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

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Friday, February 28, 2014

Cognitive errors in considering pharyngitis

Since prior to my entrance to medical school, common wisdom for treating sore throats involved the prevention of rheumatic fever. Since group A strep pharyngitis is the cause of most acute rheumatic fever, all efforts have focused on treating group A strep. Studies in the 1950s showed that penicillin treatment decreased the probability of patients developing rheumatic fever.

The prevailing theory in the 50s and 60s, that we should diagnose group A strep and ignore all other pharyngitis etiologies, persists to the present. Guidelines focus on the group A strep diagnostic problem. Articles investigating inappropriate use of antibiotics for upper respiratory infections lump pharyngitis in with bronchitis and other upper respiratory complaints. Those studies criticize physicians who provide antibiotics to patients who do not have a positive test for group A strep (either a rapid test or a culture).

The prevailing construct assumes that sore throats are sore throats regardless of age. Many pharyngitis experts are actually streptococcal experts who focus on group A strep. Many pharyngitis experts are pediatricians who focus on pre-adolescent pharyngitis. They hold any other potential bacterial pathogen to a higher standard of proof that group A strep.

When one carefully reads the pharyngitis literature, especially the literature on complications and other bacterial pathogens, one finds an interesting observation. Pre-adolescent pharyngitis actually is predominantly group A strep or viral, but adolescent (here I will use a loose definition of ages 15-30) pharyngitis has more varied bacterial etiologies.

We published the first article describing group C streptococcal pharyngitis as endemic and symptomatic in adolescents. Multiple other articles, primarily from college student health, have also documented this finding. The best randomized controlled trial of penicillin in adults found that group C pharyngitis patients had 1 day less symptoms when treated with penicillin.

More recently Fusobacterium necrophorum is gaining attention, primarily because of outstanding work in Denmark and England. I recently published an article that uses published data to estimate that the complications (peritonsillar abscesses and Lemierre syndrome) from this organism are more dangerous and more devastating than those from group A strep in this country.

Lemierre syndrome is much more common as a complication of adolescent pharyngitis than is acute rheumatic fever. It is deadlier and causes significant disabilities in some patients.

Yet current guidelines lump all pharyngitis into one bucket and only address group A streptococcal pharyngitis. Rapid tests only detect group A pharyngitis. These guidelines now mention group C and Fusobacterium but opine that we do not have enough evidence to worry about them.

Obviously I argue that we cannot wait for complete evidence in addressing adolescent Fusobacterium pharyngitis. Lack of evidence for addressing adolescent pharyngitis differently is not equivalent to evidence that we should not treat adolescent pharyngitis differently.

Not all medical questions have sufficient evidence to make good decisions. We physicians must purposefully extrapolate from what we know about pathophysiology and then make rational decisions. I submit that if we knew that an adolescent had Fusobacterium pharyngitis we would have a logical and defensible reason to treat with antibiotics, specifically penicillin. But we do not have a readily available diagnostic test for Fusobacterium necrophorum because it is a difficult to grow anaerobic bacteria.

So we must ask ourselves how much “overtreatment” with penicillin is tolerable to prevent 1 patient developing a peritonsillar abscess or worse yet Lemierre syndrome. Very few organisms show sensitivity to penicillin in 2014. Fortunately strep (both group A and group C) and Fusobacterium remain sensitive.

Current criticism of treating adolescent pharyngitis based on signs and symptoms alone represents (in my mind) a cognitive error. Our lack of prospective studies definitively answering this question should not exclude a logical approach to trying to prevent a rare but extraordinarily serious infection.

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 Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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QD: News Every Day--2 possible resistant strep B cases found

A profile may be emerging to vancomycin-resistant strep B cases, researchers reported.

Two cases of invasive group B streptococcus infection with decreased vancomycin susceptibility in New York and New Mexico, without an epidemiologic link.

Researchers reported the cases in the New England Journal of Medicine.

Local and state health authorities identified isolates as vancomycin-nonsusceptible group B streptococci and sent to the CDC, where both strains were confirmed as capsular serotype II, multilocus sequence type 22S. agalactiae.

The strains differed in resistance patterns, and the lack of an epidemiologic link suggests independent resistance acquisitions, researchers wrote.

“These cases emphasize the importance of continued surveillance for resistant group B streptococcus,” the researchers wrote. “It may be important to establish vancomycin breakpoints for group B streptococcus and guidance for clinical laboratory testing. Clinicians and laboratories should be encouraged to report suspected vancomycin-resistant group B streptococcus to health authorities for confirmation, since this resistance profile may be emerging.”

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Thursday, February 27, 2014

Obesity and oblivion, or what I've learned under general anesthesia

I am going to tell you what I’ve learned under general anesthesia, but I ask you to bear with me kindly and wait a few paragraphs for that revelation.

I am a rambunctious guy, pretty much always have been. I have always loved active recreation and was one of those kids who had to be reeled in for dinner from outside play with a winch and a cable. As an adult, I placate the restlessness of my native animal vitality with about 90 minutes of exercise every day. In addition, I hike whenever I can, and pretty much share my dogs’ attitude about it: the more miles, the better. I studied the martial arts for years. I am a lifelong, avid alpine skier, and an ardent equestrian, privileged to share that latter brand of rambunctiousness with my beautiful horse, Troubadour, who seems to enjoy running and jumping as much as I do, and is far better at it.

This is all part of family tradition. Women in the family are generally quite active, and some have their share of perennial restlessness. But the guys are a case apart. My son’s rambunctiousness is, quite literally, famous of song, story, and program. The ABC for Fitness™ program Gabriel directly inspired is now reaching hundreds of thousands of kids around the country and world, and paying forward the benefits of daily exercise in schools. Gabe helped me appreciate the importance of asserting that the proper remedy for rambunctiousness in our kids is recess, not Ritalin.

And then there’s my father, whose restlessness is the granddaddy of all, and the stuff of legend, or at least family lore. We celebrated his 74th birthday last summer with a hilly, 56-mile bike ride.

By and large, the effects of this rambunctiousness are extremely positive. My animal vitality is spared the constraints of leash or cage, and rewards me reciprocally with energy, stamina, and vitality. But everything has a price. My particular brand of rambunctiousness has involved pushing limits, and limits have a tendency of pushing back. The result is several concussions (I am now a consistent helmet wearer), too many stitches to count, roughly 20 broken bones, and general anesthesia to restore the mangled anatomy of some joint or other not fewer than a half dozen times.

Which leads, at last, to what I’ve learned under general anesthesia: Nothing. Nada. Zip.

Nobody learns anything under general anesthesia. General anesthesia involves unconsciousness, oblivion.

And on that basis, I consider it a societal travesty that hyperendemic obesity and the metabolic mayhem that often follows in its wake are treated ever more frequently, in ever younger people, under general anesthesia. Our answer to obesity is, it seems, oblivion.

True, bariatric surgery is effective. But it is also expensive, and subject to all of the potential complications of surgery. We don’t really know how long the benefits last, particularly for the children and adolescents who are candidates in growing multitudes. We do know that lasting benefit requires ancillary lifestyle change, and that there is often some, and sometimes a lot, of weight regain despite the rewiring of the gastrointestinal tract.

And we know as well that we are relying on scalpels in the hands of others to do what forks in our own hands (and feet in our own shoes) could do better, at dramatically lower cost and risk, if our society committed to empowering their more salutary use. We have evidence to suggest that schools and aptitudes acquired there could do for weight what scalpels applied under anesthesia do. But in my experience, they could do so much more. As a medical advisor at Mindstream Academy, a boarding school producing weight loss to rival bariatric surgery, I have been far more impressed with what the kids find than what they lose, impressive though the latter may be. They find pride and proficiency; confidence and competence; skillpower and self-esteem. They learn, in other words -- as nobody ever does under general anesthesia.

Our society’s tendency to “over-medicalize“ has been chronicled by others. The consequences extend to expecting from our clinics what only our culture can deliver. Among the most vivid illustrations of this is the lifelong work of my friend, Dean Ornish. Dr. Ornish was involved in groundbreaking work that showed the capacity for a lifestyle overhaul to rival the effects of coronary bypass surgery. With evidence in hand that feet and forks (and a short list of other priorities attended to) could do for coronaries what scalpels could do, Dr. Ornish set out to make his lifestyle program a reimbursable alternative to surgery. He succeeded, earning Medicare reimbursement after—wait for it—17 years! I don’t know that Dean has the patience of a saint, but he apparently does have the patience of a cicada.

It took 17 years to gain reimbursement for lifestyle as a cost-effective treatment of coronary artery disease, whereas surgery was reimbursed from the get-go. That’s how we roll, and then wring our hands about the high costs of health care.

With that in mind, I ask my fellow parents reading this column. I ask the grandparents, godparents, aunts and uncles to contemplate this: How many of our sons and daughters, nieces, nephews, and grandchildren will have passed through the O.R. doors if it takes us two decades to establish lifestyle intervention as a culturally sanctioned alternative to bariatric surgery? However many that is, I can tell you exactly what they will all learn while under general anesthesia: Nothing. Nada. Zip.

Knowledge and experience are the foundational elements of culture itself. Culture derives from the capacity of our species to learn, and pay forward our learnings to our contemporaries and our children. Among the impressive manifestations of effective school-based approaches to adolescent obesity is the capacity, and proclivity of the kids to pay their newly acquired skillpower forward. When last I visited Mindstream Academy, one of the young girls there, who had lost some 80 pounds, was most proud to tell me about her father back at home who, courtesy of her long-distance coaching, had lost about 40. There is nothing to pay forward following the oblivion of general anesthesia.

Bariatric surgery is effective and should be available to those who need it. I have referred patients for such surgery over the years. But our culture will be defined by what we learn and share. We could learn and share the skill set for losing weight and finding health, and make that our cultural norm. That remains unlikely so long as we put our money preferentially where our medicalizations are. The AMA has proclaimed obesity a disease, but that’s just symptomatic of our culture tendencies. It is more a disease of the body politic than of the often healthy bodies that succumb to it in a culture that propagates its causes.

The healthiest, happiest, leanest, longest-lived populations on the planet do not attribute such blessings to the proficiency of their surgeons or the frequency of their clinical encounters. They attribute them to the priorities and prevailing norms of their culture.

Nobody learns anything under general anesthesia. General anesthesia is oblivion. If we keep prioritizing the medical over the cultural, oblivion over enlightenment, my friend Dean Ornish will remain a lonely pioneer. And the cicadas, when next they emerge, will see nothing new. They will have cause to roll their protuberant eyes at us and trill out: same as it ever was.

It doesn’t have to be that way. We could choose oblivion a bit less often, and stay conscious instead. Conscious, we would have a chance to think outside the box of surgical gloves, and perhaps thereby perceive a new world of opportunity.

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

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QD: News Every Day--Obesity plateaus in U.S. over past decade

About one-third of adults and 17% of children and teens were obese in 2011-2012, according to a national survey study, a rate that hadn’t changed in the previous decade.

CDC researchers examined trends for childhood and adult obesity among 9,120 people in the 2011-2012 nationally representative National Health and Nutrition Examination Survey.

Results appeared in the Feb. 26 issue of JAMA.

For children, the marker of obesity was high weight for recumbent length from birth to age 2. The overall rate was 8.1% in 2011-2012, with a difference between boys (5%) and girls (11.4%). Among children ages 2 to 19, 31.8% were either overweight or obese, and 16.9% were obese. Obesity among children 2 to 5 years of age decreased from 14% in 2003-2004 to just over 8% in 2011-2012 (P=0.03).

Among adults, 68.5% were either overweight or obese, 34.9% had a body-mass index (BMI) of 30 or greater, and 6.4% had a BMI of 40 or greater. Obesity in women age 60 years and older increased from 31.5% to more than 38% (P=0.006).

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Wednesday, February 26, 2014

Paul Lee--a Washington health care lobbyist talks about why it's all good

I attended a dinner and lecture at the local dining venue where they served huge hunks of prime rib, wild rice, sautéed snow peas from some faraway place where it’s Spring, and then chocolate mousse. Global warming increased just slightly due to our excess consumption, but my portion would have been wasted had I stayed home. Beside the food, I was curious to see what the health care lobbyist who spoke had to say about where health care reform is headed. I was surprised to find that he was almost entirely positive about what was going on and that in general he said things that I agreed with.

How could this be? Health care lobbyists generally want the industry they represent to get as much money as possible. I generally want the health care industry to rein in its excesses and be more conscientious and efficient. Clearly there is some agenda here that I don’t understand. Either that or efficiency and reining in excesses is beginning to align itself with the success of the health care industry.

The speech

Mr. Lee, the speaker, bravely faced an audience that included many doctors and administrators who believe that health care is going rapidly to the dogs and that the Affordable Care Act (or Obamacare as they prefer to call it) is the end of all that is good. His message was quite succinct and described a scenario in which the growth in health care expenditures would continue to slow and populations would become healthier and more people would be insured and access care in an environment that would include more non-physician caregivers and fewer specialists.

His visit and presentations were paid for by the CEOs of the 3 local hospitals, who seemed to approve of his message. He showed graphs of trends and briefly touched on the specific issues of rural hospitals, which all 3 of the local hospitals are. He talked about how new requirements for hospitals to curb complications would lead to a safer environment for patients and fewer unplanned readmissions.

Population health

He also used a couple of terms that had the feel of buzzwords, but which were actually very interesting. He spoke of the inevitability of focusing on “population health.” We presently do fee for service medicine, though not entirely (there are health care co-ops and other pre-paid models and quite a few physicians are salaried.) This means that we get paid when patients are sick. We are moving in the direction of being paid for how well we take care of patients, otherwise known as “pay for performance.” According to Mr. Lee we are heading toward a goal of “population health” which he explained meant taking responsibility for the health of the entire community in which we practice, rather than just taking care of patients when they get sick.

There is an article in the Journal of the American Medical Association that looks at exactly this. Emma Eggleston, MD, and Jonathan Finkelstein, MD, write about how population health could be attractive to the stakeholders who pay lots of money when people get sick, but might be less attractive to entities which make their money only through treating sick people. Also, if we focus on making everyone healthy there may be a dynamic of requiring people to do certain things that interfere with their individual rights, such as exercising and stopping unhealthy habits. This may not be universally acceptable to Americans.

How it works

I know that in our small community there could be some non-hospital interventions which might significantly reduce hospitalizations. If physicians or midlevel caregivers would see patients on an emergency basis in nursing homes and maintain good continuity of care with those patients and their families we would see fewer emergency room visits and hospitalizations. If there were a community crisis center that was robust and effective, we would have fewer emergency mental health visits. If acupuncture and massage were easily available and covered under insurance, we would likely have fewer pain medication prescriptions and fewer hospitalizations for complications of these medications. If our hospital was paid a certain amount of money per year to take care of the patients in the community regardless of whether they were admitted to the hospital, low-cost ways to reduce hospitalizations would be very attractive, and the hospital would likely invest in them. If the hospital made money only when patients were admitted, they would not be inclined to do so. Mental health hospitalizations and emergency room visits are almost always a drain on hospital resources since we don’t have a psychiatrist or mental health capabilities and can’t hospitalize these patients. Traditionally these patients have also been poorly insured or uninsured as well, so there was no hope of reasonable reimbursement for the hours of care (however that may be defined) that they received in the emergency room. Hospitals such as ours might well save money by funding a community crisis center if it actually kept patients out of the emergency room.

A nearly viral piece of news was the fact that Utah has drastically reduced homelessness by giving the homeless homes. There is an initiative in Utah, begun 8 years ago, to reduce homelessness and poverty, which has several strategies for reducing costs related to chronic destitution. It costs a significant amount of money to treat the homeless in emergency rooms and intermittently put them in jail, and there is less of that if they live in apartments rather than on the street.

Utah does not provide housing for free, but does make it very affordable, charging about 30% of government funded income. Utah also has programs to prevent homelessness including interventions to keep people in their homes who are at risk of losing them. President Obama’s 2009 American Recovery and Reinvestment Act (the much derided “stimulus package”) has been partly responsible for funding these projects. This is an excellent example of “population health.” Not only does it reduce emergency room related costs, but the no-longer-homeless are much more likely to get and hold jobs than if they were on the streets.

Compressed morbidity

The other term that our speaker, Mr. Lee, used at the end of his talk was “compressed morbidity.” He explained that this was the overall goal of a good health care system. Most people, he asserted (and I agree) would like to be sick for the least amount of time possible, and die when they are not yet miserable or have only been so for a short time. The concept of compressed morbidity was first introduced by Dr. James F. Fries, now an emeritus professor of rheumatology at Stanford University, in 1980. He wrote a more comprehensive article on it in 2005. Dr. Fries noticed that almost everyone dies by the age of 110 and most people by the age of 85. As we get better at maintaining health, more people live to be older, but the true maximum age of a human doesn’t increase much. With better prevention of disease, be it vaccination or quitting smoking, people live to ages that are closer to the maximum age and spend less of their lives sick and requiring medical care. He suggests active encouragement of all of the behaviors that we know make us stronger and smarter, including such revolutionary ideas as providing alternatives to nursing homes as people age. Although we will live longer if we do those things which slow disease and decline, we will overall use less medical resources. This goal is the end result of a “population health” approach.

I am mostly but not entirely excited about all of this. I personally would like to live healthy and then drop dead, or get eaten by a bear or something, while I remain mostly independent. But I still do respect the rights of people with different values to practice them. That sounds pretty good until I think about the rights of people to become addicted to injectable drugs, get HIV and multiple abscesses all over their body, spend years in the hospital and nursing homes lingering with their stroke related brain damage and chronic pain and eventually die after costing the system many millions of dollars. I suspect that it is not really up to me and does not rest on my sensibilities whether the U.S. moves in the direction of population health and achieves progressive compression of morbidity. It will most likely be determined by how much money we are willing to spend on health care and what kind of outcomes we are willing to accept as being adequate for our money.

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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Patient, wash thy own hands!

There has been increasing attention over the past decade in engaging patients in patient safety. In infection control this trend has manifest through efforts to have patients monitor and encourage hand hygiene compliance among health care workers. In a related trend, there is also increased interest in patients washing their own hands in a framework called “patient-centered hand hygiene.”

My understanding of this approach is that having patients clean their own hands could potentially increase their engagement in infection control initiatives including encouraging health care workers to practice hand hygiene. This approach might also have the additional benefit in decreasing the organism burden on patients’ hands and interrupting direct or indirect transmission of multidrug-resistant organisms in health care settings.

It is with this background that Kundrapu and colleagues at Case Western Reserve University and the Cleveland VA completed a randomized trial of soap and water versus alcohol hand rub in reducing Clostridium difficile spore burden on patients’ hands.

Forty-four infected or colonized patients were included in the study. Hand cultures were positive in 32% of patients with C. difficile infection and 38% of colonized patients prior to hand hygiene. As you can see from the figure below, soap and water significantly reduce the proportion of positive cultures and mean colony forming units, while alcohol hand rub did not. Interestingly, around 10% of patients still had C. difficile recovered after washing with soap and water. Seems like a trial is in order to determine the role of patient hands in transmission and whether cleaner patient hands reduces the incidence of C. difficile infections and other MDROs in hospital settings. One major limitation is that this intervention could not be implemented in settings where the need is the greatest, namely ICUs, since most patients would be too sick to wash their hands.

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). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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QD: News Every Day--Vegetarian diets might be used to lower blood pressure

Vegetarian diets are associated with lower blood pressure and could be used as a nonpharmacological treatment, a meta-analysis of controlled trials found.

Researchers in Japan reviewed more than 100 years of published studies about vegetarian diets, which could include some dairy, eggs, fish or meat consumption. Seven clinical trials and 32 observational studies met the inclusion criteria of adults exposed to vegetarian diets as an exposure or intervention, and that tracked mean blood pressure as an outcome.

Results appeared online Feb. 24 at JAMA Internal Medicine.

In the 7 controlled trials of 311 people, vegetarian diets were associated with a reduction in mean systolic blood pressure of −4.8 mm Hg (95% CI, −6.6 to −3.1; P<0.001; I =0; P=0.45 for heterogeneity) and diastolic blood pressure of −2.2 mm Hg (95% CI, −3.5 to −1.0; P<0.001; I2=0; P=0.43 for heterogeneity) compared to omnivorous diets.

In the 32 observational studies of nearly 22,000 people, vegetarian diets were associated with lower mean systolic blood pressure of −6.9 mm Hg (95% CI, −9.1 to −4.7; P<0.001; I2=91.4; P<0.001 for heterogeneity) and diastolic blood pressure of −4.7 mm Hg (95% CI, −6.3 to −3.1; P<0.001; I2=92.6; P<0.001 for heterogeneity) compared to omnivorous diets.

The meta-analysis had a reasonably large overall sample size, and its focus on dietary patterns rather than on supplements or other dietary manipulations makes the findings easily applicable to general or clinical populations, the authors noted. Next, more research is needed into specifically which vegetarian diets were most effective.

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Tuesday, February 25, 2014

Should this Jehovah's Witnessed have been transfused blood?

Autonomy is a bedrock ethical principle in medicine that has supplanted medical paternalism. Patients have a right to make their own medical decisions and are entitled to know the advantages and drawbacks of all reasonable options. Clearly, informed consent cannot be given if the patient is only partially informed or has been given a slanted presentation by the physician.

When a patient does not have the capacity to provide consent, then a surrogate is used. This individual is charged to make the decision that the patient would have made if the patient were capable of doing so. Some argue that the surrogate should decide on what he feels is in the patient’s best interest, which may be different than what the patient would have preferred.

Can Christian Scientist parents deny lifesaving treatment to their children? The courts have properly ruled for the children in many of these cases. These decisions may be traumatic for loving parents who feel that conventional medical treatment may cause an irrevocable spiritual catastrophe. Is the situation more complex if the child is 15 or 16 years old and does not want surgery or chemotherapy? What about a 17-year-old?

I was asked to see a patient recently who was profoundly anemic, having lost about two-thirds of her blood. Ordering blood transfusions would have been a reflex for any physician. The patient was a Jehovah’s Witness. Practicing Witnesses will refuse blood transfusions even at the risk of their lives. I have treated many of these individuals over the years and respect their right to make informed medical decisions. This patient, however, was mentally retarded and her sister was making decisions on her behalf.

At the sister’s request, no blood transfusions were administered and the patient survived. I wondered if this case was ethically problematic as the sister was denying care that may have been lifesaving to a patient who could not express an opinion on the issue. Perhaps, she would not have wanted to die or might not have been a practicing Witness at all. Should the sister, despite noble intentions, have been entrusted with this decision?

I think that had we decided to ask a court to rule on this issue, that blood may have started to flow.

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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Social media demand higher standards of behavior from physicians

Most social media guidelines for physicians, most recently from the American College of Physicians and Federation of State Medical Boards, suggest that doctors separate their personal and professional identity. Until physicians are better educated on how best to act professionally on social networks, keeping their online personal lives private is more likely to keep them out of trouble. But is it time for that recommendation to be revised?

In a recent JAMA perspective piece, bioethicists from Johns Hopkins argue against separating physician personal and professional identities:

We contend that this is operationally impossible, lacking in agreement among active physician social media users, inconsistent with the concept of professional identity, and potentially harmful to physicians and patients. A simpler approach that avoids these pitfalls asks physicians not whether potential social media content is personal or professional but whether it is appropriate for a public space. Instead, they argue that physicians are held to a higher standard of behavior than the public, and shouldn’t frame social media as personal versus professional. Instead they should ask themselves before posting on a social media site, “Is this appropriate for a physician in a public space?”

“Is this appropriate” is a question doctors should ask themselves before posting anything on a social media site. And while this model works well for public social media spaces like Twitter or Google+, I wonder about Facebook.

Without separating identities, how do the JAMA authors suggest handling Facebook friend requests from patients?

35% of physicians receive friend requests from patients. Every physician social media guideline I’ve read says to reject them. Facebook too easily blurs that line between one’s personal and professional life. My personal Facebook profile doesn’t cross any professional boundaries, and would be appropriate in a public space. But I wouldn’t be comfortable sharing those updates, which can include vacation pictures or stories of my kids, with patients. That’s one reason why my Facebook profile is closed to both the public and my patients.

Yet Facebook has tremendous potential as a platform for patient education. But unless physicians friend patients, they can only do so with a Facebook page. In other words, a separate, professional identity.

(And yes, I’m aware that Facebook and Google+ allows you to group friends onto lists and circles respectively, where you can control the stream of information you broadcast to. But isn’t that just another way of separating your identity?)

Here’s my bottom line, which is more nuanced than both the JAMA perspective piece and current social media physician guidelines. On public social networks like Twitter or Google+, separating identities isn’t often feasible. I have a single persona on these platforms, where as a physician, I accept the expectation of being held to a higher public standard of behavior.

However, the personal nature of Facebook presents a greater professionalism risk for doctors. I continue to recommend that if physicians want to use that platform to educate patients, they do so with a page separate from their personal profile.

Kevin Pho, MD, ACP Member is co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is founder and editor of KevinMD.com, where this post originally appeared.

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QD: News Every Day--Taking opioid analgesics for longer spans may lead to depression

The risk of development of depression may increase when patients are on opioid analgesics longer, a study found

Prescription opioid analgesic use has quintupled recently. Evidence linking opioid use with depression emanates from animal models and studies of persons with co-occurring substance use and major depression. Little is known about depressive effects of opioid use in other populations.

Researchers conducted a retrospective cohort study based on medical records of nearly 50,000 VA patients without a history of opioid use or a diagnosis of depression within the previous two years.

Results appeared in the March issue of the Journal of General Internal Medicine.

The incidence of depression for the entire cohort was 6.4 %. Patients taking opioids for longer than 180 days had a shorter time to a depression diagnosis compared to patients taking them for 90 to 180 days and 1 to 89 days. The incidence of depression was 17.7/1,000 patient years for those taking them 1 to 89 days, 23.8/1,000 patient years among patients taking them for 90 to 180 days, and 27.8/1,000 patient years for those taking them more than 180 days.

Compared to patients whose prescription was for less than 90 days, the risk of depression increased significantly as the duration of opioid prescription increased (prescription 90 to 180 days: HR=1.25; 95 % CI, 1.05 to 1.46; prescription more than 180 days: HR=1.51; 95 % CI, 1.31 to 1.74).

Researchers suggested that patients starting opioid treatment should be monitored for depression, since an opioid-associated risk of depression was revealed in a population at low risk of depression given their advanced age and having no recent history of it in the previous 24 months, They suggested that some depression may have been avoided had opioid therapy not been started or limited to less than 90 days.

Authors wrote, “The term ‘Pharmageddon’ was coined to capture the epidemic nature and adverse public health consequences of opioid analgesics. Our findings add to such concerns by showing that opioid use for more than 90 days significantly increases the risk of developing depression.”

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Monday, February 24, 2014

My turning point

As an incurable compulsive introspect, I tend to brood, ponder, contemplate, and (of course) muse on “big ideas,” such as:
• What makes people choose things which cause themselves harm?
• Are some people better people than others, or are they just more skilled at hiding their problems?
• Is pain really a bad thing, or is our aversion to it a sign of human weakness?
• Does God ever wear a hat?
• Do dogs watch Oprah?
• Why did I put “big ideas” in quotes?

Tough questions.

Lately I’ve been contemplating the nature of human awareness:
• Is self-awareness (the ability to think of ourselves in the third person) a uniquely human trait, and is lack of self-awareness the essence of mental illness?
• Is empathy, or other-awareness the highest of human traits? Is this what the biblical idea of being “made in the image of God” really means?

Yeah, that’s a lot deeper than about dogs watching Oprah. The second of these questions seems to be a very important dividing point in people’s ability to have good relationships with others. Our ability to put ourselves into the place of others, pondering their motives, thoughts, and emotions, goes a very long way in helping us develop deep relationships and avoiding causing inadvertent pain.

It also seems to be a trait that is in short supply in our health care system. I am amazed and deeply disturbed by how callously many my patients have been treated by some of my colleagues. Patients are seemingly treated as a commodity, a necessary evil required for billing of services.

I do understand that doctors and nurses are drained of their ability to show compassion by a system that puts them in an adversarial relationship with patients, hospital administrators, insurance companies, lawyers, and their fellow doctors and nurses. That feeling of burn-out in me was one of the big reasons I left my old practice. Either I had to change my compassion, or my situation.

Still, I am appalled at how many times patients’ worries are not addressed, their pain is questioned, and their truth is doubted. More and more, patients are assumed to be manipulating, exaggerating, or making things up, and so must disprove these assumptions to get any kind of good care. Seeing this in the people I worked with was the other big reason I left my practice to do things differently.

While I think it’s probably part of my DNA to be more compassionate than most, there is 1 event that affected me more than any other, a moment where I suddenly saw things so differently that it dramatically changed my approach to my patients.

Ironically, my turning point was on a trip sponsored by a drug company to Puerto Rico. Yes, I know, I know, this kind of thing is now viewed as an act of evil avarice. They were trying to buy my prescribing habits by offering me all sorts of nice things. In my defense, I was young, not very rich, had 4 kids, and had never been able to afford a real family vacation. These kinds of perks were very common at that time, and I did still have to pay for my family to go with me.

Plus, as you will soon see, things didn’t quite turn out all that well. Karma, I guess.

The drug company sponsored event was at the end of the week, and we arrived in Puerto Rico early in the week so we could go to different parts of the island and see the sights. After enjoying the beaches on the east coast and the rain forest in central Puerto Rico, we arrived on the west coast city of Rincon, the surfing capital of the island.

On the second day in Rincon, I got the delusion that I was: a) younger than I was, and b) far more coordinated than I am. I tried body-surfing. The 6-foot surf unfortunately broke quite close to the beach, which turns untrained body-surfer into a projectile launched at great speed into 6 inches of water. As my face was about to be planted into the sand, I put my arm up to protect my face and (more importantly) my neck. The result: a fractured surgical neck of my right humerus.

While I immediately knew something was seriously wrong, I didn’t know it was a fracture. In my pain-induced confusion, I allowed myself to be convinced that the people on the beach (in various stages of inebriation) knew something about first aid for shoulder injuries. After a few attempts to locate my “dislocated shoulder” (and several offers of alcoholic anesthesia), I was still in really bad pain, and decided that perhaps I should seek the opinion of a real doctor.

I will skip my adventures in the Puerto Rican health care system (now a blur of oxycodone-clouded memories of Spanish-speaking soap operas, paper linens over my wet, sandy body, and my cries of “mucho dolor” to the radiology tech as she tried to twist my arm to get a better picture). I will also skip my time at the drug-company conference (also experienced in an oxycodone-induced blur).

Not long after I came home, I met up with a surgeon who also recently had broken the same ironically-named bone a few months earlier. He got a smug look on his face as he bragged, “I was back doing surgery after 4 weeks.” Four weeks seemed like a long time to be out of work, but it gave me some idea of what to expect.

But after 4 weeks of healing, with the first 2 devoted to immobilization and oxycodone, and the second 2 to the cruelty of physical therapists seemingly unaware that I had FRACTURED MY FRIGGIN’ SHOULDER, I was not anywhere near to being functional. I couldn’t lie down in bed, and I could barely move my arm without significant pain.

The words of my surgeon colleague echoed in my head as I walked into the orthopedists office for another X-ray, exam, and opportunity to satiate the sadistic needs of my physical therapist. Chris was doing surgery at 4 weeks? I could barely scratch my nose. What is wrong with me? Am I a wimp? Am I really feeling this much pain? I asked my orthopedist why our surgeon friend had such an easier go of this same fracture. Was he different? I was desperately trying to escape the obvious proof of my membership in the brotherhood of whooses. He told me he didn’t know, and said he’d get back to me.

After a few weeks of doubting my pain and my manhood, my orthopedist happily informed me that Chris had a mid-shaft fracture, which is far quicker to heal than my fracture of surgical neck of that bone. I was off the hook! I wasn’t the king of the whiners! My pain was real!

It took nearly 4 months before I could lie flat in bed, and almost a year before I was mostly pain-free. But as I pondered my incredible self-doubt and shame over my pain, I realized something: many of my patients have that same fear. Here I was, with as good of a reason to feel pain as anyone could have, and I was doubting my own experience as being valid. How much more of these feelings of doubt and shame do people with fibromyalgia, chronic back pain, or chronic fatigue feel?

This idea changed forever how my approach to my patients. Instead of judging whether a person’s symptoms were “real or not,” I try to reassure them that I believe them and didn’t doubt their reality. Over time, I’ve come to believe that my patients almost always tell me the truth about their experiences. The problem comes when they do one of 2 things: either try to self-diagnose, mixing up their theories with their symptoms; or they exaggerate their symptoms to get medical people to believe them. People are so used to being doubted that they feel they have to make the story more dramatic (resulting usually in decreasing their credibility).

This brings me back to the idea of other-awareness, or empathy. My experience of self-doubt about my experience of pain taught me one of the most important aspects of my patients’ psyches. They are afraid. They feel vulnerable. They desperately want to be heard, understood, and believed.

Fortunately for me and my patients, my new office is centered on communication, not documentation. As opposed to the rest of the health care system that seems driven to de-personalize doctors, nurses, and patients, my office is all about relationship. I used to have to offer compassionate and empathetic care despite the system we lived in, but now I am rewarded for it.

I like to think that at least some of my colleagues who have lost the emotional energy to care about patients’ needs would gain it back if given the opportunity in my environment. My degree of emotional burn-out last year was, in large part, due to my refusal to stop caring. It’s sad when a system built to care for people squeezes compassion out of those whose job it is to give that care. The need for reform is more than just a financial one, it is a human, personal, and spiritual one.

Once we solve that problem, we can turn our thoughts to the harder questions, like whether dogs watch Oprah.

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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Hospital patient IT portals are a nice idea, but ...

Patient portals are very much the future of health care. Having easy access to ones’ medical history, diagnoses, and test results, seems like such a natural thing that it’s hard to imagine that only a couple of decades ago medical information was regarded as private for the physician’s eyes only.

Of course, the Internet and a technology revolution have taken this concept to a whole new level. Health care organizations across the nation have been embracing “patient portals” to give patients online access to their records. The federal government’s Meaningful Use policy has provided significant financial incentives to do this.

Among the first to roll out the technology have been the larger multispecialty-type groups that are affiliated with established hospitals. Meaningful Use Stage 2 stipulates that at least 50% of patients must have timely online access to their records, and 5% of patients must transmit electronic health information to their provider. It remains to be seen whether imposing these targets will truly improve patient care (although the concept certainly sets the stage for doing so). But while increasing patient engagement via health care IT is an extremely useful idea for outpatient use, a debate is taking place as to how this should work for inpatient care.

Imagine the future scenario for a hospitalized patient. The doctor walks into the room, and the patient has already seen test results, whether on their own smart device or a flat screen at the end of the bed (now we really are talking about the future). Theoretically, this should make the doctor’s job easier in terms of explanation and implementing a strategy. The medical profession should welcome this model of patient-centeredness. The more engaged and informed the patient, the higher the likelihood of a better outcome.

Nevertheless, some hospital-based physicians are rather uncomfortable with the idea that hospitalized patients will be able to routinely access their results electronically. I must admit that the times I’ve walked into a patient’s room and heard them tell me what that morning’s blood test results are, it has thrown me off a bit! However, this has really only happened a handful of times, probably under half a dozen occasions in my 5-year career in hospital medicine, and typically it’s been a relative rather than the patient who has pulled up the information.

Despite the easy access that many patients now have, uptake of IT portals has been relatively slow when it comes to hospitals. Does the vision of the future involve patients rapidly accessing all of their test results while they are still lying in the hospital bed? Time will tell, but right now a number of barriers exist:
• The average age of a hospitalized medical patient is over 70 years old. Simply put, this population isn’t the tech-savvy generation that is comfortable using laptops and smart devices;
• People in hospital are often too sick to be scrolling around a screen and digesting complicated information on their own;
• Patients may not have ever used a health care IT portal before, and during their hospitalization is not really a good time to learn;
• In a significant number of hospitals, the technology isn’t yet available to enable patients to get real-time access to their results;
• Low health literacy and patient engagement. There has to be a reasonable baseline understanding of what the different test results mean. A large proportion of patients, especially those from socially disadvantaged backgrounds, are considerably less likely to use and embrace health care technology. And even for more highly educated patients, many seem comfortable putting their complete trust in the doctors and medical staff, and await their results and prognosis to be delivered to them in person rather than access it themselves.

These 5 points are important reasons why IT portal use has been limited among hospitalized patients. Another limitation is that unlike the outpatient setting, getting information in hospital is more complex and presents a whole new set of challenges, particularly when we’re talking about “real time” access to test results. Viewing laboratory values without waiting for the doctor is one thing, but what should the protocol be for getting imaging or pathology results? Or dictated consultation notes? Most of this other information needs to be “electronically signed”, which can take several hours or days. Having this information available to patients before it is reviewed and signed off could potentially result in serious consequences. And on a human level, if the patient was faced with a potentially devastating diagnosis, would it ever be better for them to have access to the result before the doctor had the chance to sit down and talk with them? Even in the ultimate patient-empowerment model, this is a difficult case to argue.

So while the future almost certainly involves hospital patients accessing results themselves, the implications of this need to be considered carefully. As patient portals become more common, health care organizations must decide how best to use them. The question is: how much real-time information is too much?

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--Secondary thyroid cancer more deadly than primary malignancy in young individuals

A new analysis has found that adolescents and young adults who develop thyroid cancer as a secondary cancer have a significantly greater risk of dying than those with primary thyroid cancer.

The findings stress the importance of screening young cancer survivors to detect early signs of a potentially life-threatening thyroid malignancy, researchers wrote.

To compare the tumor characteristics, treatment, and survival of such primary versus secondary thyroid cancers in adolescent and young adult patients, researchers reviewed all adolescent and young adult thyroid cancer cases documented in the 1998-2010 American College of Surgeons National Cancer Database. Results appeared online Feb. 24 in CANCER, a peer-reviewed journal of the American Cancer Society.

Of 41,062 cases, 1,349 (3.3%) had experienced a prior malignancy. Compared with cases of primary thyroid cancer, cases of secondary thyroid cancer were more likely to be small but to occur in more than one location. Also, patients with secondary thyroid cancer were 6.63 times as likely to die than patients with primary cancer (95% CI, 4.97 to 8.86, P<0.001) after adjusting for demographic, tumor and thyroid treatment factors, though survival with treatment is excellent for both at greater than 95%.

This study suggests that there may be differences between thyroid cancers seen with or without a prior malignancy, the authors wrote.

Primary thyroid cancers occurred more often in early teens and 20s compared to those who were 15 to 19 years old or over 30, where secondary thyroid cancers were more common. Researchers suggested that there may be a long latency—up to 30 years—in developing clinically apparent thyroid cancer after radiation or chemotherapy. Or, it is possible that older patients have had more time to develop secondary thyroid conditions such as multinodular goiter or hyperthyroidism, and then discover incidental, secondary thyroid cancer in a thyroidectomy pathology specimen.

“This is an important new observation for the 3% to 4% of this population who are already survivors of pediatric or other AYA (adolescent or young adult) cancers,” the authors wrote. “These numbers are not insignificant considering that thyroid cancer is one of the most common AYA cancers, especially among females, and patients need to be counseled appropriately. In addition, differences in thyroid cancer survival usually require 15 to 20 years of follow-up, rendering the results of this study quite significant.”

Learn more about treating adult survivors of pediatric cancers.

History is key after childhood disease, according to a previous article in ACP Internist. For people who have survived a childhood disease and those living with a chronic disease or disability, making a successful transition to adult health care means finding a physician who is informed about the special and sometimes surprising challenges ahead. Read more.

It’s tough to navigate return from cancer care to primary care, ACP Internist covered in a second article. Both the general medicine and oncology communities have paid increased attention in recent years to the transition of cancer patients back to their primary care physician after active cancer treatment has been completed. Read more.

And, most survivors of childhood cancers at highest risk for a second neoplasm in adulthood didn’t follow recommended screening intervals, according to a study reported in ACP InternistWeekly.

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Friday, February 21, 2014

Ultrasound in South Sudan: what might it be good for?

I spent 2 weeks in a small hospital in South Sudan and probably did about 100 bedside ultrasounds. The whole experience was very moving, and encompassed so much more than doing ultrasound, even though I had intended the trip to be primarily for teaching ultrasound applications. It turned out that I also had to learn as much tropical medicine as my aging brain could hold and clean up spider webs and feed people and put goop on rashes and sew up gashes and learn to say hello in Nuer and a number of other things which will occupy an important place in my heart for years.

But as an ultrasound nerd, there were many exciting nerdy moments. These were the moments that most ultrasound nerds experience when we realize, again, that this technology is totally cool and that we wish everyone could do it.

I have spent the last 2 years practicing hospital medicine and a little bit of primary care and doing thousands of bedside ultrasounds. I have taken classes and tests and spent free moments studying ultrasound anatomy books. I have taught students and shared pictures with specialists and attended meetings. I have ultrasounded friends and family members, my dog, taken a fellowship, bought 2 machines, and given one away. All because ultrasound is cool. It is indescribably awesome to look inside a person’s body without hurting them.

In the United States I use bedside ultrasound to answer pretty specific questions that are relevant to my practice. Is the heart function normal? Is there fluid in the belly or lungs which shouldn’t be there? Do the kidneys and bladder empty properly? What do the great vessels say about hydration status?

In Africa I had less standard testing to help guide diagnosis, so the ultrasound got to tell me more information. Here are few ways it helped me:
1. Strong guy, walked in limping, having stepped on a thorn 5 days before. He was sure there was something in his heel. I hate getting foreign bodies out of heels. It really hurts and the flesh is so firm that it is nearly impossible to explore a heel. I had only the phased array transducer for visualizing large deep structures, but by using a rubber glove filled with water as a stand-off pad I was able to visualize an echogenic long thin thing about 2 cm down, numbed it up generously, sliced it open and pulled out a big thorn. Wow. Just like in the movies!
2. Two women came in very short of breath after long journeys. Tuberculosis is endemic in South Sudan. Both had pericardial tamponade with moderate effusions and calcified pericardia, probably indicative of chronic tuberculous effusion. Tuberculosis is treatable, but definitively treating pericardial tamponade was not practical. Diagnosing the condition was interesting from an imaging point of view, but the two ladies died anyway.
3. A couple of patients had kidney failure. By history it seemed likely that it was not new, but ultrasound was helpful in ruling out obstruction and the kidneys of both were echogenic, suggesting that the condition was not likely to improve much.
4. One patient appeared quite short of breath, but it was unclear if she had asthma or pneumonia or something else. There is no X-ray machine. The ultrasound showed bilateral pleural effusions which strongly supported a diagnosis of tuberculosis. This was treated effectively with anti-tuberculosis medications and steroids. Her pleural effusions nearly disappeared within a few days of treatment.
5. An old man had been discharged for presumed congestive heart failure. He was clearly going to die, and his daughter had taken him to a hut in the village before taking him home. His ultrasound showed a huge tumor in his chest cavity displacing his heart, which otherwise functioned just fine. His heart medications could be stopped.
6. A young woman had come in to the hospital with a premature delivery and post-partum hemorrhage. She was anesthetized and the retained placenta was manually extracted, but it was not clear that it had been completely removed. Ultrasound showed an empty uterus, allowing her to go home when she had stabilized.
7. Other women with vaginal bleeding could either go home if they were stable, with a completed miscarriage, or could be counseled to rest if a pregnancy could be visualized.
8. There were leg infections which were slow to heal, some with pus collections that had been drained. Ultrasound could tell us if they needed repeated drainage.
9. A woman with a suspected ovarian cancer had a painfully huge belly from ascites. She responded pretty well to therapeutic paracentesis, but the ultrasound was very helpful in allowing us to dodge the large peritoneal tumor masses that might have caused bleeding.
10. Evening clinic often brought babies who were under the weather. Doctors in South Sudan see enough untreated congenital heart disease that they could be reasonably certain of a diagnosis of ventricular septal defect. Still, seeing the hole in the heart on ultrasound and the degree of heart enlargement was very useful. Some babies can make it to Khartoum, the capital of Sudan, and may be eligible for free heart surgery.
11. and also so many reassuringly normal or near normal ultrasounds.

How and who to teach in this setting is a good question. Caregivers have varying backgrounds and must actively develop new competences when patients are sick and demand is high. It is interesting that the ability to visualize a person’s internal organs with ultrasound and correlate those pictures with previously learned anatomy does not necessarily spring from an extensive medical education. Some people are just good at it. I encouraged the people I taught to ask specific questions rather than looking for weird things like tumors.

Finding a normal fetal heart rate, determining fetal presentation and estimating fetal age are very useful and not hard to learn. These will be possible to learn and practice with a little bit of supervision. Finding fluid in the belly is easy and potentially very useful. Detecting fluid in the lungs will take a little more work, but should be easy eventually. Looking for a full or empty bladder should not be too hard to master. Most hearts will be normal, so detecting that there is something wrong should come with a little practice. Diagnosing exactly what is wrong is quite a bit trickier. Protocol driven diagnostics and treatments have been very effective in resource poor settings, so a more complete training course should probably include a protocol of when to do ultrasound and what questions are reasonable to ask.

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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Procedure costs and physician income disparity

As an internist (yes I am a specialist, just not a subspecialist), I do no procedures. Patients pay me (albeit mostly indirectly) for my cognitive skills. But we live in a culture that seemingly rewards procedures more than pure cognition. Now I understand that procedures are not mindless. Physicians doing procedures must think prior to the procedure, during the procedure and after the procedure. But cognition without procedures seems undervalued.

The New York Times includes an article that tells the story dramatically, “Patients’ Costs Skyrocket; Specialists’ Incomes Soar.” In glancing at the comments, many complain that physicians never discuss prices. (Note that I use price here rather than cost. Cost has a specific economic meaning and price and cost are not equivalent.) Most physicians avoid this discussion, likely because an insurance company is usually paying, and because they are either ignorant of the price or embarrassed to discuss money.

Interestingly patients probably value cognition more that the insurers (including CMS). Many patients willingly pay extra for access, as the growing field of retainer medicine demonstrates. Patients want adequate face to face time with physicians, access through phones, texts and/or e-mails and rapid access when necessary.

Our payment system is unfortunately gamed by too many subspecialists. The decision to do a procedure is often made by the person who does and financially benefits from that procedure. Thus, these subspecialists may have a financial conflict of interest. Most physicians respond to such conflict in a healthy rational manner, but temptation can lead to abuses.

Dr. Wes, a cardiologist, takes offense at the Times article, “The Importance of Demonizing Specialists.” I do not read the article in the same way, but then I have a bias that the income disparity between those who financially benefit from procedures and those of us who “merely think” through patient problems is excessive. I believe that we do need more generalists and that potential income drives our graduates (of both medical school and internal medicine residencies) away from generalism. Money does matter.

I am happy for cardiologists to make more money than I do. I have often advocated for an adjusted pay per unit time. Those who have to come to the hospital at night for emergency care deserve a significant differential for that time. The longer training for cardiology justifies higher pay, the only question is how do we determine the proper multiplier.

Price transparency might address these issues. Perhaps this article will stimulate enough discussion to start a corrective process.

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 Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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QD: News Every Day--Medication to treat agitation for Alzheimer's disease may have cardiologic consequences

Citalopram at 30 mg per day was associated with a reduction in agitation in patients with Alzheimer’s disease, but patients experienced mild cognitive and cardiac effects that might limit its use, a study found.

Researchers randomized 186 patients with probable Alzheimer’s disease without major depression and clinically significant agitation from 8 academic centers in the United States and Canada to receive citalopram (n=94) or placebo (n=92) for 9 weeks. Interventional dosage began at 10 mg per day titrated to 30 mg per day over 3 weeks based on response and tolerability. Both groups received psychological counseling and assistance.

Results appeared in the Feb. 19 issue of JAMA.

The estimated treatment difference at week 9 (citalopram minus placebo) on the 18-point Neurobehavioral Rating Scale agitation subscale (NBRS-A) was −0.93 (95% CI, −1.80 to −0.06), P=0.04. Results from the modified Alzheimer Disease Cooperative Study-Clinical Global Impression of Change (mADCS-CGIC) showed 40% of citalopram participants having moderate or marked improvement from baseline compared with 26% of placebo recipients. The odds ratio (OR) of being at or better than a given CGIC category was 2.13 (95% CI, 1.23-3.69), P=0.01. Participants who received citalopram showed significant improvement on the Cohen-Mansfield Agitation Inventory (CMAI), total Neuropsychiatric Inventory (NPI) and caregiver distress scores. But, they did not improve when assessed by the NPI agitation subscale, activities of daily living or in less use of rescue lorazepam.

Worsening of cognition (−1.05 points; 95% CI, −1.97 to −0.13; P = .03) and QT interval prolongation (18.1 ms; 95% CI, 6.1-30.1; P=0.01) were seen in the citalopram group, leading researchers to conclude that citalopram cannot be generally recommended as an alternative treatment option at 30 mg per day.

Researchers wrote, “An assessment of individual patient circumstances, including symptom severity, value of improvement, cognitive function and change, cardiac conduction, vulnerability to adverse effects, and effectiveness of behavioral interventions can help guide appropriate medication use in patients with marked agitation or aggression.”

An editorial noted that clinicians should continue to emphasize nonpharmacological strategies and cautiously use medications.

“In addition to educating caregivers and family members about the potential risks and benefits of particular medications, physicians should carefully document their treatment plans and aim for short-term treatment to minimize the possible added risks of long-term use,” the editorial stated. “As demonstrated by the results of this study of citalopram, when behavioral interventions fail to improve agitation, multiple factors need consideration for selecting the best medication for an individual patient, including cardiac safety issues and evidence of efficacy from randomized controlled trials. Until more definitive treatments are available, the careful selection and monitoring of pharmacologic agents may help optimize the level of functioning and quality of life for some patients with dementia.”

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Thursday, February 20, 2014

On faith and data

As a scientist with a brain naturally inclined to skepticism and analysis, I suppose my spiritualism may be best captured by: Keep the faith, but get the data. While some of my fellow skeptalytics, if I may coin such a term to catalog us, may be inclined to renounce that first clause altogether, thinking there is no need for faith, I am obliged to disagree.

We are all a mass of electrons spinning madly around their nuclear bonfires, with empty spaces inside every atom vaster in relative terms than those separating the planets and star of our solar system. That so implausible a thing as a caress is possible in such a world of empty spaces masquerading as solid surfaces where skin meets skin requires an embrace of the virtual realities perceptions devise, and thus faith in the prevailing illusion. Even the faithless have faith, if only in the reliability of the perceptions that get us through each day. To partake in the implausibility of this life is an act of faith.

With regard to an almighty, my personal faith is mostly in my own ignorance. The universe is so staggeringly vast and dizzyingly complex that to call it humbling would be like calling the Himalayas “tall” or the Pacific “big.” It is oppressive to contemplate how trivial we are in so colossal and intricate a construct. I can certainly understand the inclination to invoke designs other than our own to impart to us some importance we would otherwise clearly not possess.

But it helps me little in explaining the overwhelming complexities all around us to ascribe it all to an even more complex engineer of those complexities. If a Big Bang that seeded the universe is hard to contemplate, that much more so the perfect bundle that existed the instant prior, a fusion of every potential thing and thought, substance and sentiment to follow. We may shop the lexicon for labels as we choose, but something very much like “god” was implicated in that explosion, the source of all creation.

All I know for sure is how much I don’t know for sure. And that, really, is my topic here. This column is less about faith and more about missing data.

Religious faith, of course, is supposed to run in the absence of data. That, it seems, is the very test of faith worthy of the appellation. So the religiosity native to religion is understandable. Convictions born of faith in the absence of data are welcome, even encouraged, in houses of worship.

Still, the machinations of organized religion, the codification of faith into specific rules and regulations, scripted interpretations of the will of the almighty, might give pause to more than just we skeptalytics. The various notions of god that prevail in the world attribute to that entity mutually exclusive inclinations for everything from how best to get to heaven, to the right kind of headwear.

That the interpretations are mutually exclusive is self-evident. It is the very reason why there are different religions in the first place. And, of course, discordant knowledge of who, exactly, god is and what, exactly, god wants figures saliently among the goads to war throughout history, and to terrorism in the modern world. Admittedly, those same competing visions have inspired great art, great architecture, deep contemplation, and fervent compassion. But still, an incalculable sum of human suffering derives from our competing claims to absolute knowledge.

This is where I find myself troubled. We, of course, are rather trivial beings and all too fallible. So that we should bungle in any given context is a foregone conclusion. But across an array of competing attitudes and attributes, all major modern faiths do seem to agree that any god worth all the fuss is infallible.

How is it, then, that his/her/its radio is broken?

One must presume that a benevolent and parental kind of god, the very kind of god in which many of us invest our faith, wants the best for us. And since, as the saying goes, we are “all” god’s children, one might reasonably infer further that such a god wants the best for not just some, but all of us.

One might also allow, however, that free will does its mischief. Some of us are just disinclined to be good. Short of making us good by force, god, like any parent, must accept the liabilities of wayward children.

But what of the children who are not wayward, but rather misguided? If any given religion is right in all of its details (and if all of the details don’t matter, why, then, are there so many details? God either does, or doesn’t, care what kind of hats we wear), then every other religion is wrong. Since every faith is home to people who are good and fervent and ardent and kind—people eager to know the divine truth—it all begs a question. How can the correct divine signal fail to reach those eager to receive it? Worse, how can such people get the wrong signal and find it entirely convincing?

I don’t know the answer, but it shakes my faith. In science, we know darn well that we are missing data. Science is the struggle to know truths that are subtle, and at times stubbornly elusive. The only way to them is incremental, accelerated by the occasional epiphany courtesy of rare genius. Scientific truth comes together slowly, and along the way is riddled with fenestrations.

No surprise, then, that it is vulnerable to mischief and manipulation. Pieces of truth can be misinterpreted for, or misrepresented as, the whole. Sellers do this because it’s a chance to get on the gravy train. Pick the signal you prefer, cite the evidence selectively, and peddle, peddle, peddle.

No surprise then that we are sold mere grains of truth about science, and in particular, that area of science that matters most to me: The application of diet and lifestyle to health promotion and disease prevention. No surprise that we are sold mere grains of truth about grains and fats, fruits and nuts, feet and forks.

The surprise to me has always been that we buy them. Looking on as competing factions embrace divergent theories based on selective renderings of partial truths, I have long been surprised. I have wondered why people with good sense seemed to renounce its application when titillated with magical thinking about weight loss and health. I have lamented our tendency to accept at face value ludicrously exaggerated claims about single-ingredient scapegoats or saviors, and to infuse religious fervor into considerations of what and when make for the best breakfast. I have been forced to concede that perhaps desperation breeds gullibility.

But I have kept the faith that a larger, less partisan truth would ultimately prevail. I have clung to the conviction that truth is often immediately furtive, but relentless and ultimately indomitable. Seekers of truth are patient of necessity, obliged to be disciples of time. So far, I have kept the faith that eventually enough data would rally us to common understanding and common cause.

I do still hope so. But today I concede that in darker moments, my faith is shaken. Truths taken as divine are widely contested. If even an almighty signal fails to rise above the din of discord, how mad the presumption of hope for such lesser truths from we of such small voices. Maybe no signal can rise about the static in a universe where even god’s radio is broken.

I will cling to the faith that it isn’t so, but I sure would like to see the data.

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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SHEA: obsessed, and proudly so

The SHEA guidance on health care personnel (HCP) attire is now available (free!), and is already drawing media attention. I particularly enjoyed the NBC News description of SHEA as “the group obsessed with stopping infections in hospitals and health care settings.”

Obsessed? Miriam-Webster describes obsession as “a state in which someone thinks about something constantly or frequently, especially in a way that is not normal.” I prefer the Urban Dictionary definition of obsessed: “Just a word the lazy use to describe the dedicated.” And it got me thinking that this may be behind some of the general resistance to any guidance about HCP attire. What is this group doing, suggesting what I should wear (or not wear) in the hospital, and how often I should wash my garments? They must be obsessed or something. Show me the data, weirdos!

Therein lies the rub with HCP attire, as with so many other infection prevention practices. There may be biological plausibility that clothing plays a role in pathogen transmission, there may be evidence for pathogen contamination of HCP attire, and there may be a favorable balance of benefit versus harm in implementing changes in practice (such as a bare-below-the-elbows (BBE) approach).

But we still lack that direct link between HCP attire and HAI risk. Thus the SHEA guidance ends with a laundry list (pun intended) of research priorities for HCP attire:
• Determine the role played by healthcare personnel (HCP) attire in the horizontal transmission of nosocomial pathogens and its impact on the burden of HAIs.
• Evaluate the impact of antimicrobial fabrics on the bacterial burden of HCP attire, horizontal transmission of pathogens, and HAIs. Concomitantly, a cost-benefit analysis should be conducted to determine the financial merit of this approach.
• Establish the effect of a bare-below-the-elbows (BBE) policy on both the horizontal transmission of nosocomial pathogens and the incidence of HAIs.
• Explore the behavioral determinants of laundering practices among HCP regarding different apparel and examine potential interventions to decrease barriers and improve compliance with laundering.
• Examine the impact of not wearing white coats on patients’ and colleagues’ perceptions of professionalism on the basis of HCP variables (e.g., gender, age).
• Evaluate the impact of compliance with hand hygiene and standard precautions on contamination of HCP apparel.

Now try to imagine the logistics, and costs, associated with a study large enough to demonstrate the incremental contribution of HCP attire to HAI infection risk, or the impact of BBE on HAI incidence. Knowing how long we will be waiting for such evidence, what do you plan to do in your 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. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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QD: News Every Day--Patients pay attention to online reviews when choosing doctors

More than a third of people select a physician based upon online ratings, and more than a third avoid a doctor who has bad reviews, according to a research letter in the February 19 issue of JAMA.

Researchers conducted an online survey of a nationally representative sample of the U.S. population (more than 3,500 adults) in September 2012 about their knowledge and use of online ratings for choosing doctors.

Results appeared in the Feb. 19 issue of JAMA.

Among the findings:
• 40% reported that physician rating sites were “very important” when choosing a physician, although rating sites were endorsed less frequently than other factors, including word of mouth from family and friends;
• the 65% percent awareness rating of online physician ratings was lower than for consumer goods such as cars (87%) and non-health care service providers (71%);
• 35% reported selecting a physician based on good ratings and 37% had avoided a physician with bad ratings; and
• among those who had not sought online physician ratings, 43% didn’t trust in the information on the sites.

Researchers acknowledged limitations, including that an Internet-based survey was biased toward a web-savvy population that was younger than most health care consumers. (Twenty-one percent of respondents were 18 to 29; 17%, 30 to 39; 18%, 40 to 49; 19%, 50 to 59; and 26%, 60 or older.)

“Nevertheless, rating sites that treat reviews of physicians like reviews of movies or mechanics may be useful to the public but the implications should be considered because the stakes are higher,” researchers concluded.

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Wednesday, February 19, 2014

OHSU helps to make the electronic health record SAFER

It is important for all who work in informatics, especially those in academia, to acknowledge both the benefits as well as the harms of health information technology (HIT). As noted in a recent blog post, an updated systematic review of HIT evaluation research shows there is clear value to the use of HIT in improve health and health care delivery outcomes.

But we also know that like any clinical intervention, HIT can have adverse effects. If not implemented safely, it can not only lead to harm, but also waste a great deal of money. We must therefore, just like with other interventions, implement HIT, especially the electronic health record (EHR), using best practices and keeping an eye for possible harms. The framework for HIT safety was laid out in a report from the Institute of Medicine in 2011. This report included a chapter on how to avoid “e-iatrogenesis.” The lead author was Oregon Health & Science University (OHSU) informatics faculty, Dr. Joan Ash, and I was one of her co-authors.

I are now pleased to report that Dr. Ash has led an important further contribution in HIT safety, which is serving as the lead author on the SAFER (Safety Assurance Factors for EHR Resilience) guides that were released by the Office of the National Coordinator for HIT (ONC) last week. These guides are based on the best known research evidence for optimizing implementation of the electronic health record (EHR) safety. Recent ONC Director Dr. Jacob Reider wrote in the ONC HIT Buzz Blog about the importance of the SAFER guides. Dr. Ash collaborated on the guides with Drs. Dean Sittig and Hardeep Singh of the University of Texas Health Science Center at Houston.

The SAFER guides, along with research about the value of HIT, also drive home the importance of informatics expertise in implementing HIT. Well-trained informaticians bring knowledge and experience to HIT implementation, including being aware of the existence of tools like the SAFER guides. These guides will allow informaticians and others to apply best practices to EHR implementation.

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

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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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