (EHRs).

Writing on the computers in the press room gives me the opportunity to unobtrusively eavesdrop on their interviews. They're not usually very exciting, but today I heard something noteworthy--three different EHR vendors told three different reporters the same thing. To paraphrase, "Traffic is down on the exhibit floor, but the people who come by are way more serious about buying." Either they had a secret EHR vendor talking points meeting, or the attendees at this meeting really are shopping for more than free food and pens.

This is sort of contrary to what we heard at the MGMA press conference, which was that members seemed to be holding off on EHR investments until the government better defines "meaningful use" at the end of the year. That was just the impression of MGMA staff, though, so maybe they've missed this new trend.

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Spotted in the exhibit hall.

Photo by Stacey Butterfield
Could it be the long-awaited medical home?







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More from Emanuel

I just keep coming across more interesting things in my notes from Ezekiel Emanuel's speech.

For example, he described a cooperative program between Starbucks and the Virginia Mason health care systems. Starbucks employees were frequently going to the doctor complaining of back pain (no suprise in an on-your-feet, heavy lifting job) and it was costing the company in medical expenses and sick time. So Starbucks and Virginia Mason made a deal to get these employees the most cost-effective, evidence-based care. In other words, fewer pointless MRIs and more physical therapy. Employees got less medical care but better outcomes. Of course, under the current reimbursement system, the result was less money for Virginia Mason, so they made a deal with Starbucks to get paid a little more for physical therapy to make the overall savings benefit everyone involved.

Not sure if this is a happy story about effective cooperation, or a horrifying example of how dysfunctional our current health care system is.

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Out of context

This quote from a session on communication would make a little more sense in context, but I much prefer it as is. "If the doctors don't want to wear the duck suit, then they don't want to be part of the culture of our group."

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QD: News Every Day--Senate committee passes health care reform

ACP Internist's daily digest of internal medicine in the news continues with a key vote on health care reform, severe flu cases and an ACP Fellow honored for treating the poor.

Health care reform
[Updated from its original post] At nearly 3 p.m. today the Senate Finance Committee approved its version of the health care reform bill 14-9. Observers were atwitter (and a-Twittering) every time Republican Sen. Olympia Snowe so much as shifted in her seat. Eventually, she shifted to the left and said she would vote for the bill in committee without taking a position down the line.

Following today's vote, the bill will merge with the Senate Health Committee's version over the next few weeks and then go to the full Senate. On the House side, Rep. Nancy Pelosi will send several versions of a health care reform bill to the Congressional Budget Office, including one with a government-run public insurance option.

Even if a bill is signed into law this year, it will take three years before any tax credits begin.

H1N1 influenza
About 1 in 1,000 will develop severe illness from H1N1 influenza, and when they need hospitalization, they quickly consume limited resources such as mechanical ventilation, according to JAMA. Researchers profiled the outbreaks in Canada and Mexico, and an editorial suggested regionalizing care for patients with advanced respiratory failure. Alternatives also include telemedicine and temporary staffing changes to divert experts to the point of care.

In case you missed it ...
Pedro Jose Greer, FACP, of Miami, Fla. received the 2009 Presidential Medal of Freedom for his work treating the poor regardless of their ability to pay. His profile is here.

You know times are tough when even the Mayo Clinic, the model for health care, get criticism for limiting Medicare patients to Minnesotans and the border states of Iowa, Wisconsin and the Dakotas. But if you're wealthy, you can turn to your financial planner for Medicare advice.

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Another reason to get an EHR.

There's been a lot of talk at the meeting about stimulus funding for EHR systems (I've never heard the phrase "meaningful use" so many times), but a session on physician profiling offered a new reason that you might want to invest in an electronic system.

In case you missed it, physician profiling refers to insurers' systems of ranking physicians by cost and quality (but mostly cost) and pushing insureds toward the best-value docs. The insurers make mysterious calculations comparing claims data from your patients to comparable others. Then they give you a star or multiple stars if they find your care to be cost-effective.

But if they don't think you're doing well, and you disagree, you can use data from your EHR to fight back. Although the insurers won't reveal their specific formulas, you can pull data from your system on the patients or conditions in question to prove your case (by searching for migraine codes or generic prescriptions or whatever).

One caveat, though: it's a major undertaking, and the physician profiles don't affect reimbursement, so if you have more than enough patients already, you might not want to bother, the speaker said.

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Monday, October 12, 2009

Beware, convention attendees.

The recession has hit hotels hard and they seem to have hit back by finding sleazy new ways to charge more. Two recent examples from my convention travel:

In Miami, a hotel charged me because I opened the minibar. They were willing to remove the charge when I asked, but their standard procedure is to assume you ate something and bill you $12 for it.

In Denver, my hotel warned me at check-in that they were running my card right then for the cost of my stay plus $75 "for incidentals." If I failed to buy enough incidentals, they would refund the difference at check-out.

Combine these schemes with the trend toward express check-outs that don't show you an itemized bill and you've got a recipe for hotel profit at the expense of oblivious consumers. So next time you're headed home from a convention, keep an eye out so as not to lose an arm and a leg.

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Does your waiter Xerox your credit card?

At the annual MGMA press luncheon (yes, our entire day revolves around free food), MGMA president William F. Jessee gave us the usual update on the opinions and activities of the group. (See next week's ACP InternistWeekly for full details.)

They are still avidly pursuing their plan for a standardized machine-readable patient ID card, like a credit card for your health insurance. Several big payers--Humana, United Healthcare, regional BC/BS--have signed on, but Medicare is a major stumbling block. The stick-in-the-mud agency, which is also thwarting MGMA's desire for a national health plan identifier and electronic claims attachments, is sticking with paper cards with social security numbers. (How retro!) Jessee was optimistic about Project SwipeIT, though, and said that the plan for 2010 is to "crank the pressure up a little" on insurers that haven't signed on yet.

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Statistics and predictions of the day

Since I can't share my conference-supplied muffin with you all, how about some tidbits of information from MGMA?

From Ezekiel Emanuel: 10% of the U.S. population is responsible for 64% of our health care costs, while 50% of the population spends only 3%.

From Max Rieboldt, a health care CPA: "Within the next 10 years, at least 80-90% of physicians will be employed. We're headed more and more in that direction." One of the major reasons for that? Physicians' insistence on being paid to take emergency call. Hospitals like having the responsibility for call as part of the employment contract, instead of an extra issue to negotiate and pay for, he said.

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QD: News Every Day on health care reform, primary care shortage and health care use

ACP Internist's daily digest of internal medicine in the news continues with the disconnect on who's supporting health care reform, the primary care shortage and who's to blame for how American consumer health care.

Health Care Reform
According to an Urban Institute study of 20 congressional districts where more than 30% of residents have no health coverage, members of congress whose constituents might gain the most from reform sometimes oppose it, while others representing voters who will likely pay more for little gain support it.

Primary care shortage
Kaiser Health News reports--surprise!--that little is being done to ramp up the number of primary care doctors to meet the needs of any beneficiaries of health care reform.

A paper in Health Affairs suggests using prepaid group practices, "highly structured, multispecialty medical groups that are reimbursed by capitation to serve the enrollees of a health maintenance organization," to achieve a physician-to-population ratio 22% to 37% below the national rate.

It's gotten so bad that one family practitioner earns more from her eBay services. In all fairness to the practice of medicine, she's a top seller.

In case you missed it ...
Last week we reported that doctors drive up health care costs, not patients. This week we note that doctors may order needless tests because of their patients, who read about diseases on the Internet and think they have them. Or, direct-to-consumer ads prompt prescription requests. NPR reports.

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All we need is the will.

This morning's featured speaker at MGMA was T.R. Reid, of Washington Post, NPR and new book about health care around the world fame. His speech covered a lot of territory and included some humorous tidbits (Why doesn't French health insurance cover Viagra, according to the country's health minister? Because French men don't need it.)

Anyway, after all his travels, he came to one main conclusion about why the U.S. health care system is different (and more of a mess than) others around the world: our variety of coverage. "In all of the other countries, they've settled on one model for everybody," he said. In contrast, the U.S.'s major achievement is having an example of every possible coverage plan (compare the VA, Medicare, employer-sponsored coverage, and uninsured care), which adds complexity, administrative cost and little incentive to prevent illness, not to mention being unfair.

The good news is that he thinks there's hope for us: "If the U.S. could find the political will to provide health care for everybody, the other rich countries could show us the way."

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No limos, but I did just ride down the hall in a golf cart.

Did you ever wonder who's been eating all that free food that doctors aren't supposed to accept anymore?

It's the medical group managers, from what I can tell. There's also free booze here. But last night, the Denver Convention Center seriously tested our commitment to consuming freebies. Just as the opening reception was beginning, the fire alarm went off. Photo by Stacey ButterfieldThe dilemma: heed the alarm (and the weird burning smell) and leave the building or hit the open bar? I'm sure you can guess the general decision.

The especially brave hooked themselves up at the oxygen bar. Nothing like pure oxygen, liquor and a fire to get the party started.

Note on the post title: I'm not kidding. They actually have golf cart shuttles, as well as a cappella singers and women on stilts pretending to be trees.

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Medical News of the Obvious

Kids are more likely than their peers to become addicted to the Internet if they're depressed, hostile or have attention deficit hyperactivity disorder or a social phobia. On the positive side, they also use it as therapy to overcome their face-to-face limitations or find kids like themselves.

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Sunday, October 11, 2009

Saving money with limos

Ezekiel Emanuel, senior health care advisor to the White House, wants you to have your patients picked up in a limo. Ok, not exactly, but he did list chauffeured luxury rides as one of the techniques that practices have successfully employed to get patients to show up for their appointments. If the office visit prevents a serious complication or hospitalization, then the limo's actually a cost-saver, Dr. Emanuel explained to MGMA attendees.

He has a lot of plans for saving money in health care, most revolving around the creation of comprehensive medical homes for patients with chronic diseases. (You know the drill--team care, coordinators, patient education, better transitions.) So how do we get there from here? Dr. Emanuel favors a bundled payment system. His model would be a modified fee for service system, in which the cost of a patient's care would be compared to a guideline-based, risk-adjusted estimate of what's appropriate. When a patient's care comes in under that number, physicians get to split the savings.

According to Dr. Emanuel, this system could help give doctors the feedback they want and need and provide incentives to offer quality, not excessive, care. Speaking of excessive, Dr. Emanuel also had an interesting perspective on the much-discussed impending doctor shortage. He does see a need for more primary care, but he doesn't think we are short of doctors overall. If we did fewer inappropriate PCIs and knee replacements, the existing docs would have time to get all the actually needed care done, he said.

Note: Dr. Emanuel was careful to state that he was speaking on his own behalf, not the administration's.

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Friday, October 9, 2009

QD: News Every Day on insurance coverage, primary care shortage and H1N1

ACP Internist's daily digest of internal medicine in the news continues with who's covering the uninsured, students weighing in on why they eschew primary care careers, and H1N1's widespread but less lethal path.

Covering the uninsured
While the number of uninsured people rose slightly from 2007 to 2008, more people were covered by government programs as employer-sponsored coverage continued to decline, according to the U.S. Census. The ACP Advocate reports census figures showing that 15% of the population was uninsured in 2008, increasing from 45.7 million to 46.3 million. However, coverage by private plans fell from 67.5% to 66.7% and coverage by employers fell from 59.3% to 58.5%. Government coverage rose from 27.8% to 29%.

Primary care shortage
Medical students weigh in on health reform, and have their doubts. Also, they won't go into primary care. "When it's a difference of $200,000 in your paycheck, it's tough," one student said.

Flu update
The H1N1 pandemic has been more widespread than lethal, notes the Harvard Health Letter. The virus seems to cause fewer cases of serious disease than expected. Harvard experts discussed the latest at a forum, with video posted online. In short, estimates for the death rate for H1N1 range between one death for every 2,000 symptomatic cases and one death for every 14,000 (0.007%). In comparison, the death rate for seasonal flu is roughly one death for every 1,000 to 2,000 cases. Seasonal flu infects roughly 5% to 20% of the population annually, whereas pandemics infect 25% to 40%. This H1N1 epidemic may not rise to pandemic levels.

In case you missed it ...
Doctors drive medical consumption, not patients. Illness and patient preference play a much smaller role. NPR reports on one epidemiologist's lifelong work. Meanwhile, a Newsweek columnist weighs evidence-based medical treatments against clinical judgment. It's the age-old question: How does a study impact treatment of the patient sitting before a doctor, seeking a cure?

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MGMA: Ill-advised session titles

I'll be blogging from the annual conference of the Medical Group Management Association next week, so it's time for another edition of Ill-advised Session Titles.

After years of study, it has become clear that there are certain best practices for attracting potential attendees' attention. First, resist the impulse to explain your catchy title with a subtitle.

For example, MGMA's "Can't We All Just Get Along? Successful Conflict Management Strategies" is eye-catching, but you can also guess pretty well what the session will entail. How much more intriguing are these sessions?

"Can We Talk?"
"Why People Do What They Do"
"Not All Patients Are Created Equal" and last but certainly not least,
"Execute for Results!" (Who or what are we executing? Aren't you dying to know the results?)

There's also something appealing about undercutting your topic in the title, as evidenced by these two sessions: "Successful Transition to a Hospital-Employed Practice Model (While Maybe Keeping Your Job)" and "Hospital Employment for Radiology: Maybe Not as Bad as You Think." (It's perhaps not coincidental that these sessions deal with the same issue.)

And finally, this session wins our award for best visual image: "Help Your Physicians Wear Their Many Hats." Fedoras, bowlers, ski caps?

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Thursday, October 8, 2009

QD: News Every Day--health care reform / Surgeon General / unlicensed providers

ACP Internist's daily digest of internal medicine in the news continues with sides blurring on health care reform, a new Surgeon General favorable to primary care and the suggestion of continuous credential monitoring for providers.

Health Care Reform
According to the Congressional Budget Office, the Senate Finance Committee's proposal will:
--slow spending growth on medical care
--lower the deficit
--cost less than President Obama's threshold
--cover 29 million uninsured Americans
--cover 94% of all Americans

The Finance Committee's bill requires a vote, possibly on Tuesday, and then will be merged with a bill in the Senate's Health, Education, Labor and Pensions Committee.

Now, Congress needs to figure out who will pay for it all, the wealthy or the insurance companies.

Meanwhile, some Republicans who carry the title of "former" are supporting some kind of reform: former Senate Majority Leaders Bob Dole and Bill Frist, and former Medicare administrator Mark McClellan. Former Health and Human Services Secretary Tommy Thompson cited the Senate Finance Committee's plan specifically.

And while Republican governors Arnold Schwarzenegger and Bobby Jindal support reforming health care in some way, two Democratic governors oppose expanding Medicare because of its impact on the states.

In case you missed it ...
Regina Benjamin, MD, took one step closer to becoming Surgeon General. The Senate Health, Education, Labor and Pensions Committee approved the nomination; she now goes to the full Senate. But there's no timetable to vote on Dr. Benjamin, a primary care physician.

Nearly one in 5 health care practitioners operate under malpractice allegations, an expired license or false credentials, and nearly 2% practice without a license. The study, done by a company that provides credentialing verification, prompted them to suggest continuous Web-based monitoring instead of reviews every two to three years.

Where one lives impacts the health care received, since insurance coverage, access to preventive medicine and disease treatment vary widely among states, according to a study released by the Commonwealth Foundation. Vermont focused on health care and its robust residents faired the best, followed by Hawaii, Iowa, Minnesota and Maine. As usual, the South trundles behind the rest of the nation's health care performance. Mississippi has the worst health care, with Oklahoma, Louisiana and Arkansas rounding out the results.

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Not an uplifting post

Whether you call it defensive medicine or technology infatuation, the overuse of testing has been much discussed in medicine, especially given current concerns about containing the cost of care (how 'bout that alliteration?).

But ACP Fellow Jack Coulehan puts a new personal spin on the issue in an article published in Health Affairs and the Washington Post. He found that even an expert in appropriate care can get sucked into a miserable, wasteful spiral of specialist consultations and costly testing. It's a sobering read.

And if that article makes you feel down, it might be worth checking this one, about efforts to destigmatize depression among medical professionals.

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Wednesday, October 7, 2009

QD: News Every Day--obesity, H1N1 and faking illness vs. "presenteeism"

ACP Internist's daily digest of internal medicine in the news continues with obesity programs, H1N1 updates and employees who fake calling in sick vs. those who won't when they really are.

Obesity
Schools, workplaces, food retailers and food and beverage makers are chipping in for the Healthy Weight Commitment Foundation, an effort to reduce obesity by balancing calorie consumption through physical activity. As just a few examples, food manufacturers will change product offerings, packaging, and labeling. Companies may provide exercise activities or facilities, offer weight management programs, and provide healthier foods in workplace cafeterias and vending machines. The Robert Wood Johnson Foundation, The National Business Group on Health and the University of California, Berkeley Center for Weight and Health will evaluate progress.

An internist is developing recommendations for physicians on how to guide and treat overweight patients on behalf of the STOP Obesity Alliance, a coalition of professional and labor groups, businesses, insurers and health care providers. The internist outlines his success in a case study.

H1N1 Flu
Health and Human Services Secretary Kathleen Sebelius further encouraged H1N1 vaccination, calling it "safe and secure" and adding that it's made the same way as seasonal flu vaccines.

Although H1N1 vaccination in the U.S. is slowly starting, states have ordered more than 2 million doses, mostly of nasal spray, for the first patients, according to Thomas Frieden, MD, director of the CDC. In Chicago, John Segreti, ACP Member, an infectious diseases expert at Rush University Medical Center, told Reuters his facility will distribute its first 2,000 doses to children and will wait for inactivated vaccine for health workers.

Emory University doctors licensed their interactive Web site to allow patients with potential H1N1 cases to self-screen using the same triage calculations their doctors and the CDC use. Questions about fever, symptoms and underlying health help patients determine whether they've got H1N1 flu, and what to do next--rest, call their doctor or seek immediate treatment. This site and related hot lines have been developed to keep people from flooding emergency departments. The materials, known as Strategy for Off-Site Rapid Triage (SORT) and Real-time Epidemiological Assessment for Community Health (REACH), were created and developed at Emory University. Ruth Parker, FACP, was one of the developers.

In case you missed it ...
The proportion of employees calling in sick when they're not hasn't changed among U.S. workers--at about one-third and holding--but fewer are getting fired for it, according to CareerBuilder.com as reported by Reuters. Of employers surveyed, 15% said they fired an employee for missing work without a legitimate excuse this year, compared to 18% last year.

The survey showed that most employers typically don't typically question absences (29% in 2009, 31% in 2008, 35% in 2007) and two-thirds of them let workers use sick days as "mental health days." The one-third of employers who do check on absenteeism require a doctor's note, call the person at home or have another worker call or drive by the employee's home. Employers cited stress and burnout from the recession as a reason they think employees fake illness.

The bigger fear is "presenteeism," those who show up to work no matter how sick they are. (They're also called "mucus troopers.")

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1500 calories for $5--good deal or bad?

Maybe it's an argument for the soda tax. Or further explanation of the association between poverty and obesity.

In any case, this NY Times article about the impact of posting calorie counts is fascinating. It reports on a new study which found that people actually ordered more fast food in some poor neighborhoods after calorie counts were posted. Why? From the anecdotal interviews in the article, it sounds like the customers really just don't care about calories.

Is this the fatal flaw in calorie posting? Are people overeating by ignorance or by choice? The findings raise the unfortunate possibility that the only major accomplishment of posting calorie counts could be saving yuppie dieters some math.

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Tuesday, October 6, 2009

Is there anything the Med diet can't do?

In addition to the cardiac, weight-loss and glucose-control benefits we already knew about, now comes the news that the Mediterranean diet can reduce the risk of depression. According to a Spanish study in the latest issue of Archives of General Psychiatry, "individuals who followed the Mediterranean diet most closely had a greater than 30 percent reduction in the risk of depression than whose who had the lowest Mediterranean diet scores."

So maybe it's not just be the weather that makes southern Europeans so happy. Of course, the researchers might want to be careful in making conclusions about causation, since we have anecdotally observed a certain link between depressive symptoms and the desire to eat ice cream. But this research should fix that. Next time you have a bad day, try comforting yourself with olive oil instead!

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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 Richmond, Va., 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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