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

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Friday, March 30, 2012

Ten pillars of medicine

I've been debating with myself how to break the actual practice of medicine into its essential parts. These, I think, are the basics of what we do every day in the hospital:

I. Care for the ill. Reassure the worried.
II. Know when to start.
III. Know when to stop.
IV. Fluids.
V. Diuretics.
VI. Judicious use of antibiotics.
VII. Appropriate use of steroids and immunosuppression.
VIII. Use the best available evidence and know where to find it.
IX. Use common sense and the 10 equations of physiology for the rest.
X. Listen to the skepticism in your soul but adulterate with a tincture of a hope.

Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.

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MGMA details academic physician pay

A new survey details how much less academic professors are making than their private practice peers.

Physician compensation in academic settings continued to trail that of physicians in private practice, as is customary. Family practitioners in academic settings reported median compensation of $173,801, compared with $189,402 in private practice.

Specialists in academic settings also reported median compensation that trailed physician earnings in private practice. Anesthesiologists earned $326,000 in median compensation in academic settings and $407,292 in private practice. General surgeons in academic settings earned $297,260 in median compensation, compared to $343,958 in private practice.

Academic rank is one way to escape this pay gap. Primary care associate professors reported $173,963 in median compensation, but professors reported median compensation of $198,000. Primary care department chairs reported median compensation of $282,296. Specialty care associate professors earned $260,075 and professors earned $280,000. Specialty care department chairs reported median compensation of $506,200.

Chart by MGMA
The MGMA released the salary ranges in its report, Academic Practice Compensation and Production Survey for Faculty and Management: 2012 Report Based on 2011 Data.

Geography also has an influence, the report said. Dermatologists in academic settings reported median compensation of $277,765 in the Midwest and $234,936 in the Western region. General pediatricians in the Eastern section reported $157,289 in median compensation and in the Southern section reported median compensation of $139,410. In the Eastern section, urologists reported $368,401 in median compensation, compared with $300,000 in the Midwest, $336,000 in the Southern section and $445,247 in the Western section.

Compensation in academic settings is les influenced by clinical care reimbursement, the press release explained, and more by research support, educational activity and endowments and philanthropy.

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Wednesday, March 28, 2012

What happens in Vegas can be used to teach costs of care

Funded with a grant from the American Board of Internal Medicine Foundation, Costs of Care has partnered with medical educators at Harvard Medical School and the University of Chicago (that would be us!) to start addressing this problem. We are developing a series of web-based medical education videos that use clinical vignettes to illustrate core principles of cost-consideration, including how to communicate with patients about avoiding unnecessary care and reducing overused or misused tests and procedures.

As part of the project launch, we released a new teaser video today called "What if Your Hotel Bill Was Like a Hospital Bill?" The video is a tongue-in-cheek depiction of the challenges patients face in deciphering medical expenses, and their additional confusion when they learn doctors are not trained to consider costs. - Excerpt from Costs of Care Press Release by Dr. Neel Shah.




How does this relate to Vegas?

On a recent trip to Las Vegas with my family for the holidays, I was in the Bellagio lobby admiring the Chihuly glass ceiling. While that was impressive, I was also watching the clerks check in and out the long lines of visitors to the hotel. The staff explained any charges on the bill, confirmed that the bill agrees with the expectations of the patron and then finalized the transaction, printing a copy on the spot for the traveler before they got in the cab to the airport hailed by the bellman.

What a far cry from hospitals, where most of the hospital staff have no idea how much anything costs! After all, doctors are notoriously bad at considering costs in the doctor-patient relationship, as demonstrated by a great piece by Dr. Peter Ubel on his experience with the cost of his own prescription medications. As Paolo (or Paul who works as our research project manager in his day job) from Hotel Hospital highlights, "Our hotel staff specifically focus on the highest quality of care. ... I doubt that they even know how much anything costs here." The rest of the script was easy to write. Shooting was a lot harder since we had to find a spot in the hospital that looked like a hotel, but thanks to some creative camera angles and props from our MergeLab team, we were able to get it done.

Learning about costs of care is critical to taking care of patients. This was especially poignant during my recent inpatient service block at a nearby community hospital, since I cared for many uninsured patients who paid out of pocket for their medications (not to mention their hospital stay).

Our residents were concerned about one patient who was uninsured and would have difficulty paying for Plavix, a critically important drug after his heart procedure. Review of his medications also revealed he was recently put on Lexapro, a nongeneric antidepressant (with a sordid history) that was costing him more than $100 a month when there is a generic alternative for $4 a month, which would help him afford his Plavix.

When physicians do discuss costs, they also get it wrong and perpetuate a medical urban legend such as that patients have to pay when they leave the hospital against medical advice (this is not true!). These are just a few of many examples of why teaching students and residents to bring up costs and arming them with tools to address the issue with their future patients is imperative. Without considering costs of care, we all take a gamble that costs of care are not an issue for patients. Of course, the odds are against that.

Stay tuned for more work from our Teaching Value Project from Costs of Care funded by the ABIM Foundation.

Special thanks to our production team and actors: Mark Saathoff , Andy Levy MS4, Kimberly Beiting, Paul Staisiunas, Jeanne Farnan, and Neel Shah!

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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Life at Grady: Destiny

So it all started with jury duty last week. I was sitting there in a big room in the courthouse minding my own business and happy as I-don't-know-what that they had WiFi and even happier that I had thought to bring my laptop. I watched the obligatory video, which for whatever reason, wasn't so bad this time around and even managed to write a blog post. Even though I was in jury duty, it was all good.

Then I did what I'm sure many people sitting in that holding room did. Exactly! I checked my email. Yawn. Nothing too exciting really. Work-related stuff and reminders about things that I needed to be remembering. Otherwise, not too eventful. Amongst those uneventful emails was an email from a medical student. Also not unusual--at all. Anyways. This email was inquiring about our residency program and whether or not we had any openings which we did not. I quickly shot the student back an email thanking her for her interest but letting her know that we'd filled all of our positions in the match for the coming year.

And this was also not at all unusual. Because I get these kinds of emails often--so often that I can probably type that response with my eyes closed.

So there I sat in jury duty with nothing to do but wait. I'd already blogged. I'd forgotten to bring a magazine. And I wasn't in the mood to read anything on my Kindle queue. So clearly I did what any bored person would do. Of course! I checked my email again.

And there it was. A response from that student. Just like that. Explaining a bit more about her situation but not so much that it felt like TMI. She had attended college in Atlanta and was visiting with friends. Here for spring break, she wondered if my schedule would allow us to chat.

Chat? Chat about what? I didn't have any positions. I'm sure she was nice and all but I couldn't exactly hire her or anything. And truthfully, I can't just be meeting up with any and every random person who emails me. And don't even judge me for saying that because you know you can't either.

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

Since I was held captive in that courthouse, I went ahead and responded.

"Was there something in particular that you wanted to speak with me about?"

Of course that was wrapped around a few other diplomatic sentences, but that was the gist of it. She responded back in the snap of a finger.

"We don't have to meet in person. I'd really just hoped to talk to you so that if you had something open, you'd have more insight into me."

Lawd.

I liked the humility in the email, but still. Why did she want to meet me or even talk to me if I couldn't necessarily give her a position? Maaaan. I'm a bleeding heart and all but seriously? I just don't have time. And look, y'all. Before you give me the hairy eyeball, you have to understand how residency programs work. People not only from ALL OVER the U.S. contact program directors about positions but also applicants from all over THE WORLD contact you, too. Setting up times to chat up all of the folks that email you--despite how wonderful they surely are--could take up your entire week. So I generally try to avoid it.

I prepared to quickly reply a kindly worded decline to her, but decided to just chill for a moment. What was the hurry? Hell, all I had was time in jury duty which, at the rate things were going, was about to be good and plenty.

Then, just two moments later I hear the clerk shuffling at the microphone.

"IF YOU HEAR YOUR NAME CALLED, PLEASE RAISE YOUR HAND HIGH AND SPEAK UP IN ACKNOWLEDGMENT!"

And I sat there waiting. More like yawning and waiting because I knew my name never seemed to get called in the first few batches of people. Since this was batch three, I listened just enough to see if somebody I knew was also unlucky--err. .. .had the honor of serving their time in jury duty that day, too.

That's when I heard it.

"KIMBERLY MANNING!"

I thought it was some kind of joke. I looked up from my laptop incredulously.

Awww man! Already? Dude!

"Uhh. . .HERE!"

Great. Getting called meant going upstairs to an actual courtroom. And going up to an actual courtroom meant no more WiFi and no more catching up on emails and friends' blogs. Talk about a buzz kill.

He kept rattling off names and horribly mispronouncing a few of them. Great. None of them even seemed fun. Man. This was totally going to be the group mandated for the next OJ trial--I could feel it. I closed my laptop and prepared to scuttle off to wherever we were going to be scuttled off to next. I took a deep breath and prepared myself to be a big girl about it.

Your civic duty. Your civic duty. Your civic duty.

And then this:

"IF I CALLED YOUR NAME, YOUR CASE HAS BEEN SETTLED. YOU ARE DISMISSED FOR THE DAY. THANK YOU FOR YOUR SERVICE."

Dis-WHO?

Shut the FRONT DOOR! Dismissed?! Hush yo' mowf!!

I looked at the time on my iPhone--10--fricking--23 AM. Shut. Up.

I skipped out of that courthouse and past those security checkpoints whistling Dixie. Like literally.

So I get out in the sunshine and realize that I'd expected to be in that building all day. Hell. I didn't know what to do with myself. I just sort of stood there with this dorky grin on my face smiling at people who looked at me and my big blue JUROR sticker on my chest.

I started to do the running man dance for a minute, but remembered that the last time I did jury duty, one of our big-boss deans was there, too. For all I knew, the dude could walk up while I was mid-stride.

Anyways. I sit on a bench and pull out my phone. For whatever reason, I looked at that email again from that same student. And then--and I'm not sure why--I pushed the hyperlinked number at the bottom of her email and called her right then and there.

"Hello?"

"Hey there. This is Dr. Manning. How are you doing today?"

"Uhhh. . . Dr. Manning?" she cleared her throat hard. "I'm good. Very good."

She sounded stunned as hell that I'd actually called her. But also she sounded pleasant, professional, and driven. We exchanged a few pleasantries and then I started to hear more about her story.

She was at an excellent medical school and preparing to graduate this spring. Without going too much into her business, I learned that she was sort of in a jam. Match day had been bittersweet and she was trying to get a one-year spot. That, I couldn't assist with.

But as I listened, I also figured out that we had a whole lot in common.

Like me, she was an African American female who had attended a historically black college. Like me, she had roots in the south. And she seemed to have spunk. She was almost scrappy--kind of like I was as a medical student.

I listened. I responded to her queries. And I liked her. Instinctively, I liked her.

It dawned on me then that although I couldn't help her out with her particular situation, I could put her in contact with a friend of mine at another institution who potentially could. A friend who'd gone to medical school with me who was now in a high position elsewhere.

So I called her. And she listened, too. And together we decided that we'd try to help.

And since that phone call last week, I have talked to that student four other times and emailed/texted even more than that. I've made at least fifteen calls to other people on her behalf.

And today, I called just to be of encouragement.

"Just called to remind you that you will succeed in this."

"Thank you, Dr. Manning. After last week and us talking I am really feeling that way, too." And I could tell that she meant every word.

You see, I'm not sure if you all realize it but medical school is hard. Like some parts of it are really hard. But it's not just because of the complexity of the facts you're trying to master. The environment breaks some people long before the school work. Yeah. The medical school and residency environment can be really rough for any person who is different in any way. And by different, I mean a lot of things. I mean things like being black. Or being older. Or having a kid. Or being from a foreign country. Or having some kind of disability. Or even something as simple as just being married with children (since most medical students are not.)

Unlike this young woman, I attended a historically black college AND a historically black medical school -- which meant I never felt or was treated like a minority as a medical student. But once I went to residency and then came here, I realized that black students and residents can feel pretty isolated sometimes. No, this isn't unique to my institution or where I did my training at all. In fact, my good friend who leads a program way off in another state talks to me all the time about this very thing and how it manifests at her institution, too.

So my point is--it's an everywhere thing.

Anyways. At some (and by some I mean many) academic medical centers, black medical students get lost. Especially the ones that are very good and full of promise but not necessarily stellar on paper. They get overlooked or misunderstood. And unless there is some great mentor advocating on their behalf and helping them to slug it out, it can be a hard row to hoe.

Man. Tonight when I spoke to that young lady, she sounded so encouraged. Like my time and attention had meant so, so much to her. And for the record--my friend and me had not sorted out her problem yet. We hadn't secured her a position or anything like that. But I can say this: We did listen to her and try to see what we could do to help. And when I talked to her I did my best to inspire her to keep fighting because I believed that if she did she would win.

And she said to me, "You know what, Dr. Manning? I believe that, too. I truly do."

We got off the phone and I just sat there at my kitchen table lost in thought. Then, without warning, tears started rolling over my cheeks and splashing on my lap. Tear after tear and I couldn't make it stop.

Crazy right? Maybe. Maybe not.

Like. . . .do you ever have these pivotal moments in your life that start as something super tiny but while they are happening you just know it's the start of something big?

Oh, you don't? Dang.

Well, I do. Like what if me being a student at Meharry and then a faculty at Emory and still friends with a classmate from Meharry who happens to be on the faculty at another institution AND who also happens to have connections all over the place. . .like what if all of that was just a part of a drum roll to this moment in time? All setting me up for that one moment where I randomly decided to cold call that student after being sprung from jury duty. . . .like what if that was the case?

What if the time I took--that we took--to at least try to see what we could do to help her but even more to just mentor her and inspire her -- just what if that changes her life? What if reading her emails without distractions and then calling her was like that movie Sliding Doors -- you know, the one that shows how an entire life can change with something as simple as making it onto a subway before the doors close on you?

I spoke to my other good friend, Jada R., who happens to be Meharry classmate, too. She helps me process in times such as this so I called her up. And you know? I couldn't even get the story all the way out before I started crying.

"This is so crazy," I blubbered, "I don't even know her, Jada. I don't even know her."

And Jada just listened intently and replied softly, "Of course you know her. We both know her. She's us, Kim."

Of course. She's us.

That did nothing but make me cry even more.

So now I am just reflecting and rambling about these moments in time and what we do with them. I am sitting here with a giant ball of Kleenex partly because I'm hormonal but mostly because I'm feeling so full just imagining how much one human being can do for another . . .and how just maybe the entire universe has been waiting for one of us to do this tiny part in something enormous.

Just maybe.

Jada and I always speak of this black female physician who had us over to her home for dinner when we were fourth year medical students rotating up at Case Western SOM as visiting students. We had just passed our second set of boards and had done well--and we were SO HAPPY. I'm talking CRAZY, INSANELY happy. But according to her, we were a little too happy.

"You're so. . . happy and relieved, wow. But I think I hear too much relief in your voices. This is interesting."

And we looked puzzled. She went on and said this:

"At some point, you will have to get comfortable with succeeding. You'll have to stop treating it like it's some kind of accident or fluke and accept that you are fully deserving of it. Why not? You deserve to win."

She said that while buttering a roll or sipping wine or whatever she was doing. My point is that it was just a tiny moment at her dining room table, you know? Like I doubt if it was even a big deal to her, you know? But those words--those mighty words--changed our lives, do you hear me? Changed our lives.

We talked about those words all the way home. We spoke of them around commencement time. We revisited them during residency and again when we were both asked to serve as chief residents at our respective residency programs. And even to this very day, Jada and I speak of that one moment in time at least once per year. That one moment in time.

Anyways. . .back to the student.

Honestly? I was actually very disappointed when all of our phone calls and discussions didn't end in some fairy tale ending to that student's situation. That would have made this story a hell of a lot better, right? But in my heart of hearts I know that she will be fine. In fact, she will be more than fine. She's going to win. And I told her just like that doctor told Jada and me seventeen years ago: "Why not? You deserve to win."

That may have been a bold thing to say to someone I don't even know. But you know what? That woman who said that to me didn't know me either.

But then again, maybe she did.

Sigh.

Once I ended my hyperemotional babble in Jada's ear, I finally said, "Girl, I just can't stop feeling like . . . I don't know. . . this was some kind of destiny. Like I was supposed to be in her life to. . .I don't know. . . to help nudge her to the next level."

And wise Jada responded, "That could be, sister. Unless, of course, she was supposed to be in your life to do that for you."

Hmmmm.

That could be.

The previous post is from the blog Reflections of a Grady Doctor, by Kimberly Manning, MD, FACP, a hospitalist at Grady Memorial Hospital in Atlanta. Names and identifying information have been changed as needed to protect privacy.

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Tuesday, March 27, 2012

Save the date for social mission and medicine

In 2010, a group led by Fitzhugh Mullan compiled a provocative ranking of medical schools based on a "social mission score." The criteria used in calculating the index for medical schools were:
--output of primary care physicians,
--doctor-graduates serving in underserved areas, and
--number of minority physicians trained.

This was a through-the-looking-glass approach to ranking medical schools, since it practically inverted the traditional rankings. The schools usually at the top of the U.S. News & World Report rankings (based on research dollars and reputations, among myriad other factors) were all near the bottom of Mullan’s list.

The article caused a stir in both the media and in academic medical circles. It was nice recognition for state schools and historically black medical colleges that emphasize training primary care doctors to serve in their communities. The schools at the bottom of the list were forced to explain why their missions, although different, still made a social impact.

If the world didn’t actually change, it was at least a good thing because it forced academics and the public to think a little differently, if even for a short time.

If any of this story moves or interests you, then I’m happy to tell you of an upcoming conference at which this conversation will continue. Movers and shakers in the worlds of social justice and medical education will come to Tulsa to brainstorm how we can better serve the needs of our country in the 21st Century.

[Beyond Flexner refers to the 100th anniversary of the Flexner Report, a 1912 white paper commissioned by the Carnegie Foundation that had an enormous impact on how medical education was structured and delivered in the 20th century.]

Info on the conference:
Beyond Flexner: Social Mission in Medical Education will feature the work of a recently completed study on examples of "post-Flexnerian" medical schools, as well as innovations in medical education related to the social determinants of health, public health, and social accountability in an era of market and legislative driven health reform.

Beyond Flexner: The Social Mission of Medical Education
May 15-17, 2012 - Tulsa, Oklahoma
FEATURED SPEAKERS INCLUDE:
David Satcher, MD, MPH
H. Jack Geiger, MD
Gerard Clancy, MD
Additional details will be available soon, so stay tuned!

Questions? Email mailto:beyondflexner@gmail.com

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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Coronary artery calcium the risk marker that matters most

Coronary artery calcium scores offered the most statistically and clinically significant value to Framingham Risk Score predictions among 12 coronary heart disease risk markers, a study found.

Coronary artery calcium (CAC) measurement may be the only newer coronary risk factor to add meaningful information to standard risks, such as smoking and diabetes, noted editors of Annals of Internal Medicine, in which the research appeared on March 20. But measuring coronary artery calcium is expensive and exposes individuals to radiation, so its use for coronary risk assessment requires further evaluation.

To assess whether newer risk markers for coronary heart disease risk prediction and stratification improve Framingham predictions, researchers conducted a prospective, population-based study among 5,933 asymptomatic, community-dwelling participants from The Rotterdam Study in the Netherlands.

The research measured traditional coronary heart disease risk factors used in the Framingham score (age, sex, systolic blood pressure, treatment of hypertension, total and high-density lipoprotein cholesterol levels, smoking, and diabetes) and newer risk factors (N-terminal fragment of prohormone B-type natriuretic peptide levels (NT-proBNP), von Willebrand factor antigen levels, fibrinogen levels, chronic kidney disease (CKD), leukocyte count, C-reactive protein (CRP) levels, homocysteine levels, uric acid levels, coronary artery calcium scores, carotid intima-media thickness (cIMT), peripheral arterial disease and pulse wave velocity).

Adding coronary artery calcium scores to the Framingham score improved the accuracy of risk predictions (c-statistic increase, 0.05; 95% confidence interval [CI], 0.02 to 0.06; net reclassification index, 19.3% overall [39.3% in those at intermediate risk, by Framingham]). Levels of NT-proBNP also improved risk predictions but to a lesser extent (c-statistic increase, 0.02; 95% CI, 0.01 to 0.04; net reclassification index, 7.6% overall [33.0% in those at intermediate risk, by Framingham score]). Improvements in predictions with other newer markers were marginal.

Improvements in coronary heart disease risk prediction with other newer risk markers, including cIMT, ankle-brachial index, and pulse wave velocity, which have been shown to be strong predictors of coronary heart disease in other studies, were modest, the authors reported. NT-proBNP may be more useful for coronary heart disease risk prediction at older ages. Although other biomarkers such as fibrinogen levels, CKD, leukocyte count, CRP levels, and homocysteine levels, were independently associated with the risk for later coronary events, their incremental value beyond traditional risk factors was marginal.

"The better performance of CAC score compared with other vascular measures of atherosclerosis probably reflects the disparity in contribution of various vascular beds in the disease process," the authors wrote. "However, because of variations across studies in the number of risk categories and thresholds and in clinical outcomes of interest, it is difficult to make direct comparisons of our findings with those of other population studies."

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Monday, March 26, 2012

Bewildering insurance policies and how they play out in reality

A woman goes to her urologist. She has a known stone that was partially removed through a cystoscopy a month ago. She has been having residual colicky pain for the past month that has been getting increasingly worse. Her urologist recommends a CT scan to see if there is evidence of obstruction. Her insurance denies the scan.

Now from a health economics perspective, this is where it gets interesting. She is so disgruntled that she goes to the local emergency room where she racks up a hefty ED bill, has the scan done, and gets admitted. They don't have a hospital bed for her at this particular hospital but they do at the sister hospital across town, so they send her over by ambulance and she is admitted to a medical floor for two days.

If you were the insurance company wouldn't you be kicking yourself right about now for not just getting a CT scan from her urologist's office. Maybe the outcome would have been the same, but then again maybe it wouldn't. Waste anyone?

Flabbergasting.

Justin Penn, MD, ACP Associate Member, attended medical school at the University of Washington School of Medicine and trained in internal medicine at the University of Rochester, where he is serving as Chief Resident. This post originally appeared at his blog, Musings of an Internist.

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QD: News Every Day--Medical boards issue real punishments for online conduct

Most U.S. medical licensing authorities have handed down punishments, sometimes severe ones, for unprofessional conduct online, a survey found.

Researchers surveyed the executive directors of all 68 medical and osteopathic boards about violations of online professionalism and subsequent actions taken. This study was done in partnership with the Federation of State Medical Boards (which does not track online violations; hence, the survey).

The research letter was published at the Journal of the American Medical Association.

Directors of 48 boards responded, representing about 88% of the approximately 850,000 physicians in the Federation's database, of whom 44 of 48 (92%) reported receiving at least one online professionalism violation. The most common ones were inappropriate patient communication online, such as sexual misconduct (33 of 48; 69%) for one or more violations); use of the Internet for inappropriate practice, such as online prescribing without an established clinical relationship (30 of 48; 63%); and online misrepresentation of credentials (29 of 48; 60%).

In response, 34 of 48 (71%) of boards held disciplinary proceedings, including formal disciplinary hearings 24 of 48 (50%) and issuing consent orders 19 of 48 (40%). In addition, 19 of 48 (40%) of boards issued informal warnings and 12 of 48 (25%) reported at least one instance in which no action was taken.

Serious disciplinary outcomes such as license restriction, suspension or revocation occurred at 27 of 48 (56%) of the boards.

"[T]hese violations also may be important online manifestations of serious and common violations offline, including substance abuse, sexual misconduct, and abuse of prescription privileges," the researchers wrote. "In addition, these incidents are highly problematic in their own right because they reflect poorly on physicians' values to the public."

The history of online misbehavior has been documented before, for example, by 60% of medical students.

ACP issued guidance for online behavior as part of its ethics manual.

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Wednesday, March 21, 2012

Life at Grady: Zoom

"Tell Patrick to shut that screen door!"

I nervously rearranged the covers over Ms. Abner since I couldn't meet that request. First of all, there was no screen door in this hospital room. And second of all, I wasn't fully certain who Patrick was.

"Hi Ms. Abner. It's me, Dr. Manning. I'm just here to see about you and check on your bladder infection, okay?"

"Somebody told y'all to come over here and I didn't want all that. I still got to write out bills."

I stared into Ms.Abner's eyes and searched for something, anything that would even our playing field. A glimmer or flicker to let me know we were in the same place. But we weren't.

You see, Ms. Abner had been robbed. Slowly and ruthlessly robbed. Not in that way where someone kicks in your door and ransacks the place for everything at once but in that way that takes some time to realize. A piece of jewelry here. A couple of dollars there. Until one day you look up and realize that just about everything you really cared about is gone. With the exception of the heavy furniture.

And yeah. Technically, robbery suggests that something is being taken by force. But in my mind, any time someone loses their precious memories and cognitive abilities, it has to be by force. Even if it seems sneaky like a pick pocket, no matter what anyone says, it's still brutal like robbery.

Yeah. So, Ms. Abner had been robbed. Over and over in broad daylight with everybody at home.
Her eyes were so vacant. Off in some far away land with people named Patrick and swinging screen doors. And the hardest part was that she wasn't even seventy years old yet.

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

"You're looking a little better today, Ms. Abner. Your blood pressure is better and your fever seems to have broken."

"Do she know how to get there? Somebody need to give her directions, don't they?"

"Beg pardon, Ms. Abner?" I reflexively asked.

Zoom.

Just like that, that idea was gone, too. Now it seemed like the heavy furniture was being lifted right along with the silverware.

I looked down at the blanket dutifully strewn over her shoulders. A lovely leopard-printed fleece that clearly wasn't a Grady issued item. Her face had been scrubbed clean and covered with what looked like Vaseline. The thinning gray hair on her head was tightly plaited into cornrows. It was obvious that someone loved her.

Next I saw a note taped to the bedrail:

"My mother Ms. Lola Abner is very cold-natured. Please keep cover on her shoulders even when it seem like the room is warm. Also if you take off her socks you need to put them back on her feet because she get cold. ~ Signed, Angela Campbell (her daughter)."

Written in careful cursive with love in every swirl. Followed by two phone numbers in big block letters, just in case that note wasn't clear. And so, I did exactly as that meticulous note suggested. I checked to make certain that her body was fully covered with her blanket and that her socks were on both of her feet. One was off so I replaced it.

She stared out of the window speaking in disconnected sentences. I watched her, trying my hardest to see the person that I am sure she once was. The one before the thievery and the vacancy.

"Ms. Lola." I spoke her name quietly while patting her cheek. She turned her head in the direction of my voice. I repeated myself. "Ms. Lola, Ms. Lola, Ms. Lola."

And that seemed to be something that the robbers couldn't move. Her name, Lola.

So I just stood there saying her name. And each time that I did she responded. She even smiled--at me. Not just in my general vicinity but truly at me, this person who was speaking her name. I wanted to see who she was so badly. This was the closest I could get.

And so. For the rest of her hospitalization this is what I did. I talked to her doting daughter about the details of her condition. Then I told Ms. Abner the plan -- whether she could hear me or not. And last, I just rubbed her dewy skin with the back of my hand and murmured her name.

"Ms. Lola."

And that always seemed to even the playing field.

On the day she was being discharged, I stopped by the room to see her. Ms. Abner's daughter, Ms. Campbell, was there fussing around her bed getting things ready. Once she had everything packed up in the plastic bags she sat on the chair and sighed.

"Did Patrick get what I told him to pick up from the store?"

Ms.Campbell reached down and tightened the draw string on the bag. She didn't look the least big fazed. "Mama, Patrick is gone, remember baby? But I got all the stuff you like at home from the store, okay?"

"It's weeds all out in that flower bed. I don't know why nobody don't just pull 'em up. A little bit every day so they don't get overgrown."

"Mmm hmmm, okay Mama. We gon' get you out the hospital today, okay baby? You doing better, Mama so we gon' get you on home." She looked over at me and pressed her lips together for a moment before speaking. "A nurse is going to get us discharged, right?"

"Yes, ma'am," I answered.

"Okay, good. Thanks, hear?"

I smiled and just sort of stood there thinking of what to say next. Ms. Campbell was on to the next thing and barely seemed to notice the pregnant pause.

"Umm, Ms. Campbell? What questions do you have for me about your mother?"

"Oh, huh?" She looked up from her pocketbook. She had already moved on to throwing out the old receipts and scraps of paper cluttering her bag. "Questions? None, sweetheart. We okay."

"Oh, okay."

I waited a few more seconds and then spoke again. I hoped I wouldn't regret that next question, but I just had to know.

"Ms. Campbell?"

Without glancing up from her purse she answered me. "Ma'am?"

"Who is Patrick?"

This time she stopped what she was doing altogether. She smiled and let her ample chest rise again with a big breath inward. "Patrick? Patrick was her baby brother. She loved him so much."

"He passed on?"

"Yeah. . . .an accident on the job when he was only in his twenties or so. I was just a little girl when he went home but I swear I feel like I know him. She always speak of him."

I nodded and kept my eyes fixed on her daughter. "Wow."

"She loved Patrick so much. Mmm, mm, mmm. That was her heart."

"You can tell," I responded. Then I chuckled and added, "Even if he left the screen door open."

Ms. Campbell threw her head back and laughed out loud. She glanced over at her mother and said, "Mama, you still on that screen door? Lord have mercy!"

And that laugh was easy and gentle but laced with some pain. I think I sensed it because right after she said that the room fell awkwardly silent. I bit the inside of my cheek and watched this woman who could not have been even ten years older than me. I imagined my own parents and loved ones and siblings and tried to get my mind around that laugh laced with angst.

I couldn't.

"Do you . . .miss her?"

Ms. Campbell squeezed her eyes together tight, almost like she was trying to literally create a dam to hold back tears. She shook her head and sighed again. That same big, bosom-raising sigh. "Every day," she finally said. "I miss my mama every single day."

"Mmmm." That was my response. It wasn't much but it conveyed a lot I hoped. Like, I bet you do miss her, or I don't know how you do it, or I bet you she misses you, too.

"It's hard because sometime she look at me dead in my eyes and seem so much like herself. And she say something that sound just like the mama that raised me and I do everything I can to keep her in that moment. But then just like that, she gone again. This almost worse than having her gone altogether. I think that sometimes. One minute she here, then she gone."

Zoom. Just like that.

"I'm sorry."

"Sometimes I am, too. But not for myself. She still my mama. It's still her. Deep inside I know that."

"Yeah," I said back, almost under my breath. Then I spoke up. "What was. . .she like? I mean before?"

Ms. Campbell's eyes lit up and then floated away into another time and place for a moment. "My mama was bossy. And opinionated. And a cook? Girl, what you talkin' 'bout! But she was a mean cook. She wouldn't give nobody her secrets and didn't like nobody in her kitchen when she was cookin' neither. And she didn't like nobody swingin' no screen doors in her kitchen letting flies in. Wheeewww, you want to see her mad? Open that screen while she cooking." She laughed again. But this time without the pain. "And she was a good mother to us. She took good care of us. It's six of us and she treated us all like we was the only one."

"Wow."

And after that, there wasn't much more to say. I moved toward the bed and studied Ms. Abner's face. I searched her for that person that her daughter had just painted. Instead of her frail and atrophied body, I imagined her able-bodied wiping her hands on an apron in her kitchen. I pictured her scolding children for swinging screen doors and seating them at a wooden table to say grace in unison over food she'd prepared with love. I even let that image include a young Patrick, strong and muscular, wolfing down a plate that she'd placed warming in the stove for him, her beloved younger brother.

"Ms. Lola, Ms. Lola, Ms. Lola," I whispered to her one last time.

Again she turned toward my voice and gazed right at me.

And for the first time, I think I truly saw her, too.

Kimberly Manning, FACP, is a hospitalist at Grady Memorial Hospital in Atlanta. The preceding post is adapted from the blog, Reflections of a Grady Doctor. Names and identifying information have been changed to protect privacy.

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Tuesday, March 20, 2012

What can the health care system learn from a car dealer?

A friend just bought a new car and was raving about the experience. This was not a luxury car, just a regular popular model.

Car dealership on Western Ave by David Hilowitz via Flickr and a Creative Commons licenseI personally dread the car buying experience for many reasons but one thing that bothers me is the discontinuity. You often see the sales person several times and to some extent the character of your relationship with him/her impacts the decision to purchase the vehicle.

But, the moment you sign on the dotted line, you experience the hand-off. If you have a question or problem with the car, and you try and reach the formerly very responsive sales person, you get shunted off to the voice mail of the service department.

Well, my friend was in a bit of shock because he experienced something quite unique. The sales person spent an hour after the purchase describing every feature of the car and answering numerous questions. In addition, he offered to stop by his home in a day or two to see if there were any questions that came up after he had used the vehicle.

But the real kicker came when he started driving out of the dealership. The sales person gave him his card with his cell phone number and e-mail address and said, "For any questions or problems you call me first and it is my job to ensure that they get resolved. I will arrange for any service needs and for a loaner car."

Compare this experience with that of a hospitalized patient about to be discharged. He gets a huge packet of papers including complicated discharge instructions, phone numbers to call for appointments, changed medication lists, etc., and a message "If you have problems call your primary care provider."

The primary care physician in question often has no idea of what happened in the hospital; even with electronic health records, the discharge summaries and hospital notes are often unhelpful, with critical information lost in a flood of meaningless data. Even if all the information is there, it cannot compare with the knowledge that is created from actually taking care of acutely sick patient in the hospital. It is almost impossible to transfer this "knowledge" using a paper or electronic record.

To make matter worse, the next time the patient gets admitted, he ends up with a different provider and the whole process starts us again.

Have we, in the interest of efficiency and short lengths of stay created silos that are impacting on the patient experience? This has led to the concept of the patient navigator which are being variable implemented/piloted. Based on this anecdote, every hospital needs to have knowledgeable patient navigators. Dare I say that the health care system should learn something from a car dealer who has already implemented this concept?

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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Advanced life support skills quickly unlearned after training

Advanced life support knowledge and skills decay by six months to one year after training, and motor skills fade faster than knowledge, researchers found.

Guidelines currently require retraining health care providers in advanced life support every two years or more.

Researchers conducted a systematic review of studies of how much advanced lifesaving skills are retained. They found 11 studies in the literature that applied multiple-choice questionnaires to evaluate knowledge and cardiac arrest simulation or other skills tests to evaluate skills.

Results appeared online at Resuscitation.

All studies reported variable rates of knowledge or skills deterioration over time, from six weeks to two years after training. Clinical experience had a positive impact on retention. A prospective, randomized, controlled study found that having half a year of clinical experience before training had no effect on immediate learning, but did result in better retention of both knowledge and skills at six months.

Another study showed that defibrillation and intubation skills deteriorated more rapidly for nurses than for physicians. Yet another study looked at four multi-disciplinary groups assessed quarterly for a year. The percentage of subjects able to pass the skills assessment declined rapidly to 37% at 3 months and 14% at 12 months. The group that outperformed the others had a higher percentage of critical care nurses, direct patient care providers and more frequent advanced life saving providers.

"Perhaps not surprisingly, skills appear to deteriorate more rapidly than knowledge," the authors wrote. "Similar discrepancies between knowledge and skill performance have been well documented in studies of [advanced lifesaving and basic lifesaving] and other clinical skills."

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Friday, March 16, 2012

The Match: Lessons from the Board

Good news: the stories are true.

As students, most of us have heard about (or seen, as attendees in previous years) the raw emotions on display during Match Day. From sheer elation to disappointment, from intense displays to composed reactions, Match Day often showcases a wide spectrum of emotions.

This was absolutely true for me. In the minutes before envelopes were handed out, several leaders shared some remarks, words that felt muted against my intense anticipation. I couldn't take my eyes off of the "Match Board," the vehicle Baylor uses each year to notify students of their residency matches. Each student's name is printed on an enormous board with corresponding envelopes stapled beneath to create a neatly arranged grid of fates. The entire board is sealed underneath wrapping paper and secured until the appointed time. As the speeches continued, I glanced around at my classmates. I wasn't the only one fixated on the board.

When the paper was finally torn away, a sea of eager, nervous hands descended on the board, snatching away the envelopes in staccato bursts. Some tore away the seals and opened their envelopes immediately. Others scampered back to clusters of family and friends where they opened their envelopes together. I chose a variation of the latter, walking mine back carefully to my brother and a few trusted friends waiting in a corner of the courtyard. Behind me, shouts of joy mixed with names of cities all around the country. I took a long breath and pushed back the nervousness rising within my chest. I thanked each person in my small support group and reinforced how content I was with the entire process. Then in one swift motion, I tore my envelope open.

The seconds that followed were a blur. I remember clenching my fist in gratitude before looking up and being mobbed by hugs. I had matched to an amazing program, and inside, I was ecstatic. My swelling contentment seemed to retrospectively justify the way I'd ranked my programs. The months of critical assessment and personal reflection had paid off.

I spent the next 10 minutes moving through the courtyard, congratulating my classmates and exchanging our good news. As I did, the joy inside began blending with an overpowering sense of relief, and I paused for a moment to soak in that important feeling. In one sense, I was absolutely thrilled to match to a program that fit my personal and professional goals. There was much to be excited for. But in another sense, I knew in those first moments that there was far better news than even that. Outcome aside, I had arrived after a long journey with my values intact; that I knew the immense privilege it had been to even visit such outstanding programs; that the way I handled myself had mattered immensely; that in staying true to myself, I had finally found my match.

Joshua Liao, BA, BS, is an ACP Medical Student Member and current fourth-year medical student at Baylor College of Medicine in Houston, TX. He will begin his internal medicine residency this July at Brigham and Women's Hospital in Boston, Mass. His professional goals include care redesign and the promotion of patient safety across care settings.

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The Match sets medical students in search of ourselves

Medical students quickly become familiar with residency match ("the Match"). Almost every attending and resident physician has interesting stories about his or her experience. Older students share endless advice regarding the Match, and many institutions and professional societies shine spotlights on the process each year. On a larger level, the Match receives regular attention across numerous Internet forums and occasionally in the mainstream press.

These factors have helped tether the Match in student consciousness. But behind the massive collection of coverage, opinion, anecdotal stories (and lore), we students sometimes miss what a unique way it is to find our first jobs as physicians.

On one level, considering residency programs requires uncommon diligence. After synthesizing enormous amounts of advice from mentors and peers, we must carefully construct our applications over several weeks and then invest considerable time, energy and resources visiting a number of programs. Subsequently, we spend the better part of four months methodically studying features from each, a process that proves as demanding as it is essential. While grueling, it reflects the arguably unprecedented academic importance of our choices and their implications for our careers.

(Click "more" below to continue reading.)

On another level, the Match is also unlike any other process most of us have ever experienced. At every other transition point in our educations, from high school to college, and then to medical school, we were largely in control. We applied to as many schools as desired, interviewed as circumstances allowed, and received exceptions when needed. We heard back from all schools definitively, giving us concrete acceptances, rejections, or waitlist statuses to use in our decision making. We could take full inventory of our options and arrive at choices that felt like ours.

With residency, the process is distinctly more opaque. Some programs respond more quickly to our applications than others, if at all, and ultimately, we only receive feedback from one. We must process our goals using potential scenarios and consider our preferences without any assurance of acceptance.

What makes the Match unique, however, is how this uncertainty can blend with personal reflection to create powerful self-understanding. While we sometimes visit programs that are exactly as we imagined, it is not uncommon to be over- and underwhelmed by many. While we might set up complex rubrics and systems for ranking programs, decisions often boil down to what is known in the medical community as "gut feelings." While certain features pique others' interests, they might not pique ours.

As obvious as these observations might seem, they point to crucial lessons: that to find true matches, we must understand ourselves as we try to understand programs. To emerge clear-minded from a potentially opaque process, we must diligently take inventory of our values and remain resolute in them.

In my case, that required regular exercises of courage and honesty. To my surprise, several programs did not fit my career goals despite excellent reputations and resources, while others complemented those goals but did not resonate with me. Some programs disappointed in certain domains but exceeded my expectations in others. Ultimately, I did not want to reflexively follow popular opinion or make far-reaching choices based on brief, subjective feelings.

To avoid that, and to filter through the complex array of academic and personal factors, I had to dedicate considerable time to ensure that while I could not control the outcome, I would handle the process well. The task frequently required enough honest introspection to ask myself difficult questions about my motivations, as well as the personal courage to trust my final judgment more than rankings and other opinions. That sustained disciplined proved harder than expected, a sentiment many of my peers around the country seemed to share.

Amid the important but often overwhelming attention given to the Match, this opportunity for self-understanding is crucial. As applicants, we do need evidence-based approaches to critically assess our options and soberly understand the academic rigor of each. We do benefit from early curriculum vitae preparation and knowledge about scores, attire, etiquette, and commonly asked interview questions. Anecdotal advice from mentors and older students can be appropriately tailored to our individual backgrounds. But the importance of self-knowledge, and the way it helps us create rank lists that are true to ourselves, seems too often lost in the frenzied preparation.

So despite the Match process's many attendant challenges, my parting charge to my peers is to pursue self-knowledge diligently. For some, it may mean drafting personal statements early to understand their degrees of confidence and understanding in their specialty choices. For others, it may mean deeper consideration of how research interests or advanced degrees fit with clinical medicine. Those still undecided may benefit from asking trusted advisors and loved ones about their observations. And for most, it will be essential to ask themselves what matters most to them and what they are willing to compromise.

Regardless of detail, the benefits of this pursuit are tangible: more thoughtful personal statements, clearer ways of communicating our interests on interviews, more penetrating analysis of various programs, and greater contentment that we have done everything possible to pursue the very best match for ourselves.

Ultimately, that is crucial. Behind the massive collection of opinion and information, the Match is not just a unique way to find our first jobs as physicians. It is also a unique, powerful way to find out more about ourselves and the people we are becoming.

Joshua Liao is an ACP Medical Student Member and a current fourth-year medical student at Baylor College of Medicine in Houston who will begin his internal medicine residency this July. His professional goals include care redesign and the promotion of patient safety across care settings.

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Wednesday, March 14, 2012

Life at Grady: Hurry up and wait

I was holding a patient's hand yesterday. She was the last person I was seeing on rounds that day and it had been a long day. I was feeling over-scheduled and over-tired and over-everythinged. The clock was on my back and the list of things I had to do at home was just as long as the one I had finally finished at work.

I needed to go.

It was already 5:20 P.M. The sun was already on a downward descent and late afternoon sunshine was peaking lazily through the hospital blinds. And today, there wasn't much going on with her so I felt confident I could get out in time to get both my kids on time.

If I hurried, I'd be just fine.


There was a procedure that she'd needed and that procedure had been done. She'd tolerated it well and all of the teams of physicians caring for her were now working in a lovely three-part harmony. Plans clear. Clinical course, at this point, predictable.

This was supposed to be a quick in-and-out visit. A chance to check on her pain and see if she needed anything. What would work best for my schedule would be for her to say, "Nope, I'm good" or even ask one obligatory question to which I could quickly answer.

Not so fast.

"Hold my hand," she said. She was telling me more than asking me, so I sat down on the edge of her bed and did what she said.

"You okay?" I softened my voice to let her hear my concern. And to hide my ticking time clock.

"I'm fine. I just want you to hold my hand for a little while that's all."

What? But. . .

"Okay," I answered. "I can do that." Because even at 5:22, I could. At least for a moment.

So I held her hand and waited for her to say something but she didn't. She just sat there watching Judge Judy and not even looking at me. The silence was killing me so I made some small talk.

"Are you moving your bowels okay?"

"I am." She nodded her head while saying that. Keeping her eyes on Judge Judy.

"Any pain?"

"Just a little. But the pain pills help mostly. So mostly no pain." She shook her head. Back to Judy.

"Okay."

I softened the grip on her hand and she sensed it as the warning that I was trying to leave. Her fingertips pressed into the back of my hand.

"Don't go. Can't you just stay with me for a little while?"

Eyes off the television and now on me. I didn't respond. Instead I just sat still to show her that I'd try to stay a little longer. Even though I really needed to go.

I looked into her eyes. They were unusually wide like brown saucers.

"You sure you alright?" I finally said.

"You know? Nothing is wrong right now. I just like you. I like your voice and how you look at me. It makes me feel better for some reason."

My face immediately grew hot.

"I like you, too." That was all I could think to say. But at least it was true.

After a few moments, she let my hand go. Then she said, "I know you got to go. You probably got to go on home or see other patients and I know that. I can tell you a busy person. But you know what? You got this special thing about you that don't make people feel rushed. Even when you in here quick it feels like you got time for me."

Wow.

I sat there speechless. I thought about how many times this week I'd already told my kids to "hustle up."

"If you feel rushed I guess it don't even matter if it's not a rush," she added.

I thought about the last thing I'd said to Isaiah as he dawdled that morning before school. "Come on, buddy. Sense of urgency, bud, let's go. Hustle up." Even though we were making good time this morning.

Yeah, hustle up.

"I guess perception is reality."

She looked over from Judge Judy. "What's that, Miss Manning?"

"Just what you said. What it seems like might as well be how it is."

"Yeah."

"You know what? I was kind of in a hurry when I came in here. I can't lie."

Now she was off of Judy for good. She smiled at me sideways.

"But you didn't make me feel like that, see."

"Hmmm."

I squinted up at Judge Judy and then looked back at her. The verdict was just about to be rendered. This let me know that it was very close to 5:30.

And that I still needed to go.

"You know? Some days I'm pretty sure I don't get it right."

"Today you did."

I grabbed her hand again and squeezed it. "Man. I kind of needed that today. You must have sensed that I did."

"No, Miss Manning. . . you know. . . actually I didn't."

"Well, it seemed like you did." We both chuckled.

"So what it seem like might as well be how it is. Right, doc?"

"Right, indeed."

I paused for twenty more seconds after hearing Judge Judy bang her gavel. Judgement for the plaintiff. The credits started to roll and a commercial came on.

"Alright then, Miss Manning." She gave my hand a pat of dismissal.

I stood up to leave and headed toward the door. I flicked off her light switch and replied, "Alright then."

Kimberly Manning, FACP, is a hospitalist at Grady Memorial Hospital in Atlanta. The preceding post is adapted from the blog, Reflections of a Grady Doctor.

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iPads make residents more efficient on rounds

Internal medicine residents have limited work hours for their work duties, so every minute spent on paperwork comes at the expense of direct patient care or education. Residents at the University of Chicago internal medicine service, like other programs around the country, applied iPads to see if they could boost resident workflow efficiency and patient care.

Resident Nancy Luo, MD, ACP Associate Member, wrote to Steve Jobs directly, and got the response the next day. Jobs directed an Apple marketing manager to visit the hospital for follow-up.

The iPads were password-protected. They could access to the hospital's wireless network but did not store records. Apps include access to medical journals and a clinical calculator, and links were required for PubMed, the hospital paging directory, journal club, a scheduling tool and a list of discount drug prices.

115 residents received iPads and were surveyed about their habits and self-perceived efficiency one month before and four months after receiving them. The electronic health record marked the time frame of all patient care orders placed in the first 24 hours of a new patient's admission from January to March 2011. These data were compared with the time frame for orders during patient admission in the same three-month period in 2010 to seek any change in ordering efficiency.

The rate of patient orders per admission by admission hour was compared for both groups. Results appeared in a research letter in the March 12 issue of Archives of Internal Medicine.

Almost 90% of residents (100) used their iPad for clinical duties, with almost 75% (72) using their iPad every day. 78% reported being more efficient on the wards, with a self-reported time savings of about an hour a day.

56% felt that they could attend more conferences by using their iPads. 68% percent of all housestaff reported averting patient care delays. Study authors wrote, "Interestingly, interns were more likely than residents to report that the iPad improved their efficiency on the wards (89% of interns vs. 71% of residents; P=.03)."

From January to March of 2010 and 2011, there were 631 and 675 general medicine admissions, which generated 16,770 and 17,414 total orders placed in the first 24 hours of admission, respectively. There was no difference (P=.58) in the number of orders per admission in 2010 before iPads (27 orders per admission) and 2011 after iPads (26 orders per admission).

The timing of orders changed after iPads arrived. Specifically, 5% more orders were placed prior to postcall attending rounds, and there were 8% more orders placed prior to the time at which postcall teams are scheduled to leave the hospital. More orders were placed prior to postcall attending rounds (33% precall vs. 38% postcall; P less than .001) and before departure of postcall team (56% precall vs. 64% postcall; P less than .001). There were also more orders placed in the first two hours of admission (odds ratio, 1.06; 95% confidence interval, 1 to 1.12; P=.04) in 2011 with iPads than in 2010 without them.

"We were encouraged to see that this technology could enhance patient care in the setting of restricted resident duty hours," said chief resident Christopher Chapman, MD, ACP Associate Member.

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Tuesday, March 13, 2012

Counterfeit cancer drugs have become a new source of concern

This week the FDA issued an alert about fake Avastin. The real drug is a Genentech-manufactured monoclonal antibody prescribed to some cancer patients. Counterfeit vials were sold and distributed to more than a dozen offices and medical treatment facilities in the U.S. This event, which seems to have affected a small number of patients and practices, should sound a big alarm.

Even the most empowered patient--one who's read up on his drug regimen, and engaged with his physician about what and how much he wants to receive, and visited several doctors for second opinions and went on-line to discuss treatment options with other patients and possibly some experts--can't know, for sure, exactly what's in the bag attached to his IV pole.

The problem is this: If you're sick and really need care, at some point you have to trust that what you're getting, whether it's a dose of an antibiotic, or a hit of radiation to a bone met, or a drug thinner, is what it's supposed to be. If vials are mislabeled, or machines wrongly calibrated, the error might be impossible to detect until side effects appear.

If you're getting a hoax of a cancer drug in combination with other chemo, and it might or might not work in your case, and its side effects, typically affecting just a small percent of recipients, are in a black box, it could be really hard to know you're not getting the right stuff.

What this means for providers is that your patients are counting on you to dot the i's. Be careful. Know your sources. Triple-check everything.

The bigger picture--and this falls into a pattern of a profit motive interfering with good care--is that pharmacists and doctors and nurses need time to do their work carefully. They need to get rest, so that they're not working robotically, and so that they don't assume that someone else has already checked what they haven't. And whoever is buying medications or supplies for a medical center, let's hope they're not cutting shady deals.

This issue may be broader than is known, now. The ongoing chemo shortage might make a practice "hungry" for drugs. And with so many uninsured, some patients may seek treatments from less-than-reputable infusion givers. The black market, presumably, includes drugs besides Avastin.

If I were receiving an infusion today, like chemo or anesthesia or an infusion of an antibody for Crohn's disease, I'd worry a little bit extra. I mean, who will check every single vial and label and box? Think of the average hospital patient, and how much stuff they receive in an ordinary day, including IV fluids that might be contaminated with bacteria.

It's scary because of the loss of control. This circumstance might be inherent to being a patient, in being a true patient and not a "consumer."

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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Monday, March 12, 2012

Going beyond tobacco, alcohol and drugs during the social history

As I am on service, I realized that one thing that can be easily lost in the race to take care of patients with limited duty hours: the social history. The social history is part of the admission "history and physical" that once included a myriad of information about the patient's job, life, and habits has now "fallen into despair" becoming little more than "negative for TED", or in other words "no tobacco, alcohol (ethanol) or drugs."

But, there is so much more to it than that. How do they afford to pay for their housing, food, and medications? Do they have insurance? Where do they live? Who takes care of them or do they take care of someone else? Do they have friends or family living nearby? What do they like to do for fun? Given that most of the discharge planning focuses on these elements of the social history, it seems silly that we don't include more than just "no TED."

So, when I was asked by a very astute medical student if I preferred to hear more in the social history, I said yes. The information that is usually discussed as the patient gets better and we wonder where they will go was now presented on admission, discussed as a problem just like any other medical problem.

In just a few short days, we discerned that a patient who had chronic hypoxia and shortness of breath worked in a factory which likely contributes to his interstitial lung disease. Another patient who had been hospitalized for alcohol withdrawal recently broke up with a girlfriend, which triggered this bout of drinking. Another patient who was a Jehovah's Witness would rather have IV therapy for his wound infection than surgery. Another patient with repeated hypertensive crisis had skipped his medications since he could not afford them.

Given the tremendous burden of costs of medications and the complex interplay between social factors and health, it's time that we start teaching people to take a thorough social history. Wondering what should go into a thorough social history, I first did what most physicians do: I went online. It turns out that Wikipedia has an entry on social history for medicine that starts out with the same substance abuse history. It also includes occupation, sexual preference, prison, and travel.

I stumbled upon another interesting piece by a medical student in the Los Angeles Times who admits that it is easy to skimp on the social history due to the time it takes to take a complete history. After a brief foray in PubMed, a study demonstrated that internal medicine residents do not often know the social history of patients, and this worsens if the resident is more advanced in training and when the workload is higher. Then, I recalled the seminal text that is still in use today. According to the Bates Guide to History and Physical Examination:

"The Personal and Social History captures the patient's personality and interests, sources of support, coping style, strengths, and fears. It should include occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences, such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs).

"It also conveys lifestyle habits that promote health or create risk such as exercise and diet, including frequency of exercise; usual daily food intake; dietary supplements or restrictions; and safety measures and other devices related to specific hazards. You may want to include any alternative health care practices. You will come to thread personal and social questions throughout the interview to make the patient feel more at ease."


There is another good reason to teach the social history. Another study shows that those residents who took better social histories were actually perceived to be more humanistic. As others stated, "By knowing patients better--and taking better social histories--we will provide better care and will be more fulfilled and energized in our work as physicians."

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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Sunday, March 11, 2012

Is medicine an information science? Perspective from hospitalist time studies

We tend to think of medicine as a health science or a life science, yet in many ways it is an information science, and may be becoming more so with the growth of data generated in the care of patients. If medicine is indeed an information science, then there is a critical role for biomedical and health informatics, which is the field that uses information to improve some aspect of health, health care, and biomedical research.

A couple years ago I reviewed in my blog two articles that had recently been published about the role of information in medicine. One article, by Stead et al. posited that the quantity and complexity of information in medicine requires a fundamental paradigm shift from the "power of the individual brain" to the "collective power of systems of brains"1. The authors noted that the numbers of facts per clinical decision will likely increase exponentially, especially as our knowledge moves beyond the phenotype to include the genotype (e.g., genomic variation, proteomics, etc.)

The second article, by Shortliffe, was published about the same time in a special issue of JAMA devoted to medical education2. He noted that while medical education (rightly so) goes to great lengths at teaching students how to assess, interact with, and treat patients, it devotes very little effort to obtaining, using, and analyzing another critical component of medical care, namely information.

What evidence is there that medicine is an information science? After all, most modern knowledge workers, i.e, professionals in financial analysis, aviation, and marketing, to name a few, make critical use of information in their work. A number of studies, mostly but exclusively done looking at hospitalists, have looked at how physicians spend their time, and provide clear evidence that information is critically important to their work.

Some might think that physicians spend the majority of their time with patients, such as examining them or performing procedures on them. However, these time studies show that physicians spend more time interacting with information, such as reviewing data and documenting patient care, than interacting directly with patients.

These studies assess the tasks of physician work and the time spent doing them. Some of the tasks primarily involve using information. (It is unfortunate that others in the health care environment have not been studies, but as often happens, physicians are the targets whom researchers have chosen to study.) Enough of these studies have been done to lead Tipping and colleagues to perform a systematic review3. In addition, four more studies have been done since the completion of the systematic review by Kim et al,4 Tipping et al.5, Yousefi,6 and Chisholm et al.7

The systematic review points out that the studies are heterogeneous and cannot be group to do something like a meta-analysis. Yet the results are surprisingly consistent. The systematic review develops a classification to which most studies relatively adhere.

The studies all measure in some manner "direct" patient care, where the physician interacts directly with the patient. They likewise describe "indirect care" of the patient, where the physician reviews patient data, performs documentation, and communicates with various people, such as members of the care team, the patient and/or their family, insurance companies, and others.

Finally, most studies have some sort of "other" category that includes travel (either within a health care facility or between them), education, and personal time (such as eating). The systematic review and three of the follow-up studies focused physicians who work on hospital wards (i.e., hospitalists), although one of the more recent studies looked at emergency department physicians.7The studies have been somewhat though not exclusively weighted toward academic facilities and physicians in training.

Even with the variation in definition of the categories and tasks within them, the results are remarkably consistent. While the range is wide, most of the studies show that physicians spend about 15-17% of their time in direct patient care.

Conversely, they spend about 64-67% of their time in indirect patient care, often relatively evenly divided between reviewing results, performing documentation, and engaging in communication. The tasks of reviewing results and carrying out documentation are clearly information-focused in nature, which means that physicians spend about 35-40% of their time engaged with information. One could also probably argue that aspects of direct patient care are information-focused as well, as the physician is gathering information about the patient. The education component of the other category is of course very information-oriented.

Some additional interesting tidbits come of the individual studies. The newer Tipping et al. study took place in a setting of full electronic health record (EHR) implementation and noted 34% of physician time was spent interacting with the EHR.4 This study and two others by O'Leary et al.8 and Westbrook et al.9 in the Tripping et al. systematic review looked at multitasking, finding it was being done during 16-21% of physician work time.

O'Leary et al. also found physicians received 3-4 pages per hour 8, while Westbrook et al. noted an average of 2.9 interruptions per hour 9. Kim et al. found that the amount of direct care was higher at the beginning of shifts while indirect care was higher toward the end of shifts 5. They also noted that 7% of physician time was spent in travel within the health care facility, wondering whether this might be an area where efficiency of work can be improved 5.

In their study of emergency department physicians, Chisholm et al. noted that somewhat more time was spent in direct patient care (31% for academic settings and 38% for community settings) and less in indirect care (55% for academic settings and 50% for community settings.7) They also found these emergency physicians were interrupted on the order of 10 times per hour.

These studies collectively show that hospitalists and in emergency department physicians spend a substantial amount of their time interacting with information. Going forward, the amount and complexity of information is likely to increase. It will come from diverse sources, such as patients entering data into their personal health record (PHR), clinical data coming being provided via health information exchange (HIE), and the growing amount of data from genomics and related areas. This makes the science of biomedical and health informatics even more critical to the medical field.

References:
1. Stead, W., Searle, J., et al. (2010). Biomedical informatics: changing what physicians need to know and how they learn. Academic Medicine, 86:429-434.
2. Shortliffe, E. (2010). Biomedical informatics in the education of physicians. Journal of the American Medical Association, 304: 1227-1228.
3. Tipping, M., Forth, V., et al. (2010). Systematic review of time studies evaluating physicians in the hospital setting. Journal of Hospital Medicine,5: 353-359.
4. Tipping, M., Forth, V., et al. (2010). Where did the day go? A time-motion study of hospitalists. Journal of Hospital Medicine, 5: 323-328.
5. Kim, C., Lovejoy, W., et al. (2010). Hospitalist time usage and cyclicality: opportunities to improve efficiency. Journal of Hospital Medicine, 5:329-334.
6. Yousefi, V. (2011). How Canadian hospitalists spend their time - a work-sampling study within a hospital medicine program in Ontario. Journal of Clinical Outcomes Management, 18: 159-164.
7. Chisholm, C., Weaver, C., et al. (2011). A task analysis of emergency physician activities in academic and community settings. Annals of Emergency Medicine,18: 117-122.
8. O'Leary, K., Liebovitz, D., et al. (2006). How hospitalists spend their time: insights on efficiency and safety. Journal of Hospital Medicine,1: 88-93.
9. Westbrook, J., Ampt, A., et al. (2008). All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Medical Journal of Australia, 188: 506-509.

This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, appeared on his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.

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Thursday, March 8, 2012

C. diff prevention in hospitals has to start in the community

Most Clostridium difficile infections (CDIs) are related to nursing homes and similar settings where patients receive predisposing antibiotics and C. difficile transmission occurs, according to research by the Centers for Disease Control and Prevention.

Three programs were reviewed to come to the conclusion: the CDC's Emerging Infections Program, the National Healthcare Safety Network (NHSN) Multidrug-Resistant Organism and Clostridium difficile Infection module for laboratory-identified (LabID)-CDI events, and early results from three state-led programs in Illinois, Massachusetts and New York. Results appeared online March 6 at the Morbidity and Mortality Weekly Report.

The Emerging Infections Program included persons in the catchment areas of 111 acute-care hospitals and 310 nursing homes. More than 10,000 CDIs were identified; 44% of patients were aged less than 65 years. Overall, 94% of all CDIs were related to other health-care exposures. Of these, 75% had their onset outside of hospitals. Also, 20% of hospital-onset CDIs occurred in recent residents of a nursing home, and 67% of nursing home-onset CDI cases occurred in patients recently discharged from an acute-care hospital.

A total of 711 acute care hospitals in 28 states conducted facility-wide inpatient LabID-CDI event reporting to NHSN in 2010. More than 42,000 LabID-CDI events were reported. Overall, 52% of LabID-CDI events were already present on admission to hospitals. The pooled rate of hospital-onset CDI was 7.4 per 10,000 patient-days, with a median hospital rate of 5.4 per 10,000 and an interquartile range of 6.2.

The pooled hospital-onset CDI rate across the three states' prevention programs declined 20%, from 9.3 per 10,000 patient-days.

Report authors noted in MMWR that these findings emphasize how the risk for CDI from antibiotic exposure and transmission moves with patients across multiple health-care settings. Antibiotics received in one setting often predispose a patient to develop an infection in another.

Because the incubation period is a median of only 2 to 3 days, acquisition of C. difficile is overall more likely to have occurred in the setting where symptoms have their onset and CDI is diagnosed.

"Because nearly 75% of all CDIs related to U.S. health care have their onset outside of hospitals, more needs to be done to prevent CDIs across all health-care settings," the authors concluded.

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Wednesday, March 7, 2012

Life at Grady: Top Moments on the Wards

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor and reprinted with permission. Names have been changed to protect privacy.


TOP MOMENTS ON THE WARDS
IN THE FIRST THREE DAYS OF MARCH

#9 - Ro-sham-bo!

This morning on rounds we asked our young patient this:

"What questions do you have for us?"

And he said, "I don't have any."

That wasn't surprising. Even though he wasn't even legal yet, with his chronic medical problem he knew the ins and outs of how such hospitalizations work. Then he added:

"Wait, yes I do. I have one question."

"What's that?" I asked.

"Do you know how to play 'rock, paper, scissors?'"

"Do I?"

Our patient smiled for the first time at that point. A big, bright smile that peeled back his lips and showed all of his teeth and a whole lot of his gums, too. That smile brightened up that room.

"Alright, let's see who wins!" he announced while squirming to sit upright in bed. I loved how boyish and playful he was about it.

And so we started. Me, the patient, the resident, and the intern. Playing rock-paper-scissors which I hadn't played since Isaiah was a newborn and Harry and I were trying to determine who had to wake up next.

"Rock-Paper-Scissors. . . . Shoot!"

The best part: Our patient won. Best out of three.

#8 - Sugar pie honey bunch (but not like that.)

Patient was lying in bed this morning. She'd been very, very short of breath so we wanted to limit her talking. I saw her alone on rounds today. She was resting on her back with her eyes closed which she opened only for a moment when she greeted me.

"Hey, sugar."

"Hey," I replied. "How you doin' today?"

"Good, sugar."

"Your breathing?"

"If I stay still, it's okay, sugar."

"Okay. Can I listen to you?"

"That's fine, sugar pie."

Sugar pie. Sigh.

I listened to her chest and back. Felt her tummy and made sure she was okay. When I got ready to leave, she opened her eyes again.

"You beautiful." She smiled at me and squeezed the hand I was already holding.

"You are, too."

She closed her eyes again and looked like she was falling asleep. Then suddenly they flung open.

"I wasn't trying to sound funny. Like. . .I meant you beautiful like inside and out. Not like you beautiful like I'm trying to date you."

Wait, huh?

I smiled and then laughed because that was the last thing I thought this grandmother was saying so it was funny.

"Nawww, I never thought that. I got what you meant."

"Oh okay, sugar. 'Cawse, you know, I didn't want you thinking I was trying to be all like 'how YOU doin'?'" She gave a weak laugh and then coughed.

Not. Kidding. That's what she said.

#7 You smell me?

A man gets on the elevator with me on Thursday.

"Damn! Somebody in here smell good!"

Then. He commences to sniff person after person on the lift. And I am thinking we should have moved away or something but for whatever dumb reason we all just withstood his sniffing.

Verdict:

"Doc, you smell pretty good, but I thank it's her right here that I smellt when I got in here. She smell the best." Then he looks over at this other lady and says--I kid you not--"now baby you might need you some more Sure." And he threw his head back and laughed. Then he leaned back over, sniffed her near again, and shook his head."Wheeeeew. Yeah, baby. You got to do somethin' bout that!"

Wait. Seriously? Seriously.

#6 Tell me how you really feel.

"Good morning!"

"NO!"

"Beg pardon?"

"Get out!"

"Get out?"

"Get out!"

"I need to examine you."

"No!"

"But--"

"I said NO!"

"Okay. Is there anything that I can do for you before leave?"

"Let that door hit you where the good Lord split you."

Well alrighty then.

#5 You probably think this song is about you.

"Can I go home today?"

"I'm pretty sure. We just need to confirm one more thing, okay?"

"Hmmph."

"What's wrong?"

"Manning said I could go. Manning! She's the boss. Call her so I can speak with her about me leaving. You need to call Manning."

"I'm Manning."

"You Manning?"

"Yes, ma'am."

"Oh, damn. I thought I could trick you into getting me on out. I thought you was a intern."

"Thought I was an intern?"

"Yeah, you looked kinda younger."

"And for this reason, I will totally be expediting your discharge."

#4 -- What's in a name?

"You're all set to be discharged!"

"Great!"

"Do you have someone to pick you up?"

"Yes. My lover is picking me up."

"Your lover?"

"Mmm hmmm. My lover."

*all of us laughing together*

"Your lover?" I repeat. "That sounds awesome."

"And baby if you knew my lover like I know my lover you'd know that he really is awesome."

*gives me two exaggerated winks*

Love. This. Place.

#3 -- The Hard Questions on the way home.

Isaiah: "How was your day, Mom?"

Me: "Kind of rough. One of my patients is pretty sick. She might die."

Isaiah: "Die?"

Me: "Well she has a bad illness, so yeah, she might."

Isaiah: "Did you give her some medicine?"

Me: "We've tried but for this kind of illness it won't work."

Isaiah: "Mommy?"

Me: "Yes?"

Isaiah: "Are you sure you know what you're doing?"

Ouch.

#2 -- Full Circle.

One of my interns this month is a student from my original small group -- "Small Group Alpha." I've known him since his very first day of medical school. Yesterday on rounds, every time he presented his patients or every single time I referred to him as "Dr. Wetmore" I sort of wanted to cry.

#1 -- I do not speak Spanish.

I have come to accept this. Louder and slower does not turn English into Spanish. Neither does saying "como se dice en Espanol" before every single thing you say. And so. I have vowed to call a Spanish interpreter whenever I have any situation at all where the patient does not have full mastery of English. No using the eight year-old in the room or the clerk on 7A.

On Friday, I went with the interpreter to see a patient and his family. And I did what the interpreters have taught me to do--speak exactly as I would normally speak with pauses for them to interpret. I held my patient's hand, looked him in his eyes, and even cracked jokes. The interpreter slowly faded into the background (which is their goal) and I connected with my non-English speaking patient and his family. It was awesome.

It doesn't sound so deep does it? But it was. It truly was. I realized how many patients I haven't connected with due to a language barrier. It felt so good to wait those few moments for someone to stand in and allow us that connection.

Claro que si.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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