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

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Monday, April 27, 2015

Why do we still use oral furosemide?

Most physicians do not understand pharmacology and pharmacokinetics. We use Lasix (furosemide) because we have always used furosemide. As an academic hospitalist, I often have patients admitted with heart failure (either right-sided or left-sided) who have gained significant fluid weight despite taking significant oral doses of furosemide. When they get admitted we start with IV furosemide and amazingly they pee like racehorses.

How many of us remember that oral furosemide is variably absorbed, with a general range of 20%-80%? You may not remember that, or you might just be in the habit of using Lasix. Lasix has a great name. It was generic when I was a medical student (‘71-’75). It is a magic drug. But should it be our first line oral loop diuretic.

We have two other good generic choices, bumetanide (Bumex) and toresamide (Demadex). Both drugs have consistent absorption in the range of 95%. Some data suggest that torsemide use improves outcomes, perhaps even all-cause mortality. Torsemide has some anti-aldosterone properties in addition to blocking the NaK-2Cl channel.

Recently, we had another patient taking 80 mg of Lasix twice daily and he had gained 50 pounds. IV furosemide worked beautifully. We tried Bumex 2 mg (the rough conversion between furosemide and bumetanide is 40 to 1) and he continued diuresing.

So why do we start with furosemide? And I am guilty also. Can anyone explain it or disagree?

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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Friday, April 24, 2015

Safety first? Not with my patients!

“Safety first” is a mantra of today's hovering parents. It's the default explanation that a parent invokes when an edict has been issued that cannot be challenged or reversed.

“Mommy, can I pleeeeeeze have a water pistol?”

“I'm sorry, honey. You know how Daddy and I feel about guns. This is a safety issue. Now go and practice your violin and afterwards help yourself to some kale chips.”

The safety concept has crept into the medical arena. In many cases, safety concerns about our patients are justified. I see many of our elderly hospitalized patients approaching hospital discharge who face safety concerns at home with respect to falls, understanding complex and new medication lists and monitoring active medical issues. Hospitals today have a staff of capable and compassionate professionals who do excellent work protecting patients poised for discharge. This effort saves patients suffering and saves the system cash—a medical win/win.

It's no victory for a cardiologist to rescue a patient from congestive heart failure if the patient goes home and doesn't take her medicines or veers widely off the recommended diet.

But sometimes safety should not be first. How safe would you want to be if your quality of life would suffer? To those who argue that safety is paramount, would you support the following proposals?
• outlawing motorcycles
• decreasing the speed limit by 10 mph on every road
• prohibit high school and college competitive athletics
• no swimming, anywhere
• avoid gluten, the silent killer

Don't take the above too seriously, since I don't. But, here's my point. I am often asked to place feeding tubes in elderly individual after they are tested and told that it is not safe for them to take food or drink by mouth. These patients are found to have imperfect swallowing function. The fear by those who make these recommendations is that the patient will choke while eating with some food dropping into the lungs causing a pneumonia.

These concerns are real, but we need some context. First, if all 80-year-old folks were subjected to the conventional swallowing test, many would be found to have swallowing dysfunction, and yet they are eating and drinking without significant difficulty. So, we have to be cautious about placing a feeding tube just because a swallowing test is abnormal. Secondly, many elderly patients have few pleasures remaining in their lives. Are we comfortable convincing them or their guardians to take food away when this may be a singular pleasure for them? Even if oral feeding has risks, for many of these folks I suggest that it may be the better choice. I think that we talk many of them and their families into the tube, which has its own medical risks in addition to its effect on human dignity and quality of life.

Do feeding tubes make sense for some patients? Definitely. But, it shouldn't be for everyone, We can devise a series of rules to live by that would make us much safer than we are now. Would you want to live like that?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Tuesday, April 21, 2015

Should the word 'hospitalist' be more protected?

Our specialty of hospital medicine has grown exponentially over the last decade and now finds itself at the forefront of American medicine. I'm proud to be part of such a growing movement and must say that I find the job just as rewarding as when I first became an attending physician when the specialty was still in its fledgling stage. As the number of us soars towards the 50,000 mark, the vital work we do across the country every day is rightly becoming more widely known and recognized.

The term “hospitalist” was first coined in 1996 in a New England Journal of Medicine article and has now become our job title. But at this point let me break from my esteemed colleagues who champion the phrase. I've written previously about my personal dislike of the word “hospitalist,” including in this article published last year on a top social media site entitled “Please don't call me a hospitalist.” I received a lot of emails after writing this—both positive and negative. I know a lot of our colleagues right now are celebrating the fact that the head of the Centers for Medicare and Medicaid Services and the new surgeon general are “hospitalists.” Isn't this great for the specialty?

Don't get me wrong, I mean no personal disrespect to our founding fathers who first came up with the job title or the thousands of hard working hospital doctors, but I've personally never used that word to describe myself, find it a slightly ridiculous term, and have always gone an extra mile to avoid putting the word on my business cards or even my name badge. For me, being known to my patients as their “attending physician” or “internal medicine doctor” is all I want.

But I will move on from the points I raised previously to another central question: If this is the name that we've adopted, should it be more protected? This question arises because over the last few years on my travels up and down the East Coast, I've noticed more and more people banding around the word “hospitalist” to describe what they do. For instance I've heard many specialty colleagues such as nephrologists and endocrinologists who find themselves working mainly in the hospital describe themselves as functioning as a “hospitalist.” I've heard final year residents and even medical students on-call openly say that they are working as the “hospitalist.” Nurse Practitioners and PAs frequently describe themselves as the “covering hospitalist.” I've even heard respiratory therapists and wound care nurses who are covering multiple floors describe themselves as the “respiratory therapy hospitalist” and “wound nurse hospitalist!”

Not to get stuck on names, but this situation would never occur with most other specialties. For example, neither a resident, respiratory therapist, nurse practitioner or physician assistant would boldly describe themselves as the “cardiologist” or “nephrologist” on-call.

I understand that this may not be a big issue to lots of our colleagues, but remember that you have gone through medical school and residency to call yourself an attending physician—why make yourself anything else? Without sounding arrogant, there isn't a professional out there who would ever describe themselves as anything of less magnitude than their true job title. A chief executive officer of a company wouldn't introduce him or herself as “one of the managers” and a 747 pilot would never describe him or herself as “one of the airline staff.”

We belong to an ancient profession. The word “doctor” is more than 2,000 years old, aptly derived from the Latin doctus meaning teach or instruct. Physician was used traditionally to describe a medical doctor, and King Henry VIII granted the first charter to form the Royal College of Physicians in 1518. In almost every country in the world, a medical doctor is considered to be among the most noble and prestigious professions, the title only conferred after 1 of the most rigorous university courses in existence. It is a privilege and honor to be 1.

I'm afraid to say that in my own experience, whether we like it or not, “hospitalist” in the eyes of many says “I am a shift worker,” or “I am transient,” or “I am some type of resident,” or I am “owned by the hospital.” If you are the attending physician—now that's something a lot more meaningful.

So should the word “hospitalist” be protected like a cardiologist or radiologist, and specifically is a hospitalist always a physician practicing hospital medicine? That's a question for the wider community. For me personally, as someone who doesn't use the word, it doesn't matter! But if any Tom, Dick or Harry who works in a hospital and is employed in shift work, physician or not, now feels able to call themselves a “hospitalist,” what does it mean for you to primarily use that as your job title?

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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Monday, April 20, 2015

What is community acquired pneumonia?

Back in the 70s when I was training, we diagnosed pneumonia, and then tried to understand the likely bacteria causing the pneumonia. We knew the clinical presentations of various bacteria. We had a clear illness script for diagnosing pneumonia.

Then, if I recollect correctly, we had a new diagnosis: community-acquired pneumonia (CAP). Perhaps I am too old school, but CAP seems like a “cop out” diagnosis. Moreover, the label has become a crutch for hospital admission. Patients come to the emergency department with at least one symptom suggesting a chest X-ray. The CXR suggests an infiltrate and bingo we have an admission diagnosis.

I love admission diagnoses of CAP because these patients so often have something else. We can exercise our diagnostic muscles to either confirm or deny the original CAP diagnosis.

Why has this happened? I blame the Centers for Medicare and Medicaid Services (CMS)! In 2004, based on flawed data, CMS started reporting the percentage of pneumonia patients who received antibiotics within 4 hours of emergency department arrival. A wonderful series of articles then demolished this rule! Another performance measure bit the dust because the rule led to a significant increase in inappropriate antibiotic use.

But I believe the rule has a lingering impact. The rule told us that we cannot afford to miss pneumonia. Therefore, when in doubt we label patients with a pneumonia diagnosis. And too often we ignore the patient's history, focusing merely on a chest X-ray infiltrate.

Another factor comes into play, a very unfortunate factor. We seem to need a diagnosis to admit a patient, even when making the diagnosis is really the reason. I hope that sentence made sense. We no longer seem to admit patients for abnormal chest X-ray, diagnosis uncertain. Rather we place a label on the patient, one that induces the anchoring bias.

So I accuse the system that was trying to improve quality as actually causing diagnostic errors and inappropriate treatments. I accuse the system of fostering diagnostic delays. And I still do not know why we use the crutch diagnosis of CAP.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

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Tuesday, April 14, 2015

Practical emergency airway management--human factors in response to medical emergencies

Physicians need to complete about 50 hours of some kind of continuing medical education (CME) every year. The ideal kind of class is one that we actually attend in person, with teachers who are expert in the field being taught and are somewhere near the cutting edge. CME classes are especially nice when they include something hands-on rather than just a lecture format because much of medicine is hands on and because that wakes us up and keeps us focused. There are other ways to get education, such as studying written materials or attending classes taught via video presentation, and they are an important way for physicians who don't have the leisure to leave their work to refresh or expand their knowledge base. I've always gotten more from the courses that were taught by actual living breathing people, though I have availed myself of lots of the distance options

One thing that physicians are often required to do, and rightly, is to remain familiar with how to deal with emergency situations, ones which thankfully don't happen very often. The hardest things to remain competent to do are the procedures that we perform only in extreme situations and can't be practiced on healthy or nearly healthy people because the procedures carry too much risk. The most perfect example of such a procedure is providing an emergency airway to a patient who is at risk of being unable to safely breathe for him or herself.

In such a situation, for instance if a patient comes in who is so ill and weak that they are unable to support their need for oxygen and/or for elimination of carbon dioxide, breathing must be augmented in some way. Sometimes a pressurized mask, “bilevel positive airway pressure” or “BiPAP” may work, but sometimes even that in not enough and the person must be connected to a ventilator. The ventilator provides the “good air in, bad air out” that normal breathing normally does, but a tube must be placed into the trachea via the nose or mouth to connect the ventilator to the human. This is a tricky and sometimes difficult procedure. A tube stuffed blindly into the mouth will normally go down the esophagus into the stomach, which does not actually connect to the lungs in healthy people. In order for a person to allow a tube to go down the throat (or nose in rare cases), he or she must be heavily sedated and, ideally, entirely paralyzed in order to see the clear path for tube placement.

When a person is not breathing adequately, there is still some oxygen exchange going on, but when that same person is heavily sedated and paralyzed, no breathing will happen. Artificial respiration can be performed via a mask and a bag, but that is difficult to maintain and often fills the stomach with air as well, so the endotracheal tube (tube to the lungs) needs to be placed quickly and accurately. If it accidentally goes in the esophagus and the situation is not quickly discovered, the patient will die.

Most of us physicians don't often run into a situation where endotracheal tube placement is a common occurrence so, despite the fact that we need to be very adept at it, it's hard to maintain competence. Even those of us who do it pretty often were sometimes taught in a haphazard manner which we try to overcome by practice. When an endotracheal tube does not go in easily, as planned, we have the option to place a temporary puffy internal mask which fits over the trachea through the mouth, or to perform a surgical procedure to put a tube through the cricothyroid membrane in the neck. That is likewise a procedure that demands competence, and one which is not possible to practice on real people who value their lives.

I just returned from a nearly perfect course in providing airways in emergency situations, taught by Dr. Richard Levitan, a self-proclaimed airway geek. He taught the course in conjunction with 2 other airway experts, Dr. George Kovacs from Dalhousie University Medical School in Halifax, Canada and Dr. Ken Butler, and emergency physician and airway pharmacology specialist from University of Maryland. I say nearly perfect without any real concept as to what would have made it more perfect.

The course started with a day of lectures, heavily sprinkled with video recordings of real situations, anecdotes and student participation. The students were primarily emergency physicians, with a smattering of medical residents and critical care and hospitalist type of doctors. There were not very many of us, maybe 18 total, which gave us all great access to the teachers.

Lunch was at a Greek restaurant a few blocks from the hotel venue, and we all ate together at a large table. We were encouraged to tell an airway story (which are some of the most colorful stories in most peoples' memories) after we finished eating, which meant that we knew each other as individuals by the end of lunch the first day. That is very unusual in medical conferences where it is pretty easy to depart with no new friends. Dr. Levitan has a huge amount of practical and academic knowledge of everything to do with the airway, which despite being small geographically is huge in spectrum. He digested that to give us an uncluttered approach to placing the most appropriate kind of airway device, recognizing that the psychology of stress in times of great urgency of action limits our ability to be able to use complex, multi-branched tree charts.

His co-teachers provided alternate approaches when something was controversial, which I found very helpful and reassuring. He focused on “human factors” in the procedures, a term which I have heard floating around more and more lately, often in regards to computerized documentation. “Human factor” and ergonomics are words used to describe efforts to make processes, cognitive, emotional and physical, fit real humans in such a way that they are efficient and also happier and less likely to be injured. Dr. Levitan was particularly interested in making the ways we think about performing in emergencies add to our success and reduce our tendency to fear and subsequent stupid decisions. He also taught details about holding instruments, positioning patients and breaking down complex procedures into easily accomplished bits. His presentation style was engaging and he combined media with printed data, stories and questions in a way that excellent professors do.

The second day was spent in the lab. There were about 20 relatively recently deceased people whose unselfish decision to donate their bodies made it possible for all of the students to become competent and confident by the end of the day. We gowned and gloved and viewed the epiglottises, larynges and tracheas of each of them, allowing us to become familiar with a tremendous amount of diversity of anatomy. We placed endotracheal tubes in 20 subjects, practiced use of standard, fiberoptic and video laryngoscopes, bronchoscopes and other optical gadgets. We learned exactly what twist of the wrist allows atraumatic passage of a tube. We placed tubes through cricothyroid membranes, thus de-stressing one of the most worrisome procedures in our potential practice. The bodies were softer than the embalmed bodies that I learned anatomy with in medical school, and were much like the patients we might see in this type of situation in texture. I thought it might be a little bit horrible, but it was not. I was kind of attached to our patients by the end of the class, and would have liked to have known their stories.

Beside my profound thanks to the cadaver subjects, I am so very grateful to excellent teachers who spend years learning things of immense complexity and then present them to us, with a generous helping of humor and compassion.

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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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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