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

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Friday, August 29, 2014

Doctors aren't 'healers'

It’s a seductive idea. We doctors possess knowledge and experience which can not only help people, but can save their lives. We get opportunities to be the right person at the right time to offer the right help that makes all of the difference. It’s one of the greatest things about our profession. It’s also one of its greatest traps.

I’ve heard many doctors refer to themselves as “healers,” as if we have some special power to bring about healing in our patients. This idea confers some sort of a higher status and originates, to some, from a “higher calling” to a more noble life. Again, this is a logical step, in that we have opportunities on a regular basis to help and even save the lives of people. It’s natural to believe that somehow the healing power comes from our touch, or even from our knowledge.

It doesn’t. I am not a healer.

Healing is what the patient does, not the doctor. As a physician, I am certainly one who can help the patient find a faster road to healing, but I don’t heal. I help.

Why am I taking the time to talk about this? Why get stressed out over whether I am a helper or a healer? I think that the belief in doctors as healers causes significant harm to both doctors and patients, and that getting a better perspective about the roles of each will greatly improve the care given. Here’s why I believe this is a topic that needs addressing:
1. Doctors often fail at healing (and will always ultimately fail)

There are many patient problems that do not get better, despite my best efforts. There are countless pains I can’t remove, and many problems I do not solve. Even when I succeed, the success is always temporary, as a new problem will eventually come back. And if healing is our ultimate goal as physicians, we all are total failures, as all of our patients eventually die. If healing is held as our goal, we fight a losing battle. We are the soldiers in the Alamo, offering impotent resistance to an overwhelming force.

If I believe in myself as a healer, I will face constant disappointment and defeat.
2. When healing occurs, it is often independent of doctors

My patient may follow my advice and not get better, or may disregard what I say and recover from their problem. My direction is imprecise and imperfect, based on my knowledge and experience along with what I believe to be happening with the patient. But my experience and knowledge may not be right, and my interpretation of what is happening with the patient may be inaccurate. Healing is something that happens in the patient’s body. It’s when they get better, whether or not I am involved in the process.

Belief in myself as a healer is based on a falsely high opinion of my knowledge and abilities.
3. Patients who see doctors as healers will expect too much

I’ve seen it. I’ve heard people’s frustration when I’ve told them I can’t fix their problem or remove their pain. They feel like they shouldn’t have to hurt, or that if there is something wrong it’s because I’ve missed something. These are the folks who buy the “miracle” cures pandered by Dr. Oz and other profiteers. They hear the promises of health and wellness from the media and are disappointed when we can’t offer the same.

By believing I am a healer, my patients will eventually be frustrated and disappointed.
4. Doctors who try to be healers do harm to their patients

The pressure to find the “magic bullet,” or the unifying diagnosis leads many doctors to practice bad medicine. This is a pressure we all feel when faced with the powerless feeling some patients bring. This leads to the ordering of unnecessary tests, performing of unnecessary procedures, and prescription of medications that should not be given. I believe this is what drives many doctors to overly-prescribe narcotic pain medications and other addictive drugs. We don’t want to stand helpless; we want to do something.

To protect my role as a healer, I am drawn away from my training and toward the task of finding a miracle. In doing this I can cause significant harm.
5. To protect their status as healers, doctors will oppose any other perceived competition

Doctors in the past have been held with reverence by the general public. We possessed that “secret knowledge” that others didn’t have access to, knowledge that fueled our healing power. Now everyone has access not only to all of the knowledge we have, but also to others who offer alternatives. This causes many doctors to aggressively discourage patients to research their own problems and to attack alternative providers. In defending their turf, however, they are giving patients an ultimatum: us or them. More and more patients are choosing “them” because of this and are rejecting what we offer.

By clinging to our power as healers, doctors have greatly harmed people’s trust in our profession.

So what’s the alternative? Does it really make a difference what we call ourselves as long as we practice medicine? I think it does. Now that I’ve got time to choose the best way to practice, I’ve seen that there is a much better alternative to being a healer: being a helper.

Yeah, that sounds all dull and boring, I know, but it is not only more realistic, it is a much better way to practice medicine. Here’s why:
1. By being a helper, i always can succeed

I may not be able to fix someone’s pain, but I can reduce it or can help them get through it. Every visit is an opportunity to help someone, and once I have helped them I’ve done something that can’t be taken away. I don’t have to see disease as a foe to be defeated, but as an opportunity to give to my patient from my experience and knowledge. Even when patients ultimately succumb to death, I have many opportunities to help them do so with peace.
2. Being a helper keeps my priorities straight

I don’t have some crazy idea that I have special powers. I don’t believe that I’ve been “called” or “chosen” to do magic. I just help people. My focus isn’t on me (as if my care was not a performance), but on the person I am helping.
3. Being a helper keeps expectations realistic

If my patients see me as a helper, not a healer, they will listen to my advice with different ears. I am standing beside them, not above them. They are far more likely to listen to me when I am offering help, not pronouncing my wisdom.
4. Helping means doing no harm

The temptation to offer more tests, more procedures, or dangerous drugs becomes much smaller when I take the role of helper over that of healer. I don’t see a need to prove myself, and will consider the harm of actions much more closely. I won’t over-prescribe pain medications because I will see how it harms my patients in the end.
5. Being a helper lets me exist in the information age

Like it or not, I am compared to the homeopaths, the herbalists, the chiropractors, and the doctors on TV. When people embrace alternatives to the care I give, they are not necessarily rejecting me; they are seeking what they are when they come to me: to feel better and to lessen their fears about the future. If the help I offer is held next to the miracles promised by others, I think I will win. If patients are helped by others, though, then I should be glad for my patients, not upset about the success of my “rivals.”

We call what we do “health care,” which implies a relationship built for the sake of a person’s health. I believe the best way to accomplish this is to have a realistic view of who we are and what we do. I am not a healer. When I try to be one, I always fail and am always disappointed. I am a helper, and in taking that role I can always have opportunities to succeed.

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

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Thursday, August 28, 2014

We used to make stuff

I like maps and charts. This map, from the Wall Street Journal, left me gob smacked.

Remember when we used to make stuff? Like cars? Clothes? Machines?

Apparently, most of what we do now is health care. That’s good if you’re a doctor, nurse, hospital administrator, or researcher. Especially good if you’re a health insurance executive. I suppose it’s good if you’re a patient. [We’re all patients.]

I’m left with a lot of questions.

If the health care industry is the largest employer in most states, is it because of health care’s unstoppable growth or manufacturing’s seemingly irrevocable decline? Or both?

What about California? I thought the tech industry employs lots of people, even if most of them are white males.

What about Oklahoma? I thought oil and gas were my state’s biggest industry. Nope.

At least Michigan’s #1 employment sector is still manufacturing. And Nevada’s is still tourism. Some reputations remain.

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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Wednesday, August 27, 2014

If doctors ran their practice like the airlines

Physicians could make so much more money if we could charge like the airline industry does.

Starting with appointments, there would be a surcharge for the most popular times. Last minute appointments are extra, on the theory that the patient would be willing to pay more if they are acutely ill. If we have a particularly light day, we might run a special and see patients at a discount. It goes without saying that when booking an appointment in advance, you’d would have to use your credit care to make a non-refundable deposit.

When you check in for your visit, it would cost $5 if you want to sit down while you wait. Magazines can be rented for $1 and there would be water bottles for sale if you’re thirsty. You can pay $7 for 2 hours of Wi-Fi to access the internet, or if you are sick or a hypochondriac and visit often, pay $10 per month for unlimited use.

If you’re one of those couples that book your appointments together, there will be a surcharge if you want to share the same room.

Just like it costs more for each piece of luggage you take on the plane, we would charge for each prescription we write. Medications that were more complicated to prescribe would have a surcharge. Want a form for work, to get out of jury duty or a parking permit? That will be extra.

When it comes time to undress for an exam, prepare to bring your own gown, or fork over $2.50 for the paper version. Don’t skimp paying 50 cents for the lubricant!

Do all these charges sound bad? Don’t worry. Hand washing is still complementary!

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. This post originally appeared on his blog, World's Best Site.

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No taste for truth?

This will be brief, blunt, and—forgive me—perhaps a bit brutal.

I find it incredible that a culture embracing “junk“ not only as a food group, but one of its largest; and the junkiest of such junk as the preferential food for its children, keeps looking for something to blame for rampant obesity and chronic disease other than its own blend of naïve nincompoopery (we, the people); pecuniary propaganda(marketing, media); and predatory hypocrisy (industry). Rather than supporting the health of our bodies, our body politic is feeding off their willfully devised decay.

I imagine this may stick in some craws. What can I say? The truth does that sometimes.

Think it really matters if we fixate on sugar or fructose, meat or wheat, saturated fat or omega-6? I don’t:
No One Thing
Why Holistic Nutrition Is the Best Approach
Scapegoats, Saints, and Saturated Fats: Old Mistakes in New Directions
Fructose, and the Follies of History

Think we are actually clueless about the basic care and feeding of Homo sapiens? I don’t:
Feeding Homo sapiens: Are We Truly as Clueless as We Seem?
Diet, Weight, and Health: Confused Only If You Want to Be!
Knowing What to Eat, Refusing to Swallow It

Think any of the “my diet is THE best diet” claims are valid? I don’t:
Judging the Judging of Diets
Science Compared Every Diet, and the Winner Is Real Food
Can We Say What Diet Is “Best”?

Think Ancel Keys is the anti-Christ? I don’t:
Living (and Dying) on a Diet of Unintended Consequences
In defense of U research: The Ancel Keys legacy

Think we don’t know what dietary pattern is best for health? I think we do!
Can We Say What Diet Is Best for Health?
Prevention and management of type 2 diabetes: dietary components and nutritional strategies

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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Tuesday, August 26, 2014

Who should take statins and why are researchers demanding a retraction?

I received an invitation to sign a letter authored by the Lown Institute in support of an article published in the BMJ (formerly the British Medical Journal) questioning the wisdom of prescribing statin drugs to patients at low risk of cardiovascular disease such as heart attack or stroke. Statins such as Lipitor (atorvastatin) and Zocor (simvastatin) are drugs which reduce cholesterol levels by inhibiting an enzyme on cell membranes.

The article concludes that statin drugs are unlikely to be helpful to patients whose risk of heart disease or stroke is calculated to be less than 20% in 10 years. It was written by Dr. John Abramson, a lecturer at Harvard Medical School and the author of 2 books about inappropriate use of medications and tests; Harriet Rosenberg, a social scientist from Canada who has written about the lack of good scientific study of statins in women; Nicholas Jewell, a statistician from UC Berkeley; and Dr. James M. Wright, a professor at University of British Columbia who writes about appropriate use of prescription drugs for a publication called the Therapeutics Initiative. It is excellent, concise and well written, so please consider following the link above to read it.

The work of the CTT

One year before this article came out, a group of lipid researchers called the CTT (Cholesterol Treatment Trialists) published a meta-analysis of 27 trials on the effectiveness of lipid lowering drugs and concluded that even very low risk patients (essentially everyone over the age of 50 with a few exceptions) could benefit from taking statin drugs, and that evidence showed that statin drugs cause minimal harm. Dr. Abramson et al combed through these same studies and concluded that the harms associated with statin side effects had been grossly underestimated and that actual mortality was not improved in low risk patients when they took statin drugs.

Members of the CTT pointed out that Dr. Abramson and his coauthors may have misrepresented another study in describing the magnitude of statin side effects, so the article was changed to reflect this. Now the head of the CTT, Dr. Rory Collins of University of Oxford in the UK, is asking the BMJ to entirely retract the article, arguing that it misrepresents other information, it is unclear which, and might convince people who take statins to discontinue them. It appears, from the meta-analysis, that at least 140 people at low risk need to take statins for 5 years to prevent 1 major cardiovascular event (stroke or heart attack) and that there is no reduction in mortality at all for this group.

It is also true that the vast majority of patients prescribed statins stop taking them within 2 years without any knowledge of this debate or even realization that there is a debate. Bloomberg Business Week comments on the conflict here.

Roots of the disagreement

So it appears to me that some very intelligent doctors completely disagree on the subject of whether low risk patients ought to take statin medications. It comes down to differing values, I think. The doctors who favor giving statins to just about everybody over the age of 50 believe that it is no big thing at all to take a powerful medication daily so long as the side effects aren’t horrendous or the cost individually prohibitive. Avoiding 1 stroke or heart attack in 1 of 140 patients is worth having the rest take a medication which doesn’t clearly benefit them. The doctors questioning expanding statin use put a higher value on saving the 140 patients not destined for strokes or heart attacks from taking a useless medication with some obvious, though not universal, side effects.

Side effects

And what about these side effects? What are they and why is there such disagreement about how significant they are? The most common statin side effect is muscle pain. In early drug trials the first statin, or HMG CoA reductase inhibitor, was so toxic to muscles that it resulted in the deaths of some laboratory dogs on whom it was tested. Subsequent statins were less toxic and rarely cause serious muscle breakdown, though muscle pain and spasms are common. Many patients discontinue the medication due to this side effect, but may tolerate another drug in a similar class or the same drug if it is tried again. This is often cited as evidence that the muscle pain was never the fault of the statin in the first place, though it is just as likely that patients, on finding their doctors insist that they take the drug that caused muscle pain simply quit talking about it and took the prescribed medication.

Also common are complaints of weakness, foggy thinking and indigestion. More serious side effects include diabetes, which occurs more often in statin users (1 in 100 over 2 years) and severe and life threatening muscle breakdown. My personal experience of statin side effects when I practiced primary care medicine included professors who stopped taking statins because they couldn’t think straight, middle aged hikers who discontinued statins because of progressive muscle pains, weakness and intolerable night spasms, an ancient man who had thought he was going to die because his back had become weak and painful while taking a statin, and thanked me profusely for years after for curing him by stopping his statin, and a woman who nearly died from statin induced rhabdomyolysis (sudden muscle breakdown) due to a drug interaction between her statin and another medication.

I probably saw my share of statin induced diabetes, but was never on the lookout for it since that association was not known at the time. Many of my patients refused to ever take statins again due to muscle pain though they had been prescribed for perfectly good indications including after heart attacks or stent placements. For some patients there were no side effects of taking statins, but a sizable minority found these drugs very hard or impossible to tolerate.

Who are the CTT?

... and why do they think that these side effects are unimportant? According to the 2012 article, they are about 100 researchers who wrote diverse research papers about how effective statins were in reducing cardiovascular disease, most of which were supported by the pharmaceutical companies which produce statins. Many are academic cardiologists, and probably none are primary care physicians. They are mostly not in a position to actually prescribe these medications to real people and then see those people back on a frequent basis as they complain that they just don’t feel as well as they did before starting the statin. They are also heavily cognitively invested in the truth of the research they have been involved in, which was designed, with drug company support, to be most likely to show that statins improve health and have minimal side effects.

Primary vs. secondary prevention

It is well established that statins help reduce recurrent heart attacks in patients who have known coronary artery disease. This appears to be due to these drugs’ ability to reduce inflammation which is an important cause of arterial narrowing. This use of statins is called “secondary prevention” and is pretty well accepted as a good reason to take them. There is solid agreement among mainstream physicians that use of statins in secondary prevention is usually a good idea. Treating patients who have not had an event such as a heart attack is called “primary prevention” and potentially involves billions of people who are otherwise healthy in medication treatment. Primary prevention with statins for high risk patients, say diabetic, obese and sedentary smokers with high cholesterol levels, is probably a good idea and is not part of the present debate.

The successful industry of health care

Dr. Abramson et al make an excellent point at the end of their article that because the pharmaceutical industry funds so much of cardiovascular research most of this research is limited to drugs, creating a body of scientific evidence that drugs are the only route to good health. Less exhaustive but high quality research shows that lifestyle modifications, including a diet rich in fruits, vegetables and whole grains, exercise and avoidance of smoking, is very powerful in preventing cardiovascular disease and extending healthy life. If these things made any entity good money, we would be seeing a myriad of strategies to get patients to adopt healthy lifestyles. Instead, poor health and dependence on medications fuels an economically successful healthcare industry. Medicine as an industry thrives when people live longer but require many medications and many medical interventions, so expanded use of statins with associated significant side effects is a winning combination.

Drugs and money

Statin drugs were responsible for over $29 billion in sales last year. This was a reduction of 11% from the previous year, because many of the statins have become generic. Increasing the number of prescriptions for these drugs will increase the revenue related to them and will fuel demand for newer drugs in the class or related classes. Although physicians in the CTT may only have patients’ best interests in mind, drug companies sell statins in order to make money. The power of the pharmaceutical companies is likely an important factor in calls for retraction of article by Dr. Abramson et al, which questions the present recommendations to expand indications for statin therapy.

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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When doctors break the law

I’m a law abiding blogger. Laws are meant to be obeyed. If an individual opposes a law in a free country, then he should operate within the system to modify it. I recognize that even in free societies, certain laws are so unjust and in violation of natural law that that the citizenry may be justified in relying upon other measures to affect necessary reform. I’m not suggesting that an unwelcome federal tax on gasoline be greeted with pitchforks in the street. However, our own democracy is a nation where slavery, “separate but equal,” exclusive male suffrage and Jim Crow discrimination were all legal. In such cases, can we expect a legislature to strike down unjust laws that it enacted?

Law and medicine are increasingly intertwined today, and more than they should be. Physicians no longer practice unfettered from legal encroachments and regulations. I am not referring here to the unfair medical malpractice system, a subject that has occupied a substantial portion of real estate on this blog. Look what Obamacare has wrought and what it threatens to do in the future? Private practice medicine—my gig, for example—will either be declared illegal or will be deprived of oxygen and put to sleep.

The most ludicrous intersections between law and medicine are when legislators try to play doctor for crass political reasons. This is nonsensical as even trained physicians can’t agree about medical testing and treatment. Medical experts, for example, are not of 1 mind on when mammography should be offered and at what intervals. I don’t fault our profession for failing to achieve a consensus here. The science behind the issue is not certain and differing and valid interpretations are expected. I admit here that some of these physician opinions may be politically tainted for reasons of self-interest, but even non-partisan and objective medical experts may simply interpret data differently.

When there is an important controversy in medicine, it should be addressed by additional medical research or accepting an interim position based on the views of medical professionals.

So do you think that the mammography controversy should be settled by doctors or a legislator submitting a bill that mandates mammography coverage starting at age 40?

If we allowed it, politicians would pass all kinds of medical care treatment and testing laws to curry favor with various interests groups. This might be good fertilizer to cultivate some votes, but is this how we want the practice of medicine to advance?

Ohio passed a law earlier this year that would require physicians to inform women facing mastectomy about options for breast reconstruction. The aim of the bill is to assure women that future reconstruction would be a covered insurance benefit so that they would be more likely to accept mastectomy.

Of course, I want these women to be informed of the reconstruction option. Indeed, this is the responsibility of the treating physician. I object, however, to a law that requires it. For those who support such a law, why only breasts? Surely, laws could be passed affecting every medical specialist and every organ of the body mandating certain medical advice. I advise my patients who have reached the 50 year mark that they should pursue colon cancer screening. I don’t think a law should be passed mandating this conversation, but it’s no stretch to imagine a pontificating populist politician from trying to do so. I’m not taking any chances. I’m buying a pitchfork, just in case.

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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Monday, August 25, 2014

Will immigrants make you sick?

The current immigration “problem” has got people fired up. Protesters are yelling at buses full of American kids, accusing undocumented child immigrants of every imaginable ill deed, from stealing jobs to using scarce resources to spreading disease.

The first 2 can be argued, the last not so much. Travelers from abroad can bring in some unpleasant illnesses whether or not they are immigrants. The actual risk is has been mendaciously bantered about by some politicians.

Two factors have already lowered borders that once held back the spread of some infections: rapid global travel and trade, and climate change. Global travel helped spread the HIV virus, and trade brought West Nile virus to the U.S. Trade can also spread food-borne illnesses like infectious diarrhea, but so can domestic foods. Few would argue that travel and trade should be eliminated as a method of disease control, although we can certainly develop precautions based on experience. Climate change is helping nasty diseases such as Dengue fever and chikungunya make their way into the U.S., and other than closing the borders completely it’s not clear to me how halting immigrant children at the border helps mitigate the danger.

Screening immigrants for vaccine-preventable diseases is a good policy and allows for vaccination for susceptible people, however many recent outbreaks of diseases like measles and mumps have been imported by Americans traveling abroad and returning to communities with poor vaccination rates. Vaccination of Americans is a priority for both domestic and imported risks.

Dr. Marc Siegel’s piece on the Fox News website is typical of the hyperbolic and frankly incorrect, ignorant, and inflammatory rhetoric from the right. He harkens back to the early 20th century when immigrants were excluded from the country for medical reasons. No doubt many of these were good choices, but disease was an excuse often used by nativists and eugenicists to exclude ethnic groups they disliked. The Johnson Immigration Act of 1924 leveled fines against steamship lines that allowed in “any alien afflicted with idiocy, insanity, imbecility, feeble-mindedness, epilepsy, constitutional psychopathic inferiority, chronic alcoholism, tuberculosis in any form, or a loathsome or dangerous contagious disease.”

That’s pretty broad and open to a lot of subjective judgment.

Siegel calls out some specific diseases he thinks Central American immigrant children are importing. Scabies is an unpleasant skin disease caused by small mites that burrow into the skin. It’s relatively common in the U.S., especially among people living in crowded and un-hygienic conditions, but it is not confined to any particular socio-economic class. It requires prolonged skin-to-skin contact for transmission, but can also be transmitted from inanimate objects. The mites can only live for a few days off the body, so object-to-person transmission (“fomites”) is not very efficient.

He also calls out drug-resistant tuberculosis. This dangerous disease is thankfully still relatively rare in the U.S. Imported cases are a concern, but Central America is not a hotbed of TB.

Scabies and TB are most efficiently spread in crowded conditions, like those immigrants are held in if not sent out into the general population. Keeping immigrants confined increases the risk of these diseases.

Siegal also mentions a few vanishingly rare diseases such as Hansen’s Disease (leprosy), another not-easily spread infection.

Ignorant and/or mendacious accusations like these inflame fears and hatred but do little to help prevent the spread of infectious diseases. Most of these diseases are social, not individual problems and require social solutions. One of these is to completely close our borders to immigration, travel and trade. Since this is insane, a better policy is to screen recent immigrants for important contagious diseases and see that they get vaccinations and proper treatment, including, if needed, isolation from crowded centers. Educating and vaccinating our own people is also essential.

Disease is a lousy excuse for excluding whole classes of people entering the U.S. and fanning those flames simply incites fear and hatred.

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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The next wave

I was traveling and, as I typically do, I bought a copy of Fast Company magazine to read on the plane. I don’t subscribe, but I find that it often has interesting articles on the intersection of technology and business. In the July/August issue, there was an article about GE and its CEO Jeff Immelt that I think has important parallels with the current transformation of health care delivery.

I have always admired GE as a well-run company that gave birth to a lot of the current teaching about effective management and organizational improvement. That sentiment comes in part from a course I took years ago in six-sigma quality management that closely followed the GE methodology. I have also heard Jeff Immelt speak, and was impressed with what I heard and later read about him.

The article was about how GE is pursuing a long-term strategy to create the “industrial internet.” The idea is to imbue the large expensive things that GE builds—think locomotives, jet engines, power plants—with “intelligence” that allows them to monitor their own status and couple that with “big data” analytics to predict (and avoid) mechanical failures. The article posits that even small improvements in performance or reliability could have huge economic benefits for industries such as freight railroads and airlines.

Here is the part that made me think about health care. A GE executive was describing the company’s evolution and described 3 “waves” of how they interacted with their customers. In “wave 1” (1960s and 1970s) GE sold heavy equipment with the promise of “if it breaks, we will fix it.” Wave 2 (1980s and 1990s) brought a closer relationship with customers through long term service agreements that assured a certain level of performance and included scheduled maintenance. The current wave was described this way:

“An approaching third wave, enabled by data and analytics, does something new. It strikes an agreement between GE and a customer for a certain kind of outcome, rather than a certain kind of functionality. It’s not only about measuring whether a jet engine is working up to its specifications, or about repairing it on time, but whether it is delivering, say, the agreed-upon amount of peak operational time.”

I believe we are in the midst of an analogous evolution of health care delivery. We can no longer think about health care as just providing a service (for a fee) to “fix” something that “breaks.” Health care should be—and soon will be—about achieving measurable improved health outcomes for the patients and population that we serve. Transforming our organizations to realize that goal is a heavy lift, and I think we can learn a lot from companies like GE about how to pull it off.

What do you think?

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. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

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Friday, August 22, 2014

5 ways that health care IT must get better

I had the honor of speaking at a large event in Cambridge, Mass., about how health information technology (HIT) needs to better integrate itself with the realities of frontline medicine, while also enabling doctors and nurses to spend maximum time with patients. The audience was filled with young and enthusiastic people—clinicians, IT professionals and entrepreneurs, people with great ideas who seemed committed to the cause.

HIT has of course grown exponentially over the last decade, as electronic medical records (EMRs) and computerized physician order entry (CPOE) systems have become ubiquitous. It’s funny to think that not so long ago, physicians and nurses had to trawl through piles and piles of paper charts to search for the information we needed, whether it was lab results or patients’ notes.

However, the road to this electronic environment has not been entirely smooth when it comes to implementing the technology in hospitals. There have been lots of bumps along the way as health care organizations have rushed to comply with Meaningful Use requirements in order to receive much needed federal incentives. Ironically, because of the time and effort that it takes to learn new systems, many EMRs and CPOEs have inadvertently impaired patient care to a certain degree. And due to the suboptimal nature of many of these systems, these problems have persisted well beyond their “launch”, no matter how noble the initial goals were. Here are 5 ways that health care IT must improve as we look towards the future:

1. Make systems more efficient
Entering data and orders is still too cumbersome, and needs to be made much more user-friendly. Get rid of the mouse, utilize touch screens and have minimal clicking to get what you need. Ordering something as simple as a Tylenol should not take a dozen or so clicks and several seconds of typing, as it frequently does.

2.Integrate different EMRs together
Different hospitals and primary care clinics typically use different systems, presenting significant logistical difficulties for doctors to get the information we need. There has to be a better way of bringing everything together.

3. Make everything mobile
Just like we can walk around our house with our tablet computers, doctors and nurses should be able to do the same in the hospital. Yet we are still largely restricted to our desk and PC. Using a mobile “cart” is no better, and it’s far from ideal to be pushing around heavy equipment in today’s technological age.

4. Start using voice recognition
Wouldn’t it be great to be able to just speak out our orders into a hand-held device, just like we can talk to Siri on our iPhones? How much time would this save at the frontlines? Similar to how we frequently dictate our notes now, it should be just as easy for entering orders.

5. Recognize the limitations of IT and understand that health care is a human experience
While technology is wonderful, it does have limitations. The world of IT has to understand that the field should be used as an aid, working side by side with doctors and nurses. It isn’t, and never will be, a substitute for human contact. If we’re talking about patient satisfaction and improving the health care experience, nothing trumps good solid medicine in a compassionate and caring environment.

The next few years will be pivotal in determining the type of health care we value and want for future generations. It will also determine the role of the doctor in this new medical age. It’s vital that health care IT is not only made better, but also used in the right way. Only by all parties working together—doctors, nurses, IT professionals, entrepreneurs, and even the government—will we ensure a brighter future for our patients.

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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Thursday, August 21, 2014

This is what we need more of

There’s a new randomized trial published in the Journal of the American Medical Association that evaluates the efficacy of post-cholecystectomy antibiotics in patients presenting with mild/moderate acute calculous cholecystitis. Upon diagnosis, all patient received amoxicillin+clavulanic acid 3 times a day pre-operatively and once during surgery. This open-label trial compared patients randomized to 5 days of post-operative antibiotics with the same antibiotic regimen vs. no post-operative antibiotics. Patients were followed up to four weeks post-operatively for SSI and other infections.

In the 414 patients, in the intention-to-treat analysis, the infection rate was 15% (31/207) in the post-operative antibiotic group and 17% (35/207) in the no-antibiotic group. The absolute risk difference was small (+/- 2.0%) and the 95% CI for the difference included zero for all key outcomes in the intention-to-treat analysis including superficial, deep and organ space infections.

The study appears to have high internal validity and randomization looks adequate. However, the lack of placebo and a relatively large non-inferiority outcome threshold (11%) are potential limitations. Of course, the study was also limited to amox-clav and perhaps some would favor testing other antibiotic regimens.

However, the lack of true difference will hopefully lead to further validation studies or adoption of a no post-operative antibiotic recommendation for this surgical procedure. This study and hopefully more like it are exactly what we need in order to reduce antibiotic exposure in hospitals and subsequent selection of antimicrobial resistant pathogens, including Clostridium difficile. It’s great to see important antimicrobial stewardship questions asked and answered.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Wednesday, August 20, 2014

Bad breath and oral health--what's new and what's old?

Probiotics for the gut are very popular right now, and well so, since overuse of antibiotics has radically changed the scope of intestinal illness in the U.S. When we take good effective antibiotics they kill not only the intended bacteria causing infection in our sinuses or lungs or bladders or skin but also quite a few of the innocent bystanders elsewhere in the body. Usually we manage to recover from the damage done, but sometimes we get life threatening overgrowth of bacteria or fungus which can have long lasting ill effects. Replacing bacteria killed with supplements containing beneficial organisms can reduce the harm caused by antibiotics.

But that’s not what I’m talking about this time.

I noticed that some of the people who I love most have bad breath. Sometimes, I’ve heard, even I have bad breath. Occasionally, despite having awesome oral hygiene, my mouth tastes kind of skanky and I could definitely believe that it wouldn’t be pleasant to be in intimate conversation with me. So what is in my mouth that is nasty? Definitely not rotting food, because that is gone after I brush my teeth and has no way of magically reappearing. The taste, and smell, is worst after sleeping, during which time salivation is minimal and the natural washing action of the tongue is almost non-existent.

Some people believe that nasty breath smells come from the sinuses or the stomach, but my knowledge of the plumbing of these areas suggests that I need look no further than the actual oral cavity. Genetic methods have identified over 600 species of bacteria in the mouth, most of which have not been well characterized. Some species lead to dental caries, others produce chemicals such as hydrogen sulfide or methyl mercaptan which smell nasty, while others modulate the oral environment to produce a healthy and disease resistant mouth. Dentists have identified Streptococcus mutans and Streptococcus sobrinus as being strongly associated with caries, but other patients with rampant caries did not harbor those bacteria and instead had multiple other identifiable bacterial types which may have been causal in their oral ill health. Still other bacteria may produce nasty smells but have no particular association with tooth or mouth problems. Some bacteria cleave sugars attached to proteins making it possible for other bacteria to digest those proteins, and thus produce smelly chemicals.

The human microbiome project was launched in 2008 to identify the bacteria which colonize us, including those of the mouth, gut, skin, vagina, lung and sinuses. This may well contribute to more effective therapeutics for the chronic diseases of these organs which are at present poorly treated by the heavy hitting pharmacological agents we are so good at developing. Antibiotics, so important in treating serious infection, can also kill bacteria indiscriminately leading to the growth of resistant organisms. They can also cause side effects on the kidneys, liver and bone marrow as well as serious allergic reactions. Immune modulating medications reduce our resistance to infection and cost ridiculous amounts of money. All of these are used to treat conditions of organs which have rich bacterial communities, without addressing the issue of what makes those communities healthy. Characterizing the flora of the mouth in health and disease could lead to novel therapies that might reduce gum disease and cavities as well as preventing things like strep throat and canker sores. Also bad breath.

Fecal transplant, that is introducing the bowel contents of a healthy person into a person with intestinal disease (limited right now to treatment of chronic Clostridium difficile infection) has proven to be powerful, simple and curative for people with bacterial diarrhea in whom antibiotics fail. There is increased interest now in all kinds of natural probiotics, helpful bacteria that are in foods, for overall gut health, with the hope of curing non-specific gut discomfort as well as intolerance of various food substances such as gluten and lactose. Might there be a precedent for oral bacterial transplants? Fecal transplant is abhorrent enough to humans that we have not come close to exploring its potential applications, and I can find nowhere on the internet describing a similar process for the mouth. Why would it not be useful to take oral bacteria from a person with excellent oral health and swab it into the mouth of someone who gets cavities at the drop of a hat or someone with rotten fish breath?

Presently I can’t bring myself to request a sample of mouth bacteria from a friend with awesome oral health. It sounds like a great idea, but I am not adequately motivated and also am not sure I would actually trade up. I have very few cavities and never have mouth or throat infections, so maybe the bacterial community in my mouth, despite not always smelling sweet, is doing a fine job. Still, I haven’t been able to resist trying a few of the easily available treatments that I have read about for sweetening the breath. Oral health experts recommend brushing the back of the tongue, where the taste buds grow high and the bacteria tend to congregate. After brushing and gagging, my mouth does taste better for a while. I have used mouthwashes a bit, but probably will not do so again after thinking about the implications of carpet-bombing my oral flora with chlorhexidine and alcohol. There is absolutely no reason to believe that the random bacteria which grow up after I use chlorhexidine will be any more beneficial than the ones I have now. I have bought oral probiotics which are chewed or dissolved in the mouth and contain beneficial strep strains, such as Streptococcus salivarius, which are purported to outcompete more harmful strep species. They taste nice, but I have not been impressed with any change in what I perceive as my mouth’s health. Perhaps I chose the wrong brand.

I have been most impressed with an ancient remedy, recommended by Hippocrates and Galen for diverse ills and prized by sultans’ wives for sweetening the breath. Mastic gum, from the Pistacia lentiscus tree in Greece, is harvested by allowing the sap to leak from the tree and dry to hard chunks on the ground. When chewed, it tastes a bit like cedar and softens into a substance much like chewing gum. I bought some on Amazon, and it arrived from Greece a couple of weeks ago. I think I like it. It makes the bacterial soft plaque that I notice on my teeth go away and my mouth tastes fresh. My teeth feel like they do after a dental cleaning, more smooth and shiny than they do normally, and the effect lasts for a day at least. A study from 2002 shows an antibacterial affect against S. mutans. I don’t swallow it, but a study over a decade ago showed it to be effective against Helicobacter pylori in the stomach, which can cause ulcers and stomach cancer. It’s not clear that even mastic gum is benign to the good oral bacteria, but it has sure been delightful to have shiny teeth!

Xylitol, a synthetic sugar alcohol that is common in sugarless chewing gums, has attracted quite a bit of attention as a preventative for tooth decay, and probably also for bad breath. A study that was reported in 1995 looked at 277 primarily school aged children given chewing gum flavored with sucrose, sorbitol, xylitol or a combination of xylitol and sorbitol to chew regularly. There was a slight increase in cavities with sugar sweetened gum and a significant decrease when the subjects used non-sucrose sweetened gum, especially xylitol sweetened gum. A more recent controlled trial of xylitol lozenges in adults at high risk of caries did not show significant reduction in cavities, except in the case of root caries. Xylitol use reduces bacteria that cause caries, and possibly bad breath as well, though I don’t find any actual studies to that effect. My own totally unscientific opinion, based on chewing xylitol gum and sucking on the lozenges, is that there doesn’t seem to be any lasting effect at all on breath taste or smell. Xylitol is also toxic to dogs, in whom it causes hypoglycemia and sometimes liver failure. It is not apparently toxic to humans, and doesn’t increase blood sugar in diabetics, which is handy. It is not, however, completely calorie free, but it is so sweet that it takes very little of it to sweeten something.

Bad breath is interesting not only because it is mysterious and socially significant, but also because it is an expression of complex bacterial interactions. The mouth is a small cave, populated with an interdependent community of bacteria whose health can have pretty far reaching consequences. It will be good to see what comes of the Human Biome Project. It has such wide ranging implications for understanding the human body in health and disease. Treatments like mastic gum or dietary probiotics and even ideas like oral bacterial transplant are exciting for treatment of annoying and socially very significant conditions such as tooth decay and bad breath. They unfortunately do not have the driving force of pharmaceutical companies behind their development. Treatments that can be inexpensive and in the control of people who are not in health care professions have the potential to make powerful changes without associated costs. The paucity of research into this sort of thing can be traced to the fact that we do not have a very good mechanism for scientifically exploring therapies that don’t make anybody money.

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

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Lifestyle medicine and the parable of the tiny parachute

A commentary was published on the blog site of the prestigious British Medical Journal telling us, in essence, that lifestyle medicine is ineffective. Specifically, it said that screening for chronic disease risk factors in the general population, and addressing them with lifestyle counseling in the clinical setting, is of no value.

The commentary was in response to a paper published in the BMJ that reached essentially the same conclusion. An accompanying editorial was entitled: “General health checks don’t work“ and began with “it’s time to let them go.”

The trial that provoked these responses randomized a large sample of Danish adults either to screening for chronic disease risk factors with tailored lifestyle counseling, or usual care. After 10 years, the 2 groups did not differ for the rate of heart disease or all-cause mortality.

One additional tidbit is worth noting, and a tidbit it is. The “intervention” consisted of three individualized lifestyle counseling sessions of 15 to 45 minutes each, spread over the first 3 years of the 10-year study period. If you will, the intervention was itself a tidbit of lifestyle counseling. Additional 6-group sessions were available, but that means even for the rare participants who took advantage of all offerings, less than 1 counseling session per year of observation. The sessions were made available to those study participants with overt chronic disease risk factors, including smoking, high alcohol intake, poor diet, and/or lack of physical activity.

I can’t help but initiate my reaction to all this with a rhetorical question: would anyone actually expect that between 45 minutes and 2 hours of clinical counseling over 3 years would meaningfully change health outcomes over 10 years for people who potentially smoke, drink, eat badly and avoid exercise?

To say the least, I would not. In fact, I would sum all this up metaphorically with the parable of the tiny parachute.

Imagine that the utility of parachutes was as yet unproven, and the task of proving their worth falls to us. We design an experiment accordingly. Parachutes are attached to—well, we can go with wine bottles; or ceramic eggs; or real eggs for that matter; or people if we are feeling brave—and these objects are tossed out of airplanes. A remote control device deploys the parachutes and we land to ascertain what we’ve wrought.

We find a mass of broken glass and splintered eggshells. Let’s hope we didn’t involve any live volunteers, or we would also find a jumble of mangled bodies. And so it is proven that parachutes are useless.

But we know that isn’t true. What if our parachutes were ridiculously tiny, each the size of a postage stamp? Or what if they were opened too late, each deployed within mere inches of the ground? Or maybe they were both too little and too late.

In that case, our experiment actually tells us nothing about the value of parachutes. It simply tells us that too little is too little, and too late is too late.

And so it is with lifestyle medicine. Of course it works, when it’s good medicine, timely, and dosed appropriately. The parable of the tiny parachute reveals that what might in fact be a highly effective intervention done right can be an entirely useless intervention done wrong. We are mostly doing it wrong.

For one thing, we are working against a monumental force. In the case of the parachute, the monumental force is gravity. A parachute works, of course, but even at its best, it only slows our fall rather than stopping it. A pervasive, relentless force wins against even good interventions.

In the case of obesity and chronic disease, that force pervades our culture; or more bluntly, it is our culture. Schedules that preclude time and attention to health until there is virtually no good choice left; a food supply willfully adulterated to strip away nutritional value and maximize the calories it takes to feel full; an ever greater variety of labor saving technologies; and so on. Worst of all is the hypocrisy of a culture that frets about the health of its children, but nonetheless sanctions the aggressive peddling to them of multicolored marshmallows and the like, calling such junk “part of a complete breakfast,” adding to the blatant, epidemiologic injury an insult to our intelligence.

The power of lifestyle medicine is best revealed where lifestyle is working as medicine throughout the expanse of culture, rather than delivered in medicine as an antidote to cultural misdeeds. The world’s Blue Zones exemplify this. The longest-lived, healthiest, happiest people on the planet do not attribute these blessings to high quality clinical counseling; they attribute them to a culture that puts health on the path of lesser resistance, and to prevailing norms.

That said, high quality clinical counseling can make a difference, and is most needed where culture is least salutary. But it must be high quality counseling, and most of what is provided by non-experts falls well short of that bar.

Models exist that adapt the best behavior modification techniques into the primary care setting; my colleagues and I have developed one such, available for free. Intensive skill-building programs can do far more to help people lose weight and find health than a few sessions with a clinician spread over years. And when the problem is advanced, such as severe obesity in teens, the evidence favors truly immersive therapy to offer an adequate dose of the lifestyle remedy.

Clinicians can and should play an important role in delivering lifestyle as medicine. For that to happen, the standards of such counseling, and affiliated programming, need to rise. I am privileged to serve at present as President of the American College of Lifestyle Medicine, an organization devoted both to this proposition, and to the propagation of programs that empower clinicians to provide better help, and empower patients to put good guidance to better use. We have an exciting conference coming up in the fall, so please click here if interested in learning more. We have sister organizations around the world, helping us turn lifestyle medicine into the global movement it should be.

Good clinical counseling can function like a good parachute; it can make a meaningful difference. We simply don’t see such benefit when we do too little, too late.

We can, however, do even better than the best of parachutes. We can never eliminate the downward pull of gravity; we can only resist it. But we can reverse the downward drag of culture on our collective health. We can use clinics to provide customized guidance toward better health, but we could also use our culture to put health for all on a path of lesser resistance. I have elaborated the details of what I think that effort would entail on a number of prior occasions, and invite the action-oriented to see them here, and here, and here, and here and here.

For everyone else, the parable will suffice. Of course parachutes work, but only when they are good parachutes.

When we administer lifestyle medicine effectively not just in clinics, but throughout our culture, we can do even better than slow our fall. We can climb.

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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Tuesday, August 19, 2014

When should doctors turn patients away?

A few days before this writing, a 32-year-old woman came to see me for an opinion on stomach pain. Why would I refuse to see her again? Abdominal pain is an everyday occurrence for a gastroenterologist. She was accompanied by her mother. I had never met this woman previously.

She had suffered abdominal pains for as long as she could remember. She recalled frequent visits with the school nurse when she was a young girl.

She has abdominal distress of varying severity every single day. Despite this medical history, she was not ill and appeared well. Why did I refuse to take on her case? She seemed like a very appropriate patient for my practice. I have expertise in evaluating and treating abdominal pain. The patient was pleasant and cooperative. I believe she would have been comfortable with me as her gastroenterologist.

I learned that the patient lived in another state and was only in Cleveland to spend the holidays with her family. In fact, she was leaving Ohio the day after my visit with her. I advised her that it was not in her medical interest to have a chronic condition managed by a physician hundreds of miles away.

Sure, I have some folks in the practice who live in other parts of the country, but I don’t manage their chronic conditions. These people return to Cleveland with some regularity, and I will do their periodic routine colonoscopies. Conversely, if one of my patients with active Crohn’s disease is off to Arizona to escape the oppressive Cleveland winter, I insist that he consult with a gastroenterologist there.

I know we are entering the era of telemedicine. I certainly do a lot of medicine on the phone every day, and many evenings. But, for many medical issues, there is no substitute, nor should there be, for a face to face visit with a doctor. Chronic abdominal pain, particularly in a new patient, can’t be solved in a visit or two. It takes serial office visits over time to deeply grasp the patient’s symptoms and understand the patient as a person. It needs regular physical examinations, which is a crucial piece of data for the doctor that can’t yet be acquired through cyberspace.

Managing chronic disease is a wandering journey for the patient and physician with unforeseen pitfalls and challenges. Such a patient may awaken one morning with new symptoms or a flare in his condition and may need to see a doctor on that very day. Even when the patient’s condition is relatively stable, there may be phone calls in between visits, or phone calls to determine the necessity of an office appointment.

So, I didn’t cure her in a half hour, but I did offer her advice. I recommended that she select a gastroenterologist where she lived. I forecasted the conversations that I anticipated she and the new doctor might have over the ensuing months. She and her mom understood why local medical care was the proper option for her.

Maybe eventually, my iPhone will have an app that can palpate an abdomen, discern body language and gauge if a patient “looks sick.” Until then, for most patients I will rely upon my eyes, my hands and my gut.

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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The pledge of the patient-centered physician

Medicine is a relationship between 2 people. I have my expectations, needs, and wants, and the patient has theirs.

However, the patient’s needs, wants, and expectations are more important than my own. She is the center of her health.

I will always:
• ask the patient what she wants, hopes, fears, believes to be true about her health,
• ask the patient what she prefers,
• tell the patient what options are available,
• if I am not able to do what the patient wants, explain why not, or
• ask the patient what her priorities are—whether in the moment, or in general.

I will never:
• assume that the patient wants the same things I do,
• blame the patient for their illness,
• belittle the patient for powerlessness,
• treat a patient worse than I would treat a family member, or
• check a box before I check with the patient.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.

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Monday, August 18, 2014

Why I'm skeptical about marijuana's medical benefits

There’s a little place up the street from me with a great beer list. My favorite is a Trappist ale that I order maybe once or twice a year (an ale whose name I never remember but simply refer to as “my medicine”). It’s great after a particularly stressful day, not because of the serenity of the monks who brew it, but because of its ridiculously high alcohol content. A glass of this medicine takes the edge off of just about anything.

As of July 5, the state of New York has a medical marijuana program. Medical cannabis laws have become the “gateway” law toward full legalization. Legalized medicinal use of marijuana has become less and less controversial, the main exceptions being anti-drug zealots and doctors and scientists who look at the evidence objectively.

Decriminalization and medical use of pot are (or should be) separate questions. The decision to legalize pot should be based on a risk-benefit analysis: are we better off tossing people in jail for using a relatively mild drug, and supporting an illegal trade, or should we make it legal, regulate it, and tax it?

The medical use of marijuana is a different question, not one of social policy but of science: are there specific medical benefits to cannabis? If so, what are they? Should we look at pot as another legal drug like alcohol and tobacco, or should we treat it as medicine?

If we are going to treat pot as medicine, it will have to do a better job at proving itself worthy of that title. There are plenty of prescription medicines of questionable benefit and with the potential to harm. Some are worse than useless, despite being legal, and some are nearly miraculous. Where does cannabis fit in?

The science so far doesn’t look good. At this point, despite thousands of studies, there is very little evidence that cannabis is good for any specific medical condition. If you choose to cherry-pick the data a bit, you can find some evidence for benefit in some sorts of painful nerve disorders. And that’s about it. Pot, when tested alone or compared to currently available treatments doesn’t seem to carry any of the advantages touted by its supporters.

This isn’t to say marijuana has no benefits. Many people report it helps them with the symptoms of a wide variety of medical conditions. But is this any different from my Trappist medicine?

Maybe. As research continues into the various chemicals that marijuana carries into your body, our understanding (which is already impressive) will grow. We probably will find some use for marijuana, but I doubt it will be a stand-out in our pharmacopoeia. Like any scientist, my mind is open to new data, to altering my hypothesis as the evidence changes. But one thing we’ve learned in medicine in the last century is that it can be dangerous to leap too far out ahead of the evidence. The line between excitement about a potential new medication and hucksterism is a narrow one.

The Wall Street Journal (disclosure: not my favorite editorial page) just published an opinion piece in support of medical marijuana, one that should be viewed with skepticism. The author, Steven Patierno, explains how non-smoked cannabis, in carefully documented doses, can bring great benefit. His industry disclosure shows him to chair the medical board of a company called PalliaTech that—surprise, surprise—works on developing carefully dosed, non-smoked cannabis medications. This doesn’t invalidate everything he writes, but it makes it suspect, especially if he doesn’t give us hard data (he doesn’t).

Last night I watched a CNN piece on medical marijuana (“Weed2″). It followed the sad case of a young girl with a horrible seizure disorder and her parents’ struggle to get her help. According to Sanjay Gupta, they finally found some help with cannabis, and the piece documents their struggle to get their daughter the medicine that they believe is helping her.

It makes for a great story, but it gives us no help in deciding if marijuana has any legitimate medical uses. A thorough search of the medical literature finds no good studies that support the use of cannabis or any of its constituents in seizure disorders. This doesn’t invalidate this family’s experiences: perhaps this is worthy of further study. What alarms me is the implication that a good parent is the one who gets an unproven medication for their child, no matter the evidence.

If I were the parent of a child with a rare disease, I would probably do as the family on CNN. I’d try anything. But as a doctor, I’d recommend against using what is clearly a powerful drug/medication in a way that may do no good and may even cause harm, especially in a child.

The active chemicals in marijuana have many effects on the brain, and likely elsewhere in the body. These effects are worthy of continued study, and I wouldn’t be surprised if marijuana or drugs derived from it find a legitimate place in the pharmacy. At this point, though, it’s mostly hope, fantasy, and guesswork.

The question of legalization is an important one, but distinct from pot’s potential as medicine. One is a decision based on our values. The other on cold, hard, dispassionate science. We should keep this distinction clear and stop using medical marijuana as a stepping stone to legalization.

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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More on physician autonomy

I previously wrote about the important distinction between independence and autonomy. I made the case that professional autonomy is not about each doctor doing as he pleases, but about physicians as a group taking responsibility for shaping medical practice.

I was thus pleasantly surprised when I came across a paper in Health Affairs that illustrates how effective physician leadership (autonomy) can reduce unnecessary practice variation (independence) and improve clinical care. The paper also reinforced some of my earlier thoughts about the central role that physicians must play in redesigning systems of care.

The authors report on the successful implementation of a standardized care pathway for eligible patients undergoing cardiac surgery at the Mayo Clinic. They devised a way to distinguish “routine” from “complex” patients, and established a “focused factory” model for the former group, which they define as “a uniform approach to delivering a limited set of high quality products.” It included protocol driven de-escalation of care (e.g., transfer of patient from ICU to floor), as well as cohorting of like patients, collection of process and outcome measures, and implementation of appropriate information technology. They were able to demonstrate that patients cared for in the “focused factory” had significant improvements in clinical outcomes and reductions in resource utilization compared with matched, historical controls.

There is a lot to like here. Physician leaders engaged their peers and other members of the care team with the expressed purpose of improving the “value (in terms of outcomes divided by the cost) of cardiac surgical care.” They chose their target well, since cardiac surgery is a high-cost, high-risk, high-profile endeavor. They had a thoughtful strategy, focused on reducing unnecessary practice variation. They designed a system of care sensitive to unforeseen clinical circumstances that would make “routine” care inappropriate. They measured their outcomes.

All of this follows the teachings of Richard Bohmer, who has written an influential book, Designing Care, that provides a framework for how to “better design, manage, and deliver health care.” It is a fascinating book that offers more insights and lessons than I can review here, but I recommend it highly, and will try to summarize some of the key points in future posts.

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. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

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Friday, August 15, 2014

The basic health care transaction

My life changed dramatically 18 months ago when I started my new practice. The biggest change personally was a dramatic drop in my income as I built a new business using a model that is fairly new. That’s a tough thing to do with 4 kids, 3 of whom were in college last fall. OK, that’s a stupid thing to do, but my stupidity has already been well-established.

Yet even if the income stayed identical to what I earned before the switch, the change in my professional life would have been nearly as dramatic:
• I am no longer focused only on patients in my office.
• I am no longer focused on ICD and CPT codes.
• Saving patients money has become one of my top priorities.
• I feel like my patients trust me more, and see me as an ally.
• Patients accept my recommendations for less care (avoiding unnecessary testing and unnecessary medications) much easier.
• I focus far more on preventing problems or keeping them small.
• I laugh with my patients far more.

What is most interesting to me about all of this is what is at the center of all of these changes: I changed the way I am paid for my work. Instead of being paid largely by third-party payors, I am paid by my patients, and instead of being paid more for sickness and procedures, I am rewarded for having healthy and well-informed patients. (For those who don’t know, patients pay me between $30 and $60 per month for my services, and there is no copay for office visits).

Since all of these positive changes stem from the incentives created by this different payment system, I’ve seen even clearer the reasons for all of the problems in our health care system: it’s all about the payment system, or the basic transaction of health care. From this transaction flow all of the bad things about our system, the waste, the impersonal nature of care, the physician burn-out, the spending without consideration of cost, and the blatant profiteering by companies associated with health care. Changing our system for the better, therefore, can’t happen without a basic change in the financial transaction at its center.

A business transaction involves 2 main participants: the buyer and the seller. The buyer gets a product or service they want from the seller in exchange for money.

What about the transaction of health care? Who are the participants in this transaction, and what is the product sold?
• The Seller: It’s pretty clear that health care providers, doctors, hospitals, and ancillary care facilities, are the seller in this transaction.
• The Buyer: It would seem that the patient, the one getting the “care” is the buyer here, but this ignores an important fact: providers get almost all of their money from third-party payors (insurance companies and government organizations). I think it’s pretty clear that doctors and hospitals are selling their “product” to these third-parties, not to the patients.
• The Product: Again, it would seem that the care given by the provider is the thing buyers are paying for, but this clearly isn’t the case. Reimbursement for health services is based on two main things: codes (CPT and ICD), and the documentation required to support these codes.

So, the basic transaction of health care is this:

The health care provider is paid by third parties for codes and documentation.

The codes, which are the most valuable commodity for a provider, are two types: problem codes (ICD) and procedure codes (CPT, E/M). The payment is actually only given for procedures, not problems, but the problem codes are the immediate justification of those procedures, and failure to justify will reduce or eliminate payment. So, the provider is motivated to find the best paying procedures and find problems to justify their submission.

Using this, the transaction of health care becomes this:

The provider is rewarded for finding the best-paying procedure code to match the most severe problem codes.

Documentation is done after the fact as a bookkeeping tool to prove the validity of the problem and procedure codes.

Where is the patient in all of this? Patients are the raw materials used for the product. They are a source of problem and procedure codes. What about the actual patient care? It is a byproduct of this transaction. Care is presumed to be encompassed in the procedure codes (a presumptuous presumption, as many would attest).

Let that sink in: patients are raw materials, and patient care is a byproduct. That’s pretty damning. It’s also fact, not opinion. It flows from the basic transaction of health care.

So let’s translate this to an office visit:
• The patient is nearly always required to come to the office for all “care” because this is the only place where payable “procedures” are done. For a primary care provider, the main “procedure” is the office visit itself.
• The patient history is done to find problems to which procedures can be applied.
• The bigger the problems, the better the reimbursement for procedures for the doctor.
• The main task of the office visit is to find problem and procedure codes, and to document those codes.
• “Customer service” in health care is not something that applies to patients, since patients are raw materials, not customers. Doctors are motivated to treat patients only well enough that they will continue to come and supply codes (much as a farmer would treat his/her cow who produces milk).
• True “customer service” from doctors applies to how quickly and accurately they produce codes for the customer: the payor.

Pretty brutal, isn’t it? This gets worse when you consider some of the corollaries that come from these facts:
• Solving patient problems is bad for business.
• Priority is given to patients with the best-paying payors. Conversely, lowest priority is given to those with the worst payors (i.e. Medicare and Medicaid).
• The best paid physicians are those who are the most skilled at finding the most well-paying codes for the least amount of effort.

When explaining my practice to people, I often take a slightly different take on the transaction:

You are employed by whoever pays you.

The reality of my former practice, and those of most of my colleagues, is that they are employed by the third-party payors, and so will spend most of their time doing the job required by their employer. In my new practice, on the other hand, I am employed by my patients because I am paid by them. They are no longer a cow from which I can milk codes. They are no longer a well from which I can draw procedures. They are the one I am hell-bent on keeping happy so that they’ll continue to pay for the care I give.

Finally, the care I give is no longer a byproduct of codes; it is the product for which I am paid. My kind of practice is the ultimate accountable care organization because we are accountable to our patients for the quality and value of what we do for them. If they don’t like the product we sell, they leave. The end result is more time devoted to assuring the quality of care our patients see.

More time for patients? That’s something I had to get used to when I started this practice. It’s also something my patients are still getting used to.

Surely there’s a catch.

No, I work for them, and that makes all the difference.

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

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Largest Ebola outbreak in history continues to spread

Given the myriad horrors happening around the world you could be excused if West Africa has fallen off of your radar, but from a health perspective, it deserves some attention.

I wrote in April about an Ebola outbreak in southeastern Guinea that had spread to Liberia and Sierra Leone. (Browse that first post for a history of Ebola, its symptoms, and how it’s transmitted.) By April the outbreak had already become the most geographically widespread Ebola outbreak in history, and the first in West Africa. By that time it had reached the capital of Guinea and had infected over 130 people and killed 88.

As of now, the outbreak remains to be contained, and by any measure is now the worst outbreak ever. Over 1,000 have been infected, causing over 600 deaths. The outbreak has also reached the capital of Sierra Leone. Most worrisome is that new cases are still developing, with 67 new cases reported from July 15 to 17.

Emblematic of the struggles that local health officials have faced in containing this infection is the news that the lead physician treating Ebola patients in Sierra Leone has himself become infected. At least 8 nurses in the same hospital have also contracted Ebola. This large number of infected health care workers hints at poor adherence to infection prevention guidelines or perhaps a simple lack of isolation supplies such as gloves and masks.

Officials are also battling public mistrust and false rumors about the cause and transmission of Ebola. Many locals also adhere to traditional funeral rites that involve contact with the deceased, increasing the likelihood of infection. A patient in the capital of Sierra Leone was forcibly removed from the hospital by her family and remains unaccounted for. Most recently, a possible Ebola case surfaced in Nigeria. If confirmed this would add a fourth country to this outbreak’s toll.

The World Health Organization’s recent update on the outbreak was quite frank about the shortcomings of the current efforts. It criticized, “low coverage of contact tracing; persisting denial and resistance in the community; weak data management; inadequate infection prevention and control practices, especially in peripheral health facilities; and weak leadership and coordination at sub-national levels.”

My last post worried about an Ebola patient getting off a plane in a large European or American city. I no longer have that concern. I think a country with an advanced healthcare system and an informed and cooperative public would quickly extinguish an Ebola outbreak. But the ensuing panic in which every fever is a potential Ebola case would cause much disruption.

I know you share my hope that the health workers toiling in West Africa gain the upper hand and contain this outbreak soon. Then we could go back to only worrying about all the other horrors in the world.

Learn more:

Worst Ebola outbreak ever gets worse: top Ebola doctor now infected(Vox)

A Doctor Leading The Fight Against Ebola Has Caught The Virus (NPR)

Ebola virus disease, West Africa – update (World Health Organization Global Alert and Response)

First Ebola victim in Sierra Leone capital on the run (Chicago Tribune)

Ebola Outbreak in West Africa Worries Health Officials (My post in April about the current outbreak)

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

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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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