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Wednesday, September 28, 2016

The problem of too many consultants

Recently I communicated with a patient's mother in another state. She had great angst when a series of subspecialists gave her different opinions on the ongoing plan for her grown son.

This problem happens too often in 2016. Each subspecialist seems to see the patient solely through the prism of their expertise. We have seen 1 consultant call 3 or 4 other consultants.

Many hospitalists will tell you this story. At many community hospitals the consultants do not just provide an opinion, but rather they write orders. This practice leads to confusion and sometimes conflict amongst the subspecialties.

Several years ago, I watched a video in Canada about this problem. The video discussed a patient with chronic obstructive pulmonary disease, left heart failure and chronic kidney disease. The patient told the story of how each subspecialist gave different opinions on medications. When the patient switched to 1 good internist, his management was much more clear and the patient benefitted.

Having too many consultants without a designated lead physician resembles the sound that you would get from jazz musicians who each want to play their instrument without regard for the other instruments. Great jazz ensembles communicate, and generally have a conductor.

Thirty or so years ago, during the heyday of managed care, internists and family physicians (both specialists in their own right) received the label of gatekeeper. We always hated that term and the implications that it carried.

What we need from outpatient specialists and inpatient specialists (hospitalists generally) is conducting. We are and should be the conductors for our patients. We may ask the pulmonologist for an opinion, but we should make the final decision on that opinion. We have the responsibility to balance multiple recommendations and to limit the number of consultations to just those that are absolutely necessary.

Too many consultants sometimes means that no 1 physician is really in charge. That is not good for patients. Our patients need us to take responsibility for integrating multiple medical problems, polypharmacy and complex social situations. Only when we consider all factors can we develop a logical “game plan” with the patient.

Subspecialists provide value input to patient care, but too many subspecialists seeing the same patient too often create confusion and conflict. All hospitals should require one physician to integrate all the information and make the final decisions about treatment and testing. To do otherwise too often creates cacophony.

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, September 26, 2016

Hearsay

"Believe half of what you see and none of what you hear.”

A few years back, I was in clinic and went into a room to listen to a patient's heart sounds (*details changed to protect anonymity). A resident physician working with me that day had already seen the patient first. Before I entered the room, he'd described everything about the past medical history including an “easily audible” heart murmur. Even though it was pretty straightforward, I still wanted to listen. And so I did.

“It is an early peaking, systolic murmur,” he said as we walked up the hall, “radiating to the carotids. But super loud.” That description was suggestive of a narrow aortic valve. I figured that a murmur this loud had been assessed with imaging in the past.

“Did she get an echocardiogram?” I asked. The 2-dimensional ultrasound of the heart, or echocardiogram, visualizes the blood flow and the heart valves. Though the physical findings lead us to where we are going in heart disease, actual images tear the roof off of the sucker to confirm things. The clinic was busy. And this was an upper level resident. So I cut to the chase. I wanted the echo results.

“She did,” he replied. “I need to double check the final read but I'm pretty sure it confirmed aortic stenosis.”

“Do you know how severe?”

“No. I'll have to look again when we go back into the room. But I know she doesn't have any symptoms, which is good.”

“Yeah.”

So he went on to tell me a few other things about her before we reached the room. After a quick knock, we entered the clinic room together. Nothing about it was unusual.

“Hi there, ma’am. My name is Dr. Manning and I'm one of the senior doctors in the clinic working with your doctor. We always put our heads together about your health and figure 2 brains are better than 1.” She smiled and I smiled back. After a quick review of her concerns and the plan of care, I reached into my pocket to pull out my stethoscope. “Mind if I listen to your heart?”

“Not at all,” the patient replied. “Guess 4 ears is better than 2, huh?”

I chuckled and nodded while placing the rubber tips of the stethoscope into my ears. And honestly? I wasn't even thinking too hard when I did that. I reached over to her chest and searched the classic listening areas, aortic, pulmonic, tricuspid, and mitral, with the cold diaphragm.

Sure did.

The whole “not thinking too hard” thing wasn't because she didn't matter. It was just that I'd heard the story and exam already, including the echo results. This was mostly a formality, honestly. I even made a comment about the pretty necklace she was wearing as I slid it out of the way to reach her chest. The patient began sharing that she'd splurged on it during on a vacation once and how she hasn't removed it since. I raised my eyebrows and nodded, then lifted one finger to let her know we'd need to hit the pause button for a few moments.

You know. So I could hear the murmur that already had a diagnosis.

And so. I lean in and quickly listen. And just like that, I recognize that what I was hearing isn't at all what had been described to me. I raised my eyebrows. “What did you say this murmur was from?”

“Aortic stenosis.”

I squinted my eye and listened again. “Hmmm. This murmur sounds diastolic to me. Hmmm.”

“She definitely has aortic stenosis. I heard a crescendo-decrescendo murmur. And it was during systole.”

“Okay.” I carefully listened again. I then felt the patient's pulse and listened some more while timing it out with the rhythm of the heart. And still what I heard sounded like the flow of turbulent blood during the relaxation phase of the heart cycle. I listened some more. And then once more. “Aortic stenosis, huh? Okay. I guess my hearing is off today.” And that was that.

I conceded since I knew that the imaging supported his assessment. But honestly? That murmur sounded nothing like what he was saying to me. The whole thing made me uncomfortable, especially feeling so off on something like this, a bread and butter physical finding.

“Yup. Stenosis. But let me just confirm how severe, okay?” He pecked into the computer and clicked a few screens. And while he did, the patient asked a few questions.

“Is my heart okay?”

“Have you been told about your heart murmur?”

“Yes'm.”

“We're just talking about your heart murmur. That's just the flow of blood rushing over your heart valves. Have you been lightheaded or dizzy?”

“Naw. Never that.”

“Okay. We're just checking to see how narrow your heart valve is but it sounds like this is an old issue, okay?”

“Oh alright then.”

She asked a few questions about aortic stenosis and what that meant while he moved through screens to confirm for me the final reading on the echocardiogram images. Since I was less occupied, I pitched in and explained. Even though my ears were telling me of a different diagnosis.

Yeah.

So as we discussed all of that, suddenly I notice a funny look on the resident's face. “Oh must've misread that,” he mumbled to himself. “Um, Dr. M? It's actually moderate to severe aortic regurgitation.”

He said that right after I'd finished my soliloquy on aortic STENOSIS and right after I'd finally talked myself out of what I knew to be true based upon what I'd heard with my own ears.

Shit.

And no. It didn't turn into a big thing with the patient at all. I apologized and told her that I'd misspoken and that her heart murmur was more of the kind you get form a leaky heart valve instead of a narrow one. My face felt like it was a million degrees. She laughed and said, “I was wondering. I been told before my valve was leaky. I ain't never heard of it being stiff and narrow before so that was news to me.”

Sigh.

So here's my point of telling you all of this:

The things that happen to me at Grady are simply metaphors for life. Trust your gut and what you know. Listen with your own ears and then listen again. Believe your ears, especially when they've heard a lot of things. Same goes for your eyes. But especially believe yourself even when odds stack against what you think. That is, when you feel sure.

I doubted myself. And honestly? It wasn't even a soft call. I felt embarrassed for my initial instinct to doubt the echo report when I shouldn't have. I shouldn't have at all. Plus, I hadn't seen that echo result with my own eyes. That's a lesson, too.

And no. I am not always sure. But this time I was. And I'm still mad at myself for not laying down my nickel and betting on me. I recognize it's okay to be wrong. But I think my “ah hah” moment is in that I need to be just as okay with being right.

Does this even make sense?

As for my resident, I gave him some feedback. I'm pretty sure he, too, convinced himself of what he heard based on what he thought the images showed or could have just been so junior that he misjudged what he heard altogether. So yeah, I gave him feedback right away. But as I did, I showed my own clay feet and revealed what I'd done wrong as well. I'm senior to him yet I needed him to understand that even after 20 years of being a doctor, we are still works in progress. I let him know that being scared of looking silly isn't a good reason to not push when you feel pretty sure. And mostly, I was sure, even though I was being told otherwise. I was just two seconds away from saying, “Well, I don't know what that echo is saying, but this murmur isn't consistent with aortic stenosis at all.” But I didn't. After all, the echo said it was aortic stenosis.

That is, until it didn't.

Yeah.

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, September 19, 2016

'Juneteenth'

You didn't quit smoking. Nope. Not even after that big, long, drawn out discussion we'd had about you setting the perfect quit day. ”Juneteenth!” you announced with a big, loud laugh. You banged your hand on the desk and clapped your hands after. I typed it right into the chart when you did:

QUIT DATE: JUNE 19, 2016

Then you added, “Perfect, ain't it? The day of emancipation, right?” And I nodded my head in acknowledgement, loving the idea of you being freed of the nicotine stronghold on the very day that our people came up from under the dark cloud of slavery.

“That day sounds perfect,” I replied. And I said that because it was true.

But sadly that day came and went. And you didn't quit. Nope.

Your blood pressure was high today, too. You promised that you'd take your blood pressure pills but when I looked into the pharmacy history, you hadn't picked up a refill for two full months.

Nope.

342. That was your blood sugar reading on the finger stick today. Which meant that you probably weren't taking you insulin either. (Even though you'd promised you would.)

And last was your weight. Your chief concern at the last visit was losing weight and quitting smoking. We'd talked and talked and talked all about it and you sounded so ready. So ready. Together we identified some simple tweaks that could be made to help you shed pounds and, I have to admit, I was just as excited as you.

Sure was.

But that didn't work out either. Instead of dropping a few pounds, you gained nearly 10. 9.73 to be exact. Which didn't fit the gameplan we'd discussed. At all.

So yeah. Essentially none of what was supposed to happen happened. And honestly, I'd be lying if I said that some piece of it wasn't frustrating because it was.

Yeah, it was.

And so. I creaked open the clinic room door to come see you. The undeniable scent of cigarette smoke wafted into my nostrils the very moment I stepped inside; it had found a crevice of every part of that room. I coached myself to not be disappointed in you. To not feel like you'd hoodwinked and bamboozled me into believing that this visit would be some celebratory party where I fist bumped you for your big emancipation from cigarettes and unhealthy foods. Yeah.

“Good morning,” I started. I took the seat across from you and smiled. Trying my best to not sound condescending, I added, “It's good to see you.”

I was kind of tired that morning. Isaiah had forgotten to tell me about a homework assignment he had until the very last minute which forced a late night/early morning kitchen table science combination. Zachary couldn't find his shoe and seemed hell bent on wearing only the pair that had the missing mate. Our dog decided he'd tear up a throw pillow overnight. And I'd run out of creamer that morning so had to drink black coffee which I did but did not enjoy 1 bit.

So yeah. I'd hoped for some good news from you.

“I didn't quit, you know.”

I sighed and leaned my face into my hand. “Yeah. I know.”

“I gained some weight, too. Even though I ain't had much of a appetite. I just ain't been doing so good.” Your mouth twisted when you said that and I could have sworn I saw tears glistening in the corners of your eyes.

“What do you mean by that? By ’ain't doing so good?’”

That's when those tears became undeniable, spilling over your lashes and onto your cheeks. You offered a lopsided shrug in response. And this? This was different for you. Normally you were chipper and full of happy spunk. And even though I was not so thrilled about your failure to clear the hurdles we'd pinky sworn upon, at minimum, I'd expected some funny one-liner about why it didn't happen. But not this. Not tears.

And so. I just waited. I touched your forearm and waited.

“Remember my grandson? The one who was staying with me?”

I thought for a moment and then remembered him from a visit once. He'd driven his grandmother to the clinic one day and seemed rather unhappy about having to sit in on a discussion of antihypertensives and insulin. “I do.”

“Well, he … he … “ You couldn't finish. Instead you just dropped you head into your hands and wept hard. Your ample bosom shook rhythmically along with your fleshy arms.

“Oh my goodness, did he get hurt? Is he, is he alive?” My hands covered my mouth immediately after I said that. I hated to be so direct but I'd worked at Grady Hospital long enough to know that it was a fair question. Your home address was in a rough part of town and that grandson was in your custody after drugs left his mother unfindable and incapable of raising him. The same streets that took his mama, though, preyed upon him, too. And you knew that. You'd lamented about your concerns of him selling drugs on corners and getting mixed up with the wrong crowds. So yeah. That question wasn't unreasonable.

“He got locked up. Caught a murder charge. He gone, Miss Manning. He might as well be dead. He gone for his whole life. And he ain't but nineteen.”

I felt my eyes throbbing with tears. I puckered my lips outward and swallowed hard to try to keep myself from crying, too. It didn't work. “I'm sorry,” I whispered. The tears splashed disappeared under my chin before I could wipe them away.

“Me, too,” you murmured back.

And that was it. We didn't utter another word about you blood pressure or your smoking or your blood sugars or your weight. We just sort of sat there and felt the enormity of how hard this life can be sometimes and pushed all of the rest of it to the back burner. And yes. Your blood pressure and weight and blood sugar are important. But your emotional well-being is, too. You'd lost your baby boy after losing the baby girl who made him. Your aging soul didn't deserve this pain. The streets were winning 2-0, which meant you were 0 for 2.

Later that day I thought of you. Thought of your grandson and the significance of his age--19--and that date you'd so cheerfully chosen for your quit date, June 19 or, as you said it, ”Juneteenth.” That number was supposed to be a happy one, representing freedom and a brand new day. Instead, it turned out to be symbolic of pain.

I hated that.

Here's what you taught me, though. That sometimes even when there is some pressing shit to discuss, something else more pressing should take precedent. And that sometimes the reasons that people don't follow through on things is because they physically and emotionally cannot. That slowing down and paying attention to souls matters more than slapping wrists for missing marks.

This lesson is one I need in all aspects of my life. So thank you, my friend. And know that this morning I am quietly weeping into my coffee and holding your hand. Feeling sad that nineteen hurts for you and wishing there was something I could do to fix it all. Like offer you some kind of Juneteenth to rescue you, your baby boy and his mama from the shackles of your reality.

“Let's talk about all of that other stuff next time, okay?”

“I'd appreciate that,” you replied.

I realize now that I appreciated it, 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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Thursday, September 15, 2016

No way out

Perhaps you have heard the rather grim joke about how doctors don't know when to stop treating patients who no longer benefit. It goes something like this: The oncologist goes to the cemetery to find (and treat) Mrs. Jones, since she hasn't “seen” the latest chemo-cocktail for her recently fatal malignancy. When he asks the grave-digger why she isn't in her assigned plot, he is told that she is off getting dialysis. Bah dum bump. OK, so it is crude, but everybody gets it, because it is just an exaggeration of the kind of aggressive, low-utility care that we often see (or provide) at the end of life.

Readers of this blog know that I believe that we, as physicians, often fail our patients by doing more than we would want done for ourselves. I have generally considered this a distinctly American issue, fueled in part by unreasonable expectations of the utility of medical interventions, the entrepreneurial nature of a lot of U.S. health care, and the prevalent American sentiment that death is somehow optional, or at least to be opposed vigorously at all times regardless of the circumstances.

A recent paper in Heart provided a little international—and, alas, cardiology—flavor.

In it, researchers from the UK, Israel, and France reported on their experience performing primary percutaneous coronary interventions (PCI) for acute ST-segment elevation myocardial infarctions (STEMI) in nonagenarians. It was a retrospective analysis of a series of 145 patients with no control group, which almost certainly means that there was a strong selection bias toward treating only “the best” nonagenarians. The principal finding was a 24% in-hospital mortality, with a 6 month mortality of 39% and 1 year mortality of 47%. No data on post-infarct functional status or quality of life were presented.

They concluded: “These results should encourage primary PCI to be offered to selected nonagenarians with acute myocardial infarction.” Really?

Leaving aside the fact that there was way too little information provided to support that conclusion, I just can't get past the idea of doing these procedures in the first place. It is not “age discrimination” to point out that everyone dies of something, and that employing aggressive interventions in the extreme elderly is, at best, a choice to take a different path to the same certain destination; a path that itself often encounters its own pain and suffering.

Kids, if you are reading this, please don't let them do this to me if I make it to my 90s. Make me comfortable and draw the curtain.

What do you think?

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Thursday, September 8, 2016

A silent epidemic affecting our hospitals

There's a huge problem we have right now affecting our nations' hospitals. It's not a disease you've ever heard of before, or something that cutting edge research or treatments are going to solve. It's a seemingly simple issue that has been lacking in every single hospital I've ever worked in, whether it be a large academic teaching hospital or a small rural medical center. It's rarely talked about, but endemic nevertheless. I'm hereby going to assign it a name:

“Sinking in bed syndrome”

What on earth is it you may ask? Well, the scenario goes something like this. A patient, usually elderly, is admitted to hospital with an acute medical illness. During the first few days of treatment, they are basically lying in bed while receiving all their treatments. They get more and more sunk into their bed, becoming weaker and weaker at the same time (even though their actual illness is improving). As they recover, they find it more difficult to get up out of bed and start walking again. The longer they are in bed, the more difficult it will be. Muscles have become tense and joints are stiffer. Because of this deconditioned state, recovery will be prolonged and patients will spend longer getting back to their baseline state.

All hospital-based doctors see this type of scenario unfold on a weekly basis. Sadly, lots of these patients actually report having quite reasonable and independent function prior to their admission. Of course, they have been unwell, and their illness itself will set them back. But having seen how we leave patients “sinking” in their bed for days at a time, I'm of the firm belief that keeping them in this state really sets them back even more.

In short, we just need to get them up much sooner. Unfortunately, it's not in our systemic culture to do that, and in almost all places I've worked, I sometimes need to plead just to get our patients up out of bed to the chair simply to make sure they are not lying down flat all the time. Sometimes sadly, it's family members who are the ones voicing their concern to me that their loved ones have become weak and need to sit up and walk more. It's a shame too that many health care institutions only think of getting physical therapy involved when discharging from the hospital is imminent, when actually it should be done much sooner.

Only a few decades ago, the culture was to keep patients who were sick in the hospital on complete bed rest for an extraordinarily long amount of time. Patients having heart attacks would be kept in and observed for several weeks. We now know that such a prolonged hospitalization is not only unnecessary, but also very bad for our patients.

So why do we not get our patients up sooner? I believe it's not a question of laziness or lack of resources. Nurses and nurses' aides are the most hardworking people I've ever encountered, and most nurses are aware that it's good to get patients up and moving. However, in the haze and hustle of a hospital admission, with intravenous lines, telemetry monitors, strong medications and constant tests, we lose sight of the simple little things that can make an enormous difference. In my experience, patients even just look so much better sitting up in a chair as opposed to lying in the bed.

So here's what the world of health care should really push for: A National Ambulate the Patient Week. This should involve:

 Education for all healthcare professionals about the importance of ambulation. Physicians should be encouraged to write “OUT OF BED TO CHAIR AT LEAST 3 TIMES DAILY” as an order for nearly all hospitalized patients as soon as they can, usually from hospital day 2. With that order should be assumption to “ENCOURAGE AMBULATION”, either with or without assistance depending on the circumstance,

 Invest in more physical therapy services and also dedicated PT-aides, also known as “walkers or mobility aides,” to get people up and moving early,

 Administrative oversight from charge nurses and unit supervisors to raise a red flag when they see a patient who potentially has “sinking in bed syndrome”,

 Posters around hospitals encouraging early ambulation and walks around the hospital floor,

 More comfortable chairs! This may sound rudimentary, but a common complaint I hear everywhere is that hospital chairs are very uncomfortable. However much they are purportedly designed for hospitalized patients, just glancing at them and testing them out myself, I'm very skeptical about how comfortable patients can feel sitting in them. I get the same feedback from relatives who test them out. If healthy people don't feel comfortable in any given place, how on earth do we expect sick people to?

There are certain departments that are actually already very good at mobilizing their patients. One such example is orthopedics, where surgeons are almost obsessive about getting people up as early as possible after hip or knee surgery. If they can do it, so can everyone else.

Richard Asher, the British endocrinologist and forward-thinker from the early part of the 20th Century, once said: ”Look at the patient lying long in bed. What a pathetic picture he makes! The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder and the spirit evaporating from his soul.”

That quote was from 1947. I will leave it to your imagination to think what scybala is!

Seventy years later, while we are not as bad as we were in the 1930s and 1940s, we can still do a lot better. So let's make it a national priority get all our hospitalized patients up and moving earlier. Starting from today.

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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