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

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Wednesday, September 17, 2014

Life at Grady: Feet of clay

I was a few steps behind her as she climbed up the 3 or 4 stairs leading into Grady Hospital. In her hand I saw that she was carrying one of those venti-sized coffee milkshake drinks complete with whipped cream and what looked like chocolate syrup on top. She wrapped her lips around the unusually large-diametered straw and slurped hard. My pace was faster than hers. It didn’t take very long for me to catch up with her.

“G’morning,” I said in what was likely the most mundane way ever. She pulled the straw from her mouth, nodded at me and returned the sentiment.

By my estimation, she was definitely younger than me. That said, her face lacked the mischief or innocence of youth so I’d say that she was definitely “grown” and maybe even somebody’s mother. Her skin was of a deep pecan color with eyes peeking from above her ample cheeks like two tiny slits. The sides of her face looked to be almost painted with this darker brown hyper pigmentation and, in that moment, the doctor in me sifted through my brain for the mechanism behind when such a thing happens when people carry lots of extra weight.

Hmmm. Acanthosis nigricans, maybe? Or even kind of like melasma or “the mask of pregnancy,” I thought to myself. Except this she didn’t appear to be pregnant at all. Just obese.

Very, very obese, to be clear.

Even without trying I could hear her laborious breaths as I walked alongside her. She was mouth breathing, yet balancing it with savoring deep swallows of what was surely a beverage well over her daily allowance of calories. Without even stopping myself, I made an unfair inventory of what I imagined to be her morning diet—some unrestricted 3,000 calories, most likely. She pulled back on the straw once more, her cheeks hollowing at the sides followed by more panting.

Confession: I could already feel my insides cringing, my nose metaphorically wrinkling with disdain. With each slurp, I noticed more things about her. The ill-fitting stretch pants that did little to hide the amorphous lumps that made up her buttocks and thighs, the wide feet folding over her distressed flip flops, the rippled upper arms that easily exceeded the size of one of my thighs—or likely even both of them.

Now she knows that she doesn’t need to be drinking that. Words I mostly thought, but that I probably would have uttered to Harry under my breath had he been beside me at the time.

Just then, I caught a glimpse of the crumpled McDonald’s bag in her other hand and immediately formed more unsolicited opinions about that choice as well. Judging. Disapproving. And almost, dare I say it? Disgusted to some degree. And you know? I’d be lying if I said that wasn’t true of what went on in my head. I’m also ashamed to say that such thoughts have probably entered my mind countless times before. Even though they were fleeting, they were there.

It was in the morning at Grady Hospital so there were many other passersby with me. They cast their glances in her direction as she shuffled up through the lobby. I could tell that many of them had those same thoughts yet the vast majority did little if anything to mask them. And so I let myself see what was happening—around me, in me—as it related to this innocent woman. The more I watched, the more I could see them; adjectives swirling all around her, pasting themselves to her swarthy cheekbones, her gelatinous arms, her abundant abdominal folds.

Fat. Lazy. Shiftless. Disgusting. Morbid. Invisible.

Her eyes kept shifting downward and away from those she encountered. It was automatic, a part of a shield of armor that immediately formed around her in such situations. The more I watched the more I saw. Person after person grimacing or even shaking their heads, right out in the open where she could see, feel, and be stung by it all..

Of course, many of those who tsk-tsked her could stand to shed a few of their own pounds. But now she was in a different realm. She had the kind of body that had crossed over into the kind that drew stares and widened eyes from little children who don’t know any better and adults who should. The kind that made single seats on commercial airplanes out of the question and even seatbelt restraints in a car a gamble. So yes, she’d moved into that public spectacle kind of obesity, making her a target for all of the stares, yes. But none of the pity.

Just that morning, I’d turned the radio station away from NPR because I was too tired of hearing about all of these unfortunate examples of discrimination against black people making the headlines. Black boys gunned down in Missouri, the President of the free world who gets openly dissed day after day, and yet another NBA franchise owner spitting out venomous words about the fans who look like me. Ugggh. Too much. Next my mind wandered to the op-ed pieces I’ve read on these same subjects, my eyes scrolling down to the nasty, racial slurs in the comment section.

But this? This, which I was not only seeing but participating in, was as messed up and discriminatory as anything. And worse, none of it was even hidden from sight. Blatant, open, egregious prejudices not because of race or sexual orientation or identity, but because of something universally affecting someone in every one of every group you can think of: weight.

And here I was, no less guilty than the rest of making her a pariah. Terrible.

Movies have won awards for complex tales of interracial loves fighting for familial acceptance. And, it seems, the world has gotten—or at least is getting—the memo that it isn’t cool to outwardly let the world know that your child can’t marry some black person or you aren’t interested in meeting the man your boy has fallen in love with and now calls his “soul mate.”

Yet somehow with obesity it’s different. It’s socially acceptable to shudder where others can see you or text some hurtful observation to a friend. No one is super angry, or rather, as angry as they would be about such open discrimination in any other group. And even worse, with obesity, the good guys are often in cahoots with the bad guys making it all exponentially worse.

So here’s what I am trying to work through: I’m trying to rage against my own machine—the imperfect human being with not-nice thoughts. I am thinking of the hurt I have felt when watching the news or listening to news radio about my own people being mistreated and how important it is for me to push myself to see my own shortcomings toward others. My hope is that it will give me more empathy toward those who think negatively of me just from looking in my direction.

Oh. And let me be clear. Obese people were not brought here against their will on slave ships, oppressed for hundreds of years and horrifically disadvantaged historically. But my point is that I don’t think there needs to be a contest to see who has been treated the worst. Instead, as we all fight for equality for the groups closest to our hearts, families and identities, that can’t ever happen if we aren’t willing to reflect on what we are doing, feeling and thinking about the groups that aren’t.

Here’s the truth: I didn’t even know that woman. I don’t know her life story, her trials, her upbringing, her resources, her support, or any such thing about her. And while I think it is perfectly okay for me to want a healthier life for her (and myself, too), I know it’s not okay for me to make up my mind that all of this represents laziness and self-loathing. I know as well as anyone that obesity isn’t that simple and can’t just be chalked up to being unmotivated. And you know? Even if it were, is it kind of me to focus just on that part without considering all of the things that may have led to that point? Hell no, it isn’t.

You know what? I’m a work in progress. And I’m going to work as hard as I can to “see” even more people than I ever have before…but to especially keep self-reflecting enough to see—and deal with—my own feet of clay in the process.

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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Tuesday, September 16, 2014

A letter from a medical patient to the hospital CEO

We are at a pivotal moment in health care. It’s changing so rapidly even the people leading the change can barely keep up. One of the biggest paradigm shifts over the last decade is the focus on quality over quantity. Improving the health care experience and patient satisfaction are also being talked about in boardrooms across the country (largely due to the link with reimbursements, but still unthinkable a few years ago).

As someone who has worked up and down the East Coast in a variety of different settings—from large academic centers to more rural hospitals—I have found the broad challenges to be the same everywhere you go. Unfortunately it’s also been my experience that hospital leaders often lose the forest for the trees, and are overly focused on unnecessarily complex solutions to simple problems. I’ve treated thousands of hospitalized medical patients over the years, and with my interest in quality improvement and improving the patient experience, I’ve noticed very similar patterns in what our suffering patients report back to us as their best and worst feelings towards the hospital.

While I don’t presume to be putting words into anybody’s mouth, here’s what I suspect a letter would look like from a large majority of patients who are hospitalized in America:

Dear Hospital CEO/Health care leader,

Thank you for asking me about my hospital experience during my recent bout of pneumonia. Overall I found the commitment and dedication of the frontline staff to be highly commendable. Their sincerity and professionalism was without question. However, I would like to point out a few observations (in fact, I will list them to make it easier to read).
1. I spent a lot of time in the Emergency Room waiting for my hospital bed. I know how busy it was and I’m sure everyone was doing their best, but I wanted to mention this. It’s very noisy down there and sometimes felt a little too overwhelming for me (it’s my first time in hospital).
2. There was a lot of confusion when I was admitted about my medication list. The ED and the hospital doctor both had different lists, neither of which was my actual one. I’m sorry I couldn’t remember my exact medication regimen, I’m on several different pills, but is there a better way to get an accurate list, perhaps directly from my primary care doctor or pharmacy? This nearly resulted in a small medication error on my second hospital day.
3. The nurses that saw me on the medical floor were great, but I noticed they were fixated on their computer screens and pushing around their carts more than they were looking at me or other patients! One nurse remarked to me that she agreed completely with my sentiments and proceeded to tell me all about the enormous data entry tasks that nurses now have to do. While I can’t comment on that, my mother was a nurse and my vision of a good nurse was always one who was with their patient at the bedside, talking to them regularly, consoling, and trying their best to make their sick patients feel better. I’m sure things have changed over the years, but I do hope nurses still have time to be nurses.
4. I thought the doctors were very good. Maybe a bit rushed, but again I know how busy they are. One thing though, I was seen by several different doctors in the mornings—the intern, resident, Attending, and then other specialists. All of them asked me the same questions and did the exact same examination. I was confused at first with who was in charge, but got it after a bit (some of the doctors also said opposing things to me, which needed to be clarified).
5. I found it very difficult to sleep at night. On my first night, my roommate kept calling out, and on the second night, there was a lot of commotion outside. Also, when I was already getting better, did the nursing assistant really need to wake me up at 3 a.m. to check my blood pressure? Just a thought. I’m sure I don’t need to tell you, but sleep and a good rest is one of the most important things the human body needs, and it’s especially true when we are sick. It should go without saying that hospitals should be calm, quiet and comfortable places.
6. I had 2 tests done which required me to be NPO. On the morning of each test, nobody could tell me what time the test would be. Have you ever been NPO before? I can tell you, it’s not pleasant. It would be good to have at least some idea how long it will last!
7. A couple of the scans I had, nobody told me beforehand what they were for. A transporter just walked into my room and announced he was taking me downstairs. There were also a couple of occasions where a phlebotomist suddenly showed up during the afternoon to take blood. I’m an educated person, and it would have been good to know the reasons why.
8. My family was extremely concerned about me, and asked on a couple of occasions roughly when the doctor would be around to speak with them. The nurse gave them an 8-hour window! Is this normal?
9. I know it’s a cliché, but the food! I’m not saying we need to have gourmet 5-star food, but I wasn’t a fan. Sorry, but you did ask me what I thought.
10. When I was discharged, the whole process seemed to happen very abruptly. I think we need to be more thorough and go through all the medications and follow-up very carefully. It’d also help if all the appointments were made for me. And while we are on the subject, on my second day in hospital, someone called my family at home and started talking about my “admission status” and when I was going to be leaving. This was before anyone even knew what was wrong with me! More tact please, my family got a bit worked up.

Having given you this list, I still want to tell you that the doctors and nurses did a pretty awesome job. I’m very grateful for that and understand that a hospital is not a hotel. Although you asked me honestly what could improve, that doesn’t mean I didn’t overall receive an excellent service. For that I thank you and your hospital’s dedicated staff.

Yours sincerely,

Medical Patient in America

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, September 15, 2014

Touching all the bases

Internal medicine requires knowledge, deduction, and many skills such as history taking, physical examination, and analyzing diagnostic tests. When confronting a new patient problem, we use our brains to work on finding a diagnosis. Much like police detectives, we would like to have brilliant diagnostic epiphanies, but often we make our diagnoses by painstakingly collecting all the clues and doing the necessary boots on the ground work.

We had a woman admitted to our service with confusion, decreased appetite and weight loss. In the ED, they diagnosed CKD Stage V, creatinine >5, and BUN >90. She had a 10-year history of type 2 diabetes mellitus. She had a history of ingesting high doses of salicylates and had a mildly elevated level.

The next morning as we are making rounds in the ICU she was on the bed pan. We asked the nurse to check a residual urine, because that is what we must always do with an unknown elevated creatinine. In fact her residual urine was 245 cc, despite no hydronephrosis on renal ultrasound.

The next day her appetite had returned and she no longer was confused. Three days later her creatinine was 1. Urological evaluation is the main plan now.

We had no good reason to suspect urinary obstruction, but we often are surprised with apparently newly elevated creatinine levels. We see such patients all too often. Finding obstruction when we did saved many resources.

While we love our diagnostic eureka moments, more often we get to the diagnosis through a deliberate process of touching bases and seeing what clues arise on our journey. Too often I see practicing physicians and residents skips steps. Too often I skip steps. When we skip steps we can miss the diagnosis in our omissions.

We owe our patients the deliberate process that leads to success. We need to touch all the bases.

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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Wednesday, September 10, 2014

Life at Grady: Something to think on

On rounds at Grady

“What questions do you have for me?”

He paused for a moment. “Do you think that you’re better than the people you take care of here at Grady?”

Wait—huh?

I’d just finished examining him and discussing the plans for his care. Things had gone well for us during the hospitalization so far so this took me aback. I turned my head sideways to see if this was rhetorical. He raised one eyebrow, a hint of mischief in his young face. He was totally serious and waiting for my response.

My initial answer was too fast and slightly defensive, I admit. “Definitely not.” There was this uncomfortable silence afterward. His question wasn’t meant to be offensive, I don’t think. Just provocative. So I thought a bit more while gazing into his eyes. Then I spoke again. “Do you think I think I’m better than the people I take care of here at Grady?”

I braced myself, afraid of the answer and wanting it all back immediately after it tumbled from my lips. It all sounded so insecure, so self-important.

“Uhhh, naaah. Not really. Or, I mean, it don’t really matter,” he replied. His hands smoothed the covers over his lap then he leaned back onto the pillow, placing those same hands under his head with his lean, brown elbows bowing out.

I admittedly wasn’t so keen on that reply. Noncommittal and not emphatic enough for me. I wanted him to vehemently affirm that he thought I was one of the good guys. But he just left it there.

“I wasn’t trying to offend you,” he finally said, studying my expression. “I guess I just wanted to know how you felt about being up in here every day. At Grady, you know?”

“Hmmmm.” Now I was leaning forward with my chin in my palm. My knee was propped up on the edge of his bed and our eyes stayed locked. “Grady? I honestly love being here.”

“Why, though? Like, does it just make you feel better about yourself?”

Ouch.

I wrinkled my face to try to follow where he was going. Like was he actually trying to “throw shade” my way or what? I wasn’t sure. But then I decided not to read more into it. “Um, well. Let’s see. I think I love Grady because . . . .I just love people. And the people at Grady are just. . . I don’t know. . . . just . . .amazing to me. Corny, I know. So, yeah. I guess interacting with folks here does make me feel better about myself in a way.”

Take that.

“I hear you. I guess sometimes it seem like people come in here and they’re nice to the patients but they sort of have this look in their eye like . . .you know what I’m saying. . . the folks who stand on line feeding people on Thanksgiving Day at Hosea Feed The Hungry. Like ‘Here is my good deed. Take my picture and post it on Instagram and get my good side.’” He chuckled when he said that. I sort of didn’t because I wasn’t sure what camp he thought I was in. Nor was I even sure in that moment.

“That’s kind of deep,” I replied. “Do you feel like that a lot when you’re here?” He had lots of medical problems even though he’s young. That gave him perspective to answer that question.

“Me? Naaah. Not so much. But I see it a lot when I’m here. Kind of like it’s a novelty, you know?”

Novelty. Wow.

I pressed my lips together and let all of this marinate. “I think. . . “ I paused and thought carefully about my words. “I think maybe when I was a lot younger, I’d heard so much about public hospitals like Grady that most of it felt like an idea more than a reality. I don’t know if that was a bad thing, but I’d say that, like, the first few times I met people who smoked crack or who lived outside or even just the very elderly patients with fixed incomes. . .I think. . . yeah. . .I think the idea of the people here overshadowed them sometimes. Does that even make sense?”

“Yeah, man. Makes total sense.”

I liked how at ease he was and how he called me ‘man’. Maybe I should have been offended, but instead I just enjoyed talking to him. It was provocative—probably one of the most compelling discussions I’d had with a patient in a long while.

“But back to your first question—I don’t think I’m better than anyone. I think I’m fortunate, yes. But better? No.”

“That’s good.”

I closed my eyes for a moment and then opened them to find him still looking at me. I felt sure of myself and my position so I challenged him with my stare. I responded, “It is good. I agree.”

His mouth turned upward on one side at my resolve. But I was okay with that. It was good.

“Yeah. I’m a Grady baby, so I been in this game for a minute. I think about a lot of stuff like this a lot.”

“I hear you. So what do you think is the way to get over the idea of Grady enough to get to the people part?”

“Ha. That’s easy and hard. The first part is just starting with people that really have a heart for human beings, know what I’m saying? Like not anybody that sees it like some badge on their boy scout uniform that says ‘I survived Grady.’ If you start there that’s the easy part.”

I nodded and kept listening.

“The other part is hard because that got to do with how the patient see theyself. Like me, I’m not gonna be a part of some field trip, you know? Like some cartoon character they heard about saying stupid stuff like ‘Ain’t nobody got time fuh dat!’” We both laughed knowingly at the Sweet Brown reference, one the world now knows well. He went on. “See me? I’m gonna say something, ask something, do something that jolt the person into reality. Like that ain’t what this is. Or at least what I am. Get ‘em to think. About me. Not just the fact that ‘Oh, it’s so neat to be up in Grady talking to people.’”He wiggled his fingers and spoke in this animated voice when he said that part.”Wow.”

“Yeah, because I see me as they equal, you know what I’m saying? And this ain’t no summer camp, man.”

And I nodded hard again, this time with my brow furrowed because I did get what he was saying and I didn’t want to miss anything. I also reflected on the conversation we were having right then and there and how, yes, he’d done exactly what he said. He “jolted” me. And got me to think.

“You know? That kind of makes me think of this quote by Eleanor Roosevelt.”

“Remind me of who that is again?” he said, no shame in his game. And I dug the way he came right out and asked me because I was admittedly being hyper-careful about not asking if he knew so that it wouldn’t seem like an insult.

“She was the wife of Franklin D. Roosevelt, the President during the Depression and World War II.”

“Right. Yeah. Okay, I’m with you. What’s the quote?”

“It’s something like, ‘Nobody can make you feel inferior without your consent.’”

We both sat there quietly for a few moments as those words swirled around us, punctuating the interaction.

He picked up a pencil off of the table and grabbed the cafeteria menu sitting in front of him. “Say that one more time?”

This time I pulled it up on my phone to be sure. Then I placed it in front of him so that he could write it down. And he did.

Before leaving, I told him that I write and that I’d like to share this story. He poked out his lip and shrugged. “Fine by me,” he said.

“Thanks for giving me something to think on today,” I said as I prepared to leave.

“Always,” he chuckled his hands now folded under his head again. “Always.”

“Alright then. I’ll see you later, okay?”

He dipped his chin downward and fished around his blankets for the set of oversized headphones that had apparently been there all along. Just as he stretched them out to place them over his head, he paused. “Hey, Dr. Manning?” I raised my eyebrows. “Thanks for that whole thing, man. For real. You gave me something to think on today, too.”

I smiled at him from the door one more time. And then I went on to see the rest of my patients—the ones who, I pray, won’t feel like novelties or who, at least, will refuse to allow themselves to be seen as such.

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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Tuesday, September 9, 2014

Taking patient engagement to the next level in hospital care

Improving “patient engagement” is a subject that’s being talked about in hospital boardrooms across the country. It’s become the in-fashion political buzz phrase. Certainly sounds very well and good, but what exactly does it mean? Likely different things to different people depending on what angle they approach it—all the way from a care assistant up to the hospital CEO. In a nutshell, it’s all about allowing the patient to take center stage in their health care, and being fully informed and understanding each step of the way. It’s about education, encouraging healthy behaviors, improving health outcomes, and lowering health care costs. The ideal state is to allow the patient to feel that they are in the driving seat and full participants in their own care. As things currently stand, most health care systems across the world are way off from this place. It’s not just the health care that’s to blame either, because the biggest part of patient engagement involves the patient stepping up to the plate themselves. And there are some very real barriers to this including education, demographics and motivation. There’s also the reality that most 90-year-old chronically unwell patients in hospital will have difficulty taking care of themselves. The issue is thus a complex one.

No one has a better understanding of where the opportunities for improvement lie than the doctors and nurses working at the coalface. We get to see all the problems up close and personal on a daily basis. I’m going to talk about how this pertains to my own specialty of hospital medicine, and where we have enormous room to engage patients better while they are in hospital. Here are 5 areas to focus on:

1. Encouraging patients to ask questions when they see their doctor every day
As simple as it sounds, this is not done nearly enough, and is a big missed opportunity to make a difference to patients’ understanding of their illness. There are a number of reasons why this doesn’t happen, ranging from a “rushed” hospital environment, to patients sometimes feeling embarrassed to ask certain questions. I’m actually surprised by some of the questions I hear when I ask my patients if they have anything they want to ask me, and there’s no way I would have guessed what they were unsure about unless I encouraged them to speak up.

2. Giving patients all the knowledge they need about their medical condition
Writing details such as blood count numbers on the whiteboard at the end of their bed is one way to do this. In the future, patients will likely be able to pull up some of their own data on computers. The more that patients know, the more empowered they will be to make important health care decisions.

3. Involvement of families
Just as important as the patient, is the family. This is true for any patient who is too unwell to speak for themselves, and particularly applies to the elderly. Doctors and nurses have to ensure that family is completely on board with the plan of care and what their role is in the recovery process. I’ve always said that if you want to make sure that something is done after discharge, tell the patient’s daughter. It’s been my observation everywhere!

4. Involving the patient fully in the discharge process
The discharge process by its’ very nature is a risky endeavor. Typically there are medications that have been changed, tests pending, or even an uncertain diagnosis. All this at a time when the patient is still very frail. It is a crucial transition point, more important than almost any other to get right.

5. Follow-up care
All hospitalized patients must follow-up in a timely manner after being discharged. Nipping a potential problem in the bud can help reduce readmissions and potentially serious complications. Reminders should be sent to the primary care physician and a post-discharge follow-up call from a nurse or administrator would not go amiss—and also shows that we care.

There is no one magic formula for solving the issue of patient engagement in hospital medicine. It will require a multifaceted and multidisciplinary approach. Whichever arena we are in, it is vital for a number of reasons. Whether we are talking about raising the quality of health care, improving outcomes, or lowering health care costs—there’s a great deal to play for. The more knowledge and opportunities to participate in their own health care, the better it is for both patients and doctors.

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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