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

Monday, February 8, 2016

'About as stupid as it gets'

I have to thank Eli Perencevich, MD, ACP Member, for rekindling my interest in the mandatory influenza vaccination controversy. I had resigned myself to it being water under the bridge and had not thought much about it until the last week. What I didn't realize is that another Cochrane review was published last year on influenza vaccination of healthy adults. This is very useful to our discussion, since most health care workers fall into the category of healthy adults. A free full-text version of the review can be found here.

This review examined 69 clinical trials involving 70,000 participants, 27 cohort studies with 8 million subjects, and 20 case control studies with 25,000 participants. The bottom line is that the parenteral vaccine was 60% efficacious in preventing influenza, which didn't seem surprising to me. However, the absolute difference in influenza infections between the vaccinated and unvaccinated groups was only 1.3%. That knocked my socks off! All of the energy and resources consumed and ill will created in trying to increase vaccination rates in health care workers, including firing people, for a vaccine that reduces infection by 1% is about as stupid as it gets.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, 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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Wednesday, February 3, 2016

Multitasking and not taking time to think

How could a blog post titled Learn how to think avoid my praise? This post made the Farnam Street Blog top 10 for 2015. The post refers to a wonderful essay, Solitude and Leadership By William Deresiewicz. On first reading (and this essay deserves several reads) 2 concepts resonated strongly.The first is, “Multitasking, in short, is not only not thinking, it impairs your ability to think. Thinking means concentrating on one thing long enough to develop an idea about it.”

We know that multitasking does not really work. This concept has great importance in medicine. We have added so many tasks to the patient interaction that the thought process can suffer. Our focus can get split often.

The second is, “I find for myself that my first thought is never my best thought. My first thought is always someone else's; it's always what I've already heard about the subject, always the conventional wisdom. It's only by concentrating, sticking to the question, being patient, letting all the parts of my mind come into play, that I arrive at an original idea. By giving my brain a chance to make associations, draw connections, take me by surprise. And often even that idea doesn't turn out to be very good. I need time to think about it, too, to make mistakes and recognize them, to make false starts and correct them, to outlast my impulses, to defeat my desire to declare the job done and move on to the next thing.”

All too often we see diagnostic errors occur because we do not take the time to think. We substitute algorithms for thinking. Here are some recent examples:
1. Patient comes with a heart failure label. She has some basilar crackles. Her echocardiogram suggests diastolic dysfunction. Her discharge orders include daily furosemide. On readmission she has significant volume contraction, and a completely normal echocardiogram. Her cardiac exam is unremarkable. The instinct to treat crackles with a diuretic occurs because the physician involved did not take the time to think carefully about the patient's clinical presentation.
2. Almost every patient with hyponatremia gets immediate treatment with normal saline. Too often, physicians do not consider making a diagnosis until the treatment does not work.
3. The same situation occurs with elevated creatinine levels. Again some unknown algorithm tells many physicians to give saline without considering why the creatinine is elevated.
4. I have written about several patients with decreased bicarbonate. The instinct and first thought is that the patient has a metabolic acidosis, but sometimes the patient really is compensating for a respiratory alkalosis. Making the correct diagnosis requires that we take the time to understand what has happened to cause the lowered bicarbonate.
5. A patient gets admitted to our service with multiple vertebral fractures. A very good resident does not focus on a variety of laboratory abnormalities, because being “on call” is a multitasking nightmare. The patient was anemic and had a slightly elevated calcium. That should have triggered at the globulin gap. The total protein was greater than 10 and the albumin was approximately 3.5. Once the clues get presented, the likely diagnosis becomes very clear. Focusing on each laboratory test and trying to understand the abnormalities requires time.

For years I have written about the importance of taking time in medicine. Our payment system discourages thinking time, because we do not get paid for thinking. Our payment system is perfectly designed (albeit not consciously) to discourage thinking. And now the IOM has discovered diagnostic errors.

Excellent medicine requires thinking. We need to develop systems that give our physicians adequate time to think rather than to react. As Deresiewicz writes, “I find for myself that my first thought is never my best thought. My first thought is always someone else's; it's always what I've already heard about the subject, always the conventional wisdom. It's only by concentrating, sticking to the question, being patient, letting all the parts of my mind come into play, that I arrive at an original idea.”

Practicing medicine as a reactive activity results in cognitive errors. Very often we need to spend the time to concentrate on a clinical situation. Our patients deserve our focus.

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, February 1, 2016

End or beginning for mandatory influenza vaccination of health care workers?

“Just don't let the human factor fail to be a factor at all”
—Andrew Bird, Tables and Chairs

We are all in favor of protecting patients from preventable harm. No question. With that aim, the intervention du jour (in the U.S.) is mandatory influenza vaccination of health care workers. Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, and Pediatrics Infectious Disease Society of America support such a policy, yet a recent Cochrane review stated ”there is no evidence that only vaccinating health care workers prevents laboratory-proven influenza or its complications (lower respiratory tract infection, hospitalization or death due to lower respiratory tract infection) in individuals aged 60 or over in LTCIs [long-term care institutions] and thus no evidence to mandate compulsory vaccination of health care workers.”

Yet given the inevitability of mandatory influenza vaccine policies in the U.S., what can we do to protect our patients from health care-acquired influenza and other viral illnesses since mandates would be expected to have minimal or even negative effects on nosocomial influenza transmission? To explain this further, compulsory vaccination policies are technical interventions which are relatively simple to implement. But we have seen over and over that ignoring the human equation or socio-adaptive factors behind infection prevention initiatives leads to failure. As Sanjay Saint and Sarah Krein have written eloquently in their recent book: ”Our research has shown that the principle reason is the failure of the hospitals to win their staff's active support of the infection prevention initiatives. In their focus on the technical aspects of an initiative, these hospitals have given short shrift to the human aspects.” (You can read my Doody review of their book at Barnes & Noble here.)

What are the additional components that we need to consider when implementing an influenza vaccine mandate? Some suggestions:
1. First, acknowledge that we know the vaccine is imperfect through the develop of communication strategies that highlight the proven benefits of the influenza vaccine to the individual health care worker. Since the data supporting direct benefits to patients is more theoretical at this point, highlighting the protective effects for the individual receiving the vaccine - including reduced risks of cardiovascular outcomes could improve acceptance of the mandate.
2. Next, mandate additional components in our influenza prevention bundle, especially those highlighted in the Cochrane review which included “hand-washing, masks, early detection of influenza with nasal swabs, antivirals, quarantine, restricting visitors and asking health care workers with an influenza-like illness not to attend work.”
3. Offer additional sick leave to health care workers required to receive the vaccine. Policies that include bans on presenteeism (working while sick), should be accompanied by additional paid sick leave. In this specific instance, influenza vaccine is associated with fever (especially high-dose vaccines that are associated with benefits in older adults). Providing additional sick leave shows our understanding of vaccine side-effects, demonstrates support for staying home sick and most importantly, respects the individual health care worker.
4. Include in the mandate bundle a plan to de-implement the vaccine mandate if future studies demonstrate that they're ineffective. Doing this will gain more trust with our health care workers, which may, counterintuitively, improve the effectiveness of the mandate.
5. Finally, fund large studies evaluating the efficacy, effectiveness and implementation (i.e. barriers) of influenza vaccine mandates in our health care systems. Funding research acknowledges that the data around vaccine mandates isn't perfect, but we are doing the best we can to protect patients now, while simultaneously validating the safety and efficacy of this policy to protect future generations of patients and our health care workers.

There are many things we need to consider as we implement mandatory influenza vaccine policies. The mandate is just the beginning. We have a long road ahead before we can state convincingly that our hospitals are safe from hospital-acquired influenza.

“And how
How I wish
I, I had talked to them
And I wish they fit into the plan”
—Andrew Bird, Tables and Chairs

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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Thursday, January 28, 2016


“I remember,” she said, “the day when it crossed into something else. Into that freakish range where mothers hiss to their kids to stop staring. At first you think that, just maybe, it's an accident. Then you realize that it isn't. They're whispering and pointing at you.”

I squinted my eyes and tried to imagine it. My patient, minding her own business and moving slowly through the aisles of a store. Maybe even doing something like picking up lightbulbs and hand towels in the home improvement section at Target. People walking by and doing those not-so-subtle double takes and her trying her best to not notice it. But she was right. This was more than just a little out of the range of normal. And though I wouldn't choose a word like “freakish” to describe it, I'd be lying if I said that it didn't somewhat fit the definition of that word. Even if it sounds mean to think that way.


Patients like her require special provisions. They bring in a special bed aptly or rather, horribly, referred to as a “big boy bed” to accommodate such a large body. It's hard not to hitch your breath and stare for a beat when you first see her and others of her body habitus. Legs easily larger than my husband's torso and a midsection that appears far too heavy to be supported even by those extremities. The adult in you tries not to see the large pannus lying flaccid over their thighs and fights those silly juvenile thoughts like, “What happens when it's time to go to the bathroom?” or, I'm even more embarrassed to admit, “How would she or he make love? “ I timidly raise my hand and admit that I do have these fleeting thoughts. The adult in me flicks them away. But every time, they appear and require that flick.


This encounter with me certainly wasn't helping her self-image. My patient had some shortness of breath and was, literally, too big to receive any of the diagnostic studies that we'd considered. She could not have a CT scan. Her circumference exceeded that of the scanner and her weight was more than 150 pounds beyond the limit of the table. A stress test or even an echocardiogram would be so limited in accuracy that it was almost deemed futile and a waste of her money and time to pursue. And to make matters worse, even if a stress test did find even some equivocal result, the cardiac catheterization lab wouldn't be able to handle 650 pounds on their support structure either.


Ever since I was a resident physician in Cleveland, Ohio back in the 1990's, this kind of issue has periodically come up. Without fail, no matter where you practice, some well-meaning person speaks of the urban legend of the city zoo being an option. And no, not with cackling mean-person sarcasm but with a full-on, dead serious expression. A medical student looks stunned and queries whether or not a patient can truly go to the zoo for such a thing at which point whomever is speaking affirms it as the gospel. All of it reminds me of those stories of funny names in newborn nurseries, like the woman who named her twins “Oranjello” and “Lemonjello” since that's what they fed her in labor and delivery before she had them. Somehow the mother of those twins has managed to live in Cleveland, Ohio; Nashville, Tennessee; and Atlanta, Georgia. That, or she doesn't exist.

The zoo thing, though, I must admit always intrigued me. So, a few years after I came to Atlanta, I called Zoo Atlanta on behalf of a patient of mine. He needed a cardiac catheterization and I wanted to actually sniff out this trail to see if it truly would lead somewhere. Several of my calls were met with chuckles. Even when I reached some nice tech in the Large Animal area, he notified me that the zoo veterinarians did have X-ray machines and even a cath lab made special for elephants and such, but that actually having human cardiologists come in to use them on humans wasn't something he was aware they did. After that I spoke to our cardiologists who calmly answered me (while staring incredulously) telling me that logistically, it would be too much.

“We couldn't really do interventions either, Kim.”

“Like place a stent or something?”

“Yes. And even if there was something significant enough for bypass, that wouldn't be an option either. The anesthesia risk would just be too great,” the cardiologist said.

“I appreciate you actually thinking this through,” I recall mumbling.

“This is really a sad, Catch-22 of a situation. I hate when it comes up.”

And that was just sort of where we left that. But some piece of me has always felt this weird mixture of better because I actually checked before and discouraged for the very same reason.


So the truth is that, there wasn't anything I could do other than talk to her and listen to her story. And since she'd navigated the last several years of her life as what some would deem a “freak” I just made up my mind to humanize her the best I could.

I noticed her light brown eyes that almost appeared amber, framed with sprawling black eyelashes. She had a dimple in her chin that I thought was cute, whether she was smiling or not. The right cheek had a beauty mark on it, the kind that many women wished for but she'd obviously been blessed with at birth. And her teeth were unusually straight, large and strong appearing. Even though she didn't smile so much.

And so. I listened to her story of the transition from “always a chunky kid” to “overweight” to “really obese” to “freakish.” I didn't rush her either. I just sat and paid attention and focused on her lovely eyes, her beauty mark and that cleft in her chin wondering what I could possibly do.

“Those surgeries scare me,” she finally said.

“Surgery is a big deal,” I replied.

“Yeah. I just feel like it would be such a failure to get an operation just because you couldn't stop eating.”

I twisted my mouth and paused before speaking. “Food relationships are complicated. I think of weight loss surgery as an option that is now available that wasn't before, you know? But yeah, surgery isn't something to treat lightly.”

“My relationship with food has never been healthy.”

“I understand.” I wondered if I should say the next thing in my head, but then decided not to overthink it. “I say just look into it. Make a decision after you look into it, you know?”

“Guess I'd not have much to lose, right?” After she said that we both chuckled at the unintended pun.

“Um … you could also look into … okay, have you ever heard of this organization called ‘Overeaters Anonymous?‘” I inwardly cringed when saying the name of it but felt she should consider it. I hoped she wasn't offended. But she shook her head and looked intrigued.

I told her about this 12-step organization that tackled food relationships much like other tried and true organizations helped patients deal with substance abuse issues. And we looked at the website right then and there on our cell phones and she promised me she'd check it out.

And that was that.

We discharged her a few hours after that. Honestly, there wasn't really any more tests I could order and, fortunately, she was doing well enough where most weren't indicated anyway after all was said and done. But I have found myself thinking of her. Pondering her world and that threshold of going from overweight into, to use her words, “freakish.” And usually it just leaves me feeling kind of sad.

That is, until this morning when I allowed myself to reflect on what I remember the most about her. Her smile, her enviously stunning eyes, that beauty mark that Marilyn Monroe had nothing on, the tiny indentation in her chin and especially her fearless transparency in describing her life. I realized that this is what I see in my mind when I think of her. And I see that part in greater clarity than anything else.

And that? That leaves me feeling hopeful that at some point something will happen that allows the entire world to see that, 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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Wednesday, January 27, 2016

Was granny sent home from the hospital too soon?

Over the years, I have heard families bemoan that their relative who was just readmitted to the hospital was sent home too early just a few days ago. Are they right?

First, let me say that in some instances they may be correct. It is certainly possible that the hospital, under increased pressure to kick folks out, may have pulled the discharge trigger too soon. The hospital is not always right even if their discharge check list seemed to be in order. Of course, patients are not adequately represented by a check list any more than physicians' quality can be fairly measured in the check-off, cook-book method that the government and insurance companies are now championing.

The hospital discharge check list may indicate that a patient with pneumonia can be safely discharged home as she has no fever or need for supplemental oxygen. However, this patient may be 89 years old, riddled with arthritis and needs to attend to a spouse suffering from Alzheimer's disease. Is she really ready for home life?

Hospitals these days are more careful than ever about premature discharge, not so much from newfound compassion, but because they will suffer a financial penalty if a patient is readmitted within 30 days under certain circumstances. For example, if a patient with congestive heart failure is sent home, but then returns 2 weeks later with worsening heart failure, then the hospital will lose money. This has created a robust outpatient follow-up industry with visiting nurses, physicians and social workers to try to keep folks from coming back to the hospital, at least within 30 days. (Joke alert: The terminal phrase of the last sentence was in jest.) I applaud this system which serves everyone's interests.

In the hospital, care coordinators cruise through the corridors leafing through charts to initiate discharge planning. These are nurses who have left the wards for a cleaner administrative function. Although I did disparage the hospital discharge check list mentality above, and rightly so, I have found these care coordinators to be compassionate and understanding with regard to individual patient circumstances. They know when to bend some rules, perhaps because they were once hands on nurses themselves.

Sometimes, a patient needs to be readmitted to the hospital and it's simply no one's fault. It is a difficult concept for many Americans to grasp that an adverse event could occur without an individual or an institution to blame. Remember, we live in a society where folks sued Burger King alleging the company was responsible for their kids' obesity.

I counsel families that when we are sending their relative home, particularly when they suffer from chronic diseases or other incurable conditions, that we do so based on what I and the others on the team know at the time. We are not clairvoyant. If we had this power and knew that the patient would become more ill 3 days hence, we wouldn't sent him home. It's may not be quite fair, but would be quite understandable, to wonder if a patient who is readmitted should never have been discharged home in the first place. There are some patients who are so fragile, that they can tilt backwards anytime and for very small reasons.

What we know for sure is that life and illness are unpredictable.

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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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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