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Wednesday, April 20, 2016

The ethics of performance measurement

For years I have argued that performance measurement has significant potential for unintended consequences. But today, I read an article that crystallized my concerns in an important new light. The article is written about the ethics of studying work hours, “Leaping without Looking — Duty Hours, Autonomy, and the Risks of Research and Practice.” As I read the article, the implications of the ethical arguments stimulated my thoughts about performance measurement.

While I hope you will read the entire article, these lines have particular relevance here: “Bioethicist and legal scholar Michelle Meyer has described our ‘tendency to view a field experiment designed to study the effects of an existing or proposed practice as more morally suspicious than an immediate, universal implementation of an untested practice.’ She argues that people in power often rely on intuition in creating and implementing wide-reaching policies.”

Most physicians would argue that people in power (Centers for Medicare and Medicaid Services and insurance companies) have relied on intuition in creating and implementing performance measures. Please reread the above paragraph and consider seriously the problem here. Performance measures have had serious untoward consequences. Patients have suffered because of overly aggressive diabetes control, overly aggressive hypertension control and the 4 hour pneumonia rule. In the Britain's NHS P4P program care improved only slightly for targeted care but deteriorated for unmeasured parameters.

With respect to performance measurement, I have long argued that we need prospective randomized controlled trials prior to adopting any performance measure. Advocates will argue that we cannot afford the time or money needed to perform such studies. But if we accept a non-zero probability of adverse patient outcomes due to a performance measure, how can we ethically adopt such a measure?

Imposing a performance measure can have a similar impact as a new pharmaceutical agent. If we really believe the dictum primum non nocere then we have a moral obligation to object to the potential that a policy could induce negative patient outcomes.

We should not consider this concept as radical or only hypothetical, as we have clear examples of measurement impacting patient care, outcomes and even access to care. We could argue that performance measurement raises important concerns about professionalism, if indeed concern about our report cards changes how we provide patient centered care.

These ideas are important. I thank Dr. Rosenbaum for writing a brilliant piece that made me think. If only we could get “people in power” 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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Tuesday, April 12, 2016

Do stuff

*details changed to protect anonymity (as always)

“Live while you got all your rhythm in your hips still, okay?”
—Mrs. Sanders

If you looked at Mrs. Sanders' life, you'd count it a success. Five children, all of whom were mostly healthy and all of whom grew up to be gainfully employed with families of their own. More grandbabies than the fingers on two hands could count. And a marriage that had lasted more than 50 years. Yes. If you looked at her life, you'd use those spiritual words spoke often by the Grady elders for lives like hers, “blessed and highly favored.” Descriptors for lives filled with the things that matter the most.

Her health was good. Beyond some degenerative arthritis in her knees and some very mildly elevated blood pressure, Mrs. Sanders had very few medical problems. She could do for herself and was even still driving. Again, the kind of thing we all envision when wishing upon stars for our futures as senior citizens.

Mr. Sanders had passed on a few years before. Not necessarily suddenly, but it wasn't drawn out either. Just enough time to get things in order and to allow people to get to him and love on him. His death was surrounded by family and the aftermath of it all was mostly okay since it fit into the natural order of the rhythm of life. And, yes, losing him broke Mrs. Sanders' heart. But honestly, it didn't seem to break her.

Nope.

So the point of telling you all of this is to say that this woman seemed to have a pretty peaceful life. It seemed to have followed the narrative that little girls act out with their Barbie dolls, you know? But every time I saw her, there was this sadness about her. Nothing overly somber or extraordinarily awful. Just this undercurrent of melancholia that cloaked the room whenever I was in her presence. And honestly I'd assumed it was all related to missing her husband. After all, they had been married for over fifty years. But truthfully, I'd known her before his passing and even before he'd gotten ill. And even then, I'd felt the same way.

“How are you?” I asked her toward the end of our visit.

“Am I?” Mrs. Sanders pointed at her chest to make sure she understood the question. I nodded. She released this weak chuckle and said, “I'm here.”

“Just here?”

“Well, naw. Ain't nothing wrong, if that's what you mean. Guess I ain't sure what you mean, Miss Manning.”

I pressed my lips together and kept my eyes on hers for a beat. In that split second, I reflected on the time last year that I'd screened her for depression with a series of questions. She caught on to what I was doing and interrupted me. “I ain't depressed or nothing like that if that's what you gettin’ at.” And after I completed those questions, it became pretty apparent to me that she wasn't.

But still. Each time I felt it. And even if it didn't mean there was some pathology there, I really wanted to understand it.

“You know what, Mrs. Sanders? Sometimes when I see you, you seem like. . .I don't know. . .kind of sad-like.” Sad-like? I cringed at my own language. I sighed. “I don't know. It's hard for me to put my finger on.”

Mrs. Sanders offered me a warm smile and then reached out to touch my hand. “I ‘preciate your concern. I'm okay, baby.”

“You sure?”

This time she squinted her eyes and smiled. The expression seemed to suggest I was naïve. I wasn't sure how to feel about that. Straightening up my spine, I trained my eyes on hers, making certain not to crack a smile in return. Her face became serious and pensive. Finally, she spoke.

“Miss Manning? How many kids you got?”

“Two.”

“And how long you been married?”

“Twelve years.”

“How old your kids is?”

“Ma’am? Oh. Nine and ten. Boys.”

She pursed her lips when I said that last part. “Wheeewwwweeeee. Boys is something. Something indeed. They keep you busy, too.” Mrs. Sanders shook her head and then paused. It looked like she was trying to decide what to say next. Or whether what she wanted to say was worth saying to me. She blinked her eyes slowly, glanced down at her pocket book and then back at me again. Mrs. Sanders leaned her head sideways and asked me this: “What you do for fun?”

She caught me off guard with that. “For fun?” I let out a nervous chuckle.

“Better yet, for you. For your own self.”

“Umm. Well. I … I actually do lots of stuff for myself. I mean. … I do a lot for my family, too. But I do stuff for myself.”

“Good,” Mrs. Sanders replied quickly. “Good.”

I waited. I could tell she had more to say.

“My life been good, you know? But honestly, Miss Manning? I spent my whole life doing for everybody but me. Like, we got married when I was young and started having babies. And I stayed home with them and was near my sisters so we all saw ‘bout each others' kids, too. And my kids grew up to make me real, real proud. They good people. They got to do a lot of good things and I'm glad. But I guess the more time go by the more I realize I ain't never get no chance at nothing.”

“Tell me what you mean by that.”

“I mean. . .I ‘on't know. Guess I jest mean I ain't never been able to choose something that I wanted to do just ‘cause. Just ‘cause it's what I wanted to do or where I wanted to go. Seem like every decision was connected to somebody else needs or wants. And now I find myself wishing I had done some more stuff for me. For me.”

Mrs. Sanders eyes glistened with tears. She swallowed hard and cleared her throat after saying that. Then she looked slightly embarrassed for disclosing those thoughts. Or perhaps ashamed of uttering them aloud. That said, I could tell she was serious. And honestly? There wasn't much I could say to any of that. This woman was nearly eighty and had thought about this long and hard. I certainly didn't want to trivialize it all with some Pollyanna statement, particularly one that came across canned and void of empathy.

“I'm sorry.” That's all I could think to say. And I said that because I was sorry. Not sorry in that way I was when her husband of fifty two years went on to glory. But sorry nonetheless.

I could see how things had ended up this way. I mean, like her, I'm a mom and a wife, too. And in my mind I've always noted that those mothers and wives set on the highest pedestals are the most selfless. What's also weird is that it's hard to even realize that something is being denied of you, you know? Because everything you hear and see tells you that your definition of joy gets revised the day you become a mother and/or a spouse. And that this is what you were made to do and that this idea alone should be enough.

Right?

So yeah. I got it. I got what she was saying. I did. “It's not too late, Mrs. Sanders,” I finally said. “Your health is good. There are definitely things you could still do.”

“I know,” Mrs. Sanders replied. “I know. And I don't want to seem like some ol’ charity case that stay sad. I'm not. I do some stuff. But, see, what I can't have back is doing it as a younger woman. With curves and in high heels and with young woman sass. Young enough for people hold the door for you because they think they got a chance to court you, not jest ‘cause they got enough home training to respect their elders.” She gently laughed at her wittiness. I did, too.

“I get it,” I finally said.

“Do stuff, Miss Manning. See ‘bout them men of yours. But do stuff for you, too. Live while you got all your rhythm in your hips still, okay? I tells my daughters that. I do. Wish somebody had’a told me the same.”

“Yes, ma’am,” I whispered. Then I stuck it on a post-it note in my head for later.

Last week, I went to Paris, France. Despite my 45 years on earth, I'd never been. A college sorority sister took a job there this summer and inboxed me on Facebook a few months back urging me to come for the Semi de Paris--that is, the Paris Half Marathon. She explained that it sells out pretty quickly and encouraged me to “just sign up” and figure out the logistics later.

And so I did. Register, that is.

But honestly? I never truly considered going. I mean, not really. Sure, I'd registered for the race, but still. Could I really see myself going all the way to Europe for a race? One that wasn't connected to my kids or work? That answer was a solid no. It wasn't because I don't have support. Harry loved the idea of me running strong through cobblestoned streets and past historic landmarks. Especially in Paris, a city to which I'd never been. And I did, too.

But.

I think I purchased that race number because I liked the idea of it more than anything else. Buying that registration would be affirmation that I really did consider going. Which, in a lot of ways, was nearly as significant to me.

Nearly.

A few weeks after I'd submitted my payment for the race, I was casually talking to my colleague-friend Ira S. With my feet kicked up on a chair in his office, I mentioned this opportunity to do this race in Paris and my friend living in France. He immediately began speaking as if there was no question about whether or not I planned to go. But Ira is different than me. He speaks other languages, has lived in other countries and is, in my mind, more worldly than me. Of course doing this would be a no brainer to him. But to me, it was simply a pie-in-the-sky notion. So I told him the truth. That there was no way I'd go thorough the hassle of getting all the way to Paris just for me to go and run some race. That is, one just for me and the experience.

Ira immediately began listing the litany of reasons that I should go. That life was for living and that if I tried as hard as I could and it didn't work out, that was one thing. But automatically counting myself out would be something I'd regret later. And you know? I inherently knew he was right.

Of course, I can't say that I never do anything. I've had some amazing experiences as an adult woman that called for an understanding and supportive spouse and some hands on deck from others. But nearly all of those things have been either local or stateside. Which means they could occur over a three day (or two and a half day) weekend. Nothing calling for a passport or acquaintance with another language. And I can't say that it was because of lack of opportunities. I think it was more lack of consideration, you know?

Yeah.

And so. I went. And from the moment those wheels went up and that plane rose into the heavens, I knew. I knew that it would be a pivotal experience and one that would enrich my life. And you know? It was amazing. Just. … yeah.

Another of our college sorority sisters routed a business trip from Barcelona through Paris to join us. And, in the end, we became three girls about town together. Feeling the pulse of the city, testing out our rudimentary French in cafes and on trains, window shopping and laughing so hard that we could hardly breathe. I'm so glad that I went.

So very glad.

For nearly the entire time, I thought of my family. But I also thought of me.

And you know what? I thought of Mrs. Sanders, too. I went a little harder, laughed a little louder, imagining myself as an octogenarian reflecting on this time. I sure did.

Look. I don't know all the answers. But what I do know is that my trip to Paris taught me that I really should push a bit outside of my pragmatic mom-work-wife life box some more. To put my own life experiences on the table for discussion. Especially the outlandish ones that require jumping through a bunch of hoops like this one did.

Yeah.

I hate that Mrs. Sanders has regrets. Because regrets suck. Even the little twinge-y ones that niggle at you when you know you should otherwise be happy with the hand you've been dealt. My guess is that Mrs. Sanders' narrative is one to which many women can relate. I feel honored that she trusted me with those feelings. I'm also grateful to Ira for helping me to picture myself as worthy of that experience in Paris.

When I see Mrs. Sanders again, I'll tell her of how she inspired me. And hopefully she can take solace in knowing that she helped another woman do at least one thing that she otherwise wouldn't have, and perhaps shielded her from some potential regret.

“Live while you got all your rhythm in your hips still, okay?”
—Mrs. Sanders, Grady elder.

Words to live by. And to live it up by, too.

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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Monday, April 4, 2016

Our slow motion pandemic

“We keep fantasizing about what will be the next biothreat, the next pandemic. It's actually already here! We're going to save our grandparents with triple bypass, but they're going to die from pneumonia, because we will not have the right antibiotics to save them.”
—Dr. Joanne Liu, International President of MSF, on Here's the Thing.

The CDC released its latest edition of Vital Signs, which is dedicated to the problem of antibiotic resistance (AR) among health care-acquired infection (HAI). Using data from NHSN, CDC investigators estimate that the likelihood an HAI is caused by a targeted AR pathogen is 1 in 7 in acute care facilities, and 1 in 4 in long term acute care.

There's good news in the report—the figure below shows impressive progress in reducing central line associated blood stream infection rates, and to a lesser extent surgical site infections and Clostridium difficile. Catheter associated urinary tract infections, though, are a mixed bag (pun intended), and Mike's covered this ground before. For reasons that Eli Perencevich and our colleague Dan Livorsi outline here, it's a shame that CAUTI has become such a prevention focus. Ironically, an unhealthy focus on CAUTI can drive testing and treatment practices that can result in antibiotic overuse, worsening the AR epidemic.

The CDC has released the “AR Patient Safety Atlas”, a new web app with interactive data on HAIs caused by AR bacteria. I am about to post a more detailed item from Scott Fridkin about this exciting new development. Stay tuned!

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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Friday, April 1, 2016

Incentives and capabilities

The idea that we have to “change incentives” for physicians is all the rage. Oceans of ink are being spilled over the transition away from the traditional fee for service payment model to a menagerie of value-based ones. At the core of much of the discussion about how to make the transition is figuring out how risk-bearing organizations like large physician groups, health systems, accountable care organizations, and the like are going to provide appropriate incentives to the individual, front-line physicians who are providing the clinical care. It is not a trivial problem to solve.

The usual explanation of the challenge goes something like this: In the old days, when organizational success was defined by the number of “heads in beds” in hospitals or patient encounters in the clinic, it was pretty straightforward to “share” that success with physicians. The more patients they saw (or procedures they did) the better it was for everyone, and rewarding “productivity” floated everybody's boats. Under alternative payment models, the measures of success of the organization are different and more complex—generally combinations of quality measures, patient satisfaction, efficiency, etc.—and translating that into new physician payment models is not so easy. If you continue to reward productivity, then it may defeat organization efforts at efficiency; make the payment model too complex by including many different performance metrics, and physicians don't get invested in any of them; make the model too simple, and physicians will be insulated from the organizational goals.

Lost in all of the details of how to create the illusory “perfect” physician incentive program is the fact that incentives are only a part of picture. Combinations of carrots and sticks only work where the capability to respond exists. It is not helpful to patients, doctors, or anybody else to implement incentive programs that reward or punish physicians when the systems of care in which they work have not been redesigned to achieve the new goals. For example, tying a physician's compensation to cancer screening rates in a primary care setting without designing a system to identify appropriate candidates for screening and facilitating the testing is just a demoralizing punishment for the physician.

Here is the key point that many administrators I know just don't get. It is not about the incentives. It is about redesigning the care. Yes, appropriate incentives create the economic viability of the care redesign so, in the example above, a sufficient bonus tied to cancer screening may make it possible to invest in appropriate IT systems and physician extenders to do the work necessary to close gaps in care, but it is the care redesign that gets the job done, not the incentives. Administrators, who are ignorant about how care is actually delivered, tend to believe that if they just got the incentives “right” then all those pesky doctors would just do the right thing. What they don't see is that the only effective path to success in the new world is to engage doctors in the hard work of redesigning care—something that no administrator can do—and reward them for doing so.

Final thought about the difference between incentives and capabilities suitable for spring training. You could promise me a million bucks to crush a fast-ball over the center field fence, but it is never going to happen. But, make me the manager, and allow me to put the right team together, and I can guarantee plenty of balls will leave the park.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

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Friday, March 18, 2016

It's all about the communication

Despite all the challenges that we, and every other nation, faces with their health care systems, it's worth remembering that in the broader picture we really have progressed in leaps and bounds over the last several decades. How easy is it to forget that only 100 years ago the average life expectancy was in the 20s to 40s in most parts of the world (just as it was for nearly all of human history). The simplest of infections could easily kill you, there were no vaccines, and the most natural act of childbirth was a highly dangerous and precarious process for any mother to go through.

Today, we take for granted that all of our health care interactions will be safe and successful, and that's also a testament to how high we've set our standards. In the modern and technologically advanced system that we work in, with cutting edge medications and treatments, the other side of the coin is that it's also easily forgotten that health care is still very much about human beings and real people.

If there's one common thread that links everyone who has ever needed medical attention, from those first cavemen to our current generation, it's just that. Hippocrates, the father of medicine, said over 2 millennia ago; “It is more important to know what sort of person has a disease than to know what sort of disease a person has”. It was true then, and it's just as true today.

Another one of my favorite quotes from Hippocrates is that physicians should; “Cure sometimes, treat often, comfort always”. This is something that no physician should ever forget as they go about their daily routine and what can seem like “busy work.” Every interaction is sacred, and the trust placed in us and our decisions is humbling. Communication, empathy and compassion with patients and their families is paramount, and the most important part of what we do. Racking your brains out, ordering a battery of tests, and coming to a potential diagnosis means little if that information isn't properly communicated.

As a physician who has worked in several different hospitals up and down the East Coast, and also internationally—from major academic institutions to more rural outposts—this has been universal no matter what the patient's background, demographic, educational level or social class. We as physicians need to maintain the highest standards when it comes to communicating clearly the diagnosis, treatment options, and prognosis to our patients.

By the same token, as we look to improve quality and outcomes in health care, and administrators bang their heads together to try to figure out how to do this, communication is actually at the core of many of the problems we face. Not just with patients, but between healthcare professionals too. The fragmentation in our system is undoubtedly made ten times worse by inadequate communication amongst physicians, nurses, case managers and all manner of other professionals at the frontlines of medicine. In hospitals, this applies particularly to medically complicated patients who are seeing several different specialists during their stay, aren't given crystal clear instructions on discharge, and don't get the quick follow-up they need. The downstream effects of this are what cause excessive testing, readmissions and even unrealistic expectations. Needless to say, the effect on healthcare costs is enormous.

Years ago, Bill Cliniton's campaign strategist James Carville coined the phrase; “It's the economy, stupid”, to simplify the reality of what drives election results. To apply the same quote to healthcare, so that we don't lose the forest for the trees as we search for overly complicated solutions to often not so complicated questions. Instead of looking towards expensive answers involving things such as more administrators, costly information technology, new “Apps”, and mountains of bureaucracy, just remember that with health care: It's about communication, Stupid.

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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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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