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Friday, December 27, 2013

Admission diagnosis of CAP has a high probability of error

Our residents know that I get excited when they present a patient with a presumed diagnosis of community acquired pneumonia (CAP). First, that is not a diagnosis, but rather a syndrome. Second, in my experience, these patients often have another diagnosis, and represent great diagnostic challenges. My talk on learning how to think like a clinician features at least 3 presentations that started as CAP.

On rounds I often explain why I question the diagnosis. I have developed and learned my own illness script for accepting the presumed diagnosis.

This weekend, as I was thinking about this topic, I remembered this article that I quoted in 2008. Antibiotic Timing and Errors in Diagnosing Pneumonia (article free on the website)

Precise criteria for the diagnosis of pneumonia are not available and had to be developed. We based our criteria on those found in Food and Drug Administration–directed clinical trials. Pneumonia was considered present when the medical record docu- mented the presence of all 3 of the following criteria: (1) the presence of a new or increasing infiltrate by chest radiograph or computed tomographic scan; (2) plus a temperature greater than 38.0°C or less than 35.1°C or a total white blood cell count greater than 109/µL or less than 4.5/μL , or immature polymorphonuclear leukocytes (bands) greater than 15%; and (3) plus 2 of cough, dyspnea, pleuritic chest pain, tachypnea with respirations of 30/min or greater, hypoxia with pulse oximetry of less than 90% or PaO2 of less than 60 mm Hg, auscultatory findings of pneumonia, including rales, dullness of percussion, bronchial breath sounds, or egophony, or newly required mechanical ventilation by either intubation or noninvasive ventilation.

So now I have a clearly defined illness script. Although I would add a relatively short time frame of illness.

Misdiagnosis occurred in large numbers of patients.

A total of 548 patients diagnosed as having CAP were studied (255 in group 1 and 293 in group 2). At admission, group 2 patients were 39.0% less likely to meet predefined diagnostic criteria for CAP than were group 1 patients (odds ratio, 0.61; 95% confidence interval, 0.42-0.86) (P = .004). At discharge, there was agreement between the ED physician’s diagnosis and the predefined criteria for CAP in 62.0% of group 1 and 53.9% of group 2 patients (P = .06) and between the ED physician’s admitting diagnosis and that of the discharging physician in 74.5% of group 1 and 66.9% of group 2 patients (P = .05). The mean (SD) TFAD was similar in group 1 (167.0 [118.6] minutes) and group 2 (157.8 [96.3] minutes).

On rounds, CAP gives us a chance to teach the diagnostic process. CAP is not a diagnosis, but rather a suggestion. We should never accept the diagnosis until we carefully consider whether the illness script meets the problem representation. We must remain skeptical about this (and many other) diagnoses.

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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Admission diagnosis of CAP has a high probability of error

Our residents know that I get excited when they present a patient with a presumed diagnosis of community acquired pneumonia (CAP). First, that is not a diagnosis, but rather a syndrome. Second, in my experience, these patients often have another diagnosis, and represent great diagnostic challenges. My talk on learning how to think like a clinician features at least 3 presentations that started as CAP.

On rounds I often explain why I question the diagnosis. I have developed and learned my own illness script for accepting the presumed diagnosis.

This weekend, as I was thinking about this topic, I remembered this article that I quoted in 2008. Antibiotic Timing and Errors in Diagnosing Pneumonia (article free on the website)

Precise criteria for the diagnosis of pneumonia are not available and had to be developed. We based our criteria on those found in Food and Drug Administration–directed clinical trials. Pneumonia was considered present when the medical record docu- mented the presence of all 3 of the following criteria: (1) the presence of a new or increasing infiltrate by chest radiograph or computed tomographic scan; (2) plus a temperature greater than 38.0°C or less than 35.1°C or a total white blood cell count greater than 109/µL or less than 4.5/μL , or immature polymorphonuclear leukocytes (bands) greater than 15%; and (3) plus 2 of cough, dyspnea, pleuritic chest pain, tachypnea with respirations of 30/min or greater, hypoxia with pulse oximetry of less than 90% or PaO2 of less than 60 mm Hg, auscultatory findings of pneumonia, including rales, dullness of percussion, bronchial breath sounds, or egophony, or newly required mechanical ventilation by either intubation or noninvasive ventilation.

So now I have a clearly defined illness script. Although I would add a relatively short time frame of illness.

Misdiagnosis occurred in large numbers of patients.

A total of 548 patients diagnosed as having CAP were studied (255 in group 1 and 293 in group 2). At admission, group 2 patients were 39.0% less likely to meet predefined diagnostic criteria for CAP than were group 1 patients (odds ratio, 0.61; 95% confidence interval, 0.42-0.86) (P = .004). At discharge, there was agreement between the ED physician’s diagnosis and the predefined criteria for CAP in 62.0% of group 1 and 53.9% of group 2 patients (P = .06) and between the ED physician’s admitting diagnosis and that of the discharging physician in 74.5% of group 1 and 66.9% of group 2 patients (P = .05). The mean (SD) TFAD was similar in group 1 (167.0 [118.6] minutes) and group 2 (157.8 [96.3] minutes).

On rounds, CAP gives us a chance to teach the diagnostic process. CAP is not a diagnosis, but rather a suggestion. We should never accept the diagnosis until we carefully consider whether the illness script meets the problem representation. We must remain skeptical about this (and many other) diagnoses.

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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Polio outbreak in Syria

If you remember the 1950s you probably remember the terror of polio. Polio, short for poliomyelitis, is a disease caused by a virus which can cause severe inflammation of the spinal cord. Though most infected people have no symptoms, a small fraction of patients are left with permanent paralysis and deformities. The disease is sometimes fatal. In the U.S., the 1952 polio epidemic killed over 3,000 people and left over 20,000 with some paralysis.

The isolation of the polio virus and the development of effective vaccines still stand among the greatest achievements in public health. After widespread use of the polio vaccines the number of cases in the U.S. dropped precipitously. Polio was eliminated from the U.S. in 1979, from the Western Hemisphere in 1994, and from Europe in 2002.

In the last month polio has resurfaced in a country that is in no position to manage an outbreak, Syria. This is the first polio outbreak in Syria since 1999. Ten cases have been confirmed and 12 others are suspected. At least 10 children have become paralyzed. Prior to the war vaccination rates were quite high, but in the last 2.5 years the civil war has collapsed the nation’s public health system. The war has also displaced more than 9 million people, placing populations in camps with poor sanitation and widespread malnutrition—perfect breeding grounds for communicable diseases. The World Health Organization is scrambling to vaccinate over 1 million children in Syria and 6 neighboring countries. Obviously such a massive immunization campaign will be extremely challenging during a war.

Infectious disease experts warn that the infection could spread to Europe as refugees leave the Middle East. Because most cases are asymptomatic, there is a concern that the infection could spread very widely through a population before it is detected.

The medical lesson of this tragedy is about herd immunity. Since no vaccine is perfectly effective, and since no community (or “herd”) has every individual vaccinated, there are always a small number of people in any “herd” who are not immune. They stay healthy because the vast number of people that they come into contact with are immune and can’t infect them. So they are protected by the rest of the herd. But as vaccination rates fall, the number of vulnerable individuals increases past a critical threshold at which the likelihood of an infected person spreading the illness to another vulnerable individual is high. At that point the infection can spread throughout the vulnerable members like fire through brush that has just become dry enough to combust.

Children who are denied vaccination because of war deserve our sympathy. But parents in the U.S. who refuse to vaccinate their children because of misguided beliefs deserve our reproach. They do not just jeopardize the health of their children; they weaken herd immunity. Though what is happening in Syria is difficult to imagine in the U.S., it’s easy to imagine an earthquake or large storm temporarily disrupting sewage and water systems and moving large numbers of people into crowded shelters. In such a scenario unvaccinated people would be like dry kindling waiting for a spark.

Learn more:
W.H.O., Fighting Polio in Syria, Says More Children Need Vaccinations (New York Times)
U.N. Confirms Polio Outbreak in Syria (Wall Street Journal)
A Conquered Foe Returns To War-Torn Syria: Polio (NPR)
Syrian polio outbreak could spread to Europe, experts warn (NBC News)

My post a year ago about malaria’s resurgence in Greece: Revenge of the Parasites

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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Thursday, December 26, 2013

Gaia and snake oil

My older brother is also a doctor, but not a primary care provider like me. He’s a specialist: a limnologist. If you have problems with blue-green algae in your lake, he’s the man to see. Limnology is the study of lakes, and fittingly, Bill works in the “Land of a Thousand Lakes” as a professor in fresh-water ecology.

I’m not sure he’s thinking of switching over to direct-care limnology. I’ve been afraid to bring it up.

We do have a lot in common in our professions, as we both see a mindless assault on the things we are trying to save (patients for me, lakes for Bill). My frustration with our health care system is matched by his anger toward those who deny global warming and the harm humans are causing on our world. Just as he can get my blood pressure up by asking if his child will get autism from the immunizations, I simply have to suggest this week’s cold weather as proof against global warming to raise his systolic pressure.

So it was notable when I heard a rant against an unexpected target: “You know the Gaia hypothesis?” he asked. ”They think the world is a ‘living organism’ that works toward a ‘balance’ to maintain life. They believe that humans act against nature, and so are responsible for everything that’s wrong with ‘mother earth.’”

“It’s total bullshit,” he went on to explain, not waiting to hear if I knew what he was talking about. ”Do you know that when trees appeared on the earth, they caused a mass extinction (called the Permian Extinction)! Trees! There’s no mystical ‘balance of nature;’ it’s always in a constant state of flux, of imbalance.”

Let me make this clear: Bill is not saying that it’s OK that we are harming the earth, nor is he trying to absolve us of our responsibility for what we are doing. His beef was with the notion that there is some kind of “balance” of nature, when the evidence clearly points to the contrary. The result of this belief is that that there is somehow an imputed moral goodness from this “balance” (resulting in the idea of “mother earth”), and a subsequent implied immorality to any assault on our mother’s sacred “balance.”

This has come to mind as I have had significant changes to my thinking about giving good care my patients, especially as it applies to the area of “wellness.” Since leaving my old practice, which was immersed in a world of ICD (problem) codes and CPT (procedure) codes, I have shifted my thinking away from a medical world where every problem demands a solution. I have moved my thinking away from reacting to everything that is going on at the moment, and toward the bigger picture. I am focusing less on problems and more on risk. I am focusing less on solutions, and more on responsibility.

American medicine is obsessed with identifying problems and then finding solutions so we can cross those problems off of the list. We are obsessed with cures. We seem to think that anything that departs from “normal” should drive us to push it back toward “normal.” If “wellness” is the natural state of things, then health is good; sickness ends up being a wrong that needs to be righted.

But this is not necessarily the case. For example, if someone gets an upper respiratory virus, we often/usually consider this a “problem” which requires fixing. The idiom: “finding a cure for the common cold” reveals this underlying belief. To “fix” this problem, people take vitamin C, zinc, or “drink plenty of fluids” (if they are from the “avoid medicine” camp), or they take decongestants, antihistamines, or visit their doctor looking to get an antibiotic to “keep this from turning into sinusitis/bronchitis/pneumonia/etc.” The reality is, however, that simply by allowing their T-cells to do their job, they will get better 99.9% of the time without any intervention. In fact, it is reasonable to suggest that this may even be the equivalent of exercise for their immune system. Studies suggest that infants in daycare who are exposed to the germ cesspool that is a daycare center are actually less likely to get sick when they are older than children who are kept at home. It may actually be good when people get sick.

The idea of a “balance” to be disturbed flies in the face of the reality easily seen in this world: few people get through the year without getting sick, and none ultimately avoid getting some terminal condition. In short, fighting sickness is always a losing game.

I am not suggesting that we shouldn’t treat illness; I am simply suggesting that the “every problem deserves a solution” put forth by society, modern medicine, and (especially) our payment system is, to use my brother’s words, total bullshit.

Why get so bent up about this? It does, after all, give me job security, right? There are several bad outcomes when we approach health and wellness in the “Gaia” approach:
• We tend to look for blame when there are problems. What did I do to get sick? What could I have done differently? Was I not eating properly? Did I not get enough sleep? People are constantly looking for things they did wrong when they get sick, when the real cause is that they are simply humans.
• We look for problems to justify our solutions. Why check cholesterol in low-risk people in their 30’s? Why do a “routine blood panel” on people every year? To identify problems requiring intervention. This, despite the fact that these tests (and their matching interventions) don’t prolong life or improve quality of life. In reality, there’s no good clinical motivation to do a lot of what we routinely do, but there is a huge economic motivation to do it.
• The system becomes obsessed with definitions. Is obesity a disease? There has been a recent dispute over whether or not it is classified as such. Why bother? Because disease gets a diagnosis code (for which you can bill) and allows for justification of procedures to “fix” the problems (bariatric surgery, medications, etc). What about Attention deficit disorder? Is it a “problem” (disease) or is it simply an immature kid or absent-minded adult? These types of debates will on ly increase as long as we keep the disease/cure mindset.
• We look for solutions to things that aren’t actually problems. What is a “bulging disc” on an MRI? Normal, it turns out. What is “bronchitis?” A loose cough. But the most common use of the term “bronchitis?” A justification for antibiotics.
• We look for “magic” solutions to problems, and we as health care providers feel pressure to give people “their money’s worth” when they come to the office. This leads to a whole lot of unnecessary tests, medications, procedures, and cost. Sick? Take a pill. Obese? Get surgery. Not feeling well? Get a bunch of lab tests done. Feeling anxious or down? Take another pill.
• Many of our interventions end up creating their own problems. ”Fishing” for abnormal lab tests is far more likely to lead to more lab tests and unnecessary worry than it is to help someone. Medications can have side effects, cause harm, and (in case you hadn’t noticed) cost a lot of money.
• People are much more prone to snake-oil salesmen. Whether that snake oil comes from a pharmaceutical company (Adipex for weight loss, treatment of “low T” for men getting older), neighborly advice (“drink this juice which is loaded with anti-oxidants”), or a true huckster (“bathe your feet in this water and when the water turns color the ‘toxins’ are removed from your body”), our drive to fix every problem leads us to throw our faith and money at anyone who can solve our problems.
• Many patients avoid getting care because they have bought into society’s practice of pointing a finger of blame for every problem, and so are ashamed of their blood pressure, diabetes, or their child’s asthma. Others are harmed by providers (both in my profession and outside of it) who promise “miracle” cures. Still others spend huge sums of money striving for the generally elusive (and always temporary) goal of “wellness.”

So what’s the alternative? We need an approach that accepts our human frailty and rejects the reflex toward fixing every problem.
1. Understand that sickness is inevitable, and stop blaming yourself (and others).
2. With any symptom, disease, or condition that comes along, first address the issue of risk. What is the risk? What is the worst thing that could happen? How likely is it?
3. When considering any intervention to reduce risk, be it medication, lab test, or procedure, first address the issue of risk. What does this do to lower the risk of the condition? What is the risk of this intervention? What is the likelihood that this could reduce risk, and what is the likelihood it will cause more harm? When in doubt, do nothing.
4. Once risk is determined, then address impact: what is the impact of this condition on the quality of life? What can be done to reduce the impact, and is doing so really necessary? You can treat a fever for the comfort if you want, but it doesn’t impact the ultimate outcome.
5. When considering an intervention for symptoms, first address the issue of risk. Since the treatment doesn’t reduce risk, any significant risk of treatment should be weighed carefully.
6. When a person is not having problems, consider risk. What are conditions that this person is at risk of developing? How serious is that problem? Is it heart disease? Diabetes? Gout? Chronic pain? Rectal itch? And how likely is it?
7. When considering an intervention to reduce risk in a healthy individual, first consider the risk of that intervention.

In reality, health care is not about achieving wellness in people; it is being responsible in our approach to people’s medical conditions and doing what we can to avoid them in the first place. When a person does develop a disease or experiences symptoms, good care is focused on understanding the person’s risk and taking only actions that give the best chance of giving them the best, longest life. It is irresponsible to expose people to more risk in our interventions. It is irresponsible to pay thousands of dollars for something that has marginal benefit. Just because insurance pays for the stent in the 40% heart lesion doesn’t mean it’s the responsible thing to do.

This should be medicine 101. Why is it that it seems so radical? That, I believe, is a huge problem.

Oh yes, if you need any help with your blue-green algae, I know a good doctor who can help you.

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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Health at an impasse: the case for getting past collusion

Collusion might reasonably be defined as meeting the enemy and discovering it is both them and us. In the case of health, personal well-being and public health alike, exactly this sort of thing is going on. It is way past time to take the way past these toxic impasses.

Let’s start with public health, and then get more personal. The leading public health problems of our time are obesity and related chronic diseases. This is well studied and thoroughly established. As bad as the current situation is, with chronic diseases imposing an enormous burden in both human and economic terms, things are projected to get far worse. Chronic diseases are proliferating around the globe, affecting ever more people here in the U.S. and taking hold at ever younger ages. We are losing an enormous number of years from our lives and an all but incalculable amount of life from our years.

What makes this truly tragic is that it is almost entirely preventable. We have known exactly what it takes to reduce the aggregate burden of chronic disease by fully 80% for literal decades. The relevant research is noteworthy for its power, clarity, consistency, and lack of controversy. Instead of staring down the barrel of a figurative gun at a future in which one in three of us is diabetic, we could readily be looking at a future in which 90% of all diabetes is eliminated outright. There are few forks in the road of life as flagrant as that.

But since we have known for decades that better use of our feet (physical activity), forks (dietary pattern), and fingers (not holding cigarettes) could transform public health, and have done relatively little with the information, at least with regard to diet and physical activity, we are squandering an incredible opportunity. We squander it by eating a diet in which nearly 50% of calories come from certifiable “junk,” and in which we talk about the benefits of exercise and then go on displacing every former use of our muscles with schedules that preclude them, and new technologies that do them for us.

We could blame it all on the food companies that make the junk food, and the technology companies that keep inventing more ways for us to be sedentary. But as noted, the enemy is both them and us.

What’s the collusion? We let their inventions become the mothers of our previously-unrecognized necessities. Nobody needed soft drinks before they were invented; thirsty people did just fine with water. But we sure seem to need them now, downing sugar measured in tonnage, an astronomical number of calories, and spending fortunes for the privilege of propagating our collective risk for obesity and diabetes. Rakes once seemed to suffice, but now a wayward leaf clearly demands the revving engine of a power blower. To say nothing of the need to play soccer on a screen using only our thumbs, while an actual soccer ball sits unused in the yard. You get the idea.

Nobody is making us stay on the couch or eat junk food, they are just selling stuff we keep buying.

Yes, it is true that junk food is willfully engineered to be addictive, but so are illicit drugs, and most of us choose not to use them in the first place. We have no fundamental obligation to call toaster pastries “breakfast,” French fries a snack, or to keep runnin’ on Dunkin. We do have choices.

When we complain that food companies should make better food, and they should, they counter that they make and sell what we buy and eat. It’s a bit of judo and a bit of theater on their part, but it is also one part true. If we only bought better food, they would stop making junk pretty quick. If we want to transform our food supply into one that makes loving food that loves us back the norm, we can’t just keep wagging a finger at Big, bad Food even as we stock up on their concoctions. We need to share a taste for change, by showing we actually prefer to buy products that are good for us. A process of taste bud “rehab” is readily available to us all to set just a cascade in motion.

As for personal health, the story is much the same. An 80% reduction in the collective burden of chronic disease means that you, and I, have the means available to slash our personal risk of all major chronic disease, heart disease, cancer, stroke, diabetes, dementia, by that same 80%. It means that if knowledge were power, if we used what we have long known, there are fully eight chances in 10 that our loved ones who have been diagnosed with any of the above, would not be. This is not about some remote, anonymous public. This is up close and very personal. It’s all about us and the people we love.

But here, too, we tend to squander the opportunity. While knowing just what it takes to lose weight and find health, to add years to life and life to years, we turn again and again to lose-weight-fast diets and variations on the theme of false promises and magical thinking.

Here, we could blame the fad diet authors, hucksters, and other malefactors of the military-industrial establishment. But again, the enemy is both them and us.

What’s the collusion? We could, any time we like, concede that quick fix diets cannot be a solution to the lifelong challenge of weight control. We could acknowledge that going on diets that leave our children behind in an age of epidemic childhood obesity is not only fraught with the likelihood of failure but is fundamentally irresponsible. Apparently, we are saying to our children: Grow up and get fat, then you, too, can try to sort it out for yourselves. As long as we keep buying lotions, potions, and fad diets, the individuals and industries involved will all too happily keep selling them.

What, then, is the way past the impasse? Pretty straightforward, actually:

1) Apply common sense more commonly
Reasonable, responsible people apply common sense to everything that matters, money and mortgages; education and careers; pet care and vacation planning. And yet, we turn it off and go into some kind of “trance of gullibility” when promises about weight loss and health promotion come along. We could stop, and apply common sense more commonly to health, which certainly belongs on the short list of priorities we all respect and take seriously.

2) Get real
We know that get-rich-quick schemes tend to be the stuff of sit-coms, not serious people. Serious people know that worthwhile things generally take time and some actual effort. We need to approach losing weight and finding health in the real world, not fantasyland.

3) Get empowered to be responsible
The Spiderman movies famously served up the adage, “With great power comes great responsibility.” That implies a corollary we all too often ignore: Before we can take responsibility, we must be empowered. There is an empowering set of skills for getting to health in spite of it all that successful experts apply to themselves. Such skills can be acquired, and applied, by anyone willing to make the effort. Only those who were empowered with the skill of literacy can take responsibility for all the reading and writing we need to do throughout our lives; there can be no such responsibility in the absence of ability. There is health literacy, too. There is a skill set for getting to health. We can go and get it.

4) See the forest through the trees
We do not have epidemic obesity and chronic disease because of any one food, nutrient, ingredient, chemical, or device. We live in a perfect storm of obesigenic factors. Similarly, no active ingredient or silver bullet will fix everything. We are unlikely to get out of the woods until we see the relevant forest through the trees.

5) Take one step
The journey of a thousand miles famously begins with one step. The journey to health in most cases is substantially shorter than that but also begins with one step. Learn and apply a skill to sleep better, or manage stress, and you may find you have the energy to be more active. Be more active by applying skills to fit fitness in, and you may find you sleep better, or feel less stressed. Improve your stress, sleep, and activity level, and you may suddenly find yourself prepared to start improving your diet. Do that, and you may find you feel better and want to get a bit more exercise. Rather than giving up foods you love, you could learn how to trade up foods you love to better choices in the same category, better chips, for instance, so that you keep loving the food, but the food starts loving you back. In the process, you could rehabilitate your taste buds so one choice at a time, you actually come to prefer foods that are better for you. We readily get caught up in a pattern where each thing that conspires against our health, lack of sleep, excess stress, weight gain, poor eating, lack of exercise, compounds the next, until the degenerating spiral takes our quality of life right down the drain. This process can be reverse engineered one step a time, so we are climbing a spiral staircase up to the health and vitality we want, and deserve.

That’s it.

We could, I suppose, just go with the status quo. We could all undergo more operations and take more drugs, like the statins we heard this week millions more of us need. We could let our kids get fatter and sicker at younger ages than we, and let them undergo ever more surgery and take more drugs, too. We could do that, at huge cost in both dollar and human terms.

But why would we? Lifestyle is more powerful medicine than anything ever developed by a pharmaceutical company, accessible to us all, stunningly free of side effects, safe enough for children and octogenarians alike, under our control, suitable for everyone every day, and requires no prescription. It is also the means to a truly luminous prize: a better life. That’s what health is for, it makes living better. We could add years to life, and life to years, not only for ourselves, but for those we love as well. We could give this gift to our children and grandchildren.

It may seem as if what stops our progress to health is unfixable. Just the opposite is true. If we initiate the right process, take one step on the way past the impasses, then what would fix health could very well be unstoppable.

Shall we get started?

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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Monday, December 23, 2013

Should doctors apologize to patients?

I had thought that apologizing was a straightforward act, but I now realize that it is a nuanced art form. We’ve all heard the “mistakes were made” version, usually issued by politicians who attempt to insert a layer of passive voice insulation between themselves and their screw ups. There is also the ever present conditional apology which by definition falls short of complete responsibility acceptance. The template here is: “I’m sorry for my oversight which wouldn’t have happened if …”

There have been several apologies in the news recently. First, President Obama offered a faux mea culpa with regard to his indisputable and repeated “misrepresentations” on his broken promise that we could all keep our own doctors and health insurance plans. Here’s what he said on Nov. 7th: “I am sorry that they are finding themselves in this situation based on assurance they got from me.”

Finding themselves? Really? I grade this as beyond lame on the apology scale.

CBS’s flagship and enduring news magazine 60 Minutes apologized for using a source on a Benghazi piece who was a liar. “We were wrong to put him on the air,” said Lara Logan a few days prior to airing a formal apology. The latter included: “It was a mistake to include him in our report. For that, we are very sorry.” While some have criticized this apology as inadequate, I am more lenient here. They admitted they screwed up, apologized and didn’t blame anyone for their mess up. Sure, they could have fallen harder on their sword or fired a few folks, but I think they crossed the minimum standard for contrition and acceptance of responsibility.

Recently, a newspaper issued a retraction for comments published 150 years ago. The Patriot-News, a Pennsylvania newspaper earlier this month issued a retraction for referring to Lincoln’s Gettysburg Address as “silly remarks.” Their recent editorial included the statement: “The Patriot-News regrets the error.” I congratulate them on reaching this belated, enlightened position. They certainly cannot be accused of a rush to judgment. Let’s look for other retractions from them for other errant opinions they published in the 19th century.

Martin Bashir issued 2-minute on air apology on MSNBC for a diatribe against Sarah Palin that shattered the network’s already low threshold for decency and fairness. While the apology seemed genuine, most of us would have lost our jobs for similar behavior.

What should doctors do when we make a mistake? Of course, from a moral perspective, there is no controversy . We should do what we expect others to do. When we err, we should admit it and apologize for it. Of course, some errors are trivial and do not require us to march into the confessional. If a patient receives liquid diet when a soft diet was ordered, the world will continue to spin. No foul here. But substantive errors must be disclosed.

The dilemma for physicians is fear that admission of error, which is morally required, may be used as a cudgel if the physician is sued for medical malpractice, which is an unfair arena. Personally, I believe that this concern that apologizing will increase legal risk is exaggerated and that a genuinely contrite physician may reduce legal vulnerability by explaining candidly what went wrong. It should be self-evident that an adverse event or a mistake is not tantamount to medical negligence, but so many misunderstand this. Nevertheless, physicians should choose their words carefully when disclosing medical errors to patients and their families.

Many states have physician apology laws that state that expressions of regret are not admissible in medical malpractice trials. These laws are narrowly crafted. If the physician’s statement goes beyond expressions of regret and empathy, it is admissible.

Inadmissible: “I’m very sorry that this complication occurred and that a second surgery will be necessary.”

Very Admissible: I’m sorry that I nicked the spleen and I had to remove it.”

So, how was this post? Verbose? Self-serving? Tedious? Factual errors? Arrogant? If so, don’t blame me. Sometimes, mistakes are made.

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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Why do we neglect food and sleep in the hospital?

Being a doctor, the main part of our job description is to listen to complaints. Patients come to us with their problems, and we utilize our skills to get to a diagnosis and cure. It’s what we learned in medical school. Most of these complaints, as we may expect, fall under the category of symptomatic ailments. Pains, discomfort, disabling symptoms—hearing about them and fixing them is what we do.

The reality of frontline medical practice, however, is that not all the problems patients tell us about fall under the category of symptomatic problems. In my job as a hospital medicine physician, many of the complaints I hear have little to do with the patient’s actual illness, and more to do with how they are treated when they get admitted to hospital! This may sound unbelievable to anyone who hasn’t experienced the typical hospital, but it’s very true. In fact, I’m amazed by the fact that patients, often afflicted with some of the most terrible physical illnesses (unfortunately causing a lot of suffering) will feel the need to focus on these other aspects of their hospital stay.

It’s a bad reflection on health care. I’m sure my experiences are not unique, but I’d say that the biggest complaints I hear are ironically related to two of the most basic things we need for our survival: sleep and food. To use a cliché: if I had a dollar for every time I’ve heard these two complaints.

Inadequate sleep will often be the first thing that a patient will remark about when I enter their room in the morning and ask them how they are. It will go something like this; “I hardly slept a wink because there was too much noise!” This could be for a number of reasons, but the most common will be; noisy neighboring patients, noisy staff, and the fact that they kept on being disturbed to have their vital signs measured (which may not always be needed in a stable patient).

With their food experience, I typically hear criticisms about the lack of food options and the blandness or tastelessness of the food. While I’m not suggesting that hospitals be gourmet restaurants, surely we should understand that at a time when someone is already sick, few things could be more important than good nutrition.

Let’s address sleep and food, then, in more detail.

Scientifically speaking, there’s much debate among scientists about why we actually sleep. We do know that a large amount of the body’s natural regeneration and healing processes occur during this time. Logic would therefore follow that getting a great rest is especially important when anyone is sick.

How can we go about giving our patients a better night’s sleep? The answer should be simple enough: we create a quieter and more restful hospital environment. I’ve heard of some new initiatives, such as using computers to record sound, but surely some basic common sense wouldn’t go amiss. Do we really need computers to record sound? We should all know what’s loud and what’s not! A little noise has to be expected, and certain situations cannot be helped—such as a sick patient requiring lots of attention or a new patient being rolled into a room late at night.

It isn’t possible to eliminate noise completely. But the current problem is that, bar a few scattered exceptions, we don’t even try significantly to improve the situation. Health care staff are also partly to blame. Many patients have complained to me about staff holding loud personal conversations at night, which really shouldn’t be happening. The last time you took a red-eye flight you may have noticed how quiet the cabin crew were when the lights went out. In hospitals, we have to be more careful, because noise tends to travel a long way down those spacious echoing hospital corridors. All health care staff, including doctors, should keep this in mind at night. We could also focus more on the design of hospital floors, with certain areas reserved for the less acute recovering patients, to make it easier for them to sleep.

Hospital food is the second major area of well-being that we tend to let slip. Let’s put a lot more thought into the meal choices, and while making them good for our health, also provide a variety of tasty options. At every opportunity, load the plate (diet permitting) with healthy vegetables, fruits and other nutrient-rich foods. There’s a huge opportunity here too, not just for healing, but for education. We could use healthier, tasty food choices as a teachable moment, also providing some brief educational materials to our patients on a card or pamphlet.

Or, how about food services staff getting involved? Perhaps it wouldn’t be a bad idea to collaborate more with these hard working folks, who do their good work under our noses every day, and barely get noticed. Many of them would greatly appreciate the feeling that they are playing a part in the patient’s care and recovery.

Of course not every hospital provides bad food, and everyone has their own individual tastes and preferences, but we don’t have to accept the universal joke about “hospital food being terrible.” I hardly ever hear anyone tell me that they liked their meal. The patients may be sick and not enjoying their food as much, but that’s all the more reason to make it better. Solving this problem will require a multidisciplinary approach. We need to form workgroups from a number of hospital departments; medical, nursing, food services, dietary, and administration. This would also be a great quality improvement initiative, and at teaching hospitals would be the ideal type of project for interns and residents to get involved in.

By focusing on food and sleep, hospitals will be exhibiting a much-needed “back to basics” approach. The problem with any complex organization is that we often lose focus of the little touches that really matter. We shouldn’t allow this to happen, because in reality it’s usually these so-called little things that are noticed the most. There’s also the matter of HCAHPS scores, the Hospital Consumer Assessment of Healthcare Providers and Systems, which are now being intrinsically tied to reimbursements. The drive to improve patient satisfaction by striving for quality medical care and having great communication with doctors and nurses is a wonderful goal, but how about also giving the patient appetizing food and a good night’s sleep?

The hospitals of the future should be healing institutes, which promote recuperation by also focusing on many of these other crucial aspects of health and well-being. Rest and relaxation (anyone for some soothing music?—studies have shown how this can benefit ICU patients). They will also serve up nutritious and delicious food to their sick patients.

There’s a good lesson for all of us here too. In our age of state of the art hospitals, revolutionary new technology, and miraculous new medicine—there’s one undeniable fact. Humans will still be humans. We will always need our food and sleep.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. This post originally appeared at his blog.

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QD: News Every Day--11 performance measures to gauge appropriate use of PCI

Eleven performance measures for elective percutaneous coronary interventions (PCI) directly address appropriateness of the procedure in ambulatory and inpatient settings, according to a collaborative effort among five medical societies.

The measures examine care before, during and after the procedure and incorporate other indicators of quality, such as procedural volume and whether the institution benchmarks care by participating in regional or national registries.

The 11 measures are:
1. comprehensive documentation of the reasons for PCI
2. an appropriate reason for elective PCI (benefits outweigh the risks)
3. an evaluation of the individual’s ability to receive dual antiplatelet therapy (conducted before the procedure)
4. the use of embolic protection devices in the treatment of saphenous vein bypass graft disease
5. an assessment of renal function before the procedure (including glomerular filtration rate) and the documentation of contrast used during the procedure
6. documentation of the radiation dose used during the procedure
7. the prescription of optimal medical therapy at discharge (aspirin, PY12 inhibitors and statins)
8. a referral to an outpatient cardiac rehabilitation program (to reduce the risk of recurrent events)
9. participation in a regional or national PCI registry
10. the average annual volume of PCIs performed by the physician over the last 2 calendars years
11. the average annual volume of PCIs performed by the hospital over the last calendar year

The 2013 Performance Measures for Adults Undergoing Percutaneous Coronary Intervention appeared online in the Journal of the American College of Cardiology American College of Cardiology and at the American Heart Association’s website.

According to the writing committee, the measures may “serve as vehicles to accelerate appropriate translation of scientific evidence into clinical practice.” The committee goal was to create measures that capture many important aspects of quality while minimizing the reporting burden.

The committee identified 4 areas of research that will generate better performance measures in the future:
1. measuring the filling of prescriptions (not just the prescription of drugs) and optimal dosing,
2. better use of current data systems to track PCI quality,
3. building accountability by all practitioners involved into quality metrics, and
4. using patient surveys to track performance.

The performance measures released today by the American College of Cardiology, the American Heart Association, the Society for Cardiovascular Angiography and Interventions, the AMA-Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance.

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Friday, December 20, 2013

How you can talk to your doctor about cholesterol

I’m not going to discuss the entire subject of cholesterol in this post, but one part of it: specifically, how to discuss with your doctor how much cholesterol should matter to you.

If you have read any health news recently, you know that the American College of Cardiology and the American Health Association issued new guidelines to help doctors advise patients about cholesterol medications. The new recommendations are accompanied by a calculator of heart risk into which one enters various laboratory and personal characteristics: whether you smoke, have diabetes, have high blood pressure, and the like.

Unfortunately, a kerfuffle has ensued over some errors present in the calculator. Millions of Americans, under the new guidelines, might be recommended to receive cholesterol medications, and this massive expansion of the medicated populace is under dispute.

Putting that aside, however, we will focus here on an even more basic question: how do you know what level of heart risk is important to you? Any recommendations about whether or not to use a cholesterol medication—the old ones and the new ones—depend on the application of calculation to you. The doctor will calculate the risk in the next 10 years that you will have a heart attack, and use that number to decide whether you should be taking a cholesterol medication.

However, that assumption crumbles the harder you press on it. First you should discuss with your doctor whether you are in one of the high-risk categories that places you at significant risk of heart disease in the first place: a family history of early heart disease or stroke; or a history of diabetes in yourself. Perhaps, on the other hand, you are generally healthy and your risk of heart disease is low; this is probably most people. A significant proportion will fall somewhere in the middle.

But even if your risk lies at one of these two extremes, and your doctor is confident in telling you that your risk of heart disease is high (or low), there is one essential point to keep in mind which is underemphasized in all the media coverage of the new cholesterol guidelines:

Whether to take such a medication is still, and always, your decision.

This is not “your decision” in the sense of: go play in traffic, see if I care. Rather, your decision-making must take into account a whole variety of factors, which can be clarified by thinking about the following questions, or discussing them with your doctor:

Cholesterol medications can reduce the rate of heart disease, but there’s a difference between absolute rate reduction and relative rate reduction. If a cholesterol medicine reduces your rate of heart disease by 50%, that sounds great, but it’s less impressive if your 10-year chance of developing heart disease was only 5% to start with. Maybe you can live with a 10-year chance of developing heart disease that’s 5 in 100. So you might ask: “What is my baseline risk of developing heart disease, without a cholesterol medication?”

Cholesterol medications can cause side effects not uncommonly. Some studies cite a rate of 10% for the rate of muscle-related symptoms (this is probably the upper range of the rate, including everything from muscle aches all the way to significant muscle inflammation). You are really the only one who can weigh the chance of side effects to the benefits of the medication. But you might ask, “How would you compare the risks and benefits of this cholesterol medication?”

Finally, it’s important to realize the imperfect nature of all guidelines. A guideline is merely a compendium of recommendations, and a recommendation can only be useful and relevant to you if two things are true: (a) it is based on good scientific evidence; (b) this evidence is relevant to your particular needs, sensitivities, and circumstances. About (a), you should ask your doctor, “How confident are you in the scientific evidence that backs up this recommendation?” Pay particular attention, for example, to how they understand the balance between risks and benefits in the subpopulation (i.e. the risk category) you fall into.

With regard to (b), of course, you are the only one who can make that determination, and no guideline can substitute for your considered, informed decision.

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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Tighter restrictions coming for painkillers like Vicodin

After years of consideration and debate, the Food and Drug Administration released a statement recommending that all pain medications containing hydrocodone be reclassified as Schedule II. The new policy is likely to take effect next year. This would include medications such as Vicodin, Lortab, Norco, and Vicoprofen, as well as their generic equivalents.

The Drug Enforcement Agency divides potentially addictive substances into different schedules. Schedule II controlled substances are prescription medicines that have a high potential for abuse and severe dependence. They include all the opiate (narcotic) pain medicines, like morphine, oxycodone and fentanyl. These medications must be prescribed on a paper prescription that has special security markings that prevent copying. The prescription must be taken to the pharmacy by the patient, and cannot be faxed or phoned in. And the prescription can at most prescribe a 90-day supply of the medication without refills.

Schedule III controlled substances are prescription medicines that have less potential for abuse and dependence than the medicines in Schedule II. It includes many medications that include an opiate medicine with a non-opiate in the same tablet. Examples include hydrocodone with acetaminophen (marketed as Vicodin, Lortab, or Norco), Tylenol with codeine, and hydrocodone with ibuprofen (Vicoprofen). Prescriptions for these medicines can be called in or faxed by physicians to pharmacies, can be written for more than a 90-day supply at a time, and can include refills.

In the last decade the number of prescriptions for Schedule III pain relievers has skyrocketed, as has the number of people taking hydrocodone for non-medical reasons. Prescription drugs are now a leading cause of addiction.

Proponents of the reclassification hope this will stem the tide of prescription medicine misuse. Opponents, like the National Community Pharmacists Association and the American Cancer Society, charge that this will inconvenience legitimate patients seeking pain relief. I suspect both sides are right. Both legitimate and illegitimate users of hydrocodone will be inconvenienced.

Though I’m ambivalent about the new policy, I’m reminded of a similar change a few years ago regarding pseudoephedrine (Sudafed). Pseudoephedrine used to be over-the-counter, but because it was being used to manufacture methamphetamine, a dangerous and illegal stimulant. The new law limited the amount of pseudoephedrine that can be purchased at one time and required that the patient show identification at the pharmacy to purchase it.

My objection to the pseudoephedrine rules is simply that in the several years since the new restrictions, no one has published a study (as far as I know) showing that the street price of crystal meth is higher, that the number of crystal meth addicts is lower, or any other objective measure suggesting that the new restrictions have been effective in decreasing the quantity of crystal meth available on the black market. Nevertheless, regardless of effectiveness, once a tighter regulation is in place, it is never rescinded.

I expect much the same with the new restrictions on hydrocodone—permanent inconvenience without ever measuring whether there is a benefit.

Learn more:
FDA Urging A Tighter Rein On Painkillers (New York Times)
FDA Recommends New Limits on Pain Drugs (Wall Street Journal)
Statement on Proposed Hydrocodone Reclassification from Janet Woodcock, MD, Director, Center for Drug Evaluation and Research (Food and Drug Administration)

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--Consensus statement advises vitamin D levels to prevent elderly fall-related injuries

A consensus statement offers advice to help primary care practitioners ensure that their older patients get enough vitamin D to protect against fall-related injuries.

The goal of the consensus statement, issued by the American Geriatrics Society, is to help primary care providers help older patients get adequate vitamin D from diet, sunlight and supplements to achieve vitamin D levels that are associated with protection of fall-related injuries.

All older adults should have a minimum daily vitamin D supplement of 1,000 IU daily, with calcium supplementation, to reduce falls and fractures, the statement begins. The workgroup endorsed 1,000 IU as a minimum daily supplement after a long discussion of the potential benefit of recommending a dose higher than was used in most of the intervention trials that showed protection from falls or fractures.

While there was not enough data to support a recommendation for increased vitamin D supplementation without calcium for older people, in most studies, calcium doses ranged between 500 and 1,200 mg daily.

The goal of the supplementary 1,000 IU is to achieve serum vitamin D levels of 30 ng/mL (75 nmol/L), a minimum goal for older adults, particularly frail adults who are at higher risk of falls, injuries and fractures. The goal of reducing fall-related injuries could be achieved safely and would not require practitioners to measure serum concentrations in older adults unless an underlying condition might increase the risk of hypercalcemia, such as advanced renal disease, certain malignancies or sarcoidosis.

Clinicians should review older patients’ vitamin D intake from diet, sunlight and supplements, and discuss strategies to achieve a total vitamin D input of 4,000 IU daily to reduce the risks for falls or fall-related injuries.

Clinicians should talk with older adults and their caregivers about how to get adequate vitamin D and calcium supplementation. Clinicians can discuss different vitamin D and calcium supplementation schedules with patients and caregivers and help them choose the one they are most likely to follow. For example, vitamin D supplements can be formulated taken daily, weekly or monthly, and there are different combinations of calcium and vitamin D supplements available.

“When developing these recommendations we took into consideration that the depth of the evidence in this area will expand over the next 5 to 10 years. In the meantime, it’s important that in the next 3 to 5 years, the oldest adults who are at the highest risk for falls and related injuries gain the benefits of sufficient vitamin D supplementation,” said Douglas Kiel, MD, FACP, a member of the working group, in a press release.

The statement appeared online Dec. 18 in the Journal of the American Geriatrics Society and will appear in the January 2014 print issue.

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Thursday, December 19, 2013

I'm now a certified ultrasonographer: passing the ARDMS test

I just finished taking an exam for the American Registry of Diagnostic Medical Sonography. Having passed it, I can now put RDMS after my name, standing for Registered Diagnostic Medical Sonographer. The RDMS is a credential that many ultrasound technicians carry, and occasional physicians, especially those who make ultrasound part of their practice. So now, should I ever be at loose ends, I can potentially get a job as an ultrasound tech.

To take the ARDMS qualifying test, one must first satisfy various requirements, which fit into categories meant to include ultrasonographers of great experience, ultrasonographers who have gone through a training program (usually 1-2 years) physicians who studied ultrasonography extensively during their medical school and residency training and physicians whose experience includes extensive review of hundreds of scans by experts. Proving experience requires letters from a supervising teacher. The exam is a proctored 5-hour test, 3 of which is in a specialty area and 2 of which tests knowledge of the physics and technology, with a special focus on safety. Due to the miracle of digital communication, I was able to take the test in my own time frame, in a “Pearson VUE” test site about 90 minutes from my home. The test site is in a little office space, but has a silent room with constant monitoring, manual pat downs, and rigorous identity checks. Apparently, Pearson VUE is part of a multinational company out of England which owns a large share of the Penguin publishing company and specializes in online learning. It was comfortable and low key. Short of having a cookie break and access to online resources, I can’t think of a better set up for success.

The exam is pretty specific. My ultrasound mentor recommended I take a review course which, in combination with quite a few hours of study, would probably result in me passing the test. The review course he recommended was by the company ESP ultrasound, taught by people who specialize in making sure students pass the exam. The course director is Sid Edelman, has been teaching for decades, and covers the ultrasound physics curriculum.

When I took the course, I thought that the level of trivia they taught could only have been due to some sort of collusion between the people who write the test and the people who taught the course. After taking the test, I realized that the test questions were not necessarily in the study guides for the exam, but that there was considerable overlap between what the course taught and what we were tested on. Much of the trivia that was taught was referred to in the exam questions, nevertheless, exam questions really required some knowledge of physics beyond what the course tested, and many of the questions were tricky, requiring deduction rather than straight memorization.

Preparing students to take standardized tests is a very big business in the U.S., so even in a narrow field such as ultrasound technology there are many choices, from Pegasus Lectures, providing on-site teaching in Atlanta and Tampa, and Burwin Institute which provides online material. Having a professor to emphasize the important information was really helpful to me. Without it I would have questioned the need to learn such a broad collection of detail, and would have found studying much more frustrating.

The physics part of the exam made me wish I had taken a real, in depth course on how ultrasound works, maybe something on a college level that lasted a semester and made me able to build my own basic ultrasound out of stuff I could buy at the hardware store. Since that was not possible, memory of my distant physics education and frequently consulting multiple sources to explain points that didn’t make sense helped me answer some of the more abstruse questions. Because the real physics of the complex machines we use now is beyond most people, what we learned did not truly represent reality. This was very disappointing to me, since I had hoped I would learn enough to be able to answer some questions about why the technology is so slow to develop. I wonder if the lack of detail also helped protect the companies whose livelihoods depend on producing a competitive product. I’m betting that is part of it, though that’s kind of creepy.

During the part of the course that taught me about ultrasound of the abdomen, thyroid and testicles, I developed awe for the knowledge most ultrasound technicians eventually have of 3 dimensional anatomy. Even at my very most knowledgeable, just after finishing my first year in medical school complete with cadaver dissection, I had nowhere near the depth of understanding of how the organs are packed into the body and served by so many named blood vessels. Ultrasound has repeatedly sent me back to my anatomy books to try to figure out how things lie in the human body. I will undoubtedly continue to improve, but there are many fresh faced young people with many less years of training, who make only a fraction of my salary, who will always be better at it than I am.

Passing the exam means that I know enough of the anatomy plus technical details and disease processes that I can pass the same exam as my technician colleagues, but our proficiency is in no way identical. I can’t compete with the exhaustive knowledge of anatomy a career ultrasonographer has, and he or she can’t possibly understand the level of implications of constellations of physical, laboratory and ultrasound findings and combine them with patients’ stories and priorities. It is good that this test has room for all of us. It could have been written so that either of us would routinely fail.

So why take this test? I’m not planning on a career change, after all. Being a doctor is plenty absorbing. I noticed that the ultrasound teachers who I work with usually have RDMS after their names. It is a recognition of competence that need not come with a long explanation. I have always been concerned that some group for whom I work will have extensive requirements for ultrasound credentialing. I envision myself happily examining all of my patients with ultrasound and being told that, no, that was not allowed. So far it hasn’t happened, but only because most places I work have no concept of bedside ultrasound, other than perhaps as a method of guiding procedures. It also seems likely that the credential will give both me and any employer some confidence in my ability to actually teach other people. I surely do not believe that an ARDMS test should be mandatory for physicians who employ bedside ultrasound because the requirements are way too cumbersome, but it will, for a few, be useful as a way of communicating competence in a variety of aspects of the practice.

I have been intermittently studying this stuff for about 6 months, including such questions as how fast ultrasound travels in soft tissue and the components of attenuation and how they relate to speed of the ultrasound beam and Snell’s law and how it might or might not affect real time ultrasound. I have not yet found a way to make this stuff help me, but I trust at some moment I will look back on my previous grasp of the material and wish I had learned it better.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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What really kills us

Heart disease is not the leading cause of death among men and women in the United States. Cancer, stroke, pulmonary disease, diabetes, and dementia are not the other leading causes of early mortality and/or chronic malady either.

Don’t get me wrong, these are the very diseases immediately responsible for an enormous loss of years from life, and an even greater loss of life from years. In that context, heart disease is indeed the most common immediate precipitant of early death among women and men alike. Cancer, stroke, and diabetes do indeed follow close behind. It’s just that these diseases aren’t really causes. They are effects.

We got this message loud, clear, and first, at least in the modern era, in what really should have been a culture-changing research paper published in JAMA in 1993 entitled “Actual Causes of Death in the United States.” In that analysis, two leading epidemiologists, Drs. William Foege and J. Michael McGinnis, looked into the factors that accounted for the chronic diseases and other insults that immediately preceded premature deaths. When they were done crunching numbers, they had a list of 10 factors that accounted for almost all of the premature deaths in our country every year.

Let’s digress to note we cannot “prevent” death. But what makes death tragic is not that it happens, we are all mortal, but that it happens too soon. And even worse, that it happens after a long period of illness drains away vitality, capacity, and the pleasure of living. Chronic disease can produce a long, lingering twilight of quasi-living, before adding to that injury the insult of a premature death. And that, we can prevent. We can preserve vitality, and we can postpone death to its rightful time, at the end of our full life expectancy.

Now back to our regularly scheduled program. There were two astounding things about McGinnis and Foege’s list of 10 factors. (The list is: tobacco, diet and activity patterns, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles, and illicit use of drugs.) First, we as individuals have substantial control over everything on the list, and virtually complete control over most of the entries. Second, just the first three factors on the list, tobacco, diet, and physical activity, accounted for fully 80% of the action. In other words, the actual, underlying “cause” of premature death in our country fully 8 times in 10 comes down to bad use of our feet (lack of physical activity), our forks (poor dietary choices), and/or our fingers (holding cigarettes).

I trust you immediately see the upside to this. If bad use of feet, forks, and fingers accounts for 80% of premature deaths (and a bounty of chronic disease), it stands to reason that optimal use of feet, forks, and fingers could eliminate up to 80% of all premature mortality and chronic illness. This proves to be exactly true. Feet, forks, and fingers are the master levers of medical destiny.

We know this not just from McGinnis and Foege’s seminal paper, but from a steady drumbeat of corroborating research spanning the two decades since. Scientists at the CDC replicated the findings in the original paper in an update a decade later. Population-based research published in 2009 showed that people who ate well, exercise routinely, avoided tobacco, and controlled their weight had an 80% lower probability across their entire life span of developing any major chronic disease, heart disease, cancer, stroke, diabetes, dementia, etc., than those who smoked, ate badly, didn’t exercise, and lost control of their weight.

Flip the switch on any of these factors from bad to good, and the lifetime risk of serious chronic disease was reduced by nearly 50%. But firing on all four cylinders produced a greater net benefit than perhaps any advance in the history of medicine. These very findings have been replicated again, and again, and have been shown to extend that same influence over the expression of our very genes. DNA is not destiny, and to a substantial extent dinner is. By changing what we eat and how we live, we can alter the expression of our very genes in a way that immunizes us against chronic disease occurrence, recurrence, or progression.

And so it is we have the knowledge to eliminate fully 80% of all chronic disease and premature death. The contention isn’t even controversial.

But knowledge, alas, isn’t power unless it is put to use. And for the most part, we have not leveraged the astounding memo we first got in 1993. Not only have we failed to slash rates of chronic disease, we are actually seeing them rise, with onset at ever-younger ages. We could bequeath to our children a world in which 8 times in 10, heart attacks and strokes and cancer simply don’t happen. Instead, should current trends persist, we will bequeath to them a world in which they and their peers succumb to just such preventable calamities more often and earlier than we.

So current trends cannot persist, and that, bluntly, is why I wrote Disease Proof. As a society, we clearly know the “what,” but as individuals and families; spouses and siblings; parents and grandparents, most of us, just as clearly, don’t know how. How, despite the challenges of modern living, do we adopt, maintain, and enjoy a healthful diet? How, despite those same challenges, do we fit fitness in? How do we navigate around other challenges, from sleep deprivation and lack of energy, to overwhelming stress, to chronic pain?

These questions have answers, and I know them. I know them not because I’m special, but because it’s my job to know them. Pilots know how to fly planes; nuclear physicists know how to split atoms. I am a health expert, and I know how to get to health and weight control from here. Like any worthwhile thing, it requires a skill set, but we are used to that. We had to learn how to read and ride our bikes. We had to learn how to drive our cars and use our smart phones. Every worthwhile undertaking in our lives has involved someone who already knew how teaching us. Our job was to learn, and apply.

Health and weight control are exactly the same. In Disease Proof, I share the full skill set I apply myself.

We could, as a culture, eliminate 80% of all chronic disease. But my family and yours cannot afford to keep on waitin’ on the world to change. By taking matters into our own hands, we can lose weight and find health right now. We can reduce our personal risk of chronic disease, and that of the people we love, by that very same 80%. We can make our lives not just longer, but better.

What really kills us prematurely, and all too often imposes years of misery beforehand, isn’t a list of chronic diseases, but the factors that cause those diseases. What really takes years from life and life from years is a willingness to know what, yet neglect the opportunity to know how. What really kills us is the failure to turn what we know and have long known into what we do. We can change that, and substantially disease-proof ourselves and those we love, any time we’re ready. I hope that’s now, because waiting is really killing us.

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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The debate over conflicting experts

The New York Times published one of their periodic debates – When Medical Experts Disagree

This debate actually centers on the current cholesterol guidelines, but the problem recurs often. Different “experts” look at the data and develop differing opinions. We see this with prostate screening, mammography, and treatment decisions.

As one reads the varying opinions in this debate, an understanding of the affect heuristic makes the debate transparent. When we like something, we overestimate the value and underestimate the risks and costs. This explains most conflicts of interest, and importantly conflicts of interest are not just pharmaceutical.

The “experts” writing the cholesterol guideline are heavily invested in the cholesterol hypothesis. The higher the cholesterol the worse the patient will do. Amazingly, the data made clear that only statins have excellent outcome data, so the panel dropped cholesterol goals for primary prevention and high yield secondary prevention (patients between 40-75 with type II diabetes mellitus or very high LDL cholesterol).

The controversy rests then on primary prevention. The experts like lowering cholesterol. They have accepted the data that statins trump every other drug class, and that other drug classes do not have sufficient outcome data to either add to statins or use alone. They know that primary prevention does decrease cardiac events. Because they like preventing cardiac events, they favor an aggressive approach to primary prevention.

Many other physicians worry about treating very large numbers of patients with a drug that both has significant costs and side effects (mostly muscle pain). These physicians are not as enamored with statins, unless the patient has very clear indications.

As one reads the various debaters, one can understand their contributions as resulting from the affect heuristic. One debater sees the pharmaceutical influence as a major evil – thus blames the pharmaceutical conflicts of interest (while apparently ignoring other conflicts). One debater clearly focuses on drug side effects, and cautions against using any new drugs, unless the new drug has proven major benefits.

Seeking truth where there is no truth will always frustrate physicians and patients. We have to balance risks, costs and benefits, and generally make these estimates with incomplete information. For rarely can we have complete information. We want to worship at the altar of evidence-based medicine, but we still must assess values, and values will always contain a subjective component.

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--CDC announces priorities for 2014

Most people spend the end of the year reflecting back on accomplishments or setting goals for the new year—including agents at the CDC.

The agency released its top 5 accomplishments of the year and top 5 goals for next year, according to a press release.

Accomplishments include:
• More than 100,000 smokers quit for life because of Tips from Former Smokers.
• Advanced Molecular Detection helped to quickly define and stop an outbreak of listeriosis.
• The National Healthcare Safety Network helped more than 12,000 healthcare facilities reduce infections.
• One million babies were born HIV-free over the past 10 years.
• New resources are available to prevent one million heart attacks and strokes by 2017.

The top 5 goals are:
• Increase rates of HPV vaccination.
• Promote the wise use of antibiotics.
• Reduce the risk of prescription opioid deaths while making sure patients have safe, effective pain treatment.
• End polio everywhere.
• Detect, fight and prevent infectious diseases to improve global health and protect health security.

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Wednesday, December 18, 2013

A theoretical note to my students, on a breast cancer case and future learning

My students, who are, necessarily, abstracted here, recently studied breast cancer. How the course goes is that we meet in a small group and, each week, work through a case by Problem Based Learning. The recent case concerned a woman who, at age 35, noted a small breast lump. Each day we acquired more information about the patient, such as the size and molecular features of her tumor and prognosis. We sorted through her treatment options.

It was a dense subject. Over 4.5 hours we discussed what kind of biopsy she needed: aspirate or core needle? We considered if excision in an operating room is required to establish a breast cancer diagnosis (rarely). We reviewed breast imaging methods (mammograms, sonograms and MRI) and tumor staging. We covered some pathology techniques, including OncotypeDx and Her 2 testing by IHC or FISH. We spoke about risk factors and BRCA testing, how that’s done, what it costs and when it might be indicated. We looked at the molecular biology of Her2 signaling, and how that might be pharmacologically blocked. We considered the nomenclature of LCIS and DCIS, and the concept of overdiagnosis. We talked about the woman’s decisions for surgery (lumpectomy or mastectomy) and sentinel node evaluation. We considered kinds of adjuvant therapy including hormone blockers, chemotherapy combinations, radiation, antibodies including Herceptin, and other treatments she might receive. We spoke about her prognosis and odds of recurrence.

We spent time on the statistical concept of lead-time bias. And more. Medical school isn’t easy.

What I hope for my students, real and in cyberspace, is that they’ll always try to do what’s best for their patients. Sometimes in PBL we use PowerPoint. So here’s a list of three things to keep in mind, on learning, not just about breast cancer, but about all aspects of medicine:
1. Keep studying. Patients want and rely on their doctors to stay up-to-date about medical and scientific knowledge in their field of practice.
2. Keep paying attention, so you’ll hear and recall your patients’ concerns and preferences, and offer care that’s mindful of their goals and values.
3. Keep thinking, constantly, how the data applies to the person, an individual, the real patient you’re trying to help.

Of course you should keep asking good questions, solicit advice from colleagues, and be respectful of the people who entrust you with their lives.

The best presentations don’t cover too much ground, so I’ll stop here.

This post originally appeared at Medical Lessons, written by Elaine Schattner, MD, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.

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Broken dishes

Here’s an idea that seems unfair:

Hospitals, long searching for ways to minimize their streams of uninsured patients (written off as “charity” or “uncompensated” care), signed on to the Affordable Care Act (“Obamacare”) through their trade associations.

They stood to solve one of their longstanding problems by cooperating with Congress and the Administration to help Americans.

Now, in states not accepting Medicaid expansion (e.g. Georgia, Oklahoma, Texas, etc.), those hospitals are feeling the pinch twice.

Obamacare is in part financed by funds earmarked for hospitals providing a “Disproportionate Share” (i.e. “DSH“) of unfunded care.

Now hospitals in states that aren’t expanding Medicaid not only won’t get payments from newly enrolled Medicaid-eligibles, they’ll be losing their “DSH” payments.

Double whammy.

Here’s the thing, though: Stubborn governors and legislators who will not accept the 100% federal financing of Medicaid expansion will feel the bite. Eventually.

Hospitals will close. Citizens will be angered. Employees will lose jobs.

Those last two in any order.

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--Hypertension guidelines lead to debate about creating any new recommendations

A new hypertension management guideline offers 9 recommendations and a treatment algorithm to help doctors treat patients, but its publication also triggered editorials about the development and trustworthiness of any and all guidelines.

Briefly, the 9 hypertension recommendations state that there is strong evidence to support treating hypertensive patients ages 60 years or older to a blood pressure goal of less than 150/90 mm Hg and those 30 through 59 years of age to a diastolic goal of less than 90 mm Hg. There is insufficient evidence in people younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommended a blood pressure of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease as for the general hypertensive population younger than 60.

The guideline, “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults,” was developed by panel members appointed to the Eighth Joint National Committee and appeared online Dec. 18 at JAMA.

As for which medical regimen, there is moderate evidence to support starting with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on ACE inhibitors or ARBs in patients with chronic kidney disease.

In a difference from previous guidelines, evidence was drawn from randomized controlled trials, and evidence quality and recommendations were graded based on their effect on important health outcomes. These guidelines also sought to establish similar treatment goals for all hypertensive populations except when evidence supported different goals for a particular subpopulation.

Also, rather than defining hypertension, the panel addressed threshold blood pressure for starting treatment. The report recommends beginning treatment for people aged 60 and older at a blood pressure of 150/90, and treating to below that level based on trial evidence, but the authors emphasize that “this evidence-based guideline has not redefined high BP and the panel believes that the 140/90 mm Hg definition from Joint National Committee 7 remains reasonable.”

And, clinicians should emphasize lifestyle changes to improve control and possibly reduce the need for medicines. “For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized.”

JAMA’s editor in chief recalled controversies about other guidelines, such as the U.S. Preventive Services Task Force’s updated recommendations regarding mammography screening in women, the Infectious Diseases Society of America’s guidelines for Lyme disease, and American College of Cardiology and the American Heart Association’s guidelines on assessment of cardiovascular risk and treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk. Producing guidelines has become increasingly more complicated and contentious, the editor noted, adding, “Rigorously developed, thoroughly reviewed, evidence-based, trustworthy guidelines are critical to advance clinical medicine and improve health, and biomedical journals have a responsibility to disseminate important guidelines in an objective manner.”

In another editorial, Harold C. Sox, MD, MACP, former editor of ACP’s Annals of Internal Medicine and currently with the Dartmouth Institute for Health Policy and Clinical Practice, noted that the guideline did not undergo specialty society review as originally planned. He addressed the trustworthiness of the guideline, and guidelines in general.

He wrote that guideline authors, by agreeing to share its record of the review process with anyone who asks, meets the standard of transparency and review that proper guideline development now requires. “A rigorous, transparent process for developing and reviewing guidelines matters a great deal because guidelines are increasingly driving the practice of medicine.”

A third editorialist noted that, while the hypertension guidelines will follow suit in generating controversy, there is still room to keep searching for answers. Larger randomized, controlled trials need to be done to increase generalizability of results to different patient populations. A national consensus group should draft an updated comprehensive practice guideline that would harmonize the hypertension guideline with other cardiovascular risk guidelines and recommendations to create a more coherent overall cardiovascular prevention strategy. The process of translating practice guidelines into performance measures needs to be more deliberate, such as by deriving performance measures to create awareness of the potential unintended consequences of setting treatment goals that are too strict or adherence goals that are too rigid.

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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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