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Monday, March 31, 2014

Observation versus inpatient is a different world for today's medical residents

Like a lot of physicians right now I sometimes have to stop and take a few deep breaths when I realize how quickly the world of medicine is changing. Having been out of residency and in clinical practice for just over 5 years, the pace of new developments is staggering. One of the biggest changes to take place over the last decade is the increased emphasis on cost containment and delivering real value for our patients. It simply wasn’t even talked about not so long ago. This is manifesting itself in various ways, and much of it is truly needed (like ordering tests and investigations like confetti without solid medical evidence and necessity).

One example of a new and stricter Medicare administrative distinction is whether a hospitalized patient is admitted under “inpatient” or “observation” status. Any doctor practicing in the hospital medicine environment, including a lot of specialists who see hospitalized patients, constantly now hear about the importance of this decision. For those of you not in the medical world, the decision basically hinges on the patient’s acuity level, and can have large financial implications for the patient and hospital alike. The issue is gaining national media attention, as evidenced by this recent New York Times article. Because of the controversy and perceived unfairness, there are many who believe that this distinction should be done away with altogether. It would be far simpler to have all patients either admitted to hospital or not, with no further delineation.

Sadly, I’ve already noticed a handful of patients and their relatives worried about their “status”. Thankfully, these have been few and far between so far, but will inevitably become a bigger concern as more awareness of the issue is raised. Is it right that a 90+ year-old World War 2 veteran who landed on Normandy Beach be subjected to this additional stress after they come into hospital with a bad fall, and are told that their observation stay will mean paying more?

But to the main point of this article. As a teaching attending, I always feel a bit sorry for my interns and residents whenever they present a case to me and finish up with a statement explaining whether the patient should be made observation or inpatient. Ultimately of course it is the attending physician’s decision, but sometimes I hear the intern or resident getting into overly precise details about their thoughts behind the decision. “This patient should be placed in observation status because …” “This patient is too sick to be made observation status because …” “This patient should be made inpatient because …” All very well and good; they are recognizing an important part of a modern day hospital stay. There’s the reasonable argument that this next generation of physicians should be well-versed in the realities of the medical environment they are about to enter.

To be fair, residency programs across the country have at least tried to provide some education about this pressing issue for hospitals. However, a large part of me believes that the job of an intern, resident, or indeed a medical student is to learn good medicine and not burden themselves with administrative decisions. Oh, how things have changed over the last few years! Most doctors practicing today didn’t have to even think about many of these things when they were residents. It used to be that we just saw the patient and presented our history, physical, assessment and plan. Isn’t that as it should be?

It gets into a broader debate about how much we should involve our doctors in training when it comes to the central administrative side of medicine. How do we balance this with the need to focus on medical education and how can we shield these young doctors as much as possible from the realities that will inevitably hit them after they finish their residences? Surely some more intense education in the final year of their residency about such things should suffice.

When it comes to the observation versus inpatient decision, I always try to encourage those that I am teaching to just scratch the surface of the issue. My advice to all doctors in training: Just know the bare basics and one sentence is enough at the end of your assessment. A few seconds of time only please, and no lengthy discussions or debates about this in the intern’s presentation. Your attending physician can figure out the rest. If there’s any confusion, whoever else is dealing with this decision and any “status flips”—typically case managers—can put additional energy into this. Focus on being a good and competent doctor first and foremost. You’ve got the rest of your career to understand the administrative (and political) side of medicine.

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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Gills, pills and obesity genes

Two new studies, just published online in JAMA Pediatrics, may have us fired up yet again about the genetic variation to blame for obesity. But then again, is that really the problem?

One of the studies examined variation in food and satiety responses, which we may summarize as appetite, in roughly 400 pairs of 3-month-old twins in the U.K., and tracked growth and development over time. There are always lots of important details in biomedical research, but the perhaps predictable punch line was this: the babies with the heartier appetites gained the more weight.

The second study was directed at the same basic issue, but went a bit deeper. Investigators again examined the association between appetite and weight gain in a group of over 2000 twin children in the U.K., but this team included an assessment of genes associated with variation in satiety responses, essentially how much eating it takes to feel full. Once again, more appetite meant more weight gain. But this time, more genes for more appetite was identified as the real culprit.

Finally, an accompanying editorial noted the importance of this kind of genetic research because the obesigenic environment “does not affect all children equally.”

That is undeniably true. It is equally true that the sinking of the Titanic did not affect all passengers equally. More generally, falling into water does not affect all human beings equally. Some of us know how to swim, and some do not. Some of us can hold our breath longer than others.

And while there is, I am quite confident, genetic variability we could find and associate with variation in how long we can hold our breath, I am not sure how illuminating that would truly be about the risk of drowning.

Human beings are vulnerable to drowning because we don’t have gills, and the reason absolutely resides in our genes. We have Homo sapien genes that include the recipe for lungs, and exclude the recipe for gills. In contrast, blue fin tuna and guppy genes reliably include the recipe for gills and exclude the recipe for lungs. Blue fin tuna and guppies have just the kind of trouble out of water that we are prone to have in it. We don’t have gills because we aren’t fish, and fish don’t have lungs because they aren’t people. And in both cases, the reason we aren’t them and they aren’t us resides in our respective genes.

Given that, if we approached drowning like obesity, we would go looking for those genes. We would, readily, find the divergences between human and guppy genes. And we might, I suppose, declare that a genetic basis for drowning had been identified. And once genes were indicted for drowning, we could head off down the path of drug development or genetic engineering to deal with the problem.

Hold that thought, if not your breath, and let’s probe the corresponding depths.

Imagine a people on some imaginary world that lived on a great landmass, far from any body of water, evolving and adapting accordingly throughout their long history. Then imagine that, after however many eons in their native land-locked state, and for reasons we may ignore or guess at, these people set off on an excursion, and encounter the sea for the first time. They knew water, of course, because they drank it like we do, but they had never before seen any body of water larger than a puddle.

Imagine that these pioneers were intrigued by the sea, and therefore boldly wandered in. Having no experience with matters maritime, and knowing nothing about swimming, several of them drowned. Several others nearly drowned, but managed to climb out in the nick of time.

And then imagine, rather than reaching any fundamental conclusions about the interactions of their kind with large bodies of water, these sagacious people scratched their extra-terrestrial heads and said something like (in whatever language they speak): “When we wander into that enormous puddle, some of us die and some of us don’t. Clearly, then, there must be variation in our go-forth-into-enormous-puddle genes. Let us study our genes and look for that variation so we may better understand what happened here today. Then, perhaps, we might find a way to fix the go-not-into-great-puddles-or-you-will-surely-drown genes, as those must be defective. After all, a few of us went into the big puddle and lived. Surely there must be some way for us all to have those wonderful you-will-only-almost-die-if-you-go-into-great-puddle genes. “

Gazing at these counterparts across the cosmos, they look rather like nincompoops, don’t they?

I am not refuting the value in these new studies. The editorialist very appropriately notes that early identification of genetic vulnerability to weight gain might allow for very early implementation of prevention strategies, so that obesity does not develop in the first place.

I like that, but do we really need maps of our kids’ genomes to take such action? We have pandemic childhood obesity right now, meaning legions of kids around the world are vulnerable to weight gain, whatever their genes. And yet, we routinely feed them junk. We routinely jettison physical activity from their daily routines. We peddle to them foods willfully designed to be irresistible if not addictive, and to maximize the number of calories it takes to feel full. Can we really justify the lunacy of a culture that studies genes looking for variation in satiety responses, while engineering foods to undermine satiety responses?

Yes, our genetic vulnerability to obesity is variable, much, I bet, like our genetic vulnerability to drowning. But I don’t think that invites a genetic study of the drowning victims of the Titanic. I think the bigger issue was the obvious one: the ship went down.

We are all in the same boat, and it’s sinking, too, as evidence by a global rise in bariatric surgery for ever younger children. The genes underlying vulnerability to obesity in all their variation were there a generation or two or twenty ago, too, when childhood obesity was rare. Those same genes are there now that it is rampant. Knowledge of them may be put to good use, but not if it distracts us from the sinking ship. What has changed is not within our children, but all around them. And we don’t need to wait for a genetic map of each child to fix it.

Human beings don’t have gills, and there are genes to blame. But the right response looks like swimming lessons, and lifeguards, and fences around pools, not studying genes while pushing kids into the surf. Not a new pill to fix an age-old part of who we are that was never really broken.

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--Women know to call 911 for stroke, but may not know the warning signs

Knowledge of stroke warning signs was low among women, especially Hispanics, but generally, women did know to call 911 when they recognized the symptoms, a study found.

To evaluate knowledge of stroke warning signs and what to do, researchers conducted a study of cardiovascular disease awareness that was conducted by the American Heart Association in 2012 among English-speaking U.S. women identified through random-digit dialing.

The women were asked open-ended questions about signs, symptoms and what to do next. Results appeared in Stroke.

Half of women surveyed (51%) knew sudden weakness or numbness of the face or a limb on one side was a warning sign for stroke. This did not vary by race/ethnic group. Next, 44% of women knew that impairments in talking or understanding speech was a sign, and white women knew this more frequently than Hispanic women. But, fewer than 1 in 4 women knew sudden severe headache (23%), unexplained dizziness (20%), or sudden dimness/loss of vision (18%) were warning signs, and 1 in 5 (20%) did not know even 1 stroke warning sign.

The majority of women said that they would call 911 first if they thought they were experiencing signs of a stroke (84%), and this did not vary among various races.

Researchers noted that women generally know what to do when experiencing signs of stroke, but at least half would not be able to recognize the signs. “Effective clinical counseling strategies and public awareness campaigns, such as the American Heart Association/American Stroke Association Spot a Stroke FAST (Face Drooping, Arm Weakness, Speech Difficulty, Time to call 911) campaign, are needed to reach diverse populations of women,” they wrote.

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Friday, March 28, 2014

The hospital-dependent patient

The New England Journal of Medicine published an article by David Reuben, MD, and Mary Tinetti, MD, both academic gerontologists, about patients who are unable to stay out of the hospital. The two physicians study the problems of old people, and are of the opinion that most of these “hospital dependent” patients are elderly. Certainly some of them are, but in my experience a surprising number are just chronically ill, usually also poor and with home situations unequal to their vast medical needs. Drs. Tinetti and Reuben are apparently studying these patients, thinking about solutions and now focusing us on this special population.

Hospitals potentially risk not being paid for patients who return to the hospital with new or persistent diseases within a short time of discharge. (I wrote an article on the history of this several months ago which points out some of the same issues that Dr. Reuben and Dr. Tinetti mention as well as how this fits in with the history of Medicare. Not as dry as it sounds. You should check it out.) Physicians who readmit patients after less than a 30 day hiatus are made to feel that they have participated in some sort of failure of management. Sometimes they have, but sometimes that isn’t the case at all. If a patient is readmitted with an illness that is still troublesome, but clearly improving out of the hospital, for which the patient has visited the emergency department only for reassurance, this is a failure of management, due to unfamiliarity with the patient’s history, often because the doctors in charge haven’t really read the chart, reviewed the history or talked to the patient. If a patient is readmitted because treatment has led to a preventable complication, that is a failure of management. If the readmission could have been prevented by a timely visit to an outpatient physician, this is a system failure of some kind and potentially avoidable. If the patient returns, however, because he or she is just too sick and fragile to remain well outside of a hospital, there is no failure, other than that expectation of success was overly optimistic.

The reason that we have hospital-dependent patients is that our hospitals are really quite good at keeping people alive, even when they are balanced on a knife edge of medical stability. Twenty-four hour attentive nursing and frequent visits by physicians, respiratory and physical therapists, dietitians, patient educators and social workers along with spare-no-cost life-saving technology is wondrously effective at shoring up the nearly dead. For many people, though, life without all of this is hard or impossible, so after a few days at home or in a nursing home, they will return to the hospital to be saved again.

Solutions involve difficult decisions. Is it worth the staggering amount of cash it takes to keep people in marginal health marginally healthy? How can one enter into the discussion of allowing natural death with a patient who feels mostly pretty good with ordinary hospital care? Herein lies the fallacy. Once we get to this point, hospital dependency, it is hard to back off. The trick is to not get there in the first place.

Most people who are independent and in full possession of their faculties do not want to be a burden on others. There are many moments between this point and full dependency when decisions could be made to withhold life prolonging medical care, and it is important that we present patients with these options without making them feel that they need to at least try what we have to offer. Although we as physicians are becoming more accepting of withdrawing life support or at least not intensifying it as people become desperately ill, most of us feel justified in allowing natural death only in people who have become truly miserable. Our patients, however, would usually prefer not to be truly miserable ever.

Many of our hospital dependent patients have survived some last ditch attempt at keeping them alive. Given the opportunity to do it all again, from the standpoint of their well selves, many would say no. It is interesting, though, that from the standpoint of being rescued and now dependent, many patients will continue to undergo painful and progressively disabling medical treatments until at last nothing will work.

I’m wondering if it is possible to end our love affair with medicine that defies death in our waning years. Might it be acceptable, at least sometimes, to allow our patients to die without a diagnosis? No cause of death. Death certificates could say “old age” or “natural causes” without further clarification. When death comes knocking, sometimes, if the time is ripe, we might let him in the front door, bid our loved ones goodbye and depart. Or have we as a society really decided that lengthening life is pretty much always a good thing? If we have, hospital dependent patients will be increasingly part of our jobs. Shaming ourselves when they are readmitted is misguided and very unlikely to change anything.

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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QD: News Every Day--'White coat effect' greater for doctors than nurses, enough to trigger more hypertension diagnoses

The “white coat effect” is smaller for blood pressure measurements made by nurses than by doctors, and the difference is enough to trigger more diagnoses of hypertension, reported a study from the UK.

In the meta-analysis, 15 studies (11 for hypertensive populations; 4 for mixed hypertensive and normotensive populations) were included for adults reporting mean blood pressures measured by doctors and nurses at the same visit. Results appeared online in the British Journal of General Practice.

Nurse-measured blood pressures were lower than that of doctors. The weighted mean difference for systolic blood pressure was –7.0 mm Hg (95% CI, –4.7 to –9.2). The weighted mean difference for diastolic blood pressure was –3.8 mm Hg; (95% CI, –2.2 to –5.4). White coat hypertension was diagnosed more frequently based on doctors’ than on nurses’ readings (relative risk, 1.6; 95% CI, 1.2 to 2.1).

The findings support a decade-old statement that suggesting stopping using high blood pressure readings documented by general practitioners to make treatment decisions.

“New 2013 European guidelines also still regard office blood pressure measurement as the ‘gold standard’ for screening, diagnosis and managing hypertension,” the authors wrote. “Although the UK 2011 guidelines promote use of home or ambulatory blood pressure readings for diagnosis, entry to the diagnostic pathway for hypertension relies initially on surgery-based readings, thus the risk of misclassification and inappropriate treatment with inaccurate initial blood pressure readings remains a clinical concern if doctors are systematically recording higher blood pressures than nurses.”

An editorial stated that office-based blood pressures are an entry point for further evaluation, since nurse-led readings do not eliminate the problem of white coat hypertension. Home or ambulatory monitoring can help.

“Self-monitoring or even self-management with self-titration may become the preferred approach, given the potential for patient empowerment, enhanced adherence, and reduction in workload,” the editorial stated. “Given that around one-third of people with hypertension now self-monitor, such an approach is becoming more feasible although the inability to prescribe sphygmomanometers and the logistics of ensuring regular checks or recalibration of patients’ own devices are issues which will need to be broached.”

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Thursday, March 27, 2014

ONC health IT curriculum materials are moving

One of the most enduring artifacts from of the Health Information Technology for Economic and Clinical Health (HITECH) Act may well be the Office of the National Coordinator (ONC) Health Information Technology (HIT) Curriculum. I noted last year that the funding for the ONC health IT curriculum had ended, so the materials are no longer being updated. However, they still have value, and OHSU has continued to maintain the National Training and Dissemination Center (NTDC) Web site where they are currently housed. With OHSU’s ability to fund the site ending, I am pleased to report that the materials will find an archival home in the AMIA Knowledge Center, where they will continue to be freely available. Around the end of February, the NTDC Web site itself will be retired.

Detailed documentation is available within the materials themselves, with a set of overview pages available from the links in the upper right portion of the main screen on the AMIA site. I have also provided overviews of the materials in past blog postings from 2012 and 2011. ONC still provides an overview of the program that created the materials on its Web site.

It is important to remember the main audience for these materials is educators, even though they are used by many others. But the materials are more designed to be fashioned by teachers into courses than to be used directly, even though many people do the latter.

The uncompressed size of the final (Version 3) materials is 11.2 gigabytes, contained in 18,072 files. The 20 components of the curriculum contain 9,974 PowerPoint slides and audio lasting over 136 hours (5 days, 16 hours, and 4 minutes, to be precise!). Of course, not all of the curriculum consists of narrated slides. There are also exercises, including those involving hands-on use of an educational version of VistA for Education (VFE), a fully functional version of the VA VistA electronic health record system, which is also included with the materials.

The curricular materials consist of 20 components, each of which is comparable in depth to a college course. The components are subdivided into 8-12 units, each of which contain a variety of activities appropriate to the topic, including voice-over-Powerpoint narrated lectures, references, suggested readings, exercises, and more. All of the files for each unit are organized into .ZIP files for ease of downloading, and even further, all unit .ZIP files are bundled into a single component .ZIP file for ease of mass downloading.

The topic areas of the 20 components are:
1. Introduction to Health Care and Public Health in the U.S.
2. The Culture of Health Care
3. Terminology in Health Care and Public Health Settings
4. Introduction to Information and Computer Science
5. History of Health Information Technology in the U.S.
6. Health Management Information Systems
7. Working with Health IT Systems
8. Installation and Maintenance of Health IT Systems
9. Networking and Health Information Exchange
10. Fundamentals of Health Workflow Process Analysis & Redesign
11. Configuring EHRs
12. Quality Improvement
13. Public Health IT
14. Special Topics Course on Vendor-Specific Systems
15. Usability and Human Factors
16. Professionalism/Customer Service in the Health Environment
17. Working in Teams
18. Planning, Management and Leadership for Health IT
19. Introduction to Project Management
20. Training and Instructional Design

Each component also contains a blueprint document that provides an overview of the learning objectives and content for each unit. All of the components also have an instructor’s manual that provides more detailed information, including listing of authorship and teaching information. The full set of blueprints have been rolled into a single PDF file and are available on the ONC Web site.

Three of the components are “lab” components that make use of an educational version of the Veteran’s Administration (VA) VistA EHR. A version of VistA that runs under various versions of Microsoft Windows is provided on the Web site, courtesy of the VA. This version runs under the open-source GT.M version of M.

The materials are distributed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. This means that all users of the curriculum can use, share, and adapt the materials but must attribute the originator of work, use the materials only for non-commercial purposes, and share any changes made under same license. Per the ONC, universities own the intellectual property for their components.

I am hopeful that continued usage of the materials will occur, and that some academic programs will undertake innovations with them. One example of an innovation is their organization into a Massive Open Online Course (MOOC) by the Health Informatics Forum. It may be possible that we, AMIA, and others might someday find additional funding to maintain, update, and expand the materials as well. But for now, they remain a valuable resource to the HIT community.

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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Residents and students want 'old school'

Recently I gave my rounding team individual feedback. After I give them feedback, I always ask them to comment on ways that I can improve as an attending. This group had verbalized, first as a group, then individually, that what they liked about my rounds as that I was “old school”.

What is old school and should we train all attending physicians in the old school ways?

They defined old school in 3 parts:

1) talking to the patient, taking a careful history and explaining what we are doing in understandable terms,

2) conducting relevant physical examination and demonstrating physical findings to the learners; and

3) using that information plus laboratory data and imaging studies to develop a differential diagnosis, with a clear explication of the thought process.

While I love receiving compliments, describing this process as “old school” saddens me. What about this description has become out of date? How else should one make internal medicine rounds?

What has gone wrong in medical education if this process is considered notable?

If we have many attending physicians who do not follow this process, then we need radical educational reform. We need to encourage attending physicians to honor traditional internal medicine.

Residents, students and recent graduates, please answer: Has old school become the exception? Do you want “old school”?

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--Smartphone app may support post-treatment recovery for alcohol misuse

A smartphone application appears to help patients with alcohol use disorder reduce risky drinking days compared to patients who received usual care after leaving treatment in a residential program, a study found

Researchers randomized 349 patients with alcohol dependence leaving 3 residential programs to treatment as usual (n=179) for a year or treatment plus the app (n=170) with the Addiction-Comprehensive Health Enhancement Support System (A-CHESS) application. The application featured audio-guided relaxation and alerts if patients neared a high-risk location, such as a bar they used to frequent.

Results appeared online March 26 at JAMA Psychiatry.

Patients who used the smartphone application reported fewer risky drinking days (defined as when a patient’s drinking in a 2-hour period exceeded 4 standard drinks for men and 3 for women) compared with controls. Specifically, for the 8 months of the intervention and 4 months of follow-up, patients using the app reported significantly fewer risky drinking days than did patients in the control group, with a mean of 1.39 vs 2.75 days (mean difference, 1.37; 95% CI, 0.46 to 2.27; P=0.003).

Patients using the smartphone application also had a higher likelihood of consistent abstinence from alcohol (51.9%vs 39.6%; P=0.03), with significant differences at months 8 (P=0.04) and 12 (P=0.02) but not at month 4 (P=0.13). App users were also more likely than control patients to report abstinence at all 3 time points (P=0.03). However, there was no difference in the negative consequences of drinking.

Of the 170 patients who received the app, 122 (71.8%) pressed a “panic button” feature at least once. To rule out accidental activations, researchers reported that 98 patients who pressed the panic button navigated the app to at least 1 subsequent page in the feature.

As for real-world use, while 170 patients were randomized to receive the smartphones with app and a data package to support it, there were actually 286 smartphones given out during the study. Of the 116 smartphones that were replaced, 56 did not work properly, 20 were stolen, 18 were damaged by patients, and 22 were lost.

“Whether smartphones will be practical as continuing care of AUDs (alcohol use disorders) depends in part on the cost and whether it will be reimbursed,” the authors wrote. “In this study, 8months of A-CHESS cost about $597 per patient, based on 1 hour per month of counselor time at $90 per hour divided by 50 patients, 1 hour per month for system administrator time at $50 per hour divided by 170 patients, $60 per month for each data plan, and $100 to buy each smartphone. The cost of interventions such as A-CHESS will decrease dramatically as more people have smartphones and data plans of their own, although low-income patients may be less likely to have them.”

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Wednesday, March 26, 2014

Obamacare: Read your new plan carefully

Here at the office we’ve been watching Obamacare unfold. I’ve reported to you some of the successes: decreased premiums, closing of a medical charity due to decreased need. While it seems likely that more Americans will have access to health insurance, this isn’t the same as access to care.

In general I don’t work with HMOs, but for a variety of reasons I’ve stuck with BCN, Blue Cross Blue Shield’s HMO. They are reasonably easy to work with and my patients seem satisfied with them. But some of my patients who signed up for BCN this year are finding out I’m not on their plan. When the Affordable Care Act kicked in, BCBS created a bunch of new insurance products that have similar names, and some of my patients picked the one I’m not part of. I asked a patient to send me information on which doctors he can see.

If a patient even bothers to read the list of doctors, there is no way for them to know what I saw immediately: their new health care plan is basically a private version of Medicaid. The list of doctors had many specialists and hospitalists but few primary care doctors. Most of the primary care providers who were listed were clinical supervisors, overseeing resident doctors in training.

Blue Cross is being smart by limiting which doctors the patients can see. This will help them control costs. It also means that these patients will have limited access to their doctors compared to pricier plans. The upside is that patients who were previously uninsured can now be covered well enough. People accustomed to similarly-named plans from previous years may be in for a shock. In exchange for lower premiums, they’ve given up a lot of choice.

As more Americans get insurance, they are going to see what our shortage of primary care doctors means in the trenches. If we’re serious about caring for more people, we have to get serious about creating more of the right kind of doctor.

Stay tuned.

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

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QD: News Every Day--E-cigarettes may not help with smoking

Use of e-cigarettes isn’t associated with smoking cessation 1 year later, a small study found.

The authors analyzed self-reported data from 949 smokers (88 of the smokers used e-cigarettes at baseline) to determine if e-cigarettes were associated with more successful quitting or reduced cigarette consumption.

Results appeared online March 24 in a Research Letter at JAMA Internal Medicine.

E-cigarette use at baseline did not significantly predict quitting 1 year later (OR, 0.71; 95% CI,‚ÄČ0.35 to 1.46; P=0.35), the authors found. A second model based on intent, consumption and dependence found that intention to quit (OR, 5.59; 95% CI, 2.41 to 12.98; P<0.001) and cigarettes smoked per day (OR, 0.97; 95% CI, 0.94 to 0.99]; P=0.02) significantly predicted quit status. But, past 30-day e-cigarette use did not (OR, 0.76; 95% CI, 0.36 to 1.60]; P=0.46). E-cigarette use at baseline was not associated with a change in cigarette consumption among 821 people who smoked at baseline and follow-up (P=0.25), after controlling for baseline cigarette consumption.

The authors acknowledge the low numbers of e-cigarette users in the study may have limited their ability to detect an association between e-cigarettes use and quitting.

“Nonetheless, our data add to the current evidence that e-cigarettes may not increase rates of smoking cessation,” they wrote. “Regulations should prohibit advertising claiming or suggesting that e-cigarettes are effective smoking cessation devices until claims are supported by scientific evidence.”

In a related editor’s note, Mitchell H. Katz, MD, FACP, a deputy editor of JAMA Internal Medicine, writes: “Unfortunately, the evidence on whether e-cigarettes help smokers to quit is contradictory and inconclusive. Grana and colleagues increase the weight of evidence indicating that e-cigarettes are not associated with higher rates of smoking cessation.”

Still, he supported regulation and advertising restrictions on e-cigarette advertising, adding “[W]e simply do not know what potential harm e-cigarettes may cause to their users.”

Learn more about e-cigarettes and counseling patients who use them in ACP Internist’s March 2014 story, and in a blog post by John H. Schumann, MD, FACP, that appeared at his site, GlassHospital.

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Tuesday, March 25, 2014

To vape or not to vape

This e-cigarette thing is getting interesting.

Proponents: They’re an alternative to smoking. They’re acceptable in public, even indoors. They have no tar, tobacco, or carcinogens. They help people QUIT smoking. [They’re cool.] They’re collectible. They will do to cigarettes “what the computer did to the typewriter.”

Opponents: Nicotine, whether in an e-cig or a tobacco cigarette, is still bad for you—and addictive. There’s no EVIDENCE [yet] that e-cigarettes are safe. There’s no EVIDENCE [yet] that they help people quit smoking—that’s just marketing hype. The vape (yes, verb form is “vapor,” gerund form: “vaping”) industry has already been co-opted by Big Tobacco and it’s marketing muscle, and e-cigs are already being marketed at kids, to get them hooked early.

We’re living in the Wild West, as far as vaping is concerned. Enjoy all the rhetoric around vaping for another year, until scientific evidence builds. Trust that it will. There’s a lot of money at stake.

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

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QD: News Every Day--Try an indirect approach for inappropriate antibiotics

While experts suggest that doctors directly ask patients whether they expect to receive antibiotics for upper respiratory infections, family physicians in the UK reported success by avoiding confrontations and instead eliciting expectations in an indirect manner before performing a physical examination, a study found.

A researcher conducted in-person interviews with 20 family physicians in South Wales, and outcomes from the semi-structured interviews appeared in the Annals of Family Medicine.

The doctors reported not directly asking their patients about expecting to receive antibiotics, because it sets up a confrontation with the patient. They reported instead eliciting patient or parent expectations by asking questions such as “Is there anything specific you wanted from me today?”

They also asked their questions before the physical exam, because the findings might help them dissuade the patient, for example, in those who may not have a high temperatures or may have clear tonsils.

“As clinicians are more likely to adhere to clinical recommendations that are compatible with their values, our model derived from empirical data may influence acceptance of evidence-based prescribing decisions that may be counter to patient or parent expectations,” the authors wrote. “Moreover, if this goal can be accomplished within the confines of 10-minute consultations, that will enhance its acceptance and application as an intervention by family physicians who may be seeking to adopt a different approach to a challenging consultation.”

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Monday, March 24, 2014

Can we unmuddle mammography?

A new study of mammography, showing lack of survival benefit, has once again muddied these waters and muddled the relevant messaging. The study, generating considerable controversy, as has much prior research on the topic, looked at breast cancer mortality over a 25-year period in nearly 90,000 Canadian women assigned to mammography or usual medical care without mammography during the initial 5 years of the study period. There was no appreciable difference between groups.

Perhaps you see a major problem already. To study the effects of mammography, or any cancer screening, on mortality over time requires time. Time goes by at its customary pace no matter the research goals. So, if it takes 25 years to get the desired data, the intervention needed to take place 25 years ago. And so, inescapably, this study is entirely blind to any advances in mammography technique, technology, or interpretation over the last 20 years at least. In medicine, 2 decades is just about forever.

Perhaps the value of mammography is perennially muddled, if just a bit less so than prostate cancer screening, for the most obvious of reasons. The truth is in the middle, between slam-dunk and fuhggeddaboudit. With the apparent exception of titillating (if not salacious) novels, we don’t tend to like shades of gray. But that’s where mammography falls. It’s pretty close to a toss-up.

There is a long history of research on the topic, and conclusions have been anything but consistent. Some studies suggest clear potential benefit for women who would not otherwise be screened. But, of course, women who would not be screened are apt to differ in a variety of ways from those who would, including, perhaps, their access to, and the quality of, primary medical care. Unbundling such influences is nearly impossible.

But, if, instead, you attempt to study women who would be screened anyway, how do you randomize them to a control group? What woman, inclined to get mammograms, would go without for 20 years for the sake of a clinical trial? Not very many I know.

Enrollment in a trial itself can exert an influence. Regardless of assignment to mammogram or control, there may be more attention to breast health and a greater likelihood of finding breast cancer early among all women participating in a study. This effect obscures any real world, and potentially important differences between intervention and control arms.

We are, as well, dependent on an imperfect technology. Even if finding breast cancer early through imaging is decisively beneficial, studies will produce variable results based on flawed imaging, variable performance of the same technology in different women, and variation in the quality of interpretation of mammograms. That much more so when today’s data are the product of mammography done 20 to 25 years ago. There have been improvements in scans, scanners, and the training of radiologists during that span.

And complicating things further, mammography is a source of radiation, and may be doing some direct harm as well as good.

The false positive error rate of mammography is notoriously high, and unavoidably so if we want to avoid false negatives. False positives occur when we think we’ve found cancer that isn’t there. It can be avoided by raising the bar, but then there is a risk of missing cancers that are there. We tend to favor the former error over the latter, and in the absence of perfect tests, are forced to choose.

We may have failed to translate good evidence into practice. Pre-menopausal mammography would likely be more useful if performed more than once a year. Breast cancer tends to be more aggressive and progress faster in younger women. Post-menopausal mammography might be just as useful done every other year. A 1-size-fits-all approach may attenuate benefit and raise the rates of harm to both groups.

And then, perhaps most important: not all the trouble we find through screening deserves the attention it gets. Some tiny breast cancers, like the majority of prostate cancers, are destined to do nothing if just left alone. These are cases where cure is very likely to be worse than disease, but we are not good yet at differentiating. Doing so requires analysis at the level of histopathology (i.e., tissue and cell analysis), and molecular genetics. This can be done, but it’s not routine and our abilities in this space remain limited.

One very important issue routinely ignored when parsing the benefits of any cancer screening modality, mammography included, is that screening does not prevent cancer. The goal of screening is to find cancer early, which is generally much better than finding it late. But it’s not nearly as good as not getting it in the first place. The evidence is strong that optimal lifestyle practices can slash risk for all major chronic diseases, cancer included. Related evidence shows that lifestyle as medicine can modify gene expression in a manner projected to protect against cancer development and progression. DNA is not destiny. Dinner may be! There is interesting literature on the relevant timing as well. It may be the best way to improve breast cancer in women is to focus on healthy living in childhood. That we could dramatically lower rates of cancer overall by living well across the life span is all but undisputed.

There are many reasons why decisive evidence that mammography confers net survival benefit at the population level, or that it lacks benefit and should be abandoned, is elusive. The result is something of a muddle for epidemiology. Until technology, interpretation, application and histopathological confirmation all rise to consistently high standards, we can’t unmuddle mammography for populations.

But by combining what we know about the test with what you and your doctor know about you, a basis for a good decision should be at hand. Inquire about the technology, making sure it is state of the art. Ask about the training of the radiologist reading the film. Ask as well about plans for immediate next steps if the mammogram is abnormal. Good breast care centers follow up right away with additional testing to differentiate false from true positives. Ask whether screening has been personalized, taking into account your age, breast density, family history and risk profile.

Evidence-based recommendations about mammography for the population at large where one size must fit all are, for now, ineluctably muddled. By personalizing the decision, as good clinical medicine always should, we can, I believe, unmuddle things for you.

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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Two different worlds: HIT vs. real-life, frontline medicine

A couple of weeks ago I attended a health care information technology event in Boston. The event focused on developing new technological ideas for the future. Most of the people in attendance were young, keen, entrepreneurial, and seemed to have a genuine passion for improving health care. There were some great thoughts and ideas put forward, with definite potential for bettering patient care.

I’ve actually been to several similar events and it is encouraging for health care that there’s so much energy and enthusiasm being focused towards our arena. But one thing does concern me a bit when I speak to those who are solely involved in information technology or business development, and don’t have any real world health care experience. As enthusiastic and motivated as they are, when they talk to me about their ideas and aspirations, I’m often left wondering what planet they live on!

While well-intentioned, the way they put forward hospital solutions appears to be based on the assumption that the majority of hospitalized patients are the Facebook generation, technologically savvy with the manual dexterity of a 20-year old. I’ve heard proposed answers to some of our problems in hospital medicine, including how to improve patient satisfaction, provide our patients a good health care experience, better medication reconciliation, and reducing readmissions, that don’t seem to take into account the reality of frontline medical care and the patients we are actually treating in hospital.

For example, the average age of patients admitted to the inpatient medical floor is typically well over retirement age. A majority of them have never even used a smart device, and many are even too sick to turn on the television. If an idea is put forward that utilizes technology and swipe screens for hospitalized patients, facts like this must be taken into account.

We also know that illness disproportionately affects the lower socioeconomic groups, who are less likely to be regular users of technology. And how about the large proportion of patients on any given medical floor that suffer from dementia? Asking them to be fully engaged with technology while lying in a hospital bed would not only be difficult, but also potentially dangerous.

Patient satisfaction and reducing readmissions are further examples of where health care entrepreneurs are increasingly getting involved. Again, lots of them have told me personally how their goal is “ultimate patient satisfaction” and to “transform health care.” That’s all very well and good, but will a computer program or technology device ever really be the main answer to making patients happier in the hospital? It’s a bit of a delusion to think so.

Ask any patient what will make them most satisfied, and the answers will usually be the same. They will be focused more in the human realm, such as wanting more time with caring and compassionate doctors and nurses, a quiet healing environment, and good medicine that will cure them fast. And as for reducing readmissions, when an elderly person who has multiple comorbidities is stuck in the vicious circle of frequent readmissions, very little in the way of technology can help their bodies heal and stop them coming back into the ER when they deteriorate again. Home care and close follow-up may be the only things that will really help them.

There are 2 other common patient complaints which I’ve written about previously: bad hospital food and lack of a good night’s sleep. I heard one idea for an app that can apparently help with making better food. Another one was a technology-based solution that is supposed to help patients sleep by providing background noise. Do we really need to make things so complicated? Surely we don’t need a computer to tell us the difference between good and bad food or how to make a quieter environment!

Sometimes I feel like asking these budding health care entrepreneurs to accompany me on ward rounds one day to actually see the realities of frontline clinical medicine. Most of them are thankfully too young to have barely set foot in a hospital, and I’m sure they would find such an experience insightful to say the least. They will then understand the complexities of delivering health care and how there are some problems that can’t be solved entirely with technology.

They will also realize one other very important thing: Health care is all about human contact and personal relationships. It’s an emotional field to work in. It’s about empathy, compassion and consoling (often just as much as it is about cure). It’s about well-trained doctors and nurses who practice good and thorough clinical medicine.

That isn’t to say that health care information technology, or technology in general, isn’t amazing and transformative for what we do. The benefits brought to us in terms of data access and improving quality are enormous. However, we need to take things to the next level: To bridge the gap between health care technology and frontline clinical medicine. Most physicians, and nurses for that matter, are very jaded right now with their experiences of IT and electronic medical records. Slow and inefficient systems take time away from our patients and actually tend to give them a worse experience as a result.

To really improve health care delivery, what would be good from the technology world? To understand and take into account the realities of frontline medical practice. To recognize that health care is about humanity at its core. To develop all new solutions centered around the principle of doctors spending face-to-face time with their patients, and minimal time with their computers getting in between. If we can utilize a smart device effectively at the bedside for information access, data entry and patient education, that’s ideal. But that should never involve looking more at the screen rather than the patient. Frontline clinicians need to work closely with the technology sector to design and implement optimum systems that promote good medical practice.

There’s a certain political philosophy that the best governments in the world are the ones that get out of the way and let their citizens flourish, while maintaining minimal control and obstructions. No matter what extreme you take this statement and apply it politically, to a certain extent it’s definitely true. Similarly, the best health care IT solutions of the future will be the ones that are seen and heard the least, and quietly do all the right work in the background while the doctors and nurses are enabled to spend maximum time listening to their patients and addressing their needs. When this happens, many of the problems that we face in health care may disappear all on their own, without any additional technology.

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--Fecal transplants may be effective for C. diff, inflammatory bowel disease

Although more controlled trials are needed, fecal microbiota transplantation therapy shows promise in both adults and children with gastrointestinal diseases such as Clostridium difficile and inflammatory bowel disease, a systematic review showed.

A total of 844 patients from 10 countries who had undergone fecal microbiota transplantation were identified from 67 published studies. The most common indications were refractory/relapsing C. difficile infection (76.3%) and inflammatory bowel disease (13.2%). Results appeared online March 18 in Alimentary Pharmacology & Therapeutics.

The success rate was close to 91% for C. difficile infections among all trials. There was 1 placebo-controlled trial, a successful trial in 43 patients with recurrent C. difficile infections, in which duodenal infusion of healthy donor feces cured 15 of 16 recurrent patients.

The overall success rate of irritable bowel disease, including ulcerative colitis and Crohn’s disease, in adults is 77.8%. Fecal transplantation may improve ulcerative colitis, with a success rate close to 90%, as measured by disappearance of symptoms or reduction in ulcerative colitis activity index. Fecal transplantation was not effective in remission of Crohn’s disease.

The only reported serious adverse event attributed to the therapy was a case of suspected peritonitis.

Fecal transplantation could also be effective in treatment of some nongastrointestinal disorders such as metabolic syndrome or chronic fatigue syndrome, the authors wrote. It should be recognized as a form of organ transplantation, albeit a low-tech one.

“With the development of convenient equipment for fecal preparation and oral administrable capsules filled with fecal suspension or freeze-dried preparations, more patients may benefit from a standardized FMT (fecal microbiota transplantation) therapy with less aesthetic concerns, greater convenience and perhaps higher efficacy,” the authors wrote.

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Friday, March 21, 2014

Learning about Lou Gehrig, his diagnosis, disability and pride

I can’t resist mentioning that today I caught part of another old baseball flick in the gym. Pride of the Yankees, on TCM, features Gary Cooper as Lou Gehrig. Sam Wood directed this 1942 MGM classic in which Babe Ruth appears, briefly in cameo, as Babe Ruth. A Times reviewer, writing after its July 1942 release, complained that the film didn’t include enough baseball, nor sufficient drama until its end. That may be true. But your athletically-challenged author was moved by this film, and stopped by some of the scenes depicting how information was conveyed in that era, about the star’s declining health.

I learned about Lou Gehrig in medical school. Amyotrophic Lateral Sclerosis (ALS, aka Lou Gehrig’s Disease) is a progressive and serious neurological disease that tends to affect a person’s voluntary (“motor”) muscles, such as those of the arms, legs and face. The CDC maintains a national registry for the condition, which is of unknown cause and, to the best of my knowledge today, remains on the shortening list of incurable conditions. The NIH estimates that 20,000 to 30,000 people are living with ALS, and that some 5,000 or so are found to have this condition each year in the United States. It typically affects, or “strikes” – as it’s almost universally metaphored, people in their 40s or 50s.

(Forgive me the verb, this post is both serious and personal.)

A former colleague, whom I admire and will always remember for what he has taught me about immunology and even more by his working through illness, has ALS and has continued contributing for the long time, over 20 years, that I have known him. What enables some people with illness, i.e. patients, to keep contributing in their field of expertise is, first, their wanting to keep working. But it also requires a sensitive and encouraging environment, a workplace that allows people with knowledge, who become disabled or limited by health concerns, to work as best they can.

I learned that Lou Gehrig was a New Yorker. He was born to German immigrants in Yorkville, near where I live in Manhattan. According to his biography in the Baseball Hall of Fame, the left-hander was born in June 19, 1903 and died on June 2, 1941, a few weeks shy of what would have been his 38th birthday. He was called the Iron Horse and played first base for the Yankees. In the movie, it takes Gehrig a while to realize, or admit, that he can’t play baseball, that he’s stumbling and struggling to even hold a bat, or run or walk. Once the athlete acknowledges his limitations, he is treated kindly and generously by his manager, teammates and fans.

At first, the doctor in the Scripps Clinic doesn’t want to tell him the truth about his condition. But Gehrig wants the numbers, the statistics, facts. Finally, after Cooper, playing Gehrig, asks him if it’s “3 strikes.” The doctor answers that, yes it is. The patient understands his meaning. No one in the room can pronounce the words “amyotrophic lateral sclerosis,” but Gehrig gets the picture. The patient doesn’t want to tell his wife but, as these things usually go, she figures it out.

The Yankees and Gehrig’s manager try to keep his illness a secret, but after he gives up his spot on the roster, it becomes progressively evident that something is seriously wrong. One nugget in the film is an interaction with what might be considered a peer patient. Early on, Gehrig encounters a boy who can’t walk, and offers him encouragement. Later, once Gehrig’s condition has become evident, the young man comes to tell him thanks, and to show Gehrig he’s gotten better, by not giving up. But the boy becomes tearful and appears not to enter the stadium. It seems his hero’s deteriorating condition is too much to watch.

On July 4, 1939, Gehrig gave a speech before a packed Yankee stadium. He thanked his teammates, coach, sportscasters, athletes of other teams, fans, his parents and his wife, and concluded, famously, that he was “the luckiest man on the face of the Earth.”

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

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Well child, sick child

Who doesn’t get a little bit nervous in a pediatric clinic waiting room? Even in an office that divides “sick” from “well” waiting areas, kids tend to move pretty freely, and of course the pathogens contained in respiratory droplets move even more freely. I always assumed that the risk from these exposures (of the “well-children” to the “sick-children” in ambulatory clinics) was fairly small, at least compared with the usual community exposures kids have at home, at day care, at the children’s museum, etc.

Our colleague Phil Polgreen and his group analyzed some “Big Data” (the Medical Expenditure Panel Survey) to try to determine if well-child visits are indeed a risk factor for subsequent influenza-like illness (ILI). Their findings are published in this month’s issue of Infection Control and Hospital Epidemiology, and confirm the suspicion that the ambulatory pediatric clinic is likely to contribute to viral respiratory pathogen transmission. The odds ratio for ILI after a well-child visit (within prior 2 weeks) was 1.54 (95% CI, 1.43 to 1.66), which seems pretty large, though the absolute risk was modest (~3% increased risk). However, if you consider the total number of such visits annually, the number (~800K) and cost ($500 million) of excess ILI cases is substantial.

Lisa Saiman has an excellent editorial discussing the implications of these findings, the main message being that we need to pay more attention to infection prevention in ambulatory settings. My only additional suggestion (which, admittedly, may be unrealistic for many clinics): forget about separate waiting rooms, instead have physically or temporally separate clinics for well-child versus sick-child visits (with clear signage to direct kids who happen to be sick during a well-child visit to the “sick-child” clinic).

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--New statin guidelines could create 13 million more adults eligible for prescriptions

Statin guidelines released last year could increase the number of adults who would be eligible for statin therapy by 12.8 million, mostly from new eligibility by older adults without cardiovascular disease, a study found.

Researchers applied data from the National Health and Nutrition Examination Surveys of 2005 to 2010 to estimate the number of people now eligible for statin therapy under the new guidelines released released in November 2013. They compared the number of people eligible under the new American College of Cardiology–American Heart Association guidelines to the Third Adult Treatment Panel (ATP III) of the National Cholesterol Education Program, and extrapolated results to a population of 115.4 million U.S. adults between the ages of 40 and 75 years.

Results appeared in the New England Journal of Medicine.

The newly eligible population is mostly due to people classified solely on the basis of their 10-year risk of a cardiovascular event. The number of U.S. adults receiving or eligible for statin therapy from 43.2 million (37.5%) to 56 million (48.6%) compared to ATP-III, with 10.4 million of the 12.8 million increase occurring among adults without cardiovascular disease.

More men than women would become newly eligible. The percentage of eligible patients would increase from 30.4% to 87.4% among men and from 21.2% to 53.6% among women.

Researchers wrote, “Although up to 30% of adults in the younger age group without cardiovascular disease would be eligible for statin therapy for primary prevention, more than 77% of those in the older age group would be eligible. This difference might be partially explained by the addition of stroke to coronary heart disease as a target for prevention in the new pooled-cohort equations. Since the prevalence of cardiovascular disease rises markedly with age, the large proportions of older adults who would be eligible for statin therapy may be justifiable.”

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Thursday, March 20, 2014

Same data, different conclusion

There’s an interesting study in the March issue of Infection Control and Hospital Epidemiology led by Keith Kaye, which examines the hypothesis that the burden of patients in contact precautions has an impact on compliance with contact precautions. The study used surreptitious observers to record compliance with the components of contact precautions in eleven teaching hospitals. Approximately 1,000 observations were performed in the ICU and ward settings. The authors conclude: ”As the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases.”

However, looking at the same data, I came to a different conclusion. I converted the bar graph (figure 2 in the paper) to a line graph which makes it easier to follow compliance with each component of contact precautions as the proportion of patients in contact precautions increases:

Now you can clearly see that the only problem with compliance as the burden of contact precautions increased was with hand hygiene prior to donning of gowns and gloves. Thus, decreased compliance with the contact precautions “bundle” was driven solely by the decrease in hand hygiene prior to patient contact.

It has been shown in other studies that hand hygiene is lower prior to contact precautions. And I think there is a very simple reason that this occurs: you can’t get the gloves on until your hands are completely dry. Hand hygiene before and after patient contact is an essential component of standard precautions. What sets contact precautions apart from standard precautions is the use of gowns and gloves, and the data in this study show no decrease in gown or glove use as the proportion of patients in contact precautions increases. In addition, the overall usage of gowns and gloves was surprisingly high.

So my conclusion would be that there is a negative correlation between the burden of contact precautions and hand hygiene prior to patient care. And maybe that’s not so bad.

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

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Leadership: to serve or to be served?

Most readers know that I have leadership responsibilities, both in my job and in my society work. Leadership comes with great responsibility.

Too many leaders lose their moral grounding. They view leadership as their accomplishment and their opportunity. They forget the most basic principle that leaders should serve those who they lead!

Two recent accusations of conflicts of interest should remind us of the dangers of leadership: Patient Safety’s First Scandal: The Sad Case of Chuck Denham, CareFusion, and the NQF and Payments to CEO Raise New Conflicts at Top Health Quality Group.

In both cases prominent leaders in medical quality and safety appear to be receiving financial benefit that could cloud their judgments. In neither situation can we say that the apparent conflicts of interest actually changed their decisions, but we need to require that standard to find these situations uncomfortable and disappointing.

I submit that these leaders have not followed the precepts of servant leadership. We in leadership must always ask how we can help our followers, not how we can help ourselves.

Each day I try to help our students and residents grow. It is not about me, it is about them. I fail sometimes. Sometimes my actions feed my ego. Most humans have difficulties with leadership. Too many leaders in the public eye abuse that privilege.

Of course, the easy way to avoid this trap is to ask oneself what one’s followers say if they knew about such behavior. If the “followers” would critique me, I should not do that.

We should take the ethical high ground. It is our job to serve, not to be served.

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--NSAIDs may play a role in developing new antibiotics

There may be a way for some NSAIDs to play a role in disrupting bacterial DNA and replication, and contributing to the fight against antibiotic resistance, according to a report.

Lab work has shown antibacterial properties of carprofen, bromfenac and vedaprofen, which inhibit the Escherichia coli DNA polymerase III b subunit, plays a role in DNA replication and repair. Specifically, the NSAID carprofen binds to and inhibits essential interactions of the protein, dubbed the “sliding clamp,” which is a “heavily trafficked” protein-protein interaction hub during DNA replication and repair. This structure also appears in many kinds of bacteria.

“Targeting the bacterial DNA replication machinery is a validated strategy for producing clinically useful antibiotics, as evidenced by the highly successful quinolones, DNA gyrase inhibitors. The bacterial SC (sliding clamp) is an emerging DNA replication target that is yet to be clinically validated,” the authors wrote.

The report appeared in Chemistry & Biology.

The researchers conducted fluorescence polarization competition assays on 20 commercially available NSAIDs to determine inhibitory concentrations. Vedaprofen, bromfenac and carprofen showed the strongest effects, while flufenamic and tolfenamic acids were weaker binders. Next, the NSAIDs were tested for antibacterial activity using standard minimum inhibitory concentrations on 4 species: E. coli, Acinetobacter baylyi, Staphylococcus aureus, and Bacillus subtilis. The Gram-positive species (S. aureus and B. subtilis) showed higher susceptibility to NSAIDs than the Gram-negative species (E. coli and A. baylyi).

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Wednesday, March 19, 2014

Requiem for ABC David

When I first learned to take care of patients in the hospital, as a third year medical student, we used a mnemonic to help us remember what to order when a patient was first admitted. Patients would come in to the hospital from a doctor’s office or from the emergency room and the nurses needed a set of orders to know what to do for the patient. The mnemonic we used was “ABC DAVID.” This is how it worked:
1. Admit: to medical surgical unit
2. Because: diagnosis of congestive heart failure
3. Condition: guarded
4. Diet: sodium restricted
5. Allergies: no known drug allergies
6. Activity (sorry, 2 As): bedrest with bathroom privileges
7. Vital signs: every 4 hours while awake
8. Investigations: chest X-ray, morning labs of chemistry panel and blood count
9. Drugs: digoxin, a diuretic, potassium, a beta blocker, maybe insulin or blood pressure medications, acetaminophen for pain, something mild for sleep, if needed.

It worked pretty well. It did allow me to forget certain things that I really didn’t want to forget, like having the nurses measure accurate intake and output (food, water, IV fluids, poop, pee and vomit), care of catheters or nasogastric tubes, but it made sure that I didn’t forget the main things.

Today I admitted a patient with congestive heart failure and used our hospital’s brand new computerized order entry system with its brand new congestive heart failure admission order protocol. It’s huge compared to ABC DAVID, who seemed like a strapping lad a mere quarter of a century ago. It includes the medications that experts have determined from large studies to be necessary for optimal treatment of congestive heart failure, the tests that must be done to adequately diagnose congestive heart failure, plus the other things that we think should be done on everyone who is admitted to the hospital including vaccination for flu and pneumonia, smoking cessation, prevention of blood clots in the legs, plus numerous medications that patients are felt to need even if they don’t take them at home, including laxatives, sedatives and nicotine replacement. I must use my rudimentary knowledge of hospital billing to characterize the patient as being an inpatient or on observation. End-of-life wishes must be documented. Also, of course, ABC DAVID is buried inside the order set.

Even though the computer has various habits that I find irritating, like wanting medication orders to be written in a specific way and notifying me of medication interactions that I am already aware of or which are of no clinical significance, I was grateful to have a way to remember all of this stuff that is, apparently, important and necessary. My brain is too small to hold all of these orders and even too small to hold a mnemonic large enough to remind me of all of these things. Orders are different, of course, for congestive heart failure and community acquired pneumonia, for hip fractures and bowel obstructions and for exacerbations of chronic obstructive lung disease. If I made room in my mind for all of this stuff, I’m sure I would have to jettison something that is far more precious.

It is concerning, at least a bit, to be so dependent on either a computer or a printed cheat sheet to initiate treatment for patients. Physicians being trained now don’t even have a mnemonic to fall back on, and I imagine that their brains are perhaps like giant card catalogs without any of the books in the library. This, of course, completely labels me as being nearly senile, since card catalogs only exist in primitive societies and old peoples’ memories. (I can still evoke that particular wood and paper smell as I type the words “card catalog.”) But unless physicians become familiar with techniques of advanced memory training like the ancient Greeks used for reciting epic poems, there is just too much to know in medicine. We must walk around with some of the vast amount of information that makes up our field of knowledge in order to deduce things, make connections, create solutions to complex problems, but we need to be selective. It is possible to design orders for each patient based upon disease principles and knowledge of hospital processes, recent research and individual patient characteristics. This might be better for patients, but only if we are in top form as we write them. Patient safety advocates favor order forms, for good reason, since I and my fellow physicians can certainly not guarantee that at any given moment we will be in top form.

As I remember ABC DAVID and the days of simpler medicine, it is with the bittersweet regret that makes the past look preferable to the present regardless of whether that is in any way accurate. I would like medicine to be less complicated, and perhaps it will be if we rein in our excesses. But while patients continue to be on too many powerful medications and too many expensive and potentially hazardous tests and procedures are part of everyday practice I am grateful for preprinted order sheets and even computerized order entry when it’s not too bug infested. I have found ways to be creative and innovative and to personalize my care for patients without excessive hindrance by protocolized treatment for high profile diseases. If the powers that be want me to remember to vaccinate and provide smoking cessation information to my patients as I am submerged in their acute, pressing and life threatening immediate needs, I thank whatever inanimate order generator that will relieve me of that burden.

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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Do doctors practice evidence-based medicine?

I advocate evidence based medicine. We should restrict our medical recommendations to those that have a reasonable underlying scientific basis. On the opposite end of this spectrum is quackery, when snake oil and other potions are hawked that either have no scientific support or have been shown scientifically to be ineffective.

I do not offer snake oil here as a historical reference. We have more snake oil and its congeners today than ever before. People who are sick want to believe the man who promises them healing, particularly when conventional medicine has not succeeded. This belief goes to the core of human nature, at least as I have observed over the past 3 decades.

Of course, in the medical world, we don’t have enough science yet for all of the medical issues that we physicians confront. That means that we guess a lot. How often does this occur? Every single day. Patients would be quite surprised to learn that there is usually scant or conflicting medical evidence to guide the issue that has brought them to our offices. This does not mean that your physician is rolling the dice on you. He relies upon available medical knowledge, if there is any, and his judgment and experience, 2 invaluable assets that are not measured in the various pay-for-performance schemes. These invaluable assets are not measured and rewarded by the government and insurance companies because they cannot be easily measured. Does that mean that they don’t count? Absurd, of course.

If you doubt the presence of non-evidence based medicine, consider the promised health benefits of yoga, probiotics, medication, massotherapy and the latest gluten-free rage. I’m not stating categorically that these and related techniques do not work; I am pointing out that there is no persuasive medical evidence supporting their claims. Our airwaves are clogged up with snake oil disguised as medicines promising “good prostate health” or “healthy bones”. These sound like health claims to me, but their language is carefully selected and is followed by the disclaimer “not designed to diagnosis or treat any medical disease”. Would you rather believe the false promise or the true disclaimer?

Of course, these prostate potions do not want to be subjected to rigorous scientific scrutiny. Why would they? They do not need FDA approval like prescription medicines. They can freely and legally use the phrase “clinically tested” (whatever that means) and empty their warehouse shelves to clogged prostates across the country. These companies only have to spend funds on marketing, unlike true drugs that must spend millions demonstrating to the FDA that their products are safe and effective.

There are many products on the market today that don’t want to be tested to confirm or determine efficacy. Guess why.

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

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QD: News Every Day--Psst ... you wouldn't believe what half of Americans believe about medical conspiracies

Nearly half of Americans believe in at least 1 medical conspiracy theory, and nearly 1 in 5 believe in 3 or more conspiracies, a survey found.

A political scientist at the University of Chicago conducted an online survey and reported results in a Research Letter published March 17 in JAMA Internal Medicine.

The conspiracy theories are:
1. The FDA is keeping natural cures from the public due to pressure from the drug companies.
2. Health officials know cell phones cause cancer but won’t take action because of large corporations.
3. The CIA deliberately infected large numbers of black people with HIV, disguising it as a hepatitis inoculation program.
4. Monsanto’s genetically modified foods are part of a larger plot to shrink the world’s population.
5. Doctors and the government vaccinate children, knowing that the vaccines cause autism.
6. Water fluoridation is a secret way for companies to dump dangerous mining byproducts into the environment.

(Editor’s note: I think that last one is true.)

The survey found that 49% of Americans agreed with at least 1 of these conspiracy theories and 18% agreed with 3 or more.

At least half the sample had heard of the theories about cancer cures, vaccines, and cell phones. 37% believed the theory about the FDA and natural cancer cures; 20% agreed that corporations were suppressing data linking cell phones to cancer. And 20% believe that doctors still want to vaccinate children despite knowing that vaccines are dangerous.

Conspiracy theories about water fluoridation, genetically modified foods, and the link between HIV and the CIA were known to less than one-third of the sample, and only 12% of respondents agreed with each one. (And that’s just the way they want it.)

The researcher wrote, “Although it is common to disparage adherents of conspiracy theories as a delusional fringe of paranoid cranks, our data suggest that medical conspiracy theories are widely known, broadly endorsed, and highly predictive of many common health behaviors.”

These beliefs stem from common attribution processes, the author continued. Doctors should be aware that such patients are less likely to follow medical advice, such as using sunscreens or vaccines, and are more likely to use alternative treatments.

(Editor’s note: This blog post will self-destruct in 5 seconds. Commit it to memory and clear your browser history.)

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Tuesday, March 18, 2014

DIY medicine gets a step closer

As with other industries, the Do-It-Yourself movement has come to health care—and it’s getting stronger.

Unlike engine repair, craft brewing, or laying sheetrock, the barriers to entry for DIY-ers in health care are higher. The main barrier, medical knowledge, is lowering fast as autodidacts have more tools and information than ever before—as but two good examples, see Khan Academy or what’s known in the Twittersphere as #FOAMed–”Free Open Access Medical Education.”

Another big barrier has long been established by those that pay for health care–in the U.S., primarily insurers. They’ve had rules mandating that diagnostic testing be ordered by physicians, who then “control” the results.

Last week, in a victory for self-motivated patients, the U.S. Department of Health and Human Services issued a ruling giving patients the right to obtain lab results on their own from freestanding diagnostic labs without needing the interpretation or control of information from a medical provider.

This is not likely to have a huge impact, as many if not most medical practices have adopted electronic health records and it’s now common practice to share test results directly with patients.

But for laggards that have not implemented secure data-sharing policies, a major incentive is now there as patients will be able to collect data back from the lab on their own. It is much better from the provider perspective to get out in front of an “abnormal” result.

How about you? Do you get your results from your doctor automatically, or do you wind up having to hunt them down? Does this new ruling make you more excited to take control of your own health information?

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

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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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