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

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Monday, April 30, 2012

Questions are the answer

One of the advantages of having a blog has given me incredible opportunities to works with so many doctors, patients and others interested in health care. However, one of the disadvantages is the solicitations. I get at least one email a day from someone (usually who is trying to sell something) asking me to post content on their product or ad links on my blog to their web site.

I almost always decline or just simply delete the request. I almost deleted the request the other day, when I quickly realized the requester's email ended in a ".gov." Apparently, AHRQ is using social media to try to reach out to people.

AHRQ stands for The Agency for Healthcare Research and Quality, and for those in the know, is pronounced "ark." According to their website, AHRQ's mission is: "To improve the quality, safety, efficiency, and effectiveness of health care for all Americans. As 1 of 12 agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research"

As a primary care physician who spends a lot of time with patients trying to help them make the best decisions for their health, AHRQ is a group I like to get behind. Their latest campaign which thy contacted me about is "Questions Are the Answer." The essence of their campaign is to educate patients that the best way to take care of themselves is to ask their doctors questions.

This may seem pretty obvious, but patients are often reluctant to ask us questions. They may be embarrassed for asking something that they think we might think sounds stupid. They may feel that we should be the ones asking questions. They may think that is something is important, we would have told them. The reality is that health care done right is a two way communication between doctor and patient, with both parties listening and asking questions.

Thus, I have therefore broken my usual rule, and posted a solicitor's content on my site. Their content is below. As the politicians say, "I have approved this message."

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When patients become more actively involved in their own health, there's a much stronger likelihood their health outcomes will be better.

That's why "Questions are the Answer," a new public education initiative from the U.S. Agency for Healthcare Research and Quality (AHRQ), encourages patients to have more effective two-way communication with their doctors and other clinicians.

"Questions are the Answer" features a website -- www.ahrq.gov/questions -- where you will find these free educational tools to use with your patients:

A 7-minute video featuring real-life patients and clinicians who give firsthand accounts on the importance of asking questions and sharing information – this tool is ideal for a patient waiting room area and can be set to run on a continuous loop.

A brochure, titled "Be More Involved in Your Health Care: Tips for Patients," that offers helpful suggestions to follow before, during and after a medical visit.

Notepads to help patients prioritize the top three questions they wish to ask during their medical appointment.

Clinicians can request a free supply of these materials by calling AHRQ at 1-800-358-9295 or sending an e-mail to AHRQpubs@ahrq.hhs.gov.

View Campaign Website
View Featured PSAs
View Original Video Series

Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also 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. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.

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An HgbA1c goal of 7 is sometimes dangerous

Recently we had a patient admitted for hypoglycemia. He had long standing type II diabetes mellitus being treated with metformin, glyburide and twice daily 70/30 insulin. He had had several hypoglycemic episodes previously at home.

The admission and management caused no problem and the patient was ready for discharge the next day. However, we then asked the most important question: Why?

Why did this patient develop repeated episodes of hypoglycemia?

I suspect that his primary care physician was trying desperately to achieve an HgbA1c of less than 7. I doubt that the physician added drugs because he thought the patient needed them, but rather because someone (an insurance company or a clinic manager) told him that the patient's HgbA1c was too high.

This patient likely represents one of the problems with poorly considered performance measures.

Achieving a low HgbA1c or blood pressure or LDL has challenges. Often we must use more medications. Usually we are not treating the patient as much as we are treating the patient.

Adding drugs to try to achieve a goal does increase the rate of complications. The more drugs, the more complications. The higher dose of drugs, the more complications.

PRIMUM NON NOCERE!

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

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Lamentation

I had an article published on the Atlantic's website.

I've been struck over the last few years by how many graduates in my field of internal medicine choose NOT to work as traditional internists.

Call us what you like:
--traditional internists,
--general internists,
--primary care internists,
--outpatient internists, and
--just plain old internists.

You can see we've always had a problem with what we're called. What is an "internist" anyway? No one has any problem understanding what a cardiologist is. It's right there in the name.

Subspecialties have always been a good career path for internal medicine graduates. But those of us that didn't want to do the additional training (three to four more years) to become certified in a specific body part could always be internists.

But now our graduates are choosing hospital work as the path of least resistance. And for good reasons:
--better pay,
--flexible scheduling,
--no on-call (i.e. after hour) duties,
--feeling better trained for the work

Part of me is jealous that this opportunity did not exist as such when I graduated twelve years ago. Part of me is sad that our trainees don't want to take the job that I willingly signed up for.

The hospital has excellent systems in place to provide good care for patients. The doctors that work there are part of a well-oiled (well, at least greasy) machine that caters to them as much (if not more) than it does for patients.

Not true in the office world, where there is less support. More of the administrative, financial and organizational burdens fall on the doctors. That isn't inherently bad, but it's not what we are trained to do. And by comparison, it makes the practice of outpatient (office) medicine that much harder.

More importantly, there's the relationship aspect: I chose to work in primary care because my relationship with patients would evolve over decades. I believed (and still do) that by getting to know patients more thoroughly over time, I can provide better, more informed, value-conscious care. The relationship between a hospitalist and a patient lasts days. Then it's over. For an ER doc, it's hours or even minutes. I'm not passing judgment; it's just a different type of thing altogether.

I think about my patients at night. On the weekends. In the shower. Wherever and whenever.

In site-based care, like the hospital or the ER, when your shift is over, you go home. Without your work. [I know, of course doctors in these settings think about their patients when they go home. It's just the idea of this freedom that rankles.]

I could jump ship and become a hospitalist. As I reported in the article, a colleague left her office practice after 23 years. Her patients are upset, confused, wistful. Grateful for her care over the many years. Happy for her personally on an intellectual level. But emotionally distraught.

When I started researching the article, I identified with Dr. Fingold (read the Marticle for context). To some degree, I looked at Dr. Wachter as someone who had unleashed a profession-altering (destroying?) force into the world.

By the time I was finished, I realized that things are not that simple. Dr. Wachter took me on a whirlwind tour of the history of hospitalists and their impact in American medicine, and it's quite a story. He certainly didn't unleash the disruptive force as much as he understood it, rode it, catalogued it, and helped develop it.

"I invented the term 'hospitalist' like Al Gore invented the Internet," is only one of his well-crafted interview lines.

The work I did for the article is helping me to radically re-think both how we practice and deliver health care, including how we teach it to our future doctors, regardless of where they end up practicing.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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QD: News Every Day--3 studies outline who's adopting EHRs, and how fast

A year after Medicare's incentives for using electronic medical records kicked in, small practices, rural hospitals and systems capable of reporting meaningful use criteria still lag in adoption.

Three studies released online in Health Affairs tell the tale.

In the first study, the authors used data from the annual National Ambulatory Medical Care Survey. Overall, there was a 38 percentage point increase in EHR adoption among office-based physicians, and by 2011 more than half of physicians had EHRs, or three tims as many in a decade. But physicians in solo or duo practices were less likely to have made the change (25.9 percentage point increase in adoption rate versus a 54.6 percentage point increase during the decade for practices with 10 or more physicians).

Primary care physicians increased their adoption by 8.6 percentage points more than non-primary care physicians over the decade. Physicians aged 55 and older increased adoption by 20.4 percentage points less than physicians aged 45 years or younger.

The second study found that since the federal incentive program began, the percentage of hospitals with at least a basic EHR system increased from 15.1% in 2010 to 26.6% in 2011. Also, they found that 18.4% of hospitals had achieved what is a reasonable proxy for meaningful use, a large jump from just 4.1% in 2010.

Although there was a 15 percentage point gap in EHR adoption between small and large hospitals in 2010, that gap had widened to nearly 22 percentage points in 2011.

The third study found that while slightly more than half of physicians intended to apply for meaningful-use incentives, only slightly more than one in 10 have EHRs with at least 10 of the 15 capabilities required to support stage 1 core meaningful-use objectives.

The uncertainty is driving small practices to join larger networks of affiliate with hospitals, not only to take advantage of EHRs but because there's safety in numbers. ONE practice's story is reported here.

Finally, many of the same authors from the studies compiled their reports, along with pretty charts and graphs as well as an Interview by Michael W. Painter, MD, JD, of the Robert Wood Johnson Foundation, with David Blumenthal, MD, MPP, immediate past national coordinator of the Office of the National Coordinator for Health Information Technology, in a report here.

Dr. Blumenthal's point of contention: "The first thing such a doctor needs to realize is that he is never going to get help like that available now from the federal government again. That bank is exhausted. The almost $30 billion projected to be spent, assuming that people take advantage of the incentives, amounts to $100 for every man, woman and child in the United States. That is an extraordinary investment by this country in helping doctors adopt a new technology. There is probably not another thing that those doctors will ever do in their lives where everyone walking on the streets in the United States will be paying $100 to help them. If they want to pass that up, that is their right. I don't think it is a very wise decision."

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Friday, April 27, 2012

Facts about the calorie shed excess heat, too little light

A calorie is, incontrovertibly, now and forever, a calorie. Well, a kilocalorie actually. Back to that in a minute.

Candle by kkalyan via Flickr and a Creative Commons licenseNot every gallon of gasoline poured into the tank of every car produces the same travel distance. But that does not induce us to ask: Is a gallon a gallon? Of course a gallon is a gallon; it is a precise and clearly defined unit of volume not up for debate. We recognize that variation in the fuel efficiency of cars can change what happens when a gallon of fuel is burned. But it was still a gallon of fuel.

A degree on any given temperature scale is a degree. That doesn't mean every degree will FEEL the same to you or me, because we are more sensitive to temperature change in some parts of the range than others. We are unlikely to notice the difference, for instance, between 41 degrees below zero Fahrenheit and 42 degrees below zero Fahrenheit. Both are so cold, who cares? But we might well notice the difference between 67 and 68 while sitting in an office if we happen to be a bit chilly at the former and comfortable at the latter. But still, a degree is a degree.

A mile is a mile. But walking one over flat ground when well-rested feels very different from climbing one up a mountain when exhausted. But the differences have to do with our condition, terrain and altitude, not distance. A mile is a mile.

Why, then, do we keep asking, as occurred in the New York Times, if a calorie is a calorie? Of course it is. It can be nothing else.

As noted above, the measure we actually use when talking about food is the kilocalorie. A kilocalorie (Europeans use the kilojoule, by the way) is the energy required to raise the temperature of one liter of water one degree Celsius at sea level. Does it sound as if that leaves much room for debate? It is a unit of energy, no more debatable than a unit of distance, temperature, volume or velocity.

Why, then, is there a cottage industry in questioning the calorie? And why am I so adamant that this cottage industry should be shut down? I will address these questions in turn.

Questioning the calorie sells. It sells books, articles, magazines, newspapers and air time. It exploits the difficulty so many of us have with weight control, and turns it into a dumbed-down pet theory, conspiracy theory, and/or magical thinking. It offers a false promise of weight loss independent of energy balance. And since real and keep-able promises about weight loss require the actual effort involved in dealing with energy balance, false promises perennially appeal.

My adamant opposition to this industry relates to the fact that it is harmful to health--public and personal. The more time we spend debating what should not be debatable, the more time we spend with understanding, consensus, collective effort and resources diverted from where they could make a meaningful and positive difference. The more often we buy a new answer to the "Is a calorie a calorie?" question, the more time we spend mired in epidemic obesity. Those profiting from the confusion probably don't mind, but you should.

"Is a calorie a calorie?" is the wrong question, obscuring all of the right questions and diverting our attention from what matters. It also is a classic example of creating confusion rather than alleviating it, by pretending to address a deep issue that is, in fact, profoundly trivial.

Here's what I mean: You are a little bit hungry, and on two successive days you get to eat limitless amounts of one of two foods with the same exact calorie content. One tastes absolutely great, and the other tastes absolutely horrible. Do you think you will eat exactly the same amount of both?

Eating more of a food that tastes great (as in: "Betcha' can't eat just one!") is NOT an invitation to question a basic law of physics. It's obvious to the point of truly trivial. Food made to taste really good will likely goad us into eating more calories. Duh.

Another non-controversy with which the constant questioning of calories makes hay: Two people can exercise the same, and eat the same, and one will gain weight while the other does not. Doesn't this prove that a calorie is not a calorie?

Of course it doesn't! All it proves is that I am not you, and you are not me! No one ever said that any two humans burn calories with exactly the same efficiency. As noted at the start, two cars may get very different gas mileage; that does not seem to tempt us to revisit the definition of a gallon over and over. People, similarly, differ in their fuel efficiency. Some can gain weight on very few calories. That isn't fair, of course, but no one ever promised us life would be. It is not a reason to debate the calorie.

The composition of food matters, because it can influence how many calories we are inclined to eat. We tend to eat more when food tastes better. We tend to eat more when food is energy-dense. We tend to eat more based on characteristics of everything from ambient lighting to dishware, as the brilliant work of Brian Wansink reveals.

We tend to eat less, i.e., fewer calories, when food is higher in volume and lower in energy density. We tend to eat fewer calories when food is rich in fiber content. We tend to fill up on fewer calories when foods have a high "satiety index" and properties that contribute to that include, but are not limited to: high quality protein, high water content and a low glycemic load. We tend to fill up faster on foods that are simple, close to nature and free of flavorings, additives and significant quantities of added sugar and/or salt.

In other words: Some foods are better for us than others, and one of the many virtues of better-for-us foods is that they tend to help us feel full on fewer calories. This probably seems obvious if you think about just a little. And that's exactly the point. The truth about calories is too obvious to support false promises, magical thinking, or book sales. So self-proclaimed renegade geniuses keep stepping into the limelight to rediscover the deep, dark debate about a basic unit of measurement that does not exist.

There are real challenges, and maybe even conspiracies, to deal with, and we are wasting our time and resources on pseudo-debate.

There is the fact that elements in the food industry have used brain scans to determine how to engineer foods that maximize the number of calories it takes for us to feel full. When they told us "Betcha' can't eat just one," it was a very safe bet they were placing.

There is the fact that our farm bill rewards all the wrong policies, and contributes to the low cost of high-fructose corn syrup and the high cost of produce.

There is the fact that experts in marketing are earning six- and seven-figure salaries to talk your 6-year-old into preferring foods likely to propel him or her toward obesity and the early onset of chronic disease, diabetes in particular.

And there is real and growing opportunity to use genomic advances to customize variations on the theme of healthful eating that lead to fullness, and weight control, most readily for different individuals.

You want a conspiracy theory? Maybe the frequency and popularity of the calorie debate is somehow being fueled by the elements in the military industrial establishment that profit from the status quo and don't want us to ask, and answer, truly meaningful questions. Or maybe it's just the work of those with books to sell.

Either way, we are wasting our time and precious resources. Imagine all the good that would come if instead of devoting our attention, time and money to improving the fuel efficiency of cars and finding better alternatives to fossil fuel, we devoted them instead to peddling books, articles, segments and blogs on the truly deep question: Is a gallon REALLY a gallon?

Folks, I have met enough people to know I am not unique. We have common sense in common. And our common, common sense is better than this! If it isn't, my daughter who lives in Brooklyn has told me there's a nice bridge for sale there.

We are wasting our energy debating the nature of the calorie, which is, simply, and incontrovertibly, a measure of energy.

And heat. The routine diversion of attention to a controversy about this that simply does not exist generates heat, but absolutely no light.

David L. Katz, MD, FACP, MPH, FACPM, 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. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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QD: News Every Day--Internists reluctant to stop PSA testing in elderly men

Elderly men expect to receive prostate-specific antigen (PSA) tests and doctors continue to conduct them, sometimes even in men with low life expectancy despite the recommendations against the practice. Patients' expectations and the time it would take to dissuade them are two main reasons, a study found.

Doctors know they shouldn't do prostate-specific antigen (PSA) tests in older men, but they do them anyway--at a brisk pace. An estimated 57% of men ages 75 to 79 years and approximately 33% of men with low life expectancies received screening within the past year, according to Johns Hopkins researchers who delved into the barriers to physicians stopping PSA screening.

The researchers surveyed physicians at Johns Hopkins Community Physicians, a university-affiliated practice comprised of 26 outpatient sites in 11 counties in Maryland. Providers were asked about screening practices, factors that influenced their decision to discontinue screening and what stopped them from stopping PSA screens. Resultsappeared in Cancer.

Responses from 125 of 141 providers (88.7%) showed that 17.2% of participants said they ordered PSA screening without discussing it with their patients, and 33.6% said they discussed PSA screening and typically recommended it. When providers ordered PSA screening, they overwhelmingly (90%) ordered it annually.

59.3% took age and life expectancy into account, while 12.2% did not consider either in their decisions to discontinue PSA screening. Nearly one-third of providers (32.5%) said that they did not have an age at which they typically stop recommending PSA screening. Among the 67.5% who said they stopped screening based on age, 26.8% stopped screening starting at age 70, 52.4% at 75, and 20.7% at 80.

The most frequently cited barriers to discontinuing PSA screening were patient expectation (74.4%) and time constraints (66.4%). The majority of providers agreed or strongly agreed that they typically took life expectancy into account when ordering PSA screening (76.8%).

Providers who stated that they had an age at which they typically discontinued screening also were significantly more likely to take life expectancy into account. However, 66.4% of providers described it as very difficult or somewhat difficult to estimate life expectancy in clinical practice, and 69.1% wanted a clinical decision support tool that would help predict mortality.

The authors wrote, "[I]nterventions will need to teach clinicians to take age and life expectancy into account when deciding whether to initiate and continue screening. For providers that already consider these factors, the development of tools that help clinicians more accurately and quickly estimate life expectancy may be an important next step."

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Thursday, April 26, 2012

New studies on colon cancer screening by colonoscopy and fecal blood testing

The New England Journal of Medicine published two major papers on screening for colon and rectal cancer. The most notable finding supports that colonoscopy, when done properly and not necessarily often, saves lives.

The NCI estimates that doctors will find over 103,000 colon and 40,000 rectal cancers, and the number of deaths will exceed 51,000 this year in the U.S. According to the ACS, colorectal cancer ranks third as a cause of cancer mortality in men and in women. In light of these numbers, the potential for screening to reduce deaths and costs of treating people with advanced disease is great.

Both analyses are unfortunately, almost dauntingly, complicated. An accompanying editorial by Drs. M. Bretthauer and M. Kalager lends some perspective.

colon adenoma pathology, H&E stain, via Wikipedia and a Creative Commons license: Nephron The first report comes from a group of researchers led by Ann Zauber, PhD, a biostatistician at MSKCC. This team examined long-term outcomes among 2602 adults who had adenomatous polyps removed between 1980 and 1990, followed by colonoscopy recommended at varying intervals in a trial. With a median follow-up of 15.8 years, there were only 12 deaths from colon cancer in the study population — essentially half the number expected by comparison with SEER data.

The main limitations I see in this report are two. First, what might be considered a good thing, is the high compliance rate; 81% of those with adenomas underwent some follow-up colonoscopy. A second, along a similar vein, is that the colonoscopies were performed by highly-trained physicians at academic centers in a trial that mandated a certain degree of thoroughness and quality.

Some criticism of the work is that the findings won't translate to the community at large, as mentioned in the editorial and in the paper itself. That's because some "real world" gastroenterologists don't perform the procedure so carefully. Apart from the trial, many people are genuinely hesitant about having colonoscopy out of concern about its unpleasantness and also costs. Compliance with colonoscopy recommendations runs low.

These are valid concerns. But they don't abrogate the value of the procedure. Rather, they point to the need for rigorous training of doctors who do colonoscopy, for close monitoring of facilities where it's done (and in path labs, where the specimens are evaluated), and for insurance or a national health plan to enable patients, if they choose, to have this potentially life-saving screening test covered.

The second study, from a group in Spain, examined the relative merits of checking stool samples for blood every two years vs. colonoscopy every 10 years in over 50,000 people. The preliminary finding after just one "round" of colonoscopy in those assigned to that trial arm, is that a higher proportion complied with fecal blood testing than with colonoscopy. Among those who underwent colonoscopy, cancers and adenomas were found in a greater fraction. But the absolute number of cancers detected was essentially the same in each group, because more people assigned to fecal screening completed the task.

My take from these reports, combined, is that periodic colonoscopy has the potential to halve the number of deaths from colon cancer in the general population. But it's an unpleasant, invasive and expensive test that does carry some risks. The quality of the test, both in terms of its thoroughness and risk of complication, would depend, in part, on the training and experience of the doctor who performs the test. So, as with mammography, I favor heavy regulation and careful certification of physicians who perform these procedures.

As to how colonoscopy relates to fecal blood testing as a screening method at the population level, and the optimal start and frequency of either test, those remain uncertain. Dr. Zauber, it turns out, heads the NCI-funded National Colonoscopy Study. This ongoing work will, hopefully, shed light on how testing for blood in stool samples compares with colonoscopy in colon cancer screening and, ultimately, costs and mortality from late-stage disease.

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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Don't confuse a happy patient with a well one

Patient satisfaction is all the rage. Medicare is beginning to tie patient satisfaction scores with hospital reimbursement, and doctors across the country are under pressure from administrative executives to raise patient satisfaction scores. High scores are even used by hospitals as a powerful marketing tool.

But, in the end, are patient satisfaction scores hurting patients?

I wrote about the issue previously, saying that patient satisfaction scores reward rich hospitals, as well as a previous USA Today op-ed, warning that catering to patient demands may not be in their best interest: "Quality health care sometimes means saying 'no' to patients, denying them habit-forming pain medications that can feed an underlying, destructive drug addiction, or refusing to order unneeded CT scans that can facilitate harmful radiation exposure.

But Edwin Leap, a nationally recognized physician columnist at Emergency Medicine News, notes that doctors 'are constantly under the microscope to give patients what they want, since 'giving people what they want,' has been tragically, and falsely, equated with good medicine.'"


So it comes as no surprise that a recent study from the Archives of Internal Medicine has confirmed most physicians' fears.

According to the study, "compared to the least-satisfied patients, those who were most satisfied with their healthcare were on more prescription medications, made more doctor's office visits and were more likely to have had one or more hospital stays, despite the fact they were in better overall physical and mental health. Also, despite the greater attention and all those prescription drugs they got, the highly satisfied were more likely to die in the few years after taking the survey than were those who pronounced themselves least satisfied with their physicians' medical care."

As emergency physician WhiteCoat aptly puts it, "High satisfaction with a health care facility means that you're more likely to be admitted, you're more likely to pay more for your care, and you're more likely to be discharged in a body bag."

Not only are satisfied patients more likely to die, they cost more: "Overall, the most satisfied patients incurred 8.8% more healthcare expenditures than did the least satisfied and spent some 9.1% more on prescription drugs than did the least satisfied."

Our health system provides overwhelming incentives to "do more." The flawed fee-for-service payment system gives a financial carrot to order more tests. The emphasis on patient satisfaction pressures doctors to acquiesce to demands for medications. And finally, the malpractice system punishes doctors for not ordering, or not referring, enough, never for overuse of medical resources.

We need are more incentives to do less. Reward doctors for sticking to evidence-based clinical guidelines. Back them up for saying "no" to patients, at the risk of lower satisfaction scores. Educate the public that more tests can, in fact, be harmful.

And now, patients need to know that a hospital with a high patient satisfaction score isn't necessarily a good thing.

The Archives study shows that patient satisfaction raises health costs and kills patients. How much more data do we need before realizing that patient care and patient satisfaction cannot be mixed?

Kevin Pho, MD, ACP Member, is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn. This article was originally published on KevinMD.com.

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QD: News Every Day--Internists see 2% more income, still among the lowest paid specialties

26% of physicians earned less this year compared with last year, according to a survey by Medscape.

While physician income declined in general, the top-earning specialties remained the same as last year. In 2012, radiologists and orthopedic surgeons earned $315,000, followed by cardiologists ($314,000), anesthesiologists ($309,000), and urologists ($309,000). This is a change from 2011, when radiologists and orthopedic surgeons earned a mean of $350,000 each and anesthesiologists and cardiologists earned $325,000.

The bottom-earning specialties in 2012's survey were pediatrics ($156,000), family medicine ($158,000), and internal medicine ($165,000).

Despite the ranking, internal medicine saw a 2% increase in income. The biggest income increases were in ophthalmology (+9%), pediatrics (+5%), nephrology (+4%), rheumatology (+4%), and oncology (+4%). The largest declines were in general surgery (-12%), orthopedic surgery (-10%), radiology (-10%), and emergency medicine (-8%).

Male physicians overall earned about 40% more than females. In primary care, men earned 23% more. While the gap is due to female physicians choosing to work fewer hours, that gap is closing as younger male physicians seek more family-friendly lifestyles, the report stated.

Partners in private practice were busier than employed physicians, but they far outearned other types of employment. Overall, partners in private practice earned a mean of $308,000. Solo practitioners earned a mean of $222,000, while employed physicians earned a mean of $194,000.

Physicians who are board certified earned a mean of $236,000, which was 89% more than non-board-certified doctors, who earned a mean of $125,000.

About 31% of physicians overall spend 30-40 hours per week in direct patient care. About one quarter of pediatricians, rheumatologists, and family physicians spend less than 30 hours per week in direct patient care.

As in Medscape's 2011 survey, the 13- to 16-minute patient visit is still the most common, especially for family medicine and internal medicine. This is time spent directly with the doctor, not another practitioner.

More than half of all physicians spend 4 hours or less on paperwork and administration. Another 23% spend from 5 to 14 hours per week on administrative work. Only 10% of family physicians, internists, and pediatricians spend that much time on administrative activity.

Internists and family physicians reported that they were the most frustrated specialties. This year's survey reported far more dissatisfaction among doctors across all specialties than those of previous years. In 2012, just over one half of all physicians (54%) would choose medicine again as a career, far less than last year (69%). Only one quarter of internists and one third of family physicians would choose the same specialty.

The survey was conducted among 24,216 US physicians across 25 specialties in early February via a third-party online survey collection site. Internists were the single largest responding specialty, at 15% of all responses.

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Wednesday, April 25, 2012

Captain of the men of death

I have in front of me a weathered copy of Cecil's Textbook of Medicine from 1947. It belonged to my father, who graduated from medical school in the 1940s. Even then, it was known that pneumococcus, a common bacterium, can live harmlessly in the nose and throat and only sometimes causes disease. Pneumococcal disease was and is still a leading cause of disease and death*, killing perhaps a million children per year. It causes ear and sinus infections, but also meningitis, and is the most common cause of pneumonia.

Copyright American College of PhysiciansIn the past it was referred to as "the captain of the men of death" for its ability to claim so many. It is also closely associated with influenza; the pneumococcus that may live harmlessly in the mouth may find the damaged lung of the flu patient a nice place to set up shop. The pneumonia that follows an influenza infection can be devastating and preventing it is an important public health goal.

The bacteria itself has been known for over a century, when it was discovered by U.S. Army doctor George Sternberg in a frontier post in 1881. A couple of decades later, sera were developed to fight the disease. There were no antibiotics at the beginning of the 20th century, and as influenza killed millions, often of pneumonia, scientists were working feverishly (and often dying) trying to save lives. They discovered some of the most important serotypes of pneumococcus, created serum from horses, and injected it into sick patients with significant good results.

The discovery of antibiotics significantly changed the pneumonia landscape. According to Cecil: "The role of pneumococcal infections as a cause of death has been amazingly diminished by the introduction of sulfonamide and penicillin therapy."

A fascinating report in the journal Chest was published in 1943 and described the treatment of pneumonia with sulfonamides in the Panama Canal Zone. The mortality rate for treated patients with confirmed pneumococcal disease was 1%, something unheard of until then.

But in these early days of antibiotics, the course of the disease was still described in nearly Hippocratic terms. From Cecil again: "Pneumonia may terminate by crisis or lysis. The typical crisis of pneumonia is one of the most striking features of the disease. The patient, struggling against a virulent infection, often appears on the verge of collapse. The whole organism seems to be affected by the toxemia. Suddenly the patient begins to perspire freely; there is a rapid drop in temperature to normal or subnormal, accompanied by a corresponding fall in the respiratory and pulse rate. In a few hours the entire clinical picture is changed. The patient looks and feels much better and drops off into a quiet sleep ...

"In many cases there is no definite crises, but the patient's temperature comes down gradually by lysis ..."


He goes on to describe the course when there is no crisis or lysis--death by sepsis, although he doesn't use that word.

Today, even with antibiotics, pneumococcal diseases remain an important cause of illness and death. But we have another weapon: vaccination.

Pneumococcal vaccines have been around for a long time, and the current vaccine protects against 23 strains accounting for about 90% of pneumococcal disease. The vaccine does not prevent all pneumococcal disease, but it does prevent the most severe complications.

The New York Times is now reporting that pneumococcal vaccination has the potential to prevent complications and death during the current pandemic. It should be old news, but the CDC is reporting a spike in cases, especially in young people. Pneumococcal vaccination, which is recommended for those over 65, is also recommended for many groups of young people, including smokers. Improving pneumococcal vaccine rates in recommended populations has a real potential to save lives during this pandemic and during subsequent flu seasons. With flu vaccines being sporadically available, pneumococcal vaccines, which are widely available, can help save lives. I don't think Cecil would have been surprised, but he certainly would have been pleased.

References
Cecil, Russell L. A Textbook of Medicine. Saunders, 1947.
Barry, John M. The Great Influenza. Viking, 2004.
Browne SM, Marvin HP, and Smith ER. Sulfadiazine pneumonia therapy in the canal zone. Chest, 1943;9;297-301.
*According to the CDC:
Each year in the United States, there are an estimated 175,000 hospitalized cases of pneumococcal pneumonia; it is a common bacterial complication of influenza and measles. In addition, in terms of invasive disease, there are more than 50,000 cases of bacteremia and 3,000 to 6,000 cases of meningitis annually. Invasive disease bacteremia and meningitis is responsible for the highest rates of death among the elderly and patients who have underlying medical conditions. According to the Centers for Disease Control and Prevention (CDC), invasive pneumococcal disease causes more than 6,000 deaths annually. More than half of these cases involve adults for whom vaccination against pneumococcal disease is recommended.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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Unhappy meal and the right to be obese

Last July, McDonalds' Happy Meals became a little less happy. Kids in pursuit of culinary happiness will have to be satisfied with fewer French fries and some added fruit. Surprisingly, the calorie count only decreased by 20%. McDonalds held firm on the request to discontinue toys in the Happy Meals, despite opponents' arguments that these trinkets emit an encrypted electronic signal that lure kids to the golden arches.

Fastfood by happymealy via Flickr and a Creative Commons licenseAn Indiana billboard offers this announcement along with a graphic photograph that depicts innocent hot dogs masquerading as cigarettes in a cigarette package. WARNING: HOT DOGS CAN WRECK YOUR HEALTH."

This publicity effort was spearheaded by the carniphobic group Physicians Committee for Responsible Medicine (PCRM). This organization advocates that all of us restrict ourselves to the pleasure of an all-plant diet. The billboard was a shrewd move. Beforehand, none of us had ever heard of these guys. Now, for a few hundred bucks, they achieved national exposure.

I'm for folks making informed choices. I don't like it when the government or other organizations try to impose their views and practices on the rest of us. If I want to start and end my days with a Big Mac or two, then I should be free to do so without interference from others. Just as I would not lean on my vegan friends to savor some barbecued chicken wings, I don't want to cajoled or shamed into giving up burgers for some kind of seaweed surprise.

Veggie enthusiasts point to research that concludes that carnivorous humans have higher cancer rates. If you can't easily separate a man from his steak, then bring cancer into the conversation. This research is murky and there are enough conflicting results to satisfy all points of view on this issue.

Indeed, if we eliminated all foods that have been linked to cancer, we might all be nourished by total parenteral nutrition (TPN) infused intravenously, as we do for hospitalized patients who cannot tolerate an oral diet. Of course, TPN would have to be chemically analyzed by an independent group, commissioned by the PCRM, to verify that no nano-traces of animal products were present.

I'm not in favor of obesity. As a physician and a citizen, I counsel folks to make wise food and beverage choices. But, it is their choice to make, not my mandate to impose. If more calories and girth make folks happier, and they are informed of the potential consequences, then they should be permitted to live without interference.

Is it society's responsibility to inform the citizenry of dietary risks, or does the individual have a responsibility to exercise due diligence? In 1890, an article in the Harvard Law Review (Do they still eat meat at Harvard?) penned by Louis Brandeis and Samuel Warren, opined that we have a right to be left alone, although this language does not appear in the Constitution. Indeed, doesn't this "right" define the relationship that we have with our government? It would have been more fun on this post if the "right to be left alone" was written by Felix "Frankfurter," who was an Associate Justice of the U.S. Supreme Court.

What's your definition of a "Happy Meal"? A greasy burger smothered with onions and coated with melted cheese? Kentucky Fried Chicken? Sugarless granola with 6.5 oz. of skim milk? A carrot smoothie with probiotics? TPN?

The PCRM argues that hot dogs and similar products should carry warning labels, such as appear on cigarette packages. My response? Where would the warning labels stop? Ice cream? Chocolate? White bread?

The American Meat Institute has challenged the PCRM's assertions, as we would expect. Both sides likely spin stuff to serve their agendas. One side eats Big Macs with relish. But, one side is telling Whoppers.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.

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QD: News Every Day--Statins don't lower melanoma rates

There was no significant association between statin use and melanoma risk among postmenopausal women, according to a study of data from the Women's Health Initiative.

Lab studies and one trial offered some hope that the ubiquitous cholesterol drugs might have an protective effect on skin cells as well, but as one dermatologist commented to Reuters, "[W]e're putting the nail into the coffin of that theory."

Researchers looked at nearly 120,000 postmenopausal white women, in which nearly 1,100 cases of malignant melanoma were identified over an average of more than 11 years.

Cancer was confirmed from medical records, while statin use was self-reported. Statins were used by 8,824 women (7.4%) at baseline. Melanoma occurred equally in statin users and nonusers (multivariable adjusted hazard ratio, 1.14; 95% confidence interval, 0.91 to 1.43). Statin type, potency, category or duration didn't matter, researchers reported in the journal Cancer.

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Tuesday, April 24, 2012

Our Broken System, Part 6: Lost

Lost.

That's a good one word summary of our health care system. Things get lost. People are lost. Money is lost. People are lost in the system. Lives are lost. I am frequently at a loss. Opportunities are lost. Plus, it may be a good idea to strand whoever's responsible for this mess on a desert island. Yes, "lost" is a good description for health care.

At the core, however, the greatest loss is that of the patient. They are who the system is designed to save. They are the ones for whom the words "health" and "care" are supposed to apply. Yet most patients, in my opinion, feel lost. They don't know where they are in regards to their health. They don't know where to go, or what to do.

It used to be that people came to me for a "prescription" of care: meaning that they wanted me to tell them what to do. Medicine was a mystery known only to a few who had access to the information and so was practiced behind the doors of doctors' offices and hospitals. People who wanted to have more detailed explanations were considered "bad patients," as they were prone to second-guess decisions in areas they were not trained to understand. "Good patients" would listen to what the doctor recommended and follow the instructions. "Good patients" were "compliant."

Two things changed this picture forever: the information available to all on the Internet, and social networking, which allowed people to discuss health care issues outside of the medical setting. The role of doctor went from being a benevolent monarch to that of a coach or advisor. The responsibility for care has shifted from the doctor to the patient, who uses the doctors' expertise to make the best decisions for themselves.

I think this is a good development for both patients and doctors, as I don't want responsibility for my patients' decisions; I just want to give them the best tools possible to make those decisions and tell them what decisions they need to be making.

And that's where the plot thickens. It's where the plane crash happens.

I've been thinking about this a lot lately. My patients are being bombarded with information and opinions on where they should go, from Dr. Oz talking about their thyroid, their friend who got their colon detoxified, the celebrity who eats only gluten-free vegan humanely treated plants, to Arbonne, who now (I am not making this up) tell people they should "detoxify the liver." (I never knew that the organ responsible for detoxifying the body needed itself to be detoxified. Why don't we just stop toxing in the first place?) They come to me for guidance and information, but I have my own limitations:
--I don't have access to their information. Labs and procedures not ordered by me are usually not available, and many of the specialists have stopped sending me the notes about their care for the patient.
--I don't have time to explain the different options. I am paid by the visit, so the more time I spend with my patients, the less I get paid.
--I am spending an increasing amount of my time working to comply with insurance and government requirements, forcing me to put more information into the record that I don't use, and giving me even less time to get the big picture (much less share it with the patient).

My patients are being put down in the middle of a jungle full of terrible consequences for wrong decisions. I am supposed to be their guide, the one who knows the way to safety; but instead of helping them find the way out, I am shoving a map at them and leaving their fate in their own hands. If they don't ask me, I don't tell them. If they don't know they need a colonoscopy due to their family history, or that the stent they had placed in their heart did not permanently fix the problem (a patient really thought that was the case in a recent visit), then they don't ask; and most patients who don't ask questions do not get answers.

My pondering on this whole issue has led me to conclude that patients need a GPS device for their medical care. They need something that gives them an image of the landscape and tells of the safe routes and perilous places. What is that GPS device? A care plan. Somehow patients need to be armed not just with medications and directions for their immediate problems, but a larger view of their medical locale.

--They need to know the state of their health.
--They need to know their risk factors.
--They need to know what lies on the road ahead: what tests will need to be done and how they can avoid pitfalls.
--They need to know where they've been: past tests, office visits, procedure results, or previous illnesses will put their current situation in sharper focus.
--They need to know where there are gaps in the information.
--They need to know why they should take the medicine, see the consultant, or take the test.

But our system stands squarely in the way of this. As much as I would like to use our EMR to synthesize a patient's information into a clear care plan, I am penalized for taking the time to do that. I am much better paid to see more patients or to meet the "meaningful use" criteria (which I am growing to loathe--more on that later).

Many of those involved in our health care system do not want patients to have this information to make good decisions, as they would likely spend less time in the hospital, get fewer unproven tests done, do more prevention of disease, reduce duplicate testing, and spend less time in the doctor's office asking what they should already know: where the heck they are. Hospitals, ancillary services, drug companies, device manufacturers, and even we doctors would lose a huge source of revenue with such an informed patient. Sure, there would still be enough patients ignoring the information and making bad decisions to keep us in business, but it would be a whole different world.

Would it be paradise? What, you mean like a tropical island? Don't go there.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Embezzlement from doctors' offices

I just read an article that talked about more medical practices being victims of embezzlement. In a 2009 survey of members of the Medical Group Management Association, 83% of 945 respondents said they had been the victim of employee theft. I guess this means I can come out of the closet now. I have always been ashamed that my practice of five internal medicine doctors was embezzled by our trusted long-time bookkeeper. It made me feel so stupid and I didn't know how prevalent the problem is.

Our medical practice was a small business with about 100 to 150 patient visits a day. Each of us ran an individual business with shared overhead and employees. At that time patients paid small copays of $5 to $20, mostly in cash. We thought we had good record keeping but medical practices are actually easy to rob from because doctors have no idea what they are getting paid for a patient visit.

The documented visit charge is seldom paid in full by the insurance company. Partial payment arrives months later or not at all. Many charges are "written off" when it is clear no one is going to pay it. The partial payments are not standardized, so an $80 visit could be paid $12.53 or $45.01 or $62.33 and there was no way to know. The lag in payment not only kept us on the edge financially, it lent itself to fraudulent practices.

I thought I could tract accounts receivable by getting monthly reports from the bookkeeper but the holes in payment are just too big. How can disparities between billing and collections be identified when there is no standard payment for a charge?I tracked overhead expenses, signed all checks personally when attached to an invoice and did not use credit cards for office expenses. I often opened my own mail and spot checked insurance payments and denials. I thought I had a handle on the business of Medicine.

All of us were working very hard and our incomes were pretty poor. But as primary care doctors, we were used to that. I went years without self-funding a retirement account (much to my dismay now that I'm older!)I can't remember how we uncovered the fraud but our trusted bookkeeper, Steve, had a separate account at the bank where he was depositing money for himself. He took the cash co-pays from all of us. Not enough to be noticed, but enough to add up to tens of thousands of dollars over time. We never knew how much cash was stolen. He also deposited insurance checks and patient checks into his own account and reconciled the books so we never saw it. That amount totaled over $180,000 that we knew about, meaning there was much, much more that we will never be able to discover. Why the bank allowed a business check to be deposited into his personal account we will never know.

Did we prosecute? Yes, but the judgment we got against him never amounted to any reimbursement. The money was long gone. He never served jail time and is probably out there somewhere working in another medical practice. Embezzlement can happen to anyone in business and apparently happens frequently to doctors in private practice. Some say it cannot be prevented and given the crazy way medicine is reimbursed I would have to agree.

This post originally appeared at Everything Health. Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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QD: News Every Day--9 performance measures for heart failure expand use of beta-blockers to inpatient care, among other recommendations

Updates to heart failure performance measures include an expanded use for beta blockers and new quality metrics for internal quality improvement, reports the American College of Cardiology Foundation.

The latest measures expand the use of beta-blockers to the inpatient setting. Included only as an outpatient measure in the 2005 set, this measure was added for the inpatient setting after inpatient care guidelines were developed in the 2009 guidelines update.

Clinical trial data showing that not all beta-blockers exhibit the same benefits prompted the writing committee to specify the use of one of three evidence-based beta-blockers: bisoprolol, carvedilol or sustained-release metoprolol, the report states.

Another significant change in the 2011 performance measures set was the conversion of the measure on patient education to a quality metric, which should be used for internal quality improvement purposes only, not public reporting and accountability. While the writing committee acknowledged that patient education about lifestyle, activity, diet and medication use is important for providing optimal care, they also understood that compliance with an education measure is easy to achieve without regard to the quality of education provided.

Other changes to the 2011 performance measures include the combination of both the inpatient and outpatient settings in a measure about the use of ACE inhibitors or ARB therapy for left ventricular systolic dysfunction; the addition of a new measure on the post-discharge appointment at the time of hospital discharge; and the retirement of measures on weight measurement, blood pressure measurement, and warfarin therapy for patients with atrial fibrillation. These measures were retired either because they had been included as part of a broader measure in a different set or they had become standards of care.

Other quality metrics include one on counseling about implantable cardioverter-defibrillators and another on symptom management. The 2011 performance measures include care provided in both the outpatient and inpatient setting, emphasizing the need to measure care quality over time and across providers, while also focusing on patient outcomes.

"In order to improve the quality of heart failure care, one has to provide measures of quality. The heart failure performance measures were designed for that purpose--to allow physicians and their care teams to deliver evidence-based management designed to improve heart failure outcomes without disrupting the workflow," said writing committee co-chair Robert O. Bonow, MD, MACP, of the Northwestern University Feinberg School of Medicine.

The nine 2011 performance measures include three new measures and six revised ones. Two measures apply to care provided in both the inpatient and the outpatient settings, while five measures address outpatient care only and two measures address inpatient care only. Eight measures from the previous heart failure performance measures set, which were released in 2005, were retired.

While six of the measures are appropriate for initiatives such as pay for performance, physician ranking and public reporting, three of them are intended only for internal quality improvement purposes.

According to the performance measures writing committee, consistent use of the set is key to the measures' adoption. "To be successful as quality improvement tools, the heart failure performance measures need to be integrated as routine components of patient care across various care settings, with particular attention to transitions of care from inpatient to outpatient environments," Dr. Bonow said.

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Monday, April 23, 2012

The danger of hospitalization

As an academic hospitalist, I see how the hospital affects patients. The hospital has become a necessary evil for those who are very sick. But too many patients virtually insist on staying in the hospital when a reasonable outpatient option becomes available, as described in this article in the New York Times.

Many older people fear that a hospital stay could leave them even more disabled than they were before. Unfortunately, there's new reason to believe this fear is justified. Elderly patients who are hospitalized are at much higher risk of cognitive problems afterward, according to a study published in the journal Neurology.

As a physician, I am often frustrated that older patients become confused in the hospital. The family wants me to do something, and all I can think of is discharge home to comforting surroundings.

So we are all caught between that rock and that hard place. We are stuck. But we must do all we can to either change hospitals or avoid hospitalizations as often as possible.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

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Feds plans to eliminate doctors from the prescribing loop

In our world of 24/7 media, where we seem to hear about the next big cure, important dietary change or very dangerous drug virtually every day, it is hard to believe that the news people, tweeters and bloggers could miss anything that is going on in health care today. However, it appears most everyone missed a big one. There was no mention in the New York Times, Wall Street Journal, Washington Post, etc. Only US News mentioned this by repurposing material from Health Day.

The government, through the FDA, plans cut health care costs by eliminating the need to see a doctor and shift the costs of medications to the patient.

And you should be afraid ... very afraid!!!

What I am referring to is a public hearing that was held on March 22 and 23, for which the hearing notice was placed online only a few weeks before, on February 28. The meeting was titled "Using Innovative Technologies and Other Conditions of Safe Use To Expand Which Drug Products Can Be Considered Nonprescription."

What was the purpose of such a meeting? According to the briefing document: ""The U.S. Food and Drug Administration (FDA or the Agency) is announcing a public hearing to obtain input on a new paradigm we are considering. Under this paradigm, the Agency would approve certain drugs that would otherwise require a prescription for nonprescription use (also known as over-the-counter or OTC) under conditions of safe use. These conditions of safe use would be specific to the drug product and might require sale in certain pre-defined health care settings, such as a pharmacy."

You have to read between the lines here, but essentially what this is saying is that the FDA is thinking about a completely new way to approve or classify drugs, so that some drugs if dispensed in a pharmacy would be allowed to be purchased over the counter/without a prescription.

Their rationale which I have extracted (the bolding is mine):
"Undertreatment of many common diseases ... is a well-recognized public health problem ... The requirement to obtain a prescription ... may contribute to undertreatment of ... hyperlipidemia (high cholesterol), hypertension (high blood pressure), migraine headaches, and asthma. For instance, some consumers do not seek necessary medical care... because of the cost and time required to visit a health care practitioner for an initial diagnosis and an initial prescription. Some patients who obtain an initial prescription do not continue on necessary medication because they would need to make additional visits ... Some prescription medications require routine monitoring through the prescribing practitioner such as blood tests ... FDA believes that some of these visits could be eliminated by making certain prescription medications available without a prescription but with certain other conditions of safe use that would ensure they could be used safely and effectively without the initial involvement of a health care practitioner ... In addition to improved health outcomes ... Eliminating or reducing the number of routine visits could free up prescribers to spend time with more seriously ill patients, reduce the burdens on the already overburdened health care system, and reduce health care costs.

Now, on the surface, this might sound like a good thing. Wouldn't it be great if we could find easier ways for patients to get their needed medicines? After all, as our nation gets older (and more overweight), chronic diseases are going to be main issue in health care. It is all about improving health, right?

Unfortunately, the bottom line here is that instead of finding a real solution to improving access to primary care physicians or finding real ways of reducing health care costs, the government (through the FDA) has come up with a simple plan: take the doc out of the picture and shift costs to the patients.

The fact of the matter is that though medications are expensive, they only represent about 10 cents of every dollar spent. The two biggest costs are doctors and hospitals. Thus, if we are trying to cut costs, the most economical solution would be to eliminate or at least curtail a visit to the doctor. Since prescription medications require a prescription, which requires a doctor's visit (or at least phone call), the FDA can just make certain medications available over the counter and we no longer need those annoying, inconvenient, and expensive visits to your primary care provider.

Now there are already lots of medications available over the counter. These medications are considered safe enough to use, and a medical degree is not required to figure out that you take cold medicines for your cold and heartburn medicines for your heartburn. However, what the FDA is talking about are medications to treat chronic diseases like asthma, high blood pressure, high cholesterol and though not mentioned, probably diabetes.

It was only back in 2005 when the FDA rejected Merck's bid to make their cholesterol medicine Zocor (simvastatin) over-the-counter. At that time, they knew that even drugs that seemed relatively safe and could benefit many people required expertise to properly diagnose and treat high cholesterol safely and effectively. More recently, Pfizer also tried to get their patent expiring Lipitor to be sold over the counter (see my post Why OTC Lipitor is a Bad Idea).

How can medicines that were only a few years ago considered too dangerous to be taken over the counter, would now be considered safe? According to the briefing document: "The conditions of use could include requiring pharmacist intervention to ensure appropriate nonprescription use. Additionally, conditions of safe use could involve the use of innovative technologies, such as diagnostics approved or cleared by FDA for use in the pharmacy or other setting."

In other words, for certain (particularly expensive) chronic diseases such as asthma, high blood pressure and high cholesterol; the FDA would consider these medications safe by allowing the pharmacist, not the doctor, to determine which medication is right for you. And if you needed any blood work, the FDA might clear the way for this to be done in the pharmacy as well.

But my favorite part is about the kiosks: "For example, kiosks or other technological aids in pharmacies or on the Internet could lead consumers through an algorithm for a particular drug product."

Can you just imagine patients going up to an ATM-like machine, entering their conditions, allergies, blood levels, etc. and having the computer spit out exactly what dose of what medicine that they should be taking for their high blood pressure or high cholesterol? Would there be a soda-like machine right beside it that could dispense the appropriate medication?

When it comes to prescribing, a physician is best
I have nothing against pharmacists. I value pharmacists as part of the health care team. In addition, I feel their role is substantially underutilized. Part of the problem with chronic disease is adherence to medication, a large part which has to do with education. Pharmacists are experts when it comes to informing patients about their medications, how to take them properly and why taking them is necessary. They can monitor adherence to medication and can also serve on the front lines to alert physicians if their patients aren't doing well and need closer attention.

However, when it comes to making a diagnosis and determining which therapy is best, pharmacists do not have the depth and breadth of training that physicians receive. As a primary care physician, I can tell you that even the most common conditions like asthma or sinusitis is not always that easy to diagnose, and even determining treatments for these conditions do not do well with cook book like algorithms.

Another concern I have with pharmacist essentially prescribing medications is that they are employed by the pharmacy that dispenses these medications, and thus have a potential direct conflict of interest. Now, I am sure skeptical readers will say that drug reps have been given physicians gifts and samples for years, and this is conflict as well. Though this may be true, a pen or a slice of pizza is a whole different level of conflict then direct money in your paycheck. Also realize that the pharmacy makes a bigger profit on generics, thus the pharmacist may be consciously or unconsciously biased to give you a generic when it may not be the best choice.

Patients will pay more
Usually when a drug goes OTC, it usually means the patient has to pay more. This is because most insurance programs do not cover over the counter medications. Ask any patient who suffers from seasonal allergies. OTC non-sedating antihistamines like Claritin, Zyrtec, and Allegra cost a lot more out of pocket, even when using the store brand, then when they were available by prescription. This is because the out of pocket cost for co-pay for a preferred drug (even when branded) is often less than the out of pocket cost for an entire supply of over the counter medication, even when generic/store brand.

The same is true for acid blocking medicines such as Prilosec. Generic OTC Prilosec (omeprazole) is just over 50 cents a pill, which means a patient requiring a daily dose will pay over $15 for a 30 day supply. This is generally much more than patients pay for a generic prescription of omeprazole, some paying as little as a $5 co-pay. (Some insurers have actually made the co-pays for the generic omeprazole more expensive then the acid blocking medicines that are not yet over the counter, like Nexium, to steer patients to buying the over the counter medication (full out of pocket cost), rather than request a prescription!)

Where is the outcry?
What's most shocking to me is the lack of dialogue on this topic. My guess is that this may be due to lack of awareness, since the FDA seemed to slip this past the media. Physician representation at the March hearing was pretty poor. Few groups such as The America College of Physicians seem to be interested (or aware). The AMA did testify at the hearing, and according to their website: "While the increased availability of certain prescription-based antidotes, such as Epi-Pens, appear to have few if any safety concerns, the FDA has not offered evidence that patients with hypertension, hyperlipidemia, asthma, or migraine headaches can self-diagnose and manage these serious chronic medical conditions safely on their own. This sort of self-diagnosis and treatment conflicts with the kind of care coordination and disease management that both the administration and private sector are trying to achieve through the new health care payment and delivery models."

To me the "conflicts with ... new health care payment and delivery models," is very interesting. This suggests to me that the government is trying to hedge their bets. In other words, if the new plans for health care reforms don't work, we can still lower cost and increase access simply by making many chronic disease drugs over the counter.

Most commentary that can be found on this issue seems to be coming from the pharmacist groups, who are, not surprisingly, supportive. However, there is at least one pharmacist that remains skeptical. Pharmacist blogger Eric Durbin at his blog Eric, Pharmacist states: "I've never known our government or any of its agencies to move quickly on issues, especially when it comes to our profession. But for this issue, the notification for the hearing was filed on February 27, published in the Federal Register on February 28, with a deadline to present oral comments & presentations of March 9. That's less than two weeks. With the hearing being held less than two weeks after the deadline. 3-1/2 weeks from the notice of hearing in the Federal Register until the hearings begin seems to be moving rather quick to me. Which makes me skeptical"

Bottom Line: Though this may seem like an initiative that could improve patient access and chronic disease outcomes, allowing chronic disease medications to be over the counter is a way the government can cut health care costs by eliminating expensive doctor's visits and shift medication costs to patients.

What can you do?
Though the hearing was over weeks ago, the website still allows visitors to submit comments (due May 7, 2012) online (Click here but also note the 20-minute lock out, so you may want to type in Word first and then copy/paste). You can also use the address below for regular mail:

Division of Dockets Management
(HFA–305), Food and Drug
Administration, 5630 Fishers Lane, rm. 1061
Rockville, MD 20852

In addition, you can send this post to those who know who might care about this issue and/or write your own post. You can Tweet, post to Facebook, etc. Social media has done wonders recently in getting the word out and making changes. However, time is of the essence.

Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also 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. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.

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Epidemiology is much worse for you than red meat

"Red meat is not bad for you. Now blue-green meat, that's bad for you!"
--Tommy Smothers

I generally try to avoid writing about meaningless studies that should be ignored. First, there are a lot of them. Second, I don't want to attract more attention to them than they already get in the media. But sometimes a meaningless study seems to perfectly confirm what we already wanted to believe. Then a feedback loop of reader gullibility and media misunderstanding leads inevitably to reaching a conclusion entirely unsupported by the science. Then I feel obligated to shine some light on the confusion.

Red Meat by Gonmi via Flickr and a Creative Commons licenseThis week's expedition into folly was occasioned by a study published in Archives of Internal Medicine that attempted to find a link between eating red meat and mortality.

My regular readers know that the only way to test whether some substance has some effect is to do a randomized study. That means if we wanted to know whether eating more red meat caused people to die sooner than eating less red meat we would need to do the following: Recruit a few thousand people with moderate meat intake and get their permission to control their diets. Then randomize them into two groups. One group eats a vegetarian diet, and the second group eats a whole lot of red meat. Follow them all and count deaths.

Voila! This would be good science and would teach us a lot about any link between eating red meat and longevity. It would be expensive and logistically difficult, but nature does not yield her secrets easily.

Is this what was done in the study published this week? Not even close. The study looked at data collected in two previous large epidemiologic studies, the Health Professionals Follow-up Study, which started in 1986, and the Nurses' Health Study, which started in 1980. Neither of these studies was randomized. They simply followed large groups of people and assessed their health periodically. There was absolutely no intervention done, just observation. They were given questionnaires every few years about their diet, from which their meat consumption was estimated. Then the deaths among the participants were recorded, and calculations were done to see if there is a correlation between meat ingestion and mortality.

And guess what? There is. The people who ate more red meat had a slightly higher mortality than people who ate less red meat. That means that eating red meat is correlated with increased mortality. It does not mean that eating red meat is what kills people. Meaning, it doesn't mean that changing your diet changes your risk. The authors of the study, of course, know this and never use words like "cause," but media coverage that followed completely missed this distinction and waxed hysterically that "all red meat is bad for you."

Observational studies have almost never steered us towards the truth. Remember that observational studies suggested that estrogen prevents strokes and heart attacks. It took a randomized study to show that it doesn't. That's because without randomization you never know if the people that are choosing to eat red meat are different from the people who don't in some important way that increases their mortality but has nothing to do with the meat.

For example, in this study the people who ate more meat were less likely to be physically active, more likely to be current smokers, to drink alcohol, and to be overweight than those who ate less meat. The authors of the study used statistical methods to account for these differences, but there were almost certainly other differences that could not be guessed or accounted for.

Also, an observational study can't tell us in which direction the causal arrow points. Meaning, if sick people craved more meat, then the link between the two would be due to high mortality causing more meat eating, not the other way around.

So this study teaches us absolutely nothing about a putative link between eating meat and death. It should have been completely ignored by the media, and it doesn't deserve a moment of your attention.

But let's take the study's data at face value and see what all the media hullabaloo is about. The study found that an increase of one serving of unprocessed red meat per day was associated with a 13% increase in mortality, and a 20% increase for processed meat. Let's take the higher number, 20%, that's terrible right? That must amount to people dropping dead in droves soon after biting into their hot dogs.

The study followed people for a total of 2,960,00 person-years, during which almost 24,000 deaths were counted, for an average of 0.0080 deaths per person-year. 20% of that is 0.0016 deaths per person year, which is one additional death for 619 person-years.

So let's pretend that the link between red meat and death is real (which is completely unsupported by this study) and let's imagine two groups of people. The first group is composed of 100 vegetarians. The second group is 100 people who eat one serving of red meat daily, perhaps a delicious hamburger. The group of meat eaters would have one additional death after six years and two months. In that time they would have consumed 225,935 burgers. So 225,935 servings of meat correlate to one additional death.

That makes a burger a lot less dangerous than, say, having general anesthesia, and about as dangerous as driving 300 miles, but much yummier.

So we've learned nothing about whether eating more red meat affects longevity, but we've learned a lot about what happens when preconceived opinions seem to be confirmed. People attach a lot of weight to arguments that purport to demonstrate what they already think should be true. We feel that red meat should be bad for us. We feel guilty because cows are so cute and meat is so tasty. There must be a health risk to balance the scales and atone for our guilt.

If there is, it will take a well-designed randomized study to prove it. Until then, skepticism, and a slice of brisket, is in order.

Learn more:
All red meat is bad for you, new study says (Los Angeles Times)
Risks: More Red Meat, More Mortality (New York Times Vital Signs)
Red Meat Consumption and Mortality (Archives of Internal Medicine)
I calculated the risk of driving from the WolframAlpha calculations for "U.S. auto fatalities per year" and "U.S. auto miles driven per year"

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. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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QD: News Every Day--Hospitals improve their rates of health care acquired infections

Health care acquired infections fell in recent years and remained lower, according to a report by the Centers for Disease Control and Prevention.

Hospitals reported 32% fewer central line-associated bloodstream infections, 6% fewer catheter-associated urinary tract infections, and 8% fewer surgical site infections than predicted based on the case-mix of patients and locations that were monitored.

Moreover, the central-line infection success improved between reporting periods, as the standardized infection ratios (SIR) during 2010 was significantly decreased (SIR 0.684, 32% reduction in central-line infections) compared to 2009 (SIR 0.854, 15% reduction in central-line infections). This suggests that the facilities not only sustained the prevention success of 2009, but improved even more in 2010.

Such improvement was more modest for surgical site infections. The overall SIR decreased from 0.981 to 0.916 when including all reporting facilities, but the decrease lost statistical significance when limiting the comparison to only facilities reporting in both years, according to the report.

For surgical site infections, improved prevention success over the two years was greatest for coronary artery bypass grafts (in 2010, 18% surgical site infections prevented), while stable reductions in surgical site infections were evident for two of the nine other operative procedures evaluated (knee arthroplasty, 11% reduction; colon surgery, 9% reduction).

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Saturday, April 21, 2012

Vertigo, or how I diagnosed myself at Internal Medicine 2012

Have you ever felt inexplicably dizzy? Chances are that sometime you will, according to neurotologist Michael Teixido, MD.

 “Almost everyone in this room will see a doctor at some point because they are dizzy,” he said at the start of his Internal Medicine 2012 session. Which made me feel a little better that I had picked to cover his lecture in an attempt to learn something about my own vertigo-- it's like I was seeing a doctor, just without the hassle of scheduling and payment.

I should probably add some caveat that ACP scientific sessions are not intended for self-diagnosis by lay people, but hey, this time it worked. Turns out I had benign paroxysmal positional vertigo (BPPV), which also happens to be the most common cause of dizziness (25% of overall complaints). It's easy to diagnose and treat, too. Use the Hallpike maneuver to diagnose and Brandt-Daroff exercises to treat.

The next most common causes of vertigo are migraine-associated vertigo, vestibular neuronitis and Meniere's disease. Since they didn't apply to me, I paid slightly less attention, but I did pick up a few pearls:

Migraine vertigo works a lot like migraines, with triggers and patients having a sense that it's coming on, and can be treated with the same kinds of prophylaxis. And don't think people don't have it just because they don't meet the official criteria for migraine, Dr. Teixido said.

On vestibular neuronitis-- patients will initially need meclizine, but only give one prescription with no refills, because given a chance, the body will correct the problem itself. Dr. Teixido said he's taken patients off the drug who have been on it for 30 years.

Nobody knows what causes Meniere's disease, but it seems like it might be related to migraines.

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Blog log

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other blogs of note:

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

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

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

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

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

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