American College of Physicians: Internal Medicine — Doctors for Adults ®

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Monday, November 30, 2009

QD: News Every Day--trying for health care reform by Christmas

ACP Internist's daily digest of news and events continues with the crunch to pass a health care bill from Thanksgiving to Christmas. Also, do you know any doctors whose names describe their specialty? We do.

Health care reform
There isn't much consensus among legislators as they take up debate this afternoon on health care reform. But it's a slow start to a process that will take weeks. (Boston Globe, Wall Street Journal)

Outside the beltway, regional providers aren't waiting. Baylor Health Care System in Dallas, Texas, will convert its 13 hospitals and 4,500 network physicians into an accountable-care organization by 2015. The idea is to save money by coordinating all levels of health care. (Dallas Morning News)

In rural Utah, residents are underserved, but don't seem to mind. In Northeast Ohio, doctors and hospitals are ambivalent. Who's clamoring for reform, then? The people who can't afford or access decent care. (Salt Lake Tribune, Canton Repository, Winston Salem Journal, Wall Street Journal)

The Senate health care overhaul has some patient-friendly provisions added on, but also some items that will impact health care providers. In addition to measures that promote breast feeding and adolescent self-esteem, for example, are increases to DXA reimbursement, caps on what hospitals can charge uninsured patients compared to insured ones, and transparency to the prices that pharmacy benefit managers can set. (Kaiser Health News)

In case you missed it ...
Real life doctors' names: urologist Dick Chopp, psychiatrist John Looney, orthopedist Jim Hurt and ophthalmologist Kevin Blinder. Really! (By the way, ACP has two members surnamed "Doctoroff"). (American Medical News)

First-year medical students still dissect cadavers to learn anatomy. Follow them as they make their first incisions in this profile, or learn from paintings more than 200 years old that have stood the test of time. (AP, Philadelphia Inquirer)

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Medical news of the obvious

The holiday hasn't left us much time to find obvious news. But we did find one medical headline that--given the past few weeks of debate--seems like a truly impressive understatement: Breast Cancer Risk Is Not So Easy to Figure Out, according to HealthDay.

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Wednesday, November 25, 2009

QD: News Every Day--quick hits for the holiday

ACP Internist's daily digest of news and events offers a list of quick hits to send you off for the long holiday weekend. We won't be blogging Thursday or Friday but will return with daily updates on Monday, Nov. 30.

The CDC reports a rise in secondary infections with Streptococcus pneumoniae after H1N1 influenza, especially in adults under 60. Anne Schuchat, FACP, director of the CDC's National Center for Immunization and Respiratory Diseases, reminded health professionals and patients of the need to identify and treat such infections quickly. (Reuters)

The U.S. Preventive Services Task Force recently recommended against annual mammograms for women under 50, but even a good percentage of older women are unlikely to be screened. According to U.S. News & World Report, in 2005, only about 72% of those aged 50 to 64 and 65 to 74 had received a mammogram in the preceding two years. The unimpressive rates can be blamed on lack of access and insurance, among other reasons, experts said. (U.S. News & World Report)

The New York Times looks at bankruptcy due to health care costs and how the proposed health care reform legislation would try to address this problem. (New York Times)

How much do we really eat--and travel--for the Thanksgiving holiday? The Wall Street Journal investigates. (Wall Street Journal)

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Tuesday, November 24, 2009

QD: News Every Day--a break in the health care reform action

ACP Internist's daily digest of news and events continues with updates on health care reform, influenza and other news.

Health care reform
With the Thanksgiving holiday approaching, there's not much news out of Washington on the health care reform bill, but it's just the calm before the storm. Debate is expected to start up again on Monday. (Politico)

Influenza
Most of the flu news this season has centered on H1N1, but there's a growing shortage of vaccine for seasonal influenza in one of the populations most vulnerable to it: the elderly. Nursing homes are having a hard time getting enough doses of the vaccine to protect their patients, according to Janice Zalen, director of special programs for the American Health Care Association. Federal officials are now trying to redirect supplies from pharmacies and supermarkets to nursing homes in an effort to alleviate the problem. (New York Times)

In case you missed it ...
Researchers reported today that rates of methicillin-resistant Staphylococcus aureus have increased a dramatic 90% from 1999 to 2006, and that two new community-acquired strains of the bacteria have been identified. The study, published in Emerging Infectious Diseases, looked at data from 300 U.S. labs. (Reuters)

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And the prize behind Door #2 is ...

When I first saw this MSNBC.com story about medical practices with two doors, I thought it was a metaphor. But, no, apparently some practices literally have two doors leading to different waiting rooms: one for insured patients and another snazzier one for cash-paying "boutique" patients.

The MSNBC.com investigation revealed that, as you might expect, the speed, the service and the little touches (spa robe or paper gown?) were crummier on the insurance side. The findings prompted an outraged op-ed from ethicist Arthur Caplan, but I'm a little more undecided about the system.

Sure, I'd rather get an appointment right away and wear a fancy robe, but am I willing to spend my hard-earned money on these perks? Nope. Caplan compares boutique medicine to airlines charging for checked bags, but I think the more accurate parallel in this situation is the choice between economy and first class. If some people want to pay for extra frills, does that have any negative impact on those who don't? In the case of both the flight and the two-doored radiology practice, their payments are helping to support the same infrastructure that everyone else is using.

Obviously, if the cash patients are receiving such a different level of care that they have different clinical outcomes, or the trend catches on so widely that you can't get good quality care without paying a surcharge, that's a different story. Two doors may be more ethically questionable than one, but they sure beat none.

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Monday, November 23, 2009

QD: News Every Day--health reform legislation takes small step forward

ACP Internist's daily digest of news and events continues with updates on the health care reform vote and H1N1 influenza, as well as the USPSTF's breast cancer screening recommendations.

Health care reform
The Senate voted 60-39 Saturday to open debate on health care reform legislation after the Thanksgiving holidays. As expected, the vote was along party lines, with 58 Democratic senators and two independents supporting debate and 39 Republicans opposing (one Republican senator was not present for the vote). But the bill's inclusion of a government-run option threatens the Democratic caucus, today's Washington Post reported. Key Democrats such as Mary L. Landrieu of Louisiana and Blanche Lincoln of Arkansas have said they will not vote for the bill if it includes a public option, while others, such as Sherrod Brown of Ohio, staunchly support the bill as (or nearly as) written.

Debate on the bill is expected to begin on Monday, Nov. 30, and continue through December. (New York Times, Washington Post)

H1N1 influenza
The CDC reported Friday that spread of H1N1 influenza seems to have slowed in the U.S. recently, with 43 states now having widespread activity compared with 46 states a week ago and 48 states at the beginning of the month. However, "it's still much greater than we would ever see at this time of year," Anne Schuchat, FACP, director of the CDC's National Center for Immunization and Respiratory Diseases, pointed out at a news conference. Dr. Schuchat also reported on the improved availability of the H1N1 vaccine--"11 million doses more than we were at a week ago"--and urged people to practice basic infection control measures such as handwashing, especially as the holiday travel season begins. (CNN.com)

In case you missed it ...
Coverage of the USPSTF's new guidelines on breast cancer screening, published in the Nov. 17 Annals of Internal Medicine, continues. The Washington Post features a related Q&A with Kay Dickersin, PhD, director of the U.S. Cochrane Center and the Center for Clinical Trials at the Johns Hopkins Bloomberg School of Public Health and herself a breast cancer survivor, while the New York Times looks at the Task Force members' reaction to the "maelstrom" that followed the guidelines' release. Meanwhile, USA Today interviewed several major insurers and found that as of now, none plan to stop covering mammograms based on the new guidelines. (Washington Post, New York Times, USA Today)

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Medical News of the Obvious

Other reporters may have been excited about the guidelines or trials of new drugs that came out of the American Heart Association's Scientific Sessions, but what really blew our minds was the news that fish is good for you, but not if you deep-fry it.

According to researchers, observation of men in California and Hawaii revealed that the cardioprotective effects typically associated with eating our finned friends were eliminated if you ate the fried, dried or salted varieties. This rings a bell; have we heard somewhere before that fat or salt is bad for your heart? But at least the study had practical application. Since they didn't assess grilled fish, the researchers recommended that you bake your fish, or for a weirder alternative, boil it.

Some additional good news for those who weren't sure whether the Filet-o-Fish or the soy patty was the healthy way to go: the study found that eating tofu also had a cardioprotective effect in all ethnic groups.

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Friday, November 20, 2009

QD: News Every Day--Santa's take on H1N1 influenza, part II

ACP Internist's daily digest of news and events continues with the contentious issues the senate faces for health care reform and Medicare reimbursement, as well as the pecking order for H1N1 flu prioritization

Health care reform
The Senate will vote Saturday whether to proceed with its bill. The issues are contentious: abortion, affluence and affordability, among others. According to ACP Advocate, the Senate likely won't vote on its bill until December, and even after that happens, the two versions will still need to be reconciled with each other and passed again by both chambers. (New York Times, Los Angeles Times, AP, Christian Science Monitor, ACP Advocate)

The House voted to cancel the pending 21% cut to Medicare reimbursement. Now the issue moves to the Senate, which didn't get that accomplished as a single issue when it came up in October. They'll reconsider it as part of overall health care reform legislation.

In case you missed it ...
As we reported yesterday, organizations representing mall Santas want their members added to the priority list for H1N1 influenza vaccination. Now, hog farmers are saying their proximity to pigs trumps the Santa's contact with children. They first want to protect their herd from humans carrying H1N1 influenza. The Santas respond that they should fall in the pecking order when pigs fly, not reindeer.

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Thursday, November 19, 2009

Rethink pink: breast cancer screening evidence met politics and lost

The controversy started at exactly 5 p.m. Monday, when the Annals of Internal Medicine lifted its embargo on new breast cancer screening recommendations and the rest of the medical community simultaneously released opposing positions. With lines drawn and positions taken, a furor began ultimately pitted evidence-based medicine against political machinations. So far, medicine has lost.

Shown is a mammogram of a fatty breast with an obvious cancer, indicated by an arrow. Photo by Dr. Dwight Kaufman. National Cancer InstituteThe recommendations, issued by the U.S. Preventive Services Task Force, suggest that asymptomatic individuals with no family history or other risk factors could wait before starting mammograms and undergo screening every two years instead of annually. They balanced the benefits of less frequent screening against the harms of more frequent screening by reviewing the evidence and creating models.

The recommendations have since been on the pages of every newspaper in America, from the smallest locals to the biggest dailies. The American College of Physicians is tracking "impressions," as they're called, in the millions.

There's always a downside to new knowledge, and it's playing out in week following the announcement. It will take time for physicians to digest the new recommendations. It will take time to explain them to patients. In the meantime, public discourse has been messy.

Experts have told women to talk to their doctors about how evidence-based recommendations apply to individual circumstances. But other medical societies are sticking to their guns on annual screenings at earlier ages, and it's unsettling for patients to see doctors disagree and even more unsettling when shouting matches erupt on television.

But neither the government nor insurers are rushing out to make dramatic changes to existing practice of medicine. To calm fears, HHS Secretary Kathleen Sebelius clarified that the doctors who drafted the recommendations, the U.S. Preventive Services Task Force, comprise an independent body of experts who review evidence but don't set policy. To calm fears, she stated that women should still go to their doctors to discuss their individual needs. Insurers aren't going to change their policies, either.

In short, the recommendations inform the talks between doctors and patients. They give physicians something to consider during the informed consent process. Consider the words of family physician David Baron, MD, who said, "I respect [USPSTF] a great deal. They've got no horse in the race. They are independent experts." Take it from practicing physician Jan Gurley, MD, who summarized in plain language how recommendations should impact encounters between physicians and patients.

This is in contrast to internist and TV commentator Elizabeth Lee Vliet, MD, who went on the attack about a "distant and impersonal 'review of data' from published studies." In an op-ed shopped around to media outlets, she further ranted that, "I am profoundly concerned that government 'experts,' far removed from the daily care of patients, are sitting 'on high' to proclaim that women don't need to start mammograms at age 40."

And of course, Dr. Vliet decried it as a cost cutting measure and as the start of "government-mandated, guideline-based rationing of health care." Those are her poorly chosen words. But she's not alone.

U.S. Rep. Marsha Blackburn of Tennessee bemoaned that, "This is where you start getting a bureaucrat between you and your physician." Rep. Michele Bachmann of Minnesota joined the misinformation brigade, starting her press conference on the task force recommendations by blaming President Obama and Speaker of the House Nancy Pelosi. Watch for yourself.

Hijacking evidence-based recommendations to further partisan debate is a semantic trick. And it's a disgrace.

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QD: News Every Day--Santa's take on H1N1 influenza

ACP Internist's daily digest of news and events continues with the latest progress on health care reform measures in the Senate, and a caution that Santa is looking at who's naughty, nice and vaccinated this year.

Health care reform
After a few quiet days, Senate Majority Leader Harry Reid set up a potential Saturday vote to take the legislation to the Senate floor. According to the Congressional Budget Office:
--the bill would cost $848 billion over the next decade
--the bill would reduce the federal deficit by $127 billion over the first decade and $650 billion over the second decade,
--it would cover more than 94% of Americans, and
--it would reduce the number of uninsured Americans by 31 million.

A wrap-up digests the breaking news from multiple sources. (Washington Post, Kaiser Health News)

In case you missed it ...
He was not saying Momma, Momma by don.wing45 via FlickrThe Amalgamated Order of Real Bearded Santas wants its members to be added to the priority list for H1N1 influenza vaccination, both because of their contact with children and their (likely) obesity. Meanwhile, states' attorneys general are investigating why liquid Tamiflu doses range in price from $43 to $130. That will put some retailers on the naughty list for sure. (New York Daily News, ABC News)

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Wednesday, November 18, 2009

QD: News Every Day--when evidence and politics collide

ACP Internist's daily digest of news and events continues with health care reform and how it intersects with the primary care shortage.

Health care reform
As far as the poll numbers are concerned, the public wants improvements to the healthcare system. (Who wouldn't want improvement, to anything?) But they don't want to pay for it themselves. (Los Angeles Times)

Primary care shortage
While waiting for the Senate to pick up the health care debate, newspapers' opinion sections are humming with analysis. ACP President Joseph Stubbs, FACP, and former ACP chapter governor for Massachusetts, Allan Goroll, MACP, say that health care reform is essentially a discussion of a primary care shortage. ACP's Tennessee chapter governor, Kenneth Olive, FACP, watches as his chapter's members struggle with the issues of cost, access to care, and inadequate numbers of primary care physicians on a daily basis. Sabitha Vasireddy, ACP Member, agrees. For the patients at her free clinic in Danbury, Pa., health care access is just as important as reform. It can't be worse than Oklahoma, which ranks 50th of the states in terms of active medical doctors per 100,000 population and last in primary care doctors. (The Hill, Kingsport Times-News, Danville News, Oklahoma City Journal Record)

H1N1 influenza
Despite an increase in deaths in Canada, official believe flu season may peak there earlier than predicted; 20% of the population has been vaccinated. (Reuters)

In case you missed it ...
Politicians are using evidence-based medicine as political fodder. Monday's announcement in the Annals of Internal Medicine stated that breast cancer screening recommendations should change. Now, opponents of health care reform are using it as evidence of government interference in health decisions--one slim step away from "death panels" and other easily disproven myths. (ACP Internist, Los Angeles Times)

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Ghostwriting haunts Congress' hallowed halls

The U.S. Chamber of Commerce and other business groups are shopping around for an economist to study the impact of current health care legislation and then distribute results that health care reform is a job killer, reports the Washington Post. Joining the U.S. Chamber are some other mighty big names, such as the National Association of Manufacturers.

The U.S. Chamber wanted to hire an economist to study the issue, then get other economists to sign onto the results, and then attack health care legislation in an ad campaign. (Oops, they assumed the economist's results would be unfavorable.) Isn't this like a drugmaker drafting a medical study and then shopping around for a doctor to put his or her name on it?

keyboard ~ blur by striatic via FlickrGhostwriting is a huge problem for the credibility of peer reviewed studies, so why would this be any different? Should we hold economic research to the same standards as other scientific research?

No, because this isn't peer-reviewed. This is politics.

Medical research authors are required to disclose funding for their research. In this case, any economist who might sign onto to the project would have to disclose conflicts of interest with not only the U.S. Chamber, but from the other lobbying groups who contributed to the study (in this case, $5,000 apiece).

Medical researchers are required to report their outcomes, good or bad. But positive publication bias is a known factor in medical research. In the case of the U.S. Chamber, it was questioned whether a positive outcome would be reported. After some hemming and hawing, a spokesman later said it would educate the organization's position.

Any economist who'd sign on with the U.S. Chamber's project would skip the peer review process and enter straight into the hardscrabble world of politics and lobbying. Yes, these lobbyists are entering into the public discourse and trying to influence the outcomes of legislation that impacts every person. But there are different standards for political lobbying groups like the U.S. Chamber than for medical researchers, so it's a bit Pollyanna-ish to expect them to be above board.

Besides, the Chamber's own message boards are clobbering the organization's opposition to health care reform. Check out the responses to a recent Chamber post that chastised the House vote on its legislation. Start here and keep scrolling down as members and small businesses speak their mind.

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Tuesday, November 17, 2009

QD: News Every Day--payment fix inches forward (for this year, anyway)

ACP Internist's daily digest of news and events continues with incremental progress on fixing physician payments, and a double-take on Twitter during surgery.

Health care reform
Health care reform is increasingly unlikely to fix the annual threat of Medicare reimbursement cuts. For this year, at least, the U.S. House is expected to pass its part of the fix on Thursday. (Politico, New York Times)

Instead of a legislative solution, fixing health care will require a profound shift in what patients expect from a doctor's visit. And, the patient-centered medical home has to be at the center of any future health-care system, says one doctor. (WBUR FM of Boston, Indianapolis Star)

There won't be enough doctors to handle the uninsured, said one editorial. But, without health insurance, there are more deaths, said one survey that linked lack of insurance to ED mortality. (Wall Street Journal, AP)

In case you missed it ...
One article questions whether surgeons who broadcast procedures in- step-by-step detail using social media outlets such as Twitter are going too far. When patients do it, too, then maybe it's too much. (Biz Report, ACP Internist)

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Monday, November 16, 2009

QD: News Every Day--not the intended effect

ACP Internist's daily digest of news and events continues with backlash from an analysis of proposed health care reform legislation, voices from middle American and an ACP Fellow's controversial stance on just how much money is wasted in our current health care system.

Health care reform
Medicare's chief actuary reports that legislation in the U.S. House would raise health care costs by $289 billion over the next 10 years and reduce benefits and access to services. (The Hill, Washington Post)

Meanwhile, 43% of Americans oppose the health care plans underway in Congress, 41% approve, 15% are undecided, the latest poll figures show. But opponents are more strongly against it than supporters are in favor, say numbers provided in a study by Stanford University and the Robert Wood Johnson Foundation. (AP/Washington Post)

Peter Reiter, FACP of Ottumwa, Iowa, describes the need for health care in his community, while Robert Vautrain, ACP Member, of Springfield Il., asks for a public option specifically. (Ottumwa Courier of Iowa, State Journal-Register of Illinois)

H1N1 influenza
Airlines are chafing at CDC recommendations that they filter air for H1N1 influenza even while at the terminals. They say it's costly, but just 20 minutes on the ground is long enough to spread the virus. (CBS 11 of Dallas-Forth Worth)

Primary care shortage
Concierge medicine rankles some in communities already stretched by a lack of primary care providers. Read how the controversy is playing out in Waco, Texas. (Waco Tribune-Herald)

Medical education
To accommodate the arrival of the first baby boomers, the American Geriatrics Society is proposing that elder care be added to the list of medical education's six core areas. (Boston Globe)

In case you missed it ...
Richard A. Cooper, FACP, blasts the vaunted Dartmouth Atlas for its statement that one-third of the nation's health care goes toward wasted expenses. He counters that the analysis is unfair toward urban hospitals, which treat more poor who lack primary care. His critics are just as harsh. But Dr. Cooper is not afraid of taking strong, pro-primary care position. He's taken on concierge medicine (opens as 1-hour video) and The Mayo Clinic. (Kaiser Health News)

Is Medicare fraud getting worse, or are the documentation requirements just becoming more onerous? (Washington Post)

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Medical news of the obvious

Sadly, we found no news of the obvious for this week. Maybe that's a good thing for medicine, but it means we don't get to highlight one of our favorite features. Send us your ideas and check back every Monday.

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Friday, November 13, 2009

QD: News Every Day--flu's growing tally

ACP Internist's daily digest of news and events continues with the latest numbers on H1N1 infections, more respect for primary care and a boot-strap approach to health care reform in Kentucky.

H1N1 influenza
Swine flu has killed 4,000 people and sickened 22 million, according to new estimates released this week. More vaccine is on the way; the Food and Drug Administration approved GlaxoSmithKline's vaccines and the drugmaker expects to deliver 7.6 million doses by the end of the year. (Philadelphia Inquirer, AP/The Washington Post)

Evidence-based medicine
One path to less expensive health care is to look at the common tests and procedures that really don't work, or may have adverse effects in patient care. Meanwhile, drugs that were shown to reduce some forms of cancer go largely unused. (Forbes, New York Times)

Primary care shortage
Pauline Chen, MD, (a surgeon) writes that the first way to cure the primary care shortage is to improve its image problem. (New York Times)

In case you missed it ...
Rural Kentucky has high rates of some of the worst health in America. But it also has leading facilities and residents who took a boot-strap approach to health care reform. (Kaiser Health News)

Smoking rates are (slightly) rising again. (Philadelphia Inquirer)

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Thursday, November 12, 2009

QD: News Every Day--no holidays for Congress

ACP Internist's daily digest of news and events continues with Congress' newfound work ethic and how the U.S. kept extra chickens on hand to help with H1N1 vaccine preparations.

Health care reform
Following its Veterans Day break this week, Congress may not make it home for any more holidays. The Senate may work right up until Thanksgiving to work on health care reform, said Majority Leader Harry Reid. Representatives in the House will be kept in session until Christmas, says House Majority Leader Steny Hoyer. (Roll Call, The Hill)

Having trouble keeping track of different versions of legislation in both chambers of Congress? This article breaks down the differences between bills in the House and Senate. (St. Petersburg Times of Florida)

H1N1 influenza
Special flocks of chickens were ready and waiting to prepare more eggs for flu vaccines, if needed. Seriously! Margaret Hamburg, FACP, Commissioner of the Food and Drug Administration, revealed this in a letter to America's health care professionals providing information on the safety of the 2009 H1N1 vaccines.

"Some of your patients may be asking how the FDA, the manufacturers and the scientific community can have confidence in vaccines that were available just six months after the 2009 H1N1 virus emerged," Dr. Hamburg wrote. "Understanding more about the manufacturing and approval process for these vaccines should help you to answer their questions." But why wait for the post office? The letter can be viewed at the FDA's Web site.

More than 41 million doses have been delivered for distribution, but layoffs and furloughs among public health workers have further delayed distribution, Anne Schuchat, FACP, told a Senate health subcommittee hearing. (Reuters)

Globally, China's authoritarian measures--quarantining villages or medically isolating entire planeloads of passengers--worked, officials there said. In contrast, the European Union saw its deaths doubled in three of the last four weeks. (New York Times, Washington Post)

Primary care shortage
In Davenport, Iowa local health officials are trying to encourage more doctors into rural practice, but face hurdles from physicians who fear low pay, lack of training and lack of technology at smaller hospitals. But they try to counter with low cost of living, reimbursement for education and a community lifestyle. (KWQC.com)

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Wednesday, November 11, 2009

QD: News Every Day--dry, boring health care reform? Think again.

ACP Internist's daily digest of news and events continues with how health care reform issues play out in real life, how the next generation of doctors view primary care careers, and how hospitalists are changing primary care.

Health care reform
Health care reform debates might at times seem esoteric, appealing only to economists and actuaries. For political wonks, the issue is about balancing what's possible vs. what's achievable. But the impact of reform plays out in real life and upon real lives, as profiles in Maine show. There, the need for health care reform has never been more acute. (New York Times, CBS News)

H1N1 influenza
Just in time for Christmas: flu vaccines. Drugmaker Sanofi-Aventis expects to ship 75 million doses to the U.S. market by late December, their CEO told reporters. (Reuters)

If a smartphone made its way onto your holiday gift list, an app in development could diagnose colds and flus by how the user sounds when coughing into it. (Daily Telegraph)

Primary care shortage
An internal medicine resident in San Francisco relates his eyewitness accounts of how a lack of primary care plays out in multiple care settings. A University of Alaska Anchorage student chooses to answer the call. (Los Angeles Times, The Northern Light)

Hospital medicine
Winneshiek Medical Center finished its first year with a hospitalist program. The results:
--$72,000 profit,
--decreased emergency room transfers to other facilities of 15%,
--decreased patient length of stays and an increase in observation stays by 65%,
--steady patient satisfaction of 88%, with better discharge timing,
--happier inpatient nurses, and
--approval from primary care doctors and emergency room staff.

But hospitalists aren't universally appreciated. Marcy Zwelling-Aamot, ACP Member in Los Angeles, calls them a "substitute" brought in when patients most need their existing primary care doctor. Her editorial decries all the barriers that create a wall between patients and doctors. (Decorah Newspapers of Winneshiek County, Iowa, Press-Telegram of Long Beach, Calif.)

In case you missed it ...
Do we need health care reform or health insurance reform? More than health care politics, doctors are fed up with insurance companies--paperwork, arguing on the phone, fights for what patients need. Some say they'd take pay cuts if there was a model that let them practice medical care differently. In Connecticut, internists discuss the issue in terms of health insurance reform, not health care reform. (Philadelphia Inquirer, Greenwich Time)

An Indiana health clinic is letting those who can't afford care pay for treatments by volunteering elsewhere in the community. (NPR)

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Tuesday, November 10, 2009

QD: News Every Day--more time, more patients, more quality

ACP Internist's daily digest of news and events continues with a snapshot of health care reform, as well as a look at an ACP member's findings that doctors are spending more time with more patients, and still providing better care across nine quality measures.

Health care reform
The focus has now shifted to the Democrats for health care reform.
--Some Democrats don't think it slows health spending enough.
--Some Democrats think it pits young constituents against elderly ones.
--It's either pragmatic and flexible or just as good as it gets.

As the debate moves back to the Senate next week, there's five "flash points" to consider. (New York Times, Wall Street Journal, Politico, The Hill, Cristian Science Monitor)

Patient encounter
Doctors are spending more time with their patients--21 minutes in 2005 compared to 18 minutes in 1997, reports Lena Chen, ACP Member. And, primary care visits increased 10%, from about 273 million visits in 1997 to 338 million in 2005. Yet, quality is improving across nine performance measures. The population is aging, which requires more time, but also health care in general is more complex now. And, patients are better informed and more engaged. (U.S. News & World Report)

In case you missed it ...
Medical education is changing to focus on health care reform, the patient-centered medical home and patient communication, and leaving anatomy for later. Genetics, demography and the environment are being included. Students are helping design the curriculum, too. What's going on? (Washington Post)

Kaiser Health News looks back to 1977 for a familiar scenario--politicizing living wills that might lower unneeded or unwanted health care use at the end of life.

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H1N1, or how I learned to stop worrying and love the flu

How did I get vaccinated for H1N1? I showed up at a free community health clinic. There were plenty of doses available. I didn't stand in a line. It took me longer to figure out parking than to get inoculated.

With a newborn at home, my wife and I decided to make H1N1 vaccination a priority. We'd already gotten seasonal flu shots and whooping cough updates. But the H1N1 vaccine shortage is well-documented. You need me to Google it for you? Click and pick for yourself from among 739,000 results.

But our family doctor posted a sign that he won't get the H1N1 vaccine at all. Our pediatrician's phone system collapsed under the weight of all the calls for H1N1; we couldn't get through for any reason.

We're not alone. A Harvard poll said that two-third of parents who'd tried couldn't get their children vaccinated.

So when the county announced it would have vaccines available one afternoon, my wife took our older son to stand in line. She arrived just as it started and waited 45 minutes. But by the time she left there was no line, so she called me to come over.

For comparison, here's what happened at a clinic that same day in an adjoining county. Friends of ours got stuck in that mess. Certainly, the death of a teen there spurred a lot of response. And I can imagine that some clinics are better advertised than others.

But by the time I stopped work and slogged through rush hour, the clinic in my county was busy, but there was no waiting. One piece of paperwork later I was getting injected--painless, not counting rush hour traffic. It was a pocket of availability amidst a lot of shortage. My wife wonders if we got a discount version of the vaccine--H1N2. But you can't beat free swag; I even got a nifty, palm-sized can of wipes.

(If you're interested in duplicating my success, WebMD chimed in with ways to get vaccinated.)

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Monday, November 9, 2009

QD: News Every Day--health reform ready to reconcile

ACP Internist's daily digest of news and events continues with updates from the weekend's passage of health reform in the U.S. House, a global look at H1N1 influenza, and a look at a local hospitals attempt to make a profit by hiring an internist.

Health care reform
Health care passed in the U.S. House over the weekend, and now pressure is on to reconcile it all in the Senate and with the White House. (Kaiser Health News, New York Times, Los Angeles Times)

H1N1 influenza
It hasn't been just H1N1 influenza vaccines in short supply. Hand sanitizers are also evaporating in the face of increased demand. One manufacturer is running its plants around the clock with increased workers, and has asked customers not to stockpile. (CNN)

Globally, an Amazon tribe faces hundreds of infected members and possibly seven deaths from H1N1. Meanwhile, Saudi Arabia's health minister received the H1N1 vaccination on television to calm fears and encourage vaccination among those participating in the Hajj, the once-a-lifetime pilgrimage required of Muslims. (BBC, CNN International)

New Scientist examines H1N1's impact throughout history.

Smoking cessation
America's new "anti-smoking czar" lays out his goals as head of the FDA's new agency, the Center for Tobacco Products: reduce youth smoking rates, reduce tobacco-related disease, and inform the public about tobacco products' ingredients. (Courier-Journal, Louisville, Ky.)

In case you missed it ...
Unicoi County Memorial Hospital in Tennessee was losing money. The hospital's auditor helpfully suggested, "We'd always like to see the hospital have an income." So board members hired an internist and a surgeon to join the staff. Read about their gamble to break even. (The Erwin Record)

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Medical news of the obvious

Photo by Kevin Stanchfield via Flickr; www.kevitivity.comMen who get their sleep apnea treated golf better. Twelve golfers with moderate to severe obstructive sleep apnea who started nasal positive airway pressure (NPAP) treatment saw a drop in their mean handicap from 12.4 to 11.0 (P=0.01), compared to 12 controls. The rested duffers said they felt more alert, and NPAP compliance was 85%, said researcher, who added he wants to conduct a larger, multicenter study to explore what drives high treatment compliance. (It must be those really powerful tee shots.)

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Friday, November 6, 2009

QD: News Every Day--waiting for the weekend

ACP Internist's daily digest of news and events continues with this weekend's expected vote on health care reform, H1N1 influenza's ascendance as the dominant strain, and Texas' look at doctor-owned hospitals.

Health care reform
Everyone is gearing up for the expected weekend vote in the U.S. House on health care reform. ACP President Joseph W. Stubbs, FACP, said while the legislation doesn't have every proposal the organiation wants, it "... would represent an historic step forward to achieving ACP's desired future of a U.S. health care delivery system that provides access, best quality care and health insurance coverage for 100% of its people." The American Medical Association is supporting it, with its president saying in a press release that while the legislation is not perfect, "It goes a long way toward expanding access to high-quality affordable health coverage for all Americans, and it would make the system better for patients and physicians."

While the Congressional Budget Office estimates the legislation will cost $894 billion over 10 years and reduce the national deficit by $30 billion, the actuary for the Centers for Medicare and Medicaid Services said he may not have an estimate ready by the weekend vote. While Congress is bound to budget office estimates, CMS figures may sway some votes. (The Hill)

H1N1 influenza
H1N1 influenza is now the dominant strain globally. Obesity may be a factor for complications. More on this will be reported in ACP InternistWeekly on Tuesday. (CNN, CBS News)

In case you missed it ...
This weekend's New York Times Magazine features the debate about evidence-based medicine--clinical judgment squares off against the scientific method, and what happens when doctors at Intermountain Healthcare create their own evidence base.

In Texas, legislators are debating how to treat doctor-owned hospitals. Texas has 67 physician-owned hospitals with about 50 more expected to open, state Rep. Sam Johnson told the Dallas Morning News. While pending legislation would severely curtail existing facilities and prohibit new ones, amendments may grandfather the existing ones. At is issue is whether these facilities cherry-pick the wealthiest patients.

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Thursday, November 5, 2009

QD: News Every Day--health care reform's eerie repeat history

ACP Internist's daily digest of news and events continues with updates on health care reform, "swine" flu in a cat, and two views on fixing the shortage of primary care doctors.

Health care reform
Health care reform is streaking toward a vote in the U.S. House Saturday, but is it just a case of history repeating itself--specifically, the Clintons' 1994 effort? A New England Journal of Medicine paper analyzed 30 public opinion surveys and compared the shift in public opinion, both then and now. (AP, Boston Globe, NEJM)

Waiting in the wings, the Senate's legislation is facing opposition from surgeons and other specialists. (The Hill)

One aspect of health care that needs reform is the practice of defensive medicine. One doctor was profiled about why he encourages patients not to get unneeded tests, and then capitulates if the patients insist. (AP)

Primary care shortage
Op-eds in two major dailies agree that fixing the shortage of primary care doctors is an important component of health care reform. You wouldn't normally expect the Los Angeles Times and Wall Street Journal to agree on anything but the rising cost of newsprint.

H1N1 influenza
Swine flu has jumped from a cat owner to the pet, ABC News reports.

In case you missed it ...
In case the mainstream media misses something, there's always a blogger who digs a little deeper and finds it. Hats off to the person who found this outlier right in the middle of the U.S. House legislation on health care reform--a tax credit for second generation biofuels. (FireDogLake.com)

And, an economist offers "vaguely heretical" musings on the proposed legislations floating around Congress. His social conscience doesn't override his desire to balance the books. (The New Yorker)

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Which patients sue for malpractice?

There are a lot of myths out there about which patients are most likely to sue a doctor for malpractice. Many doctors think it is "poor patients on welfare." They would be wrong. Evidence shows that low income patients on Medicaid are actually less likely to sue than others. But there are some patients and situations that should raise a red flag for physicians that they could bring a lawsuit.

--Angry patients: A patient who is upset about the doctor-patient relationship, either because something didn't work out or they perceived a lack of caring, is more likely to sue the doctor. Plaintiff attorneys say that the majority of their calls come from patients who had poor rapport with their physicians. What works in a medical error? An explanation of what went wrong and, if appropriate, an apology!
--Money Issues: Now that more patients are paying out of pocket costs, if they feel overcharged they become less tolerant of errors. If patients know the approximate costs up front, they aren't surprised and outraged when that big bill arrives. We all know, however, how hard it is to find out anything about costs in advance. Big problem!
--Doctors Dissing Others: So many lawsuits have been filed because of one doctor or nurse making disparaging remarks about another; "How did such a thing happen to you?" It's easy to be a Monday morning quarterback.
--Lousy Service: Bad service goes along with poor doctor-patient rapport. It is hard for someone to feel respected and cared for, if they get bad service or the rooms are dirty or the phone call isn't returned. If a mistake happens, the doctor must be available to discuss it. An absent doctor or poor service turns patients and family members into "angry patients" (see number 1).

Medical mistakes happen because the human body is complex, treatments are complex and there are no guarantees in life. Most patients don't sue their doctors when a bad outcome occurs. The experts in risk warn us that the relationship is the most important prevention for lawsuits, followed by meticulous documentation in the medical record.

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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Wednesday, November 4, 2009

Ties that bind, and make you gag

Here's a complex solution to a simple problem. Doctors wear ties, which may carry germs that may add to the problem of health care acquired infections. British hospitals banned ties. In America, we made them germ resistant.

SafetyTies claims to make ties and scarves with a built-in barrier for dirt, liquids and bacteria. The company describes its "nanotechnology" and cites "independent studies" that show 99.95% resistance to H1N1 influenza.

Whether the ties are attractive enough to wear is a matter of opinion, however. Patterns include those of MRSA microbes and other common germs. Do write us or send pictures if you actually buy one of these and wear it to your health care facility.

"In our effort to stop the spread of H1N1, we need every tool at our disposal," said SafeSmart co-founder April Strider in a press release. "While vaccinations and handwashing are obviously the first line of defense, SafetyTies and SafetyScarves are an easy, sensible and fashionable way for individuals to help reduce the spread of H1N1."

Or, doctors can stop wearing them. We've covered this issue before. ACP Hospitalist has a bit more practical advice from our magazine and our weekly e-news about serious efforts to reduce health care acquired infections. And, others have suggested using dedicated stethoscopes in rooms dedicated to treating resistant infections.

UPDATE: Doctors are buying these ties. Some feel a tie conveys respect to the patient and have chosen to adopt their use.

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QD: News Every Day--health care reform's 'sunshine provision'

ACP Internist's daily digest of news and events continues with findings that N95 respirators weren't all they were cracked up to be, and a look at disclosing more about doctors' financial ties with industry.

H1N1 influenza
Authors retracted findings that N95 respirators were better than surgical masks at preventing flu, causing a stir at the Infectious Diseases Society of America meeting, where the retraction was announced. Reviewers questioned the study, and re-analysis resulted in the findings being no longer significant. The original study spurred guidance from the Centers for Disease Control and Prevention and the Institute of Medicine on using the masks.

Blogger Gerald O'Malley, DO, says that he's not getting vaccinated. Hospital administrators are pressuring him, he sees flu patients in emergency wards and his two kids have it. But he's not budging. Neither are college students. (Physicians Practice, The Washington Post)

"Presenteeism" could exacerbate flu's spread, public health leaders said, since 39% of all private-sector workers do not receive paid sick days, (Bureau of Labor Statistics figure). They also send their sick kids to school because they have to work. (New York Times)

Health care reform
Legislation in the U.S. House could get a vote as early as Friday night, But in the senate, Majority Leader Harry Reid isn't making any promises to pass legislation this year, which could frustrate the White House if it delays health care reform until 2010. (The Hill, CBS News, AP)

One aspect of health care reform legislation includes "sunshine provisions" intended to disclose the financial relationships between the medical industry and doctors and hospitals. It's been tried before, though, and bioethicist Bernard Lo, FACP, argues that sunshine provisions don't go far enough. It needs to include other health professionals, and academic research. A survey in Health Affairs found that 53% of academic research faculty in the life sciences at top schools reported financial ties to industry. (New York Times, Wall Street Journal)

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Tuesday, November 3, 2009

QD: News Every Day--health care reform splits urban, rural hospitals

ACP Internist's daily digest of news and events continues with the focus of health care reform shifting toward the U.S. House of Representatives. Also, urban and rural hospitals eye each other for the lion's share of reimbursement.

Health care reform
Legislation released in the House faces opposition from abortion and immigration. The $1.2 trillion price tag over 10 years made many take a second look at what Americans would get for their money. Meanwhile, the deadline for potentially passing legislation is slipping into next year. (AP, Politico)

Rural and urban hospitals would fare differently under health care reform. For example, New York City facilities are worried about losing money to Iowa; Iowa, in turn, is already worried about subsidizing urban areas. (New York Times, WQAD.com)

H1N1 influenza
Pregnant women and children ages 10-17 need only one dose to inoculate against H1N1 influenza. But children ages 6 months to nine years still need two doses for best efficacy. Anne Schuchat, FACP, reports that half of all vaccinations have gone to minors. While the World Health Organization is recommending one dose for all kids and the use of adjuvanted vaccines to stretch supplies, U.S. officials are still recommending two doses. Adjuvanted doses have not been cleared for use in the U.S. Research on them was reported in the Sept. 15 ACP InternistWeekly. (Washington Post, Washington Times, New York Times)

Scientists have used a supercomputer to predict a third wave of H1N1 coming this spring. But others want to use handheld devices to predict which individuals might get sick before they actually do. (Wall Street Journal)

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Monday, November 2, 2009

QD: News Every Day--the public option as a Straw Man

ACP Internist's daily digest of news and events catches up with newly appointed Surgeon General Regina Benjamin, MD, fears about adverse reactions to H1N1 vaccinations, and why one ACP member says hope for recovery isn't always the best for a patient.

Surgeon General confirmed
Newly confirmed Surgeon General Regina Benjamin said preventive medicine will be her priority, following her confirmation by a unanimous Senate vote late last week. Month before, during a press conference announcing her nomination, she had spoken about losing relatives to lung cancer, diabetes and other lifestyle-related illnesses. (al.com)

Health care reform
For all the fuss over the public option, the Congressional Budget office estimates that 2% of the nation, 6 million in all, would enroll in it. (AP/The Washington Post)

Barry Izenstein, FACP, Governor of ACP's Massachusetts Chapter, writes that health care reform should cover all Americans, create more primary care doctors and reform medical liability. (The Springfield Republican)

Meanwhile, Peter Boling, ACP Member, is undertaking his own effort at health care reform by falling back on the old-fashioned house call. The House and Senate are considering such measures as part of the "Independence at Home" provision of current legislation. (AP)

H1N1 influenza
Independent experts started today tracking adverse events from the H1N1 vaccine to spot any real problems quickly, explain false alarms and separate normal disease rates from potential yet real risks. (AP/Boston Globe) There's a basis to the fear of H1N1 vaccination, and it's generational, says one psychologist. (Psychology Today)

In case you missed it ...
Sometimes, it's better to lose hope for recovery, University of Michigan researchers said.

Peter Ubel, ACP Member, teamed up on a study that noted while it's important not to lose hope, it's also important to realize that hope might make some people unhappier because they fall into a holding pattern of sorts, waiting for their condition or chronic pain to wane before moving on with their lives. They compared outlook among patients who'd just had colostomies. Some were told the procedure would be reversible, and some were told the procedures were permanent. He explains more about hope's "dark side."

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The story of two little pigs

Not surprisingly, flu was a major topic of the IDSA meeting. I'll be writing a full article about the information presented, but in the meantime, a funny story from the CDC about pigs and H1N1. The first two cases of the novel flu were identified in kids in Southern California last April. Both children had been in contact with pigs, so the CDC wanted to determine whether the swine had been the source of the flu.

The 9-year-old girl had visited pigs at the state fair, but when the authorities went there, they found that the pigs had been butchered. The 10-year-old boy had met his pig on a leash at the San Diego Zoo, and when the CDC went to test that pig, they ran into a legal tussle with the zoo. So, concluded CDC expert Dan Jernigan, MD, "This is the story of two pigs--one had been slaughtered, and one had a lawyer."

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Medical news of the obvious

Why are athletes young? Why are couch potatoes out of shape? If questions like these have been plaguing you, not to worry, researchers have the answer.

A new study from the Archives of Internal Medicine finds that "men and women become gradually less fit with age" and that "maintaining a healthy body mass index (BMI), not smoking and being physically active are associated with higher fitness levels throughout adult life."

The study authors also make a pretty dramatic leap from these findings to proposed interventions. "These data indicate the need for physicians to recommend to their patients the necessity to maintain their weight, engage in regular aerobic exercise and abstain from smoking," they concluded. Call me overly cautious, but I think we should see some data from controlled trials first. Bet there'd be no problem finding volunteers for the eating, sitting around and smoking arm.

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Send comments to ACP Internist staff at acpinternist@acponline.org.

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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