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

Friday, September 19, 2014

Boom goes the dynamite

Oh yeah. Hot dang. All right. Groovy.

Boom goes the dynamite.

I had a very great day yesterday.

I saw 3 patients who had recent diagnoses of cancer. Yeah, those 2 statements seem to contradict. They don’t. Each person I saw gave me a clear view of how the practice I’ve been building over the past 18 months is making a difference. A big, big difference.

The first patient was a guy who is pretty far along in the treatment of his cancer. I sent him to a specialist about a year ago and he was diagnosed with a serious, but treatable form of cancer. While he’s happy with the overall outcome of his disease, he has lymphedema, which is making him very uncomfortable. Lymphedema causes swelling of soft tissue that is very difficult to treat, as it cuts off the normal drainage system for the fluid that is outside of blood vessels surrounding cells.

When he asked his specialists about this, they told him that nothing could be done. He expressed his frustration at the fact, so I did what every red-blooded person in 2014 would do: I Googled his problem. I immediately found a number of useful websites which talked about the exact problem he was facing, 1 of which was written by a physician who had dealt with his form of cancer (and has written a book chronicling his experience). While I read aloud from the website, he purchased the book from Amazon. I discovered that the pessimism of his specialists was not exactly right. In fact, I found out that there were important steps to take to prevent this problem from becoming permanent.

“Why didn’t my other doctors tell me this?” he asked.

I shrugged my shoulders. ”I guess they didn’t have the time to do it.” We had just spent about an hour together talking about his cancer experience and other non-medical things (computers, music). He nodded in agreement, acknowledging the reality the big advantage he has in my office: access to me.

The second patient, coincidentally, had the same kind of cancer. In fact, it was my experience with the first patient was just a few months before this second patient’s presentation that allowed me to quickly diagnose and treat his problem.

He had a peaceful expression as he sat across me in my office. ”This whole thing got me thinking differently about spiritual issues.” he explained. ”I just keep thinking about how many things worked out to get me diagnosed and treated. I noticed the lump and thought to myself: ‘I should make an appointment with Dr. Rob.’ and then you saw me the next day. Within a week I was diagnosed with cancer and things took off from there.”

I reminded him that before he got treatment, we had a discussion using secure messaging about “alternative” treatments for the cancer that were suggested by a family member. ”You remember when I told you about how Steve Jobs’ death was probably due to the time he spent going after alternative treatments before getting standard medical care?”

He nodded. ”Yeah, and I’m real glad I listened to you. Everyone has told me I’m doing amazingly well and have a good chance to be cured.” he told me. He looked away from me and took a deep breath. “I just wonder what would’ve happened if you weren’t in this office. I usually hate going to the doctor and put stuff off. I just wonder if things would’ve turned out like they did. It makes me feel like angels were around me.”

The third patient was a younger woman who was recently diagnosed with a very serious cancer. I saw her and her husband for the first time since the diagnosis. After tearful hugs and warm greetings, I asked how they were doing.

“Once we got over the initial shock of the diagnosis,” she explained, “we are doing much better.”

She had presented with symptoms not generally suggestive of cancer which persisted and grew worse. After going after the most likely causes, I got a secure message from the husband expressing his worry and asking me to do more to diagnose and treat her. After his message we immediately ordered the test that made the diagnosis. “She got really mad at me for doing that,” he said with a smile, “but I sure am glad that I did.”

She grudgingly agreed that he was right, and that (for once) a husband actually had an “I told you so” to hold over his wife. It’s usually the other way around. ”I would have waited much longer before doing that test. I’d probably have been nearly dead before making the diagnosis.” She paused and wiped away a tear. ”I’m just so glad you are our doctor.”

All 3 patients were significantly impacted by the different ways we do things in my new practice. Two of them may owe their lives to these differences. The main difference is the markedly better access my patients have to me. They don’t have a frustrating phone system to navigate, an army of office staff to convince, or a 2-hour wait to endure to get my time or attention. They needed my help, and they had easy access me when they most needed me.

One of the worst parts of the job of being a doctor is to diagnose people with cancer. At the same time, however, there is a sense of this being the highest honor paid to me as a person: I am the person who is there to help when the stakes are highest and the future looks darkest. I have the opportunity to be the right person at the right place at the right time. Bad stuff happens, and I will likely face many more sad yet meaningful days in the future where I am called on to stand beside people on the hardest days of their lives.

But yesterday made me happy. The hardest thing I’ve done in my life, giving up my old practice and starting something completely different, is succeeding. No, I’ve not yet earned enough to pay all of my bills (I am getting closer on that front). The success is measured in other ways: I’ve saved patients’ time, saved them lots of money, decreased their frustration, and restored some of their trust in doctors. This way of practicing medicine is not just different; it’s better.

Yesterday was the day when I saw its biggest success: My new practice saves lives.

Boom. Dynamite. Boom.

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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Physicians lose right of free speech

I’m all for free speech and I’m very hostile to censorship. The response to ugly speech is not censorship, but is rebuttal speech. Of course, there’s a lot of speech out there that should never be uttered. Indecent and rude speech is constitutionally protected, but is usually a poor choice. We have the right to make speech that is wrong.

I relish my free speech in the office with patients. I am interested in their interests and occupations and sometimes even find time to discuss their medical concerns. I am cautious about having a political discussion with them, but patients often want my thoughts and advice on various aspects of medical politics, and I am willing to share my views with them. I don’t think they fear that politics or any other issue under discussion will affect their care. It won’t.

A Federal Appeal Court recently decided in a Florida case that physicians could be sanctioned if they asked patients if they owned firearms if it was not medically necessary to do so. Entering this information into the medical record could also result professional discipline. The court was considering such gun inquiries to be “treatment” and not constitutionally protected speech.

I am on the record in this blog more than once that I do not think we should look to the courts to make policy. Their task is simply to rule on the legality of a particularly claim. In other words, we should not criticize a legal decision simply because we do not like the outcome. Nevertheless, this decision is simply beyond wacky and could create a theater of the absurd in every physician’s office

Could the following examples of physician inquires be prohibited?
• A psychiatrist cannot ask about cigarette smoking as this is not relevant to the patient’s depression.
• An internist cannot ask what the patient’s hobbies are as this is not germane to the medical encounter.
• A gastroenterologist asks his patient who is a chef for a recipe and risks professional sanction for crossing a red line.
• A surgeon asks a patient’s opinion about the town’s new basketball coach and hopes that this patient is not a planted mole recording the conversation.

So for those physicians who practice in the 11th Circuit, no gun inquires unless you can demonstrate with clear evidence that it has direct medical relevance. The court left open for now asking patients about sling shots, fly fishing and skeet shooting, but medical practitioners are advised to consult with their attorneys regularly.

Apparently, idiotic judicial decisions can still be the law of the land.

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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Thursday, September 18, 2014

Sodium studies, with a grain of salt

Another week, another roiling debate about nutrition. In the immortal words of Iago the parrot, I’m going to have a heart attack and die from that surprise.

Actually, heart attacks are directly germane to this topic; strokes even more so. The particular goal of guidelines addressing salt (or sodium) intake is to prevent ambient high blood pressure, a major contributor to cardiovascular disease and the leading cause of stroke. There are numerous other health effects of sodium intake as well, including an influence on bone density, but blood pressure tends to grab the spotlight.

And spotlight it is at the moment. Recent studies have reached almost shockingly divergent conclusions about the pros and cons of sodium restriction. Compounding matters, the studies in question appeared in the very same issue of the New England Journal of Medicine, published on Aug. 14.

Two articles, by the same large, international group of researchers called the “PURE investigators,” standing for “Prospective Urban Rural Epidemiology“ study, challenged the current emphasis on restricting sodium. Or at least, that’s what the related headlines say. One of these studies looked at variation in sodium excretion in urine and its association with blood pressure; the other looked at the same measure and its association with all-cause mortality and cardiovascular disease.

For both of these studies, the authors used a database of morning urine specimens from over 100,000 people in 18 countries to estimate 24-hour sodium and potassium excretion, and from those estimated values, to extrapolate daily intake of sodium and potassium. We may leave the methods at that, other than noting that as estimates are predicated on estimates, the error bars get pretty wide, pretty fast.

As noted, the inevitably hyperbolic headlines attached to these studies suggest they found that we should abandon salt restriction, and pour it on. But here are what the authors concluded in their own words. In the first of the studies, they stated: “In this study, the association of estimated intake of sodium and potassium, as determined from measurements of excretion of these cations, with blood pressure was nonlinear and was most pronounced in persons consuming high-sodium diets, persons with hypertension, and older persons.”

If you think that’s a long way from “pour it on,” well, I agree. Essentially, the researchers found that excess sodium was most likely to raise blood pressure in older people, and those already prone to high blood pressure. And, high sodium intake was most important when sodium intake was ... high. Well, alrighty then.

Moving on. The second study concluded with this: “In this study in which sodium intake was estimated on the basis of measured urinary excretion, an estimated sodium intake between 3 grams per day and 6 grams per day was associated with a lower risk of death and cardiovascular events than was either a higher or lower estimated level of intake.”

Superficially, that translates to: we can eat too much salt, and we can eat too little. That we have long known, since sodium is an essential nutrient. Too little can result in a life-threatening condition called hyponatremia. The study may have raised questions about how much is too much, since the 3-gram threshold is higher than current recommendations, although not higher than prevailing intake. But we have to be careful not to over-interpret that isolated finding. What does it mean if your intake of sodium is lower than average for the population of which you are a member? It means you are different. That might be good, but it could readily be bad. Being “different” might mean not fitting in with prevailing norms for any number of reasons, from poor health to social isolation. A lower daily intake of salt could result merely from a lower daily intake of food. Where any of these factors is operative, they might account for variations in both blood pressure, and mortality, quite independently of sodium.

Wherever these first two studies left us, we couldn’t stay there long, because the third study followed immediately after to shake things up some more. This one, by a different group of investigators, obtained data about sodium intake and cardiovascular death for over 70 percent of the global population of adults. What’s good for the goose is good for the gander, so here is what these researchers concluded: “In this modeling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day.”

They went on to note that excess sodium intake was responsible for one in ten of all deaths from cardiovascular disease around the globe. Associated headlines either indicated that our salt intake is, indeed, too high; or more bluntly, that too much salt is killing us.

A pretty confusing batch of papers to say the least, and that, too, has made headlines.

Here’s where I think it all shakes out.

There is no doubt it’s possible to consume too little sodium, and there is no doubt it’s possible to consume too much.

Not everyone is equally sensitive to sodium excess, and in general, it matters more as we age, and to those of us prone to high blood pressure.

A lower intake of sodium than prevails in a given population might indicate other important differences in behavior, health, or social integration. The current studies account for these imperfectly.

The studies purportedly raising questions about the importance of sodium restriction are actually only challenging the optimal threshold, suggesting it should perhaps be 3 grams daily rather than the current World Health Organization recommendation of 2 grams daily.

Missing from all headlines is this important tidbit: More than twice as many adults have a sodium intake above 6 grams daily as have an intake below 3 grams daily; and nearly 7 times as many have an intake above 4 grams, as have an intake below 3 grams.

This, in my view, leads to key point one: it is theoretically possible to consume too little sodium, but whether the relevant cut-point is set high or low, the vast majority of adults living in the real world consume too much. All three studies actually agreed on this point.

So, yes, I presume if you fill a house with water, it might cause drowning. But I’m not sure that theoretical concern is of great practical value when putting out a fire.

The second key point, certainly for those of us in the U.S., is this: More than 75% of the sodium we consume comes from processed foods. This figures in the manipulation of recipes to maximize our calorie intake.

The implications are rather clear. Any shift from a diet of more to less processed foods will result inevitably in a decrease in sodium intake. That shift is advisable because of the decisive health benefits associated with it, and regardless of the specific contributions of sodium reduction to that benefit. A typical American diet tends to be too high in sodium whether the higher or lower cut-point is invoked. But its more important liability is likely the fact that it is a typical American diet, in which a third or more of calories routinely come from “junk.” There is no debate about the value of eating food in place of junk.

As ever, competing headlines propagating confusion are partly a result of the legitimate nuances associated with the incremental advance of scientific understanding, and partly the machinations of media profiting from hyperbole and intrigue. But we can bypass the potential confusion altogether if we take it all with the proverbial grain of salt.

Whether the topic du jour is sodium, or fructose; wheat or meat; gluten or saturated fat, we are subject to the impasse of perpetual confusion if we fixate sequentially on each successive study of each particular nutrient. If instead we embrace what we reliably know about healthful eating in general, sodium intake will tend to fall in the sweet spot, along with the intake of all other nutrients. In other words, we could reliably defend ourselves against hyperbole and headlines, malnutrition and misinformation alike, with wholesome foods, in sensible combinations.

Tune in next week when that news ... will be exactly the same.

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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Wednesday, September 17, 2014

Physician drug testing

The New York Times reported on a ballot initiative in California that would mandate random routine drug and alcohol testing of physicians, and targeted testing after major adverse patient events. The full text of the proposal is available here.

Proponents of the measure (Proposition 46) highlight the danger posed by impaired physicians and the ubiquity of drug testing for other professionals such as airline pilots and public safety officers. They also endorse the other “patient safety measures” included in the proposition, including mandating that providers check a controlled substance database similar to the New York State I-STOP database before prescribing. Their arguments are summarized here.

Predictably, the California Medical Association opposes the measure, mostly they say because it would also raise the current cap on “pain and suffering” payments in malpractice suits, and lead to higher malpractice insurance costs. Interestingly, the CMA website opposing the proposition doesn’t mention the drug testing provision.

My first reaction when I read about the drug testing initiative was one of sadness. What a shame that we have failed to maintain the public trust in our profession. But I was also reminded of a case I was involved in years ago in which a physician’s careless act led to a patient’s death. I have long regretted that I failed to insist that the physician be tested for drugs or alcohol at the time. If the death had been caused by a plane crash or a bus accident, we would all expect such testing to take place, and its omission would never be tolerated by the National Transportation Safety Board.

The mission statement of the CMA is: “Promoting the science and art of medicine, the care and well-being of patients, the protection of the public health and the betterment of the medical profession.” Seems to me that if they really mean it, they ought to be in favor of drug testing.

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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Tuesday, September 16, 2014

A letter from a medical patient to the hospital CEO

We are at a pivotal moment in health care. It’s changing so rapidly even the people leading the change can barely keep up. One of the biggest paradigm shifts over the last decade is the focus on quality over quantity. Improving the health care experience and patient satisfaction are also being talked about in boardrooms across the country (largely due to the link with reimbursements, but still unthinkable a few years ago).

As someone who has worked up and down the East Coast in a variety of different settings—from large academic centers to more rural hospitals—I have found the broad challenges to be the same everywhere you go. Unfortunately it’s also been my experience that hospital leaders often lose the forest for the trees, and are overly focused on unnecessarily complex solutions to simple problems. I’ve treated thousands of hospitalized medical patients over the years, and with my interest in quality improvement and improving the patient experience, I’ve noticed very similar patterns in what our suffering patients report back to us as their best and worst feelings towards the hospital.

While I don’t presume to be putting words into anybody’s mouth, here’s what I suspect a letter would look like from a large majority of patients who are hospitalized in America:

Dear Hospital CEO/Health care leader,

Thank you for asking me about my hospital experience during my recent bout of pneumonia. Overall I found the commitment and dedication of the frontline staff to be highly commendable. Their sincerity and professionalism was without question. However, I would like to point out a few observations (in fact, I will list them to make it easier to read).
1. I spent a lot of time in the Emergency Room waiting for my hospital bed. I know how busy it was and I’m sure everyone was doing their best, but I wanted to mention this. It’s very noisy down there and sometimes felt a little too overwhelming for me (it’s my first time in hospital).
2. There was a lot of confusion when I was admitted about my medication list. The ED and the hospital doctor both had different lists, neither of which was my actual one. I’m sorry I couldn’t remember my exact medication regimen, I’m on several different pills, but is there a better way to get an accurate list, perhaps directly from my primary care doctor or pharmacy? This nearly resulted in a small medication error on my second hospital day.
3. The nurses that saw me on the medical floor were great, but I noticed they were fixated on their computer screens and pushing around their carts more than they were looking at me or other patients! One nurse remarked to me that she agreed completely with my sentiments and proceeded to tell me all about the enormous data entry tasks that nurses now have to do. While I can’t comment on that, my mother was a nurse and my vision of a good nurse was always one who was with their patient at the bedside, talking to them regularly, consoling, and trying their best to make their sick patients feel better. I’m sure things have changed over the years, but I do hope nurses still have time to be nurses.
4. I thought the doctors were very good. Maybe a bit rushed, but again I know how busy they are. One thing though, I was seen by several different doctors in the mornings—the intern, resident, Attending, and then other specialists. All of them asked me the same questions and did the exact same examination. I was confused at first with who was in charge, but got it after a bit (some of the doctors also said opposing things to me, which needed to be clarified).
5. I found it very difficult to sleep at night. On my first night, my roommate kept calling out, and on the second night, there was a lot of commotion outside. Also, when I was already getting better, did the nursing assistant really need to wake me up at 3 a.m. to check my blood pressure? Just a thought. I’m sure I don’t need to tell you, but sleep and a good rest is one of the most important things the human body needs, and it’s especially true when we are sick. It should go without saying that hospitals should be calm, quiet and comfortable places.
6. I had 2 tests done which required me to be NPO. On the morning of each test, nobody could tell me what time the test would be. Have you ever been NPO before? I can tell you, it’s not pleasant. It would be good to have at least some idea how long it will last!
7. A couple of the scans I had, nobody told me beforehand what they were for. A transporter just walked into my room and announced he was taking me downstairs. There were also a couple of occasions where a phlebotomist suddenly showed up during the afternoon to take blood. I’m an educated person, and it would have been good to know the reasons why.
8. My family was extremely concerned about me, and asked on a couple of occasions roughly when the doctor would be around to speak with them. The nurse gave them an 8-hour window! Is this normal?
9. I know it’s a cliché, but the food! I’m not saying we need to have gourmet 5-star food, but I wasn’t a fan. Sorry, but you did ask me what I thought.
10. When I was discharged, the whole process seemed to happen very abruptly. I think we need to be more thorough and go through all the medications and follow-up very carefully. It’d also help if all the appointments were made for me. And while we are on the subject, on my second day in hospital, someone called my family at home and started talking about my “admission status” and when I was going to be leaving. This was before anyone even knew what was wrong with me! More tact please, my family got a bit worked up.

Having given you this list, I still want to tell you that the doctors and nurses did a pretty awesome job. I’m very grateful for that and understand that a hospital is not a hotel. Although you asked me honestly what could improve, that doesn’t mean I didn’t overall receive an excellent service. For that I thank you and your hospital’s dedicated staff.

Yours sincerely,

Medical Patient in America

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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Monday, September 15, 2014

Touching all the bases

Internal medicine requires knowledge, deduction, and many skills such as history taking, physical examination, and analyzing diagnostic tests. When confronting a new patient problem, we use our brains to work on finding a diagnosis. Much like police detectives, we would like to have brilliant diagnostic epiphanies, but often we make our diagnoses by painstakingly collecting all the clues and doing the necessary boots on the ground work.

We had a woman admitted to our service with confusion, decreased appetite and weight loss. In the ED, they diagnosed CKD Stage V, creatinine >5, and BUN >90. She had a 10-year history of type 2 diabetes mellitus. She had a history of ingesting high doses of salicylates and had a mildly elevated level.

The next morning as we are making rounds in the ICU she was on the bed pan. We asked the nurse to check a residual urine, because that is what we must always do with an unknown elevated creatinine. In fact her residual urine was 245 cc, despite no hydronephrosis on renal ultrasound.

The next day her appetite had returned and she no longer was confused. Three days later her creatinine was 1. Urological evaluation is the main plan now.

We had no good reason to suspect urinary obstruction, but we often are surprised with apparently newly elevated creatinine levels. We see such patients all too often. Finding obstruction when we did saved many resources.

While we love our diagnostic eureka moments, more often we get to the diagnosis through a deliberate process of touching bases and seeing what clues arise on our journey. Too often I see practicing physicians and residents skips steps. Too often I skip steps. When we skip steps we can miss the diagnosis in our omissions.

We owe our patients the deliberate process that leads to success. We need to touch all the bases.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Friday, September 12, 2014

Occam's Razor burn

I don’t like to brag, but if there is one area of my skills as a doctor about which I am proud, it would be my skill as a diagnostician. I like to play Sherlock Holmes and figure out what’s going on with people, and I think I’m pretty good at it.

So I lied. I do like to brag … a little.

In most people’s mind’s eye, the role of diagnostician is this:

Doctor: “So Mrs. Smith, what brings you in today?”

Patient:”I feel like I am dying. I have trouble catching my breath, I am running fevers of 108 every day for the past two months, my fingers are turning black, I pass out at least two times every hour, and I’ve been vomiting up blood.”

Doctor (puts his hand in beard in a thoughtful expression): “Hmmm … sounds serious. Are there any other symptoms you have been having over the past 2 months?”

Patient: ”Well, yes, now that you mention it, I’ve got this strange rash on my feet and they’ve really started to smell bad.”

Doctor (turns to nurse with knowing expression): “Just as I suspected. That last bit of information was crucial in tying this all together. There is a rare foot fungus that causes all of your symptoms. That’s why I always need you to tell me everything so we can find the right diagnosis.” (Doctor pulls out a vial of oil from his white coat). ”Let me put this oil (which comes from the moss of a tree that only grows in Tasmania) on your feet.”

The rash vanishes and the patient’s color returns to a healthy pink glow.

Patient: “I am healed! Thank you doctor! How did you know that was the problem?”

Doctor: “Give me all the facts and I can figure out what’s wrong. Never forget the wisdom of Occam’s Razor: ‘The simplest explanation is usually the right one.’ I look for the one explanation that ties all of the symptoms together and that is usually the answer.”

As a clinician, I fantasize about being the heroic detective who notices those obscure facts that others would miss, coming up with the life saving diagnosis when all others had failed. This, unfortunately, is not how it usually works when dealing with real human patients, and my desire to find a single diagnosis to explain what is going on can actually distract me from finding the answers my patients need.

Here’s how the real interaction often goes:

Doctor: “So, Mrs. Smith, what brings you in today?”

Patient: “For the past 6 months I’ve gotten more and more tired. I just have no energy at all.”

Doctor: “Are there any other symptoms?”

Patient: “Yes, now that you mention it, I’ve been losing a lot of my hair, I am gaining weight, I’m constipated, and my skin is real dry.”

Raise your hand if you think you know the diagnosis? If you said “low thyroid,” you fell into my clever trap. Even though these symptoms are classic for hypothyroidism, I have some information you don’t: Mrs. Smith just had a battery of blood work that was completely normal, which included thyroid testing. I also know some other facts about Mrs. Smith:
• She’s married to an alcoholic.
• Her mother recently died suddenly.
• She had a hysterectomy 3 months ago.
• She has a history of bad environmental allergies.

It turns out that Mrs. Smith isn’t sleeping well at all (related to her marital situation and loss of her mother), which explains her fatigue. Inexplicably, a large percentage of my patients who don’t sleep well fail to mention this fact, instead focusing on their extreme fatigue. I point out that there is a well-established link between lack of sleep and fatigue, and that fixing sleep will go a long way in improving fatigue.

The hair loss is related to her recent surgery and the loss of her mother. There’s a condition known as telogen effluvium where a person can lose up to a third of their hair following a particularly stressful event (such as surgery or a large psychological trauma). It accounts for the vast majority of acute hair loss in my office.

Her dry skin is related to allergies, which everyone in my town seems to have, and the constipation is irritable bowel syndrome she’s having related to stress in her life.

This is not the solution Hugh Laurie would’ve uncovered on an episode of House, nor is it the glamorous deduction Benedict Cumberbatch would’ve made on Sherlock. This would make really dull television, to be sure, but it is by far the rule as to the answers I uncover as a diagnostician.

Occam’s Razor be damned.

This is frustrating. It frustrates patients who have thoroughly researched their symptoms and have come up with the “1 diagnosis to rule them all” which explains (and fixes) everything. It frustrates doctors in training who get excited when they hear the patient say “all the right things” that point to a particular diagnosis, only to be turned back by negative lab tests. Finally, it frustrates experienced doctors like me when we have patients for which only one clinical diagnosis makes sense but the data rule out the only explanation we’ve got. Yet this is reality, and we must always bow our knee to the facts before us.

Here’s how I approach diagnostic problems in the real world (you may call this “Rob’s Razor” if you want):
Listen to the story. Patients will usually tell you what is wrong with them. Pay attention to the entire history, and don’t make theories until you’ve heard everything.
Don’t assume you’ve heard everything. Even after you’ve heard everything, you are inevitably missing important information. This may be “chapter 1” of the patient story, and simply the passage of time will make a confusing story begin to make sense.
First focus on the things that pose the largest risk. Make sure chest pain is not the heart, fever and cough is not pneumonia, and abdominal pain is not appendicitis. This can be done simply by getting a clearer history, or it may require further testing.
Then address problems that are common. Common problems presenting in uncommon ways are more common than weird stuff. I look for patterns: episodic abdominal pain suggests gallbladder. Constant chest pain lasting for two days is never ischemic heart pain. Weird chest pain in a 50-year-old diabetic smoker is more worrisome than classic pain in a 20-year-old female.
The older people get, the less likely you find a single diagnosis. Pediatrics is usually simple, as kids are usually sick with one thing. Adults, on the other hand, often have multiple problems at once. You will usually be wrong if you assume all symptoms are related in an adult.
When in doubt, blame medications. I had a person recently with itching in the ear that would not stop. We tried multiple things to relieve this, but couldn’t get it better. She was taking a blood pressure pill (ACE inhibitor) which sometimes causes a relentless cough, and I remembered that chronic cough could also be caused by irritation of the ear canal. So we stopped the medication and the symptom went away. To be certain, I had her restart it, and her symptoms quickly returned. The more medications a person takes, the more likely they are having side effects.
Be willing to wait for an answer. Stories develop, and sometimes you hear things differently when you’ve heard it the 5th time. Be patient.
Accept little victories. While I like to put oil on a patient and cure their symptoms, I usually don’t hit the home run. It’s often better to aim for a 10% improvement, or improvement of a single symptom, than to fix them all at once. Over time, a bunch of 10% improvements can make a big difference.
Remember: some problems go away on their own. Some things need Father Time, not Dr. Rob, to get better.

This all gets back to my role as a physician as a helper, not a healer. I like to be the medical magician who pulls a diagnostic rabbit out of the hat, but more often I’m the hand that helps people up when they are down, making the most out of a tough situation. It’s not glamorous, but it’s the way things usually work. Accept this fact and be pleasantly surprised on the occasion when Occam is actually right.

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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Testing doctors for drugs and alcohol

I read recently that the left coast state of California is contemplating requiring physicians to submit to alcohol and drug testing. Citizens there will be voting on this proposal this November. I do think that the public is entitled to be treated by physicians who are unimpaired. Physicians, as members of the human species, have the same vices and frailties as the rest of us.

I have no objection to this new requirement, if it passes. This will not be a stand-alone proposal on the ballot, but is a part of the ballot initiative. Why would trial lawyers in the Golden State want to include it? The meat of their ballot effort is to reverse effective tort reform that had been in place there for several years. Click on the Legal Quality category on this blog for a fuller explanation of why the medical malpractice system has been screaming for reform, and is slowing getting it. Sure, there are always two or more sides to every issue. But, when the different points of view here are fairly weighed, trial lawyers’ self-serving positions are overtaken. They offer a different spin, of course. While I acknowledge the validity of some of their arguments, I believe that the system they advocate helps very few at the expense of many more innocents.

The California ballot initiative aims to increase the financial cap for a medical malpractice award from $250,000 to $1.1 million. Trial lawyers and other supporters were concerned that the public may reject raising the cap as they have been enjoying the benefits of tort reform. Focus groups supported the notion that the public would find the drug and alcohol testing proposal appealing, which would raise the probability of passage of the bill.

There’s nothing evil about any of this. Every player in every issue uses polling and focus groups to create and tailor their message. (Ever notice how politicians claim they never read polls whenever poll results are against them or their positions?) I’m sure that the insurance companies who champion tort reform are using the same techniques to manage their message.

But, voters there and the rest of us should recognize why the drug and alcohol provision is included. It was just a spoonful of sugar to make the legal medicine go down. Why not just include the medical malpractice vote on the ballot by itself,? We’ve seen our politicians use this same technique over and over again. Add a popular poison-pill provision to an unpopular piece of legislation. When it’s properly voted down, criticize those who voted against it by pointing out their opposition to the popular add-on provision. Follow this example.

Legislator A: I am adding an amendment to the Quadruple the Minimum Wage Bill that would give all veterans and their families free First Class seating on all domestic flights.

Legislator B: I am voting against the bill because I think that quadrupling the minimum wage is bad economic policy

Legislator A: Shame on Legislator A for trashing our veterans who have sacrificed so much for this country.

Should other professions be subjected to random drug and alcohol testing? Which would you suggest?

Will Californians see through the smoke here? We’ll find out this November.

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

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QD: News Every Day--Cardiologists should consider comorbidities, study says

A quarter of adults in the U.S. have 2 or more chronic medical conditions, as do more than two-thirds of seniors, yet there are few clinical practice guidelines for cardiologists that take such comorbid conditions and their treatment into consideration. An put some numbers to how much comorbidity exists.

The authors of an article jointly developed by the American College of Cardiology, the American Heart Association, and the U.S. Department of Health and Human Services, reviewed Medicare claims for 2012 to determine the extent to which cardiovascular patients were filing claims for a range of other conditions such as pulmonary dysfunction, diabetes, arthritis and mental health disorders.

As was expected, hypertension and high cholesterol were the most common comorbidities for most of the major cardiovascular conditions. Notably, diabetes and arthritis were also very common in individuals with these conditions. For example, diabetes was a comorbidity in 41.7% of those with ischemic heart disease, 47.1% among heart failure patients, 37.1% in atrial fibrillation patients, and 41.5% in stroke patients. Arthritis was a comorbidity in 40.6% of those with ischemic heart disease, 45.6% among heart failure patients, 41.7% in atrial fibrillation patients, and 44.2% in stroke patients.

The analysis also revealed the presence of comorbidities such as chronic kidney disease, chronic obstructive pulmonary disease, Alzheimer’s disease/dementia, and depression among individuals with these cardiovascular conditions. For example, 26.3% of heart failure patients had Alzheimer’s disease/dementia, and 29.7% of stroke patients had depression.

The increase in so many comorbidities in aging patients with cardiovascular disease is an important clinical problem and makes developing new guidelines critical, the authors noted.

“We must try to better address many of the comorbidities that require special consideration,” said Jeffrey L. Anderson, MD, MACP, chair of the ACC/AHA Task Force on Practice Guidelines, and associate chief of cardiology at Intermountain Health Care, in Murray, Utah. “For example, arthritis is very common in older individuals who take analgesics that can make them more vulnerable to stomach bleeding, and blood thinners can cause serious consequences if stomach bleeding occurs, as can bladder complications.”

He said the ACC and AHA are working to provide cardiologists with a better understanding of how many drugs used to treat many conditions in older patients might react with current cardiovascular medications.

“Physicians often do not address these other conditions in making treatment decisions,” Dr. Anderson said. “This is intended as a wake-up call, since therapeutic decision making is getting more complicated because so many new drugs, devices, and therapeutic strategies for these other conditions are constantly coming into clinical practice. There is a lack of general awareness and even good clinical evidence available on possible interactions with cardiovascular and non-cardiovascular drugs.”

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Thursday, September 11, 2014

Your doctor's knee-jerk reflex: how not to get kicked

We are, I trust, all but universally familiar with the knee jerk, or patellar, reflex. A doctor taps the patellar tendon with a rubber mallet, and our leg kicks forward in response.

The reaction is famously unthinking. In fact, it is literally so. What makes a reflex a reflex is that the brain is substantially uninvolved. The stretch of a tendon by the mallet is transmitted to the spinal cord, and the compensatory command to move against the stretch is sent right back out from the spinal cord to the muscles. The brain only gets involved as chaperone, pointing out to the nerves and muscles in question that the tap of a mallet is far from a dire threat to life and limb, and the response need not be unduly vigorous. In the aftermath of a stroke that damages the brain’s involvement in this network, and removes the calming influence of a rational assessment, reflexes become hyper-intense.

Since reflexes are reflexive, unthinking, and even a bit silly, we use them as a metonym for other actions of that sort. When we act without thinking, we admonish one another against such “knee jerk“ behavior.

Bringing this full circle, then, from reflex hammers in medical context to metonyms in the context of popular understanding, I write to offer a precaution: beware your doctor’s knee jerk reflex.

There are three particular prompts for this warning at this time.

First, I recently saw and began treating a patient for the fluoroquinolone syndrome. Within just a couple of weeks, I heard from a friend who had classic symptoms of it as well, following treatment with Levaquin. In both cases, there was a valid indication for antibiotic use. But there was also good reason to doubt the need for such a high-powered, broad-spectrum antibiotic in both cases. Often, the easiest way for a busy clinician to be sure to “cover the bases” with an antibiotic is to go after a fly with an elephant gun. The collateral damage can, predictably, be considerable; a consequence of knee-jerk prescribing.

Second, a paper published in JAMA indicates that cancer screening tests are routinely ordered in both men and women with life expectancies less than 5 years (due either to advanced age or serious illness, or both). The tests in question are all good tests, recommended by the United States Preventive Services Task Force. But the whole point of screening is to look for trouble early so it does not progress over time. If there isn’t much time left, looking for potential future trouble not currently causing any is very unlikely to do any good, and can, as the authors note, do harm. Why order the test then? Reflex.

Third, and finally, a study was just published in Critical Care Medicine indicating that demonstrably futile care in the intensive care unit is not merely futile, but potentially as bad as fatal. As the rate-limiting resources of intensive care are allocated to cases where they cannot do any meaningful good, those more likely to benefit are denied access. The misallocation of resources in this case is again the product of inertia, going with the prevailing flow, or reflex.

And so it is that while we might all submit on occasion to the knee jerk test, we should not submit to the knee jerk tendencies that all too readily drive behavior, even in clinics and hospitals. Self-defense is simple, and accessible to us all.

1) Always ask “why?” This seems obvious, but even in this modern era, many patients take it as an article of faith that a doctor’s recommendation is thoughtful and well informed. It may well be; but on any given occasion, it could also be a knee jerk, born of prevailing tendencies, distractions, and want of time. The question “why” is easily addressed by those who have already thought it over; and is a necessary reality check for those of us who have not.

2) Always ask “what else?” In the case of the fluoroquinolone syndrome, it’s bad enough when a fluoroquinolone was a genuinely thoughtful, warranted choice. It’s downright tragic when a much-less-potentially-toxic, narrow spectrum antibiotic would have served at least as well. “What else?” is a reminder that there is generally more than one way to test or treat, and the one we want is the BEST of them: most likely to help, least likely to hurt. It prods our providers to do the extra work of getting us there when we remind them we want to know the options, and comparison shop them.

3) Always ask “then what?” This would certainly defend against a screening colonoscopy in an 85-year-old with congestive heart failure. If I have this test, then what? The answer would have to be: we can find potential cancer early, and fix it now so it doesn’t cause you trouble in ten years. That would invite all concerned to revisit the relevance of that “help” 10 years in the future of someone exceedingly unlikely to live that long.

Clinical assessment that includes a test of the knee jerk reflex is fine. Clinical decisions driven by it are not, but they too, are out there. Forewarned, I hope, will prove to be forearmed.

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

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QD: News Every Day--Internists losing 48 minutes a day to EMR use

Internists lose an average of 48 minutes a day to electronic medical record (EMR) use, including data entry and note writing, a survey found.

ACP members and staff sampled 1% of its membership, including attending physicians, residents, and fellows, from its research panel. Researchers then used random sampling to ensure balance and added nonmember internists. The 19-question survey was sent to 900 ACP members and 102 nonmember internists who provided ambulatory care; 411 responded. While 3 of 4 were attending physicians, trainees were more likely to respond. Respondents were experienced EMR users, as 70.6% used all of the EMR functions, and 82.5% had EMRs for more than 1 year. Researchers honed in on free time to learn more about the EMR’s overall effect on internist’s time, including nonclinic time.

Results appeared online Sept. 8 in a researcher letter in JAMA Internal Medicine.

The physicians reported using 61 EMR systems and came from a broad range of practice types. Researchers reported that 9 EMRs were used by 20 or more respondents, accounted for 324 (78.8%) of all users, and among these systems, users lost free time (P<0.05 for all). Of these 9, the Veterans Affairs’ EMR system was associated with the least loss of free time (−20 minutes) (P=0.04).

Researchers wrote, “Among all respondents, 89.8% reported that at least 1 data management function was slower post-EMR adoption, and 63.9% reported that note writing took longer. Surprisingly, a third (33.9%) reported that it took longer to find and review medical record data with the EMR than without, and a similar proportion, 32.2%, that it was slower to read other clinicians’ notes.”

Among all respondents, attending physicians lost a mean of 48 minutes per clinic day (P<0.001), compared to trainees, who lost a mean of 18 minutes per day (P<0.001). Among the 59.4% of all respondents who lost time, the mean loss was 78 minutes per clinic day.

“The loss of free time that our respondents reported was large and pervasive and could decrease access or increase costs of care,” the researchers wrote. “Policy makers should consider these time costs in future EMR mandates. Ambulatory practices may benefit from approaches used by high-performing practices—the use of scribes, standing orders, talking instead of e-mail—to recapture time lost on EMR. We can only speculate as to whether better computer skills, shorter (half-day) clinic assignments with proportionately less exposure to EMR time costs, or other factors account for the trainees’ smaller per-day time loss.”

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Wednesday, September 10, 2014


The trend-spotting New York Times published a front-pager about the growth of urgent care clinics nationwide.

These are the places that are often referred to as “minor emergency rooms,” or “doc-in-a-box” outfits. Their value proposition is simple: You don’t need an appointment. The costs are “reasonable,” and much more transparent than usual medical care at a doctor’s office, emergency room, or hospital. Best of all: They can treat a majority of acute conditions and have you in and out in under an hour. No ER can make that claim. Heck, not many doctors’ offices can make that claim.

As the article makes clear, urgent care centers have one tremendous advantage over emergency departments: They can cherry pick patients. ERs are required by a federal law called EMTALA (1986) to see and stabilize every patient, regardless of their ability to pay. Urgent cares have no such obligation. And they don’t take Medicaid. To be seen, you must have either private insurance or pay cash.

Seeing a money-making opportunity, big money (i.e. Wall Street, health insurers, hospital chains) are investing big in urgent care centers.

Naturally, skimming the straightforward acute cases out of the medical morass makes some unhappy. The article quotes one physician: “The relationship I have with my patients and the comprehensiveness of care I provide to them is important,” said Dr. Robert L. Wergin, a family physician in Milford, Neb., and the president-elect of the American Academy of Family Physicians. “While there is a role for these centers, if I were sick I’d rather see my regular doctor, and I hope my patients feel that way.”

As a doctor, I very much see Dr. Wergin’s point of view. I believe in the importance of a relationship with a doctor (or, heck, a “medical home“) over the long term. But as a patient and “consumer,” I can certainly see the value in a place that can handle acute stuff on a walk-in, cash basis. My own patients who try to see me for minor maladies are often disappointed to find I’m not available for same day appointments much of the time.

I think the article gets it right. Urgent care is a trend likely to grow at least until the market is saturated. What will keep them afloat is the value they provide, until doctors’ offices (“medical homes”) can offer truly expanded hours and availability, and come up with more transparent pricing and same day efficiencies.

Doctors and traditionalists will continue to wring their hands over this upstart economic/delivery model, but as the industry moves from cottage to corporate, this is just one more stream in a raging river.

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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Tuesday, September 9, 2014

Taking patient engagement to the next level in hospital care

Improving “patient engagement” is a subject that’s being talked about in hospital boardrooms across the country. It’s become the in-fashion political buzz phrase. Certainly sounds very well and good, but what exactly does it mean? Likely different things to different people depending on what angle they approach it—all the way from a care assistant up to the hospital CEO. In a nutshell, it’s all about allowing the patient to take center stage in their health care, and being fully informed and understanding each step of the way. It’s about education, encouraging healthy behaviors, improving health outcomes, and lowering health care costs. The ideal state is to allow the patient to feel that they are in the driving seat and full participants in their own care. As things currently stand, most health care systems across the world are way off from this place. It’s not just the health care that’s to blame either, because the biggest part of patient engagement involves the patient stepping up to the plate themselves. And there are some very real barriers to this including education, demographics and motivation. There’s also the reality that most 90-year-old chronically unwell patients in hospital will have difficulty taking care of themselves. The issue is thus a complex one.

No one has a better understanding of where the opportunities for improvement lie than the doctors and nurses working at the coalface. We get to see all the problems up close and personal on a daily basis. I’m going to talk about how this pertains to my own specialty of hospital medicine, and where we have enormous room to engage patients better while they are in hospital. Here are 5 areas to focus on:

1. Encouraging patients to ask questions when they see their doctor every day
As simple as it sounds, this is not done nearly enough, and is a big missed opportunity to make a difference to patients’ understanding of their illness. There are a number of reasons why this doesn’t happen, ranging from a “rushed” hospital environment, to patients sometimes feeling embarrassed to ask certain questions. I’m actually surprised by some of the questions I hear when I ask my patients if they have anything they want to ask me, and there’s no way I would have guessed what they were unsure about unless I encouraged them to speak up.

2. Giving patients all the knowledge they need about their medical condition
Writing details such as blood count numbers on the whiteboard at the end of their bed is one way to do this. In the future, patients will likely be able to pull up some of their own data on computers. The more that patients know, the more empowered they will be to make important health care decisions.

3. Involvement of families
Just as important as the patient, is the family. This is true for any patient who is too unwell to speak for themselves, and particularly applies to the elderly. Doctors and nurses have to ensure that family is completely on board with the plan of care and what their role is in the recovery process. I’ve always said that if you want to make sure that something is done after discharge, tell the patient’s daughter. It’s been my observation everywhere!

4. Involving the patient fully in the discharge process
The discharge process by its’ very nature is a risky endeavor. Typically there are medications that have been changed, tests pending, or even an uncertain diagnosis. All this at a time when the patient is still very frail. It is a crucial transition point, more important than almost any other to get right.

5. Follow-up care
All hospitalized patients must follow-up in a timely manner after being discharged. Nipping a potential problem in the bud can help reduce readmissions and potentially serious complications. Reminders should be sent to the primary care physician and a post-discharge follow-up call from a nurse or administrator would not go amiss—and also shows that we care.

There is no one magic formula for solving the issue of patient engagement in hospital medicine. It will require a multifaceted and multidisciplinary approach. Whichever arena we are in, it is vital for a number of reasons. Whether we are talking about raising the quality of health care, improving outcomes, or lowering health care costs—there’s a great deal to play for. The more knowledge and opportunities to participate in their own health care, the better it is for both patients and doctors.

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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Monday, September 8, 2014

Unintended consequences--we need to think like chess masters

After 12 years of blogging, I wonder if I should have titled this blog “unintended consequences”. So many rants focus on the unintended consequences that follow from health care policies.

The aphorism (falsely attributed to Samuel Johnson) states “the road to hell is paved with good intentions”.

Too often our policy makers, be they bureaucrats in government, insurance company managers or guideline creators, think like a chess beginner. They see the problem, and take the obvious solution. As H.L Mencken did say, “For every complex problem there is an answer that is clear, simple, and wrong.”

Chess masters consider a move and then do a mental pre-mortem analysis, predicting in their minds what the implications of the move are. Where will we be after that and several more moves?

Too often in health care, as well as other policy areas, we ignore the unintended consequences of premature solutions. Too often we hear the excuse that there was a good reason for the policy.

As examples, first consider the 4 hour rule for antibiotics in pneumonia patients. Any hospitalist or infectious disease expert could have predicted the unintended consequences, yet Medicare adopted the rule that led to much unnecessary antibiotic use.

Consider the VA appointment scandal. If we give bonuses to administrators for decreasing appointment waiting times, and do not provide moneys for adequate primary care physicians, we will stimulate dishonesty in some administrators. This outcome is sad, but predictable.

In Great Britain, they had a performance measure that rewarded shorter waits for appointments. This indicator improved, but continuity decreased. Duh?

Resource-based relative value units provide a great example of this naiveté. The original New England Journal of Medicine paper is a classic left brain economic analysis that totally ignores the possibility (which became the reality) of the difficult of assigning fair relative values.

Policy wonks are too quick to embrace these new solutions to a problem. They rarely think about what the policy would induce. They are lousy chess players. They do not look ahead.

Unfortunately, I do not see a solution for this problem. We fail to remember Mencken’s admonishment. We act too often without careful consideration of all the expected and unexpected consequences. Unfortunately, too many of the unintended consequences are predictable, if we would just take time to think.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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QD: News Every Day--Board finishes draft of interstate licensure compact

The Federation of State Medical Boards (FSMB) completed its draft of an Interstate Medical Licensure Compact designed to speed the process of issuing licenses for physicians who wish to practice in multiple states.

“With the drafting process complete, state legislatures and medical boards can now begin to consider the adoption of this model legislation establishing an interstate medical licensure compact,” said Humayun J. Chaudhry, MD, MACP, president and CEO of FSMB. “The FSMB is pleased to have supported the state medical board community as it developed this compact to streamline licensure while maintaining patient protection as a top priority. We look forward to working with states that wish to implement this innovative new policy.”

The model establishes the location of a patient as the jurisdiction for oversight and patient protections. It involves expedited licensure over which the member states can maintain control through a coordinated legislative and administrative process. Participation in an interstate compact would be voluntary, for both states and physicians.

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Friday, September 5, 2014

Dr. Nobody

Today I had a very special experience, one which many of my patients have faced: I was treated like a nobody while at the hospital. Yay me.

I went to visit a patient who was admitted over the weekend to see what was going on. She was a bit upset about the confusion of the hospitalist service and how orders apparently didn’t get written for her care by the admitting physician. That’s been resolved, but there are still many questions about what is going on with her and I thought that maybe I could help.

I was actually hired by this hospital when I first came to Augusta 20 years ago. They paid for my first 2 year’s salary and got my practice up and running. After concluding we could run our practice better than the hospital, we left their employment to run our own business.

I continued seeing inpatients in that hospital over the years, although I did give up the practice of admitting my own adult patients, opting to use the “hospitalist” service, something that was still fairly new when we went over to it. We felt that the negative of the loss of contact with our hospitalized patients would be greatly outweighed by the improved care we could give to the vast majority of patients who were not in the hospital.

This is a deal with the devil that many docs have made over the past few years, as the overwhelming burden of paperwork, codes, and insurance nonsense made us look for ways to simplify. It’s a deal with the devil, though, because we lose contact with patients when they need us most. This is made worse by the #1 rule most hospitalists seem to have: Never communicate with the primary care physician. I’m not sure why they have that rule, but it has been consistent through my years of practice. We primary care physicians are either evil, stupid, or very dull conversationalists. Hospitalists hate us.

Still, I am well-known to most of the other physicians in that hospital. It carries a lot of memories and good feelings. I was actually a bit excited to go there and perhaps bump elbows with the doctors and nurses who still know who I am. But from the start, the experience was less than positive. Since I am now a “nobody,” I no longer have access to the doctor’s parking lot and had to park with the “common folk.” This is fine, but the patient lot bakes in the hot Georgia sun and was packed, resulting in a long, hot walk to the building.

The hospital has changed a lot since I was seeing patients there. With all of the economic pressures they face, I find it curious how many multi-million dollar “improvements” get done on a regular basis. Walking in, it looked totally different and I knew nobody. The elevator was dressed nicely in real wood paneling and multiple advertisements for their “Da Vinci” robotic surgery. They spent a lot of money on those robots, and need to get some of it back (despite a lack of evidence robotic surgery is better).

My patient’s ward was the usual mix of patient moans, nurse call chimes, IV alarms, and distracted nurses. I found the room and went in, greeted with a big smile from my patient and her husband. They told me the tale of woe, recounting the sickness itself, the ER experience, the orders neglected, the doctors not answering their pagers, and finally the nice hospitalist they finally saw. They couldn’t answer many of my questions, as they hadn’t really talked to many people despite 2 days passed.

I went out to get a pen so I could give my cell number to the hospitalist (hoping he doesn’t remember rule #1), plus I wanted to see if I could check the chart and get some answers for my patient. After being ignored by the nurses for a minute or so, I cleared my throat, winning an icy greeting from one of the nurses. I explained that I am a primary care provider and needed a pen, also expressing my hope that I could see the chart. ”No,” she said simply. ”You can’t look in the chart unless you have privileges and have been consulted.” She wordlessly added through her facial expression: “and stop wasting my time, you useless pile of crap.”

So now I wait, hope against hope that the hospitalist will break the hospitalist code and actually call me. Today’s experience made me once again see how badly our system treats people. I was Dr. Nobody while I was there. Each patient in that hospital seems like a nobody attached to a set of problem codes and procedure codes (which may, by the way, be fixable using “Da Vinci” robotic surgery!). The nurses are overwhelmed and the doctors are hard to reach. They don’t know my patient, and will soon forget about her when she leaves. This is not health care, it’s a chaotic money-devouring machine.

I left there ever more committed to keeping my patients away from that mess. My patients are not nobodies; they are people I’ve taken the time to get to know. To them I am not Dr. Nobody; I am their doctor.

Take that, hospital.

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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Should doctors be 'political' in the office?

Our nation is highly polarized today, and often bitterly so. Democrats rail against the GOP. Pro-lifers face down pro-choicers. FOX News disses MSNBC. Isolationists push back against expansionists. Traditionalists disdain the politically correct. Free marketers duel against government advocates. Carnivores deride the gluten-free crowd. Martin Bashir trashes Sarah Palin, 2 proxies in a culture war.

There’s a philosophical divide among physicians also. Would you prefer a liberal physician or a conservative practitioner? I’m not referring here to fiscal policy or legalizing recreational marijuana use. Consider the following hypothetical scenario and the 2 physicians’ approaches from opposite sides of the medical philosophical spectrum. Which physician would you choose?

The Patient: She is a 50-year-old female with chronic fatigue syndrome (CFS). She is only able to work part time because of her condition. She has consulted with an internist, an infectious disease specialist and a naturopath, but her fatigue persists.

A new treatment for CFS has just been launched by a reputable herbal supplement company. Two well-designed studies suggest symptomatic improvement in afflicted patients after 6 months of treatment. As the product is an herb, there is no formal Food and Drug Administration (FDA) oversight.

Physician #1: ”I’m reluctant to recommend this product, despite the optimistic preliminary results from 2 medical studies. These studies were funded by the herb company and there may be bias present. Moreover, it is very typical in medicine for initial results to be favorable, with unforeseen side effects and complications emerging later when after more widespread use of a drug. I’m concerned that the FDA had no role in validating that the drug is safe and effective for its intended use. Additionally, there is evidence that the active ingredient in the product disrupts the immune system, which may have serious future consequences that may not become manifest for several years or longer. While CFS is decreasing your quality of life, your condition has been stable and will never threaten your life. I recommend holding off until we have an FDA approved medicine for CFS or the herbal supplement has been used long enough that we have a better sense of its safety and efficacy.”

Physician #2: “I recommend that you try this new herbal product. It is completely natural and showed promising results in 2 medical studies. Importantly, no serious side-effects developed in either study. Of course, we have no long term data on safety, but the vast majority of herbal supplements on the market are safe. No other treatment thus far has been successful for you, and your condition is adversely affecting your professional and personal lives. The choice is to try something new or to continue suffering as you have been. Try it for 6 months and then we’ll reassess.”

So, that’s my herb blurb. This is a common situation in the medical world where medical advice must pass through the prism of risks and benefits. These analyses are limited when the risks and benefits are unclear or disputed. Treatment acceptance also depends heavily on the patient’s risk tolerance. What if the herb referenced above had a 5% risk of cancer? What if the herb needs to be taken indefinitely? Clearly, when the disease poses a serious medical threat, the patient may be willing to accept greater risk of new or investigational therapies.

So, which of these physicians would you choose for yourself? Are you a medical liberal or a conservative?

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

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Why are we dialing it up to 11?

We recently posted an excellent summary of what’s happening in U.S. hospitals as they scurry to plan for the public health issue du jour of Ebola. He astutely points out that there seems to be a disconnect between what we know about Ebola transmission and what we’re doing (or planning to do) with regard to safely caring for patients infected or suspected to be infected. I thought it would be interesting to examine what’s driving the disconnect. As I see it, a number of factors are at play here:

Mixed messages

As noted by Dan, at a press conference prior to the transport of 2 Americans with Ebola infection to Emory University Hospital, Dr. Bruce Ribner stated: “Emory University Hospital has been asked to accept two patients who are currently in Africa infected with Ebola virus infection. Our facility was chosen for this because we are 1 of only 4 institutions in the United States capable of handling patients of this nature.” Not stated, but nonetheless presumed by the infection prevention community is that the agency doing the asking was CDC, given CDC’s physical proximity and given that quite a number of CDC physician-epidemiologists hold faculty appointments at Emory’s schools of medicine and public health. However, just a few days later, CDC’s primary message was that any hospital in the U.S. should be able to safely care for Ebola patients.

It’s also difficult to reconcile the CDC recommendation for contact and droplet precautions—highly familiar to all health care workers—with the images of health care workers on the ground in the outbreak epicenters and in Atlanta dressed in Tyvek spacesuits. And who hasn’t seen the video footage of the infected American doctor emerging from the ambulance in Atlanta also dressed in the same manner? However, it’s important to keep in mind that the exposure risk for healthcare workers in the outbreak setting, caring for multiple very ill, infected patients with scarce resources, is far different than the controlled setting of the average American ICU.

Fear and managing risk

Our greatest fears often revolve around areas where we lack experience, and very few health care workers in the U.S. have ever cared for a patient with viral hemorrhagic fever. Importantly, not only does Ebola fever not have any proven effective therapies, there is also no post-exposure prophylaxis. A simple lapse in infection control protocol cannot be undone with a pill or injection. One way we attempt to manage fear is to overprotect: if 1 barrier works, 2 must be better. In general, redundancies mitigate risk, but this isn’t absolute. As Dan pointed out in his post, we may inadvertently increase risk by complicating infection control protocols with gear that healthcare workers may find distracting, uncomfortable, and lack training to use. The litigious nature of American society also impacts our decisions regarding infection prevention strategies. And many health care workers, while willing to accept much greater health risks in their personal lives, demand zero occupational risk.

Non-epidemiologic decision making

In many hospitals today, health care epidemiology staff have become advisors to hospital administrators who ultimately make decisions regarding the logistics of infection prevention. And their decisions may not be purely based on science. They often have aversion to approaches that would appear to be out of the mainstream of what other hospitals are doing, even if that’s suboptimal. In addition, infection prevention seems to be increasingly used as a public relations tool. If you don’t believe that, do a simple Google search and you will find scores of press releases published in local newspapers from hospitals who have purchased germ-zapping robots.

By the way, I believe that one of the best uses for a hydrogen peroxide vapor robot would be terminal disinfection of the Ebola patient room. Perhaps those hospitals who have invested in this technology should be the first to receive Ebola patients.

Paramilitarization of public health

In the run-up to the Iraq War, the Bush administration sought to engage the public health and medical communities in the war on terror. Much effort was devoted to preparations for bioterrorism. Who can forget the smallpox vaccine debacle? Preparedness was all the rage, and the Joint Commission couldn’t resist jumping on that bandwagon.

Admittedly, some of the impacts of this were positive. For example, hospitals became more tightly linked to public health agencies and those agencies became much more engaged and proactive. But a new group of professionals emerged who are employed to make us prepared, and perhaps a little scared. A physician colleague who works in the IT world tells me that the constant fear mongering by IT security specialists is in part a job security tactic. So the folks who work in preparedness stand ready to help, perhaps in a more aggressive way than necessary this time.

Ok, anyone still surprised we’ve cranked it up to 11? I’m with Dan in hoping that we’ll be able to dial it down to 8 this week.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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QD: News Every Day--Flight crews may have twice the rate of melanoma

Pilots and cabin crew have approximately twice the incidence of melanoma compared with the general population, a meta-analysis found.

Researchers conducted the review of 19 studies with more than 266,000 participants. Results appeared online Sept. 3 in JAMA Dermatology.

The overall standardized incidence ratio of participants in any flight-based occupation was 2.21 (95% CI, 1.76 to 2.77; P<0.001); for pilots was 2.22 (95% CI, 1.67 to 2.93; P=0.001); and for cabin crew was 2.09 (95% CI, 1.67 to 2.62; P=0.45).

The overall summary standardized mortality ratio of participants in any flight-based occupation was 1.42 (95% CI, 0.89 to 2.26; P=0.002); for pilots was 1.83 (95% CI, 1.27 to 2.63, P=0.33); and for cabin crew was 0.90 (95% CI, 0.80 to 1.01; P=0.97).

Researchers noted that the amount of cosmic radiation to which airline crews are exposed has always found to be consistently below the allowed dose limit of 20 mSv per year. And, the amount of ultraviolet-B radiation that penetrated glass and plastic airplane windshields was less than 1%. On the other hand, ultraviolet-A radiation, the kind that damages DNA, varied significantly depending on windshield material, with very little coming through plastic and 54% coming through glasses.

The authors wrote, “Windshields and cabin windows of airplanes seem to minimally block UVA radiation, and it is known that, for every additional 900 meters of altitude above sea level, there is a 15% increase in intensity of UV radiation. At 9,000 meters, where most commercial aircraft fly, the UV level is approximately twice that of the ground. Moreover, these levels are even higher when flying over thick cloud layers and snow fields, which could reflect up to 85% of UV radiation.”

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Thursday, September 4, 2014

Dialing it up to 11

While I was away on vacation, I did my best to keep up with the advancing Ebola outbreak in Africa (see Mike’s excellent summary post). I also joined a couple conference calls about the interim infection prevention guidance from CDC. I believe this guidance to be reasonable and consistent with the mode of transmission of Ebola, combining Standard, Contact and Droplet precautions with an emphasis on eye and face protection and use of additional barriers and precautions as required by the clinical situation (e.g. copious body fluids in the environment, aerosol generating procedures, etc.). I was also gratified to see some common sense interim laboratory guidance from CDC, guidance that included reassurance that: “When used according to the manufacturer’s instructions, EPA-registered disinfectants routinely used to decontaminate the laboratory environment (benchtops and surfaces) and the laboratory instrumentation are sufficient to inactivate enveloped viruses, such as influenza, hepatitis C, and Ebola viruses.”

There’s only one tiny problem: nobody seems to be listening to this guidance. Like Nigel Tufnel, we’re dialing our responses up to 11.

The early returns from our infection prevention listserve favor airborne isolation, N95 masks, full Tyvek suits, anterooms for decontamination hose-down, etc. Similar returns from the clinical microbiology side included labs that didn’t plan to submit any testing to their main lab until they got Ebola testing results back, or requiring elaborate specimen decontamination protocols prior to any standard lab testing (some of which invalidate such test results).

This reaction is predictable and understandable, given media coverage and the early approaches taken at Emory: “Those working at Emory also can take comfort in that they have a unique place—1 of only 4 such facilities in the United States, according to Ribner—to treat such a contagious disease … The isolation unit was created 12 years ago in conjunction with experts from the U.S. Centers for Disease Control and Prevention, which is based down the street. It features “special air handling,” strict protocols on everything and everyone who goes in and out of a patient’s room, and other measures to ensure that any potential dangers are contained.”

Combine this with the only images most Americans, including health care workers, associate with Ebola, and you can see how it becomes extremely difficult to recommend anything but the most stringent possible precautions.

The problem is that such precautions are wasteful of time and resources (invest in Tyvek, now!), and can interfere with patient care. As one example, most patients returning from the outbreak area with febrile illness (those meeting the Person Under Investigation (PUI) definition) will not have Ebola, but they may be very sick. If an overly stringent lab protocol prohibits or delays laboratory testing, substandard medical care may lead to adverse outcomes. Another concern, introducing health care personnel to new and unfamiliar forms of personal protective equipment without time for adequate training may inadvertently increase the risk for transmission. Do you know how to safely remove a full-body zippered Tyvek coverall without contaminating yourself? I don’t.

I wish I knew how to dial it down, maybe to 8 or 9, but I fear that the window for clear and consistent messaging may have passed. If only we could magically package all of the resources and person-power currently being applied by U.S. hospitals in preparedness efforts and transfer them to West Africa, we’d be a long way toward containing this tragic outbreak.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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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.

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.

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.

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.

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).

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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