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

Tuesday, April 22, 2014

Do regulations predispose to diagnostic errors?

Last week I presented my diagnostic talk, “Learning to Think Like a Clinician” at the Virginia ACP meeting. Afterwards several physicians wanted to discuss the reasons for diagnostic challenges. They convinced me that many regulations from CMS and other insurers have influenced policies that increase anchoring and diagnostic inertia.

When the emergency department physicians admit to the hospital, they have to give an admission diagnosis. At least in the United States, I believe they cannot admit for abnormal chest X-ray, or fever, but rather they must postulate a diagnosis. That diagnosis then drives case managers and protocols. Patients often receive their first treatments before the admitting physician has even met the patient.

The emergency physicians get criticized if they do not proceed in a timely fashion. The hospital worries that they have a diagnosis that supports admission rather than observation status. If they designate the wrong status, they face a financial problem.

But patients do not always arrive with diagnoses. Some diagnoses take time. Patients would benefit if the diagnosis was purposely made unknown disease with manifestations rather than pick a diagnosis for billing and quality purposes.

Too often, the physicians stated, a diagnosis induces a therapeutic freight train. And then if the patient is not discharged promptly (according to the expectations of the admission diagnosis) the admitting physician gets criticized.

Something is wrong with the system. (Actually much is wrong because we do not really have a system, rather we have rules.) We need ways to more acceptably label a patient as a diagnostic puzzle. We need the “system” to allow us to not know the diagnosis and realize that pursuing the diagnosis is job #1.

We must develop systems to avoid diagnostic anchoring and inertia. Our patients deserve our full diagnostic attention. Unfortunately, we see too many diagnostic misadventures.

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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Monday, April 21, 2014

Hospital medicine doctors: In the driving seat to improve patient satisfaction

Improving patient satisfaction and enhancing the hospital experience is all the buzz today in health care. Every hospital executive across the country is talking about it, and coming to terms with how their organization’s reimbursements will be directly tied to their performance in this area. A decade ago, none of us had ever heard of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, the core metric by which healthcare facilities are now being evaluated. And while improving patient satisfaction scores is a complex issue that requires a multifaceted approach from all levels of the organization, one thing is certain: as the most visible frontline clinicians during any medical patient’s hospitalization, hospital medicine doctors are key to driving this improvement. They are the face of the hospitalization, act as the main point of contact for the patient, and are the doctors who will be most involved in their care. The old model of the hospitalist being present “to just round” on patients in place of their regular primary care provider is long outdated. It’s therefore crucial to recognize their role in improving the hospital experience. Here are some everyday ways hospitalists can do this:
• Making clear to the patient from the beginning the role of the hospitalist, their relationship with the patient’s primary care provider, and how they will be in charge of the patient’s complete care as part of a collaborative care team. This helps to reassure an often anxious elderly patient and their family;
• Regularly using aids such as explanatory introductory cards, pamphlets and business cards. Leave them on the table in the room so that family members can also see them and know the doctor who’s in charge of the care;
• Making a clear plan for the patient every day. Utilize whiteboards in the patient’s room and keep them updated;
• Developing more optimal patient rounds, including multidisciplinary rounding models to ensure that all members of the healthcare team are on the same page;
• Setting aside dedicated time for extended patient and family meetings each day, usually in the afternoons;
• Making clear that you are regularly communicating with the specialists who are also involved in the patient’s care; and
• Developing and maintaining good communication skills, always displaying empathy and compassion.

Statistics show that two of the most frequently cited patient complaints are a lack of time with their doctors and healthcare staff exhibiting poor communication skills. On a practical level, in order to maximize time with patients, hospitalists obviously need a manageable daily patient census.

Formal communication skills training is often well received by physicians, especially if feedback is given in a friendly and collegial atmosphere. It’s traditionally been an area that the healthcare profession hasn’t gotten into, and older physicians in particular are much less likely to have ever received any formal training or skills advice. Worried about pushback if you bring up the concept? Most physicians actually enjoy thinking about the topic, and are very keen to improve their skills.

Ultimately, it’s all about making the patient feel comfortable, at ease, and listened to. Some proven communication techniques that physicians should utilize include making eye contact, sitting down, and asking open-ended questions. These are very basic, but often forgotten about during a typical hectic day. They can all be taught, improved upon, and coached.

Specialists also need to step up to the mark. They need to be encouraged to maximally collaborate with the hospital doctor and to make the patient feel like all their care is being coordinated. The other touches that go into improving a hospital stay, such as regular nursing checks, being clear on wait times, and following up post-discharge with a personal (non-automated!) message from a nurse or administrator, should all be added to the mix.

Let’s remember that this isn’t simply about saying that you’ve “improved patient satisfaction” and raising survey scores for the sake of reimbursements. Patient satisfaction is really about understanding what the patient is experiencing and the emotional roller coaster that goes with being sick. HCAHPS scores, while by no means the perfect survey, may be the jolt the medical profession needs to strive for what it should have been doing all along: providing patients with a high level of customer service at a low point in their lives.

Hospital medicine doctors are best placed to engage the patient from the beginning, and by focusing on them to lead the way, organizations can soar to new heights.

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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Friday, April 18, 2014

Tranexamic acid--why you may be less likely to bleed to death in Britain than the U.S.

The other day at an interdisciplinary rounds meeting at the hospital, one of our nurses who is also an emergency medical technician mentioned that in Britain injured patients receive tranexamic acid before arriving at the hospital because it reduces death from bleeding. “What’s that?” I said. I kind of barely remembered hearing this medication’s name associated with the treatment of a rare disease, but not treatment of trauma. So I was guessing that this was some drug that was invented long ago which had been found to be quite effective in other countries, but has not been really optimally used in the U.S. because it is generic and therefore unlikely to make drug companies money.


Here’s the story, as far as I can determine.

Tranexamic acid is a relatively simple cyclic molecule that blocks the fibrinolytic process, that is, the natural breakdown of blood clots in the body. In the setting of any injury, especially severe ones, fibrinolysis is intensified, leading to a condition of excess bleeding in trauma victims. This is hardly ideal, and tranexamic acid can help reverse this. It also appears to have an effect on reducing inflammation, which may be even more significant.

There have been a couple of major studies in the last 3 years showing significantly better outcomes in patients who have traumatic injury and who are treated with tranexamic acid intravenously soon after injury. The most recent study, published in the Archives of Surgery, looked at 896 patients injured in the military from registries in the UK and the U.S. and identified the subset treated with tranexamic acid. Although this group was generally more severely injured, the mortality rate was significantly lower, 6.5% lower, than the group that had not received the drug. In very seriously injured patients, those who received massive transfusion of blood products, the difference in survival was nearly 14%.

It is not often that we see an effect this powerful, especially in a group like this who are healthy and will likely have long and productive lives after being saved. An earlier study, published in 2011 in the Lancet titled CRASH-2, showed similar results in civilian trauma victims, with a double-blind, prospective design. The Cochrane Collaboration, a group of researchers who review randomized controlled trials, concluded that tranexamic acid was safe and effective in reducing mortality in trauma patients without increasing adverse events.

So maybe it’s actually very expensive, then. I called our hospital pharmacy to ask about that. Apparently a gram of it costs about $44. The usual protocol for trauma is 1 gram intravenously right away and then another gram over the next 8 hours. So $88 times 100 equals $8,800 to save 6.5 lives (using the data from the military study), or $1,353 per life saved. That’s pretty cheap. And since it probably reduces the severity of illness in the rest of the patients treated, it may end up reducing overall treatment costs.

Presently the only FDA (Food and Drug Administration) approved indication for this drug in the U.S. is an oral formulation to be used for women with heavy periods and intravenously for prevention of dental bleeding in hemophiliacs. It is also used off-label to reduce transfusion requirements in total joint surgeries (that’s why we have it in our pharmacy), also in some places for prostate surgery, general surgery, gastrointestinal hemorrhage, bleeding around pregnancy and delivery and bleeding within the eye. It reduces the frequency of attacks of swelling in a condition called hereditary angioedema, which is rare, and was why I had even heard of it in the past. It has been available over the counter for years in Europe, marketed for heavy menstrual bleeding. The injectable formulation is also on the World Health Organization’s list of 350 essential medicines which are considered safe and effective and necessary worldwide.

So what are its side effects? It may increase the risk of blood clots in the legs and lungs, but studies have shown this to be far less of an issue than one might guess, and it looks like the lives saved far outweigh this risk. The CRASH-2 study showed that there might be a slight risk of increasing mortality if it was given to trauma patients more than 3 hours after their injury.

Why is it not FDA approved for reduction of bleeding in trauma and other similar situations for which there is ample evidence of safety and efficacy? The FDA approves drugs and devices when approval is requested, and usually the drug or device manufacturers who stand to make money from an FDA approved indication are the ones to make the request. I suspect there has been no request for approval for these other indications. Just because it is not FDA approved to reduce bleeding in trauma and surgery doesn’t mean it can’t be used, but physicians have a certain hesitance to use unfamiliar drugs off-label.

So the story of tranexamic acid is another excellent example of how simpler, cheaper and sometimes more effective treatments are not being widely used in the U.S., even though our patients may receive exorbitantly expensive medications and treatments of dubious or minimal benefit. This is because we allow powerful pharmaceutical companies to inform our practice. Sometimes this actually works, when companies produce groundbreaking innovations and encourage us to adopt them. It is unlikely, though, to help us find creative uses for inexpensive drugs that have been around a long time. This dynamic may mean that 6 or so people of the 100 who are probably just now being involved in accidents with bleeding will die when they would not have if use of this drug part of our routine practice.

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

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Thursday, April 17, 2014

We're in the post-antibiotic age

We’re so very lucky to have lived in the “age of antibiotics.” However, most of us were neither alive nor cognizant prior to 1943, so we don’t have a concept of the morbidity and mortality prevented by antibiotics. In some regards, this pre-1943 period is the future we’re facing.

Author and science journalist Maryn McKenna has a wonderful article up on where she discusses this post-antibiotic past and future using a touching story of her great uncle, along with facts such as “1 out of every 6 recipients of new hip joints would die” without antibiotics. She also discussed this article on yesterday’s CBC “Sunday Edition” radio broadcast (audio available here).

As if we need other things to add to our phobia lists, there’s a new case-report published in the Journal of Antimicrobial Chemotherapy of an elderly Spanish woman with chronic renal disease and recurrent urinary tract infections. She initially presented with pyelonephritis caused by a susceptible Escherichia coli. However, after 1 week of therapy she developed sepsis and renal failure that was unresponsive to meropenem and died. Multi-drug resistant E. coli was isolated, which was resistant to all tested antibiotics except fosfomycin, tigecycline and tetracycline.

Further analysis identified numerous resistance and virulence genes. Importantly, the authors state that this is “the first report of the co-production of KPC-3, VIM-1, SHV-12, OXA-9 and CMY-2 in a unique clinical multi-resistant E. coli isolate.”

With air pollution, it’s risky to breathe and with water pollution it’s risky to drink. I guess now it’s risky to pee.

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

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Wednesday, April 16, 2014

Life at Grady: Your game plan

I was thinking this morning about all of the things that we do in our lives and how, for the most important things, we generally have a game plan. That is, there is some bar we seek to get over or at least up to. For work, that might be one thing. As parents we nudge our children to work hard in school because a goal has been set. And the bottom line is this: Goals require game plans.

What is your goal when it comes to being healthy?

Now. Of course our goals can be broken into little mini-bite-sized ones but usually there should be some overarching big one. At least, that’s what I think.

Here is what I mostly hope every person reading this aspires to have as either her main goal or at least one of her big two: To personally reduce my modifiable risks of HEART DISEASE and CANCER.

Let’s imagine a photo of us standing in a ginormously long line. All of us different people with different stories and builds and everything. Despite all those differences, the reality is the same. Hands down, the thing most likely to cause any of us DEATH or DISABILITY is heart disease. Period, period, period—end of story.

When I say “heart disease,” let’s also include all forms of atherosclerotic disease like strokes, etc. Because that counts, too.

And let’s draw our attention to that second word, “DISABILITY.” I’ve been thinking about this a lot lately. I think since my sister Deanna left us, DEATH has always seemed like the worst possible thing that could happen with heart disease, but I recognize that disability can devastate families just as much, from what I’ve seen.

Imagine if suddenly you couldn’t walk more than a foot without being severely short of breath. What would that mean to your family and to all that you do? What if a stroke left you unable to speak or move the dominant side of your body? How would that affect everything you do? Well? Because THIS? This is as real a possibility as the whole DEATH part.

Sometimes I imagine if Deanna had been left unable to talk or move. Like if her cardiac arrest had ended not in a sudden death but instead severe anoxic (lack of oxygen and blood) brain injury. It’s so hard for me to picture us rolling her over and propping her up or cleaning off her tracheostomy tube. And please—let me be clear—I am not making light of the many reasons that people become or are born with disabilities. I’m not. But I am making sure that we are going at everything with our eyes wide open to heart disease as a cause of acquired disability. Even in the younger of us. And yes, I know this sounds super grim, but we need to recognize that we are running from more than just death. We are.

So let’s regroup. Let’s look at our goals and come up with real game plans. I know it’s time for me to look at mine again.

Are you getting at least 150 minutes or more of cardiovascular activity?

Do you know your BMI?

Are you realistic about trying to get it lower?

What are you eating?

Are you thinking when you eat?

What example are you setting for your family?

Will you be the catalyst for a generational tradition of fitness or a generational curse of inactivity?

How much are you drinking?

Are you separating weight loss from exercise and tying it to what you eat?

How do you feel? If you feel bad, what are you doing about that?

Who is your doctor?

When did you last see her or him?

What is your blood pressure?

What is your cholesterol level?

Are you up to date on your age-appropriate cancer screenings?

What is your family medical history? Do you know it? Does it affect your health risks?

What excuses are you making?

What foods are in your house that you KNOW should not be?

What do you want? For you, for your family, for your peace of mind?

Because this is stuff we have to KEEP ON ASKING ourselves. Over and over and over and over again. These realities DO NOT go away when we ignore them. They don’t. So we have to go at them head on. We do. We DO!

Anything I say here is a word for ME too. Every word. I need to hear it and read it and digest it all right along with you. But at the end of the day, only you will be accountable for these questions. You can talk about it all you want but a lot of it is visible.

And slim folks? Don’t think we don’t see heart attacks and strokes in the slight ones. We DO. So know that you still need to be doing all of these things. You DO, too.

So there. That’s the deal. Let’s get on board with our game plans and get vicious with them. And let’s rage against this machine called heart disease.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.


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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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