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

Friday, February 25, 2011

Doctors' garments colonized by bacteria within hours of starting work

Bacterial contamination of physicians' newly laundered uniforms occurs within three hours of putting them on, making them no more or less dirty than the traditional white coats, researchers reported.

This colorized 2005 scanning electron micrograph depicts numerous clumps of methicillin-resistant Staphylococcus aureus bacteria, magnified 2,390 times. Content provided by CDC/Jeff Hageman, MHS, via the CDC's Public Health Image Library (PHIL)Researchers sought to compare bacterial and methicillin-resistant Staphylococcus aureus contamination of physicians' white coats to freshly laundered short-sleeved uniforms, and to determine the rate at which bacterial contamination happens. They reported results in the Journal of Hospital Medicine.

ACP Internist's blog recently took up the debate as well. The issue has cropped up over the years, assessing not only the cleanliness but the professionalism inherent in the white lab coat.

(Click on the "More" link below to continue.)

Researchers conducted a prospective, randomized, controlled trial among 100 residents and hospitalists on an internal medicine service at Denver Health, a university-affiliated public safety-net hospital. Subjects wore a white coat or a laundered, short-sleeved uniform.

At the end of an eight-hour workday, no significant differences were found between the extent of bacterial or MRSA contamination of infrequently washed white coats compared to the laundered uniforms. Sleeve cuffs of white coats were slightly but significantly more contaminated than the pockets or the midsleeves, "but interestingly, we found no difference in colony count from cultures taken from the skin at the wrists of the subjects wearing either garment," researchers wrote.

And, there was no association found between the extent of bacterial or MRSA contamination and the frequency with which white coats were washed or changed. Colony counts of newly laundered uniforms were essentially zero, but after three hours they were nearly 50% of those counted at eight hours.

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Wednesday, February 23, 2011

Life at Grady: Medical jargon

A version of the following post, by Kimberly Manning, FACP, first appeared on her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect individuals' privacy.

Top ten medical jargon-ish terms to use about patients on rounds that (if overheard) will guarantee that they:

a.) have no idea what you are talking about
b.) kick your ass or get someone else from the waiting room to kick your ass
c.) never come to see you again
d.) all of the above

acute: (adj.) a relatively new problem

Doctor: "This really isn't an acute thing at all."

Patient: "Oh yeah? Well, I think you're a-ugly, too."

unremarkable: (adj.) in medical terms, this means completely normal, which is a good thing.

Resident to attending on rounds: "Nothing about her jumped out at me. Everything about her screams unremarkable."

Patient in hospital bed: "Well, you ain't exactly Brad Pitt yo' damn self!"

(Click "more" below to continue reading this post.)

impressive: (adj.) something that's so abnormal on physical exam that it warrants bringing the medical students in to see.

Attending: "I'm pretty sure this meets criteria for micro-penis."

Medical student: "Wow. That's pretty impressive, Dr. Johnson."

Patient (with big smile and raised eyebrows): "Ya think so? I'm so flattered."

S.O.B.: (n) shortness of breath

Resident in the ER speaking to his colleagues while putting his initials next to the complaint listed on the board:

"I think I'll take this S.O.B. right here!"

The patient sitting in a hall spot in the ER speaking into his cell phone as that same resident approaches him:

"I guess I'm stuck with this S.O.B. as my doctor today!"

appreciate: (v.) what you see on physical examination when looking at a patient.

Patient: "But look at my ankle! Can't you see it's swollen?"

Doctor: "I don't appreciate that."

Patient: "Appreciate what?"

Doctor: "Swelling in your ankle."

Patient: "Well it ain't like I twisted it on purpose, you self-centered jerk!"

presentation: (n.) what a person looks like when they arrive at the hospital, or the act of discussing a patient with another physician.

Attending: "What was her presentation like?"

Intern: "It was so impressive. You wouldn't even know she was the same person!"

Patient, in bed: "What presentation? I didn't give no presentation."

Attending: "Just one moment, sir, I'm listening to your doctor's presentation."

Intern: "Yeah, my presentation about your presentation."

Patient: "Say what?"

tachy: (adj.) an abbreviation used to describe someone who is tachycardic, or in other words, that has a fast heart rate. Pronounced "tacky." tachy = fast, cardic = heartrate

Attending (feeling pulse of patient): "You didn't tell me she was so tachy!"

Intern: "I thought I'd mentioned it during my presentation. Yeah, she was super tachy from the moment she arrived."

Patient: "Well it ain't like that comb-over and those pleated poly-blend slacks you have on scream Project Runway, either!"

express: (v.) to get pus out of something.

Attending: "Were you able to express anything from her?"

Intern: "No. We tried but couldn't express anything."

Patient: "Tha's 'cause y'all don't listen to nobody! I can express myself very well!"

marked: (adj.) pronounced mark-ed, describes something substantial or impressive.

Resident: "I think this marked weight gain represents heart failure and fluid retention."

Intern: "Hmm. You may be right. Twenty pounds in two weeks is some pretty marked weight gain."

Patient: "Wow! You think I gained twenty pounds just from trying all those samples when I was in the supermarket?"

chronic: (adj.) something that's been going on for a long time

Intern: "The chronic cough is the main thing I'm concerned about."

Patient: "Aww, damn doc! My ol' lady keep telling me to stop smoking The Chronic so much!"

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Monday, February 21, 2011

Circadian rhythms influence coronary stent thrombosis

Add coronary stent thrombosis to the list of cardiac events influenced by circadian rhythms, with more events occurring during the early morning hours and in a summertime window of late July and early August.

Coronary stent thrombosis joins several other adverse cardiac events that also follow a circadian pattern, such as stroke, unstable angina pectoris, acute myocardial infarction and sudden cardiac death, according to researcher published in JACC: Cardiovascular Interventions.

you've been warned by Robert Couse-Baker via FlickrMost studies that addressed circadian variations in cardiovascular disease were done before the advent of stents, so, researcher from Mayo Clinic-Rochester conducted a retrospective analysis of medical records and the clinic's registry, finding 124 patients who presented with coronary stent thrombosis between February 1995 and August 2009.

(Click on the "More" link below to continue.)

Researchers determined the time of day, day of week, and season of year that the stent thrombosis occurred and recorded when potential triggers were present. In addition, the team categorized each stent thrombosis based on the number of days since the initial stenting procedure: early=0 to 30, late=31 to 360 days, very late=more than 360 days.

The association between the onset of stent thrombosis was lowest at 8 p.m. and highest at 7 a.m. (P=0.006). However, when the team divided the analysis into early, late, and very late stent thrombosis, only the association between early stent thrombosis and time of day remained significant (P=0.030, P=0.537, P=0.096, respectively). Day of week wasn't associated, but stent thrombosis rates peaked between the end of July and the beginning of August (P=0.036)

In search of potential triggers, the team determined physical activity level before the onset of stent thrombosis in 62 patients. Of these patients, 33.9% were sleeping, 25.8% were lying or sitting, 29.0% were engaged in light-to-moderate physical exertion, and 11.3% were engaged in heavy physical exertion. Other medical conditions were also identified as possible triggers among the full 124-patient study sample, including medication noncompliance (5.6%), hospitalization for surgery or invasive diagnostics (4%), and acute infections (4%).

Authors speculated on physiological factors that may contribute to stent thrombosis in the morning hours: hypercoagulability and hypofibrinolysis; a higher activity level of the renin-angiotensin-aldosterone hormone system between 6 a.m. and 8 a.m., which causes higher blood pressure and heart rate; a higher degree of blood viscosity in the morning, which is magnified by sitting upright after a night of supine sleep; and lowered levels of antithrombotic medication in the morning just before the patient awakens and takes a new dose.

The lack of an association between stent thrombosis and the day of the week is unlike other adverse cardiac events that occur more often on Mondays. Researchers believe that that mental stress from employment plays a more limited role in stent thrombosis. A higher rate of stent thrombosis in the summer months, meanwhile, may be attributed to higher activity levels in warm weather.

While stent thrombosis has decreased in recent years because of dual antiplatelet therapy and improved stent design, researchers said further benefits could result from some simple steps, such as optimizing medical treatment during high-risk periods and taking antithrombotic medication in the evening rather than in the morning to prevent lowest levels of medication during the most hazardous hours.

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Un-maligning the ER

As I mentioned in an earlier post, the ER is the portal of entry to our hospitals now, for better and for worse.

On the plus side, this means that most patients being admitted to general medical and surgical services (the big exception here is elective surgery--patients having elective operations don't need to be triaged) have a workup at least started and are triaged appropriately to their destination.

A good ER evaluation should answer the following questions: (Click the "more" link to continue.)
1. What's the nature of the illness? Are we dealing with the heart, the brain, or an abdominal organ? Is the cause an infection, a blockage, or a blood clot?
2. Based on #1, where will the patient best be situated? Will the patient need intensive care, or will the "regular" floor be sufficient to attend to the issues at hand? Should the patient be admitted to a surgical team or a medical (non-surgical) team? Depending on the hospital, does the patient get admitted to a teaching service (where residents perform the care under the supervision of attending [fully trained] doctors) or a non-teaching service? Should the patient be on a specialty service (e.g. cardiology, GI, or oncology), with a hospitalist (a trained internist who mostly sees only hospitalized patients) or a generalist (an internist or family physician who sees hospitalized patients as part of the spectrum of services they provide).

Even with these two straightforward questions, the decision-making can become fairly complex, given all of the available options.

And in teaching hospitals, an extra layer of complexity is added as doctors from different services sometimes fight not to admit the patient to their roster of patients.

Contesting an admission might occur with good intentions, but one thing is for certain: it delays getting the patient out of the ER and up to a hospital ward, which compounds the problem of ER backup and overcrowding.

Monday morning quarterbacking occurs in hospitals on a daily basis. "If this patient had been admitted to the Intensive Care Unit (ICU) in the first place, a lot of these mishaps could have been avoided," is a frequent refrain heard the morning after a very sick patient has been admitted.

In teaching hospitals, admitting and triage decisions take longer, since the resident doctors, both in the ER and the ones working on the hospital floors are learning the skills of triage. There's a subtle (and not-so-subtle) dance that goes on to choose the service and the location. Most of the time it's very straightforward. The few times that it's not can lead to major worry on the part of everyone.

Patients admitted to general medical services from the ER usually come in two varieties:
1. Completely undifferentiated illness, with a first time presentation. For example: new onset shortness of breath. There are myriad possibilities, and a deft ER will help sort our which are most likely.
2. An acute exacerbation (heightening) of a chronic medical condition. Of the two presentations, this is the far more common. In an aging population with a preponderance of chronic illness (diabetes, hypertension, survivable cancers, strokes, and cardiac conditions), patients can have a perturbation of their bodily balance (e.g. a salty food binge) that can result in acute on top of chronic illness.

We've moved away from the direct admission. This occurs when a doctor evaluates a patient in the office, and determines that there's a variety #2 going on--an acute flare of a chronic condition.

Such a patient does not likely need an extensive workup to determine the nature of the illness, since it's long ago been defined. The patient requires a titration of medication in a supervised fashion (many of these medicines alter the body chemistry, and can upset the heart or kidneys) to alter the physiology back toward balance, and then the patient can be discharged.

Yet since we've become so reliant on the ER to triage everyone, we've fallen into a predictable pattern of sending all patients destined for admission to the ER.

"Let the ER sort it out," is the oft-thought, rarely-spoken mantra of a busy office physician.

Is it any wonder the ER is so crowded when on top of having people use the ER as a medical home, we have doctors shunting patients through the ER as a portal of entry?

The hospital's admitting office does not want to receive and then admit patients who might be "unstable." At the hospital at which I work, if a patient even has an IV placed (customary for a patient admitted to a general medical service) they are deemed too "unstable" to wait in the admitting area.

Something has to give.

It would be nice for patients if they could be admitted to their hospital bed as quickly as possible. The patient is relatively powerless to decide how they get into the hospital.

There's a real opportunity for the place that figures out how to transition people who are sick from the outside world to the inside-hospital world in a more seamless fashion.

In a world of medical consumerism, that'd be something to boast about.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, 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 that inhabit them.

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Friday, February 18, 2011

Locum tenens hiring on the rise

The use of temporary physicians is rising, filling until permanent physicians can be hired amid the ongoing shortage of doctors nationwide, a locum tenens firm has found. The company estimates between 30,000 and 40,000 physicians worked on a locum tenens basis in 2010.

The survey, by Staff Care, polled hospital and medical group managers about their use of locum tenens. 85% said their facilities had used temporary physicians sometime in 2010, up from 72% in 2009.

Psychiatrists and other behavioral health specialists were the most sought-after specialty (22% of all requests), followed by primary care physicians, defined as family physicians, general internists and pediatricians (20%) and internal medicine subspecialists (12%). Hospitalists were 9%.

According to the survey, the primary reason cited by 63% of health care facilities was to fill a position until a permanent physician could be found. 46% percent of health care facilities now use locum tenens physicians to fill in for physicians who have left the area, compared to 22% in 2009. 14% use locum tenens doctors to either help meet rising patient demand for medical services or to fill in during peak times, such as flu season. 53% use locum tenens physicians to fill in for physicians who are on vacation, ill or for other absences.

Most locum tenens physicians plan to stick with temporary practice in the short-term, the company noted. 60% said they plan to practice on a locum tenens basis for more than three years, 28% for one to three years and 12% for less than a year.

Freedom trumps pay, the company noted, as 82% cited flexibility as a benefit, compared to 16% who identified pay as a benefit. Other reasons cited for working as a locum tenens include absence of medical politics (48%), travel (44%), professional development (21%) and searching for permanent practice (20%).

The locum tenens option is important to maintaining physician supply, the company concluded, because during a time of physician shortages it allows doctors who might be considering full retirement to remain active in medicine.

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Wednesday, February 16, 2011

Life at Grady: 10 Ways You Know the Nurses Hate You

A version of the following post, by Kimberly Manning, FACP, first appeared on her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect individuals' privacy.

Ten ways you know the nurses hate you:

Way #10
They scowl and answer every single one of your questions with "Wh-aaaat?"

Way #9
They don't save you when you're getting ready to majorly screw up in front of the attending (unless, of course, it involves a patient's safety.) And if they really hate you, they ask a question on rounds in front of the attending that they know 100% for sure you don't have the foggiest notion how to answer.

Way #8
They page you every hour, on the hour, between midnight and six a.m.

Way #7
They don't offer you any of their food. (The nurses always have the best food--especially the ICU nurses!)

Way #6
They approach the attending or the fellow with all of their questions or suggestions instead of talking to you.

Way #5
They approach the medical student with all of their questions and suggestions instead of talking to you.

Way #4
They start off all conversations with you by saying the words, "Look, I'm not sure if you realize it, but. . . "

Way #3
The nurses' lounge gets quiet every time you enter.

Way #2
The nurse stands there staring at you for thirty seconds after everything you say, kind of like you're stupid.

And . . .drum roll please. . . . the yop way to know for sure that the nurses hate you:

Way #1
They tell you.

A pearl of wisdom from a doctor who has made good with the nurses:

Love thy nurses. Why? Because NURSE = butt-saver, hands-on-deck, extra-brain, person-who-remembers-next-step-in-a-code, shoulder-to-cry-on, cheerer-upper, differential-diagnosis-suggester, back-into-reality-smacker, teammate-extraordinaire, knower-of-fine-details, wind-beneath-tired-wing, wingman-or-wingwoman, explainer-of-drips-that-you-are-clueless-about, teacher, and best of all, friend.

So here's to all the nurses...and to those of us who work with them. May they always share their food with you and never hate your guts!

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Thursday, February 10, 2011

Should physicians wear white coats?

[Editor's Note: This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College.]

A while back, a first-year med student asked me if I think physicians should wear white coats. There's a debate about it, she mentioned. Indeed, in the spring of 2009 the AMA considered an unenforceable mandate that physicians in the U.S. not wear white coats. The news was getting around that doctors spread infection from one patient to the next by our garments.

My thoughts on this have always been clear. "Yes," I answered. "But they've got to be clean white coats."

(Click "more" below to continue reading this post.)

This week I came upon two stories that led me to pick up the thread on the white coat debate. First, a recent post from the Singing Pen of Doctor Jen, by Jennifer Middleton MD, MPH, who writes from western Pennsylvania: "We physicians might make assumptions about what patients want us to look like, but what does the evidence say? A cross-sectional survey in Tennessee a few years ago found that patients prefer family physicians who wear white coats. Another study in a South Carolina internal medicine office found that patients "overwhelmingly" preferred physicians in white coats. A Northeast Ohio OB residency found similarly; patients preferred a white coat and professional dress to scrubs. A quick PubMed search pulls up the same theme over and over: The patients studied have more trust in, and comfort with, physicians who wear white coats."

Today in the New York Times, a piece by Sandeep Jahuar, MD alludes to the issue by its title: Out of Camelot, Knights in White Coats Lose Way. He considers disillusionment of many doctors with medicine as a profession. He writes: "Physicians used to be the pillars of any community. If you were smart and sincere and ambitious, the top of your class, there was nothing nobler you could aspire to become. Doctors possessed special knowledge. They were caring and smart, the best kind of people you could know. Today, medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future."

As a doctor, I think physicians should wear white coats for several reasons. First, the white coat reminds the wearer that medicine is a special kind of profession, that doctors have extraordinary obligations to patients. Second, the white coat recalls medicine's basis in science, from which we wouldn't want to stray too far. Third, it's to protect ourselves: going home to dinner with your family, loaded with hospital germs, is just not smart.

As a patient, I like it when my doctors where a white coat. It's reassuring in a primitive kind of way; it makes me feel like the physician is a real doctor who is capable of taking care of me. But the coat should be clean--every day a fresh one, with extra changes if needed.

Of course there are some circumstances when the white coat is appropriately relegated elsewhere: in places like the OR, in most psychiatrists' offices and in pediatrics, so as not to scare the children, I once learned although I'm not convinced it would.

It takes a certain effort for a doctor to put on a white coat. When I used to get called back in late at night, or after weekend rounds, I'd occasionally just go straight to the patient's ward or ER, without stopping by the room where my coat was kept. That was easier, sure, but when I skipped the white coat I felt as if I weren't fulfilling my part of the deal: to look and act like a doctor should.

Patients need that, usually. And maybe that's a hang-up, a superficial wanting, a simple reassurance of authority. But maybe it's also a sign that you're serious in your duties as a physician, that you're not cutting corners, that you will do everything you can to fulfill your obligation to the persons under your care, that you know who you are as the doctor.

Maybe, when younger doctors elect not to wear the white coats, for whatever legitimate reasons, or out of laziness in finding a clean one, it's really that they don't want the responsibility the coat conveys.

It could also be that they're just hot, or uncomfortable.

I'll leave this open, at that.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She 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.

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Wednesday, February 9, 2011

A hospitalist rap song by ZDoggMD

Thanks to The Entrepreuneurial MD for posting this riff off of Jay-Z's "Hard Knock Life" (which, of course, is a riff off the song from the musical "Annie"). The rapper is Zubin Damania, MD--otherwise known as ZDoggMD. He has his own blog, too. Please note there is some mild "adult language" in this video (and in the lyrics, posted below).

And here are the lyrics:

It’s the Hard Doc’s Life for us
Hospital Doc’s Life for us
Specialists, they got it made
We do the work while they get paid
It’s the Hard Doc’s Life
From standing on the unit roundin’
To learning some of the thickest charts a doc has ever seen
and hearing some of the sickest hearts a doc has ever heard
Do the weekend, working nights and, all the shifts between
You know me well from Pull & Pray and the Ulcer Rap
Still I take crap from insurance and the housestaff
Eff that

To PCPs treatin’ sick folks
Mad props
While the consultant’s tellin’ d*** jokes
That flop

I fill out paperwork all day long
No doubt
Then nurses tell me that I did it wrong
White out

See 20 patients but get paid squat, uh uh
The radiologist just bought a yacht, what the?!?
Nurses be laughin’ at the ties I bought
Shop frugally and save money at Marshalls and Ross
They call a code when I come thru
Just don’t be asking me to run it, man, I got notes to do.

It’s the Hard Doc’s Life for us
Orthopods consulting us
See their train wrecks every day
They fix the bone then walk away
It’s the Hard Doc’s Life

I flow for those gomed out; sundowning
Locked down in the Posey vest, just tryin’ to bust out
I roll with old folks, got no veins for IV pokes
Septic and found down, in stool, a Code Brown
Yellow gown itchin’, deep in debt from med school tuition
C diff, MRSA, up in my kitchen?!?

Intern’s bitchin’ bout work hours, he’s checkin’ the clock
But I’mma be on call whether I’m on call or not
We went from lukewarm to hot; fillin’ the hospitals with docs
Who practice evidence-based logic like Spock
Straight talk from my homies who work in the ED
Mad luv, ‘less you’re calling ’bout another syncope
I disagree with the phony UM docs, mess with my homies
I’m like still, y’all don’t control me, s***
I like to bill, but when my patient census ain’t improving
I’m tryin’ to dispo everything moving
It’s the Hard Doc’s Life for us
Too many patients for each of us
Try to discharge, make ‘em pack
Overdo it, they bounce back
It’s the Hard Doc’s Life for us
Hospital Doc’s Life for us
Hardest job we’ll ever do
Next to cleanin’ baby poo
It’s the Hard Doc’s Life

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ACP bloggers up for weblog awards

Readers of the ACP blogs may recognize two frequent contributors and Fellows of the American College of Physicians, Toni Brayer, MD, and Kim Manning, MD. Both are finalists in the Seventh Annual Medical Weblog Awards conducted by MedGadget. If you've enjoyed either columnist and their posts on ACP's blogs, please take the time to vote for them.

Kimberly Manning, FACP, posts content from her blog Reflections of a Grady Doctor, at ACP Hospitalist. She's entered in the Best Literary Medical Weblog category. Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century. She's entered in the Best Health Policies/Ethics Weblog category.

Voting will close at 23:59:59 on Sunday, February 13.

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Life at Grady: The "Chief Thing"

A version of the following post, by Kimberly Manning, FACP, first appeared on her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect individuals' privacy.

It starts with someone tapping you on the shoulder and looking from side to side during your second year of residency. "Pssst!" they say. "I need to talk to you in confidence."

Immediately you start wondering: a.) Did I kill somebody? b.) Was I supervising somebody who killed somebody? c.) Am I behind on my dictations? d.) Did somebody find out that the program coordinator accidentally gave me three extra meal tickets to the cafeteria?

You follow the person (usually the program director or chairman) down the hall. The same way people follow those handbag salesdudes down some murky corridor in New York City, only to get horribly disappointed by the "totally authentic" Chanel bag that you keep explaining to the salesdude isn't "totally authentic" since Chanel starts with a 'C' and not an 'S' and has only one 'N'.

But instead of getting tortured with scary pleather handbags and polyester scarves, you sit in silence across from the biggest wig you know, wondering what the hell landed you there. First they smile at you, kind of warm and goofy like. Then they make small talk about your rotation which you try to pretend doesn't suck even if it does. Next comes some ramblings about all of the times you managed not to be an assassin and (hush yo' mouth!) actually do something that resembled a good job. And finally they're out with it:

"How would you feel about spending an extra year with us as chief resident?"

(Click "more" below to continue reading this post.)


Okay. Maybe you think you are halfway decent, but I'm telling you. No matter how rad you are as a resident, your second year is absolutely the point where you feel the most inadequate. Something about that transition from being the intern data-miner to actually having to know what the hell is going on is terrifying. And marks the climax of your fear of being an assassin.

I always say:

"Being an intern is the best possible role. If you do well, you're awesome! If you screw up, you're just an intern. But being a resident? Now that's tough. You nail the diagnosis? You were expected to, so no confetti gets thrown. You miss the diagnosis? You suck."

So somewhere in the midst of that, someone representing the powers-that-be says, "Not only do you not suck, we actually trust you enough to pay you to teach others." And most times, unless your personal life prohibits you from doing so, you are so caught off guard/flattered/gobsmacked that you say, "Yes." Yes to the mess.

Interns and medical students:
"All hail The Chief!"

Residents and faculty members:
"Awww, hell! The Chief!"

(Damn. That was kinda witty, if I do say so myself.)

Anyway, where was I? I'd say the first tricky part is taking boards while serving as the golden boy or girl of your residency program. Let me explain.

You have been selected amongst a slew of others as one of the best the program has to offer. Your embroidered coat screams to all of the new interns during orientation that yes, you are kind of a big deal.


You just finished your residency. And people who finish residencies need to take board examinations to render themselves sho' nuff and bona fide. For folks in internal medicine, that big ol' exam comes in August. Right at the start of your reign as the chief of the whole nest.

Sure, you were picked to be chief so you're smart. Of course. And just maybe (if you are scary smart) you don't even bat a lash at this.

But if you are like me, surely it crossed your mind that you would be the first chief in all of chiefdom history to be branded with a scarlet letter 'F' at the start of your year as "it girl" or "it boy"--forever known as the "suspect chief." I recall breaking out in a cold sweat over that horrid thought. And what's worse is that I did combined training in IM and Pediatrics--doubling my anxiety. Medicine boards in August, Peds board in October. A heinous little combination, I tell you.

But Hallelujah, I lived to tell--and to become certified.


The parts that I loved were predictable. Teaching the residents and medical students. Serving as a liaison between the faculty and the house staff. Running morning reports and conferences. Coming up with innovative ideas. That part rocked.

There were also the stinky parts that I saw coming. Like making schedules before the invention of the Excel spreadsheet or shmancy programs. Or listening to people whine about this and that and that and this. And calling folks in for jeopardy calls on Saturdays. That part stunk. But every chief sees that coming.

But then there's this one part that I can only describe as...indescribable. This unpredictable weird thing I would guess has affected many a chief, but certainly stands out as memorable to me...

It was discovering that the faculty members to whom I most looked up were...gasp!...mere mortals.

Some imperfect.
Others, weak leaders.
At times, not so noble in their professional interactions.
Shockingly less than helpful.
And a few, just downright disappointing.

I hated seeing peoples' clay feet. I loved my little Pollyanna world during residency...the one where several attendings and administration leaders walked on water. In chief residency, you're in this wonky time warp between little guy and big guy. It's like suddenly being moved from the kiddie table during Thanksgiving to the grown-up table, where you discover that Aunt Clara actually drinks too much or Great Uncle Mike swears like a sailor and tells racist jokes. I often found myself longing for the blissful view from the kiddie table...where "grown-ups" are awesome and make only sound decisions worth emulating.

Fortunately, the flip of that is discovering all of the amazing folks that you may have overlooked during residency. That quiet junior faculty member who is actually quite kick-ass, that tireless program coordinator that helps you put out the worst of fires, that short list of residents who always, always take one for the team without so much as a hint of complaining, that standoffish attending that seemed mean but is totally approachable, and that less-than-popular faculty member that you later learn is your strongest advocate and sounding board. Now that part? That part is pretty cool.

It's a year that's chock full of learning. And since only a tiny number of folks in training programs get the chance to do's definitely a road less traveled.

Of it all, the best thing I gained was perspective on my future. During my chief year, I slowed down and looked around. Instead of making a rushed decision at the divergence in the woods, your chief year forces you down several paths for a little while, at least, and that's majorly advantageous. On Monday, you might have to be a cardiologist, on Tuesday, a pulmonologist, and by Friday, an infectious disease maestro--all the while, constantly wearing your Dr. Phil hat in the event of an unforeseen meltdown.

I paid attention to people and situations and my reactions to them all. And in that year, I had a ginormous ah-hah moment. All along, I though that I would work in an office somewhere seeing a combination of adults and children while welcoming residents and students to occasionally join me. I saw a practice with mostly insured people like my folks and their families, and I imagined myself happy and fulfilled and everything else you can think of, too.

That is, until I became chief resident.

That year, I recall standing at the board each morning at 8:30 A.M. for Pediatrics morning report. The post-call teams would present patients, and we would teach straight from the hip. Bam! Turns out that all that frantic studying for boards paid off. It was exhilarating. I attended on the wards, and felt drunk with teaching excitement. Rounding the way I had always wanted to round and finally discovering my own voice as a teacher. On those months, I connected with patients, but especially the indigent ones. I would go home thinking about them and hoping they were okay. Remembering how their faces would light up when our team would come to see them and collectively envelope them in the kind of respect and empathy that had become a rarity in their lives. That's when I knew.

I knew for sure that I wanted--no, I needed--to teach. I mean teach-teach. Not just sometimes or once per week, but all the time. And not only did I need to teach, I needed to get to a sho' nuff and bona fide public hospital to do it. I felt drawn to the least of these. That year helped me to discover that I wanted a job that would never feel like one and that could somehow also feel a little like a ministry. Instead of sending people away because they failed a wallet biopsy, I wanted the folks who consistently shook me to my core, taught me the most, and touched me the most.

Did this job even exist? My chief year gave me time to realize that indeed it did.

That job meant going to a public hospital. If you know anything about public hospitals, there aren't a lot on the list. They are in Atlanta, New York, Miami, New Orleans, Chicago...and only a few more places. Interestingly, as a Med/Peds trained physician, I didn't care if I was teaching learners in the adult or pediatric setting. I just knew the environment I was looking for, and that part wasn't negotiable. Lucky for me, Grady was my only job interview that year, and the one that I continue to say "yes" to every single day. I definitely have my chief year to thank for that.

Final thoughts about chief residency:

•You find great lessons about leadership there. Even if they hurt sometimes.
•The best way to become one is to do a great job.
•Campaigning to be chief resident generally guarantees you won't be.
•The year is exactly what you make of it.
•It is an outstanding year of discovery.
•Best of all? The chief year is a great time to linger before choosing a path along the yellow wood.
•It can make all the difference. It sure did for me.

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Friday, February 4, 2011

Five things to help good doctors stay good as they grow older

I asked my age-matched colleague the other day: "Do you think we'll know when it happens to us?" He responded: "I know. I worry about that, too … a lot. I'm getting out before it happens to me."

We were talking about our fears of being labeled as an "old" doctor. Not just old in years--our children and bifocals remind of us of that--but old in our mindset. We fear becoming one of the dinosaur doctors who get known for their excessive attachment to old dogma, premature dismissiveness of novel new approaches, fear of social media, and of course the tell-tail (pathognomonic) sign of agedness, ranting mindlessly in front of Fox news about health care reform in the doctor's lounge.

This transition can happen fast. One moment a doctor might be in their sweet spot, period of time where the nearness of training meets with the treasure of experience in a capable mind, body and spirit. Sadly, and obviously this period is finite. It's limited by aging. Getting older happens to all of us, but the pertinent fact for medical practice is that, like all humans, doctors age at different velocities.

(Click on the "More" link to continue reading the post.)

The topic of how best to deal with aging doctors came up after this provocative piece in the New York Times highlighted a couple egregious cases of bad care at the hands of doctors who should have been retired. Kevin Pho's follow-up piece emphasized the relevance of this topic when he suggested that more than one in three U.S. doctors are over 65 years old, and that unlike pilots they are "grandfathered" into not being required to take re-certification exams. That policy is hard to defend.

Since I'm writing this post with the aid of reading glasses, how to handle aging doctors hits me pretty hard. It's a quandary. For instance, I know a cardiologist in his early sixties who behaves like a chief resident--quoting journal articles, presenting interesting cases and even voluntarily re-certifying (he was grandfathered). Here's a doctor with both 25 years experience and knowledge of the cutting edge. The quality of his doctoring speaks loudly against any arbitrary age cutoffs. But then there are the outrageous cases cited in the Times piece.

I'd like to think there's a way to extend the sweet spot of doctoring. Perhaps the answer is obvious: The same things that make healthy people healthy might make good doctors stay good longer. Things like:
1. Staying physically fit. Sleeping well, eating well, and exercising regularly have all been shown to improve mentation and dexterity. Quick thinking and nimbleness both make for better electrophysiologists.

2. Staying mentally engaged. I feel like a better doctor after returning from a medical meeting. Likewise, I certainly feel more informed after researching a journal article for a blog entry. (Immediate disclaimer: I am not saying bloggers make better doctors. Some might argue the opposite.)

3. Staying emotionally engaged. In other words, caring. Healthy people seem to have a cause that's important to their self-esteem. The best doctors I know hang a lot of their self-esteem on their doctoring peg. But not too much--no peg is that strong.

4. Staying balanced. Healthy people exude balance. They may focus on one thing primarily, but keep other interests, too, things like spending time with family, reading fiction, watching movies, riding a bike or volunteering their time.

5. Staying open-minded. This doesn't come naturally to aging doctors. (First off, they are mostly Republican.) Sure, much of what worked in the past stays timeless, but not always. For instance, if I wasn't open-minded, three of my afternoon patients may still have atrial fibrillation symptoms, and a few more would still be taking a drug that poisons rodents.

Let the quality people try and measure these five traits with checklists and spreadsheets.

This post by John Mandrola, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Thursday, February 3, 2011

The eroding 'doctor' label

It came as a Twitter "follow" from @coldfeet65, a self-proclaimed "Nurse Practitioner Hospitalist." I had never heard this term before. Does it mean a nurse practitioner who cares for hospitalists? Or is it a hospitalist who is a nurse practitioner? Or maybe it's a nurse practitioner who helps hospitalists? (Honestly, I think I know which one she means, but you get my point.)

Perhaps this is a prescient glimpse to health care of the future, where our more typical nurse and doctor labels are supplanted by more and more monikers that serve to confuse, rather than clarify, each of our roles in health care delivery. As specialists in cardiology, we've seen a similar trend with cardiology hospitalists. But we should be clear what this means to the patients and doctors going forward.

(Click "more" below to continue reading this post.)

No doubt most people in America still expect to see a doctor when they come to the hospital. Increasingly, it appears that might not be the case. Your doctor might be a robot while a nurse (aka, nurse practitioner) will be the one providing the hands-on care in the inpatient setting. Is that a good thing? Honestly, I'm not sure.

No one argues that the costs in health care need to be cut. No doubt the central authority has deemed that doctor salaries will be a big part of that effort. Already, 20 states have cut physician Medicaid payments for fiscal year 2010 and, given the current economic pressure on our states both now and after they start feeling the financial impact of the "Affordable" Care Act in 2019, this trend is not likely to improve anytime soon. As a result, we are seeing that the world is full of "creative solutions" to our health care access crisis and the evolution to "nurse practitioner hospitalists" might be one of these.

But what are doctors of medicine becoming as a result? Are our current cohort of primary care doctors becoming little more than nurse managers and fact checkers of mandated protocols, treatment guidelines, and care directives? Hopefully not.

But increasingly it appears that those without a hands-on, invasive skills in medicine (like surgery) are being marginalized in the health care models going forward. This trend now appears to even be affecting the much-heralded inpatient hospitalist care model as the doctor shortage intensifies. Consequently, the image of "doctor" as we knew it is changing, not only for what patients can expect to encounter when they come to a hospital, but for the type (and caliber) of the doctor we attract to our profession going forward.

-WesMusings of a cardiologist and cardiac electrophysiologist.

This post by Wes Fisher, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Wednesday, February 2, 2011

Life at Grady: Payback

A version of the following post, by Kimberly Manning, FACP, first appeared on her blog Reflections of a Grady Doctor. Names and identifying information have been changed to protect individuals' privacy.

Sometimes, despite my Pollyanna exterior, I just don't feel like doing all the things people ask of me. I open emails and see requests for all kinds of things and check messages that query if I can be here or be there, and most times, it's cool. But sometimes, I just want to growl.

Sometimes, it gets to be a lot. A whole lot.

On those days, I just want to run out of my front door screaming, "No!" (Or to set my email with an out-of-office reply that simply says, "No." And nothing else.)

That's why I love working at Grady Hospital so much. Every time I feel this way, something happens to right my thinking and put me back on track. To snap me out of my doldrums and give my soul a charge. To remind me of how much greater all of this is than me. In that way that only Grady can.

This was one of those times.

(Click "more" below to continue reading this post.)

In the Grady clinic:

"Okay, Mr. Felton. Let's just recap all of this. You have the appointment to get your echocardiogram, the appointment with the cardiologist, and then depending upon what they say, we'll know what the game plan is for you getting the defibrillator put in."

This is what my excellent resident, Maggie, said to one of our Grady elders the other day in the clinic. We had come back to the room after their initial encounter where, after having me repeat a few key points of the physical exam and history, we were now wrapping up the complicated visit with Mr. Felton and his heart failure.

"Alright," said Mr. Felton with a smile. Even thought we'd welcomed him to sit back in the chair, he remained perched on top of the examining table like a regal hawk. His eyes were focused on Maggie's mouth as she spoke, almost as if he was reading her lips. I stood near the door taking it all in.

Mr. Felton had been feeling more and more short of breath. We already knew that his heart was very weak from his remote use of alcohol. Heavy drinking is one of the most common causes we see of dilated hearts that don't pump right. Mr. Felton fell into that category, and it seemed that the hollow pump in his chest was trying harder and harder to poop out on him.

"Mr. Felton, you are such a wonderful patient. You get an A+ for always following the directions we give you," Maggie affirmed. They locked eyes and smiled. "Now tell me, sir. What questions do you have for me?"

Mr. Felton zipped his coat and placed his weathered cap on his head. "I reckon I'm alright," he replied.

I finally chimed in. "Sir?"


"Your doctor was telling me that you didn't make it to these appointments when we referred you a couple of months ago. How do you get to your appointments? Do you rely on Grady transportation?"

"No, ma'am. My daughter, she brang me to all my 'perntments."

"Oh...okay." I paused for a moment. "Does she live with you, sir?"

"No'm. But she do see about me every day. She was gone out of town for a few days and she normally see about my mail. It backed up some, and I thank she didn't see the 'perntments."

I loved his pronunciation of the word "appointment." It was so Grady elder of him.

Maggie, being the intuitive resident she is and a person who has worked with her very predictable attending for the last two years, saw where I was going with all of this. "Mr. Felton? Sir, I'm not sure I've ever asked you this. How far in school did you go?"

"I went to 'bout seven. I mean grade seven."

She looked at me quickly and then back at him. "Sir, are to read?"

"Yeah ma'am. I do alright."

Maggie caught my eyes again, searching me for suggestions. I thought for a few moments and decided to explore this further.

"Mr. Felton? We were just thinking about how much stuff we asked you to do today. It sounds like the appointments and directions can be pretty confusing. How comfortable would you say that you are with reading the things we send you or better yet your mail in general?"

"You know what? Tha's a good way to put it. I can read. But I ain't too comfortable with it at all." He chuckled.

"I hear you, sir," I said with a big smile. "There's a lot of things that I can do, but I'm not too comfortable with." Mr. Felton seemed to like this, so I went on. "Like...I can mow the lawn in my front yard. But I'm not exactly comfortable doing it, and would be happy to let somebody else step in and do it for me."

We all laughed.

"I know tha's right!" Mr. Felton cosigned. He seemed tickled at the image of me charging around my grass with a roaring lawn mower.

"Mr. Felton, sir," I continued, "maybe we can work harder to make sure the directions we give are such that you can do them even when your daughter is out of town. That sound okay?"


Maggie went into the computer, and began to do just that.

"The echocardiogram--" she stopped mid-sentence and corrected herself. "--the ultrasound of your heart that tells us how strong your heart pumps--that's going to be on the second floor on Tuesday. One o' clock. You see the heart doctors or what we call the cardiologists at three o'clock on the same day."

I felt proud of Maggie. We had discussed health literacy numerous times, and the importance of taking a "universal precaution" approach to all of our patient communication by always using straightforward language and confirming understanding. Admittedly, this part of the encounter was not unusual. Many of our patients have limited literacy, and we know for sure that this can sure make it rough to navigate your health care.

Maggie diligently wrote the times onto a sheet of paper.

"Give this to your daughter,okay?" Maggie added a few more words and handed it over to him. Mr. Felton took the paper and held it back from his eyes.


I studied his long, leathery, espresso-colored fingers as they trembled while holding the 8 x 11 scrawled with Maggie's words. Then, I thought about what had just happened. He had just read the instructions--aloud.

Here's the thing: Mr. Felton was two beats away from his ninth decade and had only reached seventh grade. I was surprised at how well he could read, even if he wasn't always comfortable doing it. I immediately wanted to know more of his story.

"Mr. Felton? Did you learn to read when you were a child?" I asked.

"Nawww. I didn't even start school 'til I was round eight years old," he quickly responded. We listened in silence as he went on. "I remember that first day--shoot--that teacher put five words up on that chalk board and I didn't know what it was!" He shook his head. "Back then, they didn't always make sure you could read. And if you missed school to work, nobody came looking for you, you know?"

"Wow," I said. I hung on his every word, nudging him to continue.

"See, I'm from the country. When you come of age, they needed you in the field or if'n you was a girl, to see about the other chil'ren. School wasn't no guarantee."

As my husband says, this was "real talk."

I imagined Mr. Felton as a young tween, waking up one day and learning that his school days were up. Exchanging his knapsack for a basket and a hoe to plow the field. Just like that. Whether he liked it or not. I felt an intense wave of gratitude for the evolution of the times. For some reason, the moment moved me in a way that caught me off guard. I found myself coaching away the tears that were gathering in the corners of my eyes.

Maggie spoke up. "So, then, when did you learn to read, Mr. Felton? That was awesome the way you read that to us."

"My daughter," he responded with a proud smile. "My daughter. When she was just a little thang, she taught me how to read. She showed me how to string all them sounds together to make words. And you know she wasn't even more than nine or so when she did. She would go to school and then come home and want me to play school with her." He laughed at the memory. "She liked to be the teacher. And she still steady bossin' her Daddy around."

This punched me in the chest and brought even more tears forward.

Your daughter? Taught you to read when she was a fourth grader?

I couldn't take it. I was officially on the tippy-tip edge of crying and knew that if I didn't get out of there, I would blow.

Mr. Felton smiled and shook his head. "Seem like every generation get a little more chances. Here you are a doctor, teaching me about my heart." He looked me in my glassy eyes, warm and genuine. The tears pushed out onto my lashes as I drew in a deep breath.

Despite being on the tippy-tip edge of crying, I reached out and grabbed his hand. I had to. I needed him to know how thankful I was, and how true his words were. I wanted him to know that I was touching and agreeing with him, and part of me wanted to be infused with his spirit and his history.

There goes another punch to my chest. I had to get out of there.

I abruptly stepped away and put my hand on the door. "Okay, Mr. Felton, let me leave. You're going to make me cry."

"Aww, now don't do that, Miss Manning," he said with a chuckle. Maggie watched me carefully, knowing that I was serious. I turned my back before he'd know I was serious, too.

I indeed excused myself from the room and waited for a moment outside the door. I allowed myself a few seconds to process that exchange. I patted the corners of my eyes, and took a deep breath.

I regrouped and headed down the hall to see more patients.


This morning, I am reflecting on the evolution of time and opportunities, and all that it has afforded so many people like me. I am reminding myself of why I have been charged to do all that I have to do, and I am coaching myself to do as much as I can to live up to why I am here. It's so much bigger than me.

I am picturing my father sitting across from his high school counselor in a 1961 Birmingham, Alabama office, hearing that counselor say to my 17-year-old father in the clearest way ever, "Don't major in biology or try to go to medical school because you won't get in. Go study engineering."

And him saying, "But I'm not very good at math."

And him replying, "Well, that's what you need to study if you want to get a job and not waste your time."

I'm seeing myself as a ninth grader, working on a science project with my dad, the reluctant engineer, who meticulously helped me with every detail. And me telling him that I wanted to be a doctor some day, and him telling me that I will be a doctor some day. For sure.

Then I'm thinking of all of the love that had to go into Mr. Felton raising a daughter who would not only teach her father how to read, but some sixty years later, accompany him to every doctor's appointment-- and "see about him" every single day. I recognize it as the same kind of love that went into getting me to this very moment in time where I, a young woman of color who became exactly what my childhood dreams imagined, sat across from him, an older man whose dreams were limited by ceilings made of not just glass but his doctor. The doctor my father wanted to be, but was advised that he could never become.


I caught a glimpse of Mr. Felton's daughter holding the door for him along with a bag, his umbrella, and most importantly, his hand on their way out.

I look down at my stiff white coat, the stethoscope folded neatly in its pocket, and all it represents. I feel renewed, recharged and indebted to those who wished they could wake up to all of the things that I don't always "feel like" doing.

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Tuesday, February 1, 2011

Carrots and sticks

Depending on your viewpoint (and the pertinent issue), government regulation either snarls the wheels of commerce and chokes American competitiveness OR enables us to live productive, happy, equitable and safe lives. [As Oprah says, "Live your best life ..."]

Medicine is full of regulations. For the most part, this is good. Certification and licensure of doctors means that there's an explicit level of vetting and trust that a patient can bring to any encounter. Agencies like the FDA test and certify the safety of medications and devices for the public's good. Controversy abounds in its decisions, but for the most part the agency is looking out for us.

Which brings me to medical records. For hundreds of years, medical records were inscribed on paper, and locked away inside health care institutions and doctors' offices. With the advent of computers, it made sense to keep these records electronically. For one thing, this saves paper and space. And now your doctor's crappy handwriting is less of an issue--for you, the insurance company, or the pharmacist.

In theory, the computers (servers, really) housing electronic medical records could be connected for purposes of data sharing (epidemiology) and research. Moreover, if you are enabled to view your own records and lab results online, you (well, let's say the average patient) might be more inclined to take initiative with regard to your own health. Such opportunities would make the doctor-patient relationship much more of a two way street.

Whose information is it really, anyway? Does it belong to you or your doctor (or your HMO or medical home or "provider" or whatever you want to call it)?

The feds in their role as regulators-in-chief and encouragers of best practices passed something called the HITECH Act, as part of the 2009 stimulus package ("ARRA"). The idea is simple: entice medical practices into going electronic by subsidizing the cost. Practices that "meaningfully use" electronic records can get up to $44,000 in payments. Sounds like a good deal, right?

Anything is certainly better than nothing.

Here's the rub: How is meaningful use defined? The government has issued its first stage of criteria in this regard, with stages 2 and 3 expected in 2013 and 2015, respectively. The rules make some intuitive sense: What good is computerizing medical records if you can't collect and measure basic data to show that you're providing quality health care? Also, if computers simply become just large cul-de-sacs of information that don't communicate or allow data retrieval/submission, then what will implementation have really accomplished?

Okay; so far, so good.

Up until now, the vast majority of doctors have stayed on the sidelines, perhaps awaiting these incentives. Most were probably taking the "No, I insist, you go first!" approach. Why would a doctor or practice invest in the major costs of hardware, software, maintenance, and security not knowing if a product would be adaptable for future use and/or meet the government's performance criteria?

Now comes the big news: According to the most recent national data, more than half of office-based doctors have now adopted electronic medical records! The carrots (or at least the promise of future carrots) seem to be working!

And though we like to gripe about regulations, these new ones regarding electronic medical records level the playing field to a certain extent.

What's most impressed me, however, is how amidst the maelstrom of change the regulations have unleashed, new market players have sprung up to fill the void. Take as a prime example Athenahealth. (Please know that I have never used their products, have received no consideration from them, and have not spoken with anyone affiliated with the company. My comments are merely as an interested observer.) This New England-based company started by doing electronic claims (billing) for doctors' offices and groups. Anticipating the direction that health care was taking, they invested heavily in programming platforms that would appeal to doctors looking to make the jump to electronic medical records with a minimum of hassle.

At one point, they were running ads boldly guaranteeing clients that they'd qualify for "all of" the stimulus payments, though I haven't see those ads running for some time. The idea is compelling: What busy doctors' group has time to research, trial and invest in value-conscious but appropriate medical information technology? Instead, outsource it! Let it live in The Cloud! Pay a monthly subscription only (without the huge startup cost) and rely on a vendor to deliver updates, promise security, and offer compliance.

From regulation springs rules but also blossoms major new markets. Perhaps this is why America is able to keep re-inventing (and investing in) itself over and over. Maybe there is some hope our economy will soar once again.

Or I am merely drinking from the IT world's Kool-Aid? The pessimist in me can see a "tethered" future. See here. And here.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, 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 that inhabit them.

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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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