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Thursday, March 31, 2011

QD: News Every Day--Brand-name drug requests lead to less compliance, more costs

Patients are less likely to fill a prescription when the brand name drug is requested than a generic, even if the patients requested the brands themselves. Researchers studied the noncompliance rate among retail pharmacy customers to discover that "dispense as written" instructions led to 50% greater odds of not filling the script and billions in higher costs for patients and insurance.

The costs issues also affect Medicaid savings, according to a second study, since generic drugs could generate savings without requiring an overhaul to the health care system.

While every state has generic substitution laws, doctors can override them on the script and patients can do so at the pharmacy. Even though the conscious choice to select a brand drug might suggest willingness to take it, studies show it actually leads to less compliance.

Researchers studied 5.6 million prescriptions for more than 2 million patients receiving drugs through a pharmacy benefits manager from any pharmacy in January 2009. Claims were defined as physician-assigned dispense as written (2.7%), patient-assigned dispense as written (2%), or neither. Results appeared in the American Journal of Medicine

A majority of prescriptions designated as dispense as written by physicians were products for which no generic was available.

"It is interesting to observe that physicians request dispense as written frequently for single-source branded products, medications for which no generics could be automatically substituted," the authors wrote. "Physicians with a strong preference for branded medications may not be aware of whether a generic is available and may request the branded agent as a preventive measure. Alternatively, physicians may request the branded medication to ensure that pharmacists do not substitute a different medication in the class," even though therapeutic substitution isn't allowed without contacting the physician.

Most patient requests for the brand name were for multi-source brands, among patients 55 to 74 years of age, for maintenance medications, and almost exclusively at retail pharmacies.

Patients and their insurance plans, respectively, paid an average of $17.90 and $26.67 for generic medications, $49.50 and $158.25 for single-source brands, and $44.50 and $135.26 for multi-source brands. Authors noted that in the one month of their study, substituting generics for the multi-source brands would have saved patients $1.7 million and the health plans $10.6 million. Scaling that assumption upward to the 3.6 billion prescriptions filled annually, patients could save $1.2 billion annually and health system costs could save $7.7 billion.

Also of note:
--Older physicians were more likely to request dispense as written than younger ones, and patients age 55 to 74 years were most likely to receive physician dispense as written prescriptions.
--Specialists were 78.5% more likely to write brand-name scripts (P <.001). ---Among new prescriptions for chronic medications, physicians requesting brands (odds ratio 1.50, P<.001) and patients requesting brands (odds ratio 1.60, P<.001) were associated with greater odds that patients did not fill the prescription.
--Compared with oral antidiabetics, patient requests for the brand name were more common for ulcer agents (OR 6.1), hypnotics (OR 4.3), migraine medications (OR 14.4), contraceptives (OR 3.7), thyroid medications (OR 16.5), estrogens (OR 3.6), anticonvulsants (OR 4.8), anticoagulants (OR 4.5), and analgesics (OR 4.5) (all P<.001).

A second working paper released by the American Enterprise Institute analyzed 2009 Medicaid drug data and identified 20 multi‐source drugs in which the generic could generate savings.

In 2009, states’ Medicaid programs paid $329 million more for brand names when alternatives were available, according to the report. Total spending on these 20 drugs was approximately $1.5 billion, so Medicaid overspent by 22% ($1.5 billion versus $1.17 billion). While Medicaid is a joint federal‐state program, the federal share is generally about 57% of the total.

Overspending in 2009 attributable to drugs with generics launched in 2008 totaled $142 million, the report said. Overspending from products with generic launches during 2009 totaled $94 million ($129 million on an annualized basis, given that the generics launched in 2009 were not available for the entire year). Thus, nearly three‐fourths of total identified waste is for spending on drugs with generic launches during or after 2008. However, there are important exceptions to this observation, such as Flonase and Duragesic, which have faced generic competition since 2006 and 2007, respectively.

Ten more drugs go off-patent in the next two years: Actos, Combivir, Concerta, Lexapro, Lipitor, Plavix, Seroquel, Singulair, Xopenex, and Zyprexa. Assuming that substitution rates are 70% to 80% and that the generics are half the price, Medicaid programs could overspend by $289 million to $433 million.

"The approach of a significant 'patent cliff,' when many blockbuster brand drugs will begin to face generic competition upon losing patent protection in 2011 and 2012, makes the likely future overspending in this program even greater if new policies are not promptly adopted," wrote the author.

The report also noted:

--Among the 20 drugs studied, Medicaid spent an average of $95 more per prescription.
--Most of the overspending (85%) was concentrated in eight identified chemical compounds, for which states spent roughly $279 million more.
--The greatest total amount of unnecessary spending was in the larger states of California ($102 million), Texas ($31 million), Georgia ($25 million), and Ohio ($21 million). The smaller states spent more per person, Vermont and Iowa ($31 per enrollee in each state), Maine ($18 per enrollee), and New Hampshire ($17 per enrollee).

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Wednesday, March 30, 2011

QD: News Every Day--Online tools show how communities influence health, lifespan

Two websites show how much that education, jobs, income and environment play in health and longevity for every county in America. The two sites show how much what goes on outside the doctor's office influences the types of encounters likely to be found inside it.

The County Health Rankings compare the overall health of counties against others in the state, and also compare performance on specific health factors against national benchmarks of top-performing counties.

Published by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation (RWJF), the rankings look at factors that affect the rate of people dying before age 75, high school graduation rates, access to healthier foods, air pollution levels, income, and rates of smoking, obesity and teen births. Users can compare how their county performs in areas such as diabetes screening rates or number of uninsured adults to national benchmarks. A second site, the County Health Calculator, by Robert Wood Johnson Foundation and the Virginia Commonwealth University's Center on Human Needs, shows how much higher levels of education and income influence premature death rates.

Not surprisingly, people are nearly twice as likely to be in fair or poor health in the unhealthiest counties. The unhealthiest counties have lower high school graduation rates, more than twice as many children living in poverty, fewer grocery stores or farmer's markets, much higher unemployment rates.

"It's hard to lead a healthy life if you don't live in a healthy community," said Risa Lavizzo-Mourey, MACP, president and CEO of the Robert Wood Johnson Foundation. "The County Health Rankings are an annual check-up for communities to know how healthy they are and where they can improve. We hope that policymakers, businesses, educators, public health departments and community residents will use the rankings to develop solutions to help people live healthier lives."

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Mental health needs integration into the primary care setting

I briefly scanned the Robert Wood Johnson synthesis report on mental and medical co-morbidity so I thought I'd summarize the highlights for the blog. If you'd rather watch the recorded web seminar you can hear it here.

The report relied on systemic literature review to look at the relative risk and mortality associated with co-morbid medical and mental health conditions. They looked at studies using structure clinical interviews, self-report, screening instruments and health care utilization data (diagnostic codes reported to Medicaid).

This is what they found:
--68 percent of adults with a mental disorder had at least one general medical condition, and 29 percent of those with a medical disorder had a comorbid mental health condition
--These findings support the conclusion that there should be strong integration of medical and mental health care
--Psychiatric disorders were the most expensive conditions to treat among Medicaid beneficiaries, but also the most common when combined with cardiovascular disease
--Medical conditions and psychiatric conditions have a reciprocal risk relationship: having one disorder increases the risk for having the other
--Both medical and mental disorders are associated with low income, poor education, early childhood trauma and chronic stress
--Four modifiable risk factors are responsible for high rates of co-morbidity: alcohol and drugs, tobacco, poor nutrition and lack of exercise
--The treatments themselves may worsen co-morbidity (somatic meds cause psychiatric side effects, psychiatric meds may cause or worsen medical conditions)
--Public mental health clients die 25 years earlier than the average life expectancy. The relative risk of six common psychiatric conditions includes panic disorder, 1.9; major depressive order, 1.7; alcohol abuse/dependence, 2.0; personality disorders, 4.0; schizophrenia, 2.6; and bipolar disorder, 2.6)
--Multidisciplinary team approach to treatment is most effective: fully integrated medical, mental health and substance abuse services

So instead of having a public health care system that is fragmented between freestanding clinics, we should have integrated clinics that follow a collaborative care model and that provide a broad range of services. For me this means that we can no longer afford to have disjunction of care between state agencies: correctional facilities and public clinics need to coordinate care for both medical and mental health conditions. This study describes my typical clinic population: poor, poorly educated, sick, traumatized and under chronic stress. They are at greater risk of dying and the most costly to care for.

This post by Anne Hanson 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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Tuesday, March 29, 2011

QD: News Every Day--Better handoffs needed from ERs back to primary care

Improving handoffs from the emergency room back to the primary care physician will require changing how electronic health records are used, better reimbursement to both the hospital and ambulatory doctors, and malpractice reform, according to a study.

Haphazard communication and poor coordination can undermine effective care, according to a new research conducted by the Center for Studying Health System Change. Researchers conducted 42 telephone interviews between April and October 2010 with 21 pairs of emergency department and primary care physicians, who were case-matched to hospitals so the perspective of both specialties working with the same hospital could be represented.

Among the findings in the report, telephone communication was essential in some cases, but particularly time-consuming. Both emergency and primary care physicians reported successful completion of each telephone call often required multiple pages and lengthy waits for callbacks. While placing and receiving telephone calls might seem straightforward and quick, providers said each small action multiplied across dozens of patients can become a daunting burden, with little immediate reward or reimbursement.

Faxes and e-mails can be reviewed at a provider's convenience but do not provide an opportunity to ask questions. Physicians had little confidence that faxes were carefully reviewed by their intended recipient and often reported that faxed records were poorly organized and difficult to decipher. "What used to be a few pages is now 20-30 pages," said one primary care provider during an interview.

While shared electronic medical records are valuable tools for billing and liability documentation, they are not designed to offer a rapid overview with the level of detail that could help an emergency provider direct care.

Larger groups and more elaborate cross-coverage systems means that emergency physicians are less likely to speak with a physician who has direct knowledge of the patient. And, while rising hospitalist use and the growth of larger primary care groups help office-based providers decrease their call responsibilities, the result is fewer interactions between office-based and hospital-based physicians. Many emergency physicians reported that they had no venues for ongoing collaboration with primary care practices in their community.

The authors further noted that even if practical barriers are removed, liability concerns divide providers because emergency and primary care physicians have different constraints and fundamentally different assumptions regarding patients' reliability and resilience.

The authors noted that physicians aren't reimbursed for communicating, and that reimbursing for this task is an option. But better policies might include changes in meaningful use criteria for electronic medical records, payment incentives that reward both primary and emergency providers for managing utilization, and malpractice liability reform.

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Monday, March 28, 2011

QD: News Every Day--Patients want to talk to doctors but pay bills online

Patients may not want to discuss clinical matters via social media, but they'd gladly set pay their bills when reminded. Social media's value in communicating with patients is limited to the administrative aspects of it.

Americans still want traditional ways of communication when they need a clinical consult. A survey finds 84% would not use social media or instant messaging channels for medical communication if their doctors offered it, according to the communications firm Capstrat.

Respondents were more favorable toward conferring with the doctor via e-mail (52%) than they were by Twitter and Facebook (11%), chat or instant messaging (20%) or a private online forum (31%).

Even among those 18 to 29 years old, 21% said they would take advantage of an online forum if their doctor offered it, while 72% would take advantage of a nurse help line if available.

Respondents said they'd take advantage of online appointment scheduling (52%), online access to medical records (50%), or online bill payment (48%).

"It appears consumers are willing to move administrative experiences such as bill payment and records access online, but when it comes to conferring with their health care providers, people still prefer more traditional communications," said the firm's president, Karen Albritton, in a press release. "The implications include a way for doctors to free up more time for their patients by moving the right interactions online, and an opportunity to forge stronger connections through personal interaction."

Patients want the same convenience of online appointments and bill paying from their doctor that they get in other areas of their lives, reports a second survey.

73% of those surveyed would use a secure online option to get lab results, request appointments and pay medical bills. The first caveat is that this survey was done by Intuit. The company is best known for QuickBooks, but its health care division offers patient portals for doctor's offices. The second caveat is that respondents were surveyed online, which would skew results to people digitally inclined anyway.

With those two caveats in mind, the survey also found that:
--Almost half would consider switching doctors for a practice that offered online access.
--81% would schedule their own appointment via a secure Web service and fill out medical/registration forms online prior to their appointment.
--78% would use a secure online method to access their medical histories and share information with their doctor.
--59% of generation Y respondents said they would switch doctors for one with better online access, compared to only 29% of baby boomers.
--45% of patients wait more than a month to pay their doctor bill, and when they pay, half still send a paper check in the mail.

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May I call you 'doctor'?

I've previously considered the relationship between the Prince Albert and his speech therapist in The King's Speech. One aspect I wanted to explore further is why the future king initially insisted on calling the practitioner "doctor."

In real life, now, patient-doctor relationships can be topsy-turvy. This change comes partly a function of a greater emphasis on patient autonomy, empowerment and, basically, the newfangled idea that the people work "together, with" their physicians to make informed decisions about their health. It's also a function of modern culture; we're less formal than we were a century ago.

Patients enter the office with their own set of information and ideas about what they need. The recent Too-Informed Patient video highlighted this issue, effectively.

Doctors are human, we are painfully aware in 2011. They make mistakes and they sometimes need to have dinner with their families. They may even let us down.

When I was a young physician, my patients almost universally called me "Dr. Schattner." I considered it appropriate, and I always introduced myself as such. After I turned 40 or so, with a few graying hairs, a higher faculty rank and more experience, I gradually changed my approach. Usually I'd say "I'm Dr. Schattner," along with a firm handshake at the start of a visit. If a patient chose to call me "Elaine" I was comfortable with that; by then I was sufficiently secure in my authority to let people call me by my first name or by my title, whichever they preferred.

As I aged, more often, when I returned calls from patients I'd known for years, I would say, "Hi, it's Elaine Schattner returning your call," or something like that. But, and here is where the movie ties in, there were some patients who clearly preferred to call me "Dr. Schattner," no matter what. Some were older, some quite accomplished in their fields, so much so that I felt uncomfortable presenting myself on anything but equal terms.

Still, most chose to say "doctor." The reason, I suspect, is that many people want a doctor who fits the part: their idealized conception of a good, caring physician who will take care of them. For others--and these reasons are not mutually exclusive--it's a matter of wanting to convey respect for the person who has studied so much and is using his or her knowledge to help them get well.

In The King's Speech, Mr. Logue lacked the credentials of a doctor of any kind, which may be the reason he's so adamant that the prince or king not refer to him as such. Why the royal character wants to call his therapist "doctor" is, I think, at least twofold: that the caregiver would be constantly mindful of his professional duties in the manner of the white coat, and out of genuine regard for the physician's training, knowledge and work.

"Doctor" conveys respect. There's nothing wrong with that, in my opinion as a patient. And it's good, even reassuring, to find and know deserving physicians.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She 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.

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Friday, March 25, 2011

QD: News Every Day--In case you missed it ...

With all the hubbub of recent weeks, some news stories have slipped through the cracks.

A vision of the future of medicine
Continuous monitoring, telemedicne and social media may work in tandem someday to alert of impending heart attacks, said Eric Topol, FACP, at a health care executives summit this week. Alerts would be sent to people's smartphones to warn people to seek help fast. (He didn't mention whether someone's Facebook status would automatically be updated, though.)

Dr. Topol, director of the Scripps Translational Science Institute in San Diego and former chair of the Cleveland Clinic's department of cardiovascular medicine, gave his keynote addresses to the American College of Healthcare Executives in Chicago. He said the more common use of social media involves the patient communities that develop around disease states, leading to trust in those peer groups rather than in physicians. (Free registration required to view.)

Primary care shifting to pharmacies
Pharmacists are taking advantage of their face time with patients, filling in the roles of drug educator and chronic disease coach while filling scripts.

One pharmacist described a monthly coaching program that covers a disease each month. At one meeting, a pharmacist delivered an overview on managing cholesterol, then weighing and measuring everyone and giving them a pedometer to encourage them to walk 10,000 steps a day.

Who'd move for single-payer salvation?
Doctors from around the country told an activist group that they would move to Vermont if the state adopted a single-payer system. They see single-payer systems as a better alternative to insurance dictates and paperwork and would be willing to vote with their feet, so to speak.

Hidden expenses to health care
Out-of-pocket costs not accounted for in previous analyses can reach $1,355 per consumer, in addition to the $8,000 on the books for doctor fees and hospital care. Hidden costs adds up to $363 billion, or nearly 15% more than what's officially recorded, according to a report from the Deloitte Center for Health Solutions. The report accounts not only for time off to care for elderly relatives, which accounts for half of the hidden costs, but also money spent on ambulances, alternative medicines, nutritional products and vitamins, and weight-loss products.

Drug-resistant tuberculosis spreading
Multi-drug-resistant strains of tuberculosis could kill hundreds of thousands of people and infect more than 2 million people by 2015, reports the World Health Organization. And treating this group with the wrong drug could create 25,000 cases of extensively-drug-resistant tuberculosis each year.

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Thursday, March 24, 2011

QD: News Every Day--Office-based doctors are economic powerhouses

The nation's office-based physicians generate $1.4 trillion in total economic output, 4 million jobs, $833 billion in wages and benefits, and $63 billion in state and local taxes, according to a report. While office-based physicians are largely made up of solo and small-group practices, their economic impact compares to the hospital industry in all fifty states and is more than nursing homes and home health.

The report, sponsored by the American Medical Association, analyzed the economic value of direct impact by each physician (for example, employee wages) and the indirect impact in the industries that are supported by physicians’ offices (for example, when employees go shopping with their wages).

There were nearly 640,000 office-based physicians in the U.S. as of October 2010. On average, each office-based physician supported $2.2 million in economic output, 6.2 jobs (including the physician's own), $1.3 million in wages and benefits, and more than $98,000 in state and local tax revenue across the nation.

"In these times of rapid change in the health care industry it is important to understand how changes affect office-based physicians," the report reads. "It shows how strong physician practices not only ensure the health and well being of communities but also critically support local economies and enable jobs, growth and prosperity."

Office-based physicians generated more economic impact and more wages and benefits than the fields of higher education, home health, law, and nursing homes in 2009. Only in Washington, D.C., did the legal industry boost the economy more than office-based office-based physicians--five times as much, actually. Hospitals hired more people than office-based physicians, but offices had better wages and benefits.

Data were generated from three databases, the AMA Masterfile of physicians, the Medical Group Management Association's Cost Survey of physician expenses, and the Minnesota Implan Group's models on employment multipliers and tax revenues.

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Wednesday, March 23, 2011

QD: News Every Day--Gold standard is needed for better clinical guidelines

Eight standards are needed to create quality clinical guidelines, according to a report issued by the Institutes of Medicine.

Guidelines have become vital to clinicians trying to stay afloat in the flood of new medical discoveries. The number of randomized controlled trials published in MEDLINE grew from 5,000 per year from 1978 to 1985 to 25,000 per year from 1994 to 2001. They're of mixed or even suspect quality, authors wrote in their reports.

There were a handful of guidelines that synthesized best practices in the 1990s. But there's so much research that now there's now a glut of guidelines. The Agency for Healthcare Research and Quality’s National Guideline Clearinghouse contains nearly 2,700 of them, 722 added in 2008 alone.

With so many groups creating guidelines, the Institutes of Medicine wants to standardize them. First, the organization updated the definition to: "Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options."

The new definition is meant to distinguish clinical guidance derived from widely disparate development processes such as consensus statements, expert advice, and appropriate use criteria.

Next, the Institute of Medicine set eight standards:
--Establish transparent funding;
--Manage conflicts of interest;
--Balance guidelines writing committees among medical disciplines, between experts and clinicians, and including patient populations;
--Use systematic reviews that meet Institute of Medicine standards;
--Establish evidence foundations for and rating strength of recommendations, including a clear description of potential benefits and harms, evidence summaries and levels of confidence in the evidence;
--State recommendations in a standard form detailing precisely what the recommended action is, and under what circumstances it should be performed;
--Include all stakeholders in external reviews, including scientific and clinical experts, organizations, government agencies and patients and the public; and
--Update guidelines as needed.

An interactive graphic is here.

"These standards are necessary given that there is little documentation to judge the quality and reliability of many of the existing clinical practice guidelines," said Sheldon Greenfield, FACP, chair of the committee on guidelines, which also included Cynthia D. Mulrow, MACP, Senior Deputy Editor of the Annals of Internal Medicine.

Another report outlines 21 standards for systematic reviews, including starting them, finding and assessing individual studies, synthesizing evidence, reporting findings and improving quality.

"We recognize that it will take an investment of resources and time to achieve such high standards, but they should be adopted to minimize the chances that important health decisions are based on information that may be biased or erroneous," wrote the chair of that committee.

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Primary care to specialists: We should talk more often

Whenever I refer a patient to a specialist, a copy of the patient's recent notes, labs and diagnostic tests is faxed to the specialist, in many cases, prior to their visit. And most of the time, after they see the specialist, I receive a fax back describing what happened.

You'd think this is standard procedure, but it doesn't happen as often as it should.

Abandonded Fax Machine by Abhisek Sarda via Flickr/Creative Commons licenseA study from the Archives of Internal Medicine, found that "That while more than 69% of primary-care physicians said they always or mostly passed on a patient's history and reason for a consultation to the consulting specialist, fewer than 35% of specialists reported always or mostly receiving that information."

The flip side is no better: "81% of specialists said that of course, they always or usually send consult results back to the referring primary-care doctor, but only 62% of those doctors said they got that info."

The lack of communication has the potential to affect patient care. It's important that a specialist know what had been done prior, lest duplicate tests are ordered. And I need to know what happened to my patient after he sees another doctor.

I found that specialists who still dictated their notes had the longest reply time. That only makes sense, since the added transcription step takes time. The solution, obviously, is better incorporation of health IT. I should be able to log into a patient's chart and see both my note and the specialist's note side by side. That's the way it works in the VA, which has a single, unified electronic health record system.

But the way we're doing it, with fragmented systems that don't talk to one another, is only marginally better than the old way of dictating a note, waiting for a transcription, then faxing it.

I anticipate the consolidation of practices, facilitated by health reform and impending accountable care organizations, to help as health IT systems are also amalgamated.

But that vision is pretty far away. Until then, primary care doctors and specialists need to make a concerted effort to communicate their office visits in a more timely manner.

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 44,000 subscribers and 36,000 followers on Facebook and Twitter, KevinMD.com is the Web's definitive site for influential health commentary.

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Tuesday, March 22, 2011

Radiologists' experience matters in mammography outcomes

There's a new study out on mammography with important implications for breast cancer screening. The main result is that when radiologists review more mammograms per year, the rate of false positives declines.

Image from the National Cancer InstituteThe stated purpose of the research,* published in the journal Radiology, was to see how radiologists' interpretive volume, essentially the number of mammograms read per year, affects their performance in breast cancer screening. The investigators collected data from six registries participating in the NCI's Breast Cancer Surveillance Consortium, involving 120 radiologists who interpreted 783,965 screening mammograms from 2002 to 2006. So it was a big study, at least in terms of the number of images and outcomes assessed.

First, and before reaching any conclusions, the variance among seasoned radiologists' everyday experience reading mammograms is striking. From the paper: "We studied 120 radiologists with a median age of 54 years (range, 37 to 74 years); most worked full time (75%), had 20 or more years of experience (53%), and had no fellowship training in breast imaging (92%). Time spent in breast imaging varied, with 26% of radiologists working less than 20% and 33% working 80% to 100% of their time in breast imaging. Most (61%) interpreted 1,000 to 2,999 mammograms annually, with 9% interpreting 5,000 or more mammograms."

So they're looking at a diverse bunch of radiologists reading mammograms, as young as 37 and as old as 74, most with no extra training in the subspecialty. The fraction of work effort spent on breast imaging, presumably mammography, sonograms and MRIs, ranged from a quarter of the group (26%) who spend less than a fifth of their time on it and a third (33%) who spend almost all of their time on breast imaging studies.

The investigators summarize their findings in the abstract: "The mean false-positive rate was 9.1% (95% CI; 8.1% to 10.1%), with rates significantly higher for radiologists who had the lowest total (P=.008) and screening (P=.015) volumes. Radiologists with low diagnostic volume (P=.004 and P=.008) and a greater screening focus (P=.003 and P=.002) had significantly lower false-positive and cancer detection rates, respectively. Median invasive tumor size and proportion of cancers detected at early stages did not vary by volume.

This means is that radiologists who review more mammograms are better at reading them correctly. The main difference is that they are less likely to call a false positive. Their work is otherwise comparable, mainly in terms of cancers identified.**

Why this matters is because the costs of false positives: emotional (which I have argued shouldn't matter so much), physical (surgery, complications of surgery, scars) and financial (costs of biopsies and surgery) are said to be the main problem with breast cancer screening by mammography. If we can reduce the false positive rate, breast cancer screening becomes more efficient and safer.

TIME provides the only major press coverage I found on this study, and suggests the findings may be counter-intuitive. I guess the notion is that radiologists might tire of reading so many films, or that a higher volume of work is inherently detrimental.

But I wasn't at all surprised, nor do I find the results counter-intuitive. The more time a medical specialist spends doing the same sort of work, say examining blood cells under the microscope, as I used to do, routinely, the more likely that doctor will know the difference between a benign variant and a likely sign of malignancy.

Finally, the authors point to the potential problem of inaccessibility of specialized radiologists--an argument against greater requirements, in terms of the number of mammograms a radiologist needs to read per year to be deemed qualified by the FDA and Mammography Quality Standards Act and Program. The point is that in some rural areas, women wouldn't have access to mammography if there's more stringency on radiologists' volume. But I don't see this accessibility problem as a valid issue. If the images were all digital, the doctor's location shouldn't matter at all.

*The work, put forth by the Group Health Research Institute and involving a broad range or investigators including biostatisticians, public health specialists, radiologists from institutions across the U.S., received significant funding from the American Cancer Society, the Longaberger Company's Horizon of Hope Campaign, the Breast Cancer Stamp Fund, the Agency for Healthcare Research and Quality and the NCI.

**I recommend a read of the full paper and in particular the discussion section, if you can access it through a library or elsewhere. It's fairly long, and includes some nuanced findings I could not fully cover here.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She 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.

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QD: News Every Day--10 areas of diabetes research to highlight for the next 10 years

A new strategic plan to guide diabetes-related research over the next decade identifies 10 broad areas with the greatest potential to help patients.

Diabetes by Jill A. Brown via Flickr/Creative Commons licenseThe plan focuses on 10 areas of diabetes research with the most promise:
--genetic basis of type 1 and 2 diabetes, obesity and their complications,
--type 1 diabetes and autoimmunity,
--type 2 diabetes and its effects on multiple organ systems and metabolism,
--obesity as a risk factor,
--beta cell dysfunction,
--development of an artificial pancreas,
--clinical research and clinical trials,
--special needs for special populations,
--diabetes complications, and
--translating clinical research to practice.

The plan was developed by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), headed by Director Griffin P. Rodgers, MACP, (who is profiled here). Under the plan, the National Institutes of Health will continue to emphasize clinical research in humans, which already has led to highly effective methods for managing diabetes and preventing complications, Dr. Rodgers said.

In addition, the plan addresses gestational diabetes. Women who develop gestational diabetes during pregnancy are at increased risk for developing type 2 diabetes, and the child of that pregnancy may also be at increased risk for obesity and type 2 diabetes.

Today, about 1 in 10 adults in the United States has diabetes, according to the Centers for Disease Control and Prevention. About 1.9 million Americans aged 20 years or older were newly diagnosed with diabetes in 2010. In addition, an estimated 79 million American adults have pre-diabetes. (Learn more about addressing pre-diabetes with patients here.)

By 2050, as many as one in three adults could be diagnosed with diabetes if current trends continue, according to the CDC. The projection assumes that recent increases in new cases of diabetes will continue and people with diabetes will also live longer, which adds to the total number of people with the disease. Total costs of diabetes, including medical care, disability and premature death, reached an estimated $174 billion in 2007.

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Monday, March 21, 2011

QD: News Every Day--Happy 1st birthday, health care reform

First Birthday by reserved by Arthur40A via Flickr/Creative Commons licenseHealth care reform survived its first year despite a painful birthing process, contentious lawsuits and attempts to de-fund its main provisions. Wednesday marks the day that President Obama signed the But the next year won't be much easier:
--people don't know what to call it, or whether it's helped them personally,
--proponents continue to prop it up using bogus statistics,
--more than half of small business owners don't know about tax credits that offset mandated insurance plans, and nearly two-thirds don't know about state-regulated insurance markets.

And the predictions continue that health care reform won't survive its infancy. But the bill's supporters are praying for its success.

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Telemedicine, e-doctors and getting paid for the work

When I use the term "telemedicine," what does it mean to you?

In current parlance, it usually refers to radiologists looking at digital images of X-rays and other scans from locations remote from the site of acquisition. [Think "outsourcing" where the radiologist could even be as far away as India.]

But according to a recent conference I attended, telemedicine could mean so much more: It can range from synchronous video chat between a patient and a doctor, to conferencing between doctors, to allied health professionals (nutritionists, physical therapists) giving live (or canned) presentations to groups of patients who are geographically far apart.

The technology is already here. The biggest obstacles to widespread adoption of telemedicine is, you guessed it, payment. Or what health care people call reimbursement.

Our current system rewards in-person visits in a fee-for-service model. Each episode of care is monetized. The more episodes, the more charges. Health care reform will supposedly bring about bundled payments, whereby health care teams (not just us doctors) will provide care for patients assigned to us for monthly charges paid to us by insurance companies, as part of an arrangement known by the widgety name "accountable care." In an accountable care model, doctors would be paid for seeing patients in person or not, so suddenly e-mail, video chat and data transfer sound a whole lot more convenient for both parties in terms of time and convenience.

How can a doctor examine a patient remotely, you say?

No one thinks telemedicine will replace the face-to-face encounter; instead, it will augment it. For certain items, a doctor can get readings from a machine,e.g. blood pressures, weights, or glucose levels. Digital photos and video chat work well for skin issues.

In mental health, where resources are often in short supply, telemedicine has taken on an increasing role in doctor-patient virtual visits.

Soon, your smartphone will have a front-loaded camera, which will allow real-time video chat. No more having to use a desktop or laptop to Skype; even basic calling packages will have this functionality built in.

Technology and innovation will drive medicine toward a more patient-centered convenience; there will be more remote diagnostics and consulting, and less face to face time. Patients will respond by taking more charge of their own records, and decide with whom and to what extent to share them from cloud-based, encrypted storage systems.

The day cannot be too far off. After all, we already have a plethora of e-patients.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. 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, March 18, 2011

The value of at least one patient's physical exam

I've remarked in the past how rarely I ever learn anything useful from physical exam. It's one of those irritating things about medicine. We spent all that time in school learning arcane details of the exam, esoteric maneuvers like pulsus paradoxus, comparing pulses, Rovsing's sign and the like. But in the modern era, it seems like about half the diagnoses are made by history and the other half are made by ancillary testing. Some people interpreted my comments to mean I don't do an exam, or endorse a half-assed exam, which I do not. I always do an exam, as indicated by the presenting condition. I just don't often learn much from it. But I always do it.

The other day, for example, I saw this elderly lady who was sent in for altered mental status. There wasn't much (or indeed, any) history available. She was from some sort of nursing home, and they sent in essentially no information beyond a med list. The patient was non-verbal, but it wasn't clear if she was chronically demented and non-verbal or whether this was a drastic change in baseline. So I went in to see her. I stopped at the doorway. "Uh-oh. She don't look so good," I commented to a nurse. As an aside, this "She don't look so good" is maybe 90% of my job, the reflexive assessment of sick/not sick, which I suppose is itself a component of physical exam. But I digress. Her vitals were OK, other than some tachycardia*. Her color, flaccidity and apathy, however, really all screamed "sick" to me. Of course, the exam was otherwise nonfocal. Groans to pain, withdraws but does not localize or follow instructions. Seems symmetric on motor exam, from what I can elicit. Belly soft, lungs clear. Looks dry. No rash.

Sigh. Probably another case of urosepsis. Sorry, I mean UTI with sepsis. Boring, and unsatisfying. Let's scan her and cath her and lab her and see what shows up. Let me just take a look at her legs and make sure there's no cellulitis or anything there. Nope, but boy she really groaned when I moved that leg, didn't she? Weird. Seems that left hip hurts her when I push on it. Did she fall out of bed? Maybe she's got a broken hip. Is there a bump on her head? That would explain the altered mental status. Nope. So I flip up her gown to look at the hip better, and I was surprised to see a bright red rash all around her leg and pannus (she was quite large). Huh. Here we go, she has a rip-roaring cellulitis. That would explain the altered mental status quite nicely. Good. I'd better take a look at her backside, though. She might have a pressure sore there that could be the source, and we have to document that it was present on admission. The nurses glared at me a bit, but we got a team together and rolled her on her side so I could examine her sacrum. No pressure ulcer, and I was about to let them roll her back, when I noticed something. "Hey, what's that?"

It was a little dark area, like a bruise, just the size of a quarter, on the back of her thigh. But it wasn't quite like a bruise. It was too sharply demarcated, and too dark, almost black. I poked at it, but she didn't groan, and the skin was intact. Weird. It was involved in the cellulitic area, though.

I didn't like it. So as I put in the orders I decided to add on a CT scan. Shortly afterwards, the labs started to come back, and it was clear this was looking serious. White count of 22,000. Glucose 950. Creatinine 3.5. All bad. Then the call from the radiologist**. I pulled up the images:

There was extensive air all through the soft tissues of the thigh, tracking to the perineum and the abdominal wall. Aha! Now this made perfect sense. She had necrotizing fasciitis, commonly known as the "flesh eating bacteria!" This is a true surgical emergency, and indeed she got a very big surgery. The whole area involved simply had to be excised, and in such a sick patient, that's a huge operation, with a very high mortality. When the family eventually showed up, I prepared them with the "She may very well not survive" talk. (And, yes, it turned out this was a dramatic change from her baseline level of function.) To everyone's great surprise, she did pull through the surgery (and the repeat surgeries), and last I saw was getting prepped for discharge to rehab.

The take home point here, really, was that the physical exam, while a rote and generally unrevealing exercise, simply cannot be skipped. This lady had no crepitance, the crackling underneath the skin that is classically the hallmark of subcutaneous gas. I think she was just too fat, and the thigh too tense, and maybe the air too widely disseminated. If I had not taken the time to look at her backside, I would never have seen the black spot that clued me into the fact that this was more than a routine cellulitis. Had I sent her to the floor on antibiotics, she would have died. This is not at all to be taken as a recantation of my original thesis. In 99% of cases, I learn little to nothing from the exam. She just happened to be in the 1% that actually had a critical finding, which proves the corollary to my thesis, that despite the seeming pointlessness of exam, you still have to do it.

* Pro tip #1 for Emergency Medicine interns: Respect tachycardia.
** Pro tip #2: The radiologist never calls to discuss the fortunes of your local sports team, or a pleasant surprise he experienced in the market. It's always something bad when the radiologist deigns to speak directly to the emergency physician.

This post by Liam Yore, 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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Should doctors treat asymptomatic strep throat?

Occasionally, I see patients who have received throat swabs for strep that have come back positive ... even if they have no signs or symptoms of pharyngitis.

In this situation, there are two main actions a physician may take (I am biased toward one):
1) Prescribe antibiotics until throat cultures are normal.
2) Do nothing.

tools of the trade by cjc4454 via Flickr/Creative Commons licensePersonally, if a patient is without throat symptoms and has no history of rheumatic fever or kidney damage, I would not have even bothered obtaining a strep test. What for?

Also, a person can be a carrier for strep without suffering any health problems. As such, even if the strep test is positive, but if the patient has no symptoms, I do not recommend treatment (which again begs the question of why bother getting a strep test if no treatment will be recommended regardless of the test result).

I would go so far even to say follow-up cultures are not necessary after antibiotic treatment for strep throat if a patient does not have any more symptoms and exam is normal, which is why I find it surprising when children and adolescent patients receive multiple courses of antibiotics when they feel perfectly fine, but have received treatment just because a strep test came back positive.

Of course ... that's just my opinion as I do acknowledge that there's another school of thought which supports antibiotic treatment of all strep positive cultures with follow-up cultures to ensure eradication.

This post by Christopher Chang, 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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Doctors choose Camel cigarettes in an old TV commercial

Recently I came upon an old TV ad that features doctors smoking Camel cigarettes.
This commercial came my way via LongartsZwolle, a blog by a Dutch pulmonologist. Times change, and the world gets smaller.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She 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.

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QD: News Every Day--Death rate tapers for tenth straight year

The U.S. age-adjusted death rate fell for the tenth consecutive year, to an all-time low of 741 deaths per 100,000 people in 2009, 2.3% lower than 2008, according to preliminary 2009 death statistics released by CDC's National Center for Health Statistics.

The findings come from "Deaths: Preliminary Data for 2009," which is based on death certificates from all 50 states, the District of Columbia and U.S. territories.

Life expectancy at birth increased to 78.2 years in 2009, up slightly from 78.0 years in 2008. Life expectancy was up two-tenths of a year for men (75.7 years) and up one-tenth of a year for women (80.6 years). Life expectancy for the U.S. white population increased by two-tenths of a year. Life expectancy for black men (70.9 years) and women (77.4 years) was unchanged in 2009. The gap in life expectancy between the white and black populations was 4.3 years in 2009, two-tenths of a year increase from the gap in 2008 of 4.1 years.
Other findings:
--The 15 leading causes of death are: diseases of heart, malignant neoplasms, chronic lower respiratory diseases, cerebrovascular diseases, accidents, Alzheimer’s disease, diabetes, influenza and pneumonia, nephritis, suicide, septicemia, chronic liver disease and cirrhosis, essential hypertension and hypertensive renal disease, Parkinson’s disease, and homicide.
--Age-adjusted death rates declined significantly for 10 of the 15 leading causes of death in 2009: heart disease (by 3.7%), cancer (1.1%), chronic lower respiratory diseases (4.1%), stroke (4.2%), accidents (4.1%), Alzheimer's disease (4.1%), diabetes (4.1%), influenza and pneumonia (4.7%), septicemia (1.8%), and homicide (6.8%).
--Suicide passed septicemia to become the 10th leading cause of death. While suicides increased 1.7%, deaths from septicemia declined 1%.
--Overall, there were 2,436,682 deaths in the United States in 2009, 36,336 fewer than in 2008 (-1.5%).

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Thursday, March 17, 2011

QD: News Every Day--Academics see slightly higher pay

Academic faculty physicians in primary and specialty care reported slight pay increases, according to the Medical Group Management Association.

Go. by Shayne Kaye via Flickr/Creative Commons licenseThe organization's Academic Practice Compensation and Production Survey for Faculty and Management: 2011 Report Based on 2010 Data, annual compensation for internal medicine primary care faculty physicians increased by 6.84% since 2009, and increased 4.46% between 2008 and 2009.

Median compensation for all primary care faculty physicians was $163,704, an increase of 3.47% since 2009, and median compensation for specialty care faculty was $241,959, an increase of 2.7% since 2009.

Department chairs and chiefs received the greatest compensation, $292,243 for primary care faculty and $482,293 for specialty care faculty. Primary care professors received $190,815 in compensation and specialty care professors received $268,786.

"Recently, higher salaries have been required to hire internal medicine faculty. It is the law of supply and demand," said Jonathan Tamir, MBA, associate chairman of Finance & Administration at Yale's Department of Internal Medicine, in a press release.
Other influences include:
--more demand for part-time roles and less for on-call duty,
--increasing demand for more highly paid hospitalists,
--senior physicians who are retiring earlier,
--increasing paperwork,
--decreasing reimbursement,
--the change in the doctor-patient relationship, and
--increasing regulations.

Some specialty care faculty also reported pay increases since 2009. Compensation for pulmonary medicine faculty rose 7.38%, and noninvasive cardiologists' compensation increased 6.7%. Ophthalmologists saw moderate decreases.

Compensation in academic settings continued to trail that in private practices, as is customary.

"Overall, academic practices provide a different environment for their faculty than private practices," Mr. Tamir said. "Even the very best academic clinicians will not be as clinically productive as their private-practice counterparts, since at least some of their time is devoted to research and teaching efforts, which are never as well compensated as clinical care."

This year's report contains data on 18,776 faculty physicians and nonphysician providers categorized by specialty and 1,993 managers.

Unemployment gutted health insurance rates
Despite signs of economic recovery, unemployed people still can't access health insurance, according to a report by The Commonwealth Fund.

Using data from the Commonwealth Biennial Health Insurance Survey of 2010 and prior years, the report examines the effect of the recession on the health insurance coverage of adults between the ages of 19 and 64 and the implications for their finances and access to health care. The survey included 3,033 adults from July to November 2010.

In the last two years, 57% of men and women who lost a job that had health benefits became uninsured. Among other findings:
--24% of working-age adults, an estimated 43 million people, reported a job loss by themselves or a spouse
--among those who reported a job loss, 47% lost health benefits as a result
--among respondents who had health benefits through their lost jobs, 57% became uninsured. One-quarter were able to go on to their spouse's insurance or found another source of coverage. Only 14% continued their coverage through COBRA

Adults who sought coverage on the individual insurance market over the past three years were charged higher premiums, had a health condition excluded from their coverage, or were denied coverage altogether because of a preexisting condition, the report continues. Those who found health insurance had higher deductibles, struggled to pay medical bills, faced cost-related barriers to getting needed care, or skipped or delayed needed care, including prescription medications, because of the cost.

"These survey findings demonstrate that the passage of the Affordable Care Act last year was critical to the future health and well-being of working families," the report said. "As the law's provisions go into effect, the nation's health insurance system will move from one in which 52 million adults suffered a time uninsured in 2010 to one in which few people will be without health insurance, even during a recession."

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Wednesday, March 16, 2011

QD: News Every Day--MedPAC recommends primary care pay raise

The Medicare Payment Advisory Commission (MedPAC) recommended a 1% raise for physician fee schedule services in 2012. MedPAC, the Congressional agency that advises Congress on issues affecting the Medicare program, released its report Tuesday. (A summary of the 384-page report is here.)

In addition, MedPAC advised Congress to raise payment rates for:
--acute care hospital inpatient and outpatient prospective payments by 1%. Congress should also adjusts inpatient pay rates in future years to fully recover all overpayments due to documentation and coding improvements;
--ambulatory surgical centers by 0.5%, while requiring them to submit cost and quality data;
--outpatient dialysis payments by 1%; and
--hospice rates by 1%

MedPAC recommended no rate increases for long-term care hospitals, inpatient rehabilitation facilities, home health care services or skilled nursing facilities. The number of home health agencies has increased to an all-time high and Medicare’s payments have exceeded their costs by nearly 18% for the tenth consecutive year, the report said. Also, the commission found that Medicare payments for skilled nursing facilities appears to pay providers relatively more for patients who need therapy than for patients with complex care needs.

MedPAC is made up of primary care and specialty physicians, lawyers, nurses and business experts. Its vice chair is Robert Berenson, MD, a Fellow of the American College of Physicians. It recommends Medicare payment rates for 10 Medicare fee-for-service payment systems.

The commission also reviews the status of the Medicare Advantage, which saw 2010 enrollment increase to 11.4 million beneficiaries, or 24% percent of all Medicare beneficiaries). Enrollment in HMOs grew by 7%.

And, the Commission’s report also outlines Medicare's Part D program. The centers for Medicare and Medicaid Services estimates the average monthly premium in 2011 will be $30, a $1 increase over the 2010 average.

IOM identifies immediate health priorities
A new report from the Institute of Medicine singles out 12 indicators as immediate, major health concerns that should be monitored and 24 objectives that warrant priority attention as part of its master plan for improving the health of the American population over the next decade.

The 12 recommended indicators include measures of access to care, quality of health care services, healthy behaviors, injury, physical environment, social environments, chronic disease, mental health, responsible sexual behavior, substance abuse, tobacco use, and healthy births.

Areas to increase include:
--the proportion of children developmentally ready for school, and educational achievement of adolescents and young adults,
--the proportion of people with health insurance, a usual primary care provider and who get appropriate evidence-based clinical preventive services,
--health literacy,
--condom use,
--sleep, and
--exercise.

Areas to decrease include:
--cancer deaths,
--air pollution,
--teen pregnancies,
--central-line-associated bloodstream infections,
--coronary heart disease deaths and hypertension,
--fatal and nonfatal injuries,
--major depressive episodes,
--low birth weight rates
--the proportion of obese children and adolescents,
--consumption of calories from solid fats and added sugars,
--binge drinking of alcohol and past-month use of illicit substances, and
--tobacco use by adults, and starting smoking by children.

From Leading Health Indicators for Healthy People 2020: Letter Report, Institute of MedicineHealthy People 2020, the U.S. Department of Health and Human Services' plan, covers 42 topics and nearly 600 objectives, expanding on the 10 leading health indicators that served as priorities for Healthy People 2010. IN 1990, there had been 15 topic areas and 226 objectives.

The recommendations on what should be the priorities for the latest version of this decadal health plan reflect the consensus of a committee comprising population health experts, epidemiologists, health statisticians, and others. Indicators provide yardsticks that health experts and policymakers can use to measure progress, and objectives set out clear, concrete goals for improvements.

The report suggests specific measures for three topics: social determinants of health; health-related quality of life and well-being; and lesbian, gay, bisexual, and transgender health.

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Tuesday, March 15, 2011

QD: News Every Day--Most states aren't prepared for nuclear disasters

States would be unprepared for nuclear disasters resulting from natural or terrorist events, concluded researchers who surveyed health departments to assess their levels of readiness.

Advanced Test Reactor core, Idaho National Laboratory by Argonne National Laboratory via Flickr and a Creative Commons licenseA survey of state health departments found substantial gaps in preparedness for a major radiation emergency, according to a report posted online by Disaster Medicine and Public Health Preparedness. The entire issue, devoted to nuclear preparedness, is open access.

According to the study, of the 38 states that responded to the survey, including 26 or the 31 states with nuclear power plants, the majority of states had a written radiation response plan and most plans include a detailed section for communication issues.

But most states had completed little to no planning for public health surveillance. Only Four states reported having enough resources for any of the epidemiologic functions associated with a radiation incident.

Only three states reported having enough resources to conduct population-based exposure monitoring. They'd be unable to collect, process and ship samples for and conduct radioactivity analyses of biological/clinical or environmental samples.

Only four state health departments reported having sufficient resources to provide predictions on long-term health effects and medical consultations on radiation effects. Seven states reported sufficient resources for early detection of radiation contamination in first responders, and most reported insufficient resources for worker health/safety consultations, health alerts, potassium iodide plans, risk communication, and community relations.

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Do women need an annual pelvic exam?

A new article in the Journal of Women's Health by Westhoff, Jones, and Guiahi asks "Do New Guidelines and Technology Make the Routine Pelvic Examination Obsolete?"

The pelvic exam consists of two main components: The insertion of a speculum to visualize the cervix and the bimanual exam where the practitioner inserts two fingers into the vagina and puts the other hand on the abdomen to palpate the uterus and ovaries. The rationales for a pelvic exam in asymptomatic women boil down to these:
--Screening for chlamydia and gonorrhea
--Evaluation before prescribing hormonal contraceptives
--Screening for cervical cancer
--Early detection of ovarian cancer

None of these are supported by the evidence. Eliminating bimanual exams and limiting speculum exams in asymptomatic patients would reduce costs without reducing health benefits, allowing for better use of resources for services of proven benefit. Pelvic exams are necessary only for symptomatic patients and for follow-up of known abnormalities.

Screening for chlamydia and gonorrhea
Screening for chlamydia in young women is evidence-based: It reduces the rate of pelvic inflammatory disease. New tests are available (on urine and self-administered vaginal swabs) that do not require a pelvic exam by a doctor. They are sensitive and cost-effective. Supporting references are listed in the article.

Hormonal contraception
Doctors used to require pelvic exams before they would dispense prescriptions for oral contraceptives. This was never shown to be necessary--no findings from these exams influenced the decision to issue a prescription. One concern, the possibility of a pre-existing pregnancy, can't be entirely ruled out by a pelvic exam, but the risk can be minimized by starting the pills after a normal menstrual period. Now all the major guidelines (from the FDA, WHO, ACOG, Planned Parenthood, etc.) specify that a pelvic exam is not required for hormonal contraception.

Cervical cancer screening
Pap smears have been proven effective in reducing morbidity and mortality from cervical cancer. Speculum exams are necessary to obtain specimens for Pap smears, but Pap smears need not be done annually and speculum exams need not be accompanied by bimanual exams. Current recommendations are to begin screening at age 21 and to re-screen at intervals of two to three years. New technology currently in development may eventually allow for equivalent screening without a pelvic exam.

Ovarian cancer
The evidence shows that bimanual exams are useless for detecting ovarian cancer, and they are no longer recommended for this purpose.

Other benefits and risks of pelvic exams
While other conditions such as fibroids, ovarian cysts, and yeast infections can be detected by examining asymptomatic women, there is no evidence that early diagnosis improves outcomes. Overscreening for cervical cancer has been shown to lead to harm. Findings on pelvic exams can be false positives and can lead to unnecessary interventions.

"U.S. rates of ovarian cystectomy and hysterectomy are more than twice as high as rates in European countries, where the use of the pelvic examination is limited to symptomatic women."

Is it time to abandon the annual pelvic exam?
Yes, I think so. The existing evidence indicates that omitting it in asymptomatic women would not affect health outcomes. This article is representative of a growing consensus in the medical community, especially in other countries; but many U.S. doctors are still doing annual pelvic exams. I suspect (just my opinion) that they are afraid of looking stupid or getting sued if they miss something, or are clinging to what they were taught to do out of inertia. Meanwhile, science-based doctors are leaning away from annual physical exams in general. As WebMD says: The annual physical exam is beloved by many people and their doctors. But studies show that the actual exam isn't very helpful in discovering problems. Leading doctors and medical groups have called the annual physical exam "not necessary" in generally healthy people.

Even in patients being followed for diagnosed diseases, the physical exam sometimes degenerates into a token ritual. I've noticed that although I have no heart or lung symptoms, my own doctors like to check my lungs at every visit by putting the stethoscope on four spots (right, left, front, and back) for one breath each, and to check my heart by applying the stethoscope briefly to one spot. I tolerate it because I know it makes them feel better, but I consider it totally useless.

Admittedly, there is a human element involved: Hands-on interactions and the perception of "doing something" can be reassuring and can enhance the doctor-patient relationship. But can't a caring clinician attain those same benefits within the realm of science-based medicine? A doctor's time is better spent on proven health screening measures and in educating and counseling patients than in carrying out nonproductive rituals.

This post by Harriet Hall, 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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Monday, March 14, 2011

QD: News Every Day--Massachusetts residents satisfied with health programs

Massachusetts announced that 84% of people are satisfied with the state's subsidized health insurance coverage and 4% are dissatisfied, a sign of success in the state with the longest experience with mandatory health care coverage.

The Massachusetts Health Connector, the independent state agency that helps residents find health insurance, released a survey that showed 86% of respondents gave high marks to the range of services covered, and the quality of care available, while 82% had similar feelings about the choice of doctors and provider networks. More than 80% percent reported seeing a doctor at least once during the year.

Among members who pay a monthly premium, 63% felt the price was reasonable. Monthly premiums range between $10 and $151 per month. Only 17% reported experiencing problems paying their medical bills.

Among those who qualify for the state' low- or no-cost insurance program, Commonwealth Care, 81% have seen a doctor for regular care at least once since becoming a member. All members have a primary care provider and only 11% reported putting off needed doctor care during the past year. But 31% reported they were told by a provider that they didn’t accept their type of insurance and 23% of members reported being told by doctors they were not accepting new patients.

Commonwealth Care survey respondents used emergency rooms nearly the same as all residents of the state, at about one-third in the past year, and among those who did use an ER, 56% said they needed care after traditional office hours.

The telephone and mail survey of 695 members was conducted last year and had a sampling error of plus or minus 3.7%.

In case you missed it ...
The National Institutes of Health unveiled a new high-speed robot screening system that will test 10,000 chemicals for potential toxicity. Tox21 was established among several federal health agencies, the Environmental Protection Agency and the Food and Drug Administration to more effectively predict how chemicals will affect human health and the environment.

The 10,000 chemicals screened by the robot system include compounds found in industrial and consumer products, food additives and drugs. The robot will evaluate if these chemicals have the potential to disrupt human body processes enough to lead to adverse health effects.

The system can test in one day what it would take a year to do by hand. Tox21 has already screened more than 2,500 chemicals for potential toxicity.

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Thank you for not smoking redux

Your employer can tell you to smoke outside. Can they tell you not to smoke at all?

As a doctor, I'm pretty happy that many states and institutions have banned indoor smoking. With the patients I treat, there's a drastic difference between smokers and non-smokers in terms of suffering and longevity. Smokers get lots more of the former, less of the latter.

SMOKER_  by matteo.maretto via Flickr / Creative Commons licenseI wrote previously about e-cigarettes and their growing ubiquity in the para-smoking world. I also blogged from the Cleveland Clinic's 2010 Patient Experience Summit, where I learned that Mike Roizen, the Clinic's Chief Wellness Officer, had successfully banned all smoking in employees.

"Kind of par for the course for a hospital," I remember thinking at first blush. Then he repeated his statement: he'd banned smoking entirely.

Translation: if you smoke, they don't hire you. If you start smoking, they fire you (at the time I heard him the policy was three years old; two employees had been fired to that point under the policy).

"How can they know what you do on your own time?" you ask. Well, like life insurers, the Clinic tests prospective employees for nicotine metabolites in the urine. You can fib on the questionnaire, but if you've recently smoked tobacco, you can't escape the test.

Now the New York Times is reporting that hospitals in eight states have adopted similar policies. Many have been consulting the Clinic for guidance, where the policy has been in place since 2007.

I've always been slightly amused when I walk by clusters of nurses, transporters, environmental service workers (janitors) or patients clustered near the exits of our medical center, getting their fix, usually in shirt sleeves, before heading back into the building. Sometimes I wish the designated smoking areas were a couple of miles away from the exits--then we'd be less likely to inhale a train of smoke as we walk the gauntlet. At least the employees should know better, I often think, stunned to see respiratory therapists in the mix. The same therapists whose job it is to suction pus from the lungs of asthmatics and emphysemics.

Though I find the article's trend-spotting interesting and in line with my professional values, I think it goes a bit too far in the personal privacy realm. After all, cigarettes, though vilified, are still legal for adults. Will employers start the practice of not hiring other "health-risky" employees (e.g. obese, hypertensive or diabetic patients)?

What do you think about this?

Clever incentive to make workers at health care institutions walk the walk, or trampling of a civil liberty? Let me have your comments.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. 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, March 11, 2011

QD: News Every Day--Obesity trumps adiposity for cardiovascular risk

Obesity contributes to cardiovascular risk no matter where a person carries the weight, concluded researchers after looking at outcomes for nearly a quarter-million people worldwide.

Body-mass index, (BMI) waist circumference, and waist-to-hip ratio do not predict cardiovascular disease risk any better when physicians recorded systolic blood pressure, history of diabetes and cholesterol levels, researchers reported in The Lancet.

The research group used individual records from 58 prospective studies with at least one year of follow up. In each study, participants were not selected on the basis of having previous vascular disease. Each study provided baseline for weight, height, and waist and hip circumference. Cause-specific mortality or vascular morbidity were recorded according to well defined criteria.

Individual records included 221,934 people in 17 countries. In people with BMI of 20 kg/m2 or higher, hazard ratios for cardiovascular disease were 1.23 (95% CI, 1.17 to 1.29) with BMI, 1.27 (95% CI, 1.20 to 1.33) with waist circumference, and 1.25 (95% CI, 1.19 to 1.31) with waist-to-hip ratio, after adjustment for age, sex, and smoking status. After adjusting for baseline systolic blood pressure, history of diabetes, and total and HDL cholesterol, corresponding hazard rations were 1.07 (95% CI, 1.03 to 1.11) with BMI, 1.10 (95% CI, 1.05 to 1.14) with waist circumference, and 1.12 (95% CI, 1.08 to 1.15) with waist-to-hip ratio.

BMI, waist circumference, or waist-to-hip ratio did not importantly improve risk discrimination or predicted 10-year risk, and the findings remained the same when adiposity measures were considered.

"The main finding of this study does not, of course, diminish the importance of adiposity as a major modifiable determinant of cardiovascular disease," the authors wrote. "Rather, because excess adiposity is a major determinant of the intermediate risk factors noted above, our findings underscore the importance of controlling adiposity to help prevent cardiovascular disease."

Still, the authors said, adiposity remains an important measure in risk assessment to promote weight loss or in communicating the risks of obesity to patients.

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Thursday, March 10, 2011

QD: News Every Day--U.S. cancer survivors grows to nearly 12 million

The number of cancer survivors in the United States increased to 11.7 million in 2007, according to a report released by the Centers for Disease Control and Prevention and the National Cancer Institute (NCI), part of the National Institutes of Health. Women survive more often, and survive longer, according to the report.

There were 3 million cancer survivors in 1971 and 9.8 million in 2001. Researchers attributed longer survival to a growing aging population, early detection, improved diagnostic methods, more effective treatment and improved clinical follow-up after treatment.

The study, "Cancer Survivors in the United States, 2007," is published today in the CDC's Morbidity and Mortality Weekly Report.

To determine the number of survivors, the authors analyzed the number of new cases and follow-up data from NCI's Surveillance, Epidemiology and End Results Program between 1971 and 2007. Population data from the 2006 and 2007 Census were also included. The researchers estimated the number of persons ever diagnosed with cancer (other than except non-melanoma skin cancer) who were alive on Jan. 1, 2007.

Study findings indicate:
--As of January 1, 2007, an estimated 64.8% of cancer survivors had lived five or more years after their diagnosis of cancer.
--Among all survivors, 4.7 million received their diagnosis 10 or more years earlier.
--Of the 11.7 million people living with cancer in 2007, 59.5 %, or 7 million people, were 65 years or older.
--Women are the larger proportion of cancer survivors, at 54%. Among those who had lived with a diagnosis of cancer for more than 15 years, 67.5% were females.
--Approximately 1.1 million of the 11.7 million cancer survivors had lived with a diagnosis of cancer for more than 25 years. Of those survivors, 75.4% were females.
--Among the three most common cancers, breast cancer survivors are the largest group of cancer survivors (22%), followed by prostate cancer survivors (19%) and colorectal cancer survivors (10%).

"As the number of cancer survivors continues to increase, it is important for medical and public health professionals to be knowledgeable of issues survivors may face, especially the long-term effects of treatment on their physical and psychosocial well-being," said Arica White, PhD., MPH., an epidemic intelligence service officer in CDC's Division of Cancer Prevention and Control. "This understanding is critical in promoting good health and coordinating comprehensive care for cancer survivors."

ACP Internist detailed how primary care follow-up was critical for breast cancer survivors, and how the 2009 release of U.S. Preventive Services Task Force guidelines changed screening recommendations.

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Hard water: Is it hard on your skin?

Hard water is tap water that's high in minerals such as calcium and magnesium. Hard water isn't harmful, except the minerals prevent your soap from sudsing. Some people think that hard water is more likely to cause a rash than soft water.

Day 121 By Perfecto Insecto via FlickrTake a recent patient of mine: He moved his family to San Diego from the East Coast (good move this winter, no?) After they moved here, they noticed their skin became dry and itchy. He blamed San Diego's notoriously hard water and installed a water softener in the main water line. It was costly, but did it improve their skin?

A recent study from the U.K. looked at this question: Does hard water worsen eczema? The answer was no, it doesn't. Water hardness did not seem to have any impact on eczema, the most common skin rash.

What's more important than the hardness of the water is the type of soap you use. True soap tends to strip the skin of its natural oils, leaving it exposed and irritated. Non-soap cleansers, of which Dove is the prototype, leave more oils on your skin, keeping it hydrated and protected.

paneidolia by thebadastronomer via FlickrMy patient and his family didn't get any better after installing a water softener (although he said they could drink our tap water without gagging now.) I advised him to change to a moisturizing soap and to apply moisturizer daily.

San Diego is drier than most of the country, and the low humidity can be a shock to skin accustomed to humid air. Many people who move here find they have to moisturize more often than they did back home. When they complain, I suggest they could alternatively move back to the East Coast this winter--no takers so far.

This post by Jeffrey Benabio, 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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Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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