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

Friday, April 18, 2014

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

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


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

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

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

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

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

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

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

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

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

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

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Thursday, April 17, 2014

We're in the post-antibiotic age

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

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

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

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

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

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

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Wednesday, April 16, 2014

Life at Grady: Your game plan

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

What is your goal when it comes to being healthy?

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

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

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

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

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

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

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

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

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

Do you know your BMI?

Are you realistic about trying to get it lower?

What are you eating?

Are you thinking when you eat?

What example are you setting for your family?

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

How much are you drinking?

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

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

Who is your doctor?

When did you last see her or him?

What is your blood pressure?

What is your cholesterol level?

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

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

What excuses are you making?

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

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

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

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

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

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

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


Monday, April 14, 2014

The 96-hour rule and other ridiculous requirements in payments to small hospitals

My home hospital is small. In a town of just over 20,000 people, this hospital has 25 beds and is designated “critical access” by Medicare because it is felt to be necessary to the health care of the community.

Critical access is a designation which was introduced in 1997 when modernization of Medicare payment systems threatened to close a large proportion of hospitals in small communities which were unable to benefit from economies of scale. A small hospital needs to remain capable of providing services to small but significant floods of patients when everyone gets sick at once, and maintain skills and staff to care for a variety of different diseases. This can make such a hospital less financially efficient (though various other factors can partly offset this) and the critical access program spares my hospital some of the Medicare belt tightening that would make admitting Medicare insured patients prohibitively unprofitable.

Most larger hospitals are now paid for their Medicare insured patients according to the Prospective Payment System, in which a fixed amount of money is paid to the hospital according to what disease the patient has. This means that if a patient presents with pneumonia the hospital will get maybe $8,000 for all of the expenses involved in treating the patient, excluding doctor fees which are billed separately. If the patient does very well and only stays in the hospital 2 days, the hospital does very well and if the patient languishes and requires more resources, the hospital loses money. It is designed, ideally, to work out so the hospital survives, covers its costs and makes a profit. This encourages hospitals to make patients well as soon as possible by making sure that they don’t profit from taking poor care of patients.

It’s generally a good system. Small hospitals, though, are very sensitive to individual patient disasters, and if a patient or 2 uses more resources than the Prospective Payment covers, the hospital can fail. For this reason critical access hospitals are paid “fee for service”. Medicare pays 101% of its allowable fee for each service a patient uses in the hospital. Overall, this can end up costing Medicare more per patient, but it does keep small hospitals afloat.

In order to be critical access, a hospital must have 25 or fewer beds, though it can also have separate units for rehabilitation or psychiatric services, at 10 beds each. It must be 35 miles by primary road or 15 miles by secondary road from another hospital, or 15 miles in mountainous terrain. Up until 2006, it was also possible for the states to designate a hospital as a “necessary provider.” Hospitals so designated remain critical access, though this loophole is no longer available. The 2014 budget will address this definition again, proposing to remove critical access status from hospitals within 10 miles of another hospital.

Because critical access hospitals don’t have the usual built in incentives of the prospective payment system to limit the length of hospital stays, theoretically they can just make more money by keeping patients longer. Thus, the 96-hour rule. Originally it was stipulated that critical access hospitals couldn’t keep patients longer than 4 days. Since this was patently ridiculous, the law was changed to allow hospitals to average no more than 96 hours, which was a wee bit better.

So why do we even want to have little hospitals? They don’t have very many medical specialists, they don’t have dialysis units or cancer centers or cardiac cath labs. Sometimes they can’t do MRI scans or nuclear stress tests, and the littlest ones can’t even do surgeries. When you put all critical access hospitals (there are about 1,300 in the U.S.) in a big pot and average their results, they have a higher mortality for many diagnoses than the bigger hospitals. Some of these hospitals are probably not good. But so are many larger hospitals.

Communities often depend on the existence of hospitals. Businesses don’t want to locate themselves far from a hospital. When a local hospital closes, the chronically ill and the poor who have trouble with transportation are prohibitively far from health care. Small hospitals support the work of primary care doctors with labs and radiology suites and emergency services. Communities without a hospital often have only very few and basic outpatient providers. Small hospitals often provide more appropriate care for patients because everyone knows everyone else, so we remember what happened last time, what worked, what didn’t. The nurses know who drinks on the sly or is abused by their husband. The specialists and the hospital physicians know each other well and also know and share patients, which makes care more personal and makes patients feel more secure. Communication is excellent and things get done right away.

For those patients who have problems that are beyond the scope of a small facility, the emergency department can stabilize and transport. In our hospital we have a heliport on the roof and our patients can be up and out and at the major referral center that is 90 miles away in next to no time. The very old and very sick who want comfort rather than life prolonging procedures can get that right near home, with physicians who know them and often know their family and friends, and share their concerns.

So I guess I am a fan of good little hospitals. But I am not necessarily a fan of the critical access system. Our hospital is occasionally so full we need to turn away patients, but we have more actual physical room and could definitely squeeze in a few more patients if we weren’t limited to 25 beds. Also, the fee-for-service system really does not encourage us to develop innovations that make patients get better faster. I think we do a great job at my local hospital of reducing over-testing and over-treatment, but there is no financial incentive to do so since we make more money if we do more. We would be better at creative thriftiness if it actually saved us money. Our creativity is stifled by the need to be little and by being paid fee for service.

Lately, we are being encouraged to take the 96-hour rule more seriously. We need to certify when we admit a patient that they will only require 96 hours in the hospital. If we think they are likely to be in our hospital longer than that, we theoretically need to transfer them to the larger hospital 90 miles away. Seriously? And if we think they will only need 96 hours but we are wrong, theoretically we should then transfer them.

So, our dear sweet 96-year-old who is admitted with diarrhea and turns out to have a small bowel obstruction and then develops pneumonia would need to take an ambulance ride or a $40,000 helicopter ride on day 4 just as we have her really nicely stabilized. The alcoholic with pancreatitis who never gets better in 4 days but is perfectly appropriate for our level of care would go straight from the emergency room to the tertiary care facility. The overworked doctors at those hospitals are so definitely not going to love that, as they deal with their own sick patients.

I’ve been on both sides of this situation, as the doctor transferring a patient and as the one receiving the patient. If a patient is being transferred solely because it is difficult to design an appropriate discharge, it is more difficult to do that from a hospital 90 miles away from their home. It is also extremely likely that subtleties of the history will be lost and that procedures and tests and mistakes will be repeated. Transfer to a different hospital is necessary if the patient’s recovery is stalled because of lack of expertise or technology, but if it is only to save the payer (Medicare) money, I expect it will do the opposite.

What to do? I’m thinking that the whole critical access system needs to be reconsidered. Managing all small community hospitals the same way doesn’t make sense. Clearly little hospitals need support in order to survive, but giving them arbitrary rules and paying them by fee-for-service is hardly the way to make them function better and certainly doesn’t encourage creative innovation.

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

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Another kibosh on fecal transplants

Increasingly, my work life seems to revolve around Clostridium difficile. Yesterday I performed 3 fecal transplants. All were elderly patients who had been suffering with recurrent C. difficile for many months. Using stool from OpenBiome’s stool bank greatly simplified my job and made the entire process much easier for the patients.

Since OpenBiome’s donors are extensively screened, the patients did not have to identify a donor and bear the unreimbursed costs of donor screening. Family members of all three patients commented on the ease of the process, and were quite happy with not having to identify a donor. The daughter of one patient who been transplanted previously with a directed donor, specifically commented on her preference for using a standard donor. And as always, the patients and family members were incredibly grateful and very happy to think about life without vancomycin. I left clinic feeling as though I had made a real difference by providing these patients a therapy that still is unfortunately relatively rare. One of the patients yesterday had to travel 3 hours to see me for this very simple, yet highly effective treatment.

Last night, on the way home, one of our infectious diseases fellows called me to discuss fecal transplant for a critically ill patient in the ICU who was failing all the drugs we have available to treat C. difficile. I happily told him that fecal transplant should not be a problem as we have frozen stool now available in the pharmacy.

This morning I spoke by phone with a woman whose mother is hospitalized 2 hours away after having multiple recurrences of C. difficile regarding coming to Richmond for transplant. And a patient that I transplanted a few weeks ago (the first patient I transplanted with donor stool from OpenBiome) called to tell me how well he was doing.

It seemed as though the whole fecal transplant process was finally working very smoothly. But as I went to bed last night, I took a final look at my phone and saw an e-mail from a colleague with a link to new information from the FDA on fecal transplant. Those of you who follow this blog may recall that the FDA had previously proposed that all fecal transplants would require an IND number; however, this requirement was later relaxed. I was stunned by the FDA’s proposed new rule. Since the FDA seems to write in a different language, I will paste their verbiage here:

After publication of the July 2013 Guidance, FDA has continued to review this area and is clarifying its enforcement policy. FDA intends to exercise this discretion on an interim basis, provided that:

1. The licensed health care provider treating the patient obtains adequate informed consent from the patient or his or her legally authorized representative for the use of FMT (fecal microbiotica transplantation) products. The informed consent should include, at a minimum, a statement that the use of FMT products to treat C. difficile is investigational and a discussion of its potential risks.

2. The FMT product is obtained from a donor known to either the patient or the treating licensed health care provider.

3. The stool donor and stool are qualified by screening and testing performed under the direction of the licensed health care provider for the purpose of providing the FMT product to treat his or her patient.

FDA does not intend to exercise enforcement discretion for the use of an FMT product when the FMT product is manufactured from the stool of a donor who is not known by either the patient or the licensed health care provider treating the patient, or when the donor and donor stool are not qualified under the direction of the treating licensed health care provider.

So it seems that the FDA is not happy with the concept of banked stool from standard donors and would prefer directed donors. If I test a donor once for infections and that donor is known to the patient, I don’t need an investigational new device exemption (IND). But, if I obtain the stool from a stool bank that has a small number of highly selected donors that are tested serially every 60 days, and the stool is quarantined to avoid the problem of an infected donor in a seronegative window period, I need an IND? The blood bankers actually discourage the use of directed donors as the directed donor may be less likely to disclose risk factors for infectious diseases. There is no reason to think that would be different here.

I called the number on the FDA’s announcement. The person I talked to was polite but I felt as if I was talking to someone in a parallel universe. After 10 minutes, I didn’t feel like I had any better understanding of the issue. She told me that there were no data that fecal transplant is effective for C. difficile. Really? I reminded her that the randomized controlled trial published in the New England Journal of Medicine was stopped early because it worked so well.

She could not tell me whether I could even get an IND if I was using product from a stool bank, though later implied it could only be used in a clinical trial. She transferred me to “Manufacturing” and felt sure they could help me. The person in Manufacturing was not even aware of the announcement and said that I need to talk to someone in “Vaccines.” Between this issue and the IV zanamivir issue, I have come to the conclusion that the FDA is so isolated and so sucked into the parallel universe of its bureaucracy that’s it has lost touch with its mission.

While I might not be able to understand what the FDA is saying, here is what I do know: recurrent C. difficile is a terrible illness that is becoming increasingly common. In a subset of patients, antibiotics are not curative. It destroys quality of life, and if untreated in the elderly leads to wasting and ultimately death. A simple treatment is highly effective in curing the infection. And a group of really bright students in Boston found a creative solution to make stool transplants readily available and quite safe for patients. But a behemoth bureaucracy chooses to stand in the way.

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. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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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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