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

Monday, March 2, 2015

What the Northeast's snow preparedness can teach hospitals in winter

Significant snow in New England every winter is about as certain as sun in Florida every summer. When I moved to the USA from the south of (old) England to do my medical residency in Maryland, my first few years living in the United States were relatively snow-free. But when I started my first job as an Attending physician in central Massachusetts, I was in for a big shock. I had never yet shoveled snow in my life, but soon realized it was a rite of passage every winter in this part of the world.

Having now lived here for the last several years, I've become as used to it as all the seasoned New Englander's around me. Every winter the heavy snow invariably comes, and every winter I'm always impressed by how quickly towns and cities work to prepare beforehand and rush to clear the roads in lightning quick time afterwards. The large snow blizzards this winter, followed by more—again showed the importance of preparation for any big task (see the above picture of my car buried in the snow, the roads around it quickly cleared by the Boston snow plows within a couple of hours). Hundreds of trucks stood ready and hundreds of emergency personnel were drafted in for the clean-up efforts.

And sticking with this theme of winter, speaking as a doctor who has worked in a lot of different hospitals in the Northeast, I believe that hospitals can learn an awful lot from how towns and cities prepare for snowstorms. The typical scenario for hospitals goes something like this: winter comes and thousands more people fall sick: coughs, colds, pneumonias, and of course the dreaded flu. For the already sick and frail, it doesn't take much to push them over the edge to the point where they need a hospitalization. It happens every winter across the country, resulting in hospitals experiencing a “surge” of patients. Yet still every winter, many hospitals are taken off guard and struggle to cope with the increased need. Resources and staff are stretched, and ultimately patients have to wait longer for much needed services.

Instead of this situation always happening, hospitals could prepare better by:
• convening committees in the Fall to discuss and implement upcoming winter arrangements,
• creating a nursing staffing winter schedule to ensure a “float pool” of extra nurses,
• having for certain medical specialties such as Emergency Medicine and Hospital Medicine a special winter schedule that includes extra available physicians, made well in advance (not at the last minute),
• forming arrangements with neighboring hospitals for emergent bed diversion situations, and
• planning to reduce the volume of elective cases such as orthopedic surgeries during winter months in order to free up beds for other medical cases.

Winter patient surges for hospitals are only likely to become more severe with the ageing population and increase in chronic conditions including chronic obstructive pulmonary disease and congestive heart failure. Rather than being caught out, hospitals would do well to remember what Benjamin Franklin said about any big task: “By failing to prepare, you are preparing to fail.”

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, February 27, 2015

The very palpable doctor shortage and how to help solve it

The nationwide shortage of physicians is a very real crisis across all 50 states, causing a huge strain at all levels of health care. Hospitals and clinics are struggling to hire, current physicians are overworked, and ultimately patients are having to wait longer. There are number of reasons why this has happened, but one thing's for sure: with the ageing population, the problem is only going to get worse.

One estimate from the Association of American Medical Colleges predicts that the shortfall could be as high as 90,000 doctors by 2020. The problem is most acutely felt in primary care, but many hospital-based specialties are also in short supply in certain geographic areas. A number of alternative solutions have been proposed, including increased use of other professionals, including Nurse Practitioners and Physician Assistants, and allowing patients to see primary care doctors through non-traditional routes such as standalone “retail clinics”.

Before we discuss any further, let's focus here on why there is such a shortage to begin with. After all, it may seem bizarre at first glance when you consider that so many people apply to medical school to become doctors and that the number of medical graduates is at an all-time high. So why the shortage? One of the main reasons is that over the last couple of decades, American medical students have understandably been drawn to much more lucrative niche specialties, including radiology, anesthesia and dermatology. As well as the lower pay, primary care is also widely perceived to be a significantly more stressful career choice compared to these other specialties, with mountains of paperwork and bureaucracy to navigate, and never mind an increasing need to see more patients in less time.

The other very real problem is that the number of residency slots for newly graduated physicians to train in internal and family medicine, has not budged over the last 20 years. This at the same time the U.S. population has increased by almost 50 million. It doesn't take a mathematician to work out how this quickly becomes a problem. In fact, the number of residency positions has remained the same since the Balanced Budget Act of 1997 (when Bill Clinton was still President), which set a broad limit on training positions according to what Medicare would fund.

At the current time, there are actually hundreds of physicians out there who are qualified to enter residency, but have not been able to find internal medicine or family medicine residency slots. That's a travesty at a time of such a shortage. Many of these would undoubtedly make fine practicing doctors who would serve their patients well. Another congressional bill is desperately needed on the U.S. Capitol.

So here is a summary of the 3 things we can specifically do for primary care:
1. Make primary care a much more attractive career option for medical students.
Incentives should include generous loan repayment packages and sign-on bonuses to serve for a set amount of time. Fortunately this has already been happening to some extent in many places (I've encountered many more medical students telling me about these opportunities), but still, more is needed.

2. Drastically expand the number of internal medicine and family medicine residency slots, especially in universities affiliated with underserved and rural areas.
Medical school intake probably still needs to be expanded further as well (this shouldn't be a problem since the number of medical school applicants greatly exceeds the number of slots available). While we are at it, how about taking a serious look at the problem of medical school debt, which can easily exceed $250,000? Aside from the debt burden, this has serious downstream consequences including specialty career choice and ultimately driving up health care costs.

3. Substantially reduce the bureaucracy involved in the practice of primary care.
This push needs to start right at the very top if the government really wants a strong primary care sector. One example over the last decade of where things haven't gone according to plan is with the introduction of electronic health records, incentivized by the federal Meaningful Use program. Unfortunately, the technology hasn't yet lived up to its promise and has made life more inefficient and cumbersome for frontline physicians. We need to realize that less bureaucracy for doctors and more time to be productive and see patients is a win-win scenario. Concierge medicine, which is starting to take off, is one such way that physicians have found to eliminate the middle man, but hopefully this isn't the sole answer.

These are just 3 options for rejuvenating primary care. It is undoubtedly the backbone of any solid health care system. Other hospital-based medical specialties that suffer with shortages, such as hospital medicine and emergency medicine, will also need similar policies over the long-term.

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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Wednesday, February 25, 2015

Where better begins

When I was a medical student and later, a resident, I had no idea how capable I was. I mean, I knew I was competent. Or at least, I had it in me to be competent. But most of the time I tip toed around hoping and praying that I wouldn't get the covers pulled back on the real me, the one who really wasn't so great at all.

I've talked about this before, this idea of thinking of yourself as an imposter. With each accolade, I felt the spotlight brighten. It was nauseating to think that people would look at me and point in my direction expecting some level of excellence that honestly, I was pretty sure wasn't a deliverable from my end. It was a sucky way to feel.


At some point I chose to start fighting against those insecure ideas. I coached myself to believe that I was who people thought I was or better yet, someone even greater if I could fight my fears long enough to explore what that meant.

I think of this every day. I ask myself, “Who are you? What are you doing with your spiritual gifts? Are you using them? Are you trying your best to transform a piece of this world?” The answers are mixed sometimes. But I strive to eventually attain very confident and firm answers someday.

I fight to help my learners see themselves as excellent. Some part of me wants to accelerate things for them and quickly push them away from self-deprecating thoughts as early as possible. To look them in the eyes and say, “You are more than even you realize. And I see it.” I want to be sure that they know what I didn't know then.

Especially those who perform at high levels. For some reason, those are the ones that doubt themselves the most. And so. I'm specific when I give them feedback. It's more than just “strong work.” It's, “Here is why I think you are awesome. Specifically, this is what you did that stood out.” Then I observe and coach them, trying my best to dissect the liking them part from the here is why I think you are a highly competent individual part. Because sometimes that distinction gets blurry.


I guess my point of this ramble is this: I want to fight the imposter phenomenon with all of my might. I want those girls like me who come to majority schools to feel like they deserve to be there. I want those students who've had an academic hiccup to not think this is what defines them for the rest of their career. I guess I just want them to know what I didn't know. At least not fully.

I'm a lot closer to believing in myself than I used to be. One of my goals every day as a clinician and as an educator is to convince people, through my interactions with them, of who they are and what they can do. To me, that's half the battle. Better begins with belief.

Yeah, man. That's all I've got.

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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Resident burnout--not fixed

An article in Academic Medicine has this conclusion: “Job burnout and self-reported sleepiness in IM resident physicians were unchanged after the 2011 DHRs at 3 academic institutions. Further investigation into the determinants of burnout can inform effective interventions.

This conclusion shows that the authors of the regulations and of this study do not understand the determinants of burnout. Burnout generally follows a lack of control. Changing work hour rules, if anything, worsens lack of control.

To decrease burnout we need a more fundamental residency reform. We need to convince hospitals that trainees are not slave labor. We need to convince attending physicians that micromanagement does not help residents grow.

The ACGME rules are not helping residents. They are not improving patient safety. They are likely impacting education.

They hamper continuity. They make attending physicians unhappy, and therefore because everything flows downhill, resident-attending relations often suffer.

We need to look at programs that are successfully addressing burnout before we speculate on ways to decrease burnout. We need to treat residents with proper respect. We need to remember what being a resident was like.

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, February 24, 2015

When health care workers strike

In a relatively unusual development, mental health professionals who work for Kaiser Permanente in California went on strike.

At issue is the demand for mental health services, and the perception by the employees that they are understaffed, overworked, and not meeting their ethical obligation to see Kaiser patients in a timely fashion.

Job actions in the health care world are pretty uncommon, because of the direct impact they can have on day-to-day patient care. It's a fine line between taking a negotiating position and potentially harming the people that we've signed on to help.

In health care, perhaps the most prominent unionized workers are the nurses and/or service employees (food service workers, custodial employees, etc.), who generally belong to local chapters of national unions like National Nurses United (NNU), the National Federation of Nurses, and the Service Employees International Union (SEIU), just to name a few.

KQED radio health reporter April Dembosky covered the Kaiser story, and was featured on NPR's All Things Considered. She pointed out a couple of interesting reasons for the appointment backlog:
1. The Affordable Care Act has provided coverage to more than a million Californians who were previously uninsured, so demand has risen.
2. A state initiative has worked to reduce stigma associated with mental illness, which has also driven up demand, especially in the University of California system, site of another backlog.

I was lucky enough to interview Dembosky for Studio Tulsa on Health, our local public radio show, in which we explored this issue in more depth. If you're interested, you can hear it here.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is Interim President of the University of Oklahoma-Tulsa. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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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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