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

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Friday, April 30, 2010

QD--News Every Day: What's keeping you busy these days?--part II

Physicians spend nearly 12% of net revenue to pay for the costs of billing third-party insurers, adding to the list of things that keep them working harder than ever, according to a report in Health Affairs.

As reported in yesterday's post, Richard J. Baron, FACP, (a member of ACP Internist's editorial board) tracked for one year the uncompensated tasks he and his colleagues perform every day and was "stunned" by how many calls, e-mails and tests his practice's physicians processed and the administrative tasks required.

Now, researchers said that the administrative end of medical practice is needlessly complex. Of the administrative waste, almost 75% of it can be attributed to the time spent by doctors and their staffs preparing paperwork and contacting payers about prescriptions, diagnoses, treatment plans, and referrals. Most egregious was the examples where practices hired full-time staff solely for referral processing.

Authors suggested that a single transparent set of payment rules for multiple payers, a single claim form, and standard rules of submission, among other innovations, would save $7 billion annually. Each doctor would recoup four hours of professional time each week, and practice support staff would save five hours each week.

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Thursday, April 29, 2010

Primary care shortage expected to worsen

This post by Toni Brayer, FACP, originally appeared at Everything Health.

The new reform law that is called the Patient Protection and Affordable Care Act (PPACA) will be a huge disappointment to the millions of previously uninsured people who finally purchase insurance policies when they try to find a doctor. Primary care physicians are already in short supply and the most popular ones have closed practices or long waits for new patients. Imagine when 2014 hits and all of those patients come calling. Who is going to be available to treat them?

It takes 8-10 years for an under supply of physicians to be corrected because physicians have to go through medical school and residency. There has been no upswing in physicians choosing primary care specialties for years and, in fact, the shortage is predicted to be 46,000 full time physicians by 2025, according to the Association of American Medical Colleges. Now add millions of new patients and baby boomers reaching Medicare and you have a disaster in the making.

I have been sounding this alarm for at least 10 years as I saw what our lack of policy and attention has done to primary care. Comprehensive internal medicine is one of the hardest lines of medicine. Patients are complicated and the work is long and arduous, yet primary care doctors save the "system" millions of dollars. Why it has not been recognized and rewarded in the United States is a mystery, especially when every other industrialized nation has build their health care policy on primary care.

When thousands of new primary care doctors are needed to care for our population, doesn't it seem foolish to cut residency training slots and pay specialists two to four times as much? Some suggestions at this late hour are to use nurses or physician assistants to fill the gaps. Others have suggested shortening the residency time. Both are terrible ideas for our population as medicine is becoming more complicated, not less.

I watched as anesthesiology and radiology became the most sought after residencies. I don't think there was a sudden interest in putting patients to sleep or reading X-rays in the dark all day. When I was a senior resident an anesthesiology friend encouraged me to switch immediately to anesthesiology. He said "You'll work half the time and make four times the money." He was right and I saw what happened in the years to follow.

What can we do today?
--Increase primary care residency program slots effective 2011 at teaching hospitals and pay more for those programs to increase.
--Enact forgivable loans for all medical students who choose primary care and practice it for at least five years. You can't enslave people forever.
--Raise the Medicare reimbursement by ... oh, let's say, 40%. Even that may not be enough to turn this ship around. The inequities are just too large.
--Allow even higher reimbursement for primary care doctors who practice in rural communities or underserved areas. The pressures in those areas are magnified and should be rewarded.
--Develop true systems of care where physicians treat the most complicated patients and nurse practitioners handle routine care.

It is time to quite admiring the problem and get to work solving it.

Toni Brayer, FACP

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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QD--News Every Day: What's keeping you busy these days?

Richard J. Baron, FACP, (a member of ACP Internist's editorial board) used his electronic health record system to track for one year the uncompensated tasks he and his colleagues perform every day at his five-doctors practice, Greenhouse Internists in Philadelphia.

--Calls averaged of 23.7 per physician per day: 35.7% for an acute problem, 26.0% for prior authorizations or documents for insurers or employers, 6.3% for consultations, 17.5% test results, 9.5% for advice for clinical decisions faced by patients, and 5.0% were for clinical follow-up.
--E-mails averaged 16.8 per day: 59.3% to interpret test results, 21.7% for patient responses, 9.3% for administrative problems, 5.0% for acute problems, 2.8% for proactive outreach to patients, and 1.9% for discussions with consultants.
--Refills averaged 12.1 prescriptions per day, excluding those handled during visits or calls for other issues, but each requiring chart review.
--Laboratory reports averaged 19.5 per day, each requiring a response, analysis and possible medication adjustment.
--Imaging reports averaged 11.1 per day, usually requiring patient communication and work-ups.
--Consultation reports averaged 13.9 per day, with more work required.

Before the EHR, a nurse handled such tasks. The practice implemented its EHR and the nurses' job fell to non-clinical staffers. Now, they have so much information, they hired an RN for "information triage" of lab reports, calls and consultation notes.

Dr. Baron told the Washington Post that he was "stunned" by the numbers he uncovered. How do his compare to your practice? Let us know.

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Why We Need Private-Practice Primary Care Doctors

This post by Rob Lamberts, ACP Member, appeared at Better Health.


A recent post on KevinMD by Joseph Biundo, a rheumatologist, challenged my assertion that primary care doctors can save money. In reference to my claim:

That may be true in theory, but I see patients in my rheumatology office every day who have been "worked up" by primary care physicians and come in with piles of lab tests and X-ray and MRI reports, but are diagnosed in my office by a simple history and physical exam.

Prior to that, an article in the New York Times along with a post by Kevin Pho noted the fact that more solo practitioners are leaving private practice and joining hospital systems. Why are they doing this?

Dr. Kevin suggests the following:

Lifestyle matters. More doctors are entering the workforce seeking part-time jobs in order to maintain a family balance. By removing the administrative hassles from their plate, they can go back to focusing solely on practicing medicine and coming home at a reasonable hour.

The NY Times article suggests possible benefits to patients:

In many ways, patients benefit from higher quality and better coordinated care, as doctors from various fields join a single organization. In such systems, patient records can pass seamlessly from doctor to specialist to hospital, helping avoid the kind of dangerous slip-ups that cost the lives of an estimated 100,000 people in this country each year.

So as a primary care doctor in private practice, am I soon to go the way of the dinosaur? Is this simply a shift in the business model as demanded by the times, or should people be concerned? Would the system function better with fewer primary care doctors or ones who are employed by large hospital systems?

Those who read my blog regularly already know my answer. Private primary care is essential for a healthy health care system.

Why primary care?

While I can't disagree with Dr. Biundo on his point regarding the physical exam skills of primary care physicians (PCPs), I do disagree that this raises question of the cost-effectiveness of primary care. In his case (the practice of rheumatology), there are few expensive procedures, the diseases are less common (compared to fields like cardiology and other high cost specialties), and the patients don't spend a high number of days in the hospital. One overnight stay for a cardiac catheterization will pay a large part of a rheumatologist's salary for a year.

Like primary care, rheumatology is largely an outpatient practice, with success being measured by the ability of the practitioner to keep the patient out of the hospital and away from expensive procedures. Lately, rheumatologists have started having biologic medications (like Enbrel) that are quite costly, but the number of people on this relative to the general public is still quite small.

Primary care, on the other hand, is the fountainhead of all health care costs. A good PCP is also measured by patients staying out of the hospital and away from expensive procedures. In general, a PCP is less likely to:
--order an X-ray compared to an orthopedist,
--get an EKG compared to a cardiologist, or
--order an endoscopy compared to a gastroenterologist.

There are some high-consuming primary care doctors, but much of the blame for this can be placed on the payment system that encourages expensive procedures and the ordering of tests. For example, one of the PCP groups in our area has their own stress-testing equipment and CT scanner. I am 100% sure that the physicians in this group order many more CT scans and stress tests when compared the physicians in my practice. I am also sure that the care quality in my practice does not suffer from our lack of test-ordering.

Why? Because the physicians are financially motivated to order these tests, making the appropriate business decision clash with the appropriate medical decision. As long as it's not harmful to order the test, the doctor can justify it.

Even these physicians, however, are not going to do any of these tests as much as a specialist, who depends on the presence of chronic disease to make a living. The only specialists I have seen who are slow to order tests and procedures are those who don't financially profit from their ordering: academic specialists.

Why private practice?

This brings me to my second point, which is the necessity of having primary care physicians who are in private practice.

Why do hospitals have an interest in hiring primary care physicians? The answer is twofold: first, they allow them to negotiate contracts with the insurance companies in a position of strength. Primary care is a must for most insurance contracts. Patients will change insurance plans if their PCP is not on the plan, but they won't do so nearly as much for specialists (with the possible exception of OB/GYN, which often act as PCPs) or hospitals. Plus, most insurance plans do their care management by requiring referrals, denying or accepting them being their means of cost control. Primary care physicians are the referring physicians, and without them the hospital's negotiating power is greatly diminished.

The second reason hospitals want PCPs under their wing is that they generate business by ordering radiology tests, lab tests and sending patients to specialists who will do expensive procedures in their facilities. Primary care is a loss-leader to hospitals. Hospitals make no money off of their PCP practices directly but make a huge amount from the referrals and procedures they generate.

This shifts the mission of the PCP. The "success" of the PCP in the eye of the hospital system is not to avoid referrals or costly procedures, but to order them. It's not bad in the eye of the hospital that the PCP has higher hospitalization rates; it's better.

The answer

The solution from an overall cost standpoint is to give primary care physicians incentive to do what they should be doing in the first place: Keep people healthy and away from hospitals. Any system that places too much value on procedures is going to fail at this, as the institutions and individuals who profit off of the procedures are going to fight for control of PCPs. Independent PCPs who profit from keeping people well are the best thing for a system.

I have lived in both worlds, as a private PCP and as a salaried physician from a hospital. I left the latter because it was clear that they had no interest at running my practice well and really just wanted me to be a turnstile into their money-making procedures. It would be a big mistake to take away the one specialty that restrains cost. We need to do the opposite and encourage good primary care medicine.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Wednesday, April 28, 2010

QD--News Every Day: Consumers losing confidence in health coverage

A newly created index of consumer health care confidence has fallen steadily this year, reports The Thomson Reuters Consumer Healthcare Sentiment Index. Consumers report declining confidence in their ability to access, use, and pay for health care. The index, set at a baseline of 100 in December 2009, is now at 97.

More consumers reported difficulty paying for services and insurance, or reported a reduction/cancellation of their insurance. More delayed or failed to fill a prescription in the past three months, or canceled a diagnostic test (such as blood work, X-ray or mammogram.

Further, consumers expect the situation to worsen in the next three months, including putting off elective surgery.

Thomson will report figures monthly and has published their methodology online.

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Tuesday, April 27, 2010

One more update from IM10

I was looking through my notes from Internal Medicine 2010, and I realized that I never got a chance to blog about the session on ADHD. It was well-attended and the attendees seemed nearly unanimous in their desire for instructions on treating one particular patient: the adult who comes in, says he or she has been diagnosed and treated for ADHD before, and wants you to write a script for stimulants.

It's a tricky business, said presenter Jeffrey M. Levine, ACP Member, because ADHD in adults is hard to diagnose and the drugs have potential for abuse, especially among college students and Wall Streeters.

He offered some tips:

  • He starts patients on buproprion, even though it doesn't seem to have much effect on ADHD. "It never works but it buys me time to get to know the person."
  • Given the example case of a patient who demands Concerta (methylphenidate), he would prescribe a little and schedule him to come back for a consultation.
  • To prevent abuse, "Most docs will say something like this, 'I can fill one prescription one time early, but that's it. If you lose it, you lose it.'"
  • And an interesting anecdote about ADHD diagnosis in childhood. Apparently Michael Phelps' doctor wanted to put him on Ritalin. Instead his mom said, "I'm going to take him to swimming class and see if he does better," Dr. Levine reported. That treatment seems to have worked out for him.

And while we're on the subject of mental health, a tip about suicidal patients. Suicide contracts have shown little effectiveness, so Dr. Levine urges physicians to approach the issue from the opposite direction. "Ask the patient, 'What keeps you going? Why should you live?'" Obviously, if the patient doesn't have any good answers, you should be worried.

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QD--News Every Day: Triple threat lurking in American population

The CDC put some numbers on how many Americans have the triple threat of high blood pressure, high cholesterol and diabetes, the three conditions associated with heart disease, which in turn is the nation's #1 killer.

That number is 45%. Nearly half of us have at least one of the three.

The Centers for Disease Control and Prevention issues its report to compare prevalence across ethnicities, based on its National Health and Nutrition Examination Survey, a series of at-home interviews, standardized physical examinations and lab tests on blood and urine. Among the findings:
--One in eight adults (13%) had two of the three conditions; and 3% of adults had all three;
--Nearly one in seven U.S. adults (15%) had one or more of these conditions undiagnosed;
--Blacks were more likely than whites and Hispanics to have at least one of the three conditions, either diagnosed or undiagnosed;
--Blacks and whites were more likely than Hispanics persons to have both diagnosed or undiagnosed high blood pressure or high cholesterol. Blacks and Hispanics were more likely than whites to have both diagnosed or undiagnosed hypertension and diabetes.

One of the study's authors, epidemiologist Cheryl D. Fryar of the CDC's National Center for Health Statistics, told the Los Angeles Times that while the figures are entirely expected, the report "crystallizes exactly what the burden is."

That burden, she continued, is caused by individual choices: smoking, junk food, inactivity and obesity.

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Monday, April 26, 2010

QD: News Every Day--Vermont doctors spurning gifts they'd have to report

Vermont doctor's accepting pharma marketing largesse has declined 13% in the past three years, following the state's 2002 passage of a law that requires physicians to report gifts. A new federal law might have the same effect. The Physician Payments Sunshine Act requires doctors to report gifts, stocks, grants, speaking fees and travel reimbursement and see their names reported online in a searchable database beginning in September 2013. Exempt from this rule are PAs and NPs, who are clamoring for the power of the pen and likely to get visits from pharma reps when they do. Even pharmacists and optometrists are taking on more of a primary care role, as educators take a serious look at promoting providers who aren't physicians. (Kaiser Health News, ACP Internist, Richmond Times-Dispatch, Health Leaders Media)

Medicare news
Health care reform could extend Medicare's solvency by 12 years, until 2029, but may also push 15% of Medicare hospitals and other providers into the red, the Health and Human Services department's Office of the Actuary reported last week. Adding 34 million more enrollees to Medicare and Medicaid will increase spending by slightly less than 1%, or about $311 billion. (McKnight's Long-Term Care News & Assisted Living)

Rural physician shortage
Texas Tech is starting the first program in the country to graduate family physicians after three years of medical school and three years of residency to fill gaps in the state's rural areas. At issue is whether the shortened time span allows students enough time to learn the wide scope of knowledge needed to properly practice. But recruitment is tough and 27 Texas counties have no doctor at all. In one such area, a local rancher runs a mobile clinic staffed with nurses and a nurse practitioner. It's a problem in any rural area, including rural Kentucky. (Columbus Dispatch, Christian Health Center (blog), Louisville Courier-Journal)

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Saturday, April 24, 2010

Guys, you missed out.

Since very few male internists attended the session on Contraception this morning, I thought they might want to know what they missed. A few key points:

IUDs are great, so use them. "We are going to urge you to think about an IUD in any woman who doesn't want to be pregnant for a year and a half or longer," said one of the presenters. (Apologies to Anne Eacker, FACP, and Eliza Sutton, FACP, but I forgot to write down which of you was which.)

Don't be fooled by the commercials for Yaz. Although it's the most popular pill on the market, the evidence indicates that it's not any better than the similar alternatives. And if you have a patient who actually has premenstrual dysphoric disorder (which is way less common than PMS), try an SSRI first, the experts said.

Oh, and one more funny note: Despite what you may have heard (personally, I hadn't) Coca-Cola douching is not an effective method of contraception, for many reasons, including that putting all that glucose in the vagina is not a good idea. "One possibility would be to use Diet Coke," said one of the presenters. (She was kidding!)

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Friday, April 23, 2010

Silence, please

A post in which I reveal that I am a crabby old lady:

During the session on IMGs, Gerry Whelan, MD, offered some general tips on proper behavior that apply to both IMGs and U.S. grads. Among those tips was this advice: during conferences, put your phone on silent, and don't talk or text.

Not a minute later, a text beep went off two rows in front of me. And not only did the young woman read it, but she consulted with her neighbors on it, passing the phone around. Then five minutes later, someone else's phone rang. Grrr.

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Fast facts about heroin

From this morning's session on treating illicit drug users (led by Jeffrey Samet, FACP):

  • Why is heroin so pleasurable? In part, because it crosses the blood-brain barrier super-fast--within 15 seconds
  • After being administered by IV, 68% of heroin reaches the brain, compared to less than 5% of morphine
  • Within a half hour, heroine is metabolized to morphine
  • The annual mortality rate of injection heroin users is 2%; half of these deaths are due to overdose
  • Overdosers are most likely to be in their late 20s to early 30s; be experienced users (using for 5-10 years); and be users of multiple drugs (like benzos and alcohol, in addition to heroin)
  • High-risk periods for overdose are the first 12 months after addiction treatment (because tolerance is low, so relapsers are overwhelmed when they take their 'usual' dose) and the first two weeks after release from jail, for the same reason.

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Is Garrison Keillor part of your GME?

I just attended fascinating session offering advice to international medical graduates on how to fit in and succeed in U.S. medical practice. Expect an article on it eventually. But in the meantime, here's a slightly silly example of the kind of cultural differences that can cause confusion for IMGs. Speaker Vijay Rajput, FACP, started to make a point using the good old analogy of Lake Wobegon. Then he paused and asked how many attendees knew about Lake Wobegone. Only two raised their hands.

That's the problem right there, he said, only half-joking. "You need to be listening to NPR!" Clearly it takes a lot to become an American and a doctor at the same time.

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Tips on performing a urinary stress test

At a 7 a.m. session today on urinary incontinence in women, Neil M. Resnick, FACP, offered the following advice on performing a urinary stress test in the office:

--The bladder should be full, but the patient should not have an abrupt urge.
--The pelvic muscles should be relaxed (check the gluteal creases).
--The cough should be single and forceful.

With a positive test, the patient will instantly leak and the leakage will immediately cease. With a negative test, there will be no leak or a delayed leak with 150 to 200 mL or more in the bladder. Dr. Resnick noted that the test should replicate the symptom or symptoms that led the patient to present for examination.

He also emphasized the importance of asking patients to keep a voiding diary for at least three days. One of his patients, a 58-year-old woman, did so and found that her incontinence always occurred at around 1:00 in the morning. The cause, Dr. Resnick determined, was a generous nightcap she drank before bed.

"She didn't need something for her bladder. She needed to quit drinking," he said.

The patient wasn't happy with this solution, but she agreed to try it, and even bet Dr. Resnick a case of beer on it. "To this day, I still, once a year, get the case of beer," Dr. Resnick said. "This has been six years, and she's been completely dry for six years."

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Those lucky Canucks

If any meeting attendees have been considering staying permanently in lovely Toronto, the young Canadian doc who asked a question during the Washington Update this morning probably heightened their interest.

He's a recent IM grad, who actually works in Montreal, not Toronto. But he said that he left med school with $2000 in profit, and he and his peers are likely to make between $200,000 and $700,000 next year!

His question, effectively, was why don't we do that in the U.S.? He wanted to know whether ACP had considered single-payer as a solution to the health care system problems. The ACP officials' answer: Yup, but it was clear that the idea doesn't fly politically in the states.

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The limits of empathy

Perhaps you heard the soft strains of jazz drifting from a conference room Thursday afternoon. That was the session "From Jazz to Medicine: Exploring Improvisation in Clinical Practice." Attendees learned some patient communication skills, heard some great jazz, and came to understand the parallels between the two activities.

The musical interludes gave me time to think about communicating with empathy, one of the principles of the session. We watched a video in which a physician elicited a patient's chief complaint with questions like "Tell me about yourself" and by repeating everything the patient said back to her again and again.

If I were the patient, I would have wanted him to throttle him. Is there such a thing as being too empathetic? And does empathy really work if you're putting it on as a strategy? Motivational interviewing makes sense and is evidence-based for mental health issues, but is it really necessary for treating a cough?

I have to admit I might have learned the answers to these questions if I had stuck out it out to the end of the session, but I ducked out early. I was impatient to review the slides for the session on ADHD. Ironic?

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Thursday, April 22, 2010

Pediatric diseases, adult patients

At a Thursday session on caring for adult survivors of pediatric diseases, Bradley J. Benson, FACP, and Niraj Sharma, FACP, had some interesting statistics to share. For example, more than 90% of children with a chronic or disabling health condition are expected to live more than 20 years, meaning they’ll eventually need an internist’s care, and more than 500,000 children with special health care needs turn 18 every year. As Dr. Sharma noted, “We’re not talking about a handful of folks.”

Some other statistics:
--Approximately 50% of patients with cystic fibrosis are 21 or older.
--More than 80% of children with spina bifida reach adulthood.
--80% of children who get cancer will become long-term survivors.
--20% of female Hodgkin’s survivors develop breast cancer by age 40.

Drs. Benson and Sharma stressed the importance of developing a comprehensive plan to transition survivors of childhood diseases from pediatricians to internists, something the patient-centered medical home concept could help accomplish.

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Not everyone wants to live in a PCMH

In the midst of a comment so critical of the College that her attendance at the meeting was somewhat surprising, a questioner in a session this morning offered this quip: "I see no future for the medical home, which is really the medical orphanage."

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Grab the pens while you can

If you make your way to the exhibit hall today, grab any free pens you can. Swag is about to become scarcer following the passage of stricter ethics codes adopted by medical groups, including the American College of Physicians.

The Council of Medical Specialty Societies (and ACP) formally adopted new rules intended to limit the influence of drug and device makers. The rules suggest that medical societies:
--publicly post industry support, including for continuing education
--decline industry funding for developing medical practice guidelines and require most members of a guidelines panel be free of industry ties,
--disclose the financial ties of board members and journal editors have with companies, and
--ban company or product names and logos from conference swag.

Do you recognize this pen? by Plutor via FlickrSo, make a note of this ... if you can find a pen to do it with.

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Wednesday, April 21, 2010

A cardiological mystery

Why does everyone (or at least two speakers I saw today) who discusses electrocardiograms put ECG on their slides and then say EKG?

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Yum.

The Toronto convention center may be unwieldy in size and design. (I've already set a personal best for escalators ridden in a single day.) But having a food court with lots of healthy options right across the street makes it one of my favorite conference locations (take that, San Diego).

It's particularly helpful when you've just spent the day learning cardiology, hearing tons of stats on the effect of healthy lifestyle on cardiac risk. Specifically, a prospective study found that not smoking, not being fat, eating your veggies and working out reduced cardiac events by 40%, explained Steve Kopecky, FACP (whose own successful lifestyle changes were recently reported in the Wall Street Journal).

Sounds like evidence for making that next escalator ride a stair climb. Except...Dr. Kopecky also showed us how a few days of exercise can dramatically reduce triglyceride levels. So maybe it can wait until next week.

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A pearl for you

I have to admit that this piece of advice went a little bit over my non-doctor head, but presenter Howard Weitz, FACP, promised attendees that this would be the best clinical pearl they'd get all meeting. So here goes:

When doing a preoperative cardiac evaluation, keep in mind that if a patient has severe mitral regurgitation, that will actually increase their ejection fraction. So a normal ejection fraction in this case should not make you complacent, and a low one should really make you worry.

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Did someone really just rip on Vitamin D?

It's such a rarity these days that I almost couldn't believe my ears when one of the cardiology lecturers (it was during the question and answers so I didn't catch which one) came out against no-questions-asked Vitamin D supplementation.

After a European study found a possible risk of increased cardiac events, he's advising caution. "I wouldn't just jump on the bandwagon." Of course, the next questioner proceeded to jump on him-- pointing to the Vitamin D insufficiency "epidemic."

The cardiologists were big on another trendy supplement, though. Fish oil got their stamp of approval.

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Internal Medicine 2010: Precourse funnies

Here's the first of many posts from Internal Medicine 2010 in lovely Toronto, Canada. The official meeting starts tomorrow with precourses today.

As you'd expect during a cardiology lecture, Steve Kopecky, FACP, reviewed lots of studies known by cool acronyms. He also explained why picking an inspiring name like COURAGE is important for your trial, based on his attempt to recruit a patient for the BARI trial.

"Oh no, doc, you ain't going to bury me," the patient replied.

Because that joke was funny, I'll forgive Dr. Kopecky the implied insult with which he began his lecture. "The Wall Street Journal's become one of the best medical journals you can read." Harumph.

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QD: News Every Day--Survey says ...

Two surveys out today take the temperature of the primary care working environment.

In the first, recruiters took a median of six months days to fill positions for internal medicine or family practice physicians, according to the In-House Recruitment Benchmarking Survey: 2010 Report Based on 2008 Data.

The report is a collaboration between the Medical Group Management Association and the Association of Staff Physician Recruiters. Among the findings:
--It cost less to recruit specialists, due to the economic downturn and a 30% rise in the use of Internet job boards as a primary recruitment method.
--It takes longer to fill a position in non-metropolitan areas, where the impact of the primary care shortage is greatest.

The second may be news of the obvious; physicians feel that defensive medicine hampers their ability to deliver care. But to quantify how much so, Jackson Healthcare, a recruiting and hospital management group, conducted its third survey. The company compiled 1,400 physician respondents (124,572 invited; 1.13% response rate; 95% confidence level: +/-1.7%) of doctors who'd participated in a confidential online survey in an effort to quantify the costs and impact of defensive medicine.

Among the results:
--76% reported that defensive medicine decreases patients’ access to healthcare.
--72% reported that it negatively impacts patient care.
--71% reported it has had a negative effect on the way they view patients.
--67% reported that defensive medicine comes between the doctor and patient.
--57% reported that defensive medicine hampers their decision making ability.

EDITOR'S NOTE: QD: News Every Day will resume publication on April 26 following our live coverage from Internal Medicine 2010 for the rest of this week.

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Tuesday, April 20, 2010

Hospitals: Check doctor's communication skills before buying the practice

This post by Steven Wilkins, MPH, appeared at Better Health.


Hospitals today are aggressively buying physician practices in their local markets. Why? Hospitals want to solidify their referral base for inpatient and outpatient referrals as well as increase their negotiating power with insurance companies.

Over 50% of physician practices are now owned by hospitals, according to the Medical Group Management Association. As such, many one-time private practitioners are now hospital employees.

Having done physician recruitment in a prior life, I know that before buying a practice that hospitals look at a variety of things including the practice's patient volume, number of hospital referrals, estimates of patient turnover, and so on. One of the things we did not consider years ago in evaluating and buying a physician practice was the quality of the physician's patient-communication skills and supporting practices. I doubt that things have changed much since.

Hospitals today are under a lot of pressure from Medicare to address inpatient medical errors that compromise patient safety and often result in costly re-hospitalizations. As the line between doctor and hospital becomes blurred clinically and legally, hospitals need to start paying close attention to the way their doctor-employees communicate or don't communicate with patients.

Consider the problem of medication errors
Miscommunication between doctor and patient is thought to be a leading cause of such medication-related errors as patients not knowing:
--the names of all the prescribed medications they are taking
--indications for using or not using the medications
--dosage and frequency instructions

According the Institute of Medicine, approximately 500,000 drug errors or adverse drug events are reported every year in doctor's offices and other outpatient settings.

In fact, the evidence suggests that medication-related errors in ambulatory care settings may be substantially under-reported. Consider a recent study of patients prescribed a blood thinner, warfarin. Among older patients, warfarin and similar oral blood thinners account for 10% of all preventable adverse drug events. In this particular study, 50% of all patients differed from their doctor in term of understanding how they we supposed to take the medication. In other words, one-half of the study population was taking a warfarin, a medication with serious side effects, incorrectly.

These finding are consistent with another 2006 study of physician-patient communications during primary care visits in which the physician prescribed a new medication. This study found that physicians:
--did not tell the patient the name of the new medication in 26% of the cases
--did not explain the purpose of the medication to patients in 13% of cases
--did not tell patient about adverse side effects of the medication in 65% of cases
--did not describe to patients how long to take the medication in 66% of cases
--did not tell patients the number of pills to take in 45% of cases
--did not tell patients about medication dosing and timing in 42% of cases

Doctors rely on patients to accurately tell them what prescription medications and what dosages. In instances where the patient sees another doctor unfamiliar with their medication history, not knowing the name or dosage of a medication can cause serious problems. This is because "the other physician" may unknowingly prescribe a course of treatment that may have an adverse interaction with the patient's primary course of treatment.

Failure to inform patients about abnormal test results
Failure to inform a patient of an abnormal outpatient test result is another example of a serious error. The "failure to inform" rate was estimated at 7.1% in a 2009 study of 5,434 older adults in 23 primary care practices. "Failure to inform" rates for practices in the study ranged from a high of 26% to 0%. In cases like cancer where time is of the essence, any delay in treatment can have serious consequences for the patient.

Today hospitals are under pressure from regulators and payers to clean up their act with respect to inpatient quality, safety and outcomes. As hospitals employ more one-time private practitioners, the list of quality, safety and outcomes issues faced by the hospital will grow to include issues like those described here, issues previously handled by physicians in their own office.

My advice to hospitals? Know exactly what you are buying. Conduct a communications audit of the physicians in the practice before you buy. You will be glad you did.

Sources:
Schillinger, D. et al. Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words? Advances in Patient Safety. 2007.
Tarn, D. et al. Physician Communication When Prescribing New Medications. Patient Education and Counseling. 2008.
Casalino, A. et al. Patient-Physician Communication about Out-of-Pocket Costs. JAMA. 2003.
Casalino, L. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Archives of Internal Medicine. 2009.
Preventing Medication Error. Institute of Medicine (IOM). 2006.


This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--Stick to the script

E-prescribing rates tripled last year to 191 million transactions, excluding refills, according to the company that acts as the clearinghouse for handling them. Coming soon is the long-sought ability to send narcotics and other controlled drugs that Drug Enforcement Administration rules had previously required to be written to a pad. The trend comes at a time when U.S. prescription drug sales climbed 5.1% last year, compared to 1.8% in 2008. (Wall Street Journal, Reuters)

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Consumer-driven health care: Is price shopping the answer?

This post by Davis Liu, MD, appeared at Better Health.



In a recent TIME magazine article, the author suggests, as many others have done in the past, that forcing patients to be more like customers and comparison shop will drive health care costs down. Nothing could be further from the truth.

The theory of consumer-driven health care goes like this: If there was more information about the costs of doctors, hospitals, imaging tests, and procedures, people would hunt around to find the best deal, stimulate competition and drive pricing downward.

photo by by planetwrite via FlickrProponents always point to the example of how LASIK eye surgeries have gotten less expensive because of price transparency and increased competition as more eye doctors enter the market in what used to be a very expensive procedure. But this is always the only example that they give. They fail to demonstrate how price transparency alone results in decreased costs.

Look at elective plastic surgery which, like the LASIK example, has doctors providing a service which isn't medically necessary. Shop around. Get pricing. Has plastic surgery gotten less expensive like LASIK surgery? Of course not. Why?

In the past, LASIK eye surgery required the very skilled hands of an ophthalmologist. Over many years, however, understanding precisely who made a good candidate and the optimal surgical technique to be used become more clear. Consequently the procedure became standardized. As a result, these days LASIK surgery is typically performed by a machine that is essentially automated under the supervision of an ophthalmologist. Because of this standardization and precision, LASIK surgeries are done more reliably and quickly for those who are good candidates. For those of us who have conditions that don't fit into this neat workflow, we will still need to rely on the human doctor's expertise and experience. In those situations, the pricing won't be inexpensive.

It isn't price transparency alone that will drive costs down, but the standardization of treatments for a particular ailment. Specific treatments for bladder infections (urinary tract infections), sore throat, like strep throat or mono, pink eye (conjunctivitis) are fairly clear cut and straight forward. This is why walk-in clinics like Minute Clinic can drive costs downward using less expensive physician assistants and nurse practitioners, rather than doctors. For sore throat, the workflow is pretty obvious (and available at www.familydoctors.org).

Note how they avoid back pain and chest pain. It may be for liability issues, but also because the amount of precision needed isn't quite there. Once medical science can determine which tests or interventions can reliably differentiate a symptom or problem into a specific treatment will costs come down. This is probably why plastic surgery won't quite ever become a commodity like LASIK surgery. How would you like to have a standardized nose job or face lift?

Proponents of consumer-driven health care also believe that having patients pay more of their health care expensive or "having more skin in the game" will also drive costs down over the long-term. The thinking goes that if people understood the high costs of having a chronic illness like diabetes or heart disease, they would choose healthy behaviors. They should appreciate that preventive interventions like cancer screenings were less expensive than dealing with a cancer diagnoses and subsequent treatment. Getting a simple vaccination to prevent influenza or pneumonia would be far better in preventing emergency room visits or hospitalizations. People would begin to make rational choices and opt for less-costly therapies today to put off very expensive theoretical losses in the future.

Odds this will occur? Highly unlikely.

Simply look at how the American consumer fared when given financial responsibility to make decisions presumably for their best interest, retirement planning, to determine how successful the public might be in embarking on consumer-driven health care.

Starting in the 1970s, employers started to shift employees from pension plans (defined benefit plans) to 401(k) plans (defined contribution plans), where employees would have more financial responsibility and have "more skin in the game" in determining how much to save and how to invest for retirement. The thinking was that employees, looking out for their best interest, would do research and demonstrate the rational behavior needed to ensure that they retired with a nest egg that suited their needs. After all, who would have more motivation to save for retirement than the individual himself?

Did it work out as planned?

A recent article from CNN Money found that 43% of Americans have less than $10,000 saved for retirement. More importantly "the gap between what Americans have saved and what they'd need for retirement is forcing workers to prolong their working years."

In other words, the American consumer isn't doing well to save for retirement even though it is in his best interest. At least in retirement planning, consumers have the option of delaying retirement and working longer.

Consumers as patients, however, won't have that luxury of putting off medical care if they suddenly become ill. It is very likely a large number of Americans instead of losing weight and controlling blood pressure will have a devastating heart attack that requires open heart surgery. Colon cancers will be detected at later incurable stages requiring very expensive chemotherapy for months rather than having been removed years earlier with less costly colonoscopies. It is very likely in consumer-driven health care, much like defined contribution retirement plans, that the consumer or patient hasn't saved enough to pay for these very expensive future therapies or treatments.

As a graduate of the Wharton School of Business, however, I wouldn't do my education justice if I completely dismissed the concept of efficient markets, consumerism, and competition. If consumer-driven health care is to work, it will require a few elements, which unfortunately the American health care system at this time is ill equipped to deliver on.

I will discuss these crucial elements in a future post.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Monday, April 19, 2010

QD: News Every Day--'House' calls

For all the ups and downs of getting health care reform signed into law, it was easy compared to the task of actually implementing it. Even as White House staff turn the law into actionable steps, special interest groups continue to lobby for advantages even as the law is implemented. No wonder people are still confused about how health reform will affect them. (New York Times, AP, Los Angeles Times)

So patients turn to a source of information they trust: their doctors. Even though physicians may not understand the legalese as well as they do medicine, what doctor hasn't spent the better part of a day interpreting Medicare coverage, untangling private insurance issues, or now explaining the law of the land as well. Roger Evans, FACP, of Wichita, Kan., tells his story. (New York Times)

Other doctors are taking it a step further. They're not just reading the legislation, they want to help draft it. Spurred in part by watching health care reform pass, forty-seven doctors are running for Congress this year, three times the number currently seated. (USA Today)

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Friday, April 16, 2010

Inside a Haitian Medical Clinic

This post by Jon LaPook, ACP Member, appeared at Better Health.


Dr. Jon LaPook visits one of Haiti's medical clinics nearly three months after the country's devastating earthquake:


Watch online

Small Miracles In Haiti

Seven days ago, at a mission in the north of Haiti, I watched a nurse remove oxygen from a premature baby boy in order to give it to a woman in labor. The heartbeat of the baby who was about to be delivered had dropped dangerously low and there was only one working oxygen machine.

Perhaps the cord was wrapped around the baby's neck or there was some other problem. A Caesarian section--which can quickly and safely deliver a baby who is in trouble--was not an option. The public hospital was at least an hour's drive away over bumpy roads.

These kinds of cruel triage decisions are commonplace in Haiti and existed long before the earthquake struck on Jan. 12. The poorest country in the Western Hemisphere has never had an effective public health system. Thousands of non-governmental organizations (NGOs)--by some counts more than 10,000--are trying to plug holes in the ship. What's really needed is a new ship.

So far there's been no significant spending on rebuilding because there's nobody to spend it. The best hope is effective action by the Interim Haiti Recovery Commission co-chaired by President Bill Clinton and Haitian Prime Minister Jean-Max Bellerive. The Haitian parliament is still in the process of approving this commission, which will help allocate donor funds and oversee reconstruction.

Meanwhile, the clock is ticking in a major way. The rainy season has already arrived. With it will come an increase in problems such as malaria, dysentery and lung infections. Malnutrition, disease and stress--all exacerbated by the earthquake--are a particular threat to pregnant women and their offspring. And, of course, the generally miserable conditions present on Jan. 11 not only persist but are significantly worse.

Where do NGOs fit in? The Haitian people are desperate for relief today. They need the basics: food, clean water, housing, and medical care. In the absence of an effective government response, NGOs have been stepping up. One Haitian man living in a tent told me that "the foreigners are helping us more than the government." There is no question that the activities of NGOs need to be coordinated; too many people are doing their own thing. But until a strong, effective central authority arises, the NGOs will continue to fulfill a crucial role.

A powerful example is Partners in Health (PIH), an NGO that has been helping Haitians for over 20 years. On April 5th, I visited the largest tent camp in Haiti: Parc Jean Marie Vincent. It houses almost 50,000 people displaced by the earthquake. PIH has set up a small clinic right inside the camp. Every worker I met was Haitian. Ten doctors see a total of 400 to 500 patients a day. Physicians, nurses, and other health professionals arrive first thing in the morning and don't leave until the last patient is seen. A rudimentary lab tests patients for pregnancy and illnesses like malaria, HIV, syphilis, and urinary infections. There's a small pharmacy. Family planning, psychological counseling and social services are all provided. There are definite logistical challenges, such as maintaining enough supplies given the limited storage space. And the doctors and nurses told me they could use more of pretty much everything (space, health professionals, medications, lab equipment, supplies). But I couldn't help marveling over the small miracle PIH has created in the midst of a nightmare.

Back to the mission in the north of Haiti. After some very tense moments, a healthy baby girl was delivered and the premature baby boy survived the temporary lack of supplemental oxygen. And I left Haiti wondering whether the country will ever reach the point where the fate of its children doesn't rely on the roll of the dice.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--Medicare payment cuts delayed until June 1

Threats of lowered Medicare payments have been postponed again until June 1. ACP's Neil Kirschner, PhD, had reported that some physicians were postponing nonemergency appointments until the issue resolved. Medicare had announced Thursday that it would start paying doctors' claims at the lower rate. Now, restored payment levels are retroactive to April 1, so internists will be paid at the 2009 rate for all services provided in April. Included in the legislation are extensions of unemployment benefits to restore aid to thousands of Americans who had exhausted their benefits or whose eligibility was expiring. (MedScape, Washington Post, New York Times)

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Thursday, April 15, 2010

QD: News Every Day--Fixing Medicare reimbursement cuts a few weeks at a time

In another down-to-the-wire vote, and following political procedural points Wednesday, the "doc fix" and an extension of COBRA benefits will likely pass the Senate today. The move extends the freeze on cuts to Medicare reimbursement to April 30 and extends COBRA benefits to May 5. The Senate, acting ever retroactively on the issues, would carry the temporary extensions forward yet again until they adopt a permanent fix--or more extensions. (Wall Street Journal, Washington Post)

Defensive medicine
Nearly one in four doctors ordered cardiac catheterization due to defensive medicine and even more because they thought a colleague would have done the test, according to a study in Circulation: Cardiovascular Quality and Outcomes. The study aimed to detect whether physicians in areas with higher spending overall did so because of peer pressure.

In case you missed it ...
The lawsuit by states against federal health care reform will move forward quickly because the judge hearing the case demands it. During a scheduling hearing between U.S. attorneys and those for the states posing the challenge, the judge said that the stakes are high and, "I would like to remind everyone we're working for the taxpayers. Including myself." Even if the lawsuit fails, the states determine how federal health care reform plays out anyway. The federal legislation lets the states choose whether to enact some programs, how to expand Medicaid and the enforcement of regulations. (Pensacola News Journal, The Greenville News)

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The Primary Care Shortage: Killing the Golden Egg-Laying Goose?

This post by Steve Simmons, MD, appeared at Better Health.


This past Monday, I was drawn to an article in the Wall Street Journal: "Medical Schools Can't Keep Up." The article detailed the growing shortage of primary care doctors in our country and reminded me that we in the U.S. may have something called "insurance reform" now, but without physicians to translate insurance access into health care, the state of our health care system will continue to beg additional attention and reform.

untitled eggs by erix! via FlickrAlthough new medical schools are opening and some schools have increased enrollment numbers, there are a limited number of residency positions in this country. The government has always funded these residency positions and our new reform law tries to address the primary care shortage with "slot redistribution," whereby money from unused residency positions will be deferred to primary care or general surgery residency programs.

However, the slot redistribution strategy equates to something of a shell game when set against the fact that in 1997 Congress put a cap on funding for medical residencies, and this limit is still in place today.

Too, we must take into account that it takes time to train doctors. Students desiring to become physicians must be motivated to endure the long training periods involved. Over the 11 years of my training (four for college plus four years accruing debt as a medical student plus three years as a resident), I was acutely aware of the concept of delayed gratification. Sometime in college my father told me that he'd never seen a doctor starve to death. This observation, intended as wit, helped to illustrate the fact that I would have job security and a comfortable living in the future, a fact that did help motivate me through inevitable rough patches.

The well spoken and timeless adage, "Man does not live on bread alone," should help us to understand that tomorrow's physicians will not be motivated solely by the promise of job security or a comfortable salary. Debt forgiveness to serve in underserved areas may lure graduates towards primary care but I harbor my doubts that this will make up the 150,000 doctor shortage, as estimated by the Association of American Medical Colleges. A 2007 survey of practicing physicians found that between 30 and 40% would not choose to enter the medical profession if they were deciding on a career again. Thirty-five years earlier, the same survey found the number closer to 15%. There is real risk in ignoring the reasons for such dissatisfaction. We could run out of primary care doctors, a resource as irreplaceable as Aesop's golden egg-laying goose.

As a young man, I felt a calling towards the profession of medicine and still do today, but I constantly battle against becoming something altogether different. A good friend of mine, an orthopedic surgeon, best explained it when he told me that he "is a part-time surgeon but a full time clerk." He lamented the time spent focusing on medical codes, charting, and cataloging supplies while attending mandatory meetings on everything but medical knowledge. He plans to retire soon and actually wringed his hands with anticipation while sharing his plans with me to volunteer in the Third World so he can "become a full-time surgeon again by becoming a part-time doctor."

Today, we in the U.S. have insurance reform but needed health reform. Talking heads on TV are now asking how to "bend the cost-curve downward" and are starting to ask who will see the patients if there aren't enough primary care doctors to implement insurance reform. All good questions, but I would pose one more. How can we expect our youth to sacrifice years of their lives, amass six-figure debt, and move towards a profession that leaves them dependent on government money and beholden to onerous and often nonsensical government rules and regulations? Our society should take care, lest we kill our goose and run out of golden eggs.

Until next week, I remain yours in primary care,
Steve Simmons, M.D.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Wednesday, April 14, 2010

Solving the Primary Care Crisis: Are We Training Enough Doctors?

This post by Davis Liu, MD, appeared at Better Health.

In a few years, every American will be required to have health insurance. As a result, the 32 million people currently uninsured will seek out a personal physician. This role typically is filled by a primary care doctor, like an internist or a family physician.

While passage of the healthcare reform bill affirmed the belief that having health insurance is a right rather than a privilege, the legislation falls short on building a healthcare system capable of absorbing the newly insured. Universal healthcare coverage is not the same as providing universal access to medical care. Having an insurance card doesn't guarantee that individuals can actually get care.

One doesn't need to look any further than the Commonwealth of Massachusetts to see what problems lay ahead. In 2006, the state required everyone to have health insurance. It was believed that having universal coverage would have slowed health care costs. Expensive emergency room visits would be averted as newly insured individuals would have a personal doctor who could address the problems sooner and at less cost.

Unfortunately, that scenario never occurred. According to the state medical society over half of internists and about 40% of family physicians were not accepting new patients. So the newly insured still didn't have a personal doctor to call upon even though Massachusetts has the most primary care doctors per capita than any other state. Insurance coverage does not mean access to medical care.

If a manageable patient load per full-time primary care doctor is about 2,000 patients, then the nation would need an additional 16,000 doctors to care for the newly insured. With some evidence that the nation is expected to be short about 40,000 primary care doctors over the next decade, one should wonder if we are training enough doctors to fill the gap.

The answer is no. With the 2010 residency match, U.S.-trained medical students have indicated that primary care is not what they want to do. Of the roughly 2,300 positions in family medicine residency programs, only 45% were filled by students attending American medical schools. While the American Academy of Family Physicians proclaimed the 2010 Match as the most successful ever with 91% of residency positions filled, the sad reality is obtaining this rate required eliminating 600 positions over a decade. In 1999, there were over 3,200 family medicine positions available for medical students to match into.

Internal medicine numbers are better, but won't address the primary care crisis either. Though nearly 5,000 students are training in internal medicine, the trend has been to use the three year residency program as a prerequisite for more lucrative medical subspecialties like cardiology, pulmonary or oncology, to name a few. While in 1998, 54% of internal medicine residents planned on becoming primary care doctors after training, by 2003, the number fell to only 27%.

Solving the primary care crisis can't be done with ancillary clinicians. As Americans are paying more for healthcare, I don't believe that they would willingly choose to have primary care done by nurse practitioners or physician assistants. That is not to say that there are not plenty of excellent clinicians out there, but adding these physician extenders won't bend the health care cost curve. Their costs often are comparable even as their knowledge base is less.

Though the health care reform legislation tries to maintain the primary care workforce via increased income for primary care doctors providing Medicaid services as well as increase the numbers with grants for more primary care training and loan repayment for doctors working in underserved communities, the reality is medical students won't be signing up. The specialty's relatively low pay, absence of work-life balance, and low prestige compared to other medical fields doesn't resonate with today's students.

That's too bad because the nation and the public needs more primary care doctors than ever. Not only can primary care doctors decrease costs, but also the amount of time wasted getting to the right specialists. One health plan that focused on using primary care physicians to coordinate care discovered use of specialists fell by 14%, emergency room use decreased by 16%, and prescriptions declined by 11%. When patients self-referred to specialists, about 60% went to the wrong specialist. More troubling is that on average $1,500 was spent on various tests and diagnostic services over an 11-month period before patients were told that the specialist could not help them.

So having a personal doctor is important and can save you time and money, but more importantly get you feeling better sooner. Too bad the nation won't have enough to go around. Hurry and find a primary care doctor you like and trust because it is possible later on you might find yourself without this indispensable advisor and guide for many years to come. Result to you and implications for the nation? Spending more time and money and not getting any healthier.

Want a crystal ball on how this legislation will affect the country? See what Massachusetts does next.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--'Dr. Nurse' will see you now

Nurse practitioners are demanding a wider scope of practice and even to be called "doctor" if they have a doctorate. And 28 states are considering giving them what they want, to which physician societies object. Health policy analyst Jack Needleman, (a PhD, so he gets to be called doctor, too) says the quality of care is the same. (He's also an honorary fellow of the American Academy of Nursing.) AMA president-elect and internist Cecil B. Wilson, MD, a Master of the American College of Physicians, (who is definitely called doctor) says the primary care shortage is a call for more physicians, not for fewer.

But it's not just the dependent practitioners breathing down primary care's neck. CVS announced it will double its number of retail clinics and expand the range of services from acute, episodic care to screening and even chronic illnesses. Walgreen and Wal-Mart are increasing their numbers of clinics, too.

And another health analyst said that as primary care pay approaches specialty pay levels, specialists will take on more primary care duties.

Suddenly, everyone is rushing to get back into primary care.

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Tuesday, April 13, 2010

QD: News Every Day--Sit with patients for better interaction

One in 14 Americans are using personal health records, a figure that has doubled since last year, says research by the California HealthCare Foundation. For those who keep their health information online:
--Users say they take better care of themselves, are better informed and are more involved with their doctors after using a personal health record.
--Wealthier patients are more likely to use them, but poorer patients or those with chronic illnesses are more likely to benefit.
--Two-thirds of the general public are concerned about privacy and security, but those already using them are not. And most users and non-users don't want concerns to stop them. Among non-users, 40% are interested in starting a personal health record.

They most want to use a record offered by their provider, or maybe their insurer, the research showed.

Primary care shortage
Primary care will see more funding for students and more reimbursement for primary care doctors, but the step in between, residency, remains status quo for the time being. (Wall Street Journal)

In case you missed it ...
Do you sit or stand when you consult with a patient? You can spend less time sitting and make the patient feel like you've spend more time in the room, according to a small study from the University of Kansas. The researcher also boosted his patient's satisfaction rate from 61% to 95% when sitting with patients instead. (Kansas City Star)

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Monday, April 12, 2010

Hospitalists and primary care docs

The following post is by Jamie Newman, FACP, editorial advisor of ACP Hospitalist:

I read the April 6 Annals of Internal Medicine with great interest. In it, many readers responded to Howard Beckman's previously published essay on the relationship between hospitalists and primary care physicians. Many physicians bemoan their loss of inpatient control of patients, and perceived lack of communication.

I think back to my own private/university hybrid practice. When my patients were admitted to the resident services, I never heard a word. There was absolutely no communication. I would say that most hospitalists do a much better job of communicating with the outpatient physician then any resident team. It's a double standard.

And nothing stops a physician from paying a call to a patient while he or she is in the hospital. It's all the PR with none of the paperwork, and guarantees improved communication. Many of the physicians who no longer practice in the hospital have given it up because they don't want to do it for financial or workload issues. You can't have it both ways. I wholeheartedly agree that it is in the patients' interest that communication and transitions of care be as seamless as possible, but a return to the old system is not the way to do it.

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QD: News Every Day--Head-to-head headlines consider health care reform

Newspapers touching on similar points about health care reform's impact on the primary care shortage cast vastly different headline on what essentially were mirror articles of one another.

From The (Nashville) Tennessean:
Health law may worsen family doctor shortage
Health reform will drive demand, but medical students would rather specialize

From The (Spokane, Wash.) Spokesman-Review:
Health care reform may ease shortage of local physicians
Cantwell, doctors point out incentives in new law

From The Las Vegas Review-Journal:
INSURANCE REFORM: Short supply of Nevada doctors could be strained even further
Guaranteed coverage in Massachusetts, but good luck with appointment

From the (South Mississippi) Sun Herald (which punted on the issue in its headline):
New health care law may impact numbers

It may reflect the red-state, blue-state divide of our nation's hometown newspapers, or at least their copy desk chiefs. But on the same day comes the same article with a different spin in the headline--from Canada:
Doctors’ crisis pending
N.L. government must prepare as overworked specialists cry out

Write up your best headlines about health reform and the primary care shortage and leave them in the comments field.

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Friday, April 9, 2010

QD: News Every Day--some wrestle with paperwork, others with second-year students

Cincinnati faces a primary care shortage similar to the rest of the nation. Local practices are looking to the patient-centered medical home to extend the capabilities of existing practices, but one internist retorts that the need is still for doctors, not "physician extenders." Maybe they could just do less paperwork. (Cincinnati Business Courier, New York Times)

In case you missed it ...
Pathologist Ed Goljan, MD, got into the hobby of arm wrestling. He describes taking on all comers in tournaments, but also colleagues and second-year med students. Ves Dimov, ACP Member, offered case studies of arm wrestling injuries from spiral fracture of the humerus.
Arm wrestling in Bricklane II by fabbio via Flickr

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Thursday, April 8, 2010

Rearranging Deck Chairs on a Sinking Ship

This post originally appeared in Musings of a Distractible Mind earlier this month after the health care reform legislation passed.

I have been asked by patients, readers, family members, and by fellow bloggers what I think about the bill passed by the House of Regurgitants Representatives yesterday. I resent this. I have tried hard to remain neutral as possible, finding equal cause to point and sneer at both conservatives and liberals. It's much more fun to watch the kids fight than it is to figure out which one is to blame.

disbelief comes first by notsogoodphotography via FlickrBut given the enormous pressure put on me by these people, as well as threatening phone calls from Oprah and Dr. Oz, I will give my "radical moderate" view of the health care bill. My perspective is, of course, that of a primary care physician who will deal with the aftermath of this in a way very few talking heads on TV can understand. The business of health care is my business, literally. So, reluctantly, I take leave of the critic's chair and take on the position where I will be a target for any rotten fruit thrown.

1. It's not Armageddon.

We are all still alive and breathing, and will continue to do so after this law is passed and signed. The bill does not change things as radically as the shrill voices on the right suggest. It does not constitute a government takeover of health care, nor does it seem to extend any government programs by a whole lot. It is really not about health care at all, but instead about health insurance.

The goal of getting more people insured is a good one. Our system clearly (from my perspective) makes my services unaffordable, especially if you consider what people pay for procedures and medications I order. The lack of affordable insurance does harm people; I see it every day. The system is broken and needs fixing. Anyone who says otherwise needs to get a urine drug screen ASAP and then seek professional help.

Beware of the fear-mongers who make this out to be the "pro-death panel" legislation. It's really not that bad.

2. It's not Nirvana.

It's actually more like the Foo Fighters ... no wait, that's another blog post.

There are folks on the Left who think that we are entering a golden age because of this. Some suggest this is the "Waterloo for the Republicans." No, this bill is simply a rearrangement of how money is being spent, not a fount of blessings to those in need. Some people will benefit from this, especially those with no insurance, but most people won't see a whole bunch of change from it.

This bill addresses the problem of the uninsured, but does not deal with the much more important issue of cost. If anything, it may worsen the problem that is actually at the core of the troubles: out-of-control spending. Figuring out how things are going to be paid without controlling what is being paid for is like rearranging chairs on the Titanic. The reason people cannot afford insurance is not because there are enough insurance options, it is because of the incredible amount of waste in the system. Agreeing to cover more with insurance without controlling cost will make the situation worse, not better.

3. The process was a national embarrassment.

The debate in D.C. did not seem to be about people getting the care they need; it seemed to be about which side would win. The lack of bipartisanship is a condemnation of both sides, an indication that power is more important to our representatives than is representation. Why didn't the Democrats agree to tort reform (which nearly everyone supports)? Why couldn't the Republicans concede that having people with no insurance is a problem the government should address?

We have a terrible situation in our country: a health care system that is out of control in its cost and that will bankrupt us if nothing is done. Yet what this difficulty has won us is not a national resolve to fix this problem, it is an increase in the partisan screaming and a worsened environment to effect real and beneficial change.

To me, the debate turned debacle is a very good argument for term-limits for members of Congress.

4. It missed the point.

The real problem in health care, again, is not who is paying. The real problem is that it costs far too much. We are not in a crisis because of insurance; we are in a crisis because of what is being paid for by insurance. For legislation to have a real chance for fixing this problem, it must find a way to control spending.

The problem of health insurance is far easier than that of cost. Here's why I think cost-control is going to be an even harder thing to tackle:

--There are industries making billions of dollars off of the inefficiency and waste in health care (see my post about the sea creatures). Devices don't really help people, and specialty procedures that are unproven are paid for while primary care gets the shaft. People like shiny technology and legislators have a hard time saying "no" to it, especially with the lobbyist dollars that will protect this waste-eating industry. It's boring to promote primary care and doesn't play well to the constituents.

--We don't have the IT to do it. Any attempt at cost control will fail without good health IT. Doctors control a huge percentage of health care costs, yet most are operating blindly. We rely on the word of the patient for what happens in other health care settings. If you are going to expect physicians to make prudent medical decisions and eliminate waste, you must give them adequate information. Unfortunately, the current push for EMR is not about delivering information to physicians, but instead about letting doctors document more efficiently. Use IT to inform, not conform. Use IT to enable docs instead of burdening them more.

--"Rationing." Any control of cost will be about denying care. I believe that denying care that harms patients is a good thing to do, as is suggesting cheaper alternatives if they are equal in benefit. Patients are angry when they can't get Nexium covered by the insurance company, but over-the-counter Prilosec is just as good for them. Patients are angry when they can't get an MRI for their back pain when it is really not appropriate for 98% of back pain sufferers. People don't want to be denied. Americans want an all-you-can-eat buffet of medical care. Unfortunately, any change for the positive will inevitably involve some sacrifice.

So, what do I think about the legislation? I honestly don't think it's that big of a deal. I think it's good that something is being done about those without insurance, but I worry that nobody is checking the balance on the credit card. I like the arrangement of chairs on the deck, but perhaps the hole in the boat merits a little consideration.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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QD: News Every Day--State of the states

States are varying in their reactions to health care reform:
--Wisconsin is creating an office of health care reform to develop its health insurance exchange and explain changes to constituents.
--Tennessee won a court ruling to remove 100,000 from its Medicaid rolls.
--Leaders in 18 states vow to challenge the new law in court. But in Idaho, a challenger for the governor's office proposes instead taking advantage of a federal waiver that exempts states that enact reforms that control costs and improve access better than the federal laws do. (Milwaukee Wisconsin Journal Sentinel, Kaiser Health News, Reuters, Idaho Reporter)

At the federal level, President Barack Obama and supporters continue to try to sell the reforms to Americans while the opposition tries to figure out its next steps. "Soak the rich" might be one phrase to revive; but they'd do best to distance themselves from the tea-baggers, who have spiraled out of control. (The Hill, Los Angeles Times, USA Today)

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Wednesday, April 7, 2010

Diagnosis and Care: Just a Phone Call Away

This post by Alan Dappen, MD, appeared at Better Health.


In my medical practice, I have a simple yet revolutionary idea: I get paid to answer the phone. Every one of my 3,000+ patients has my cell phone and e-mail address so that they can reach me the instant they need help, which is no different than any of my friends or family who may be trying to reach me. Our practice motto: "Talk to your doctor anytime, anyway, anywhere."

It's not that I'm trying to not see you, or want to be impersonal or to practice risky health care. In fact, each of these common assumptions is pointedly wrong. By answering my phone, I can know my diagnosis and treatment worked (or not), or I can help someone avoid an ER visit or unnecessary office visit. My patients call me when they're traveling, or at work, or from their car, at night and on weekends. There've been occasions that I need to see a patient NOW and I've come to the office a 2 a.m. to keep someone out of an ER. No matter what, by picking up the phone to talk to my patients, I'm the first person in the healthcare system to know something is wrong, not the last.

Although good examples supporting the power of a doctor answering a phone occur daily, I have one I want to share with you.

It began about six weeks ago during one of Northern Virginia's biggest snowstorms in recorded history. Already 20+ inches were on the ground and I was huddled next to my wood stove in the basement, having lost electricity 18 hours ago. Fortunately my cell phone worked. I got a call from Mr. AA, who was referred to me by a mutual acquaintance.

AA, a 30-year-old who traveled a lot, had been in many several countries including East Africa and Indonesia in the last six months. Five days before calling me, he developed a high fever associated with headaches and body aches. These symptoms resolved within six hours. He visited an urgent care center where labs and exam were normal. For the next four days, he'd been fine. But then, trapped at home in the middle of the snow storm, he found himself racked with a temperature of 104.2 degrees with a headache and body aches. When we first spoke, he felt he was through the worst and was recovering, after six hours of fever and a dose of ibuprofen.

During our phone conversation, he explained that he'd not been to East Africa in over three months, where he'd taken malaria prophylaxis. However, he'd returned Bali and Indonesia several weeks before, and he'd not taken malaria medicine while there, having been told by a reliable source that he didn't need malaria meds where he was traveling.

Banana-shaped gametocyte diagnostic of P. falciparum infection. Image (c) American College of Physicians.Suspecting malaria, I asked if he still had any malaria medicine at home. As luck would have it, he did. I advised a treatment immediately. Falcipaurm malaria (usually acquired in Africa) has a 30% mortality rate if left untreated, while Plasmodium vivax (most frequently acquired in Indonesia) also would respond to the treatment. I did tell AA that recurrence rates later are common with vivax malaria due to a chronic liver stage and we could easily cross that bridge if that happened.

We spoke 24 hours later and his symptoms had not recurred. But 30 days later, my cell phone rang. AA's fever had returned. He had been perfect for three weeks, but within the last week he'd had two fever attacks, each lasting six hours. The second had recurred three days after the first.

We then met at our practice offices, even though his fever was gone. A recurrent high fever is a good reason to see your doctor in person, and one of our practice tenets is you must meet the doctor face to face at least once.

During our visit, he'd told me that his friends in Indonesia had pooh-poohed the idea of malaria. He produced a list of possible causes of his fever that he'd researched on the Internet. Being a causality of the American health care system with no health insurance, he was all ears when I explained that rushing pell-mell through thousands of dollars of tests, ER visits, and specialists encouraged under the insurance model was unnecessary. Instead he would pay our office less than $100 for the tests he needed, which he could access via a local lab at a discounted rate. At the next episode of a fever he would take the lab order to the hospital no matter the time of day to get the five tests I requested.

Three days later AA's mother called me at 8 p.m. She was taking her son to the hospital lab since his temperature had started going up an hour before. To avoid any possible glitches, I called the lab to clarify the orders and account. At midnight, as I headed for the ice arena to play my weekly hockey game, I received a message from the lab: "He has a positive malaria parasite smear," reported the lab tech. "Specific typing between vivax and falciparum malaria will be done by the pathologist in the morning."

I immediately pulled my car over and called AA. He was feeling better and the fever was gone. I told him that everything pointed to vivax malaria, but we'd wait until the morning for the pathologist's findings. If it was vivax, I'd research the best drug to use, considering the resistance patterns out of Indonesia. I'd want him to return to the lab in the afternoon for a G6PD blood test, which would see if he could take the drug safely that would eliminate the recurrent liver stages of the malaria.

Our predictions were correct: vivax malaria. His G6PD lab test was normal. I called AA four weeks after he'd started the two medications to treat vivax malaria. I was relieved that he was well and not bankrupt from medical costs. He, like me, is a convert to having the doctor answer the phone to solve a problem. In the future, I'll be the first one he calls for a medical need, whether a fever or anything else.

And, the total cost of service from first call until cure including costs of labs and tests (excluding meds): $401.

Until next week I remain yours in primary care,

Alan Dappen, M.D.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Contact ACP Internist

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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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