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Friday, September 28, 2012

One more monitor

At about 3:30 p.m., I sat down in my family room, raised my feet onto an ottoman, and conked out until 5:00 p.m. with a copy of a medical journal in my lap. My wife nudged me on her way out to meet a friend for dinner.

When I'm sleepy, my first reflex is to check my continuous glucose monitor for a high blood sugar level. Nope. 95 and steady. As they say on the beer commercial: "It don't get any better than this." I also wear (as in attached to my body, not my clothing) an insulin pump and a heart monitor. Neither of those could offer help in this situation. So I turned to my newest monitoring system: LARK (See Wired's "How Lark Went From Idea to Apple Store in One Year').

My wife and I often drive up to Los Angeles for the day, a 300-mile round trip. Lately, especially on our return trips to Escondido, I've been almost nodding off at the wheel. A lot more serious than falling asleep in my family room!! On these occasions, my wife is not so gentle in rousing me. In June, she'd had enough and marched me down to the local Apple store to purchase a specialty device called LARK. According to the accompanying app on my iPhone, my "time asleep needs work", meaning I should be averaging 8 hours of sleep per night, but I'm only getting 6. LARK suggested I go to sleep earlier and at the same time each night.

Because she is hearing impaired and doesn't pick up many audible wake-up alarms, Dee Dee bought LARK primarily for the wristband which pulsates at a scheduled time. While I also use this new silent alarm system, I am more interested in the objective data the accompanying app provides about my sleep patterns. Using this data, I'm alerted to possible corrective actions I can take to improve performance throughout the day. I can also share this data wirelessly via Facebook or Twitter.
Coincidentally, in June, when I bought the device, Dr. George Sledge authored an article on sleep ("Perchance to Dream", Oncology Times, June 25, 2012, pg. 28), and a second article entitled "Decoding the Science of Sleep" appeared in the Wall Street Journal, August 4-5, 2012, pp. 1-2. Both document how common sleep disorders are.

To illustrate, the annual number of prescriptions written for sleeping meds last year was about 60 million. And studies have demonstrated that these pills don't work. Unfortunately, they can impair short-term memory so that people believe they slept better than they actually did. So poor sleep habits "can also be a data problem" in that the medicated individual can't really remember how well or poorly they slept. Devices like LARK can collect this information for us, and supply analysis for possible solutions.

Before you can designate something as abnormal, it has to deviate from what is considered normal. A. Roger Ekirch, a Virginia Tech history professor, spent 20 years researching sleep and provides the seminal work defining "normal sleep." He found that, until about 200 years ago, our normal sleep pattern was divided into two phases: the "first sleep" started just after sunset and lasted until just after midnight, when the person would wake up for about an hour, then fall back into the "second sleep" ending with the rising sun. The time between the two episodes of sleep was spent reading, praying, contemplating dreams or having sex. This normal sleep pattern was totally altered by Thomas Edison and the electric light. The result is that about 20% of our general population has some type of sleep disorder. We've become a "wired and tired" society.

Dr. Sledge estimates that 45% of cancer patients have insomnia. Some are afraid to fall asleep as they might not wake up ("somniphobia"). Sleep disorders tend to be intertwined with other problems, especially fatigue, depression, and pain, "making it hard to tease out cause and effect."

For example, I saw a patient today with multiple myeloma who said his main complaint was fatigue. On further questioning, he was taking longer naps during the day because he didn't sleep well at night, sometimes taking an Ambien. When this didn't help, his primary care physician tried Lunesta, which didn't work at all. Turns out he wasn't sleeping because his Velcade-induced neuropathy only bothered him at night. Fortunately, this patient has a good memory and an attentive wife, who happens to be a nurse. So we were able to figure out the problem without a device like LARK. But most situations are not this straight-forward, and data-driven solutions can be quite beneficial.

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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Improving patient satisfaction: lessons from 18,000 feet

"Your call is important to us. Please listen carefully because our options have changed."

Reader query: During your current or any prior lifetime, has any phone menu option ever changed?

I have more than once experienced an option not offered on the robotic phone menu option choices, a dead phone line after a 30-minute wait.

Have you tried this customer plea as I have? Could you pretty-please jot down my cell phone number in the event that we are disconnected? Here are some of the responses one might expect from such in insolent request.
--Are you joking?
--I would but I think it's illegal.
--Sorry, our phone bank only receives incoming calls.
--No, but if you prefer, I can transfer your call to our grievance hotline. Just click on option #17.
--Uproarious laughter from the entire phone bank who heard my request on speaker.

As I write this, I am at 18,000 feet in a propeller plane that I trust will land safely in Cleveland. Hopefully, the air traffic controllers are all awake and alert. I'm flying in from Canada where my mom and I observed how indifferent the airline and customs personnel were to the plights of the passengers. Regrettably, this level of "customer service" isn't restricted to our neighbor to the north. Air travel isn't much fun these days for anyone anywhere.

I'm sure the airline folks are as hassled as we travelers are. Would you want to face angry and frustrated passengers each day when you are powerless to remediate their complaints? At times, the lines of happy travelers at the customer service desk in the airport for lucky folks who have missed flights or lost luggage reminds me of the lines I endured at Disney World. This analogy is apt since both sets of lines lead to adventure!

Here are my observations as an airline customer.
--I do not feel that my business is appreciated.
--Reaching a living, breathing human being on the phone should only be attempted if a physician has cleared you for this activity. Cardiac patients need not apply.
--Flexibility to adapt to customers' needs or to changes in circumstances have been left out of the playbook.
--Fees charged to make even the most trivial change in ticket reservations are unconscionable.
--No obvious regard for the value of customers' time with regard to flight delays.
--Service on board? Now we passengers can ask, "Are you joking?"
--Dissatisfied customers have no recourse. In other spheres of the marketplace, if we are not treated well, we dump them and walk down the street to a competitor.

There are lessons here for the medical profession and for our patients. Fortunately, patients and physicians enjoy much better partnerships than do airline industry have with its customers. But, our relationships with patients have been challenged from many internal and external forces. How are we doing in with regard to patient satisfaction? What do our patients say? While there are many legitimate reasons why high levels of patient satisfaction are more difficult to achieve today, patients still deserve our best effort and outcome. I am skeptical that pay-for-performance and similar efforts are the right tools to get this job done. When your only tool is a hammer, than physicians start to look a lot like nails. Haven't we been hammered enough?

While it is a generalization, I believe that private practice medicine, like any private business, has stronger incentives to provide high levels of patient satisfaction. Employed physicians, the emerging dominant model for doctors, may not be as vested in catering to their customers, although I know there will be disagreement here. For employed physicians, their sense of patient satisfaction may be feedback survey results from patients, which will be reviewed by their supervisors and placed in their personnel files.

Private practitioners, in contrast, may be more concerned with pleasing the patient directly than in pleasing the survey. This difference may appear subtle, but I believe it is substantive. In the same way that teachers are criticized for teaching to the test, physicians who must answer to bean counters may be practicing medicine with an eye toward the survey. This can lead to gaming the system.

As I noted on a prior post, the airline industry has taught the medical profession important lessons on medical check lists. I don't think, however, they have much to teach us about customer service. If you disagree, give them a call for some pointers on how to soothe seething passengers. Remember, your call is important to them.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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QD: News Every Day--85% of doctors got flu vaccines last year

Two-thirds of all health care professionals got a flu vaccine last year, the Centers for Disease Control and Prevention announced in the Sept. 28 MMWR.

Flu vaccination was most common among physicians (85.6%), followed by nurses (77.9%), and other health care professionals (62.8%).

At a press conference announcing flu vaccinations for health care workers and the general public, Howard K. Koh, MD, FACP, received his vaccination in an effort to set the example. Dr. Koh, Assistant Secretary for Health at the U.S. Department of Health and Human Services reinforced the need for ongoing, collaborative efforts to improve influenza immunization.

"I urge everyone to join me and get a flu vaccine this year," Dr. Koh said.

Vaccination coverage was 76.9% among health care professionals working in hospitals, 67.7% among those in physician offices, and 52.4% among those in long-term care facilities.

Physicians who worked in hospitals received the vaccine at a rate of 86.7%, compared to other health care professionals who worked in long-term care facilities (50.2%).

At hospitals that required influenza vaccination, coverage among health cre professionals was 95.2%. At hospitals not requiring vaccination, coverage was 68.2%.

Among the third of health care professionals overall who did not get vaccinated, three most common reasons were a belief that they did not need it (28.1%), a concern about vaccination effectiveness (26.4%) and a concern about side effects (25.1%).

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Thursday, September 27, 2012

Cleaning out the pharmaceutical junk drawer

I cleaned out a drawer in my desk today. There were a lot of pens, many of which had drug company logos attached to them. As I looked over this menagerie, I was mildly awed and moderately amused by the variations on a pretty mundane medium. I ended up taking a bunch of pictures, and hope to share them over time, giving my take on what makes them, uh, special in their own way.

The subject is made more interesting by the fact that we no longer get these because of the incredible influence they had on doctors' prescribing habits. My wife had to physically restrain me to keep me from calling patients insisting that Viagra was right for them.

So let's start with a Caduet pen.

Caduet was the genius of Pfizer pharmaceuticals, mixing two very popular drugs and was the first of many drugs to use the word "duet" in its name. It combines the cholesterol drug Lipitor with the blood pressure drug Norvasc, serving as kind of anti-French fry. This pen is very big and fat, and is made out of metal. This makes it heavy, and while not ideal for the front shirt pocket (and a little embarrassing if put in the pants pocket), it is very effective when used in hand-to-hand combat.

I got this at a booth at the annual conference for the American College of Physicians.They were not only offering this pen/weapon as a gift, they offered to put my name on it for free!



I didn't give them my real name. I got a lot of funny looks at the booth, but nobody challenges me in hand-to-hand combat any more.

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

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How do we achieve high value cost conscious care?

The New York Times has an important and provocative piece, "Overtreatment Is Taking a Harmful Toll."

The title is a bit misleading. The article focuses more on over-testing. We test too much and we treat too much.

The article, while mostly accurate, does not really explain the reasons for the problem Unless we can accept and understand the underlying reasons for these problems, we cannot successful correct these problems.

Let me suggests the major reasons for over treatment and over testing and then address them over the next couple of weeks. Prior to writing about each one, I do want to see if readers can suggest any more or disagree with the list.

Our payment system that pays for each thing (i.e., diagnostic tests, visits) encouraging us to do more things. We get paid the same when we spend less time with the patient and order more tests.

Advances in technology, by which we have better imaging and more laboratory tests. Sometimes the tests are too good, and suggest that we do more tests. Perhaps we should do more careful history and physical exams and do less testing.

Guidelines based on single diseases. We use too many medications to achieve targets that may help a disease but hurt other diseases. Too often we have guidelines that do not give us enough "leeway" to individualize therapy.

Patient demand. Patients think they need an MRI of the head, because a friend said so. That friend knows someone whose 2nd cousin had a rare brain tumor found because of an MRI, thus you must get an MRI.

Malpractice fears. Studies never document this, but all physician know that it is true. This is especially true in emergency departments. Every time I write this my comments fill up with emergency physicians justifying all the studies they do. But ask any hospitalist about excess CTs in the ED. The first abdominal CT for cryptic severe pain makes sense. Perhaps the second, but certainly not the 5th, 6th and 7th.

Marketing from big pharma leads to more expensive drugs and increased patient demand for those drugs. This occurs especially from direct to consumer advertising.

Lack of information from other physicians. Our obsession with privacy and HIPAA decreases the sharing of important medical information across sites. Every time a patient sees another physician the order the same tests because it's easier than trying to get the old results.

I am certain that I have not been totally inclusive in my list. This is really a multi-faceted problem. Please add your thoughts.

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--Don't know much about health care reform

Medical students don't know much about the environment they'll practice in under health care reform, a study found.

To characterize medical students' knowledge of and attitudes toward the Affordable Care Act and the variables of political affiliation, medical school year, specialty choice, and financial considerations, researchers e-mailed an online survey to all 1,235 Minnesota medical students at in January 2011.

Students were asked to indicate their level of agreement to three questions using a 5-point Likert scale: "I understand the basic components of the Patient Protection and Affordable Care Act (the national health care reform bill passed in March 2010)"; "I support the Patient Protection and Affordable Care Act"; and "Physicians are not professionally obligated to play a role in implementing the new healthcare reform bill."

Results appeared in a research letter in the Sept. 24 issue of Archives of Internal Medicine.

There were 843 respondents (68%), of whom 55% identified themselves as liberal and 52% expected to go into primary care.

The study found that less than half of the respondents (48%) agreed with the statement, "I understand the basic components of the Patient Protection and Affordable Care Act." A large minority (41%) of students had no opinion regarding support for the ACA, and only 13% of students did not support the legislation. Most respondents agreed that physicians are professionally obligated to play a role in implementing the ACA (69%). Most students also indicated that monetary considerations influenced their choice of specialty (53%).

Among the respondents, 72% who understood the ACA supported it, while 20% who did not understand the ACA did so. Most students who did not understand the ACA indicated no opinion (72%) regarding support, while only 11% of students who understood the ACA had no opinion about support.

Liberal students compared to conservatives were significantly more likely to understand (odds ratio [OR], 15.1; 95% confidence interval [CI], 8.6 to 26.8]), support (OR, 2.2; 95% CI, 1.4 to 3.3) and have a sense of obligation to implement health care reform (OR, 3.3; 95% CI, 2.1 to 5.1).

Students who responded that their choice of specialty was or would be influenced by medical school debt or future earnings were significantly less likely to agree that they supported (OR, 0.5; 95% CI, 0.4 to 0.7), understood (OR, 0.7; 95% CI, 0.5 to 0.9) or felt a sense of obligation to implement health care reform (OR, 0.6; 95% CI, 0.4 to 0.8).

Compared with students who anticipate a primary care specialty, students were significantly less likely to support health care reform if their future specialty was surgical (OR, 0.6; 95% CI, 0.3 to 0.9) or undecided (OR, 0.6; 95% CI, 0.4 to 0.99).

Third-year students, compared with first-year students, were less likely to agree that physicians are obligated to play a role in implementation of the legislation (OR, 0.6; 95% CI, 0.3 to 0.9).

Researchers noted that "future physicians remain largely ignorant and indecisive about the ACA, with a minority of respondents indicating understanding and 41% of students indicating no opinion regarding their support of the legislation."

Still, 69% of students endorse a professional obligation to implement the ACA.

"While future physicians believe they have a responsibility to participate in implementing the ACA, these data raise concerns that they may not possess the knowledge necessary to implement reform measures in the coming years," researchers wrote. "Our data reflect previous research demonstrating insufficient policy education in medical school and suggest that increasing such efforts may be required for successful implementation of the ACA and future health care reform initiatives."

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Wednesday, September 26, 2012

American heft

The Centers for Disease Control and Prevention released its latest report on obesity in the U.S.

The report generated copious media attention, with the usual hand-waving about the issue. A quick web search reveals mostly local stories along the lines of "Our state's collective girth is increasing and we need to do better" or "Phew! Our state isn't as fat as those other states."

To visualize the magnitude of the problem, look at the CDC's visual map.



Note how the percentage of obese Americans has continually risen over the last twenty-five years. If you click on the right arrow button in the embedded map, you'll see year after year of increasing percentages of obese people in nearly every state. Interestingly, the color choices go from white (no data) to blue (10-20% obesity) to orange/red (more than 20% obesity). Is there a coded message here? One big take home: What's Colorado's secret?

What gets lost in all of the superficial coverage of "Fat state vs. Not-as-fat state" is how obesity is measured.

In health care we use the BMI, or body mass index, as the determinant. The BMI is a measurement that adjusts weight for height: the taller you are, the more weight you're 'allowed' to carry. The calculation is straightforward: Take your height (in meters squared) divide by your weight (in kilograms). It gives you a number, and the range is as follows:
BMI---classification
Less than 18.5=underweight
18.5-24.9=normal
25-29.9=overweight
30-35=obese
Greater than 35=morbidly obese
There are many reputable BMI calculators out there that we use in our office all the time. In fact, I'm embedding one below that will let you enter your height and weight in our usual units (feet, inches, and pounds). It'll do the converting for you. Just enter the numbers and click "Calculate."

Write down the number and bring it to your next visit with a health care provider. They'll be impressed that you know about this. Especially if it motivates you to do something about it.

BMI For Adults Widget

To GlassHospital readers that are bodybuilders or football players, know that BMI is NOT reliable for you in determining obesity. For those with a large percentage of body mass from muscle, the BMI is inaccurate. It's far from perfect, but for the general population it's a reasonable guide.

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--Ciprofloxacin associated with increased MRSA in hospitals

A decrease in hospital-wide ciprofloxacin (a fluoroquinolone) prescribing was strongly associated with an overall decrease in MRSA infection, a study found.

Researchers investigated the evolution of methicillin-resistant Staphylococcus aureus over a 10-year span at St. George's, a large, acute-care teaching hospital in London over a 10-year period.

Results appeared in the Journal of Antimicrobial Chempotherapy.

Three clones caused the majority of infections, CC30 SCCmecII (EMRSA-16), CC22 SCCmecIV (EMRSA-15) and ST239 SCCmecIII.

The only substantial hospital-wide change to antibiotic prescribing occurred in 2007, when ciprofloxacin and cephalosporins were cut back. The timing of this decrease coincided very closely with the decrease in MRSA incidence in mid-2007, the researchers noted.

However, the decline in prescribing of cephalosporins was compensated for by an increase in the prescribing of other b-lactamase resistant b-lactams, such as co-amoxiclav and piperacillin/taxobactam.

Hospital clones of MRSA were nearly universally resistant to ciprofloxacin and maintained this resistance during the span of the study. Researchers wrote, "A possible explanation is that the hospital-wide prescribing of antibiotics to which MRSA is universally resistant, such as ciprofloxacin and b-lactamase-resistant b-lactams, selects for MRSA in colonized patients. This selection would lead to a higher likelihood of endogenous infection. If so, this could link the decrease in prescribing of ciprofloxacin with the decline in MRSA infection incidence."

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Tuesday, September 25, 2012

Get your flu shot

Temperatures are dropping. Children are returning to school. (Parents are elated.) Families are planning a last summer outing on Labor Day. It must be time for flu shots.

This season's influenza vaccine has shipped from manufacturers. Our office just received them. So it's a good time to remind ourselves that the flu can be fairly nasty and that the most reliable way to protect yourself is the influenza vaccine.

The flu shot is recommended for everyone over six months of age. It's especially important for:

--people who are at high risk of developing serious complications like pneumonia if they get sick with the flu. This includes people who have certain medical conditions including asthma, diabetes, and chronic lung disease; pregnant women and people 65 years and older;
--people who live with or care for others who are high risk of developing serious complications. This includes household contacts and caregivers of people with certain medical conditions including asthma, diabetes, and chronic lung disease.

The following groups should not receive the vaccine:
--people who have a severe allergy to chicken eggs,
--people who have had a severe reaction to an influenza vaccination,
--children younger than 6 months of age (influenza vaccine is not approved for this age group),
--people who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated), and
--people with a history of Guillain-Barre Syndrome

Follow the links below to learn more about the flu. And get the shot now, before the flu season starts.

Learn more:
Seasonal Influenza (Centers for Disease Control and Prevention page)
Key Facts About Seasonal Flu Vaccine (Centers for Disease Control and Prevention page)
Google Flu Trends

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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QD: News Every Day--Doctors retreating from full-time practice in a 'silent exodus''

Physicians are working 6% fewer hours than they did four years ago and are seeing close to 17% fewer patients per day, a survey found.

Tracking the many ways that physicians intend to change their practice patterns, the survey continued that more 44,000 physician full-time equivalents will be lost over the next four years. And, doctors currently spend nearly one-quarter of their time on non-clinical paperwork, the equivalent of some 165,000 FTEs.

Further, the survey indicates that more than half of physicians plan to change their practice patterns over the next one to three years, either cutting back on patients seen, switching to a concierge practice, working part-time or finding a non-clinical job.

And, 100,000 physicians may transition from practice-owner to employed status over the next four years, such as working in a hospital.

The survey was conducted by e-mail from late March to early June 2012 among 630,000 physician e-mail addresses, or about 84% of the approximately 750,000 physicians in active patient care in the U.S. There were 13,575 respondents. The survey was commissioned by The Physicians Foundation and conducted by the physician search firm Merritt Hawkins.

These changes in practice patterns amount to a "silent exodus" from the workforce, the Physicians Foundation announced in its press release.

In other findings, the survey reported 52% of physicians have limited the number Medicare patients among their panels, while 26% have already closed their practices to Medicaid patients, the survey shows. Physicians cited rising operating costs, time constraints and diminishing reimbursement as the primary reasons why.

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Monday, September 24, 2012

EHR installation redux

Well, here I go again. I'm about to install an electronic medical record for the second time. I installed the first exactly 10 years ago this week. Boy am I nervous (and boy is my right index finger tired).

I am nervous about what I know is to come, from prior experience, and about what I don't know is to come, because every electronic record is different, and because I now have not one but two partners looking to me to have configured it perfectly. (Remember the known unknowns and unknown unknowns our old friend Donald Rumsfeld spoke of? I have to grant he was right about that, if not much else.)

After having put in about 50 hours, I can tell the new system won't be even close to perfection. The last one cost me 200 man-hours. But the vendor tells me it is unrealistic to expect to get it right the first time; every practice they work with spends the first 6 months polishing and refining. I know that better than anyone.

But this will not be a rant about electronic medical record software in general or about its influence on medical care. I already did that one a year ago. Instead, I want to share a response I gave at another website to the blogger whose commentary I found interesting, valid and provocative, as well as to the substantial commentary that followed ranging from cynical to outraged. That part I disagreed with. So here is my take on the original topic.

I wrote: "I'm sympathetic with all that has been said by the commenters but I think there is a level of hyperbole and hysteria in their reactions to EMRs. I have used one for our three-man practice for 10 years, and because it does not qualify for meaningful use we have had to replace it.

After a few months of searching and three site visits we selected one that is set to go live in 4 days. Naturally, I am quite apprehensive. The first time around we were slowed substantially for several weeks. I put in over 200 hours configuring it, and I don't see that the new one will cost me fewer than that. The old one had no order-tracking, such as the ability to follow-up on orders to see if they were done and what the results were. The new one does that, and I have worried for 10 years about the lost blood test, or more likely, the one the patient failed to go for.

The new EMR still generates a note that looks robotic in authorship, just like the old one, but it does look a bit neater and prettier, if such can be said about a medical report. And although the interface is seemingly more complex, it is more powerful and customizable. The old system and its replacement both force us to think about the list of possible diagnoses and lab tests that might not have otherwise entered my mind.

They both allow me to edit my note at the end of the day, unlike ones that I simply dictated before 2002. They both allow me to use Dragon Speech, and I have been using this voice-to-text application fairly happily these 10 years (although I have to watch it diligently as it does commit grievous mis-transcriptions every few lines). One of my partners, who prizes speed over completeness, is worried greatly he will have to slow down, and he will for a while. But he has been clicking on "non-contributory" or "ROS essentially negative for 14 systems" for the past 10 years and I doubt he will change.

I am not worrying about the questions I have to ask my patient for my new system to qualify for meaningful use as specified by the new health care law, the way everyone among the commenters who are already using one of the new EMRs seemed to be. Maybe I have not yet experienced it for myself, but I am planning to have staff enter most of the past history, review of systems, and other important data.

Of course the use of an EHR will not offer the kind of efficiencies we are hoping for yet. We will need new generations that allow me to view the blood count that is in my referring doctor's EMR so I don't have to order redundant studies or have my staff nag his staff to fax the reports. We need better prescribing abilities that don't set off alarms about drug interactions for every pair of medications prescribe, to the point that frustrated physicians disable that feature. We need computer-aided diagnostics.

Of course we have a long way to go. And I know I will want to throw the tablet through the window at least once next week, as I did for the first 6 months the last time around. But overall, I am still hopeful.

And stop blaming the government for everything that's wrong in medicine. Without government, we would have no Medicare, and no clean air and water, for that matter. So to all the incensed commenters, stop all the grousing and make some constructive suggestions!

The problem is not that we have the wrong incentives, but that we need new and better incentives for my colleagues to remain in primary care and for new trainees to enter it. Forgive me, but as someone who can hope to see his internist retiring before I expire, I would prefer not to see a physician "extender" when he goes. But that's a whole 'nother rant.

And thus endeth this one.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Are medical educators teaching what we want doctors to learn?

We all know that:
--the amount of information is increasing rapidly, and
--the half-life of knowledge is shrinking; what we knew few years back does not hold true anymore.
As Alvin Toffler said, "The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn."

Once our students leave the formal education settings of medical school, they will have to learn how to keep up with literature and new advances on their own. Thus medical educators want to teach students how to become self-motivated self-directed, lifelong learners.

The hidden curriculum is the unintended lesson/s, usually about norms, values, beliefs or behaviors, learned during a learning experience. Thus in medical schools students are taught a particular way to communicate with patients. When students see health care practitioners interact with their patients differently, they get a different message.

One of the biggest hidden curricula is the way students are expected to learn in medical schools. Traditionally, they are expected to attend lectures and seminar, show up in clinical rotations and have information delivered to them, drilled into their heads. [A number of medical schools are trying to break out of this mold]. These students get the unintended message that someone else is taking the responsibility for their learning. This hidden message is more powerful than the intended message for their need to be self-directed learners.

To truly help students become the independent, self-directed learners we want them to be, schools need to reform the way they educate. Instead of large lecture halls, early in the training the students need to learn how to look up and find information to solve problems. Students can learn individually or in small groups (e.g. problem-based learning and team-based learning).Passive learning should be avoided. This will create a hidden curriculum that will help our students learn the only useful lesson we can teach!

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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You're nuts to skip almonds

I eat a handful of almonds a day because they are "healthy fat" and the crunch and taste are so good. But I have always wondered about the caloric intake and how it might adversely affect my constant focus on weight loss. I am happy to report on a study published in The American Journal of Clinical Nutrition that shows what we thought we knew about almonds and their effect on weight may be all wrong.

The objective of the study was to determine the energy value of almonds in the human diet and compare it with the value calculated from prior known measures known as "Atwater factors." The Atwater system has been used for over 100 years and nutritionists and government labeling of foods have depended upon it to predict fat digestibility, heat combustion and caloric content of foods. The Atwater measurements have influenced the USDA National Nutrient Database for Standard Reference and this reference is used to report on protein, fat and carbohydrates contained in a serving of almonds.

These researchers found that the directly measured digestibility of fat and carbohydrates in the diet were actually decreased when almonds were eaten daily with the food. These fell far below the Atwater predicted values, which had overestimated the energy content by 32%. This means rather than adding calories, simply adding a handful of almonds to my diet could result in more than a pound of weight loss a month.

In summary, the way we have been measuring and reporting calories, carbohydrate and fat consumption may be wrong for other foods as well as nuts. The nutrient labels that guide us use the Atwater general factors but these researchers found, in the case of almonds, that those labels may be off as much as 26%. The new method used in this study to measure the energy value of a single food is a significant improvement over past methods and older inaccurate methods may need to be revised so we actually know that labels are correct.

I look forward to more studies on nutrition that single out my favorite foods and show they are not fattening.

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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QD: News Every Day--Primary care doctors earn $2.8 million less than specialists in their lifetime

Primary-care physicians averaged as much as $2.8 million less than specialists, potentially making primary care a less attractive choice for medical school graduates and exacerbating the already significant shortage of medical generalists, a study found.

The results, published online in the journal Medical Care, lead the study's authors to recommend reducing disparities in physician pay to ensure adequate access to primary care.

"The need for primary-care providers is greater than ever before and expected to grow as millions more Americans become insured under the Affordable Care Act," the lead researcher said in a press release. "Without a better payment structure, there will be extraordinary demands on an already scarce resource."

After adjusting for covariats that also affect earnings, the researchers evaluated incomes for more than 6,000 doctors in 41 specialties. When merged into four broad career categories, lifetime earnings in surgery, internal medicine and pediatric subspecialties, and all other medical specialties averaged from $761,402 to $1,587,722 higher than in primary care:
* surgery: $4,588,249
* internal medicine subspecialties and pediatric subspecialties: $4,100,183
* all other medical specialties: $3,761,930
* primary care (geriatrics, family practice, general practice, general internal medicine and general pediatrics): $3,000,527

The earnings differences were more dramatic when compared as 41 separate specialties, according to the press release. Medical oncologists, for instance, earn up to $7,127,543 during a 35-year career, while family medicine practitioners earn as low as $2,838,637.

Richard Kravitz, MD, FACP, one of the study's authors who serves on an independent commission to assess physician pay, said, "These huge lifetime pay disparities have to be discouraging for medical students considering primary care as a career If we truly value primary care, we need payment schemes that don't send the opposite message."

The study is a follow-up to research in 2010 on differences in annual wages by specialty. Researchers compared lifetime earnings to demonstrate how annual wage differences accumulate over physicians' careers. The earnings data came from the 2004-2005 Community Tracking Study, a periodic evaluation of physician demographic, geographic and market trends.

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Friday, September 21, 2012

QD: News Every Day--Internists look askance at industry-funded studies

Study design, not industry funding, should be the key reason why internists doubt results from a clinical trial, a study concluded.

Internists in a study discounted hypothetical examples of small, poorly designed trials and accepted outcomes from large trials that tested clinical end points. But they also downgraded the credibility of hypothetical industry-funded trials compared with the same trials attributed to NIH funding or having no source of support listed.

But should internist pay more attention to well-design studies despite industry funding?

Researchers presented 269 board-certified internists (a 53.5% response rate) with one of 27 possible abstracts describing clinical trials of three hypothetical drugs: "lampytinib" for dyslipidemia in patients who had unacceptable side effects from statins, "bondaglutaraz" for diabetes and low levels of HDL cholesterol in patients taking metformin and a sulfonylurea and unable to add insulin, and "provasinab" for angina in patients with untreatable multivessel coronary disease who were taking maximal doses of beta-blockers.

The hypothetical abstracts varied the drug being tested, the trial's methodologic rigor (high, medium or low), and the funding source (industry, NIH or none).

Results appeared in the New England Journal of Medicine.

Physicians reported that they were less willing to prescribe drugs tested in low-rigor trials than those tested in medium-rigor trials (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.46 to 0.89; P=0.008). They were more willing to prescribe drugs tested in high-rigor trials than those tested in medium-rigor trials (OR, 3.07; 95% CI, 2.18 to 4.32; P less than 0.001).

Disclosure of industry funding, as compared with no disclosure of funding, led physicians to downgrade the rigor of a trial (OR, 0.63; 95% CI, 0.46 to 0.87; P=0.006), their confidence in the results (OR, 0.71; 95% CI, 0.51 to 0.98; P=0.04), and their willingness to prescribe the hypothetical drugs (OR, 0.68; 95% CI, 0.49 to 0.94; P=0.02). Physicians were half as willing to prescribe drugs studied in industry-funded trials as they were to prescribe drugs studied in NIH-funded trials (OR, 0.52; 95% CI, 0.37 to 0.71; P less than 0.001). These effects were consistent across all levels of methodologic rigor.

Researchers noted that excessive skepticism concerning industry-supported trials could hinder how internists practice. They cited an example of a poll conducted at NEJM in which many of readers believed that the results of the JUPITER trial did not justify a change in clinical management, citing industry funding as a key reason.

"Although attention to potential sources of bias is necessary, such skepticism apparently can also reduce the credibility and acceptance of even high-quality research that is industry-supported," the researchers wrote. "Financial disclosure is important, but more fundamental strategies, such as avoiding selective reporting of results in reports of industry-sponsored trials, ensuring protocol and data transparency, and providing an independent review of end points, will be needed to more effectively promote the translation of high-quality clinical trials--whatever their funding source--into practice."

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The myth of exploding cookies

If you reduce the sodium content of cookies you bake (or talk someone into baking for you), they won't explode. I have data! We'll get back to this.

There seems to be debate these days about almost everything we thought we knew about nutrition and health. There is the argument that sugar, and more specifically fructose, is toxic and the one thing fundamentally wrong with the modern diet, and there are opposing views, mine among them.

There is the argument that excess sodium may be the single most important liability of modern eating, accounting for some 150,000 deaths a year, and opposing arguments. There are the time-honored arguments for the importance of the calorie, and arguments that calories don't really count.

I maintain, however, through all the sound and fury, much of which signifies nothing more than a theory du jour, that we are NOT clueless about the basic care and feeding of Homo sapiens. The basic pattern of healthful eating is very well-established, and convincingly evidence-based. And the health benefits attached to such a pattern are profound.

That pattern, foods close to nature, minimally processed, mostly plants, is inextricably associated with less sugar intake, less sodium intake, and lower calorie intake. So however important each of these trees is or isn't, they are an important part of the forest.

Getting there from here would be a good thing, but it's clearly something most Americans can't figure out how to do. The fact that it's so hard is not by accident, the food industry has done all it can to keep you lost in the dark woods of a profitable status quo.

Part of what the industry has done is to propagate an arms race, with your taste buds. Human taste buds are predisposed to like sweet, so putting sugar in food is apt to make people like it. Now imagine, though, that your competitor's product is outselling yours because it has just a bit more sugar, what are you to do? Increase your own sugar content.

See where this can lead? More sugar means sweeter; sweeter means tastier; tastier means more sales. As manufacturers compete in this area, taste buds start acclimating to more, and more, and more sugar. The more they get, they more they want. And so we wind up with ever more sugar in our food partly because we're asking for it! We're asking for it because our taste buds are desensitized to sugar the more they get, and need ever more to register satisfaction.

This same scenario applies to salt, and other properties of foods, too, such as creaminess. The more we get, the more we tend to want. The more we want, the more we get.

Personally, I remain convinced that excess sugar, sodium, and calories are harmful for most if not all of us. But whatever your point of view about sucrose, fructose, or salt, we should be able to agree on this: Whatever blocks our path to a basic, healthful dietary pattern is bad.

Well, sugar and salt do exactly that. Because if your taste buds have acclimated to high levels of both, you will simply prefer more highly processed foods, and reject the simple, unadulterated flavors of simple foods close to nature. You will NOT eat "food, not too much, mostly plants," because you won't like doing that! And you, and perhaps your family, will miss out on the enormous health benefits associated with doing so, which is a terrible shame, because healthy people have more fun.

But this is all fixable. Taste buds can be rehabilitated. They are, in fact, very malleable little fellas: When they can't be with a food they love, they can quite readily learn to love the food they're with. Particularly if the food they're now with is familiar overall, but just a bit better for you. I maintain: We can love foods that loves us back.

The food industry arms race, the race to make and sell products we can't resist, has resulted in some very odd formulations. Breakfast cereals routinely are more concentrated sources of added salt than items in the salty snack aisle. Pasta sauces and salad dressings are frequently more concentrated sources of added sugar than desserts. And we're supposed to be ok with this?

Apparently we are. Every recipe for home-baked cookies, for instance, includes added salt. Have you ever thought to ask, why do cookies need salt? Do I LIKE salty cookies?

My wife and I did ask, some years ago while working on one of our books. We made the obvious inference: If you don't put salt in home-baked cookies, they presumably explode. But we are both scientists, my wife has a Ph.D. in neuroscience, so we decided to test our hypothesis.

Well, my wife did, really, I mostly watched. We are both scientists, but only my wife knows how to bake! She grew up in Southern France, and learning at her mother's and aunt's knee, is a whiz in the kitchen. But I think my "ra, ra, go Catherine!" was crucial.

In any event, we took the salt in cookie recipes down, and out, and the cookies did not explode. The shelf life didn't seem to change much either, although admittedly, cookies don't tend to sit around too long! But no obvious liabilities with texture, survival time, or tendency to detonate were discerned.

We really noticed only one thing: Suddenly, the cookies were too sweet. We had not altered the sugar content at all, but now they were too sweet. The reason is that salt can mask the taste of sugar, and vice versa. Less salt competing for taste buds' attention meant the sugar was more discernible.

So we did the obvious thing: We took down the sugar content, too. And with the sodium reduced, we found the cookies tasted plenty sweet enough with half the sugar they had at the start. We've been eating variations on the theme of these cookies ever since. Much less sodium, much less sugar, and still delicious. Go figure!

The real message of the non-exploding cookie epiphany is, of course, how it can be generalized. There are commercial products that aren't supposed to be salty, like breakfast cereals, with a lot of added salt. But there are others without that salt. Choose those lower-salt versions, and you are not just reducing salt in your diet, you are helping your taste buds be more sensitive to salt. Doing so helps them help you to prefer, and get to, a more wholesome diet overall.

Ditto for the sugar in places like pasta sauce. I call this "stealth sugar" because it may make you eat more, but you don't even realize it's there. Cut down on stealth sugar, and you can make your taste buds more sensitive to sugar, getting to satisfaction with less, before ever touching dessert. Before long, you will prefer your desserts less sweet, too.

Personally, I think we eat too much sugar, salt, the wrong kinds of fat, and calories, and I think all of this counts. But regardless of your position on the competing dietary theories du jour, the benefits of a wholesome diet overall are a forest we should all be able to see through these trees. Getting rid of stealth additions of sugar and salt to innumerable foods, and rehabilitating your taste buds, is an important strategy for getting out of these dark woods, to the luminous health benefits beyond.

Our homegrown data suggest it can readily be done, we can love food that loves us back, and there will be very few injuries related to exploding cookies along the way.

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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Thursday, September 20, 2012

Combating burnout

It happened again. I was talking to a particularly sick patient recently who related another bad experience with a specialist.
"He came in and started spouting that he was busy saving someone's life in the ER, and then he didn't listen to what I had to say," she told me. "I know that he's a good doctor and all, but he was a real jerk!"

This was a specialist that I hold in particular high esteem for his medical skill, so I was a little surprised and told her so.

"I think he holds himself in pretty high esteem, if you ask me," she replied, still angry.

"Yes," I agreed, "he probably does. It's kind of hard to find a doctor who doesn't."

She laughed and we went on to figure out her plan.

This encounter made me wonder: Was this behavior typical of this physician (something I've never heard about from him), or was there something else going on? I thought about the recent study which showed doctors are significantly more likely than people of other professions to suffer from burn-out.

Compared with a probability-based sample of 3,442 working U.S. adults, physicians were more likely to have symptoms of burnout (37.9% vs. 27.8%) and to be dissatisfied with work-life balance (40.2% vs. 23.2%) (P less than .001 for both).

This is consistent with other data I've seen indicating higher rates of depression, alcoholism, and suicide for physicians compared to the general public.

On first glance it would seem that physicians would have lower rates of problems associated with self-esteem, as the medical profession is still held in high esteem by the public, is full of opportunities to "do good" for others, and (in my experience) is one in which people are quick to express their appreciation for simply doing the job as it should be done. Yet this study not only showed burn-out, but a feeling of self-doubt few would associate with my profession.

Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment.

Yet my own experience with my own emotions in medicine, as well as my experience with other physicians, suggests that half of the physicians in the survey are probably lying. Being a doctor is certainly a great privilege, but it is also an enormous tax on the emotions. Since I haven't done other jobs I can't compare, but there are many days I find myself wishing I had a job I could just do and then just leave at the office. The changes in health care over the 18 years I've practiced have increased that frustration and fatigue, causing me to catch myself pining for the "good old days." Ugh.

It is interesting that the study showed the highest rates of burn-out in the "front line" professions, such as family medicine, internal medicine, and emergency medicine. So what is it in my job that makes me feel symptoms of burn out? Here's my top ten list:
1. The pressure to see a high volume of patients. Because I am paid by volume, I am constantly pressured to spend less time with my patients. This makes me feel like I'm not doing a good job on anyone.
2. The fact that good work is penalized. When I do explain things, call people, or just act friendly toward my patients I am rewarded with a lower salary. I constantly have to choose between doing good and getting paid, and that's really lousy.
3. The piles of paperwork. This has grown steadily over time, and is barely reimbursed at all. The time I spend doing paperwork either takes away from my productive time with patients, time with my family, or my own personal time to take care of Rob.
4. The ridiculous rules. Complying with coding requirements for documentation, with "meaningful use rules," and with increasingly invasive rules around prescribing controlled drugs makes me nauseated. Not only are these rules complicated and confusing, but noncompliance (intentional or not) to them could make me lose my license or worse.
5. Dr. Oz and his cronies. I single out Oz only because of his overall influence (and to get back at Oprah for her vendetta against me), but the increasing invasion of medical information with self-serving balderdash is both annoying and destructive. I don't want to explain why all fatigue is not thyroid, or why gluten is not a toxin, yet I must do so to be able to care for my patients.
6. The Evening News. The love affair the networks (CNN and company included) have with the "latest study" is enough to make me consider experimentation in television/baseball bat mating. Every day there is a study showing that what was helpful last month will now kill you. It's all headline-grabbing for money, and I spend an increasing amount of my time dealing with it.
7. Drug seekers. Fueled by codependent doctors who can't say no to requests for controlled substances, far too much of my day is spent explaining why Percocet is not a good choice for chronic pain, and daily Xanax will just make things worse. A huge percentage of my phone messages are about these medications and I would gladly stop prescribing them altogether if they didn't help some of my patients as much as they do.
8. Politics and medicine. I've already said enough on this issue. Unfortunately, the politicians are supposed to fix this mess, and that's a pretty depressing reality.
9. The constant weight of responsibility. Over the past 18 years I have never had time away from the reality of this. It isn't gone when I go home, and it doesn't disappear when I go on vacation. I can do 18 years of good work, but I can never coast. The next exam room may be that child with subtle meningitis, or the person seriously considering suicide. It's in the fine print of the job, and I accept that, but it gets pretty heavy over time.
10. Knowing that it can all crash any moment. If I miss one case of meningitis, don't address the depression properly, or simply have a bad day, I can see my reputation ruined. Any day could be "that day" when my life can become 100 times harder. Despite a career of doing good, one bad day can put me in the spotlight as a "bad doctor."

So do I want you to feel sorry for me? Please no. But I do want people, especially those who regularly put doctors in their crosshairs, to remember that this is a really, really tough job. Yes, it's a privilege, but sometimes the pressures can turn the nicest doc into a jerk, the most careful clinician into a quack, and the most caring person cold.

Some of the things on my list are just part of the job, regardless of the system, while others are caused by the ills of society and our ridiculous system. We need to fix what we can for both doctors and patients. We also need to understand that we are all humans (despite repeated evidence to the contrary).

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

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Are we treating too many patients for hypertension?

What defines hypertension as a diagnosis? The absolute number must be arbitrary, and should be chosen to predict that treatment improves outcomes. If we believe in using the evidence, then we must examine the evidence in favor of treating "mild hypertension." A new meta-analysis suggests that we need not treat mild hypertension. This should make us wonder at the definition of hypertension.

Antihypertensive treatment in patients with a systolic blood pressure of 140 mm Hg to 159 mm Hg or a diastolic pressure of 90 mm HG to 99 mm Hg did not significantly reduce all-cause mortality, stroke, coronary heart disease, or total cardiovascular events, Diana Diao, of the University of British Columbia in Vancouver, and colleagues reported in a Cochrane review.

That lack of benefit was accompanied by a significant increase in withdrawals due to adverse effects (RR, 4.80; 95% CI, 4.14 to 5.57), which occurred at a rate of 8.9% in the single trial that provided that information.

For those readers who have been reading recent rants, you can anticipate the outcry from the hypertension community. The affect heuristic changes how we view any situation. Hypertension experts like the IDEA that lowering blood pressure to "normal" should help all patients. Thus, they will overestimate the value, and undervalue any dissenting data.

In general, the medical community labels too many people with "disease." We use too many drugs, and all drugs have side effects.

I hope we see more exploration of this issue. Bravo to the authors for having the courage to fight the establishment.

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--'Chemo-brain' exists after recovery from breast cancer

Small cognitive deficits exist in verbal ability and visual-spatial abilities in breast cancer patients who received chemotherapy, a meta-analysis found.

Seventeen studies on 807 patients previously treated with standard-dose chemotherapy for breast cancer were reviewed to seek out associations in attention, executive functioning, information processing, motor speed, verbal ability, verbal memory, visual memory, and visual-spatial ability.

Results appeared in the Journal of Clinical Oncology.

Researchers noted deficits in cognitive functioning compared to control patients or prechemotherapy baseline verbal ability (g=−0.19; P less than .01) and visual-spatial ability (g=−0.27; P less than 0.01).

This information can be used to inform interventions to educate patients with breast cancer regarding the long-term impact of chemotherapy on cognitive functioning, authors noted. Patients should be referred to a neuropsychologist for evaluation and management, one of the study authors noted in a press release. Developing an awareness of the situations in which cognitive impairment plays a role help patients compensate, and "can make a big difference in daily life when cognitive difficulties do arise."

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Wednesday, September 19, 2012

What's the beef with unneeded antibiotics in livestock?

I've already written about the overuse of antibiotics in this country. This overutilization costs money and causes medical complications. It also is believed to be the cause of a new generation of superbugs, that can attack us with impunity as we may have no effective antibiotic to defend ourselves with.

As an aside, I remember when I first learned the meaning of the word impunity. Here's the opening paragraph from the short story written by a nineteenth century master.

The thousand injuries of Fortunato I had borne as I best could, but when he ventured upon insult, I vowed revenge. You, who so well know the nature of my soul, will not suppose, however, that I gave utterance to a threat. At length I would be avenged; this was a point definitively settled -- but the very definitiveness with which it was resolved precluded the idea of risk. I must not only punish, but punish with impunity.

Without resorting to Google, can any readers name the work and the author?

Digression over. Antibiotic overutilization is not just an issue that affects man; it affects beasts also. Farmers have been prescribing antibiotics to fowl and cattle for years to make their animals heartier. This issue falls under the jurisdiction of the Food and Drug Administration, who have imposed restrictions on antibiotic use in livestock over the years. There is tension between those who feel that antibiotic should be banned and those who favor a more permissive policy.

Surprisingly, more antibiotics are prescribed to animals than to humans in this country.

Farmers and veterinarians feel they should be free to prescribe antibiotics to keep their animals in good health. Antagonists claim that antibiotics should not be allowed simply to prevent infections that result from unsanitary conditions. Moreover, there is a widespread view that overutilization of antibiotics in cattle creates superbugs that can threaten humans. Farmers counter that these fears are hyped.

These are real issues that need real science to separate facts from politically correct arguments:
(1) It's true that antibiotic use in cattle and livestock have increased.
(2) It's true that superbugs are on the rise.
(3) This does not mean that (1) has caused (2).

The FDA has tightened the rule requiring now that farmers will need veterinarians' prescriptions for antibiotics, a requirement that is expected to substantially decrease their use.

I'm inclined to agree that both animals and humans receive more antibiotics than they need. But, I wouldn't want to create new mandates based on a hunch or even a logical belief. Before we adopt policies that affect industries, livelihoods and jobs, let's ask "Where's the beef?"

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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Overuse from flu to you

Antibiotic overuse is a big problem: it contributes to antibiotic resistance, changes the distribution of beneficial bacteria within our bodies, and, more generally, is an example of a wider problem, treatment that doesn't work which many people continue to expect anyway and thus ends up prescribed on a wide scale.

Some common circumstances in which antibiotics are given when they shouldn't be include upper respiratory infections. A fascinating piece of research in the latest issue of the Annals of Internal Medicine addresses a question relevant to those infections and antibiotic overuse: Does the context of a patient's illness, that is, the other illnesses that the doctor might have seen around the same time, affect the likelihood of prescribing antibiotics for febrile illness? The answer is a qualified yes: that is, as the number of cases of febrile illness that a doctor had seen during the previous week increased, their likelihood of prescribing antibiotics for the case seen decreased. In other words: if the doctor was exposed to more cases of what were likely flu, or flu-like, they were less likely to give antibiotics.

As interesting as the article itself was the accompanying editorial, which talked about the multiple factors contributing to antibiotic overuse. Sometimes patients want them even when the doctor thinks they don't work; sometimes the doctor thinks they would work when they wouldn't; and sometimes the doctor isn't sure what the true diagnosis is, and prescribes the antibiotic just in case the illness is bacterial.

The last paragraph of the editorial hits the nail on the head: How exactly [does] knowledge about the [flu] pandemic enter into interactions between patients and clinicians? This is a relevant question because antibiotic prescriptions for respiratory illnesses are usually the result of a verbal negotiation between a patient (or parent) and clinician, during which different perceptions of the illness and appropriate course of treatment may be at play. ... On-the-ground observations not only produce ... nuanced explanations of clinical priorities and practices, they can also disentangle the complex interplay of tacit knowledge, social norms, economic pressures, and broader cultural trends--all of which shape patients' perceptions, clinical reasoning, and prescribing decisions.

Even more relevant: antibiotic overuse is just one kind of overuse. As we become more attuned to the general problem of overuse of multiple diagnostic tests and therapeutic modalities, we should try to understand the culture of overuse underlying all of it.

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. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.

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QD: News Every Day--Projections cite half the population of 39 states could be obese in 20 years

The vast majority of America will be overweight or obese by 2030, according to projections, with 39 states having half of their population in this category, reports two public health organizations.

Following up on the release of current obesity levels in August, the news comes from "F as in Fat: How Obesity Threatens America's Future 2012," by Trust for America's Health and the Robert Wood Johnson Foundation.

"This study shows us two futures for America's health," said Risa Lavizzo-Mourey, MD, MACP, the foundation's president and CEO. "At every level of government, we must pursue policies that preserve health, prevent disease and reduce health care costs. Nothing less is acceptable."

The analysis is based on a peer-reviewed model published last year in The Lancet. Findings include:

If obesity rates continue on their current trajectories, by 2030, 13 states could have adult obesity rates above 60 percent, with Mississippi having an obesity rate of 66.7%. Another 39 states could have rates above 50%. All 50 states could have rates above 44%, including Colorado, which topped 20% obesity prevalence for the first time in this year's results.

This could trigger a 10-fold increase in type 2 diabetes, coronary heart disease and stroke, and hypertension and arthritis between 2010 and 2020, only to double again by 2030.

That's more than 6 million cases of diabetes, 5 million cases of coronary heart disease and stroke, and more than 400,000 cases of cancer in the next 20 years.

Medical costs associated with treating preventable obesity-related diseases are estimated to increase by $48 billion to $66 billion per year in the United States by 2030, not counting the loss in economic productivity.

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Tuesday, September 18, 2012

Why cancer research requires constant vigilance

One of my favorite writers on medical subjects is fellow ASCO colleague George W. Sledge, Jr., MD. I make it a point to read his essays in Oncology Times as they are always informative and well written. One that caught my eye appeared on May 25, 2012 entitled "Fraud, Poor Ingredients, and Shortcuts in Cancer Research." Also in that issue is an article by Wendy S. Harpham, MD, called "Scientific Fiasco." Whoa!! Worth a second look.

The three examples of fraud cited by Dr. Sledge all involved deliberate falsification of data and elaborate attempts to cover up deceit. In fact, they could have been the basis for episodes of "Law and Order."

Tthese examples all occurred at respected academic institutions: the University of Montreal in Canada, the University of Witwatersrand in Johannesburg, South Africa, and Duke University in North Carolina. The most severe consequences to patients occurred in the South African example. A toxic and sometimes lethal treatment (high dose chemotherapy + bone marrow or stem cell infusion) was given to women with breast cancer who should have received less toxic standard chemotherapy. The toll in injuries and deaths that resulted was enormous.

The other two cases also impacted highly respected research institutions: the National Surgical Adjuvant Breast Project or NSABP was closed down for two years pending audit of all their trials, and Duke had to repay all grant money given to the researcher and suffered severe damage to its reputation. Sad, but fraud and greed are an international phenomena, even in the field of cancer research.

As Dr. Sledge states: "My major concern with fraud is how long it takes us to catch on."

How can we prevent these atrocities from occurring? One would think that our peer-review process would be a good place to start. But as Dario Maestripieri explains in his work, Games Primates Play, as cited in Dr. Harpham's article, academic politics get in the way. Because of the need to "publish or perish," some reviewers will review anonymously in order to trash the competition to give themselves an inside track. Obviously, when there is transparency and all reviewers are named, the review is less likely to be slanted and more likely to be honest and fair.

Even more insidious and dangerous is when researchers and others in the industry of cancer research take shortcuts. Basic sloppiness is responsible for the epidemic of retractions of published papers when initial reports cannot be validated in different labs or institutions. The system encourages "getting published first rather than getting the science right." This type of behavior is unfortunately common. Again, it is sad that this takes place in an area that is supposed to be concentrating on the health and safety of human beings.

The issue of faulty cell cultures and contamination of tissue samples, which I've written about in previous blogs, result in poor ingredients. An extensive article in Wired a few years back documents how antiquated our tissue storage techniques are, and that a high percentage of specimens are no longer suitable for research purposes when needed. The entire field of individualized or personalized oncology (indeed medicine in general) depends on viable tissue specimens that may require storage for long periods of time in tissue banks. A related issue is actual contamination of cell cultures by HeLa cells, highly malignant and rapidly growing cervical cancer cells. All this leads to inaccurate results and slows progress in the field.

The committee at each institution responsible for overseeing the conduct of clinical and laboratory research is the Investigational Review Board (IRB) or Committee (IRC). This is where the peer review process for research occurs. I have been Chairman of our IRC for the last 24 years. Clinical Research has become a complex industry, both scientifically and administratively, during this time period. As a result, our IRC's workload and responsibilities have increased dramatically. It's easy to see where items can "fall through the cracks." Since our charge is to protect the safety of research patients, eternal vigilance is mandatory.

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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The anatomy of a shortage

"If you think health care is expensive now, wait until you see what it costs when it's free."
--P.J. O'Rourke


I distinctly remember that in first grade I had an idea of breathtaking wisdom and profundity. Candy should be free. You may have had a similar thought at the same age. This idea was supported by an incontrovertible rationale, namely that I really liked candy.

Photo by vortistic via Flickr and a Creative Commons licenseTragically, it only took a moment for my parents to expose a flaw in my otherwise revolutionary scheme. They suggested that if candy were free, no one would bother making candy. All candy makers would do something else that allowed them to make a living. Thus exposed to the painful realities of life, I put the thought out of my head for about 40 years.

But now I realize that modern bureaucracy makes my vision more possible than ever. Candy makers obviously won't work for nothing, but they could be paid to give away candy by a national program (Candycare or maybe the Affordable Candy Act). Employees through their work could contract with third party payers (like Blue Candy) to pay for their candy needs. Thus candy would still be free to the consumer and no first grader would ever have to be denied his gummy bears.

Complications may still arise in this ingenious scheme. Prices, after all, play a critical role in marketplaces. They reflect the resources consumed and risks taken in producing a product. They force consumers to make important decisions about what they need and what they can do without. And they encourage conservation. The only reason we don't all buy the most expensive product in any class of products (cars, houses, shoes, whatever) is because we'd rather do something else with the money we save. Prices also give producers a powerful incentive to improve quantity and keep prices low, that is they cause competition between producers.

In the absence of prices, all these details become corrupted in our otherwise idyllic candy utopia. Customers would demand more candy than they ever ate before. They may simply eat more candy, but much would just go to waste. If it's free, no one will stop to think about whether they really want another Snickers bar. Attention to quality would also decline for two reasons. Consumers would not be able to pay more for better candy, so they would have to be satisfied with whatever they got. And candy makers would no longer have to compete since they would suddenly have all the business they could handle.

There would be a dramatic imbalance between supply and the very high demand. Economists call this imbalance a shortage. Long lines would form at candy stores and supplies would not last until the end of the day. Lots of people who previously were content paying for their candy would now not be able to get any. And though the costs to the consumer would be zero, the cost to society would keep escalating as candy makers would consume ever more resources trying to meet a bottomless demand. In a few years candy would become both mediocre and, for society, disastrously expensive.

Sounds familiar?

Health care in general, and especially primary care, is operating in exactly such a system. I've been writing for years (see links below) about the shortage of primary care doctors that will happen as the baby boom ages. But with the implementation of the Affordable Care Act (ACA) looming in 2014 the shortage promises to worsen dramatically and is receiving some media attention.

An opinion piece in the Wall Street Journal warns that 30 million people will acquire health plans starting in 2014. The article predicts "the result will be gridlock." Waits for care will lengthen, and many practices will close to new patients. The author predicts that concierge medicine will grow rapidly as patients flock to doctors who promise them attention and access. I urge you to read the very sobering article.

A recent Medical Economics article asks how an influx of 30 million patients will impact primary care. New physicians certainly will not be trained in time. The article suggests various bureaucratic solutions and states "nurse practitioners know they are about to be elevated in the national health care dialogue." This is jargon for "patients should not expect to see a doctor." The article warns that in Massachusetts, a leader in experimenting with universal health insurance, only half of primary care practices are accepting new patients.

Finally, The Doctor's Company, a medical malpractice insurance company recently released a survey of 5,000 physicians to measure doctors' opinions and thoughts about the coming ACA implementation. 60% of respondents thought that the increased patient volume will hurt the level of care they can provide. 43% said they are thinking about retiring in the next five years. And nine out of 10 said they would discourage friends and family members from pursuing a career in medicine.

Sooner or later we will be forced to rediscover the credo that there's no such thing as a free lunch. Shifting costs from one person to another doesn't lower costs. A central plan to make something affordable always makes it unaffordable.

Until then, patients should find a primary care doctor who they really like. They should do so right now. And they should ask frankly how he or she plans to handle the coming wave of newly-insured patients. And now that I'm thinking of it, they should buy him some candy.

Learn more:
John C. Goodman: Why the Doctor Can't See You (Wall Street Journal opinion)
Affordable Care Act brings influx of patients (Medical Economics)
Nine Out of 10 Physicians Unwilling to Recommend Health Care As a Profession, Exacerbating Anticipated Physician Shortage (The Doctors Company press release)

My previous posts on the primary care shortage and the economics of healthcare:
Rescuing Primary Care
More Match Day Misery
Rational Rationing
Torpedoing Primary Care
The Healthcare Meltdown
On Being Doc and Being Happy
Will Primary Care Survive?



Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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QD: News Every Day--When studies overstate benefits, news reports pass the spin along

When abstracts from studies overstate benefits, the effect gets passed along by press releases and news reports, a study found.

Researchers went looking for "spin," which they defined intentional or unintentional reporting from studies that emphasized the beneficial effect of the experimental treatment. They searched for all press releases indexed in the EurekAlert! database between December 2009 and March 2010, finding 70 releases from two-arm, parallel-group randomized controlled trials that were linked both to the original study and to related news items that appeared at the same time.

Results appeared Sept. 11 in PLoS Medicine.

Researchers identified spin in 28 (40%) scientific article abstract conclusions and in 33 (47%) press releases. Mainly, the spin consisted of no mention of nonstatistically significant outcomes (20%); interpreting "P greater than 0.05" as demonstrating equivalence (7%); inappropriate extrapolation (9%); focus on statistically significant results such as subgroup analyses (6%), within-group comparisons (9%) and secondary outcomes (4%); or inadequate claim of safety (6%).

About half of the press releases (33; 47%) had at least one type of spin. The only factor associated with spin in the press release was spin in the article abstract conclusion (relative risk [RR] 5.6; 95% confidence interval [CI], 2.8 to 11.1; P less than 0.001).

News items were identified for 41 trials, for which 21 (51%) were reported with the same spin found in the press release and study abstract conclusion. Findings were overestimated for 10 (24%) news reports.

"Of course, press releases are not meant to be condensed versions of scientific papers; they are meant to summarize the most important findings, contextualize these finding for journalists, and provide contact details for authors and quotes," the researchers wrote. "By being condensed, they always lack details that are contained in the papers. The use of 'spin' or a particular emphasis could be a way to increase the interest of journalists and subsequent citations in the peer-reviewed literature."

This becomes a problem when it changes how readers interpret research findings, they continued. "These findings raise the issue of the quality of the peer review process and highlight the importance of this process for disseminating accurate research results."

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Contact ACP Internist

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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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