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

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Thursday, September 30, 2010

Diagnostic context lost to constant patient churn

A recent study from the Annals of Internal Medicine found that doctors often discounted a patient's social situation when making a medical diagnosis.

Lead researcher Saul Weiner "arranged to send actors playing patients into physicians' offices and discovered that errors occurred in 78% of cases when socioeconomic concerns were a significant factor."

Evan Falchuk, commenting on the results, provides some context: "It's hard to expect even the most gifted clinician, trying to make it through yet another week of a hundred or more patient encounters, to get these difficult decisions right. Too much of the context of a patient's care gets lost in the endless churn of patient visits that the health care system imposes on doctors. I suspect this is enormously frustrating for doctors, although it's worse for patients. What the researchers call a failure to 'individualize care,' a patient might call 'not being paid attention to.' It's a dynamic that anyone who's been ill has probably seen first-hand."

These findings are entirely unsurprising. Uncovering social factors that potentially underlie a patient's symptoms takes time to find out. And sometimes, patients are reluctant to disclose their social situation to doctors until a relationship is made--an acknowledged limitation of the study, which only observed first-time encounters.

Primary care doctors are restricted by a payment system that doesn't value time, and subsequently, "most physicians are under incredible time pressure and don't want to go there because it could open up a whole can of worms."

The best way to value time is to pay primary care doctors by the hour. Reduce the pressure to see a huge number of patients. And you'll miraculously see the problems brought forth by this study markedly improve.

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 33,000 subscribers and 23,000 Twitter followers, KevinMD.com is the Web's definitive site for influential health commentary.

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QD: News Every Day--ADHD linked to ATCG

British scientists announced that attention deficit-hyperactivity disorder (ADHD) has been linked to deleted or duplicated DNA segments (copy number variants), which leads to developmental difference in the brains of children with the condition.

Researchers scanned genomes of 366 children with ADHD and compared them with 1,047 unrelated, ethnically matched control subjects. They reported full results in The Lancet.

Rare copy number variants were almost twice as common in children with ADHD compared to the other children. Researchers commented to Reuters that there was a significant overlap between copy number variants found in ADHD and elements of the genome linked to autism and schizophrenia, specifically in a region on chromosome 16.

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Debating and dining over diabetes

There's something kind of evil about a conference that offers you delicious chocolate chunk brownies and statistics like "51% of Americans' mortality risk is due to lifestyle factors" at the same time.

But yesterday's "Diabetes Symposium: Seeing Patient-Centered Solutions to a National Epidemic," sponsored by the Jefferson School of Population Health, did have more to offer than sadism.

We heard about some innovative programs for diabetes patients that appear to be working, like Jefferson's family practice medical home and group visits. And some that haven't been so successful, like an initiative to elimiate diabetes-drug co-payments at Christiana Care in Delaware. The patients reported that the program made it easier to pay for their drugs and improved their compliance, but their A1cs hadn't budged even after a year.

Richard Wender, MD, who described the Jeff practice, offered a number of tips on the implementation of a medical home, some practical (they schedule most of their appointments 24 hours or less before) and some a little more abstract ("Create a joyful practice.").

The discussion of health care financing, especially on how to profitably convert practices to medical homes was not so joyful. "If we don't come up with a payment model, we're just kidding ourselves," said Dr. Wender. Medical directors from UnitedHealthcare and CIGNA were on hand, but they didn't have much new to offer, saying that fee-for-service is unlikely to go away anytime soon.

Robert Ratner, MD's report on the current state of evidence-based medicine was pretty gloomy, too. "Our guidelines are not being driven by data," he said, noting that although tens of thousands of randomized, controlled trials come out every year, every evidence review ends with the caveat that available evidence is too limited to draw firm conclusions. But he sees hope in the future, specifically in the hundreds of millions of dollars that the stimulus and health care reform laws will provide for comparative effectiveness research.

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The medical profession: Is it devolving?

I had lunch with a group of physicians recently, and along for the ride was a college student thinking of applying to medical school. When talking about the future, I suggested that the work of a physician 30 years from now will be hardly recognizable to today's physician. Everybody disagreed and the student was confused. There was a lot of denial and myopic rationalization.

But I can't blame them, really. Most of us see what's immediately changing in our day-to-day work and the bigger picture gets lost. For most of us, the role of the physician is hard to see for anything other than it always has been. Most live and work as the self-determined independent care coordinator, reactively working to treat disease just as it has been done for over a century. But change is happening around us.

I see three forces driving change in the physician role:

Technology. In the 19th century we treated symptoms. In the 20th century we treated diseases. In the future we will predict and prevent disease. Much of what we do diagnostically will be replaced by technology.

Third-party control. The days of independent decision making are numbered. Evidence-based measures rooted in resource control will rule the future. Much of what we do will slowly approximate automation.

Patient empowerment. Since the dawn of medicine physicians have been defined by their unrestricted access and control of information. But unbridled access to information is changing the role of the patient. This shift is changing the way we see patients and the way they see themselves.

I'm in no way predicting the end of the physician. There will always be disease and the need for a human docent somewhere amidst all this technology, information and administrative control. I just think that the way we understand the physician will be remarkably different 30 years from now.

As doctors, none of this is in our control. But we may ultimately be defined by the role we play as these changes evolve.

I want to cultivate this into something a little more involved. If you have any ideas that might be helpful, leave a comment here. If you're a transparency-conscious physician, feel free to drop me a line via electronic mail or tightly sealed envelope.

This post by Bryan Vartabedian, MD, appeared at Get 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, September 29, 2010

QD: News Every Day--Physician-owners focused on revenue, system-owners on efficiency

Physician-owned medical groups reported a slight increase in total relative value units (RVUs) per patient (0.09%) and a nearly 13% increase in work RVUs per patient, while hospital/integrated delivery system-owned practices reported a slight decrease in total RVUs per patient (0.55%) and a 17.85% decrease in work RVUs per patient.

The Medical Group Management Association’s (MGMA) "Cost Survey for Multispecialty Practices: 2010 Report Based on 2009 Data" highlights other differences.

In practices not owned by hospitals or integrated delivery systems:
--Operating costs per full-time-equivalent (FTE) physician increased by nearly 2% since last year;
--Total medical revenue after operating cost per FTE physician decreased slightly (0.16%) since last year;
--Staff and provider costs in 2009 (including support staff, non-physician providers and physicians) comprised 76.06% of total costs; and
--The number of patients per provider has decreased nearly 9% in the past five years.
Chart provided by MGMAPrivate practices are likely affected by purchasing an electronic health record, said an MGMA analyst. EHR-buying incentives spurred purchases, which were reflected in the bottom line.

In practices owned by hospitals or integrated delivery systems:
--Operating costs per FTE physicians decreased by 0.37% from 2008 to 2009;
--After operating costs, total medical revenue per FTE physician increased by 2.4% for the same time period;
--Staff and provider costs in 2009 (including support staff, non-physician providers and physicians) made up nearly 89% of total costs; and
--Groups reported about a 9% increase in patients seen per provider in the past five years.

Chart provided by MGMAAgain, EHRs played a role, but this time they had a bigger impact in reducing costs and administration when deployed in a larger system, the analyst noted.

The survey reflects data from 45,000 providers, an increase of 8% over last year. Still, MGMA noted that participation is voluntary and may not be representative of the industry.

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Tuesday, September 28, 2010

QD: News Every Day--Coping with the daily grind with coffee beans

The Coffee Tower by wrumsby via FlickrNurses and doctors depend on coffee to perform their jobs the most of any profession, reports a survey.

Nurses ranked first and doctors second when asked if they needed coffee to get through their day. The rest of the coffee-fueled careers were a mixed bag of white collar and blue collar positions. Among other findings:

--48% of those in the Northeast said they were less productive without coffee, compared to 34% of Midwesterners;
--40% of those aged 18 to 24 said they can't concentrate as well without coffee; and
--37% say they drink two or more cups a day.

The study was funded by CareerBuilder and Dunkin' Donuts.

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Monday, September 27, 2010

QD: News Every Day--Government meddles in new practice models

Government health care reform efforts are picking up the pace to roll out new reimbursement and practice models for primary care.

Medicare is giving out $10 billion for pilot projects encouraging new models of primary care, including the patient centered medical home. New Jersey just passed legislation to explore the patient-centered medical home. Now, Massachusetts, the early adopter of mandatory health insurance, is now ambitiously planning how to take on the fee-for-service reimbursement system and moving toward accountable care organizations. Under discussion are the scope of power for state regulators, what rules will apply to accountable care organizations and how to get rid of the existing fee-for-service system.

Blogger and pediatrician Jay Parkinson, MD, MPH, comments about the "bureaucrats in Washington" that, "They've decided for doctors that we'll get paid for strictly office visits and procedures when, in fact, being a good doctor is much, much more about good communication and solid relationships than the maximum volume of patients you can see in a given day."

Now, it's those same bureaucrats who are changing the system, trying to find a model that will accomplish just those goals. (CMS Web site, NJ Today, Boston Globe, KevinMD)

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Collecting sighs

My billing manager came to me again today with the infamous blue folder. In it was a list of patients who were significantly delinquent in their payments to our practice. The names on the list weren't the kind of people you would expect; they were really nice folks, the kind of people I am glad to have in my practice. My manager saw me looking at them sadly and rushed to justify herself. "These folks have been contacted numerous times, with offers to stretch out the payments to keep them small. They just don't return our calls" she explained. "This woman said she would bring by $10 last Friday, but never showed up."

It wasn't just individual names I was looking at, it was families. I pictured the children; one little girl always asks for me when she was not feeling well. I thought about how I'd get the bigger kids to laugh. I thought about the parents, who were really nice people and were good parents.

Sigh.

"We just can't let them keep coming in and building up more of a bill," my manager added. "These families both have outstanding balances of over $300 and they haven't even made an attempt to work things out with us. I know it's hard for you, but we have to draw the line somewhere."

Sigh.

I signed my name in the box next to their name. They will be sent to collections and given a letter of discharge from the practice.

I hate it. They are really nice folks, and I understand how bills can be overwhelming at times. We really do whatever we can to accommodate this, sometimes having them pay $10 per month for a year and calling it even (even if their bill is well over the $120 this represents). We have never been predatorial. I don't want this to be about money, but if they don't even work with us ...

Sigh.

I don't think I could tolerate not being my own boss. I don't take authority too well. But I absolutely hate this side of private practice. I hate it when money stands between me and a little girl that wants me every time she is sick.

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

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Friday, September 24, 2010

QD: News Every Day--Give us your drugs

The Drug Enforcement Administration is coordinating “National Prescription Drug Take-Back Day” this Saturday, encouraging people to turn in their unused prescription drugs. The agency hopes the event will help decrease rates of crime and addiction linked to prescription drug abuse, the New York Times reports.

Doctors who are overweight are more comfortable talking to their overweight patients about slimming down, possibly because they’re considering doing so themselves, according to the LA Times. And in related news, the Washington Post looks at the financial consequences of weight loss therapy for patients whose insurers won’t cover it.

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Doctors and social anonymity

I don't think doctors should be socially anonymous. We need to be seen. Here's why going underground isn't good policy for physicians:

Anonymity makes you say stupid things. When you're shouting from the crowd it's easy to talk smack. Come up to the podium, clear your throat, and say something intelligent. You're a physician, not a hooligan.

It's 2010: Anonymity died a long time ago. You think anonymity offers shelter? You're funny, you are. Anonymity is a myth. You can create a cockamamie pseudonym, but you can't hide. And if I don't find you, the plaintiff attorneys will. They found Flea.

Being a weanie is no excuse. Just as you're unlikely to consult a lawyer before speaking at a cocktail party, commenting as Dr. You is unlikely to kill you or land you in court. Just a few pointers: Don't talk about patients, help people out, and be nice. Trust me, I'm a doctor.

We need you, darn it. There are, like, 12 doctors in the free world with regular blogs. And all the rest are either working or peeking from under their desks hopin' this social stuff all goes the way of the hula hoop. If we all just spoke up, we could change the world. As for me, I'm typing as fast as I can and I'm tired of doing it alone.

Anonymity soils credibility. We need to be out there helping to keep check on the nonsense circulating in the infosphere. I think it was Dr. Val Jones who once said that "the Internet needs lifeguards." Of course patients can swim. No one needs to be rescued, but there's nothing wrong with a few strategically placed lifeguards to blow the whistle every now and again (mind you, these aren't paternalistic lifeguards, but lifeguards seeking a partnership with empowered, engaged swimmers.)

"I'm not a doctor, but I play one on the Internet." In the end, no one trusts a lifeguard in a ski mask. Unless we know who you are, you don't count. If you're anonymous, I have to assume you're actually a disgruntled medical assistant with an axe to grind. Show your face and create a digital footprint that we can all see. Look at me. Look at my blog. Crosscheck me with Texas Children's Hospital, Baylor College of Medicine, the quarter-million other ventures I've been engaged with. I'm real. Those links are real.

Go and be real so that your voice can be credible. What am I missing here?

This post by Bryan Vartabedian appeared at Get 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, September 23, 2010

QD: News Every Day--First health care reform provisions kick in

Today is the six-month anniversary of the signing of the Patient Protection and Affordable Care Act, and accordingly several of its provisions are scheduled to kick in.

Starting today, says a rundown in the Washington Post, children can't be denied coverage because of preexisting conditions and will be able to stay on their parents' insurance plans until age 26. Insurers won't be allowed to limit lifetime benefits in most cases, and won't be able to retroactively cancel a policy unless they can prove fraud. Patients will have the right to appeal claims denials, and some preventive services will be free. Patients won't be penalized for going to the nearest emergency department and will be able to choose their primary care doctor, pediatrician or ob/gyn without referral.

President Obama is promoting the benefits of the new law to the public ahead of the midterm elections, and insurers and state workers are gearing up to implement the changes. Meanwhile, Bob Doherty at ACP Advocate reports on a new AP poll showing that many Americans still don't understand the law's provisions.

ACP has partnered with AARP to release a patient's guide to the new law, and has updated its guide for internists. (Washington Post, New York Times, ACP Advocate, ACP)

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Wednesday, September 22, 2010

QD: News Every Day--Preparing for disaster

Emergency preparedness has improved across the U.S. at both the state and local level, according to the CDC. Its recently released report, "Public Health Preparedness: Strengthening the Nation's Emergency Response State by State," found that almost 90% of states and localities are able to activate and rapidly staff emergency operations centers; most had excellent biological lab capability and capacity; and all states could handle urgent disease reports around the clock, among other findings. Speed in reporting relevant data to the CDC also improved, Medpage Today reported.

Remaining challenges include preparing for simultaneous outbreaks and improving quality surveillance and epidemiology. "We must foster improvements for rapid awareness, identification, and communication of health threats; measurable preparedness goals and response plans; and ongoing support for state and local public health," Ali Khan, FACP, director of CDC's Office of Public Health Preparedness and Response, said in a press release. (CDC, Medpage Today)

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Tuesday, September 21, 2010

QD: News Every Day--Overestimating cardiovascular risk

How accurate is that online calculator for cardiovascular risk? According to a recent study, it depends on the formula behind it. The New York Times reports that some popular online versions of the Framingham risk score use a simplified formula that may overestimate a patient's risk.

Approximately one in three office-based U.S. doctors are now using e-prescriptions, a steady increase from 2009 and 2008, according to new data released today by electronic prescribing network Surescripts and reported by Reuters.

And finally, obesity is bad not only for your health but also for your wallet. Researchers from George Washington University found that obesity costs $4,879 annually for women and $2,646 annually for men. Men's costs may be lower because unlike women, they don't appear to suffer wage penalties because of their weight, the researchers said. (New York Times, Reuters, MSNBC.com)

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Monday, September 20, 2010

QD: News Every Day--Should people die of "old age"?

The Washington Post asks whether "old age" should be reconsidered as a legitimate cause of death for the elderly. Because more people are dying at very advanced ages with multiple system failure, it's often harder for physicians to pinpoint the specific underlying cause, but using "old age" as a catchall term could make mortality data less meaningful, the article said. An upcoming revision of the International Classification of Diseases might provide some guidance: "Each revision of the ICD is the right moment to reconsider this question," the co-head of the ICD's mortality statistics committee told the Post. (Washington Post)

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Friday, September 17, 2010

QD: News Every Day--Taking aim at fake diseases

Ever heard of adrenal fatigue? Wilson's temperature syndrome? If not, there's a good reason: They exist only on the Internet. The Hormone Foundation, an affiliate of the Endocrine Society, recently issued two fact sheets for patients debunking these so-called conditions, which were "apparently conceived only in an effort to sell products promoted to treat them," the LA Times reported. No medical evidence supports either faux disease and there are no tests or treatments for them, but patients still try to alleviate them with supplements, some of them potentially dangerous, the Times said. Adrenal fatigue is characterized by such "symptoms" as having salt and sugar cravings and needing coffee to get you through the day, while the man who discovered Wilson's temperature syndrome also coincidentally promotes a product to treat it, according to the Times. (Hormone Foundation, LA Times)

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Thursday, September 16, 2010

QD: News Every Day--Ranks of the uninsured swelled with the recession

The ranks of the uninsured rose from 46.3 million (15.4%) in 2008 to 50.7 million (16.7%) in 2009, reports the U.S. Census Bureau.

Among the findings:
--The number of people with health insurance decreased from 255.1 million in 2008 to 253.6 million in 2009, the first year since 1987 that the number of people with health insurance has decreased.
--Private health insurance decreased from 201 million people to 194.5 million people; employment-based health insurance decreased from 176.3 million to 169.7 million; government health insurance increased from 87.4 million to 93.2 million; and Medicaid coverage increased from 42.6 million to 47.8 million.
--In 2009, 10% (7.5 million) of children were without health insurance.
--Uninsured rates decreased with household income, from 26.6% for households earning less than $25,000 to 9.1% in households of $75,000 or more.
--The Northeast had the lowest uninsured rate, but all four geographic regions saw increases in uninsured rates.

SOURCE: U.S. Census Bureau, Current Population Reports, P60-238, Income, Poverty, and Health Insurance Coverage in the United States: 2009
In case you missed it ...
Today, we know the role of Helicobacter pylori in ulcers, but in the 1980s, physicians thought they resulted from stress. Antacids made billions in profits, and patient were miserable because they were told it was all in their heads.

Slate interviewed Australian physician Barry Marshall, then an obscure researcher who came at the experiment sideways, noticed the correlation between bacteria and ulcers and then drank a cocktail of bacteria to prove himself right. He tells his story and how clash between evidence-based medicine and the medical establishment launched him to a Nobel Prize.

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Even private social networks may one day be public record

I recently wrote about the hidden dangers of physician social networks, and how private posts can potentially become public at a later date.

With the recent controversy surrounding former Washington Post blogger Dave Weigel and Journolist in mind, I commented that: "... passionate, controversial debate is frequent on Sermo, along with discussion of patient cases. Part of what makes the site so provocative and insightful is the fact that the conversations are shielded from the public. But there's no guarantee that will always be the case, as 'perhaps a physician-turned-hospital administrator who went looking for dirt on a trouble-making internist, [or] a malpractice attorney who used his brother-in-law's log-on ID to troll for cases,' are both plausible scenarios."

Bryan Vartabedian has a more positive take. He likens physician social networks to water cooler talk, no different from doctor lounges of days past. Physicians there often discussed patient issues informally, and engaged in provocative conversation on various health issues.

It's not often that a doctor can get sued over this. "The medical malpractice attorneys I've consulted on the matter have suggested that a plaintiff must prove that the physician has a duty to the patient in question. And that duty only comes through the establishment of a relationship. Or, in other words, it must be shown that the doctor is responsible and obligated for the patient's care. And in the case of the curbside consult there is no duty on the part of the doctor interrupted during his coffee break."

Dr. Vartabedian argues that the malpractice risk of physician social networks is no different, and thus, doctors should be less concerned about potential liability.

There is one difference, however. Every conversation on a social network is recorded electronically, and can potentially surface in the future. Taken out of context, it can present the doctor in an unflattering light. No such record exists from a physician lounge conversation.

I would still advise physicians to be careful about what they say behind closed virtual doors. Be aware that after you hit the enter key, whatever typed is singed into cyberspace forever.

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 33,000 subscribers and 23,000 Twitter followers, KevinMD.com is the Web's definitive site for influential health commentary.

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Wednesday, September 15, 2010

QD: News Every Day--Patients swap doctors rather than discuss their care

Patients won't confront doctors if they think there's been a mistake. They'll just find a new doctor, even if there'd been no medical error.

Researchers looked at adult visits to seven primary care practices in North Carolina during 2008. They asked patients about their perceptions of medical mistakes and how did it influence the choice to switch doctors.

Of 1,697 patients, 265 (15.6%) reported a mistake had been made, 227 (13.4%) reported a wrong diagnosis, 212 (12.5%) reported a wrong treatment, and 239 (14.1%) reported changing doctors as a result. Results appeared in the Archives of Internal Medicine.

But anecdotes cited by patients as mistakes were often normal diagnostic or therapeutic challenges. A typical scenario might be the patient reported symptoms, the doctor did not correctly diagnose it at first presentation, and a specialist or second physician offered a specific diagnosis. Other scenarios included medication trials or side effects from the prescription.

The study's lead author told Reuters that this occurred even when the doctor hadn't done anything medically wrong.

Patients with chronic back pain, more education and poor physical health were more likely to perceive mistakes. Whites were more likely to report mistakes (19.6%) than blacks (13.1%) or Hispanics (13.4%).

And, patients reported more harm as a result of the mistakes than rates of harm reported in the literature, the researchers noted.

Communication and relationship problems or trouble seeing the doctors were reported as mistakes such as a misdiagnosis, according to the study. And, patients frequently reported as mistakes things such as medication trials that doctors consider a normal part of diagnosis and treatment.

Knowing which patients are at increased risk for perceiving mistakes may be useful to doctors so they can temper patients' expectations, study authors wrote. An editorial said, "Some of these may be true mistakes; others may be due to the progression of disease, community-accepted stepwise testing and monitoring of symptoms to reach a diagnosis, well-known medication adverse reactions, and the sensitivity of medical diagnostics," and called for better measures of patient safety in the ambulatory setting.

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Tuesday, September 14, 2010

QD: News Every Day--Berwick speaks, seeks to lower costs and improve care

Medicare's administrator, Donald Berwick, publically outlined his views on what his agency will do for health care and rebuked his critics on what he would not yesterday. In a speech (transcript) to insurance executives, Berwick promised to bend the cost curve while improving patient care.

Partisan views criticized his approval of Britain's national health system, saying it would lead to health care rationing in America. Berwick's speech said that the U.S. system doesn't work as is and the federal government doesn't have all the answers. But the Centers for Medicare and Medicaid Services is looking at pilots of the patient-centered medical home and accountable care organizations as ways to make health care delivery more efficient.

Previous attempts at health care reform have focused on tort reform and improving shortages in primary care. But malpractice adds 2.4% ($55.6 billion) to the nation's health care tally. And good primary care is good primary care, even in medically underserved areas, reported two studies in Health Affairs. (Wall Street Journal, The Washington Post, The Fiscal Times)

Antibiotic resistance
U.S. infectious disease experts want doctors to be on the lookout for antibiotic-resistant superbugs, following reports of British patients infected after returning home from medical procedures in India and Pakistan infected with the bacteria. Other cases have been reported in the U.S. and Canada, so officials want physicians to be suspicious and ask if people if have recently visited there.

At question is a gene variation, NDM-1 (named for New Delhi) that links with common bacteria to create the resistant strains. Even in common use, antibiotics can disrupt good intestinal flora for far longer than the immediate course and shortly thereafter. And, it may contribute to more superbugs. (Philadelphia Inquirer, Reuters)

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Monday, September 13, 2010

QD: News Every Day--A year into practice and a half-million in overhead

Newly minted MDs face student loans the sizes of mortgages and might go 18 months without an income if they try to start up their own practice. And although in the words of one student, "Medicine shouldn't be treated like a business," physicians still have to operate their practices like one. That's resulted in one doctor facing a half-million in operating expenses every year in Manhattan. A half-dozen other new physicians describe their first years in practice in these two profiles, while a third details how Leslie Saltzman, ACP Member, took advantage of some resources on hand and guidance from ACP’s Running a Practice section to quickly grow her solo practice into a full-service resource for women’s health. (New York Post, Kaiser Health News, ACP Internist)

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Back to school

For five years I worked at GlassHospital's Student Care Center.

One of the great things about GlassHospital is that it sits on the campus of a well-known and fairly well-respected former Big Ten university.

(What's that you say? That's right ... Big Ten ... in the 1930′s! You can still go to the main athletic gym and see the very first Heisman Trophy!)

Like all colleges and universities, our place acts in loco parentis to the students that grace its campus. This means responsibility for our students' health and well-being.

I loved working at the Student Care Center. Taking care of 18-22 year-olds and the occasional rowdy MBA student is completely different than the "grown up" patients I usually care for. My grownups frequently suffer from a multitude of chronic medical conditions like diabetes, high blood pressure, or shpilkes. Come to think of it, shpilkes is really the only affliction of the college-aged.

That and crabs.

One of the dirty little secrets of working in a place like Student Care is that if you work the morning shift, you have a lot of time in between patients since most college kids are busy "studying" all morning. Things tend to get much busier in the afternoon when the patients are actually awake.

For some reason, college health centers almost invariably have terrible reputations. Students love to badmouth the place. I know I did when I was a student. One perpetual legend is about how Mom and Dad get the billing statement from the student health center, and it always has a pregnancy test charge, even when the presenting complaint is "sore elbow." This occurs especially if the patient is male.

It's fun for the students to complain about the health center, just like they do about the cafeteria, the administration, and, if you live in Chicago, the weather.

But as my colleague Dr. Alex Lickerman points out in this article, students don't know how good they have it.

College health advocates like to say that college is a formative time in which healthy habits can be achieved for a lifetime of wellness. My roommate from medical school, who now runs a college health service at an elite eastern institution, describes it as having the opportunity to "get 'em where they are."

By this, he means that when students come in with fears about STDs real or imagined, he preaches not only about safe sex and sexual health, but emboldens the students to think about more prosaic health habits for the rest of their lives. Like not picking up smoking, as a major example. With students, the die is not yet cast.

Working in student care, it was always interesting to try to find the transition point for students between Mom & Dad calling the shots ["You should go to the doctor ... Did you go to the doctor? ... What did the doctor say?"] to some form of graduated independence ... like actually taking responsibility for health and other behaviors. Some of the firsts on the long road toward maturity.

Here's to a great school year! Thanks for reading ...

This post originally appeared at GlassHospital. John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, 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 that inhabit them.

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Friday, September 10, 2010

Humane farming to prevent Salmonella infected eggs

More than a thousand Americans are ill from eggs contaminated with Salmonella and it has forced a recall of a half-billion eggs and increased scrutiny of the safety of eggs. The Centers for Disease Control and Prevention have tracked the contaminated eggs to two Iowa facilities, one with over 1 million chickens. It turns out that less than 200 big companies supply 95% of the eggs in the United States. Wholesalers and distributors routinely repackage the eggs for sale under other names, like Albertsons or Wholesome Farms.

According to National Public Radio, the Iowa egg producer is part of the DeCoster family business who has run large hog and chicken operations. They have faced a number of complaints and charges including employment discrimination, environmental violations, federal immigration charges and animal cruelty charges against their chickens. They paid millions in fines to settle the charges.

There have been nine studies published in the last five years that show higher rates of Salmonella in chickens who are kept in forced confinement compared to a cage-free environment. A caged hen is given only 67 square inches of cage space to live her life. That is less space than a single sheet of paper. The hen cannot nest, perch, spread her wings or walk. Even cage free animals aren't outside pecking on the ground, but they can at least walk and lay their eggs in nests, which is a natural behavior and reduces levels of stress and frustration.

A study published in the American Journal of Epidemiology reported that by switching to cage-free systems, the egg industry may be able to cut the risk of Salmonella for the American public by half.

California passed a law requiring that all whole eggs sold statewide be cage-free by 2015. Michigan has also passed laws to phase out the use of cages to confine hens. With 95% of egg-laying hens confined to cages, this is a small start and more legislation is needed to protect food safety.

You can do your part by buying only cage free eggs at the market.

This post originally appeared at Everything Health. 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--'No simple relationship' between primary care access, better health

More primary care visits and services don't necessarily lead to recommended care, better outcomes or fewer hospitalizations, according to a new report by the Dartmouth Atlas Project.

Instead, geography was a leading driver of health care, more so than race or income. For example, 77.6% of people in the study had an annual visit to a primary care clinician, but visits varied widely depending upon where patients lived. Primary care visits ranged from about 60% of beneficiaries in the Bronx, N.Y. and Manhattan to nearly 90% in Wilmington, N.C. and Florence, S.C.

Researchers studied enrollment and claims data among fee-for-service Medicare population from 2003 to 2007. No HMO patients were included. Geographic areas were based on Dartmouth Atlas hospital service areas, defined on the basis of travel for common causes of hospitalization, and Dartmouth Atlas hospital referral regions, larger natural markets of travel for tertiary care that include one or more service areas and at least one major referral hospital.

There was no correlation between the supply of physicians and access to primary care. In some regions, a relatively high proportion of beneficiaries had at least one annual visit, even when there were fewer primary care physicians per capita. In Wilmington, N.C., which has 69 primary care physicians per 100,000 residents, 87.4% of patients had at least one annual primary care visit. In White Plains, N.Y., which has 101.4 primary care physicians per 100,000, less than 70% of beneficiaries had at least one primary care visit.

Dartmouth Atlas of Healthcare, copyright Dartmouth College"A commonly cited reason for the wide variation in access to primary care is a shortage of clinicians, particularly physicians. This may contribute to the problem in some locations, but the findings suggest that there is no simple relationship between the supply of physicians and access to primary care," said Elliott S. Fisher, MD, MPH, report author and co-principal investigator for the Dartmouth Atlas Project. "As is often the case in health care, it's not always how much you spend, but how you spend it."

For example, there was no relationship between rates of breast cancer screening and the amount of primary care delivered. There was a modest relationship between rates of A1c testing in beneficiaries with diabetes and the overall likelihood that beneficiaries saw a primary care physician annually. There was no relationship between rates of blood lipid testing and eye exams and the overall likelihood that beneficiaries with diabetes saw a primary care clinician at least once a year.

Rates of leg amputation also had no relationship with an annual visit to a primary care clinician. Again, geography played a bigger role. There was a tenfold difference in the rate of leg amputation, ranging from 0.33 per 1,000 beneficiaries in Provo, Utah to 3.29 per 1,000 in McAllen, Texas.

The report also found that having an annual primary care visit did not keep patients out of the hospital for diabetes and congestive heart failure. There was a more than fourfold difference in the rate of ambulatory care-sensitive discharges among Medicare beneficiaries, ranging from 30.7 per 1,000 in Honolulu to 135.0 per 1,000 in Monroe, La.

The report postulates that primary care is most effective when it is embedded within a health care system where care is coordinated, physicians communicate with one another and with other clinicians about their patients, and feedback is available about performance that allows physicians and local hospitals to continually improve.

"Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage," said David C. Goodman, MD, MS, lead author and co-principal investigator for the Dartmouth Atlas Project. "Policy should also focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals."

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Thursday, September 9, 2010

QD: News Every Day--'Moderate' cost increases for health care this decade

Health care will cost slightly more than previously predicted, according to Medicare's actuary. Spending this decade could increase 6.3% annually as the reform legislation is implemented, according to the report published in Health Affairs.

The Centers for Medicare and Medicaid Service's Office of the Actuary report described the impact as "moderate". By 2019 Americans will be spending $265 per year more than they would have without health care reform.

The "Cadillac tax" will drive a 9% out-of-pocket cost increase for consumers as employers whose plans fall under that provision seek to escape it by increasing co-pays and other deductibles. But as more consumers take up insurance under the mandate, within a decade the cost curve will begin to bend. (Health Affairs, AP, The Fiscal Times)

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Wednesday, September 8, 2010

QD: News Every Day--Primary care doctors see fewer acute-care patients

Only 42% of acute care visits are to primary care doctors, reports Health Affairs.

Americans made 1.09 billion outpatient visits each year from 2001 to 2004, (321 visits per 1,000 people per month) with slightly more than a third of the 354 million visits per year for primary care. General and family practitioners managed 22%; general internists, 10%; pediatricians, 13%; subspecialists, 20%; hospital outpatient departments, 7%; and emergency departments, 28%.

Emergency departments most frequently saw patients for stomach and abdominal pain, chest pain and fever. General practitioners more frequently saw coughs and other throat-related symptoms. Specialists saw patients for vision problems, knees and other joints such as the hands/fingers or shoulders, and for stomach problems.

More than 95% of office-based visits occurred on weekdays, as did 89% to hospital outpatient departments. But in the emergency department, 30% of visits occurred on weekends and 37% on weekdays after office hours.

Researchers pointed out that two-thirds of ambulatory visits are for nonacute care, much less than in the past. Hectic s schedules make same-day access difficult, and patient volume means primary care doctors are prone to steer more patients toward specialists.

While health care reform is encouraging the development of the patient-centered medical home, the definition of one does not mandate same-day scheduling, evening or weekend availability, or a timeframe to return after-hours phone calls. Other emerging models such as accountable care organizations and retail clinics remain to be evaluated.

More likely to have an impact on reducing emergency department use are adding 15,000 new providers to federally qualified community health centers, as well as higher reimbursement for primary care.

Hiring and pay comparisons
Physician recruiters The Delta Company released quarterly data showing that internal medicine placements receive higher overall compensation than hospitalists, despite a slightly lower starting salary. For internal medicine hires, average starting compensation was $197,636, sign on bonus was $22,241 and total annual compensation was $265,545. For hospitalists, the figures were $199,666, $15,909 and $256,133. "Total annual compensation" data reflects average yearly compensation at full production excluding benefits.

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Tuesday, September 7, 2010

QD: News Every Day--Don't stop smoking cessation treatments too soon

Doctors may want their patients to stick with a smoking cessation regimen even if it's not initially working, report researchers who found that "delayed quitters" accounted for a third of former smokers who went a year without cigarettes.

Butt Stop by quinn.anya via FlickrQuit rates may be significantly increased by just continuing in motivated but initially unsuccessful patients during the first eight weeks of treatment, according to research published online in Addiction. There's actually two types of successful quitters: those who quit immediately and those who are "delayed" but eventually successful.

Researchers analyzed data from two identically designed, published studies (Gonzales et al. JAMA 2006 and Jorenby et al. JAMA 2006) conducted between June 2003 and April 2005. Participants included 2,052 healthy adult smokers who randomly received either varenicline or bupropion or a placebo for 12 weeks of treatment plus 40 weeks of follow-up. All participants received brief smoking cessation counseling at clinic visits. Investigators were blinded to the treatment assignments, and disclosed support from Pfizer and GlaxoSmith-Kline, the makers of the two drugs studied.

Successful quitters were defined as smokers who achieved continuous and absolute abstinence for the last four weeks of treatment. Among successful quitters, two groups were identified: "immediate quitters," smokers who quit and remained abstinent from their target quit date through the end of week 12; and "delayed quitters," who smoked prior to attaining continuous abstinence for at least the last four weeks of treatment.

A substantial proportion of smokers who quit by the end of 12 weeks of treatment smoked in one or more weeks during the first eight weeks before achieving continuous abstinence. This was true of successful quitters treated with drugs and with placebo. Researchers described this as a previously unreported and natural pattern of quitting. Had the delayed quitters quit treatment, continuous abstinence could have been lost for up to 45% of eventually successful people.

While delayed quitters did not fare quite as well as immediate quitters following the end of active treatment, they still accounted for approximately one-third of those who remained continuously abstinent at 12 months regardless of treatment group.

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Friday, September 3, 2010

FDA actively monitoring medical and health care apps

Bradley Merrill Thompson, an attorney with expertise in the FDA approval process for medical devices, is stating that the FDA is actively monitoring app stores on various platforms. Regulating medical devices and health care-related applications falls under the FDA's jurisdiction.

James Kendrick from JkOnTheRun spoke with Thompson, where he stated the following:

The FDA is actively engaged in surveillance of various app stores to see if apps should trigger their involvement. Applications where a smartphone is connected in any way to imaging are under scrutiny, in particular. Any app that is used to transmit images to a medical facility requires FDA approval.

By "various app stores," Thompson is likely referring to the App store [Apple], Palm App Catalog [Web OS], App World [BlackBerry], and the Android Marketplace [Android OS].

Thompson also mentioned that although some medical app developers are attempting to get FDA approval, the specific apps required to do so still remain murky. Concurrent with Thompson's above statement, earlier this year Health Canada, a body similar to the FDA, approved an imaging app, Resolution MD Mobile, for diagnostic imaging use by Canadian clinicians.

Another question this type of monitoring raises is: Will the FDA ever "force out an app?" We have documented before how there are currently apps taking advantage of consumers, such as the so-called "blue light therapy apps." We were able to show through data how these apps are distorting the truth, but is it enough for the FDA to get involved?

This post by Iltifat Husain appeared at Get 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--Fat mice, omega-3s and obesity

Scientists have honed in on why omega-3 fatty acids are good for you. Well, at least why they're good for mice. Omega-3s stimulate a cell signaling molecule in fat cells that is also found in white blood cells that promote inflammation. Chronic inflammation can lead to insulin insensitivity. Enter the mice. Fed a high-fat diet, they gained weight, had chronic inflammation and had insulin insensitivity. When omega-3s were added, inflammation dropped and the insulin response normalized. Mice with genetic manipulation who were unable to produce the cell signaling molecule didn't respond to omega-3s added to their diet. This is going to take a while to translate to humans. (Los Angeles Times)

Photo illustration by Ryan DuBosar, based on pictures by by Olis Olois and hermzz via Flickr

Gender, careers and pay
It's only a matter of time before female physicians outnumber men, say medical school heads who are seeing more women in their programs. Although women have broken the gender barrier in medicine, they may want to keep going in to nursing, because nurse practitioner salaries grew faster than primary care physicians' pay--nearly 5% compared to nearly 3%. Physicians can take some comfort that their average pay is more--$191,000 compared to more than $85,000--unless they're women, who among all the life sciences average $13,000 less than their male counterparts in comparable positions and with similar experience. (WCSC TV, Fierce Practice Management, Academic Medicine)

Mandatory flu vaccines
The flu fight is gearing up again, as slightly more than half of health care workers in California received flu vaccines last year. While public health agencies and medical societies are seeking stronger compliance, the state is having trouble fully accounting for just how many workers even had vaccines. (Los Angeles Times)

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Does Twitter belong on your medical school application?

As more students participate in social media, like Twitter, Facebook, and blogs, Bryan Vartabedian asks, "Does Twitter Belong on Your Medical School Application?"

Great question.

I'd say that the majority of doctors and medical schools fail to see the utility of social media, and are generally behind the curve. Indeed, as Dr. Vartabedian writes, "Some academics, after all, see social media as a waste of time."

But that's going to change. With sites like the Mayo Clinic recently announcing their Center for Social Media, there's no question that many more hospitals academic centers will follow in its wake, once they discover that social media is here to stay in health care.

Once they do so, these prospective medical students who are actively using Twitter and Facebook in their professional pursuits will be seen as innovators.

But we're not quite there yet. So, while I agree that social media experience should be viewed as a competitive advantage, follow Dr. Vartabedian's advice on how to discuss Facebook and Twitter during an interview.

The last tip is the most helpful: "When in doubt, bring it back to the patient. Even the most pompous paternalist wants to believe he's there for no one other than the patient. Positioning social health as the next great bridge from doctor to patient is not only spot-on but compelling and likely to create memorable attention in the minds of an interviewer."

That single point should be the take-home message that medical students need to convey.

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's KevinMD.com, social media's leading physician voice. Voted best medical blog in 2008, and with over 33,000 subscribers and 23,000 Twitter followers, KevinMD.com is the Web's definitive site for influential health commentary.

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Thursday, September 2, 2010

QD: News Every Day--Home-grown medical students more likely to stay nearby after graduation

Nearly a third of medical graduates at the University of North Dakota continue in primary care, down from nearly half just two years ago. This is the university that leads the nation for the percentage of students (about 20%) choosing family medicine.

North Dakota overall will be short about 160 physicians by 2025, and the need is now affecting urban areas as well as rural ones, said Joshua Wynne, FACP, dean of the university's School of Medicine and Health Sciences.

Aaron Sinclair, MD, on life as a small-town doctor: Keeping medical students interested in practicing primary care in rural America depends upon whom medical schools choose to admit. For example, one-fourth of the University of North Dakota's student population hails from small towns, and 80% are in-state.

More and more medical schools are looking at locally grown talent to fill their residencies, believing that these students are more likely to stay after graduation. Bruce Pitts, FACP, president of Sanford Clinic Fargo in North Dakota, tells local news source Inforum that he uses "trap lines" to cull physicians who grew up locally, or have a spouse or friend who did. Once he finds a recruit, he then expands the network a little further.

These programs also use more familiar means, such as loan forgiveness for service in areas of medical shortage, such as the RuralMed Scholarship at the University of North Dakota.

In Kansas, the University of Kansas School of Medicine-Wichita accomplishes similar recruiting and retention efforts via its Scholars in Rural Health program, which identifies promising potential medical students raised in small towns. During their undergraduate freshman and sophomore years, they shadow a rural doctor at least 40 hours each semester as well as during the summer months between their junior and senior years, and complete reports and projects. With good grades, the students are guaranteed acceptance into med school.

Garold O. Minns, FACP, professor and program director in the department of internal medicine at the medical school, said, "We are concerned about where we are today because we are just barely meeting the needs for rural Kansas. The pipeline of doctors is not as full as we would like it to be for the future."

And, programs in Maine, Arizona and New York have tried similar methods to great success by dangling half-tuition scholarships and condensed study programs to students interested in staying close to home. For the most part, students are interested, even if they haven't seen the opportunities.

Said Robert G. Bing-You, FACP, at the Maine Medical Center, "We want to show the students they can have a very productive career in a community or rural site."

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Cruel shoes

GlassHospital is on vacation this week, writing to you from vibrant Toronto. Toronto is home to the Bata Shoe Museum, well worth a visit if you're ever here on a Thursday night when admission is free. In addition to a display featuring shoes of Elton John and Shaquille O'Neal (among others), there is a nice historical series featuring shoes from the ages that seem very strange to someone from the 21st century.

Well, at least to me.

Running Shoes by Josiah Mackenzie via FlickrMy family was intrigued by the tiny shoes that Han Chinese women wore during generations of the practice of footbinding. Beside those doll-like appendages, I haven't been able to get over the chopines, foot high platform shoes worn by upper class women in Renaissance Italy.

All of this reminded me of a story about feet that shows some of the craziness of our technologically-driven health care system.

A thirtysomething friend of mine, let's call her Sally, started running last year in an effort to get in better shape.

As often happens in these scenarios, Sally developed some foot pain. So she went to a "foot" doctor (I'm not sure whether she meant a podiatrist or an orthopedic surgeon specializing in feet).

Reasonably enough, the doctor ordered an X-ray of her foot. The official reading showed no fracture, but there was a "questionable" finding on the edge of one of the midfoot bones such that the doctor couldn't rule out some more insidious process. A stress fracture, perhaps? Those can be awful, and take a long time to heal.

So, again in reasonable fashion, the doctor ordered a CT scan of Sally's foot. This is the logical next step if a plain old X-ray is abnormal. Heck, a lot of the time, even when an X-ray is normal, we still order the CT scan looking for something that we can't see on the X-ray.

And though I said this was a reasonable choice, if you really think about it, was it so reasonable?

I mean, did Sally really need a $1,000 test to see what was causing her foot pain? If you're Sally, you sure might think so. You want to know what the heck's wrong. You want to know why you're having pain when you run. You want to keep running. After all, as a primary care doctor, I love it when a patient tells me that they're serious about exercise. Aside from not smoking, that's the best thing I can hear from a patient.

But Sally hadn't traumatized her foot. She hadn't dropped a bowling ball on it. She probably had an overuse syndrome. A repetitive stress injury. A running "tweak."

The X-ray showed that, for heaven's sake. We knew there was no broken bone. No smoking gun. [I told you, we hate smoking.]

So a week after sitting for the CT, Sally still didn't know the result of her scan. She called the doctor's office to no avail. She was put off by the staff, even told by a nurse she'd have to come in for an appointment to discuss the results with the doctor.

By this point, she's worried. "Is there something terrible that he's waiting to tell me?" she wondered. "Do I have foot cancer?"

Sally adjusts her schedule, dutifully shows up for the appointment, to hear the doctor tell her that her CT is normal. Did she really have to wait a week and have an office visit to find this out? That is one shoddy patient experience in my book.

Nevertheless, she reasonably asks the foot doctor what she should do about her pain.

Physical therapy? Low impact exercise (use an elliptical trainer, perhaps, or bicycling)?

She doesn't get much of a concrete answer.

She decides to buy some new shoes.

She goes to a local shoe store that caters to runners. Let's call it Fast Feet.

There, they measure her feet. No charge. Lo and behold, her feet have grown 1/2 a size.

Sally was running with shoes that were too small! That was the source of her pain. No CT was needed. In fact, probably even an X-ray was unnecessary.

Now, this story shows how when a patient comes to see a doctor, we often go right to diagnostics. We want to get you an answer, after all. We're not shoe salesmen, for heaven's sake. We don't even have those thingie-dingies that measure feet. [Do foot doctors?]

Next time someone comes in complaining of foot pain, I'm going to ask them when the last time they had their feet measured.

[Author's note: re: the title of this post, google Steve Martin and read about his books.]

This post originally appeared at GlassHospital. John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, 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 that inhabit them.

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Wednesday, September 1, 2010

Practicing primary care: A lesson in treading water

As a primary care physician, I am becoming painfully aware of how hard it is to be good --I mean really good--at what we do today. I would prefer to believe that it has always been so, yet I do not believe that our predecessors in the medical profession found it nearly as difficult to excel in their time as we do now.

With all of the technological and medical advances, you might ask how I could believe this to be true. Too, you might consider it pessimistic or even crazy to suggest that physicians 20, 30 or 100 years ago found it easier to practice medicine well in their time.

Drown-Proof by Eustaquio Santimano via FlickrYou could counter with numerous or obvious examples such as antibiotics, pharmaceuticals, robotic surgical procedures, or even our wondrous ability to peer inside the human body without cutting it open. You also would be correct to point out that the technological advancements of the 20th century opened the way for the medical profession to become a real science thus giving me and my colleagues the chance and knowledge to make a real difference in our patients' lives today.

Yet, none can benefit from knowledge they and their doctors lack, so time studying science is a requirement for physicians wishing to properly wield all of this lifesaving technology. Unfortunately, this time is currently needed to learn ICD-9 and CPT codes (with ICD-10 and 10,000 new codes coming soon) or to scour the HHS ruling just released defining "meaningful use" in the practice of medicine.

It would be hard for many to believe that some larger organizations are required by OSHA to actually have their physicians spend time filling out yearly paperwork reminding them to wash their hands or pointing out that needles are sharp and might transmit HIV. This seems to me the equivalent of making an employer remind an electrician not to stick his wet finger in the socket.

Fifteen years ago, my first office was next door to a hospital where I was granted privileges to perform a multitude of invasive procedures including intubations, bone marrow biopsies, and the placement of central lines. An average day would start and end with hospital rounds, with office appointments sandwiched between, and, if I was lucky, a medical conference at lunch time would provide both food and education.

Today, many internal medicine residents choose to either become a hospitalist or to practice only outpatient primary care medicine. And statistics show that patients have better outcomes and shorter hospital stays under the care of a hospitalist than a general "old-fashioned" internist, a trend that points out the challenge today's primary care doctor has in keeping up in his field while not spreading himself too thin.

Furthermore, the inordinate and incessantly growing amount of time spent on cutting or avoiding the red-tape spun by innumerable government rules and regulations monopolizes our time and makes it difficult to find the time or energy to pursue further medical education.

I believe that some of these restraints preventing us from practicing medicine to our true potential are unique to the primary care doctor and this is, precisely, why many can describe us as "endangered." It is all most of us can do just to keep our heads above water each day- leaving little time for study and less for research. The Hippocratic Oath I took included the promise to protect the noble traditions of the medical profession, a promise, in my estimation, that is growing harder to keep with each successive Congress.

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

This post by Steve Simmons, MD, appeared at Get 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--Risk-reducing surgeries may spare lives following breast cancer

New evidence supports risk-reducing mastectomy and salpingo-oophorectomy for women with the BRCA1 and BRCA2 genetic mutations, according to newly published research.

Researchers wrote in the Journal of the American Medical Association that no breast cancers were diagnosed in a cohort of 247 women with risk-reducing mastectomy, compared to 98 women among 1,372 breast cancer patients without it.

Illustration by David Cutler from ACP InternistFurthermore, women who underwent salpingo-oophorectomy had a lower risk of ovarian cancer, including those with prior breast cancer (6% vs 1%, respectively; hazard ratio [HR], 0.14; 95% confidence interval [CI], 0.04-0.59) and those without prior breast cancer (6% vs 2%; HR, 0.28 [95% CI, 0.12-0.69]).

An editorialist told Reuters that 10%-20% of breast and ovarian cancers are due to BRCA1 or BRCA2 mutations, so prophylactic surgery can save many patients. And, she added, it falls on primary care physicians, gynecologists and the patients themselves to be aware that genetic tests are available.

The editorial from JAMA continued, "From the time BRCA1 and BRCA2 were identified and testing for them became an option, not all primary care physicians have been convinced of the benefits of hereditary risk assessment. However, risk-reducing surgery has been proved effective--and this evidence has emerged because of the willingness to adopt testing, identify women at risk, and study interventions in this specific population."

The issue is becoming more important, as the survival rate of breast cancer overall has risen to more than 80%, as ACP Internist examined in May 2009. Patient need to be checked not only for cancers, but then for the host of ailments that might get lost to follow-up as this population ages.

How do physicians decide which patients would most benefit from which new prevention and treatment strategies? ACP Internist next reported in June 2009 how detection and prevention are changing in the face of new tests and treatments.

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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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