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

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Friday, September 30, 2011

Median hospitalist compensation up slightly

Hospitalists in adult medicine reported an increase in median compensation from $215,000 to $220,619 in 2010, while pediatric hospitalists median compensation rose from $160,038 in 2009 to $171,617 in 2010. Though hospitalists earned more in 2010, they also reported higher productivity. The annual median adult hospitalist physician work relative value unit (wRVU) rate was 4,166, a 1.4% increase over last year.

According to the Medical Group Management Association (MGMA) and Society of Hospital Medicine’s (SHM's) State of Hospital Medicine: 2011 Report Based on 2010 Data, compensation varied by how it was structured. Adult hospitalists with 50% base salary or less reported median compensation of $288,154, while adult hospitalists with 51-70% base salary reported median compensation of $249,250. Adult hospitalists who reported 71-90% base salary earned $213,542 in median compensation, and those with 91 to 99% base salary reported $221,270 in median compensation. Adult hospitalists with 100% base salary earned $205,003.

An analyst with MGMA said in a press release that hospitalist compensation is still evolving, which provides hospitalists room to negotiate for productivity and quality bonuses.

The report contains information on 4,633 hospitalists in 412 groups and 726 academic hospitalists in 68 academic hospital medicine practices, as well as group-level data on compensation methodology, group size and staffing mix, turnover and growth, staffing models and financial support.

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Wednesday, September 28, 2011

Life at Grady: Mountains vs. molehills

A version of the following post, by Kimberly Manning, MD, FACP, first appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission. Identifying information has been changed to protect privacy.

Yesterday I was in a crabby mood because the garage door opener in my car has a dead battery. It's one of those fancy, special batteries that requires you to go over the river and through the woods (read: not in the kitchen "junk drawer") to replace.

The whole act of getting out of my car, manually opening the garage, and then getting back in my car and driving was just too much for me to bear. Oh me, oh my.

When I grumbled to my husband about it, he just stared at me exactly like Rhett Butler used to stare at entitled Scarlett O'Hara. And whenever he does that, I almost always get a grip. But not yesterday.

I continued my whine-fest and marched out of the house. I could overhear Harry mumbling something about people out there with "real problems." That didn't stop me from pouting though.

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I perked up a bit when I got to Grady, which is usually the case. I worked with CM, who I 100% adore and J, who qualifies as a work-sibling to me. We laughed and learned and taught the residents cool things. The energy was great and, as always, so were the patients. Somewhere in the back of my head, I kept thinking about my interaction with my husband before I left home. I remembered him muttering about people and "real problems" and felt a teeny, tiny bit embarrassed by my little rant.

Just as I was feeling that way, I stepped into a room with a resident to see a Grady almost-elder who, despite her age, still worked a full-time job. Night shift even. Why? "To keep the lights on." This woman started telling us about these pains that she was having, and none of them were really correlating with any physical findings. Her labs and tests looked great, and so did she.

So what was up with all this pain? Could it be a manifestation of anxiety or depression? I wasn't sure. From there I started asking her questions about her life. What do you do? What is it like for you? Are you under stress? How would you describe your day-to-day life?

And then she shared. Just one tiny piece of her life, and boy, was it telling.

"I work for 911 dispatch, and it's real, real stressful sometimes."

911 dispatch? Damn. I'd never met a person who did this, especially in inner-city Atlanta. Well, this sixty-something year-old woman did just that. She sat at a bank of phones and took call after call, all night long, from people in emergency situations. All night long. To make ends meet. To pay the bills.

"It's real hard, sometimes. I done heard it all. One night somebody having a heart attack. Another day somebody got shot at. This one lady was on the phone with me and I heard somebody doin' a home invasion on her. She was jest screamin' and screamin'. I wanted to help her so bad but I couldn't, you know? You could hear her door cracking clean off the hinge."

I kept listening.

Sheh told me about how hard it is to hold on the phone while people are getting robbed or having life threatening illnesses or getting the crap kicked out of them by someone who allegedly loves them. That's her job. To hold the receiver and repeatedly tell someone that "it will be okay" or that "someone is on the way." She does this job in a major metropolitan city where someone is not always as "on the way" as one might hope. But these days, according to this patient, things are worse. She explained that she's "been doin' this a long time and ain't never seent it get this bad" and that "folks ain't got nothin' to live for and it's so bad that they don't even care what happen if they do somethin'."

I started biting my cheek listening to her sharing all of this and trying very hard not to think of the truth behind my husband's snarky reply earlier that morning:

"There's people out there with some real problems."

And like the pop of a rubber band, I was snapped into the reality of what it actually means to have a "problem." Mine that morning seemed a little dumb in comparison. More than a little dumb, actually.

I could go on to talk about how terrible it is to be nearly seventy and required to work this hard. How sad it makes me that she can't work in her garden or hug on her grandbabies all day instead of sleeping before her next shift. I could tell you about how she heard someone getting beaten horribly by her spouse and begging for her to help just one day before, and how troubled she felt when that woman stopped talking. How my patient wanted to cry or hang up or both because she feared that the worst had happened, but how she couldn't because it's her job and it has benefits and how she didn't because, honestly, isn't this what she hears every single day? I could go on and tell you all of that.

Instead I'll just say that in the grand scheme of life and issues, maybe I needed that stinging snap on my wrist.

Now, I don't trivialize every single aspect of my own life and its little mini-hurdles. But I do force myself to take pause more ...shaking my head at the enormity of mountains existing in the midst of my molehills. Grady sure helps me with that. And I'm learning that it's a whole lot easier to move molehills than mountains.

On the way home that evening, I stopped and picked up a dime-sized lithium replacement battery for my garage door opener. It cost me $3.29 and actually was right there in my neighborhood Kroger.

Mole hill moved.

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Friday, September 23, 2011

All the information is in the computer

Disclaimer: This is a hypothetical case. Any resemblance to anyone is purely coincidental.

Students learn about patient centered interviewing and focusing on patient problems and complaints. That is the point of history of present illness (HPI). When they come to work with a primary care provider, who has know his/her patients for a long time, some of these question can be irritating to the patient who expects the physician to remember everything about their health history.

The HPI helps when approaching a patient with a new problem. Students are often not familiar with the patient who has five serious chronic problems but no complaints. They start by asking something like, "So what brings you in today?" and they get something like "Oh, this is just a follow up. I am fine!" and then they don't know what to do next.

Part of the problem is that many medical students get only an acute exposure to chronic diseases. They do an eight-week rotation in internal medicine where they almost never see the same patient again.

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Recently I had a patient who came in to establish care. She was the first patient of the day and she was 15 minutes late. I had come in earlier than usual as I knew I had a third-year student with me in clinic. Because of these reasons, I had extra time to review her electronic health record (EHR) data in some detail. She had received all her care at our institution, and this meant all her data was in one system.

The student was very bright and very comfortable with history taking but new to EHRs. The previous day, she had faced the typical patient scenario, "Why are you asking me all these questions? It's all there in the computer!"

After that last encounter, we had discussed how a lot of information can be gleaned from the EHR. So we had decided to spend some time going over the strategy of using the EHR prior to seeing the patient.

We started off by looking at a patient summary screen (a snapshot of her problem list, medications and health maintenance alerts). We saw that she had the following issues noted in the EHR by her previous physician:
1. Hyperlipidemia
2. Goiter
3. Smoker
4. Hypertension

Her medications included
1. HCTZ 25
2. Pravastatin 40

So in this patient we went over her chronic issues (problem list) and dug into each one to see what we could glean from the EHR. This is how the conversation went:
1. Let's look at the hyperlipidemia. What would you want to know?
--last lipid level
--target LDL (how do we calculate this?)
--what medication, dose, is she compliant, tolerating?
--liver test results
--diet and exercise
So we click on Chart review >>; Lab results>> Select the last 2 lipid panels >> view in table form >> find that her LDL was about 150 one year back. We discuss ATP III >> go to the ATP calculator online >> put in her risk factors >> calculate that her LDL should be less than 130 mg/dL. We assume that whoever ordered that last lipid panel must have done something when the LDL came back above the target. Go to Medication tab >> medication history >> sort by therapeutic class >> look for lipid lower meds >> find that she used to be on pravastatin 20 mg and had been increased to 40 mg after the date of the lab. Did that work? Lab results >> see that lipids and ALT had been ordered for three months after the change in dosage but were not done. So we create one agenda item: Find out if she is taking the 40 mg dose, and check lipids on that dose.

I recall reading about the new study in the Journal of the American Medical Associationon the dietary portfolio (oatmeal, soy and nuts) being better than just following a low-saturated-fat diet at lowering cholesterol. Find it in Google Reader easily and share with student. So we create a second agenda item: Discuss diet with patient and discuss with her this study.

2. Goiter: What questions do we have?
--Has this been worked up?
--What was found?
--What was done?
--What is her thyroid status?
--She is not on any meds, so is she euthyroid?

So we click on the problem "Goiter" in the EHR and find that it was first noted in 2007. Chart review >> Imaging>> USG thyroid >> has one large nodule and rest diffusely enlarged. D/w student what she would do>> FNA >> Who does this? Endocrinology>> chart review >> Encounter tab >> sort by department >>Endocrinology >> saw them in 2008 >> had an FNA done>> Lab results tab>> Sort by test >> Surgical pathology >> Thyroid bx>> Benign. Also check last TSH >> low normal 2 years back. So we create a third agenda item: Update problem list with this information so next physician does not have to do this again! Another agenda item: Ask also about symptoms and recheck thyroid-stimulating hormone levels.

3. Smoker: What would you want to know?
--Is she still smoking?
--If so, is she interested in quitting?
So we create an agenda item to ask these questions.

4. Hypertension: What would you want to know?
--What is the blood pressure today?
--Is she taking her medication? Are there side effects?
--How has her control been?
--Any evidence of end organ involvement?
In EHR to go graphs>> BP >> see that she is usually <140/80 over last four years. Chart review >> Cardiology>> Echo >> none, EKG >> normal (no evidence of LVH). Chart review >> Lab results >> BMP>> Creatinine normal, K normal; UA >> no Hb or protein. So we create an agenda item: Ask about home blood pressure measurements, does she have a machine, do cardiovascular exam for murmur, gallop, heave, bruit, pulses and look at her fundus.

The student looks at me amazed! She did not know the EHR could hold the answers to so many questions. I tell her how she can create her own agenda before going into the exam room. Once she has elicited the patient's agenda and addressed it, she needs to cover the items on her own agenda. Hopefully both the agendas are the same. Hopefully there is time to cover both the agendas.

We have spent 30 minutes discussing and reviewing all these issues. We are lucky we got an early start and the patient was late!

So what is the point of this story?
1. EHRs can hold an amazing amount of important information
2. Getting this information out of the EHR takes a lot of time, clicks and knowledge of where to find this information.
3. These benefits are visible when all the data is in one system. If the consultants and labs and imaging were all done at different places, this would not be possible. Even when external reports are scanned in, this data is not easily accessible. As we develop electronic data interfaces this should not be a problem.
4. Some patients expect that just because all the information is in the computer, it is also in the physician's brain! Wish they could realize how much effort it takes to dig all this information out.
5. As physicians use EHRs and spend time reviewing and summarizing the information, they should take time to encode it in a way that makes it easy for the next provider or the subsequent visit.
6. Students learn how to get the history from the primary source but will also need to get comfortable getting the data from the EHR in a meaningful manner. While looking up the information in the EHR prior to talking to a patient can create a huge bias and a kind of filter bubble, it is a great way to look up chronic problems.
7. The time that it takes to review all the information occurs outside the exam room and it can become non-reimbursed care. Doing this review is very important for patient care. Will this become a non-issue once we move to accountable care organizations?

Addendum 8/28/2011: Link to G+ discussion on this post.

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

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Wednesday, September 21, 2011

Life at Grady: Mother Wit

A version of the following post, by Kimberly Manning, MD, FACP, first appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission. Identifying information has been changed to protect privacy.

I heard a talk given by one of the Grady senior faculty on something intriguing: "Wisdom in Medicine." He suggested that wisdom can be found in many places and that we need to role model this for our learners. I was sitting at the end of the table next to one of my favorite Grady doctors, RK, who looked over at me and said, "Hey, do you feel wise sometimes?"

And the thing is, I laughed because secretly there are moments where I do. I looked at RK and said, "You know? I don't know everything. But sometimes I do feel a little bit wise." And we chuckled because honestly, who admits to being wise?

Just then, the speaker showed a picture of Socrates and said that "Socrates was the only wise man of his time because he was the only one who didn't think he was wise."

Whoops. My bad.

Maybe "wise" sounds a bit pompous and pretentious and that's why Socrates avoided claiming it. Fine, then. How about we refer to it as "mother wit" instead? Mother wit is that knowledge you get with time that can't be found in books. It's mostly learned from trials and errors and watching and sitting at the feet of elders. And Lord knows you don't need to be a doctor to have or gain that kind of wisdom.

Here's an example.
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There was a man I was caring for who I'll call Mr. Everett. He'd had a stroke and a prolonged hospitalization. Mr. Everett had to learn how to do the most basic things all over again, and lucky for him and us, he was super motivated to do just that. He worked with PT to walk again. He worked with OT (occupational therapy) to lift a fork and comb his hair again, too. There was only one problem that kept making things difficult. His blood sugar control.

Technically, it wasn't that problem per se. The thing is that Mr. Everett was having issues with eating and chewing after his stroke, which greatly affected his caloric intake. With wacky food intake, the insulin he received for his diabetes was all over the place. Talk about frustrating. He was hell bent on not having any kind of feeding tube placed, yet no matter how many times we tried to advance his diet, he'd gag and sputter and have issues. He'd passed the swallowing studies and the speech/chew folks assured us that his mechanical ability to eat wasn't the problem. Which kind of sucked considering he'd come so far with regards to everything else.

So on and on it went. Liquids ----> thickened liquids ----> soft mechanical diet ------> regular diet -----> gagging, sputtering, not eating----> thickened liquids --->soft mechanical diet -----> regular -------> gagging, sputtering, not eating...

Uggh.

"Mr. Everett, I'm not sure we can pull off having you eat this regular diet. Even with help, you have trouble," I'd say.

"I don't want no feeding tubes feeding me. I can eat and I want to eat."

That's all he would say. So this went on for easily more than seven days.

Then one day I came in and saw Mr. Everett sitting up in the bed throwing down on his tray. Cutting, slicing, peppering, grubbing. I was totally perplexed, as was his nurse.

"Mr. Everett!" I exclaimed, "You're eating! And swallowing! I'm so happy!"

His nurse had similar things to say and we were so happy that we did the cabbage patch dance around his bed. He simply smiled, swallowed and dug in more.

What the ?

And so a few hours later, I was rounding with the team and gushing about Mr. Everett's esophageal epiphany. I went on and on about him feasting on the breakfast tray and even demonstrated the dance that I did with the nurse.

"I guess it just all finally came together!" the senior resident said with a triumphant smile. "He must have just needed some time."

"Yep. Time seemed to be the key," I responded, "but it's really kind of amazing how all-of-a-sudden it was, you know?"

And we all sat there over tepid coffee, smiling at feeling all proud of ourselves for "curing" Mr. Everett. Now his blood sugars were consistent and he was on his way to getting discharged. Score.

Then, in came one of the interns, Nicki M., who'd been off dealing with another patient. Her co-intern looked up and said, "We were just talking about Mr. Everett. Can you believe it? He's eating! Like a champ! Dr. Manning said he cleaned his plate this morning--a regular diet, too!"

We were all so invested in him as a team that, even though Nicki wasn't the primary intern caring for him, this good news was for her, too. Nicki scooted her chair up to the table and nodded. "I'm so glad that worked for him."

I was puzzled by the statement. "What? What do you mean 'that worked?'"

Nicki rocked on the back legs of the chair and answered with a nonchalant shrug, "Poligrip. Extra-strength."

We all looked at each other in disbelief.

Yes. You read that right. Poligrip. Extra-strength.

It turns out that Nicki had heard about Mr. Everett so much on rounds that she'd decided to go hang out with him in the middle of the night during her call night. She looked and listened and asked and explored. And you know what she discovered? That at home he used extra-strength Poligrip for his dentures and that the kind he'd been given in the hospital both irritated his gums and didn't work. Every time he tried to macerate his food, he couldn't. Because his dentures were too loose.

Seriously?

So Nicki called the pharmacy and they didn't have it. The next day, she personally went to CVS and bought him some. Simple as that.

Now. You tell me--was that mother wit or what? Something had told Nicki to go in there that night. It wasn't even her patient, but she went. Something made her think beyond all the technicalities and academic things to something as simple as denture adhesive. Denture adhesive.

So, yeah. I've had a few of those Poligrip extra-strength moments in my life. Medicine and life are about a whole lot more than just being smart. You need the knowledge, yes. But most of all you need you some "mother wit" and an ability to just "get it."

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Thursday, September 15, 2011

To compete with the sea of MacBooks, offer edu-tainment

Although Steve Jobs has stepped down as CEO of Apple, his legacy for physicians-in-training is very palpable. Or should that be visual? As I looked into the auditorium of eager and bright incoming medical students this summer, I saw a bunch of Apples staring back at me, sleek, silver and unmistakably MacBooks. This is the millennial generation, so why would I be surprised? Maybe because it is more ever-present than before this year. Could it be that the entering class of 2015 had more millennials?

Summary of 2010 by localjapantimes via Flickr and a Creative Commons licenseActually, another hypothesis has also been put forth that is equally if not more plausible. Our medical school auditoriums were installed with new desks and chairs. While these were well received, the desks served as an inviting surface just beckoning for the MacBooks to be placed there. As a result, you're never sure if you're competing with Facebook, the Internet, or even e-mail messages that appear more interesting than your class. Since lecture capture technology has made it possible for people to view lectures from home, it's important to make attending lecture in person worthwhile. Well, here are some tips for medical educators who "lecture" in this new age.

1. Engage in "edu-tainment." As Scott Litin at Mayo refers to it, "edu-tainment" is the goal, entertainment via education. How does one incorporate entertainment into lecture style? Well, the easiest way is through humor. This is difficult, since not everyone is funny by nature, so it may be that you have to inject humor in odd ways.

2. Play games. Games are inherently fun and interactive can stimulate a lot of learning and discussion. While you may be thinking about computer games, easy games can often stimulate learning. One of our research ethics faculty played 20 questions with the group of students to teach about landmark research ethics cases.

3. Turn into a talk show. There is nothing more boring than watching the same person for an hour give a talk. It is much more interesting to watch a panel of people tell a story about themselves, whether it be a patient, another physician, or another student. I still remember medical school lectures with invited guests that had this talk show appeal due to the lack of power point and focus on the story. While I'm not suggesting a Jerry Springer approach, who doesn't love Oprah? At least Chicago has several role models to choose from.

4. Showcase video. Video is one of my favorite teaching tricks. One well made video can communicate a thousand research articles. In our week of Scholarship and Discovery, our faculty used videos from Xtranormal (no it was not the famous orthopedics vs. anesthesia) but a similar one. One faculty who could not attend taped a welcome introduction, and another used a clip from "Off the Map" which is now off the air but is still an effective reminder of how NOT to perceive global health.

5. Use audience response. Use of Turning Point clickers can result in instant feedback and engagement with students as they see the results of their poll immediately. It also tells you how many people who show up to class! The only problem is that passing out the clickers and collecting them can be rather time consuming. So, another possibility is to issue them at the start of class which is done in some colleges and used as a way to count attendance (until a brilliant undergrad brings in a bunch of clickers to class to vote for their lazier friends!). Here Steve Jobs can help again. Turning Point has audience response systems for iPhones and iPads that can be used and automatically identify people, but it would require that everyone have a smartphone and purchase a license to the software.

6. Refer to the Internet. Given that students are on the computer, you can take advantage of it and ask them to visit internet resources in class by showing them URLs or web pages that are of use. Sometimes you may actually refer to your own course website like we do.

7. Provide fancy color handouts. While handouts may sound like they have gone by the waste side, there is nothing like a fancy color brochure or handout to create a "buzz". It's almost like a souvenir of their hard journey to class that day. If you ever want to provide someone with a "leave behind" that looks important, lamination is key. A color laminated leave-behind is even better. Pocket cards are some of my favorites.

Is there any guarantee these tips will work? Of course not. But, what's the harm in trying? While some professional schools have gone so far as to block wireless in lecture halls, the truth is that current medicine is augmented with the help of computers and online resources, so we should figure out how medical education can be too.

Vineet Arora, MD, is a Fellow of the American College of Physicians. She 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, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

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Wednesday, September 14, 2011

Life at Grady: Redemption

A version of the following post, by Kimberly Manning, MD, FACP, first appeared on her blog Reflections of a Grady Doctor. It is reprinted with permission. Identifying information has been changed to protect privacy.

A few weeks ago I was talking to this woman who had gotten off of crack cocaine. It had been four full years since (to use her own words) she'd been "delivered from the stronghold" of addiction, and boy was she proud about it.

"I was out there bad," she said with a shake of her head. "But one day, I just woke up and looked around myself. This was rock bottom. I was flat on my back and all I could do was look up from there."

"Wow, that's awesome," I replied. "Did you go to a recovery program?"

"Nope." She lifted the cover to her breakfast tray and frowned. Covering it back up she looked back at me and smiled. "I prayed about it. Asked God to take that desire away from me. I knew that was the only way for me to do it."

"Hmmmm." I listened to her words and thought about this idea of this desire being "taken away from her." I cast my eyes over to the other members of my team, wondering how her description of drug abstinence was resonating with them.

(Click "More" below to keep reading this post.)

"What do you mean by 'out there bad?'" one of the interns asked. We all swung our heads in his direction. I felt proud of him for asking this, even if it had broken my train of thought. I liked that he wanted to know more about her and especially her story.

She laughed and recanted, "You sure you old enough to hear all that?"

Our team shared her chuckle and waited for her to go on. "When I said 'out there bad' I'm talking bad as you can imagine. Turning tricks, robbing folks, doing whatever you got to do to get high. That's what a stronghold do to you. It make your mind crazy, like you can't make good decisions." She shrugged and removed the cover to the food again. Ripping open a salt packet she continued. "I feel so bad about that time in my life. But see, the last few years it's like I'm a new person. Like my life got handed back to me. When they test me for the AIDS and told me I didn't have no diseases, I couldn't believe it. That's when I knew I had a chance, you know? A real chance."

Something about her words immediately pushed tears into the front of my eyes. They began stinging like rubbing alcohol in a fresh wound; I tried my best to blink them away in the most inconspicuous way I could. She sighed and stuck her fork into the tepid eggs on her plate. Her mind seemed peaceful, as did her comfort with telling us all of that.

"Congratulations to you for getting your life back," I finally said. "I know you're so proud."

She nodded her head and smiled. "You know, doc? I ain't gon' even lie. I'm real proud."

And as I watched her eat her eggs my eyes became prickly again with fresh lacrimation. If she wasn't eating and if it wouldn't have seemed lame, I swear I would have hugged her right there in front of my entire team. Okay, I take that back--it was really that she was eating that stopped me.

Today I am reflecting on redemption. Redemption. I can barely type the word without crying. Damn. Here I go.

This is one of the main reasons why I love working at Grady. There is nothing that moves me deeper in my core than stories of redemption. They resonate with me so--not because I've had some hard life with tacks and splinters--but because I know that within us all dwells that need for a clean slate at some point in our lives. We need to have people see us with more than their eyes and to accept us not because we have straight teeth and straight spines or straight lives but instead just because.

I remember when I took care of a patient once who had an urgent surgical problem. The resident surgeons didn't agree with my assessment, yet I was senior to them. Instead of calling their attending physician, I shook my head and told the team that my patient would "eventually declare himself." He did just that--and subsequently needed an emergency operation after which he had a perioperative myocardial infarction (heart attack.) And then? He died. Yep. He died.

I deeply struggled with that experience. I wished in the hollows of my heart that I had fought harder for that man. That I had pointed my finger and said my piece and then stepped clear over their heads to get that patient the help he needed -- faster.

When I saw that man's son, he squeezed both of my hands hard at the same time and thanked me for all I had done for his father. And do you know what I did? I cried right there in front of him. It was as if he wrung those tears right out of me with that tight grip and I couldn't reel them back. Sure, it was probably unprofessional but there was nothing I could do to stop myself from the emotion. Partly because as a daughter and a mother I was sad that a man had lost his dad and a child had lost his granddad. But also because there was something about the way he took both of my hands into his during his deepest moment of grief to say those words that felt like redemption. Like they said, "Look, I know that you are a human but there was love in the care you gave my dad." Or even, "There is something complex about the expression on your face that is telling me you need this moment even more than me." And you know, I needed it. As selfish as it was, I did. And he gave it to me freely.

Anywho.

Even though that lady who'd abstained from crack for four whole years spoke of higher beings and deliverance from strongholds when giving her testimony, I know for sure that redemption comes in many forms. Sometimes it comes when you're lying on the ground and you finally realize that you can still look up. It also happens when a doctor looks across a table and casually tells you that, No, you aren't HIV positive. Other times it happens when someone takes your two hands in theirs and squeezes them tight. When for all intents and purposes you should be grabbing theirs.

I guess the most redeeming qualities come through everyday acts like listening carefully and smiling genuinely and seeing people with more than just our eyes. Man. Every day I'm hoping someone does that for me and the people I love. I really am.

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Friday, September 9, 2011

Medical students need to get comfortable with uncertainty

Medical students are usually taught a rather comprehensive approach to history and physical exam. They appear to go through a mental check list of all the things that need to be asked and examined. They start off by following this check list regardless of presentation. They may also think that a test is needed to rule in or rule out each condition on the differential. It takes them a while to realize that a good history and physical can diagnose almost 70-80% of unknown cases presenting in the out-patient clinic and that even when one is not sure of the diagnosis, one does not always have to order tests.

When they first show up in clinics students tend to be quite confused that the clinical world is very different from the one they were training for. The experienced doctor seems to ask questions in a very different order than what they expected and seems to be quite comfortable with uncertainty, tending to order far fewer tests than they would have thought.

What can we do to ease the transition to the clinical years?

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Some techniques I have tried are:
1) I teach a mantra that "Time is a diagnostic tool." This is particularly true in outpatient medicine. Some conditions can best diagnosed by waiting and watching. Either they will go away or they will show new features which will help diagnose them.
2) Empiric treatment is also a diagnostic tool. Sometimes a short course of medication can help. If the condition gets better (or it does not) it can point to the diagnosis.
3) I give them a framework and ask them to try and place the patients' possible diagnoses (from the differential) into one of three buckets (categories):
--Potentially serious (e.g. life threatening) and urgent (needs to be diagnosed or ruled out quickly).
--Potentially serious but not (very) urgent. This is on a scale.
--Likely not serious and not urgent.

I then ask them to see if they can eliminate any condition on their differential that falls into category 1. If that cannot be done, they need to absolutely do something right away including ordering a test. If they can, then they have time and then they can try still order a test or try empiric treatment or wait and watch.

Forcing a student to try and place the likely possible conditions in these categories helps them ask the questions that matter, rather than go down a checklist of history of present illness, review of symptoms and past medical history that are often irrelevant.

They students are often confused that they spend a long time with the patient asking questions and doing a head to toe exam and then when the preceptors talk to the patient, they ask one or two pointed questions or check a couple of physical exam findings that change the management completely. Discussing this with the student early in their clinical rotation can help smooth their transition and reduce their frustration.


Syndrome: Low back pain
Category 1: epidural metastases (history of cancer), abscess (systemic features of infection), (spine tenderness), (nocturnal pain)
Category 2: sciatica (straight leg raise test)
Category 3 muscle strain (paraspinal tenderness, history of unusual exertion)

Syndrome: Chest pain
Category 1: Acute coronary syndrome (previous stress test/cath,), aortic dissection features of affected arteries or nerves (e.g horner/recc, laryngeal etc.)
Category 2: gastroesophageal reflux disease, viral pericarditis (systemic features, rub, EKG findings)
Category 3: Rib/muscle strain (reproducible tenderness)

Syndrome: Headache
category 1: aneurysm (neuro findings check the pupils disc), temporal arteritis (age, jaw claudication, eye symptoms, scalp tenderness)
category 2: migraine (photophonophobia, triggers, caffeine)
category 3: scalp hematoma from minor injury

The items in parentheses are just examples of types of questions or exam findings that may not be part of the standard check list that a student my use. These not meant to be inclusive of all such questions. Also there are several guidelines that students can be directed to e.g. the guidelines regarding which head injuries should get a CT scan.

This is not to say that there is no role for the comprehensive history and physical. Often the students will discover something important about a patient that their primary care provider was unaware of. This is especially important in someone who has an unresolved symptom/s even after being seen by multiple providers/consultants. A fresh look at the case with a systematic approach can reveal clues to the answer.

Clinicians will sometimes miss a diagnosis but if the patient is appropriately instructed regarding any red flags and followed closely, the prognosis will usually not be any different.

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

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Wednesday, September 7, 2011

Life at Grady: Lost in translation

The following post, by Kimberly Manning, FACP, was adapted from her blog, Reflections of a Grady Doctor. All identifying information has been changed to protect privacy.

It was time to talk to you. And I am so ashamed to admit that I had secretly dreaded this time. Not because of you, but because it would be awkward and lumpy like it always is when the doctors can't speak your language. The thing is that usually even when "the doctors" aren't fluent in someone's native tongue, somebody somewhere in the hospital is. A crafty student or resident finds that person and--just like a combination lock that finally had the right code entered--everything is opened to us.

But not this day. There isn't that person lurking on the Mother-Baby unit or at some desk down in the Emergency Department. No person from your home country willing to change your words from a plume of smoke floating from your lips to crystal clear images that paint a picture and explain why your face has that twisted snarl of pain. Not even someone from your family to rush in after work, still in uniform and waiting with anxious eyes on the end of the page the nurse just sent to the team.

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So for this reason, I wasn't looking forward to this time on rounds when I needed to see you. My eyes glanced over the clock hanging on the ward--4:45 p.m. Afterschool care pick-up on the horizon and yes, I knew, that was my problem, not yours. But that problem of mine was making me even less excited to hear about yours. Especially because my 5:20 deadline would unfortunately become yours.

The medical student was perched beside the door waiting.

"You ready, Dr. M?" he asked, all bright-eyed and bushy-tailed.

"Yep!" I announced with as much spunk as I could muster. But inside I was saying, 'No. I am not'.

We approached your bed and found you curled in the fetal position. Your eyes squeezed shut and a tsk-ing sound was the first thing you said in response to my pseudo-chipper greeting in English. My patience drained down into my feet and formed a puddle on the floor. I didn't speak "tsk-tsk" and you didn't speak "pseudo-chipper."

"We can use the phone interpreter," the student offered.

He must have stepped into that puddle and decided to have patience for us both. I would need it.

"Oh, that's good," I replied, "So, we have a phone interpreter that speaks this language?"

"Sure do," he answered in a real-chipper voice that wasn't pseudo like mine. "I used it earlier."

He smiled gently at you and picked up the bedside phone. Looking at a laminated card retrieved from his overstuffed medical student pocket, he dialed a number and entered a few codes. I could hear a muffled voice and he announced your language in response. And then we waited.

"Looks like we're in queue," the student said, being careful to keep including you. He held your hand and patted it. "There aren't many interpreters speaking this language, so sometimes there's a wait."

Of course. A wait. A wait to have a perforated discussion with you between a tiny voice coming through a hospital telephone, a medical student who already had spoken to you, and me--who still needed to get her two children from school before six p.m. That pool of patience oozed out the door and down the hall.

I rubbed my neck hard which is always what I do when my patience wanes. And then, finally, an interpreter.

"Hello, my name is Dr. Manning and I'm the senior physician that will be caring for you with the team."

I announced this into the telephone and passed the receiver over to you. The muffled voice said a version of my greeting and you mumbled something in return.

"She says, 'Good to meet you, madam.'" Which was little surprising because the look on your face didn't seem to say that. It looked angry and tired and like it wasn't down with any pleasantries such as 'glad to meet you' and damn sure not 'madam.'

"Tell me about your pain that you've been having." I extended my arm back toward you with the phone. This time your answer was longer with more "tsks" peppered throughout. The "tsk" was not a good thing--mostly a sound of frustration. I wanted to "tsk" too.

I learned of your pain. The student interjected and filled in blanks about your very complicated past medical history. We put down the phone receiver and examined you, picking it up to ask things like, "Right here?" or "What about this?" Between the student, the telephone interpreter, and your tsks it came together. The diagnosis wasn't a good one. In fact, it was a bad one. A really bad one.

Now what? Tell you of a life-threatening, life-abbreviating diagnosis through a choppy back-and-forth via telephone? Did I do that, knowing that no matter how nice that tele-interpreter man sounded over the phone, he can't see your facial expressions or know exactly when to soften his intonation? Even in the King's English it's no walk in the park to tell someone, "Oh this diagnosis that you have? Well it's essentially trying very hard to shorten your life. And we don't have a lot of medicines to stop what it's trying to do to your body." Yes, this sucked. How did I tell you something like that under those circumstances?

I looked at the student and he looked at me. A decision had to be made about you. Tell you all of it or no? Right then, right there I decided.

"Do you have any family at all who speak your language here in Atlanta? Anyone that you know that can come and help? There are so many complicated things to talk about. Some hard things. We would rather not have this conversation over the phone."

I stuck my hand in my lab coat pocket and secretly crossed my fingers. Someone had to help me with you. Not a mystery man inside of a phone but a real person with warm blood and three dimensions.

I put the phone to my ear and what I heard washed me with relief.

"She says that she has a son. He can come tomorrow. After work to speak with the team."

Yes.

We exchanged a few more words with you, the tiny voice, and your pain. We confirmed that you were comfortable at moment and made a plan to meet with your son. And you nodded when the tiny voice told you this through the phone.


At 5:18 p.m., I turned the ignition in my car. Life goes on and surely I would find kids covered with Georgia dusty red clay and unidentified stickiness on their cheeks. Full of the vigor and joy of life, of safety and consistency and familiarity. Then I thought of your frail body, the disjointed communication, and the worst part of it all--the fact that you were dying. In this foreign land with its confusing culture and impatient people whose cell phones play music and whose wall-phones are bilingual, you were dying.

And here I was worried about me and my time.

"Tsk," I said aloud to myself. "Tsk tsk."


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Tuesday, September 6, 2011

A death well spent

One of my patients whom I have cared for for many years has been slowly declining due to chronic pulmonary disease and is now in the hospital dying.

She was an inveterate smoker and continued to smoke cigarettes even when she reached the point that she could barely breathe when she walked and needed to wear oxygen at home. She was tethered to an oxygen tube while at home and it was only when she became dependent upon portable oxygen to get out of the house that she finally gave up cigarettes altogether.

She belongs to a class of patients who I've come to think of as the "smoking coffee drinkers." They are thin, older women with gravelly voices and outgoing personalities. They usually consume six cups of coffee a day and smoke a pack a day of cigarettes, and try as they might , are completely incapable of quitting smoking, even though they know perfectly well that is going to kill them. Most of them are complete teetotalers and hardly the type of people that you would expect to be substance abusers. Nonetheless, they are as addicted to nicotine as any heroin addict is to narcotics.

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When I ask them how much they are smoking lately, they nearly always say that they've "cut down" since their last visit, without answering the question directly. But when pressed, they always report a daily consumption that is no fewer than the amount they admitted to at the last visit, not recalling that they said the very same thing last time I saw them: "Only a few." Once in a while they will even tell me they have given up the habit, but on closer questioning they admit it has only been for the past two days or some such painfully brief interval, and not in any premeditated fashion.

I have tried every trick I know to help them quit. Medications such as nicotine patches, Zyban, Chantix, anti-anxiety agents and antidepressants are more often than not either ineffective or result in intolerable side effects in this type of patient. Or she is unwilling to try them because she is afraid of possible adverse reactions, or because her friend tried it and "went bonkers" or had some other dire result.

Motivational tricks are equally ineffective. "You wouldn't believe how many of my patients have succeeded in quitting!" I tell them. "Well, if you were able to quit for a week last year, that proves you are strong enough to do it again!" A rare few have tried hypnosis without success. Even my constant efforts at counseling from the point of view of my admittedly remote and brief experience with quitting smoking in college, and the techniques that I was able to use, always come to naught.

Of course, as physicians, we are instructed always to gently mention at every visit, "Have you thought about quitting lately?" Usually they say they have, but in the same labored breath, that they are not ready or don't think they can, or that they want to, but their life has been too stressful lately to do so.

Thus they all progress more or less gradually in the direction of what was once called chronic bronchitis and emphysema before I entered medical school. Shortly before my medical education began, someone decided that "COPD" was a better all-encompassing term. I have always felt that it serves only as blander shorthand with less stigma and threat attached to it than the frightening word "emphysema."

Trying to halt their slide toward becoming pulmonary cripples is a frustrating and discouraging endeavor, requiring that I periodically rescue these women from their intermittent bouts of acute exacerbation of their chronic bronchitis. Inhalers and cortisone medications are helpful and antibiotics occasionally have some value, but after several years, the repeated bouts and continued smoking take their toll. The decline is inexorable. I watch them graduate from home oxygen to portable oxygen. Oftentimes, the end is a three-week stay in the intensive care unit on a respirator while pneumonia finally puts a period to it.

What is remarkable about the patient I am caring for at the moment has been her incredible determination in clinging to life, in spite of respiratory disability, as stubbornly as she had formerly clutched her pack of smokes. She treasured her ability to bake an apple pie for her grandson and was heartbroken when she no longer had the strength to roll the dough. But she hung to life fiercely so that she could be with her family to the last moment, and then, without hesitation, decided it was time to call it quits.

Her last month was spent in a pulmonary rehabilitation hospital, but even that was to no avail. She had reached the point that even with all of the oxygen supplementation available, her lungs were incapable of excreting the carbon dioxide that her body would generate. This condition is called hypercarbia and results in lethargy, stupor, and ultimately, near-coma. I only learned that she had been readmitted to the hospital when her family member called me the following day. At that point, he related that she had had a frank discussion with the hospitalist responsible for her and had made the decision that she didn't wish any further efforts to keep her going and she would absolutely not accept being intubated. She had emerged from her stupor long enough to make clear her wishes and was adamant that there should be no further efforts. She had had enough.

The decision having been made, in order to keep her from feeling short of breath she was receiving an intravenous morphine drip and the maximum possible oxygen. By the time I came to visit her, she was already essentially unresponsive.

For the past five days, her husband and children have been keeping vigil by her bedside 24 hours a day. Her husband has been sleeping on a futon sofa bed that the nurses make available to family members. He has been going home for an hour every day so he can take a shower and change his clothes. Her children and grandchildren are all by her side. Everything that there is to say has already been said and they are just being with her at this point. Their only concern is that the morphine drip is adequate to be sure that she is comfortable.

What strikes me about her situation is the profound sense of appropriateness in her family's acceptance of the inevitability of her passing and the fact that they are all in agreement about how it should go. She has already expressed her wishes as to the disposal of her remains and what sort of service she wants. There has been no acrimony. There have been no demands of "Isn't there anything else you can do, doctor?" There is no attitude of "Spare no expense." There is only love and grief.

To visit this hospital room gives me a very old-fashioned a sense of rightness. It is an all-too-rare experience for me lately. I have watched over the years as death has become protracted, agonizing and expensive. This one is by no means cheap. But it is well worth it.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Thursday, September 1, 2011

Whittling costs in white coats

At the beginning of last week, I was excited to be invited to take part in the American Board of Internal Medicine Foundation's Summer Forum, where the who's who in medicine convened to discuss how to create a sustainable health care system, where costs are controlled and quality of care is preserved. We heard some bold visions and ideas, many of which were focused on badly needed policy levers or system redesign.

White Coat Ceremony by GLMS1 via Flickr and a Creative Commons licenseHowever, as I ended my week on Sunday with investing the University of Chicago Pritzker School of Medicine's new medical student class with their white coats, I was wondering how we can teach and empower individual trainees to do their part. As our speaker highlighted so eloquently, the most powerful thing about the white coat is what and who is in it, and also the learning that takes place in it. So, in that vein, here are some thoughts for what students and residents can do.

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Read up on the topic
Here are some excellent resources I heard about at the meeting:
Physician Stewardship of Health Care in an Era of Finite Resources, a recent article in the Journal of the American Medical Association by Drs. Chris Cassel and David Reuben regarding the various levels of stewardship.
Personal Reflections on the High Cost of American Medical Care, a recent article in Archives of Internal Medicine by Dr. Steven Schroeder.
The Pricing of U.S. Hospital Services: Chaos Behind a Veil of Secrecy, a classic by noted economist Uwe Reinhardt.
"Less is More Series, a great resource in Archives of Internal Medicine edited by Rosemary Gibson and others.

Listen to the patient
Of course, this sounds simple, but the truth is that more times than not, the answer is in the patient history. With duty hours and workload, taking a detailed history sometimes takes a backseat to reviewing the electronic iPatient.

One approach is to start with two open questions: (1) Tell me about yourself; and (2) What are your health care goals? Often, the key is to try to understand the baseline. I once took care of an older patient who had abdominal pain and had received over 40 abdominal CTs over the past several years. When we were able to gather more information from the patient and her family, it turns out that she has had bad abdominal pain for over 30 years that would come and go! By working this information into her discharge summary and plugging her into primary care, our hope was to have her avoid future costly and harmful workups. As I've mentioned before, students often have more time with patients than residents or attendings and can often take the most helpful and detailed history!

Learn the physical exam
Often times, we rely on tests since we do not trust our physical exams. It is too easy to get an echo when you are wondering if you are truly hearing a murmur. The lore here is that you need to listen to a lot of normals to be able to detect the abnormal. Because of this, when I am on service, I usually invite the third year student to examine every patient with me so they can see a lot of exams. Usually by the end, they are more confident in their ability to detect crackles or murmurs.

As stated by our white coat speaker, the stethoscope is indeed a powerful tool. Interestingly, with the infectious increase in global health experiences among medical students and residents, working in resource poor settings requires ingenuity and reliance on the lowest technologically feasible solution. Closer to home, volunteering in a free clinic is likely to provide one with the same experiences.

Don't just check boxes. Ask why the test is indicated
Trainees can ask the difficult question, why are we ordering this test or medication? Is it indicated? An even better question to research is whether there is a cheaper (we can't shy away from using that word anymore) alternative that would provide the same information?

For example, before every pulmonary embolism protocol CT or Doppler to rule out deep venous thrombosis, I always ask my team to calculate the Wells score so we understand if the test is indicated and what our pretest probability is. In addition, every study has a downside, whether it be hospital-acquired anemia from phlebotomy or incidentalomas and pseudodisease from excessive imaging. It is easy to check boxes, it is harder to question why you are checking them.

Try to find out how much the test costs
While the answer is elusive, the goal is to start the conversation in your own backyard. There are anecdotal reports of residents going back over 10 years who have tried to work with their hospital billing departments to find out how much things cost. Moreover, greater knowledge of costs will change practice patterns as we've discussed before.

Counsel patients
One impressive thing about the ABIM Foundation Forum was the representation of patient advocacy groups who were willing to partner with physicians and physician groups to reduce the costs of care. While the image that may immediately come to mind most is of a patient coming in to request a test that is not indicated, engaged and informed patients expressed the desire to work together and that less is more. In some communities, there is a lot of distrust of the medical care system and these conversations have to start one patient at a time.

Unfortunately, whittling health care costs is not as easy as teaching trainees. As long as our systems and the faculty within them promote costly workarounds such as misrepresenting tests as urgent to expedite them, ordering tests as fast as possible for fear of discharge delay, or wasteful lab testing, trainees will be reprimanded for not doing something. Therefore, to truly make change in our teaching hospitals, we must also ask that our faculty reach deep into their own white coats and find the courage to say "Don't just do something, stand there."

Vineet Arora, MD, is a Fellow of the American College of Physicians. She 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, supervising internal medicine residents and students caring for general medicine patients, and serves as a career advisor and mentor for several medical students and residents, and directs the NIH-sponsored Training Early Achievers for Careers in Health (TEACH) Research program, which prepares and inspires talented diverse Chicago high school students to enter medical research careers. This post originally appeared on her blog, FutureDocs.

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Contact ACP Hospitalist

Send comments to ACP Hospitalist staff at acphospitalist@acponline.org.

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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