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

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Thursday, May 31, 2012

Birds of a feather

I know, I know, I've been remiss in blogging about quackery. My infrequent ramblings have been more inward-focused lately. Sometimes, though, something comes across my desk that just blows me away and I must share it with you.

I recently came across this guy, a local "chiropractic neurologist" (it sounded bizarre but familiar, so I had to hunt down the skinny on this).

In my opinion, this guy's website is just screaming, "Watch out!" For one thing, the front page seems deceptive. It promotes "Dr. Roy Picard" without explicitly listing what kind of "doctor" he is. It's only one click away, but still, the implication is that he is a "regular" doctor (DO, MD). Given the range of conditions he says he treats, the confusion is understandable.

While the "official" scope of practice of chiropractors is a bit vague, it's hard to believe it includes "Hashimoto's Disease" and "Blood Sugar Imbalances." It's no secret that I don't believe chiropractors are qualified to treat anything, but they're best known for back pain. It's hard to see how a chiropractor could do anything useful for thyroid disease or glucose disorders. In my state, they aren't allowed to order lab tests except, "to measure the outcome of nutritional counseling or to determine the need to continue treatment or refer to another health care provider if a patient has not responded to treatment." How can you treat real thyroid disease like Hashimoto's without access to levo-thyroxine? How can you treat "blood sugar disorders" without access to the medications we use in conjunction with diet and exercise?

This guy's real focus, though, seems to be peripheral neuropathy, an often-painful condition seen in diabetes and other disorders. The website is vague about how he treats neuropathy, but given the limited tools available to chiropractors, it's hard to see what he could possibly do.

Much of the treatment of neuropathy is the treatment of the underlying disorder, such as diabetes. There is no amount of spine manipulation that can fix it. But for only $27, he will do an assessment to see if you would benefit from his therapy. I wonder how he decides who would benefit?

I get worried when I run across things like this.

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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More on Henrietta Lacks and compensation for medical test subjects

A few weeks ago, my wife and I attended "A Conversation With David 'Sonny' Lacks" at the California Center for the Arts in Escondido. The event was a sellout with 900 attendees. As it turns out, most of the colleges and universities in San Diego County designated "The Immortal Life of Henrietta Lacks" as the book discussed by students and faculty this past academic year. The conversation was sponsored by California State University, San Marcos. As an added bonus, Mr. Lacks' daughter appeared with him on the podium. I had previously attended a similar lecture with the author, Rebecca Skloot, at the University of Calirfornia-San Diego.

The story of Henrietta Lacks can be viewed from several vantage points. As a medical oncologist, and Chairman of the Investigational Review Committee, as well as Medical Director of the Research Institute at Palomar-Pomerado Health, ethics in medical research certainly occupies a position of paramount importance to me. In fact, the book is being discussed locally primarily from this perspective.

Ms. Skloot points out that obtaining "Informed Consent" from patients to do research on their tissue was not required, nor was it considered, in 1951 when Mrs. Lacks' biopsy was obtained for research purposes. Mr. Lacks stated he did not feel the family should receive financial compensation for using her tissue for research purposes. But, Henrietta and the family should have been told that her cells were going to be used for research purposes, what the research involved, and knowledge of the results--in other words, informed consent as we now require in all patients undergoing clinical trials.

On the other hand, he did feel that the family should receive financial remuneration from the companies that commercialized his mother's cells by selling them to labs around the world. This proposal seems fair. To date, no financial restitution has occurred.

Despite all this, Mr. Lacks maintains an air of dignity that engenders respect. Throughout the evening, there was no expression of anger or hostility; no complaining. When asked if he thought that racial discrimination played a role in how they were treated, Mr. Lacks said no, people of all races were treated the same at that time. Sonny said that although no one from Johns Hopkins has ever formally apologized, they have honored his mother in other ways.

Sonny Lacks was 3 years old when his mother died. So, he has no direct recollection of her. In fact, the picture on the front of the book is the only picture of Henrietta in existence. All that he and his daughter know about her they learned from his older siblings and Ms. Skloot's research for the book. When Henrietta was treated, Johns Hopkins was the only hospital in the state of Maryland that treated the uninsured.

Fast forward to the present and this sore is still festering in our country. Mr. Lacks stated that he recently required stents placed in his coronary arteries on an urgent basis and he, like all the members of his family, is uninsured. This brought an audible gasp from the audience. He said he had $100,000 in unpaid bills, and he opined that health care should be a right as it is in other countries, not a privilege for only those who can afford it. This elicited a vigorous round of applause from the audience. I would add that the number of people in the U.S. who can afford access to healthcare is dwindling also. [Author's Note: For specific discussion on the impact in the black community, see: "Blacks See Largest Decline in Health Insurance Coverage."]

The closest we have to universal healthcare provided by government is Medicare and Medicaid (MediCal in California), see: "Medicare: The Basics." I recently crunched the numbers in my own situation at age 70 to decide whether or not to convert from my medical group's health plan (since I'm still working to full Medicare coverage. Plan A is free and mandatory at age 65. But I needed Plan B, a and Medicare Part D for prescription drugs.

Part B involves an annual fee of $140 plus monthly premiums of $99 plus something called "Modified Adjusted Gross Income" (MAGI). The IRS now sends Medicare a report of my income and a graduated monthly charge is added to my premium. The monthly total amounted to $259.70. Added to that is the cost of the Supplement and Medicare Part D. Then the out of pocket expenses including cost of drugs in the donut hole and now you're talking "real money." Of course, you can opt for a Medicare HMO but choices are limited. So for effect, I will quote myself (drum roll please!): My conclusion was that being insured does not equate to being covered, and I needed to be a CPA to figure this out. So, I stayed with my group health plan.

The most poignant moment of the evening occurred when Henrietta's granddaughter was asked how she felt her grandmother should be remembered. Her answer: "The gift that keeps on giving."

Not a dry eye in the room.

This post by Richard Just, MD, ACP Member, originally appeared at JustOncology.com, a joint publication of Richard Just, MD, aka @chemosabe1 on Twitter and Gregg Masters, MPH, aka @2healthguru on Twitter. Dr. Just has 36 years in clinical practice of hematology and medical oncology.

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QD: News Every Day--Nearly 1 in 8 doctors is blogging

A lot of doctors are blogging.

Researchers looked at 1,750 primary care physicians, pediatricians, obstetrician/gynecologists, and dermatologists. Results appeared in the Journal of the American Medical Informatics Association.

Among the study findings, in the previous six months, 80% had used a smartphone to access information, 60% used a social networking website, nearly 50% used e-mail to communicate with patients, and 13% reported blogging.

Among the bloggers, those in practice less than 5 years were more likely to do so than those in practice more than 20 years (odds ratio, 2.17; 95% confidence interval, 1.25 to 3.76; P less than 0.01). Men blogged more often than women (odds ratio, 1.59; 95% confidence interval, 1.15 to 2.20; P less than 0.01).

How far can physicians take blogging? Ves Dimov, MD, points out one successful physicians blogger who is on pace to surpass 1 million page views this year. Stephen W. Smith, MD, a faculty physician in the Emergency Medicine Residency at Hennepin County Medical Center in Minneapolis, boiled down his efforts to blog about electrocardiography into a scientific abstract presentation that's available at his blog.

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Wednesday, May 30, 2012

I am not a doctor

This morning started off like any other. I parked my car, walked into Starbucks and pulled up my iPhone app while waiting in line. The usual suspects were already there: the elderly fellow that always flirts with the baristas, the business man with his freshly pressed suit and the tired-looking mother. As I approached the counter, I ordered my usual summer morning beverage and went through the motions to pay.

As I meandered toward the pick-up counter, one of the baristas grabbed my attention: "Hey, Amanda! You're in medical school, right?"

I stopped in my tracks and turned my attention toward him. Immediately, I braced myself for the worst; in our Medical Humanities course, the professors warned us that upon entering the profession, family and friends would suddenly start turning to us with their medical questions. We were cautioned that because there would be no escaping the situation, we needed establish an appropriate response to the request. But never did I imagine that as a first year medical student, an acquaintance would turn to me for advice.

"Yes, but ..."

He cut me off. "I have lower back pain that radiates down my leg ..."

The gears in my head started turning. I thought back to my latest clinical experience; one of our patients described a similar chief complaint and during our discussion with the preceptor, we discussed differential diagnoses for that particular symptom. I tried to clear the cobwebs clouding my knowledge of Anatomy and Neuroscience and considered the nerves that could be affected. I wondered if there was an inciting event that precipitated the pain. But in the end, although these thoughts raced through my mind, I never had any intention of sharing them.

"... and I was wondering ..."

As I stood there listening to him, it struck me how entering medicine was almost synonymous with being entrusted with a stranger's thoughts, feelings and ultimately, their life. We are taught how to ask open-ended questions and how to probe for the whole story. We are told to trust our instincts if something just doesn't feel right. But for the most part, patients come prepared to talk about what is bothering them because it is embedded into our culture to have an unspoken confidence in physicians.

As medical students, we reside in a paradoxical limbo. In order to become competent physicians, we need to interview patients and suggest diagnoses. We need to try procedures or practice them to obtain perfection. However, because we have little to no experience, patients tend to shy away from our [supervised] care. Additionally, at this early stage of training, most of us do not feel confident in our knowledge to provide even basic explanations of diseases.

When he continued with, "... what kind of doctor should I go see?" I let out of a sigh of relief and directed him toward his internist. This time, I was posed with a question that I could answer. But the situation gave me an opportunity to consider how I would respond to future questions that I am not qualified to answer. In class, our professors explained that when faced with a medical question outside of the hospital, they defer to the patient's internist because they do not know the details of their medical history. Today, had I been faced with that situation, I would have responded the same way but with the added note that I am just a medical student; I am not a doctor.

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. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.

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How many tests do doctors need to make a diagnosis?

History matters. I didn't realize this as a kid, but I sure do now. I endured two years of U.S. history in high school, as New Jersey state law required. Can you say, soporific?

Only years later, as an adult, did I realize that history is a potent intoxicant that lured me into a deep addiction. Along with my dad and brother, we sojourned many times across the country to many of our nation's historical treasures. Most of these were civil war sites, which we properly regarded as hallowed ground.

Through happenstance nearly two decades ago, I learned of an aging physician in Saginaw, Michigan, Dr. Richard Mudd. I read that he had spent nearly his entire life trying to clear the name of his grandfather, Dr. Samuel Mudd, who was convicted as a participant in the conspiracy to assassinate Abraham Lincoln. My dad and I drove up to Dr. Mudd's home and listened to him tell his stories in in his parlor. The memory of this wonderful afternoon is vivid and indelible. This man, just two generations removed from the civil war, led me straight back to Lincoln.


As a physician, I also believe that history matters deeply, but it has been devalued. The medical history, the narrative that physicians elicit from our patient, remains the cornerstone of high quality medical care. Experienced physicians know, even if we often deviate from this practice, that a thorough medical history is the most significant and relevant data that will be available to us. Too often, short circuiting occurs, such as the hypotheticals listed below:
--a patient with chest pain is summarily referred for a cardiac stress test
--a patient with abdominal pain is whisked off for an ultrasound of the gallbladder
--a patient with a headache is sent for an MRI of the head

I'm not suggesting that these diagnostic tests may not be the proper responses to the listed patient complaints. But, they may be premature or unnecessary.

Medical tests are often ordered mechanically in a reflexive mode rather than after reflective moments. Medical tests are not tools for obtaining a medical history. In contrast, it's the history that determines which test, if any, is necessary to narrow the diagnostic possibilities.

Patients have a hard time grasping this concept and have come to believe that lots of medical tests, particularly imaging studies, define high quality care. This is not their fault. Who taught them these lessons?

Using chest pain as an example, in many cases, a thorough history can lead to the diagnosis. While many diseases can be sly and masquerade as other conditions, experienced physicians can usually obtain solid evidence that chest pain is cardiac, pulmonary, gastrointestinal or muscular simply by listening to the patient's story. A medical test should be ordered to answer a specific and significant question that remains after the medical history and a physical examination. (While the physical examination has real value, in general, it does not approach the worth of the medical history.)

For example, we do not order an ultrasound of the gallbladder because a patient has a stomach ache. We do so because the history is suggestive of gallbladder pain, and the ultrasound will confirm the specific diagnosis under consideration. Here's why this is so important. If an ultrasound of the gall bladder is ordered casually on a patient with stomach pain, and gallstones are discovered, then it may be falsely assumed that an explanation for the pain has been found. This patient may be referred to a surgeon for a "curative" cholecystectomy, or removal of the gall bladder. What should have happened at the initial visit was a careful medical history, which may have excluded the gallbladder as the culprit. Most gallstones found these days are innocent bystanders, and not a cause of symptoms.

Israeli researchers showed how powerful physicians' basic clinical skills and acumen were in making a correct diagnosis, without scans and other imaging studies. It's nice when a study confirms our gut instincts.

If a medical test is ordered, ask what specific question it is designed to answer. Is it a fishing expedition? Will it decide between three competing diagnoses? How will the test result change the care? If the results won't change anything, then should the test be done?

Medical history counts in a big way, even if the pay-for-performance schemes can't measure it. Will physicians still be taking old fashioned medical histories four score and seven years from now?

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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Health policy catfight

The New York Times featured a front page story about squabbles between the Obama Administration and the Food and Drug Administration (FDA).

It's a well-written piece which contains solid inside reporting. I also think the article is especially powerful because it takes the esoterica of a dispute between policy makers and politicians and brings it to life via brief personality sketches of the main players:

"There's Nancy-Ann Min DeParle, White House policy adviser and point person on the health reform law. She used to run the behemoth federal agency that is Medicare and Medicaid (now known as CMS). The writer describes her as " ... whip-smart and sometimes caustic ..., deeply loyal to the President."

Whip-smart. I like that.

Dr. Margaret Hamburg, who runs the FDA, is presented as "... polished, cerebral ... and a well-known public health advocate."

Dr. Hamburg, like FDA commissioners before her, wants her agency to be left alone from political calculus and meddling in what are considered to be purely scientific/public health decisions."

Battle lines drawn.

Supporting cast in this ongoing battle include Health and Human Services Secretary Kathleen Sebelius, with a cameo by Cass "Nudge" Sunstein, who directs the Office of Information and Regulatory Affairs.

An example of the questions wrestled with: "Should the FDA have the power to mandate movie theaters to list nutrition information about the popcorn they sell?"

On the one hand, information is power. If you at least know the caloric information of the junk you choose to eat, you might conceivably make a better choice.

On the other hand, no White House wants to come off looking as a buzz-killing, namby-pamby nutrition nag. People generally know that movie treats are junk; why take the paternalistic position and scare them out of enjoying it?

What do you think? Hands off the FDA, or should the President and his staff get final say on these issues, depending on how they play in Peoria?

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--EHRs driving dictation the way of the dodo

Physicians who dictate their notes appeared to have worse quality of care than physicians who used structured forms in an electronic health record (EHR), a study found.

Researchers conducted a randomized, controlled trial of a documentation-based clinical decision support system for coronary artery disease and diabetes. Physicians were at one of 10 primary care practices that were part of a larger network in eastern Massachusetts. Researchers measured the quality of care of physicians who used dictation, structured documentation, and free text for their notes.

The main outcome measures were 15 EHR-based coronary artery disease and diabetes measures assessed 30 days after a primary care visits. Results appeared at the Journal of the American Medical Informatics Association.

During the 9-month study period, 7,000 coronary artery disease and diabetes patients made 18,569 visits to 234 primary care physicians. For these visits, 20 (9%) of doctors predominantly dictated their notes, 68 (29%) predominantly used structured documentation, and 146 (62%) predominantly typed free text notes.

Quality of care appeared significantly worse for those who dictated notes than for physicians using the other two documentation styles on three of 15 measures (antiplatelet medication, tobacco use documentation, and diabetic eye exam). Quality of care was better for those who used structured documentation for three measures (blood pressure documentation, body-mass index documentation, and diabetic foot exam). Those who used free text documentation had a higher quality of care for one measure (influenza vaccination). There was no measure for which those who dictated notes had a higher quality of care than physicians using the other two documentation styles.

Lead author Jeffery A. Linder, MD, FACP, and colleagues wrote, "Physicians who used the EHR more intensively for documentation could have paid more attention to necessary items that were missing from coded fields. In addition, physicians interacting with the EHR had greater potential to see and respond to clinical decision support before, during, or after the patient visit, some of which was relevant to CAD/DM [coronary artery disease and diabetes] documentation and care.

"Notes could be dictated without interacting with or even necessarily looking at the EHR," the study continued. "Dictations were uploaded to the EHR as unstructured, free text. In addition, dictation built in a documentation delay with unstructured information reaching the chart potentially days after the patient visit, when an opportunity to take action may have passed."

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Tuesday, May 29, 2012

What do internists take home from medical conferences?

I attended a local conference today sponsored by our Department of Pediatrics and Riley Hospital for Children. Many of our residency graduates, especially those who live and work locally, return for this meeting. It really is great to see our graduates and what they are up to. I enjoy hearing about how they have transitioned to practice, and learning about their own successes and challenges.

This particular year, I was not a presenter, nor did I run any workshops. I went to this conference strictly to learn. It was simply wonderful to do so. The day started off with a dynamic visiting speaker reflecting on the state of well child visits and potential innovations around how to be more effective with these, especially given the changes in medicine that are occurring and will continue to occur.

One might think that this topic is not all that interesting (which the speaker himself even acknowledged). Plain and simple, I was inspired! It brought me back to why I chose to go into medicine in the first place: to make a difference. Other extremely well-presented sessions reminded me of things I should be doing when encountering patients with specific conditions. A lunchtime talk on mentoring solidified a successful day for me (and that was only halfway through the day!). Other great "high-yield" topics in the afternoon piqued my interest as well.

When some people come back from conferences similar to this one, they realize that while the conference was wonderful, there is still a stack of paperwork that needs to be completed, that there is more work to be done, patients need to be seen, and e-mails must be answered. I also have all of those things looming over me. But I also gained a sense of purpose, connectedness, and excitement for the future of medicine from the conference. In addition, I learned some new things, was reminded of things I should already know, and also heard about changes coming in the future.

What do you get out of going to conferences besides the acquisition of information? What other "informal curriculum" things get you jazzed up, and how can conference organizers effectively capture that for other attendees? I am curious if others see this similarly or differently.

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

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Hidden health care costs ramp up patient aggravation

More and more employed people who have health insurance are facing large deductibles so they are actually paying "out of pocket" for tests, X-rays and doctor visits. Health care policy-makers talk about involving the consumer in the cost of care as a way to force competition and hold down prices. But finding out how much something costs can be a herculean effort and take hours of time phoning around. Despite a law in California that dates back to 2006 that requires hospitals to post common test prices, it is nearly impossible for a patient to find out ahead what something costs.

I gave my patient an order for a hip X-ray to evaluate pain that would not go away. Because she has a $5,000 deductible with Anthem Blue Cross insurance, she knew that she would be paying for it. She spent hours calling local hospitals to compare prices and became more frustrated and confused as time went on. She was told they couldn't look it up without a code. She was asked what hospital campus she would use for the X-ray (implying there are different prices at the same hospital if you used a different X-ray machine). She was placed on hold and cut off when transferred. She was quoted a price of $745 at one hospital and $886 at another and this did not include the radiologist fee for reading the X-ray.

I have advised her to call her insurance company, but I have doubts they will tell her their contracted price (which becomes her cost) in advance.

This is the reality of health care in the United States. Even patients who have insurance struggle with decisions about cost and benefit of tests and spend hours trying to get information to make health decisions. It is time for patients and employers who buy health insurance to stand up and demand transparency of costs.

This post originally appeared at Everything Health. Toni Brayer, MD, 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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Dangerous electrolytes, part 3

The patient, a 40-something year old woman, has a long history of alcohol abuse. Recently she has had minimal oral intake with much vomiting. BP 100/60, pulse 120
120, 67, 32, 99
1.9, 21, 0.7, 8.9

pH=7.6
pCO2=26
pO2=100
HCO3=21

I have several more points to make.

First, the patient has clinical signs of volume contraction. The patient has an appropriate increase in ADH. Volume contracted patients when they drink free water can become hyponatremic. This presentation is classic.

Second, we should address the hypophosphatemia. The patient presents with a dangerously low phosphate. We should worry about all phosphate levels below 1. Around 5 years ago, we had a similar patient present with a low phosphate and die. Severe hypophosphatemia leads to 5 possible organ system dysfunctions:

1) Central nervous system, seizures or altered mental status
2) Cardiac, arrhythmias or depressed cardiac function
3) Respiratory, respiratory failure secondary to muscle weakness
4) Rhabdomyolysis
5) Hematological, hemolysis and/or leukocyte dysfunction

The following is a great review of hypophosphatemia: Hypophosphatemia: an evidence-based approach to its clinical consequences and management. Here is their recommendations for treatment.

Indications for different modes of therapy in hypophosphatemia
--Severe hypophosphatemia (less than 1.0 mg/dl [0.3 mmol/l]) in critically ill, intubated patients or those with clinical sequelae of hypophosphatemia (e.g. hemolysis) should be managed with intravenous replacement therapy (0.08-0.16 mmol/kg) over 2-6 h
--Moderate hypophosphatemia (1.0-2.5 mg/dl [0.3-0.8 mmol/l]) in patients on a ventilator should be managed with intravenous replacement therapy (0.08-0.16 mmol/kg) over 2-6 h
--Moderate hypophosphatemia (1.0-2.5 mg/dl [0.3-0.8 mmol/l]) in nonventilated patients should be managed with oral replacement therapy (1,000 mg/day)
--Mild hypophosphatemia should be managed with oral replacement therapy (1,000 mg/day)

Once you have a dangerous phosphate level (less than 1.0) you should prevent further drop in phosphate. Therefore, we must understand why phosphate levels get dangerously low. This patient had a confluence of two reasons. Alcoholics often eat poorly and have total body phosphate depletion. When you provide glucose to these patients, they develop the refeeding syndrome. In this syndrome, patients with total body phosphate depletion use phosphate and further lower the serum phosphate. Quoting from the article: "The proposed mechanism of hypophosphatemia in these patients is increased insulin release that causes an intracellular shift in distribution of phosphorus. Enhanced synthesis of ATP, 2,3-diphosphoglycerate (DPG) and creatine phosphokinase (CPK) might contribute to the hypophosphatemia associated with refeeding syndrome."

Given this problem, while the phosphate level is dangerous, we should stop refeeding. We must first replete the phosphate prior to giving glucose. In this patient, the team stopped the IV glucose appropriately.

The second factor leading to the initial hypophosphatemia is the respiratory alkalosis. Respiratory alkalosis leads to decreased serum phosphate. Usually alcoholics present with normal phosphate that decreases over the next two days from the refeeding mechanism. This patient presents with severe hypophosphatemia likely secondary to chronic respiratory alkalosis. This presentation put the patient at great risk. Fortunately, my colleagues did a great job and the patient recovered from all disorders.

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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QD: News Every Day--The 99% worry about health care costs, quality

Nearly nine in 10 people think the cost of care is a serious problem and two-thirds believe the cost of care has gotten worse in the past five years, according to a poll by the Robert Wood Johnson Foundation, NPR and Harvard School of Public Health.

Many sick Americans (who comprised 27% of adults surveyed) reported having problems due to the cost of their own medical care, according to a press release. More than 40% say that the cost of their medical care over the last 12 months has caused a "very serious" (20%) or "somewhat serious" (23%) problem for their or their family's finances.

17% reported that high health care costs prevented them from getting needed medical care in the past year. In this group, half could not afford it, a quarter said insurance wouldn't cover it, and one-tenth reported being turned away by a doctor or hospital for financial or insurance reasons.

The poll also found that three-fifths of the general public believe the quality of health care is a serious problem for the country. About four in five people said not being able to afford to get the tests or drugs they need is a major reason for quality problems, while more than six in 10 said the influence of health insurance plans on treatment decisions is a major reason for quality problems.

The poll was done by telephone among a representative national sample of 1,508 adults age 18 and over from March 5 to 25, 2012. The margin of error for the total sample is plus or minus 3.1 percentage points. The margin of error for the "sick" population is plus or minus 5.3 percentage points.

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Friday, May 25, 2012

I'm learning to like weekends

This was a well-earned weekend for the Pal Family, and what a day! It's back in the 60′s (which, for my Canadian readers, is like minus 13 or something). Our local gopher is nibbling on walnuts out back, and I just deleted my bookmark for my board review questions. And I'm pretty sure I fartleked today. Afterward, I drove the car to meet the family for lunch, windows down, and caught the last two movements of a live performance Beethoven's Fifth on CBC.

There were lots of folks out on the trail today, and I'm sure that tomorrow there will be plenty in the office, so it seems a good time to go over a spring ailment. This time of year the poison ivy is just starting to leaf out, and with people getting back into their yards, I start to see a lot of intensely itchy rashes.

Poison ivy leaves a rash typical of an "outside job"; often you can tell the eruption was caused by an external agent just by the pattern. There tends to be small blisters, many of which occur in distinct lines where the plant brushed across the skin. It's a pretty benign rash, but horribly uncomfortable. Occasionally, people can develop a secondary immune reaction, or the rash can become infected with bacteria, creating a honey-colored crust on top.

The best treatment is avoidance. Learn where the poison ivy is in your area, and stay the hell away from it. My daughter has been able to recognize it since she was three; I don't want her to associate hiking with itching.

The rash is caused by oils secreted by the plant. Once you have showered in soap and water, you cannot spread it or give it to others. People will erroneously believe they have spread it because the rash can develop more or less rapidly and intensely in different areas, but these are areas that were usually exposed at the same time. Once you realize you've been exposed, the best you can do is take a hot, soapy shower, and put all of the exposed clothes into a hot, soapy wash.

Berry brambles and other benign plants often grow in the same areas as poison ivy. If you're not absolutely sure, don't touch it. If you do get the rash, your doctor will probably prescribe an antihistamine such as oral Benadryl for mild cases. Benadryl and calamine creams are usually not helpful.

There was plenty of the stuff growing along the rail trail this morning, something to distract me on my run. Running sometimes scares the hell out of me. I think it's the fear of discomfort or the fear of not being able to do it. Last weekend I hit the trail and after about 100 meters, I was done. I just. Couldn't. Move. Today was much nicer. As I mentioned, I tried the whole fartlek thing, and while I only did about two miles (for our neighbors to the north, about 1,200 centimeters or something); the variation made it much more interesting and much more comfortable.

I suspect this fear is what keeps a lot of people away from exercise, especially those who have been away from it for a while. I try to encourage my patients to get back into exercise slowly, to remind them that any physical activity is better than none. We tend to be wired to fall back on old and easy habits and when we don't exercise for a week, or we don't lose 20 pounds, we give up because we all know it's much easier to sit on the couch eating Mallomars.

So put down the cookies. Get out there, hit the trail, even if it's only a few hundred yards (or for our Canadian neighbors, three Imperial gallons or something).

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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Mentoring in medical education takes its cue from the movies

A big part of medical education is mentoring. The term mentor originates from Homer's the Odyssey and refers to an advisor. The role of mentors vary, but generally serve to guide mentees through work, support them during the process, keep them grounded and focused on the task at hand, and provide general moral support.

Over the weekend, at the Pritzker Revisit session on Scholarship and Discovery, our own students stated the number one thing to consider when finding a project was finding a great mentor.

How does one find a great mentor? Well, our students are encouraged to seek "CAPE" mentors; think superhero mentors. The mentor should be Capable, Available, have a Project that is of interest to the student, and Easy to get along with.

Capable means that the mentor has the skills to not only be a good mentor, but also to carry out the task or project at hand. This may sound like odd, but sometimes faculty are so excited to have a medical student work for them, they may make the false assumption that the medical student will help them with tasks (i.e. statistics) that they themselves don't know.

Availability is especially important as it is the number one reason our students state they had a less than optimal experience in the summer doing scholarly work is that their mentor was not available. While availability of all doctors is an issue, the question is often whether faculty make themselves available when they can (i.e. answer student email, take phone calls, meetings). Setting expectations for when and how to meet can be very important.

Ideally, the mentor has a project that is interesting to the student since if the work is not interesting, it will be even harder to make progress.

Last but not least, the mentor has to be easy to get along with, meaning that their style meshes well with their mentees. Some people simply do not work well together do to different personality types. So, I often tell our students to consider that when meeting potential mentors or deciding between two mentors.

As I was thinking about ways to highlight effective mentors, I recalled some classic movies with mentoring relationship. In relooking at these scenes this weekend, it struck me that there are some interesting reasons why they are good mentors that correlate with our model. Some of them are a stretch but they are still fun to watch!

Yoda in Empire Strike Back encourages Luke Skywalker to not just try, but do. When Luke fails to resurrect the wing fighter, he does not allow Luke to make excuses but instead demonstrates that he can do it, showing that he is CAPABLE.


Mr. Miyagi with the Karate Kid mentors through teaching small movements related to everyday house chores, "wax on, wax off." While he is certainly gruff and challenges Daniel, Mr. Miyagi also makes himself AVAILABLE to Daniel at that moment and in the future by saying at the end "Come back tomorrow" to continue the training.


Remus Lupin goes so far to use a simulated Death Eater to challenge Harry Potter to learn the patronus charm (and making all standardized patient experiences seem like a cake walk). When Harry fails at first, he is patient and nurturing, stating that he did not expect Harry to get it on the first try. He also makes suggestions to the technique which turn out to be the key. Since Harry really needs this charm, this is a PROJECT THAT IS OF INTEREST and Harry ultimately succeeds in casting the spell.


Gandalf in Lord of the Rings provides consolation to Frodo during a moment of despair by highlighting that it his job and also showing that Gandalf is sensitive to Frodo's needs and EASY TO GET ALONG WITH.

In addition to these highly acclaimed superhero and superstar CAPE mentors, let me know if you know of other model mentors from the movies.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She 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, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

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QD: News Every Day--Sodas, whether regular or diet, associated with hypertension

Sugar-sweetened and artificially sweetened beverages are independently associated with an increased risk of incident hypertension, but it may not be the fructose that's responsible, a study found.

To examine the associations between sugar-sweetened and artificially sweetened beverages with incident hypertension, researchers conducted a prospective analysis of three large, prospective cohorts, the Nurses' Health Studies I (n=88,540 women) and II (n=97,991 women) and the Health Professionals' Follow-Up Study (n=37,360 men).

Results appeared online the Journal of General Internal Medicine.

Both types of sweetened drinks were associated with an increased risk of developing hypertension. Those who drank one or more sugar-sweetened drink a day had an adjusted hazard ratio for incident hypertension of 1.13 (95 % confidence interval [CI], 1.09 to 1.17) compared with those who did not.

Those who drank one or more artificially sweetened beverage a day had an HR of 1.14 (95 % CI, 1.09 to 1.18). The association between sweetened beverage intake and hypertension was stronger for carbonated beverages versus non-carbonated beverages, and for cola-containing versus non-cola beverages in the NHS cohorts only.

Higher fructose intake from sugar-sweetened drinks as a percentage of daily calories was associated with increased hypertension risk in the NHS studies (P for trend=0.001 in both groups), while higher fructose intake from sources other than sugary drinks was associated with a decrease in hypertension risk in NHS II participants (P for trend=0.006).

"These observations raise the possibility that a common element in sugar-sweetened and diet soft drinks is at least in part responsible for the abnormalities associated with the metabolic syndrome, and in particular blood pressure," the authors wrote. With sugar ruled out by the study of diet sodas, other suspects might include caramel coloring, carbonation of the beverages, or the amount of sodium they have, which is tough to measure from questionnaires.

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Thursday, May 24, 2012

Learning the best way to assess jugular venous pressure

Of all of the physical exam findings that are often taught in medical training, I think one of the most important is the ability to judge volume status from examining neck veins. It's a skill that a lot of medical students and residents strive to become competent in; often many trainees will ask their attendings to verify their findings from their morning rounds.

Finding the level of the jugular venous pressure is hard, but I think it's something that's really worth mastering as it will inform your decision making more so than many other aspects of a daily exam.

To prove my point I ask you, does the quality or quantity of bowel sounds matter in a patient without bowel complaints? Is there any part of the head exam that would change in the course of an inpatient admission? The lung exam may change in a case of pneumonia but isn't the fever curve and the general appearance of the patient better and more important to note? The rales of heart failure may improve in a case of congestive heart failure, but I'd say that when your patient is sleeping flat, no longer dyspneic, and no longer tripoding, the pulmonary finding of rales is irrelevant.

Here is a great website about jugular venous pressure from the University of Washington School of Medicine. Where I got the information at the bottom of this post.

Here is a classic film about the JVP:



I think all of us as internists, hospital and ambulatory, nephrologists and cardiologists should have a good sense of how to find and measure the top of the jugular venous pressure in order to monitor the volume status of our patients on a day-to-day basis. The great challenge in interpreting neck veins, the expert clinician, is to be able to perform wave analysis as Dr. Wood does in this video.

The "a" wave represents the atrial contraction, the x decent represents atrial relaxation, the "v" wave represents ventricular contraction, and the "y" descent represents ventricular diastole.

The most prominent aspects of the neck waves are not the contractions or waves themselves but their troughs: the x and y descent.

Timing of the descents can be done while palpating the carotid or when listening to the heart. The x descent falls into the dub of S2. Lub-clap-dub. The y descent falls during ventricular diastole so it comes after S2. Lub-dub-clap.

Alternatively if you can time the carotid pulse with the x descent by saying C every time you feel the carotid pulse. Then start staying down quickly after every C; C-down, C-down. The x-descent will be occurring as you say down.

Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.

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The lunacy of weight loss by nasogastric feeding

I have previously expressed my concerns that weight loss and common sense have trouble co-habitating, and might even be at war. The discord is understandable: Desperation breeds gullibility, and wishful thinking. People with more than ample common sense are lulled into a state of hypnotized bemusement by magical claims of effortless weight loss. Again, and again, and again.

Certainly nothing else accounts for the popularity of such patent nonsense as the HCG diet. The diet gained fame by combining a 500 calorie/day meal plan with injections of a pregnancy hormone. The pregnancy hormone, essentially, Dumbo's feather, has induced legions of people to pay a fortune to lose weight by starving themselves. If they were to starve themselves at no extra charge, they would lose weight just as fast.

Leaving aside the fact that clinical trials robustly debunk HCG diet claims, there is the simple expediency of common sense. Anyone who has ever had anything to do with pregnancy knows that those hormones are NOT turning off appetite or inducing weight loss! I have plenty of firsthand experience, and not just as a doctor; my wife and I have five kids. There were times in any of my wife's third trimesters when if food was not readily at hand, I feared she would eat my arm! And absent the influence of those pregnancy hormones, my wife, who happens to be French, is a very thoughtful, moderate eater.

I thought common sense couldn't go any deeper into a coma than believing that pregnancy hormones were the reason a 500 kcal diet was causing weight loss. But I was wrong. Common sense, it seems, along with medical ethics, has come off life support altogether with the advent of the "K-E diet."

"K-E" stands for ketogenic enteral nutrition. "Ketogenic" may sound familiar, because it refers to the burning of ketone bodies that occurs with a very low intake of carbohydrates. It figured in the original Atkins diet, and more recently in the Atkins diet with a French accent, the Dukan diet. Another example of dietary common sense lapsing into unconsciousness, by the way, but we've got bigger fish to fry.

"Enteral" is a medical term that refers to putting food into the gastrointestinal system. In contrast, "parenteral" feeding bypasses the GI tract altogether by putting nutrients directly into the bloodstream.

A better, more descriptive term for the new diet is the nasogastric tube diet. The K-E diet involves inserting a feeding tube into the nose, down the esophagus, through the stomach, and into the duodenum, and then infusing a feeding solution continuously.

This is done in the hospital routinely for people who can't eat. But that's not what the K-E diet is about. It's about brides-to-be who want to lose 10 pounds or so in a hurry to look good in a wedding dress.

This "diet" is little short of lunacy on the part of any such bride-to-be, colossally misplaced priorities on the part of any groom-to-be watching it happen, and as profound an abrogation of professional ethics on the part of doctors peddling it (for $1,500) as I have ever seen.

Everything about this is appalling. Not so much because of the risk of metabolic complications from a ketogenic diet over a period of just 10 days. These are real, and include stresses on the liver, kidneys, and skeleton, but for people healthy at the start, such concerns are both minor and remote. Bone loss will occur, but will be inconsequential if limited to a 10-day span. Constipation is the one complication that will occur almost without fail. A ketogenic diet is used in medical practice to treat intractable seizures, but that's a case where the inconvenience and adverse effects of the diet are the lesser of two evils, because the alternative is uncontrollable epilepsy.

What makes the K-E diet truly appalling is that it transforms a medical therapy into the indulgence of a short-term, short-sighted, vanity-driven whim. It opens up a whole new world of shockingly bad ideas:

Why not chemotherapy-induced nausea and anorexia for weight loss? If you don't need a medical condition for a nasogastric tube, why should cancer be required for chemotherapy? Why not a medically-induced coma/anesthesia for weight loss? Or perhaps a serious metabolic stress to melt off the pounds, such as, why not medically-controlled anaphylaxis?

If self-induced vomiting after meals constitutes an eating disorder, what, exactly, is infusing liquid formula through a tube into the duodenum without medical indication? If the K-E diet survives a while, and I sure hope it doesn't, I bet it will come to be defined as an eating disorder in its own right. I fully appreciate the frustration many people feel when trying to lose weight, but if bulimia is not the right answer for that problem, neither is this!

A nasogastric tube is an unpleasant, undesirable medical procedure we impose on sick patients who can't eat. It carries with it a risk of aspiration pneumonia, which can be fatal. Ladies, not to put too fine a point on it, but: do you really want to marry a guy who stands by while you risk your life to lose 10 pounds? If my then-wife-to-be had proposed any such thing (not that she would have), my answer would have been equally emphatic and immediate: over my dead body!

In terms of quick weight loss, this dangerous nonsense is a guarantee of quick rebound with interest, since it involves no useful behavior change whatsoever. It has nothing at all to do with health, and basically endorses the notion that weight loss by any means is acceptable. If that is so, why not a 10-day pre-nuptial cocaine binge? It will work as well or better, and almost certainly be more fun, than a nasogastric tube.

As for the doctors involved in peddling this travesty, I condemn their actions. The job of physicians is not to come up with any way to satisfy a patient's whim, no matter how fundamentally at odds with health.

Our professional mission is to promote and protect health, and to serve the patient in that context. In that context, the patient is the boss, and we are, or should be, at their service. But we are abdicating our profound responsibilities and most sacred pledges when we renounce a commitment to health, and adopt an "oh, what the hell" approach to make some extra money by exploiting a patient's faith in us, and their desperation. On behalf of my profession, I am ashamed.

This is weight loss lunacy. Resuscitate your common sense while there's still time. Love the skin you're in, 10 extra pounds and all, and marry a guy who does, too!

Step away from the nasogastric tube, and one less person will get hurt.

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--Diabetes kills far fewer as treatments improve

Death rates among diabetic mean and women declined substantially between 1997 and 2006, particularly among excess death due to the disease, a study found.

To determine whether all-cause and cardiovascular disease mortality declined between 1997 and 2006, researchers from the Centers of Disease Control and Prevention compared 3-year death rates of four consecutive nationally representative samples (1997–1998, 1999–2000, 2001–2002, and 2003–2004) of U.S. adults using data from the National Health Interview Surveys linked to National Death Index.

Results appeared in the June issue of Diabetes Care.

Among diabetic adults, the cardiovascular disease mortality declined by 40% (95% confidence interval [CI], 23% to 54%) and all-cause mortality declined by 23% (95% CI, 10% to 35%) between the earliest and latest samples.

Men and women shared the benefits of declining mortality rates, the study noted.

The excess cardiovascular disease mortality rate associated with diabetes compared with nondiabetic adults decreased by 60% (from 5.8 to 2.3 cardiovascular disease deaths per 1,000) while the excess all-cause mortality rate declined by 44% (from 10.8 to 6.1 deaths per 1,000).

Authors noted that, while results of the study are encouraging, diabetes prevalence is likely to rise in the future if diabetes incidence is not curtailed.

The authors wrote, "Although excess mortality risk remains high--about 2 deaths per 1,000 due to CVD and about 6 all-cause deaths--this excess risk is now considerably lower than previous reports and consistent with improvements in several risk factors, complications, and indicators of medical care and representative of gradual, ongoing improvement in health for people with diagnosed diabetes."

But the gains are fragile, the authors noted. As fewer people die from diabetes, it will become more prevalent overall, requiring physicians to diagnose and treat its vascular and neuropathic effects.

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Wednesday, May 23, 2012

My love-hate relationship with early clinical exposure

Last semester when I saw an in-patient for the first time, the overall experience was exceedingly positive. I didn't have any confidence in my ability to diagnose anything, but that wasn't the purpose of the encounter. Furthermore, it was still my first semester of medical school; no one expected me to be able to integrate the patient's symptoms with a clinical diagnosis and course of treatment. There was nothing to lose.

My first experience left me wishing for more time with the patient and a sense of purpose when I returned to my textbooks. It reminded me that medical school wasn't only comprised of hours of time with my head spinning; there was a light at the end of the tunnel called third-year clerkships, and with each passing day I came closer and closer to being able to practice medicine.

However, during our most recent clinical experience, I walked away conflicted. The premise of the exercise wasn't too different from the first, but we were responsible for doing a bit more with the physical examination. And with an OSCE looming on the horizon, I was happy to have an excuse to practice.

After we met our preceptor for the day, we headed to a different unit to see our patients. This time, we had two different patients to interview and do a pertinent physical examination on. Prior to walking into the patient's room, the preceptor told us the chief complaint so I felt prepared to solicit more information. We walked into the room and following a brief introduction, I sprang into action.

Our patient's story tumbled out without any resistance; it caught me off-guard how easily pertinent facts could be collected from her responses. After collecting what I needed, I moved on to an abridged physical examination and wrapped up my encounter with that. We thanked the patient and left the room to discuss the encounter.

My preceptor's feedback was mainly positive, but he noted that I was a bit nervous [Well, yeah!]. There were a couple of things that I failed to obtain, but it was a learning experience so these things are to be expected.

We then moved on to our second patient, and my partner conducted the interview and physical examination while I took notes. He finished promptly and we moved outside to wrap up the experience.

It was as I was walking out of the long hallway of the hospital when a wave of dissatisfaction and frustrated rolled in. As one of the patients listed medications, I recognized a couple of them but ended up misclassifying one of the drugs. Even though I am still a first-year student, I am just about halfway done with my preclinical years. Shouldn't I at least be proficient in recognizing and identifying basic information that I already learned? How will I be comfortable with all of this knowledge for the boards and clerkships if I cannot keep simple material I learned a month ago in my head?

I know that I still have time. I know that it's still early. But I am disappointed that the medicine I keep learning seems to slip away so quickly. My knowledge feels transient and fleeting. I just want to be able to feel just slightly confident in my ability in something but it seems that I am far from it.

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. She has a Bachelor of Science in Engineering [Biomedical Engineering] and Master of Science in Engineering [Biomedical Engineering, again] from the University of Michigan. This post originally appeared at her blog, "And Thus, It Begins," which chronicles her journey through medical training from day 1 of medical school.

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Slow medicine

I can't tell you exactly when it happened, but sometime in the past two decades, the practice of medicine was insidiously morphed into the delivery of health care. If you aren't sure of the difference between the two, then "God's Hotel" is the book for you. It's an engaging book that chronicles this fin-de-siecle phenomenon from the perspective of San Francisco's Laguna Honda Hospital, the last almshouse in the United States.

Dr. Victoria Sweet, a general internist, came to Laguna Honda for a two-month stint more than 20 years ago and ended up staying. Laguna Honda was home to the patients who had nowhere else to go, who were too sick, too poor, too disenfranchised to make it on their own. The vast open wards housed more than a thousand patients, some for years. Laguna Honda was off the grid, and this, Dr. Sweet discovered, was to the benefit of the patients.

Unencumbered by HMOs and insurance companies, the doctors and nurses practiced a very old-fashioned type of medicine, "slow medicine," as Dr. Sweet terms it. There was ample time for doctors and nurses to get to know their patients, and ample time for patients to convalesce. Many a written-off patient recovered within the comforting, unhurried arms of Laguna Honda.

Sweet realizes that the inefficiencies of this old-fashioned hospital, from the doctors who had time to fully research their patients' complicated histories, to the nurse who knitted a handmade blanket for every charge on her ward, to the chicken that wandered regularly through the AIDS ward, bringing a spark of life to even the most demented patients, were actually its secret weapon. The inefficiencies were actually quite efficient, if your metric was healing patients.

Then arrived the consulting firm of "Dee and Tee, Health-Care Efficiency Experts." Horrified by the rambling open wards and the old-school style of medicine, never mind the chicken, Dee and Tee quickly cut out excessive head nurses, consolidated departments, speeded up discharges and created committees, PowerPoint presentations and forms with 1,100 boxes. The consulting firm never consulted with any staff members who actually took care of patients, but they did stand to earn 10% of any savings engendered.

Thus Laguna Honda was rapidly schooled in the inefficiencies of efficiency, as patients without nurses grew sicker, and enthusiastically discharged patients spiraled downward, had multiple ER visits and were eventually readmitted to the hospital. Dee and Tee, of course, did not have to pony up for any additional costs the consultancy caused.

Over the course of Dr. Sweet's 20 years as a staff physician, Laguna Honda made this painful transition from the practice of medicine to the delivery of health care, and it was the patients who suffered most, followed by their caregivers.

During this period, Dr. Sweet found solace in her doctoral studies of Hildegard of Bingen, the medieval healer, nun, mystic and composer. Hildegard's pragmatic and thoughtful approach to medicine appealed to Dr. Sweet and even informed her own practice of medicine. Stymied by an oddly agitated patient who'd already been given a full diagnostic workup, Dr. Sweet had a What-Would-Hildegard-Do moment, and decided to simply sit with the patient.

She sat with the patient for a good long time, watching her, thinking about her, being in the moment with her. There was something frankly medieval about the patient's twisting and writhing, as though she were trying to expel something, as though she were poisoned.

Reviewing the chart, Dr. Sweet realized the woman was indeed being poisoned, by her own medications. A toxic brew of antidepressants, antipsychotics, pain meds and sedatives had led to serotonin syndrome. Dr. Sweet decreased the patient's medications, and within hours the patient improved. She eventually stopped nearly all the medications, and the patient became well enough to go home.

Untangling the mass of medications that most patients arrived with became Dr. Sweet's hallmark. She found that nearly all her patients could be relieved of a portion of their accrued medications. But this could only work in the setting of "slow medicine," of having time to watch patients carefully over an extended period, of digging deep into the convoluted lives of these patients, of having time to "just sit" with each patient.

This, of course, is highly inefficient, if you are Dee and Tee. But it's remarkably efficient if you are a patient and are interested in being cured, cared for and comforted.

You might not expect a book about San Francisco's most downtrodden patients to be a page-turner, but it is. With its colorful cast of characters battling the tide of history, "God's Hotel" is a remarkable journey into the essence of medicine.

In 1925, Dr. Francis Peabody told a graduating class of medical students that, "the secret of the care of the patient is in caring for the patient." Simple, eh? If Dr. Peabody were practicing medicine today, he'd surely be consolidated with a midlevel provider to deliver health care with maximal quality indicators and operational excellence. Sigh ...

(from The San Francisco Chronicle, April 22, 2012)

Danielle Ofri, MD, PhD, FACP, is the author of three books, including "Medicine in Translation: Journeys with My Patients," which is about learning the individual stories of patients. She is an Associate Professor of Medicine at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review. She is currently writing a book about the emotional life of doctors. This post originally appeared at her blog.

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How history taking and a Toyota mechanic beat a diagnostic computer

If you give enough time to an experienced clinician working in an ambulatory setting, what percentage of acute complaints would s/he be able to diagnose correctly with just taking a good history? What about with history plus physical examination?

The answer is about 50% with history alone and about 80% with history and exam. Yes, s/he would probably order some confirmatory tests or try some medications as empiric treatment but the above numbers would hold up.

The importance of history taken by an experienced diagnostician was borne out recently. A warning to regular readers of my blog, this is another car story. Don't tell me I did not warn you!

I have a 1999 RX300 which was bought mainly to combat the snowy northeast Ohio winters. It has been a reliable vehicle and I fully intend to keep on driving it until it falls apart. You will probably accuse me of being an emotional fuddy-duddy, but it holds a special sentimental value for the family. So it was particularly upsetting when last year, early in winter it started to have all kinds of problems.

I took it in to the place where I get the oil changed and they are really nice folks, polite and accommodating. The check engine light was on, and they queried the car computer, read the code, looked up the computer and told me that some sensors needed to be changed. We did that but within a day the engine light came on again. This time the mechanic told me that the transmission was gone and it would cost more than the resale value of the car to fix it. I was crushed but appreciated the fact that he did not make me spend a ton of money before telling me this. I began to look for someone who would buy it.

Then a friend of mine recommended that I speak to this guy who works at a Toyota dealership. The Toyota Highlander is almost exactly the same vehicle as the RX300. So he might be able to tell me more. So I gave him a call. I fully expected him to read him the codes from the computer readout. Imagine my surprise when he asked me to describe what the car was doing!

I told him how I had gone abroad (a workshop I did for physicians in Singapore in October) for about 2 weeks. Right after I came back the car started misbehaving. It would work fine for the first 10 minutes or so and then when I tried to accelerate beyond 40 mph it would start revving up like it was stuck in a lower gear. I could not go on a freeway for fear of this. He started laughing and asked me if we had seen any rodents in the garage. I felt like I was talking to Sherlock Holmes! My wife had told me that she had seen a rodent near where we kept the dog food bags.

So he explained. The Highlander and the RX300 have an engine intake area that rodents love to nest in. If the car is not used for a while they start nesting there. This is particularly true of the fall season as they prepare to hibernate. The intake area is close to the wires that run to the knock sensors. The rodents eat the rubber on the wires and this shorts out the sensors (or something like that). The guy to whom I took the car to first read the computer code for the knock sensors being faulty and changed them without realizing that the problem was caused by the wires. Thus he replaced the sensors but did not fix the cause.

Long story short, (well not really but it was a pretty cool story) the Toyota mechanic changed the wires and the sensors and the car now drives like new. The key portion of history was that I did not use the car for a while during the nesting season, that we had rodents, that the problem was same as that caused when a knock sensor is faulty. His experience with having seen this before due to working on similar cars in northeast Ohio for years helped him recognize the problem.

This is a story I will tell all my trainees, that a well-directed history taken by an experienced clinician can beat multiple tests and technology!

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

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A JAMA briefing on comparative effectiveness and helicopters that allows time for questions

The Journal of the American Medical Association held a media briefing on its Comparative Effectiveness Research (CER) theme issue. The event took place in the National Press Club. A doctor, upon entering that building, might do a double-take waiting for the elevator, curious that the journalists occupy the 13th floor--what's absent in some hospitals.

CER is a big deal in medicine now. Dry as it is, it's an investigative method that any doctor or health care maven, politician contemplating reform or, maybe, a patient would want to know.

The gist of CER is that it exploits large data sets, like SEER data or Medicare billing records, to examine outcomes in huge numbers of people who've had one or another intervention. An advantage of CER is that results are more likely generalizable, i.e. applicable in the "real world." A long-standing criticism of randomized trials held by most doctors and the FDA as the gold standard for establishing efficacy of a drug or procedure, is that patients in research studies tend to get better, or at least more meticulous, clinical care.

The JAMA program began with an intro by Dr. Phil Fontanarosa, a senior editor and author of an editorial on CER, followed by 4 presentations. The subjects were, on paper, shockingly dull: on carboplatin and paclitaxel w/ and w/out bevacizumab (Avastin) in older patients with lung cancer; on survival in adults who receive helicopter vs. ground-based EMS service after major trauma; a comparison of side effects and mortality after prostate cancer treatment by 1 of 3 forms of radiation (conformal, IMRT, or proton therapy); and, to cap it off, a presentation on PCORI's priorities and research agenda.

I learned from each speaker. They brought life to the topics! Seriously, and the scene made me realize the value of meeting and hearing from the researchers, directly, in person. But, we'll skip over the oncologist's detailed report to the second story:

Dr. Adil Haider, a trauma surgeon at Johns Hopkins, spoke on helicopter-mediated saves of trauma patients. Totally cool stuff; I'd rate his talk "exotic." This was as far removed from the kind of work I did on molecular receptors in cancer cells as I've ever heard at a medical or journalism meeting of any sort.

Dr. Haider indulged the audience, and grabbed my attention, with a bit of history: HEMS, which stands for helicopter-EMS, goes back to the Korean War, like in M*A*S*H. The real-life surgeon-speaker at the JAMA news briefing played a music-replete video showing a person hit by a car and rescued by helicopter.

While he and other trauma surgeons see value in HEMS, it's costly and not necessarily better than GEMS (Ground-EMS). Helicopters tend to draw top nurses, and they deliver patients to Level I or II trauma centers, he said, all of which may favor survival and other, better outcomes after serious injury. Accidents happen; previous studies have questioned the helicopters' benefit.

The problem is, there's been no solid randomized trial of HEMS vs. GEMS, nor could there be. (Who'd want to get the slow pick-up with a lesser crew to a local trauma center?) So these investigators did a retrospective cohort study to see what happens when trauma victims 15 years and older are delivered by HEMS or GEMS. They used data from the National Trauma Data Bank (NTDB), which includes nearly 62,000 patients transported by helicopter and over 161,000 patients transported by ground between 2007 and 2009. They selected patients with ISS (injury severity scores) above 15. They used a "clustering" method to control for differences among trauma centers, and otherwise adjusted for degrees of injury and other confounding variables.

"It's interesting," Dr. Haider said. "If you look at the unadjusted mortality, the HEMS patients do worse." But when you control for ISS, you get a 16% increase in odds of survival if you're taken by helicopter to a Level I trauma center. He referred to Table 3 in the paper. This, indeed, shows a big difference between the "raw" and adjusted data.

In a supplemental video provided by JAMA (starting at 60 seconds in): "When you first look, across the board, you'll see that actually more patients transported by helicopter, in terms of just the raw percentages, actually die." – Dr. Samuel Galvagno (DO, PhD), the study's first author.

The video immediately cuts to the senior author, Dr. Haider, who continues: "But when you do an analysis controlling for how severely these patients were injured, the chance of survival improves by about 30 percent, for those patients who are brought by helicopter ..."



Big picture:

What's clear is that how investigators adjust or manipulate or clarify or frame or present data--you choose the verb--yields differing results. This capability doesn't just pertain to data on trauma and helicopters. In many Big Data situations, researchers can cut information to impress whatever point they choose.

The report offers a case study of how researchers can use elaborate statistical methods to support a clinical decision in a way that few doctors who read the results are in a position to grasp, to know if the conclusions are valid, or not.

A concluding note:

I appreciated the time allotted for Q&A after the first 3 research presentations. There's been recent, legitimate questioning of the value of medical conferences. This week's session, sponsored by JAMA, reinforced to me the value of meeting study authors in person, and having the opportunity to question them about their findings. This is crucial, I know this from my prior experience in cancer research, when I didn't ask enough hard questions of some colleagues, in public. For the future, at places like TEDMED, where I've heard there was no attempt to allow for Q&A, the audience's concerns can reveal problems in theories, published data and, constructively, help researchers fill in those gaps, ultimately to bring better-quality information, from any sort of study, to light.

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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Twitter 101 for aspiring SoMe physicians

So you've decided to take the plunge (or at least, dip your toes) into the Twitterverse. Congratulations! Welcome to a vibrant interactive community. You'll find plenty of different personalities here and lots of opinions. But if you are like I was back in January 2011, you currently have no idea how to actually use Twitter, let alone how a physician might want to use it.

There are plenty of places to find information about how to start a Twitter account, (for example here), so I am going to take a leap of faith and say that if you are reading this, you have already set one up. If not, check out some online resources regarding starting your account and come back to this blog so you can figure out what you might want to do after the basic infrastructure is laid down (or, if you are just relatively adventurous, just head to Twitter and start your account without listening to any of the "pundits").

This post is not meant to give you the ins-and-outs about Twitter. I think they do a pretty good job explaining the basics on their help center. There, you'll find the "how's" of Twitter, like how to post a tweet or how to follow others.

Instead, this post contains some of my basic recommendations about how you might first want to get involved in Twitter a professional manner. As .I have said before, getting involved means starting small. I think you will quickly see why many people have stayed involved.

Consider starting with a private account. If you are still treading the water about getting involved for one reason or another, remember that you can have a private account. No one can follow you unless you let them. This means that your posts (or "tweets") will be hidden from view of everyone except those whom you permit. I suggest using this feature really only as a place to test the waters to get the hang of writing in 140 characters and see if Twitter is for you. Be aware that with a private account, your voice will not be heard. You are not really contributing your expertise; you can still listen to and follow anyone with a public account, but you limit your prospective audience. You can always change from private to public once you've established your account, so this is often a good way to test the platform, but I do not recommend maintaining a private account unless you want to remain silent or limited in your interactions.

Start following some accounts. This is the key to finding out the power of Twitter. The majority of the time, you will end up listening (i.e., reading) more than speaking (i.e., posting). Let me spend a few extra moments answering: Who should I follow and how do I find them?

Specialty societies and journals: By now almost all major societies and journals have Twitter accounts. These are generally staffed by communications professionals who often tweet recent articles or news items you might find of interest. You can try doing a search on Twitter for their accounts, or go to the societies'/journals' home pages and find the place on the website where you can "Follow Them". If you are logged in to Twitter, you can usually just click that link or icon, and you will be taken right to their Twitter account where you can choose to follow them. Once you're there, check out who they are following. Chances are, they follow accounts or people with whom you may have some common professional interests.

Let Twitter suggest some accounts: This tool might not give you the most interactive accounts, but at least you can continue to explore accounts that you may be interested in.

Search for accounts with similar interests: Do you have a particular area of interest? Maybe a disease or subspecialty? Do a search on Twitter to find people to see what people are saying about your area of interest.

Listen to what others are saying. Are you surprised I said this before I talked about what to tweet? For everyday folk (and by everyday folk, I mean those of us who aren't "follower millionaires"), Twitter is often more about listening than anything else. By listening, you will get the feel of how people tweet, what people tweet, the format of a tweet, etc. Believe it or not, listening to the voices might lead you to the next step.

Decide what to tweet. This is probably the most common question I get asked about Twitter. There are lots of people on Twitter saying many, many things all the time, but Twitter is not just about tweeting what you are just about to eat at the local diner. Being on Twitter in a professional manner means you are starting to define your own digital footprint and your voice. Did you read a tweet that you liked? Retweet it. That is one easy way to tweet, but that doesn't create any new content of your own. Are you an expert in one particular area? Start tweeting about it. I strongly recommend avoiding tweets relating to patients directly. Use common sense when creating original tweets; remember that patient privacy is paramount. However, you might find it easier though to get started by another common type of tweet. Find an article or a news item about an important health issue or topic in your field and tweet it (or comment on it). Any webpage can easily be tweeted nowadays with one of a number of tools that will shorten the web address to easily fit into the 140 characters of a tweet, like Tiny or bitly. Once you've shortened the link, you can import that into any tweet you'd like. For an example, see the Twitter stream of Dr. Orlowski (@Myeloma_Doc), who tweets virtually exclusively about multiple myeloma.

Find a hashtag. OK, now we're starting to get to "Twitter 102 for Docs". But if you've come this far and you're ready to explore a bit, you might want to head over to symplur.com's Healthcare Hashtag Project to see what they've created. Let me give you an example. In the tweet below, "#GERD" acts as a tag for the tweet. You can search for tweets by including the hashtag to increase the likelihood you'll find something directly related to your topic of interest.

Well, I hope these hints help you get started navigating your way through Twitter as a medical professional. Please feel free to comment and add your own suggestions or feedback.

In an upcoming post, we'll delve a little bit more into "Twitter 102 for Docs", where I'll discuss some ways to enhance your professional community.

Special thanks to Natasha Burgert (@DoctorNatasha) for helpful hints!

Ryan Madanick, MD, is an ACP Member, 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. This post originally appeared at his blog, Gut Check.

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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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