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

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Friday, May 28, 2010

QD: News Every Day--Doc fix delayed past deadline

The U.S. House will consider the doc fix today, which doesn't leave enough time for the Senate to vote before its Memorial Day break. Again, Medicare will delay processing payments beginning in June, to allow Congress to pass a fix and still process claims without applying the pay cut. But it's not like doctors make a lot from Medicare patients, anyway. (The Hill, Politico, Health Leaders Media, CNN)

It's part of a larger scramble by legislators to wrap up what they can before the holiday. But the American Medical Association lashed out against Congress members in an angry accusation, using words like desertion and mismanagement. (American Medical Association, The Washington Post)

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10 rules for giving good care

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


The recent discussion of the appropriateness of bringing patients back to the office has really gotten me thinking about my overall philosophy of practice. What are the rules that govern my time in the office with patients? What determines when I see people, what I order, and what I prescribe? What constitutes "good care" in my practice?

So I decided to make some rules that guide what I think a doctor should be doing in the exam room with the patient. They are as much for my patients as they are for me, but I believe that thinking this out will give clarity in the process.

Rule 1: It's the patient's visit
The visit is for the patient's health, not the doctor's income or ego. This means three things:
--All medical decisions should be made for what is in their interest, including: when they should come in, what medications they are given, what tests are ordered, and what consults are made.
--Patients who request things that are harmful to themselves should be denied. People who ask for addictive drugs or unnecessary tests should not get them. Patients who are doing harmful things to themselves should be warned, but only in a way that is helpful, not judgmental.
--All tests done on the patient should be reported to them in a way that they can understand.

Ten Commandments @ Loew's Ohio Theatre (Cleveland Call and Post; November 17, 1956; Pg. 8) by ClevelandSGS via Flickr

Rule 2: Minimize
Many doctors and patients have a "more is better" mentality. This not only costs more money to the system, but it can cause harm to the patient.

Here's what I think should be done:

--Patients should only be seen when a visit is appropriate.
--Use as few medications as possible, and when necessary, use the cheapest one that will do the job.
--Order as few tests as possible. No test should be ordered for informational purposes only; the question, "What will I do with these results?" should always be answerable. If it is not, the test should not be done.
--When changes are made, make only a few at a time. Many simultaneous changes make it hard to tell what helps and what hurts.

Rule 3: Relationship = better care
Relationship is one of the best tools for achieving optimal care. This means that the patient knows the doctor and trusts them, and the doctor knows the patient. This does not happen with sporadic care, but instead with consistent, long-term care by one provider. The result of this includes:
--Patients with long-term significant medical problems should come in on a routine basis.
--The best-case scenario for regular visits is that there are no medical problems, in which case the visit will be mainly social.
--There is a medical benefit to the social visit, with the doctor understanding the patient better and the patient trusting the doctor more.
--There are frequent cases where the patient doesn't think there is something wrong, but a regular visit reveals either serious problems, or allows intervention to prevent a serious problem.

Rule 4: Keep priorities straight
When a patient comes in with a problem, there are three goals:
--Rule out bad things.
--Make the problem better.
--Make a diagnosis.

Numbers 1 and 2 are of equal importance, with Number 3 a distant third. This means that you always should address the fear that caused them to come to be seen (e.g. patients with chest pain should be reassured it is not the heart, if possible). But stopping with number 1 is unacceptable; number 2 must be done as well. Sick people want to feel better, and it is the doctor's job to try to accomplish this.

Rule 5: There is ALWAYS a reason
It's very easy to actually believe that people's actions revolve around you when you are a doctor. It's not only human nature to take this view, it's a natural response to the stress and pressure of the job. But there are bad consequences to this state of mind:
--If you can't figure out why people come in, then they are just wasting your time.
--If you can't make sense of symptoms, then they are not telling the truth.
--If a person is acting in a way that is irritating and annoying, they are doing so by choice to bother you.
--A person who seems emotionally weak is that way by choice.

Avoiding these assumptions will make care better, both in the ability to see things objectively and to offer care and compassion.

Rule 6: If the house is burning down, don't cut the lawn
Focus is one of the most important things in an office visit. Both doctors and patients can lose sight of the purpose of the visit. I use this line whenever someone asks me about minor issues in the face of bigger things. Weight loss may be important in the long run, but it is not pertinent when a person is in the office with a heart attack.

There are no quick fixes or magic wands.

Rule 7: Compliance follows communication
I have a hard time remembering things, so I am not surprised when my patients aren't compliant. In my experience, it is far easier to remember things I think will benefit me. My job is to help my patients with this, not seeing perfect compliance as the norm. The best way to do this is to communicate. I need to communicate in a way that doesn't just convince them of my opinion, but gives them reason to change theirs. This means that I need to know what they think is important (by listening) and then find a way to turn that into motivation.

100% compliance is not expected, but it is nice to see motivated patients; it's my job to encourage, not judge.

Rule 8: People come to the doctor's office
When people come to see me, they interact with more than just me; they interact with my staff. They deal with our system that we have set-up, good or bad. A bad experience in the office usually has nothing to do with the quality of medical care, it usually is because of a poorly run office encounter.

A big part of taking care of patients is running the office efficiently (which was one of my biggest frustrations in a practice run by the hospital. They didn't care about the patient encounter; they cared about the referrals). This takes a lot of work that doesn't seem to be reimbursed and doesn't seem pertinent to medical care, but patients who are frustrated and upset don't listen as well, and frustrated healthcare workers don't give as good of care.

Rule 9: The buck stops here
I believe in primary care. I believe I am the one who my patients call "my doctor," and I see this as a big responsibility. I need to know as much about them as possible, getting information from anywhere else they get medical care. My problem and medication lists need to be as accurate as possible.

I am advocate, doing what is in the best interest of the patient, not the drug companies, hospitals, or specialists. I am confidante, listening to anything the person has to bring to me and knowing as much about them as anyone on the planet. I am an advisor, collecting medical information and giving them an opinion as a trusted person with their best interest in mind. I am comforter, shutting up and listening when that's appropriate to do.

Rule 10: Enjoy the good stuff
There's a lot to complain about in our system. There are a ton of stressful things and a lot of bad stuff we see. The simple fact that so many of us keep going back to work is witness to a lot of benefits. Remembering what's good about being a doctor is key to maintaining the energy to face the rest. Here are some of my favorite things:
--I have a lot of patients who I really like, enjoying my interaction with them.
--I see a lot of inspiring people, getting up when they are knocked down time after time.
--I get to play with babies and tickle kids (and get paid for it!).
--I save people's lives and make them feel better.
--I get to say the right thing at the right time, really making a difference when it counts.
--People openly tell me how much they appreciate what I do.
--I work with a bunch of folks who are good to be with and like-minded in their desire to help our patients.

These things are what get me up in the morning. They are what make dealing with insurance companies, stupid government policies, and rude doctors and patients possible. They are the balance to the suffering and pain I see. No, they greatly outweigh all of that stuff. Really. I wouldn't do the job if that weren't the case.

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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Thursday, May 27, 2010

Lifestyle, not just financial decisions, drive exodus from primary care

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.


I've written previously that the days of the private practice physician are numbered. A detailed piece from the New York Times confirms the exodus.

Young doctors, who are burdened with medical school debt exceeding $150,000, are opting for the financial stability that a salary from a hospital-owned practice or a large integrative medical center can bring. Gone are the days where a solo practitioner can hang a shingle and practice in a small office, or in days past, a room adjoining their home.

Today, there's too much bureaucratic paperwork and too many insurance hassles to deal with. Combined with increasing costs and downward pressures of reimbursement, doctors are loath to take a risk of essentially running a business in this toxic environment.

Some are puzzled by this. Dr. Gordon Hughes, chairman of the board of trustees for the Indiana State Medical Association, says, "When I was young, you didn't blink an eye at being on call all the time, going to the hospital, being up all night. But the young people coming out of training now don't want to do much call and don't want the risk of buying into a practice, but they still want a good lifestyle and a big salary. You can't have it both ways."

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.

There is a downside, of course. By divorcing new doctors, already naive to the business of medicine, from administration, they are going to have less clout in the decisions that affect their professional futures. But that's a trade off that some would make in order to have a more balanced lifestyle, which makes the private practice physician a species growing slowly extinct.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 29,000 subscribers and 21,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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QD: News Every Day--U.S. House cuts 'doc fix' duration and guts primary care bonuses

Under the legislation that cleared the U.S. House Rules Committee Thursday night, reimbursement would increase 2.2% for this year, 1% for next year and return to current levels in 2012. Primary care won't get the additional bump for primary or preventive care. Susan Crittenden, ACP Member, says uncertainty over rates--they're low to begin with--makes it hard for her to accept new Medicare patients. (U.S. House Rules Committee, HealthLeaders Media, AP)

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Wednesday, May 26, 2010

The positive power of compulsive medicine

This post by Steve Simmons, ACP Member, appeared at Better Health.


Most experienced physicians expect uncertainty in caring for real people with average everyday problems. Yet those inexperienced or uninitiated in medicine tend to see the practice of medicine as exact or even absolute.

I remember waiting in vain as a medical student and resident for my instructors to illuminate a path towards certitude. Instead, I was given something far more real and lasting: an acceptance of the indeterminate mixed with the drive to be compulsive on behalf of my patients.

During my internal medicine internship, I remember a more-senior resident during our daily morning report bemoaning her uncertainty by saying, "But I just don't know what's wrong with my patient." Although she was visibly upset, our program director's reaction to her comment bordered on amusement, culminating with, for me, an unforgettable response: "Well, you certainly have chosen the wrong profession."

I can remember my program director explaining his role in our development: "I'm not trying to make you smart. I selected you, in part, because of your intelligence, but it's my job to make you compulsive." This surprised me as I previously had thought compulsion to be a negative trait, one that could identify a personality disorder or eventually lead to obsession.

However, now I realize that much about today's medical profession reads like a Lewis Carroll novel, and so I see compulsion as a powerful tool in a time when the value of common sense and logical thinking is being diminished by innumerable outside influences.

Compulsion can be used for the good of any patient as it drives us to doggedly pursue a set of symptoms and signs, craft a working diagnosis, and tirelessly work to discover a cause, hopefully with a treatment available to help a patient at the end. Today, compulsion is needed at every step in medicine. Perhaps I will need to fight with an insurance company to get a test approved, repeatedly call a lab to track down a test result, or make sure that claustrophobia doesn't prevent my patient from having an MRI.

Physicians should be comfortable with the lack of certainty as we move forward through this process but we will be hindered by those who see uncertainty as a failure or act in a way that belies a belief that uncertainty doesn't exist. My medical school mentor, Dr. B., derisively referred to anyone hindering his medical practice as a "bean counter." I worked with Dr. B in the early 90s and watched him struggle with the growing use of ICD-9 codes, which imply certainty in their use. There is a paucity of symptom codes, while no codes exist for ruling out a problem.

The current diagnostic code book (ICD-9) has roughly 12,000 numerical codes to identify a specific disease or problem. Failure to report a string of numbers correctly can result in a variety of negative consequences spanning from denied payments to refused tests and treatments.

Dr. B kept a file of letters from insurance companies that he considered nonsensical yet tragically funny. One was a letter from Medicare denying payment and admonishing him for his decision to admit a patient to the hospital on a certain date for a condition that "did not warrant a serious enough illness for hospitalization." Stapled behind this reprimand was a copy of the patients' death certificate with the same date as her hospitalization. His failure: using a code for simple urinary infection instead of urosepsis.

Dr. B began his medical practice in a time that understood and expected ambiguity, a time when patients might be admitted to the hospital for tests--an absolute anathema today. He struggled loudly against the restraints being placed on his practice as the years advanced and resisted focusing his attention on codes. While those of us practicing medicine today are largely used to our insane daily struggles, I imagine it must have appeared to Dr. B. and other doctors of that era that mid-career they had been dropped down the rabbit hole with Alice or forced to practice medicine from the other side of the looking glass.

Each day I feel more concerned as common sense and logic seem scarcer, and it does appear to me that we have arrived in our own strange, counterintuitive Wonderland. As I struggle to understand and function effectively, I feel a deep gratitude towards my teachers for showing me the power I can wield for my patients by remaining compulsive so that I may help them navigate the medical "reality" that envelops us all today.

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--Health care costs affect timing of 'doc fix'

House Democrats are dickering over the duration for the "doc fix" legislation being considered this week by Congress. The fix, which among other things defers a 21.3% reimbursement cut for Medicare, is fully a third of the cost of the legislation. Congress has to act on the issue before its Memorial Day break, because the cuts take effect June 1. Congress members had agreed to a three-and-a-half year extension of Medicare reimbursement rates with some raises thrown in for primary care, but Senate Budget Committee Chairman Kent Conrad now wants to lop off that third year to reduce a third of the legislation's costs. The issue will come forward in the U.S. House this morning, and has the votes to pass, said one top Democrat. (The Hill)

If the bill doesn't clear Congress before its break, they'd have to pass yet another 30-day extension to keep doctors paid and accepting Medicare patients. Congress may look past bipartisan bickering to keep doctors happy, both to appease them and to preserve their elderly patients as a happy constituency. (Kaiser Health News)

Health care costs
Stimulus dollars for small-business loans to doctors have expanded their capabilities, but may eventually lead to higher overall health care costs. Doctors have used the loans to increase office space or buy new equipment. But, says health policy analyst Elliot Fischer of the Dartmouth Atlas of Health Care, radiologists who've bought new equipment will (naturally) do more imaging, which leads to higher health costs overall. But, internists have also used loans to expand their office space, which lets them hire more doctors to see more patients. (Kaiser Health News)

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Tuesday, May 25, 2010

QD: News Every Day--Doc fix bill earns low marks, strong remarks from analysts

The doc fix being considered in Congress this week is a way of again preventing a 21.3% cut to physician Medicare reimbursement. But health policy analysts call such measures among the worst pieces of legislation ever because they simply delay the inevitable while driving up the eventual costs of the legislation. ACP and the American Academy of Family Physicians support a three-year measure being considered this week that will stabilize payments to doctors while Congress creates a permanent solution to the entire issue. The American Medical Association wants a permanent fix now, and it's for the same reason the economists hate the temporary measures: They cost too much. Each delay simply adds to the amount the government will pay down the line. (Politico, ACP Internist)

Iin the meantime, more and more doctors are dropping Medicare. One in four osteopaths will drop Medicare if the cuts were to ever take effect. (Lubbock (Texas) Avalanche-Journal, American Medical Association News)

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Monday, May 24, 2010

QD: News Every Day--A week of waiting for Medicare reimbursement

Congress is considering the doc fix this week, a measure to stave off the 21.3% cut to Medicare reimbursement rates. The deadline expires June 1, and Congress goes on break the week after Memorial Day, so if they don't pass it this week, doctors face the same cuts that have been dangling over their heads for months. The House could vote by Tuesday, and then it heads to the Senate. (The Hill)

The spending package is controversial in tough economic times, though. While everyone agrees it's important to pay doctors, no one wants to drive up the deficit to do it--like this ACP Internist reader. (Washington Post, ACP Internist)

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Friday, May 21, 2010

QD: News Every Day--Can Congress halt Medicare cuts before Memorial Day?

The U.S. House will take up a jobs and tax bill that would set Medicare reimbursement rates for the next three years. The measure would offset a 21.3% cut in Medicare reimbursement with $60 billion in funding over three years. Doctors would get a 1.3% raise this year and another 1% raise next year. In 2012 and 2013, primary care doctors would get an additional raise tied to the gross domestic product. The bill also extends the Federal Medical Assistance Percentages until June 2011, a key issue for hospitals. The House is expected to vote next week, and the Senate then takes it up. But Congress takes a one-week break for Memorial Day, so the Senate would have to move quickly.

Primary care's medical societies support the measure. ACP supports the plan because it increases reimbursement, provides an expected reimbursement and creates a framework for a permanent fix. The American Academy of Family Physicians embraced the measure, but the American Medical Association barely acknowledged the three-year fix before continuing to press for a permanent solution to Medicare reimbursement rates.

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Thursday, May 20, 2010

Google changes doctor's role from internist to interpreter

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.


More patients are on the Web researching health information, and for the most part, this is a good thing.

But are doctors in danger of being "phased out" by Google and other search engines?

In an interesting perspective piece by Pamela Hartzband, FACP and Jerome Groopman, FACP, in the New England Journal of Medicine, the answer appears to be no.

Data without expertise in interpretation is largely meaningless. Consider this patient the authors interviewed: "I really don't want to read what's on the Internet, but I can't help myself." Her condition is currently stable, but she finds herself focusing on the worst possible complications of the disease, such as cerebral vasculitis. Although her doctor gave her detailed information, she cannot resist going on the Web to seek out new data and patients' stories. "It's hard to make out what all of this means for my case," she said. "Half the time, I just end up scaring myself."

Patients like these are not alone, and will only grow in number as more turn to the Web prior to seeing a doctor.

This may be good for the medical profession. "Information and knowledge do not equal wisdom," the doctors write. "Physicians are in the best position to weigh information and advise patients, drawing on their understanding of available evidence as well as their training and experience. If anything, the wealth of information on the Internet will make such expertise and experience more essential."

Doctors have to get used to the fact they are no longer the sole source of a patient's health information. Instead, they need to serve more as interpreters of data, and be willing to separate the tangible information from the increasing amount of noise patients find online.

This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 29,000 subscribers and 21,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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QD: News Every Day--Doctors face another short-term Medicare pay fix

With no agreement in sight on permanently fixing Medicare reimbursement, Congress will need to pass another extension to keep doctors paid at current levels for their patients after June 1. A 21.3% pay cut takes effect then, but it's not likely to clear both chamber of Congress before the Memorial Day weekend. (The Hill)

Treating the uninsured
Uninsured patients are not more likely to seek primary care in the emergency department, concluded researchers at the Centers for Disease Control and Prevention. Those with and without insurance were equally as likely to have visited the emergency room in the past year.

Instead, CDC researchers reported that those older than 75 years, blacks, the poor and those with Medicaid were more likely to have been to the ER. The uninsured were no more likely to have gone to the ER for nonurgent visits than those with private insurance or Medicaid.

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How small adjustments via telemedicine can make a difference

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


Last week we examined how, in a typical practitioner's day, he or she often needs to make adjustments in patients' care to keep them on the path to getting or staying healthy.

Usually a face-to-face physical exam isn't necessary to make accurate changes to a patient's care regiment. Instead, all discussions can be done via a form of telemedicine, such as a phone call, e-mail, or video conferencing. Unfortunately, it's become standard that face-to-face time is required between patient and doctor, creating more hassle for the patient while not impacting the quality of the outcome.

I'd like to visit the case of a particular patient, Mrs. EE, and discuss how telemedicine allowed me to make small, ongoing adjustments to her medical regiment quickly and easily, and with very positive outcomes.

Mrs. EE is a 79-year-old homebound patient. She recently was discharged from the hospital after developing bilateral deep thigh vein thrombosis. At discharge she was started on Coumadin (warfarin) by mouth to be monitored and the dose adjusted to an International Normalized Ratio (INR) standard of at least 2.5 before stopping the Lovenox injections (enoxaparin, sanofi aventis), which were being given twice a day by a trained nurse assistant.

We arranged for a visiting nurses association to draw routine lab work to monitor the bleeding times and report response so we could adjust the Coumadin dose properly and decide when it was appropriate to stop the Lovenox. Over 10 days, the visiting nurse called me on my cell phone every two to three days, with the INR results. The Coumadin doses then were adjusted appropriately (and we've now arrived at the proper Coumadin dosing).

If I had any doubts about managing the anticoagulation therapy, I instantly could pull up one of many algorithms built into our electronic medical record (EMR) that are managed by our doctors. These algorithms would help me with a decision tree for Coumadin dosing change and frequency for getting the next blood test. I could gauge when the next INR was to be done and when to discontinue the Lovenox injections.

I now get monthly phone calls from the visiting nurse regarding Mrs. EE. Both she and the patient have my cell phone number. My fees during the first two weeks of starting the monitoring was less than $200.

The patient now pays me $25 a month to have me supervise her Coumadin dosing and to have my cell number on her speed dial. She much prefers this to the second option: organizing two people to get her into a wheelchair and moved into a car and finally wheeled into a doctor's waiting room for the privilege of figuring out how to manage her Coumadin dosing.

These small tweaks are examples of discussions that I have least five times a day. Multiply this exercise at least five times a day for every doctor in the country. Imagine how much time and money, real money, is being wasted on people trekking to an office visit when something as simple as a phone call can provide the right care. The power of a doctor being paid to answer a phone means that patients are expecting their doctor to answer a phone and get paid to do so. But no doctor in his right mind will consistently do a micro-tweak if he's not getting paid for it. Why would he?

Some patients will argue that their doctor will answer a phone and handle these micro tweaks for free, but believe me nothing is free, and sooner or later your doctor is going to force you into an unnecessary office visit, make you go through the hoops of hassle and delay for the single purpose of getting paid. Time is money; that's what the bottom line is about.

Until next week, I remain yours in primary care,

Alan Dappen, MD

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, May 19, 2010

Working Overtime Increases Heart Disease Risk

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

The European Heart Journal studied 6,000 British civil servants and followed them for 11 years. They found that working an extra three to four hours a day is associated with increased coronary heart disease. The researchers controlled and adjusted for lifestyle, cardiac risk factors and other factors that would skew the results and still found that people who worked three to four extra hours a day had a 60% increase in risk for heart disease.

These results were for both women and men (ages 39-61) and the outcome measure was fatal myocardial infarction (heart attack) and non-fatal MI and proven angina. Other risk factors like smoking, elevated lipids and diabetes made no difference in the results.

The conclusion: "Overtime work is related to increased risk of incident coronary heart disease independently of conventional risk factors. These findings suggest that overtime work adversely affects coronary health."

Yikes ...

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--AMA rejects hospice approach to Medicare pay cuts

Is it worth it to keep a comatose patient on life support for five years, hoping that medical science might develop a miracle cure?

Alternatively, is it worth it to defer Medicare reimbursement cuts for five years, hoping that Congress might pass a permanent fix to the Sustainable Growth Rate formula?

Members of Congress have floated for months the possibility of a five-year fix to the Medicare reimbursement system. Cuts of 21.3% take effect June 1 unless Congress applies yet another patch, a fifth temporary reprieve, to stave off the cuts. The American Medical Association objects to the five-year plan, saying it will only result in even steeper cuts when it expires. As the organization's immediate past president, Nancy H. Nielsen, MACP, pointed out in February, pushing off a permanent solution just increases the eventual price tag each time.

The Texas Medical Association points out that this current round of cuts isn't actually a 21.3% cut, it's a cumulative 83% cut since 2001. They have a reason to grieve over an ailing system. Medicare's morass is already driving the state's primary care internists and subspecialists alike to drop Medicare. This especially hurts in a state already strapped for primary care physicians.

There could be a permanent solution to Medicare reimbursement, if some political willpower could be mustered. Maybe that's what the AMA is holding out for. But right now that willpower is flagging and possibly flat-lining in the face of partisan opposition and concerns over the eventual costs of paying physicians to care for patients. Meanwhile, there's still patients to care for, not hypothetical, vegetative ones but real ones who are walking, talking and concerned about their health and their relationship with a primary care doctor. So reimbursement fixes will continue to require a hospice approach, holding out for a month at a time, or possibly getting a reprieve until the end of the year.

(The Hill, Fierce Healthcare, Texas Medical Association, Houston Chronicle, Politico)

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Chaos in theory is chaos in practice, as well

Chaos theory--Noun. The branch of mathematics that deals with complex systems whose behavior is highly sensitive to slight changes in conditions, so that small alterations can give rise to strikingly great consequences.

Alternative definition: Chaos theory--Noun. The branch of health care that deals with making the payment system increasingly complex and ever changing. The complexity and confusion impact physicians and patients in such a way that appropriate services in care of the patient are subject to rules and regulations that are deliberately complex, making alterations from the momentary rules inevitable. This exists so that even small alterations will free the insurance company from the responsibility to pay for said service.

Chaos Theory by jurvetson via FlickrI am no physicist, but I honestly think that a grasp and understanding of the first type of chaos theory is more likely than that of the second. Let me give a demonstration of the second chaos theory in action:

Step 1: Patient comes in to be seen.

Step 2: What insurance do they have?

Step 3: Patient produces insurance card

Step 4: Office has to verify that this plan is actually valid for this patient, with several alternatives:
--The insurance is valid.
--The patient has changed insurance but still holds an old card.
--The patient has been dropped from the insurance due to nonpayment or losing employment.

Step 5: Once verified, the patient does one of several things:
--Pays co-pay when that is required
--Pays past due balance. However, if past due balance is due to the insurance company not paying on a claim yet, the patient won't be required to pay (as long as it is a reasonably short period of time).
--Does not pay (either because of insurance like Medicaid that pays in full or because of indemnity insurance).

Step 6: Insurance card is scanned in, documenting what patient presented at the time of the visit and giving access to the card by clinical staff for the rest of the visit.

Step 7: Once settled, the patient comes back to the office to be seen by the medical staff.

Step 8: Patient is seen by clinician.

Step 9: If procedures are performed, they may or may not be billed by clinician, depending on insurance coverage. Several possibilities exist:
--The procedure is covered.
--The patient has Medicare or Medicaid, which does not pay for certain services. In this instance, the procedure code pays less than simply coding the visit at a higher level (E/M) due to complexity of the visit.
--The patient has HMO which is paid by cap and the procedure is not an "over and above" and so won't be covered. Here it doesn't matter if the procedure is billed or not.

Step 10: If immunizations are given, the insurance must be checked to see if the vaccine is covered. Since there are numerous plans under a single insurer, simply knowing the name of the insurer (e.g. Aetna, United Health Care) does not guarantee coverage. Often, this results in step 10(a), which is for the clinical staff to call the insurance company and ask directly if the immunization is covered (the results of which are only somewhat reliable).

Step 11: Once insurance coverage of the immunization is determined, several possibilities exist:
--The immunization is covered and so is taken from regular stock and administered to patient.
--The immunization is not covered, but others are by the insurance company. In this case, the patient is informed by the billing staff that they will have to pay out of pocket for this before the immunization is given. The patient is generally aghast at the cost and often foregoes the immunization, making step 10 superfluous.
--Immunizations are not covered by this insurer or the patient has no insurance and the patient is a child. In this case, the immunization is taken out of a different stock of vaccines ("Vaccines for Children") and given. The procedure is billed under an entirely different code.
--The patient has Medicare, and the immunization is not covered (like Zostavax, the shot for shingles). In this case, the patient is given a prescription for the immunization and picks it up at the pharmacy, brings it back, and gets it administered by the nurse.

Step 12: If the patient requires labs, the patient's insurance needs to be checked so they can go to the proper lab. A single payer such as Aetna can have different policies that require different lab facilities to be used, so there is significant risk that the sample will be sent to the wrong lab. Here, too, several possibilities exist:
--The patient can get the labs drawn in the office, and it does not matter which lab is used. In this case, the nurse sends the sample to the lab that is easiest for us to use.
--The insurance company allows "pass-through billing," which allows our office to bill for the labs and pay the lab a negotiated amount.
--The insurance company specifies a lab that picks up samples from our office, in which case we draw and put the samples in the collection bin for that lab.
--The insurance company specifies a lab that does not pick up samples, in which case we send the patient with a printed requisition to get labs drawn at that facility.
--The lab sample cannot be drawn here (needs to be frozen, for example) or the patient does not want the test drawn at the time of the visit. In this case, the proper lab facility needs to be determined and the appropriate requisition filled out and given to the patient.

Step 13: If the patient requires an X-ray to be done, it needs to be determined if the insurance requires authorization for that X-ray. Several possibilities exist:
--The insurance does not require authorization and does not specify where the X-ray must be done, in which case the patient is given a requisition and told to go to the preferred facility.
--The insurance does not require authorization, but specifies a specific facility. In this case, the patient is told to go to the appropriate facility.
--The insurance requires authorization, in which case a note is sent to our referral coordinator (full time position), who gets authorization and then informs the patient where the procedure needs to be done.
--The insurance does not require authorization, but the procedure must be scheduled. In this case, the referral coordinator is notified of the request and schedules the procedure with the preferred facility.

Step 14: If the patient requires a referral, it needs to be determined which physicians or facilities are on the list of providers for that insurance. This too can vary under different plans, as HMO will be very specific, PPO's will be somewhat specific, and indemnity insurance will not be specific as to which providers must be used. Furthermore, some types of referrals do not require referrals (dermatology, ob/gyn, ophthalmology, psychiatry) and so the patient is told to make their own appointment. Once it is determined which physician to use, there are several possibilities that exist:
--The visit is urgent, and the insurance does not require authorization. In this case, the patient stays until the appointment is made by the referral coordinator.
--The visit is urgent, and the insurance company does require authorization. In this case, the referral coordinator gets authorization from the insurance company, then calls the referral facility to make an appointment, giving them the authorization number. The referral coordinator must know just how urgent the visit is (immediate, today, this week?) and depending on that, either makes the patient stay until the appointment is made.
--The visit is non-urgent and the insurance does not require authorization. The appointment is made by the coordinator and the patient is contacted by phone/email with details.
--The visit is non-urgent and the insurance requires authorization. Same as above, plus authorization.

Step 15: If the patient requires a prescription, several non-clinical factors come into play:
--Is the drug on the formulary for the patient's insurance? This can vary with plans, and also may be different under a single carrier.
--If on formulary, what tier is it? If it is a higher tier, the patient may not be able to afford it or be willing to pay.
--If not on formulary, which drugs in the class are? Have others been tried?
--If not on formulary and still necessary, what is the process to get this authorized? In this case the prescription is given, the patient gets it filled, the pharmacy notifies us of the need for prior authorization, and we try to obtain it. This process can take up to three weeks.
--If denied by the insurance company and still necessary, what is the process for appeal?
--If patient has to pay out of pocket, then which drugs are cheap and which do we have coupons for?
--If patient is Medicare, then we cannot give coupons (because for some reason it is wrong to make the government pay less).

Step 16: The patient is dismissed with a plan and is scheduled for a follow-up appointment.

Step 17: The patient is asked to pay the remainder of the balance at check-out, depending on what the doctor ordered and what was done in the office.

There are a number of possible pitfalls.

--If the patient supplies the wrong insurance information, then all of the above is invalid and may not be covered.
--If the patient (or their blood) is sent to the wrong lab, X-ray facility, or referral facility, the insurance company will not cover the procedure (even if appropriate).
--If the patient is sent for an appropriate referral to an approved facility, but the proper authorization is not gotten, the visit will not be covered.
--If the lab/referral/consult is sent with the wrong diagnosis code, or one that is no longer valid, the insurance will not cover.
--If the lab is done at all early (under three months for a Hemoglobin A1c, for example), the insurance will not cover.
--If the immunization is given even one day early, it will not be covered, and won't be counted as being given.
--Who pays for these pitfalls? Either the patient (who then gets mad at the doctor for doing it wrong), or the doctor's office.

Confusing? Yes, that's my point. Multiply all of this times the number of different insurances the office accepts (including all managed Medicare and Medicaid), and watch what chaos ensues. Who benefits?

Not the doctor.

Not the patient.

Not nurses.

Hmm .... Who's left?

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Tuesday, May 18, 2010

Shocking statistics of the week

In the mind-numbing blur of numbers I've heard in the past few days, these two statistics stuck out:

First, here's a reason to get out of bed even if you were partying far too late in New Orleans last night. (Or the speaker could have been making some point about the importance of mobilizing ICU patients.) Even a healthy adult can lose 1 to 3% of muscle strength after a single day of bedrest!

So you should get moving, but it seems obvious that if you're feeling really tired, you shouldn't get behind the wheel. Not everyone seems to have gotten that message, though, because, as I learned in a session on obstructive sleep apnea, 37% of Americans reported having fallen asleep while driving in the past year!

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QD: News Every Day--Where the government's inflexibility fails doctors

Medicare's view on reimbursement is one-size-fits-all, says essayist Joanna Weiss. As Brent James, MD, chief quality officer at Utah's Intermountain Healthcare explains, Medicare's reimbursement system leaves little room for improvement in quality outcomes, and in some instances pays less for better care. Health care reform involves new ways of looking at reimbursement, including offering hospitals and other providers a set amount of money to spend on care, matched with quality markers to ensure proper care. Other options, though, might involved competitive bids for care, which would save Medicare money but drive down reimbursement to physicians. (Boston Globe)

Another festering issue involves the federal government pushing doctors to use electronic health records, touting their efficiency and improvement for care. Doctors resist buying them for a good reason: Such systems cost more than the government is dangling as an incentive, and then require time to research, buy, set up and learn. It takes a year to reconfigure a doctor's office, but for hospitals, it's a "multiyear, multimillion-dollar project." The government is giving users a year to meet 20 or so criteria that would qualify them for reimbursement from the incentive package. (Politico)

At the state level, internist Chris Rangel, MD, wonders if Massachusetts was wise to put language in a state bill to tie accepting Medicare patients to licensure. And in Minnesota, hospitals are in a scramble to adjust as the state hands changes Medicare for its poorest, most difficult patients, some of them homeless, or mentally and chronically ill. (KevinMD, Minnesota Star-Tribune)

In each case, physicians are asking for more flexibility to treat patients and get paid for that care. It's a simple message.

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Monday, May 17, 2010

Weird image of the day


Incoming ATS president Dean Schraufnagel, MD, explained his objection to smoking rooms like the one pictured here at the Atlanta airport. "It's akin to having areas for urination in a swimming pool," he said. "Eventually we all get that air."

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Year of the Lung

Did you know that 2010 is the year of the lung? No, it's not some little-known sign of the Chinese zodiac. It's an effort by ATS and its international counterparts to publicize lung disease--"our red dress campaign" as one ATS rep put it.

There's no clothing component as far as I know, but the ATS did pull out all the stops in their press conference today--6 speakers and another half-dozen or so representatives of lung diseases. Unfortunately, they significantly outnumbered the reporters in attendance. Perhaps that proves the presenters' point that lung diseases (particularly COPD) get less attention and funding than other major killers.

One their proposed remedies is World Spirometry Day on Oct. 14. It's months away, but if this holiday comes off as the lung specialists hope, primary care physicians better start getting ready now. "We want every patient to go to a doctor and say, 'Can I have a breathing test?'" said Nobert Berend, MD, of the Asian Pacific Society of Respirology.

I was tempted to question the cost-effectiveness of that plan, but it seemed too mean under the circumstances. So consider this your warning: if the year of the lung catches on, you'd better have your spirometer fired up on Oct. 14.

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My lunch-hour flight

I learned in a session this morning about how researchers are looking into simulated space flight as a method for mobilizing ICU patients. So far, the virtual reality program has only been tried out on healthy subjects and is still a ways from the critical care bedside. "There are some obvious resource limitations," noted speaker Doug Elliot, RN, PhD.

But attendees at the ATS meeting can try simulated flight right now, in the COPD Foundation's Journey to the Center of the Lung ride. Just like at Disney World, I stood in line to ride this exhibit hall attraction this afternoon. A dozen or so people were seated in the space-shuttle-shaped capsule and instructed to hold on. A video screen at the front opens with an image of the Earth and a warning that a "killer" is "preying on millions of people."

Then, with some tilting and bumping, we zoom down to Earth, all the way down the throat of some unsuspecting (cartoon) COPD sufferer. After a quick tour of the ailing lungs and some patient-oriented explanation about COPD, our group was expectorated back up (which, I have to warn you, is a bumpy process).

All in all, it was a pretty goofy experience, but the designers did manage to sneak quite a lot of information about COPD into the silliness. And a rep from the Foundation says they're already getting requests for the simulator from schools and public events. So, while I got in line with every intention of making fun of this ridiculous stunt, I have to admit that my journey to the center of the lung may have changed my mind.

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QD--News Every Day: Crowded ERs, but empty staff lounges

California's upcoming budget threatens $523 million in state Medicaid cuts, including a freeze to hospital payment rates. Hospitals lost $4.6 billion last year treating low-income patients. The payment freeze will be accompanied by a raise of patient's co-pays and a 60% reduction in state funds to local mental-health programs. The heads of hospital societies say the moves will hamper their facilities' abilities to deliver care at a time when more people may seek primary care from emergency departments. And, a survey of 1,800 emergency room doctors by the American College of Emergency Physicians shows that three-quarters say their facility's ERs are overcrowded at least three or four days a week, while one-quarter say it's always overfilled. HealthDay reports that 71% of those surveyed feel the problem will only get worse. So, there needs to be not only a push for more doctors, but for emergency room capacity. Architects who specialize in health care facilities are calling for an immediate start to a long-term building campaign. (Modern Healthcare, HealthDay, The Hill)

Nurses are seeking to fill the primary care pipeline left by a shortage of doctors, but the nurses are in short supply in some areas as well. Georgia has one of the lowest nurse per capita ratios in the country, so low they can't find instructors to teach students, who wait for years to enter training. Even populated regions have trouble keeping nurses. Florida has a 60% attrition rate for nurses, so major gains get wiped out quickly. It's something few mention when discussing using nurse practitioners to replace physicians. (Voice of America, The Newnan (Georgia) Times-Herald, South Florida Business Journal)

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Sunday, May 16, 2010

Exhibit hall silliness



You know the COPD epidemic has gotten out of control when even teddy bears need mechanical help with airway clearance.

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What do we want? Slides!

In my conference-attending experience, it's pretty standard for the speakers' slides to be posted on the conference website (often behind an attendees-only login). That's not the case at the ATS meeting, where I was told to contact the speakers individually if I want their slides. Apparently, I'm not the only one who finds this frustrating. Out of the 6 people sitting near me during this afternoon's session, 3 (and I was not one of them) were shooting pictures of the slides with phones or cameras, despite posted warnings forbidding photography. The docs have been driven to civil disobedience!

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Do all medical societies meet in Lake Woebegone?

During several conference sessions I've attended lately speakers have mentioned common practices that are not in accordance with established recommendations. They usually take the opportunity to rip on other specialties--"I know you guys don't do this, but those surgeons..." But during today's session on ethical dilemmas (which was really good--I plan to blog more on it later), Robert Fine, MD, brought the issue home.

He asked the audience how many of them would put a patient with advanced dementia on dialysis? No one raised a hand. Then he asked how many had seen it done and almost everyone raised a hand.

I think there's a clear explanation: all the good, guideline-compliant docs are at the conferences and the bad ones are left at home taking care of the patients.

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Get your COPD patients moving

I'm at the American Thoracic Society annual meeting for the next couple of days, learning what's new in critical care, pulmonary and sleep medicine.

This morning's press conference discussed new research on how to improve the condition of COPD patients. To sum it up briefly, exercise.

One trial found that being active on a regular basis was more associated with patients' functional status than their maximal exercise tolerance. It may sound sort of obvious (that post's not until tomorrow) that moving around during the day would increase your ability to move around during the day, but this gets at a larger issue about whether the secret to health is fitness or just regular activity, according to conference moderator Richard Casaburi, MD. "This suspicion is growing that perhaps the most important factor is that people are active," he said.

Another study found that COPD patients benefit from exercise (ie, pulmonary rehab) just as much even if they are obese.

And if that's still not enough evidence to get your patients off the couch? Maybe you should poke them with electrical prods. No, seriously, a small trial of neuromuscular electrical stimulation in patients with serious muscle wasting found improvements in their muscle mass. "These sort of devices have a little bit of a bad name from the ab exercisers you see on TV," said Dr. Casaburi. Note: researchers did not actually use the "as seen on TV" device, although I bet the one they did use costs more than three easy payments of $9.99.

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Friday, May 14, 2010

QD--News Every Day: Government to crack down on Medicare fraud

U.S. government officials are hoping that increasing fraud enforcement will pay off. The government will spend more than $350 million during in the next decade to identify and fight fraud. Some new measures include fingerprinting providers, site visits and background checks before billing Medicare and Medicaid, and withholding payments if an investigation is pending. The government is also concentrating on suspicious companies and on areas prone to fraud: south Florida and Tampa, Fla; Los Angeles; Houston; Detroit; Brooklyn; and Baton Rouge, La. The incentive is to recoup even more money from fraud. Investigations garnered $2.5 billion last year, a 29% increase over 2008. The U.S. Senate is also holding hearings into practices by some home health care companies' practices and their relationships with referring doctors. (Kaiser Health News, Washington Post, Wall Street Journal)

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Thursday, May 13, 2010

QD--News Every Day: Doctors delivering diagnoses online

Your doctor is now online and prescribing. Texas internists are enrolling in a service that sets them up to consult with patients over the Internet for $45 for 10-minute stretches. Telemedicine proponents play it up as a way of alleviating unneeded ER visits, for the uninsured who can't get to a doctor, or for rural areas that don't otherwise have physicians.

The doctors accept the limitations of telemedicine and their limited role. They diagnose conditions that wouldn't normally need a hands-on visit. They won't prescribe controlled substances, or may prescribe just enough of other kinds of drugs to get a patient through the weekend, for example.

Is "doc in a box" a good thing? The Texas Medical Board is adapting its telemedicine policies to address the changing practice modality.

There's no mention of how much the doctors are reimbursed per consult, either. But there's easier ways for doctors to make money online. (Kansas City Star, CNN)

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Is it OK to find patients on the Web? (Try Googling the answer)

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.

It's well known that patients Google their doctors, a practice that's performed with increasing frequency. But what about doctors researching their patients on the Web?

It's an interesting idea that I hadn't thought of. I have never Googled a patient, and can't see any reason to in a primary care setting. But the context of the piece, which I first saw in the WSJ Health Blog, was in psychiatry. It would be helpful for a psychiatrist, for instance, to know if a patient was blogging about suicidal thinking, or in the emergency room, when a patient arrives unconscious with minimal identifying information.

But in routine cases, there are few reasons to do so. Authors of a cited essay agree, suggesting that "doctors ask themselves honestly about their intent in conducting the search and whether the outcome might compromise the trust and relationship between the doctor and patient."

They even go as far as suggest asking patients for their consent before Googling them. That's questionable, since we're talking about information that's publicly available.

There are few ethical guidelines on this, with opinions on both ends of the spectrum: "Some people say absolutely it should never be done; it's a breach of privacy ... But then many say it should be done as a matter of routine. It's information that is in the public domain, and it may be information that is clinically relevant."

The overriding question should be, "Will researching my patient online improve their care?" If the answer is "yes," only then, perhaps, will there be a legitimate reason to do so.


This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 29,000 subscribers and 21,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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Wednesday, May 12, 2010

How to Micro-Tweak Diagnosis and Treatment

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

A common problem in health care is the number of times that small adjustments are needed in a person's care. Often for these little changes, a physical exam and face-to-face time have nothing to do with good medical decision making.

Yet the patient and doctor are locked in a legacy-industrialized business model that requires the patient to pay a co-pay and waste at least half of their day driving to and from the office, logging time in a waiting room, and then visiting five minutes with their practitioner for the needed medical information or advice.

Today I'd like to visit the case of a patient I'll call "DD," who I easily diagnosed with temporal arteritis (TA) through a 15-minute phone call after she'd spent four weeks as the health care system fumbled her time with delays and misdirection via several doctors without establishing a firm diagnosis.

A single phone conversation with DD led me to immediately order an erythrocyte sedimentation rate (ESR), and I sent her to the lab near her home. A mere 24 hours later her test confirmed the diagnosis (ESR=90) and she was already feeling better. I called her the next day with the results, after having already called in her medicine (prednisone) to start immediately, based on the lab test. I wanted to move with utmost speed because delaying treatment increases high risk complications, such as going blind.

Since then, she's experienced enormous frustration trying to access her Medicare physician. She consequently has given up on this approach, which includes forced office visits and delays, and instead manages her TA by paying me directly each month for 10-minute phone conversations (when she can reach me anytime she wants to).

She calls at a time that's convenient for her and we follow her progress with TA and the prednisone dosing. As is typical with most people, she did not want to believe that TA usually requires a year of prednisone dosing and that tapering the medicine too fast can lead to problems. Once she called me with increasing headache because she was tapering the dose faster than I had suggested. A second time I measured her ESR that showed her that her level was still not normal enough to recommend lowering the dose even though she was not feeling any headaches. At this point, I suggested she increase the dose of prednisone slightly. She is by now familiar with the classic long-term side effects of prednisone, some of which she's experienced personally and some that we have reviewed via phone and then have taken steps to stay ahead of.

Today she called me with her monthly update. She is feeling "perfect" after a month of being on prednisone regiment of 7.5 mg/day. DD wanted to know if it's reasonable to reduce the dose to 5 mg a day. I agreed and as long as she has no headaches or body aches during that month we should consider rechecking her ESR at the lab in a month before considering further tapers over the next six months. I called her pharmacy with prednisone 5 mg/day dispense #30 and placed a calendar reminder in our medical record calendar for a month from today and charged her five minutes of my time (which is $25). Compare that charge to a typical $20 co-pay or billing Medicare for another $40, plus the cost of gas to get to the office and the lengthy waiting room delays, all to get similar advice.

The answer to DD and me is simple: Telemedicine wins hands down in both speed and, therefore, quality of diagnosis, as well as cost.

What, dear reader, do you think?

Until next week, I remain yours in primary care,

Alan Dappen, MD

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: Feds address obesity, 'bad' ads in two campaign launches

The White House issued a report offering solutions to childhood obesity. The full scope of the report addresses issues from birth and breastfeeding through the educational system, with resources for parents, too. Among other measures:
--Food companies should limit children's advertising, food retailers should limit in-store marketing and media should curtail ads targeted at children lest the Federal Communications Commission do so by regulating commercials;
--The FDA should standardize nutritional information;
--Schools should reduce unhealthy offerings an increase exercise; and
--Pediatricians should reconsider routine obesity screening.
(Wall Street Journal)

In a second action, the executive branch is launching its "bad ad" campaign, asking physicians to report misleading advertising practices that occur in their offices, such as during drug detailing. The Food and Drug Administration's Division of Drug Marketing, Advertising, and Communications (DDMAC) will send a letter to prescribers to outline how they can ensure that prescription drug advertising and promotion is truthful.

Three times as much money is spent on promotions to prescribers than on direct-to-consumer advertising. And DDMAC can't monitor doctor's offices, dinners or promotional speaker training sessions. So, they are offering educational sessions at major medical conferences, anonymous reporting and e-mail and toll free reporting options at 877-RX-DDMAC.

Primary care shortage
Connecticut’s thinly stretched primary-care capacity is becoming practically see-through. Nearly one-fourth of primary care doctors don't accept new patients (28% of internists and 26% of family physicians). The state's medical society published its survey results for the first time.

More so:
--New patients must wait 18 days for a routine office visit;
--Half the doctors reported getting referrals to specialists had become more difficult over the past three years, mostly because of health-plan restrictions and then a lack of specialists; and
--Administrative requirements are driving doctors to consider a career change (22% of internists and 25% of family physicians).

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Tuesday, May 11, 2010

QD--News Every Day: What's made clearer in a transparent health system?

Congressional Democrats want more transparency in health care, believing it would further drive down the cost of care. Hoping to drive competition, some lawmakers are grumbling to force doctors to reveal business negotiations between them and drug and device makers. Opponents worry that manipulating economics would backfire. If everyone knows their competitor's business, why bother negotiating lower prices? (Politico)

But, transparency worked in Wisconsin, not in business dealings but in reporting outcomes. By voluntarily revealing clinical outcomes on the Web, the Wisconsin Collaborative for Healthcare Quality was able to spur low-performing hospitals to improve, high-performing facilities to eliminate tests that didn't improve outcomes, and create an informed health care consumer with choices where to receive care. (The Fiscal Times)

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Does Group Health's "Medical Home" Leave The Poor Behind?

This post by Richard A. Cooper, FACP, appeared at Better Health.


Group Health has published two papers recently, one in Health Affairs and the other in JAMA, both extolling the virtues of its medical home. These follow their brief report last fall in the NEJM and the lengthy description of their model in the American Journal of Managed Care. Their model has been promoted by the Commonwealth Fund, and it is cited in the current issue of Lancet.

The big news is that costs were a full 2% lower than conventional care, hardly a great success--it wasn't even statistically significant. But was even this small difference due to the medical home, or was it because the medical home patients were less likely to consume care?

Group Health assured us that the 7,000 patients still enrolled in their medical home were the same as the 200,000 controls because "burden of disease, as measured by Diagnostic Cost Groups (DxCGs), was similar." But while the DxCG system adjusts for diagnoses, age and sex, it does not adjust for sociodemographic factors, the strongest determinant of utilization. Nor does it appear to have accounted for health status. The chart below, from the AJ Managed Care publication, shows just how different these two groups are. Sadly, these differences are not described in papers in the NEJM, JAMA or Health Affairs, which are read more widely.


Anyone should be able to get better outcomes with patients who are more highly educated (and presumably higher income), who are more often white and whose baseline health status is better. Indeed, it's remarkable that the DxCGs could have been so similar, since health status was so much better among medical home patients. What's most amazing is that this favorable group consumed only 2% less resources. I would have expected at least 20% less.

But even if the model were valid, it's important to recognize the practical limitations in generalizing from it. It took eight physicians to constitute the six FTE physicians who provided medical home care, and these physicians had patient panels that were almost 25% smaller than Group Health's usual clinics.

Nonetheless, medical home patients were more frequently referred to specialists (and that was statistically significant). Not surprisingly, physicians in the medical home had less stress. Patients were more satisfied, too. But there are not 25% more primary care physicians available (really 50% more, when their part-time nature is considered) to allow all of the primary care physicians in America to reduce their panels and work part-time as these eight did, nor will there be enough specialists for them to refer to if the nation doesn't train more (see: No One is Home in the Medical Home).

Beyond all of this, I'm left with two nagging questions. Why, if the Medical Home is patient-centered, did it start with 9,200 patients in 2006, decline to 8,094 by the end of 2007 and fall further to 7,018 by the end of 2009, a loss of 24% of the patients in less than three years? Where did they go? And why?

And why, if Group Health's Medical Home is to be a model for the nation, does Group Health accept commercially-insured patients from eighteen counties (top panel) but Medicaid patients from only three (bottom panel)?



If we want high-performance primary care, it will have to be delivered in high-performance systems that use scarce physician resources more efficiently. Panel size will have to be increased, not decreased, as physicians defer more care to others. And physician satisfaction will have to increase not because of less stress but because physicians are rewarded for exercising the complex knowledge that they worked so hard to attain.

Most of all, if we want to decrease health care spending, we will have to recognize that the major remedial costs are associated with the added care that is provided to low-income patients. It is time to stop talking about wasteful medical homes for college grads and start talking about safe neighborhoods, high-quality schools and workable systems of care for a diverse and needy nation.

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, May 10, 2010

What Your Kids Will Never See

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


The one thing we can all agree on is that nothing stays the same. We marvel at the customs and habits of our great grandparent's era and everything looks so grainy and antique. But Victrolas gave way to record players, CD players, and Sony's Walkman, which all yielded to the iPod.

Here are a few things that we baby boomer physicians took for granted that our kids and grandkids will never see, except in old photos:

--Mercurochrome
--thermometers that need to be shaken
--glass reusable syringes
--nurses' hats

Add these medical marvels to the list that includes a rotary phone, a pay phone stand, and eventually any land line phone. Medical students are using their phones not only to access medical knowledge, but to generate it. Smartphones can record and diagnose patient's coughs, or take their pulse.

I no longer have an ice man or a milk man. (I did see an ice-cream man the other day.) Let me know what I've missed. What are some things medically related or otherwise that your kids or grandkids will never know except for old photos?

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--President promotes health care reform's immediate gains

President Barack Obama said over the weekend that health care reform has already improved lives. Many of the examples he cited tie into how the act will regulate the insurance industry. (Video of the 4:39 minute speach can be found here.)

Highlights of the speech include:
--Insurers have agreed to stop canceling coverage of sick people, ahead of their September deadline,
--A new federal office, the Office of Consumer Information and Insurance Oversight, will help states more tightly regulate insurers who game the system. Already, the administration stopped Anthem Blue Cross of California from raising health insurance rates by 39%,
--Four million small businesses benefited from health care tax cuts,
--Seniors will receive a $250 rebate check for prescription drug coverage,
--Young adults can stay on their parents' coverage until age 26, and
--The administration will draft a patients' bill of rights for consumers to educate consumers and then create an appeals process to enforce those rights.

(Business Week, Voice of America, AP, The New York Times, The Christian Science Monitor)

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Friday, May 7, 2010

QD--News Every Day: Doctors meeting less often with pharma reps

More doctors are refusing to meet with pharmaceutical reps, and the reps may have taken the hint. They're not scheduling appointments with those who aren't accessible. Cuts in the pharma industry have also lessened requests, but detailing via the Internet is also taking hold, letting reps meet with docs more spontaneously. Internist* and ACP Member Peter A. Lipson, MD, (aka PalMD) blogs that pharma influence is "a subtle influence which we are working hard to purge." (Wall Street Journal, White Coat Underground)

* Peter A. Lipson, ACP Member, was originally identified as a hospitalist in this post. He no longer does, as described in the comments below.

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Thursday, May 6, 2010

Must those licensed to heal be licensed to carry guns, as well?

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com.


With the attention focused, rightly, on patient safety, what about health care workers?

It's somewhat of a hidden phenomenon, but attacks on doctors and nurses are on the rise.

Rahul Parikh writes about this in a recent Slate piece. He cites data from the Bureau of Labor Statistics, which found, "Health care workers are twice as likely as those in other fields to experience an injury from a violent act at work, with nurses being the most common victims."

He goes on to detail an attack on a physician who initially refused to give his patient opioid pain medications: Mansfield's attacker wanted pain killers. "I need you to give me more Percocets, given the shape I'm in after what I've been through," the patient said in a soft but gravelly voice. "What I've been through" apparently referred to a grudge he held against an orthopedic surgeon whose rough examination exacerbated his neck pain. Mansfield says, "[H]e tried to reproduce the 'painful range of motion exam' on me, such that if I knew how painful it was--I would understand how much he needed the Percocet.

S&W Pre 34 22/32 Kit Gun by ~Steve Z~ via FlickrMuch of teaching on how to avoid potentially violent situations are ineffective in the long term. That leads to more extreme solutions--like carrying a gun.

Indeed, according to a survey conducted in 2005, 40% of emergency physicians admitted to carrying a gun. That seems like an incredibly high number to me.

Just like we should be concerned about patient safety, the safety of health care workers is no less important. That means doctors and nurses need to tell their stories and bring this issue to light.

And in the case where patients attack doctors or nurses, getting the police involved and pressing charges is an option that needs to be seriously considered.


This post originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 29,000 subscribers and 21,000 Twitter followers, KevinMD.com is the web's definitive site for influential health commentary.

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QD--News Every Day: Caring for the 'medically homeless'

Again, Medicare's pending 21% pay cut looms, and Congress until the 31st to figure out how to balance physician pay with a rising federal deficit. Doctors are faced with the prospect of closing their doors to their Medicare population, as ACP's immediate past president Joseph Stubbs, MACP, explains. The constant struggle to set reimbursement is one of the problems that contributes to a class of "medically homeless" patients, writes the president of the Patient-Centered Primary Care Collaborative. (NPR, Roll Call)

Add to this list those high-risk patients who can't find insurance. States continue to figure out how to bridge the gap until a federal law kicks in Jan. 1, 2014, that would ensure high-risk people get insurance coverage. New Mexico's likely solution will be to stretch limited government funding for high-risk insurance pools by insuring only 1,000-1,500 of the state's 5,000-50,000 people who qualify as hard to ensure. (The New Mexico Independent)

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Wednesday, May 5, 2010

One More Medical Acronym To Add To The Pile

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


In medicine, hardly a week passes without the introduction of some new acronym, previously unspoken in the average practice, which then grows to prominence--take HIPAA, PECOS, CPT, ICD, etc.--the list goes on and on.

I believe that after 14 years of practice I've earned the right to introduce an acronym of my own: CRAPP. For the last several months, my partner and I have used this term to describe the volumes of denials, pre- and prior- authorizations (is there really a difference?), and faxes that seem to grow like weeds on the fertile planting grounds of our desks.

More specifically, in our office the acronym CRAPP stands for Continuous Restrictive And Punitive Paperwork. To put it blithely, CRAPP could represent any document you wish someone had put on your partner's desk instead of yours.

On a more emotional level, this acronym captures the visceral response I have whenever my attention is drawn away from my patients and redirected towards some nonsensical busywork, much like someone yelling at a golfer during their backswing.

One does not have to explain to you that a piece of paper in your hands is CRAPP; you know it when you see it. If an office worker scurries away apologetically after putting a piece of paper on your desk, it might be CRAPP. If your good mood evaporates and is replaced by a confused affect after reading the first two sentences in a never before seen type of document, it might be CRAPP. If a fax makes you revisit a clinical decision you have made over and over again, well by now you should get the point so I'll leave the Jeff Foxworthy cadence aside.

Last Monday began with a document denying a brain MRI for a patient suffering for almost two years from headaches because I was not "in the system." Setting aside the visual image of being drawn into someone's system, I remembered that I had previously answered all their medical questions explaining the reasons my patient needed this MRI and my staff had faxed the entire medical record to them the preceding week. So, I answered all the personal questions confirming my qualifications and shared the collection of numbers unique to me (NPI, UPIN, Tax ID #, etc.) thus, finally, enabling my patient to have the MRI without paying for it himself.

As I walked this completed document to the office fax machine, my attention was drawn to the letterhead on the fax: "Medical Solutions." In a moment of clarity, I conceived the second rule of CRAPP (the emotional loss of focus being my first rule). The second rule identifying a document as CRAPP is, if the antonym of the company name accurately describes the process a document has set in motion it might be CRAPP. My thesaurus listed muddle as the antonym for solution and the second rule of CRAPP had passed its first test.

Which brings me to the heart of it all. We've all heard that "two's company and three's a crowd." Well, the doctor-patient relationship is crowded with a third "partner" that is always present, whether you think of them or not. This invisible partner makes its presence known in innumerable ways, robbing busy doctors of an always rare daily resource: time.

CRAPP steals time from our patients and takes away from the quality of the practice of medicine and in large part explains the growing shortage in primary care medicine doctors. I would like to tell you that it will get better with the new reform bill. However, I suspect Uncle Sam and the insurance industry will be spreading CRAPP much like Johnny Appleseed spread his famous seed.

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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QD--News Every Day: Medical homes work, but will anyone notice?

The patient-centered medical home received an evidence-based endorsement that the practice model can lower the costs of care while improving patient outcomes. Health Affairs reported outcomes from a 10,000-patient pilot of one practice. Patients incurred 29% fewer emergency visits and 6% fewer hospitalizations. After start-up costs of $16 per patient per year and 21 months of adjustment, total savings reached $10.30 per patient per month. The system has since expanded the model to 26 medical centers that treat 400,000 patients. (Kaiser Health News, Health Affairs)

But, medical students will earn $3 million less in their lifetimes by choosing primary care. So, Health and Human Services Secretary Kathleen Sebelius is touting health care reform's emphasis on health information technology, medical homes and accountable-care organizations. (Modern Healthcare)

Despite the promise of better care in either a medical home or under health reform, most patients admit they are ill informed about the issue, a survey showed.
--76% of adults graded the current health care system a C or less,
--half believe that more than half of health spending is wasted, and
--23% understand how the health care system works.

But, 57% said they were satisfied with their health plan and 75% of those with a recent hospitalization said they were satisfied. So where's the disconnect? Researchers chalked it up to fear of the unknown being greater than discontent with a flawed system. (Reuters)

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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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