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The Treatment of Solid Tumors: Some Recent Approaches

Physicians News — Tue, 07 Feb 2012 16:14:45 +0000

By Punit Dhillon At some point in their lives, one in five people will suffer from skin cancer, and the fraction is steadily rising. In spite of innovation in sunscreen technology and public attention to the need to be shielded from the sun, data reported recently by Dermatology Times show a rise in the average American lifetime risk of one skin cancer variety—invasive melanoma—from 1/600 in 1960 to 1/50 in 2008. Despite previous diagnosis and innovations in approaches to treatment, the age-adjusted number of annual deaths per 100,000 population is rising. Additionally, the expense to the healthcare system and society continues to increase. As U.S. and European populations age, the incidence of skin cancer and other solid tumor cancers will grow. According to the latest United States Cancer Statistics, published by the Centers for Disease Control and Prevention in 2007, the top 10 cancer types (based on incidence rate) are in the solid tumor category; today the priority is probably even higher. Thus, there are clear medical needs going unmet and the creation of novel, cost-efficient and patient-friendly treatments remain a top priority for both the healthcare community and patients. Various challenges of traditional treatments The treatment of solid tumor cancers, which range from melanoma and Merkel cell carcinoma to cutaneous T-cell lymphoma, continues to be a substantial challenge for physicians. For example, in spite of innovations in drug discovery and development, it is still challenging to simply deliver efficient drugs into cancer cells in a safe and effective manner. Meanwhile, today’s therapeutic approaches—involving surgery, radiation therapy and chemotherapy—each have characteristic and major drawbacks. Surgery, the current first-line treatment for localized and operable tumors or lesions, requires resecting the tumor mass and a surrounding boundary of healthy tissue to make sure that no cancer cells remain at the tumor site. Surgery can potentially cause physical disfigurement and/or debilitating effects on organ function, and the patient quality of life has been demonstrated to be negatively impacted. Also, surgery can require an expensive and long hospital stay. Radiation therapy is occasionally used in conjunction with surgery to shrink a tumor prior to surgical removal, or afterward to destroy any cancer cells that might remain. Yet surgery plus radiation can damage important normal tissues like nerves, blood vessels, or vital organs such as the heart that are within the designated zone of treatment. Radiation is also a costly therapeutic approach, and demands substantial expertise, precautionary measures and infrastructure to administer. Radiation entails major complications, such as nausea, diarrhea, dry mouth, taste alterations, loss of appetite, and the potential for the formation of new cancerous lesions. Those who get radiation to the heart often suffer from various types of heart failure in subsequent years. Typically, chemotherapy is a secondary or palliative treatment to help mitigate systemic or metastatic tumor growth, whereas surgery and radiation may be considered local treatments. In response to cancer’s spread, physicians will administer chemotherapeutic agents that circulate throughout the body, systemically and in high concentrations, to counter the challenge that some chemotherapeutic agents have in reaching and penetrating the cell membrane to trigger cell death. Yet the system-wide use of chemotherapeutics frequently has major side effects by killing healthy as well as cancerous cells. This systemic and non-targeted administration of anticancer agents can trigger alopecia; nausea; vomiting; myelosuppression; and drug resistance. Chemotherapy is curative for only a few tumor types. Additionally, all of these conventional treatments are only minimally effective on aggressive types of cutaneous cancers, especially in later stages of the disease. Some potential approaches We now offer an abbreviated look at some current approaches to override these challenges in treating solid tumors. One possible strategy for solid tumor treatment involves a new class of small-molecule drug candidates called vascular disrupting agents. Via interaction with vascular endothelial cytoskeletal proteins, these agents may selectively target and collapse tumor vasculature, thereby depriving the tumor of oxygen and causing death of the tumor cells. Another approach involves the use of new therapeutic monoclonal antibody candidates that target CD27, a member of the tumor necrosis factor (TNF) receptor superfamily. Anti-CD27 monoclonal antibodies have been demonstrated to effectively promote anticancer immunity in mouse models when combined with T cell receptor stimulation. In addition, CD27 is overexpressed in various lymphomas and leukemias and can be targeted for direct activity by anti-CD27 monoclonal antibodies with effector function against those cancers. There are many other antibody drugs on the market, some also with linked toxins or radiation. A third tactic involves the creation of an orally available nucleoside analogue for various cancers including solid tumors. This agent could act through a novel DNA single-strand breaking mechanism, leading to the production of DNA double strand breaks (DSBs) and/or DNA repair checkpoint activation; unrepaired DSBs go on to cause apoptosis or programmed cell death. Alternatively, solid tumors could be treated using a technique called tumor ablation, which involves destroying the tumor inside the body via various approaches. Radioactive pellets, shorter than an inch and approximately the width of a pin, can be inserted into the tumor; the pellet subsequently emits lethal radioactive atoms that irradiate the tumor from the inside out. As the tumor breaks down, it starts to release antigens that trigger an immune response against the cancer cells. Sometimes, the body also develops an immune memory against the future return of tumor cells. Another proposed ablation technique, called “pulsed electric current ablation,” involves the insertion of electrodes into tumors, which subsequently emit very high-energy electrical currents; these currents create a physical reaction that destroys the tumor cells. A separate approach involves applying local heating to the tumor using radio frequency techniques. In this instance, a thermal energy delivery device can be focused and targeted according to the shape, size and position of a specific tumor. Adjusting the frequency, phase, and amplitude of the radio waves, combined with different applicators and adjustment of the patient’s position, could conceivably permit a doctor to optimize the delivery of damaging energy into the tumor. Cancer scientists are also interested in attacking solid tumors by delivering drugs specifically into diseased tissues. Such a targeted approach can result in more efficient therapy while using smaller drug doses with fewer negative side effects. For example, in animal studies, immune-deficient mice carrying human forms of various cancers have been simultaneously injected with a range of anticancer agents and a peptide known as iRGD. iRGD can find and attach itself to receptors on solid tumor cancer cells and later activate their internal transport systems so that the peptide is essentially passed through cell after cell, moving progressively deeper into the tumor structure. Anticancer drugs lingering near the peptide molecules may also get pulled into and through the tumor mass by this transport mechanism, enabling them to attack cancer cells previously beyond their reach. By their nature and cellular architecture, solid tumors are equipped to limit the efficacy of most anticancer drugs. Tumors have poor vascular systems, which reduces exposure to drugs that have been administered into the circulation. The lesions are densely fibrous, which serves as a physical barrier against transport. Also, the tumors have high internal pressures, causing further physical challenges to any molecule attempting to enter the lesion. The iRGD peptide is designed to act like a key, switching on the internal transport mechanism of the cells so that they absorb anything that is proximal to certain cell surface receptors. Researchers believe the iRGD peptide could penetrate many tumor types and might be useful in treating most solid tumor cancers. An encouraging aspect of this approach is that both the peptide and anticancer drugs are effective together without being chemically attached. Yet another promising strategy for treating solid tumor cancers involves targeting the tumor itself without affecting any of the surrounding healthy tissue. This ensures that the drug or therapeutic agent is absorbed at once by the cancer cells and not normal tissues. One such targeted therapy could harness a physiologic process known as “electroporation.” Derived from the words “electric” and “pore,” this involves applying a brief electric field to the cancerous cell. The electrical pulse triggers the temporary creation of pores in the cell’s outer membrane—pores that close again within seconds once the electric field is discontinued. These transient pores can improve uptake of various drugs more than a thousand-fold. Several electroporation systems have been manufactured that consist of a generator that creates the pulsed electric field, and various handheld applicators with electrode needles at their proximal ends. The applicator delivers a controlled electric pulse to the cancer cells, thus causing any cancer cells within the affected region to undergo electroporation. The cell takes up therapeutic agents within the region of electroporation. This technology platform is being developed for use in two varieties of anticancer therapies: electrochemotherapy and electroimmunotherapy. In the former, an anticancer drug is injected into a targeted tumor; the lesion is then electroporated and the drug carries out its planned mechanism of action in killing the cell. As a result of the targeted, local therapy, the amount of drug needed to kill the cells is substantially less than that required in traditional, non-targeted chemotherapy. The lower quantity of systemic drug (cytotoxic agent) reduces harmful side effects linked to traditional chemotherapy. Electroimmunotherapy, the second application of electroporation, involves the use of a gene encoding a specific cytokine, a substance known to boost the human immune system against cancer cells. An immune response can have both a local and a distant effect against cancerous cells. These therapeutic approaches have been shown to be safe and effective across various types of tumors. Both patient outcomes and pharmacoeconomic benefits are substantial. This technology is in clinical testing in North America and is available for commercial sale in some European countries. Therapies such as those discussed here may provide a compelling set of novel approaches to the treatment of solid tumor cancers. ### Punit Dhillon is President and CEO of OncoSec Medical Inc., a biotechnology company developing its advanced-stage Oncology Medical System (OMS) ElectroOncology therapies to treat skin cancer and other solid tumor cancers. He can be reached at pdhillon@oncosec.com.

Resolutions Reflect the Changing Influences On Our Profession

Physicians News — Thu, 17 Nov 2011 14:59:06 +0000

By Lynn Lucas-Fehm, MD, JD

When the AMA was formed in 1847, the founders could not have imagined how health care delivery would change in the ensuing 150 years. The goals of the 19th century medical profession were ambitious but clear - to assure that the highest standards of excellence became the foundation for the practice of medicine. At the first meeting of the AMA, the delegates developed policies by introducing, debating, amending and ultimately passing resolutions. One example was the policy establishing the requirement for "gentlemen" entering the profession: Resolved, that this convention earnestly recommends to the members of the medical profession throughout the United States to satisfy themselves, either by personal inquiry or written certificate of competent persons, before receiving young men into their offices as students, that they are of good moral character, and that they have acquired a good English education, a knowledge of natural philosophy, and the elementary natural sciences, including geometry and algebra, and such an acquaintance, at least, with the Latin and Greek languages as will enable them to appreciate the technical language of medicine and read and write prescriptions. Today, resolutions affecting how we practice medicine are still introduced, debated, and voted upon in the same basic format as a century ago. Parliamentary procedure is aptly enforced by the speaker of the House of Delegates. When resolutions are passed, they are sent to the Board of Trustees for implementation while others are delegated to governmental liaisons who lobby politicians in hopes of favorable legislation. From October 14 through 16, I attended the annual meeting of the Pennsylvania Medical Society as a delegate. Over the many years that I have attended this meeting I find myself constantly looking for the changes which have occurred in the process and content of the event. What I have discovered is that the protocol has not changed but the issues that we address have persistently expanded to include government, political, business and legal issues which have taken control of our profession. Examples of this outside influence were quite apparent in the resolutions presented for consideration at the PAMED House of Delegates. A synopsis of the adopted resolutions taken from the PAMED website is as follows: Energy sources, risks to public health: Supporting energy sources that decrease environmental risks to public health and studying the state’s public health infrastructure State regulation of medical spas: Collaborating with state and national medical organizations to advocate for state regulation of medical spa facilities Professional liability coverage for physician volunteers: Seeking legislation requiring the state to provide free professional liability coverage in return for volunteering at free non-government clinics Medical Staff Code of Conduct: Adopting the American Medical Association’s (AMA) Model Medical Staff Code of Conduct Observation care codes; Medicare reimbursement: Advocate for an increase in Medicare reimbursement for observation care codes Physical fitness guidelines: Work with other organizations to develop a checklist to identify risk factors in patients starting physical fitness programs Water fluoridation: Working in conjunction with the Pennsylvania Dental Association to urge the state to adopt federal fluoride standards and apply them through legislative or regulatory initiatives Collective bargaining: Supporting federal legislation authorizing collective bargaining Several issues were referred to PAMED’s Board of Trustees for further study, which included consideration of Medicare as a public option, reforms to address problems with health plan pre-authorization programs that are outsourced to benefit managers, and controlling children’s misuse of prescription drugs. Resolutions affecting the practice of medicine have certainly evolved since 1847. Response to these adopted policies will likely be diverse. Healthy discourse is always good. However ultimately I hope that whether physicians agree or disagree with the resolutions that were passed at this year’s Pa Med House of Delegates, at least a few will be encouraged to get involved in the process. There is no question that we have little time to do anything except take good care of our patients while complying with the endless red tape that is necessary to run a practice. If we are lucky we find a little time to enjoy our family and friends. However, as the rules and regulations continue to increase, the need for all of us to be involved will be essential. For more information about these resolutions please go to the Pennsylvania Medical Society website at www.pamedsoc.org. ### Lynn Lucas- Fehm, MD, JD, is a radiologist at Abington Memorial Hospital and the 150^th President of the Philadelphia County Medical Society.

Going mobile: How EHRs and mobile technology are shaping one physician’s practice

Physicians News — Fri, 28 Oct 2011 13:38:51 +0000

By Dr. Michael West Two classes of physicians are slowly forming, those who use electronic medical records and digital mobile technology and those who stick with paper charts. You might call these the digital haves and the digital have-nots. No one among my friends and colleagues has yet pooh-pooh'd the idea of mobile tech, but I admit that the mobile tech crowd is still fairly small in the world of electronic healthcare. The bottom line is that most doctors are still on paper charts. In my case, though, my EMR and mobile technology are essential both to my work and my goal of having the highest efficiency possible in my practice. In an effort to share how that works, I thought I'd take the readers on a field trip into my life and my year-and-a-half old private medical practice in Washington, DC. In my office and on the road, I use Practice Fusion, a SaaS-based electronic health record. Practice Fusion has over 100,000 users and currently provides electronic medical records for more than 10 million patients. The nice thing about any SaaS-based record is that doctors can log in just about anywhere with an internet connection. One example of how this works for me came in mid-July, when I was at the New Jersey shore for a 5-day getaway. Unfortunately, there was a poor signal in the beach house for my personal MiFi 2200 device from Virgin Mobile. However, on the road home, the wireless signal was stronger and I was able to login to my EHR system, retrieve messages, review labs, and return patient phone calls. Thank goodness someone else was driving! Another example of my love affair with mobile health technology: I found myself lying in bed surfing the Net one night when my iPhone rang. It was my after-hours answering service calling to let me know that my patient, a young man with diabetes had run out of his insulin and needed help immediately. In a flash, I called him back, and with my wireless MacBook Air sitting on my chest, I opened up a new tab in my Safari browser and logged into Practice Fusion. After opening his file, reading his medication list and verifying that the patient was still using the same pharmacy to which I had previously e-prescribed his medications, I sent in insulin refills with a few clicks. It took me about three minutes in total, without even getting out of bed. Easy. So, am I suggesting that this approach would work for everybody, in every situation? Not necessarily. As with any technology, mobile EMR use has limits. For example, I'll admit that although doctors can reportedly access Practice Fusion using a Logmein app to run on the iPad, it's apparently not the same as using PF via a native iPad app. (To be fair, I've not tried this and don't know the basis for the concern.) Generally speaking, though, being a mobile-friendly physician isn't very tricky. In fact, I would say that this should not be any more of a hassle that upgrading to the next cell phone every few years. Sure, things might get more complicated if you use multiple mobile devices, but so far it's been manageable for me. I recommend that any physician who’s uncertain give mobile technology a try. After all, if you're going to use an EHR, you've already made a commitment to digital patient management. At that point, going mobile is just a no-brainer. ### Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009. He blogs regularly at The Happy EMR Doctor and can be reached by email at doctorwestindc@gmail.com.

Watson: Extreme Evidence Based Medicine

Physicians News — Thu, 13 Oct 2011 14:44:46 +0000

By Lynn Lucas-Fehm, MD, JD Most of us recall the literary character Dr. Watson who served as the steadfast confidant, supporter, physician and assistant to the brilliant detective Sherlock Holmes. Now there is a new Watson in our midst, an artificial intelligence computer developed by IBM and named after IBM’s first president Thomas J. Watson. After handily defeating the formidable human Jeopardy champions, Brad Rutter and Ken Jennings, Watson’s developers have expanded the computer’s medical databases to create what may become the ultimate digital collection of medical information. However, what truly sets Watson apart is that it can analyze facts gathered in natural language and generate differential diagnoses. It even assigns a ranking to each diagnosis based on its understanding of medical knowledge in textbooks, journals, and case reports. At a recent demonstration for The Associated Press, Watson was asked to consult on a fictional patient with an ophthalmic disorder. As additional symptoms, medical history and personal information was presented — blurred vision, family history of arthritis, Connecticut residence — Watson’s suggested diagnoses evolved from uveitis to Behcet's disease to Lyme disease. It gave its final diagnosis a 73 percent confidence rating. Dr. Herbert Chase, a Columbia University medical school professor and Watson consultant commented that “You do get eye problems in Lyme disease but it’s not common… you can't fool Watson." [caption id="attachment_3626" align="alignleft" width="255" caption="."][/caption] IBM's Dan Pelino, general manager for global health care said possible future uses for Watson include allowing a doctor to connect to Watson's database by speaking into a hand-held device using speech-recognition technology with cloud computing serving as the database for the most advanced research. There is little doubt that Watson will help physicians with a major problem in modern health care: information overload. The potential to have immediate access to every resource of evidence based medicine is exciting. However, Watson developers and consultants will go a step further. Dr. Chase stated that anecdotal information — such as personal blogs from medical websites — may also be included. Chase remarked, "What people say about their treatment … it's not to be ignored just because it's anecdotal. We certainly listen when our patients talk to us, and that's anecdotal." This is where the issue of Watson’s involvement in medical practice becomes a slippery slope. Since Watson has the ability to interpret natural language will it be able to listen to patient’s complaints, analyze them and give a differential diagnosis? Watson could become the ultimate physician’s assistant. In fact, with the increasing reliance on “apps” one might wonder if Watson could truly become “Dr. Watson”. I have always embraced new technology, reveling in the acquisition of every new smart phone technology, iPAD app and software innovation. However, reliance on such technology to the exclusion of the human factor in the practice of medicine may lead to increased productivity but suboptimal patient care. A balance must be achieved in the upcoming decade where technological tools are utilized to provide the physician with the evidence based medicine to assist in accurate diagnosis while allowing the irreplaceable intuition, compassion and humanity only we as physicians can provide. ### Lynn Lucas- Fehm, MD, JD, is a radiologist at Abington Memorial Hospital and the 150^th President of the Philadelphia County Medical Society.

Hospitalists: A Consumer’s-Eye View

Physicians News — Tue, 27 Sep 2011 17:23:27 +0000

Larry C. Kerpelman, Ph.D. As a result of a freak fall while jogging, my wife, Joanie, sustained a subdural hematoma. It took three emergency room visits, two hospitalizations, one neurosurgery, and several months of rehabilitation before she regained her lost capacities. During her first hospitalization, we became acquainted with the hospitalist’s role which, while not new in the United States, was new to us. In the book I wrote about our experience with her injury, treatment, rehabilitation, and recovery, I included a commentary on the hospitalist phenomenon as we experienced it at one Massachusetts hospital. That commentary, below, is excerpted from Pieces Missing: A Family’s Journey of Recovery from Traumatic Brain Injury, Two Harbors Press, 2011. With the rise of the hospitalist phenomenon, primary care physicians often now assume the role of passive receivers of information about the hospitalized patients for whom they normally have primary concern. Joanie had at least three different hospitalists caring for her during her first hospital stay of four days. Her primary care physician did not see her during that time, nor during her second hospitalization, either (she changed her primary care physician shortly after her second hospitalization, partly as a result of this). A 1998 article in Physicians News Digest(1) states: “About 2000 physicians nationwide call themselves hospitalists. Specializing in the management of hospitalized patients, the hospital becomes their office. A hospitalist takes over for a primary care physician when it comes time to admit a patient. For your average primary care physician, this means fewer, or no, visits to the hospital at the end of their office hours for rounds. Usually working on flexible, yet intense shifts of eight to twelve hours, the hospitalist turns his or her pager off when the shift is over.” In just eight short years after that article was published, the number of hospitalists practicing in the U.S. was estimated to have grown to 12,000, with the expectation that it will eventually grow to 30,000 (2). [The Society of Hospital Medicine estimates that the latter number has already been reached (3).] Since a key role of the primary care physician is to manage health care for the whole patient, turning that care over to hospitalists while the patient is in the hospital (even if the hospitalists keep the primary care physician apprised) weakens that key component of caring for the whole patient. Moreover, a hospitalist does not have the same sense of connection with a patient that the patient’s primary care physician has. Plus, since different hospitalists often see the patient during a hospital stay, there is a greater chance that communication about each case is, perforce, going to be less clear than if only one person, the primary care physician, is handling the case. Those in favor of the hospitalist movement counter that the hospitalist, being based in the hospital, is more available to both the patient and the nurses who provide care for the patient than a primary care physician, whose office is often not in or near the hospital, would be. Should untoward developments in a patient occur, the hospitalists are there to act. In addition, because they work defined shifts, hospitalists tend to be fresher and more alert than primary care physicians, who may see their hospitalized patients at the middle or end of a busy day, would be. Those sympathetic to the hospitalist movement also point out that hospitalists’ treatment and activities are monitored more closely by the hospitals in which they work than are those of primary care physicians providing care to their hospitalized patients. All things considered, though, it seems to me that the major benefit of having a hospitalist care for a hospitalized patient accrues mainly to the primary care physician, who no longer has to suffer the inconvenience and wear and tear of visiting the hospital to see his or her patients, nor suffer the inadequate reimbursement that insurance companies provide for such visits. It’s the patient who gets the short end of the stick in terms of continuity of care, in my opinion. Although she is seen by hospitalists while in the hospital, she is not necessarily seen by the same one during the course of her stay, potentially leading to communication disconnections among providers and disruptions in continuity of care. Even if the patient is seen by the same hospitalist throughout her hospitalization, she does not receive the benefit of being seen by a physician—namely, her primary care physician—who has an in-depth understanding of her, her prior history, and her health concerns. The point that some raise, that hospitalists’ treatment and activities are monitored more closely than are those of primary care physicians seeing their hospitalized patients, is hardly relevant. It implies that primary care physicians cannot be monitored as closely, but what is to say that they cannot? They may not be used to being monitored so closely, but that does not mean that they cannot be. Changes in hospital practice happen all the time (albeit slowly). The medical community itself is not unaware of these issues, as they are a matter of vigorous discussion in the medical literature. An acquaintance of mine, an internal medicine physician who very much favors the hospitalist system, recognizes that most patients do not agree with him. “Patients hate it,” he plainly admits. Although the whole hospitalist issue is still a work in progress in the medical community as it tries to adapt to this change and perfect its workings, I think that the medical community is inclined to believe that the tradeoffs are worth it to them. From the health care consumer’s point of view, however, the tradeoffs are not. Perhaps the vigorous discussion in the literature will come to encompass an examination of the shortcomings I have pointed out here and result in the provision of hospital care that is more satisfying and continuous. ============================================================ References

Christopher P. Noel, “The Emerging Role of the Hospitalist.” Physicians News Digest (February 1998): p. 298.
Niraj Sehgal and Robert M. Wachter, “The Expanding Role of Hospitalists in the United States.” Medicine Weekly 136 (2006): pp. 591-596.
http://www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm [accessed June 22, 2011].

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ Larry C. Kerpelman, Ph.D. is an award-winning health care writer and editor who has published two academic books and written numerous articles for publications. His book, Pieces Missing: A Family’s Journey of Recovery from Traumatic Brain Injury (Two Harbors Press, 2011) is available from www.LCKerpelman.com, www.Amazon.com, or your local bookseller. He can be contacted at lkerpelman@gmail.com.

Doctors Will Remain a Target Until They Wake Up

Physicians News — Tue, 06 Sep 2011 15:42:32 +0000

[caption id="attachment_4056" align="alignleft" width="118" caption="Dr. Hal Scherz"][/caption] By Hal Scherz, MD It never ceases to astonish me how ill informed my colleagues are about what is currently going on in healthcare. I recently sat in a board meeting of a physician- hospital organization and the topic being discussed was accountable care organizations (ACOs). The doctor sitting next to me leaned over and asked me what an ACO was. This is a board member representing 800 physicians in contract negotiations with insurance companies! Unfortunately, he is not an outlier. Too many of us just show up for work and then go home at the end of the day. I might be describing you. Unless doctors take an interest in the business and politics affecting medicine, they will have no one to blame when their autonomy is lost, when their income suffers, and when their patients are placed at risk. It is not sufficient just to educate oneself about these issues. Actions also need to be taken. Most doctors have the false assumption that their specialty organizations and state medical societies are watching out for them and they don’t need to do anything on their own- but they would be wrong. These organizations focus on concerns affecting only a small group of doctors and consequently, our profession is fragmented and vulnerable to insurance companies, the federal government, hospitals and other interests that take advantage of doctors. The American Medical Association should be watching our flank but instead, they are just as bad as other special interests that prey on physicians because they seek to maintain their financial and political power. Despite the fact that the Affordable Care Act is law and the "train has left the station", where things end up is not yet determined. In the Obama administration’s view of this issue, doctors will make less money and likely work harder for it. They are doing everything possible to see to that. Obamacare cuts 0 billion dollars from Medicare. This means that there will be less money to pay for services- decreased reimbursement for services. There are other ways that the federal government has ensured that doctors will earn less. On January 1, the "doc-fix" comes up again. This is the sustainable growth rate or SGR that was part of the 1997 Balanced Budget Act. It means that when Medicare spending exceeds a certain rate relative to GDP, reimbursement to physicians will be downwardly adjusted. Each time that this has come up, Congress has postponed it, but the reductions have been accruing. It was put off 6 times in 2010-11 alone, but expires on December 31. On January 1^st, Medicare reimbursement to doctors is set to be decreased 30%, unless the government makes an accounting adjustment of 0 billion dollars- money that we don’t have and a move that is considered unpopular with many. One of the many hidden treasures of Obamacare is IPAB or the Independent Payment Advisory Board. It is a 15 person, unelected group of bureaucrats, within the executive branch which is given the power to decrease Medicare spending when it exceeds a certain level. Their decisions are binding, and not subject to Congressional oversight nor Judicial review. And to make this even better, hospitals are exempt from the reductions in Medicare spending until 2020, which means that doctors take the entire beating. Just when it didn’t seem possible that the government couldn’t find another way to ensure that doctors made less money for seeing patients with government insurance, they have found a way. It came out of the "debt- ceiling crisis" and in the words of Rahm Emanuel, a good crisis shouldn’t go to waste. The Congressional Super Committee was formed to come up with an additional .5 Trillion dollars in cuts and when this group is unable to reach consensus, automatic cuts go into effect through a process called sequestration. Half of the money will come from defense, but the other half will come from entitlement programs- including Medicare. These cuts will once again be made in reimbursements to physicians. As long as doctors sit back and allow this kind of behavior to continue, it will not stop. Critics of plans like that of Paul Ryan, which attempts to fix and preserve Medicare by having patients contribute something to their own healthcare, abound and continue to demagogue this issue. Until patients are once again forced to re-establish the financial connection with the healthcare that they receive, someone else will be paying the bill and calling the shots. Skin in the game is crucial to rehabilitating the healthcare system, and doctors need to be united on this point. But first, doctors need to wake up and pay attention now, before it is too late. ### Hal Scherz MD, FACS, FAAP, is President and Founder, Docs 4 Patient Care.

Dr. Smith Goes To Washington (Again)

Physicians News — Thu, 05 May 2011 14:26:00 +0000

[caption id="attachment_4056" align="alignleft" width="132" caption="Dr. Hal Scherz"][/caption] By Hal C. Scherz, MD Recently, I returned to Washington DC for the 11th time in two years, with a group of doctors from Docs 4 Patient Care. It was a very busy week in DC. As always, there were groups from around the country who came to Congress to advocate for their interests, including a large group of orthopedic surgeons. The most pressing issue that week was an impending government shutdown over the budget. You can imagine how distracted the Congressmen and Senators were with this potential disaster looming. In spite of this, we had no trouble getting in to see the elected officials or the legislative healthcare teams on our list. In fact, we had so many appointments, that we had to divide our team of 10 people into 4 groups at times. The highlight of our visit was a 30 minute session with Speaker of the House, John Boehner, in his office. No one else had the success that we had getting to speak with elected officials, especially Mr. Boehner. Why did we have such easy accessibility? Because we are different from other organizations and they know this. Groups regularly come to Washington with their hands out, asking for something. In contrast, we came to Congress offering something. We offered to them our help, our time, expertise, and resources. We did not send lobbyists to Congress to “soften them up”. We came ourselves, acting on our own behalf, as we have on prior trips to DC, as an initiative that we call "House Calls on Congress". We believe that it is far better to have personal relationships with members of Congress, and offer help in understanding complex medical issues which are difficult to fully grasp, than to delegate this role to others. We came with several messages. Most importantly, we wanted them to know that we can and are willing to help them. We wanted them to know that their healthcare message fails to stir the emotions necessary to rouse people to act. They heard from us about the resources that we have developed and made available to them so that they and their staffs could better understand complex healthcare matters which we instinctively know and take for granted. It was important to make them understand that it was not enough to keep saying repeal, without a clear plan to replace. We have such a plan and shared it with them. One of our objectives was to make them understand that the only way that they can hope to develop a plan that will make sense and be successful, was to bring doctors into the process- those of us who see patients daily and get our hands dirty, and stay up all night- not medical bureaucrats or ivory tower academicians who have not laid hands on a patient in decades. Finally, we wanted them to realize that we have a tremendous amount of influence amongst our patients; the electorate in this country. We shared stories about our experiences during the 2010 elections in which we helped get candidates elected to Congress. We are stronger and better organized for 2012 and will have much more success next time. Much to our amazement, the people that we spoke with, including Speaker Boehner, were already aware of these points that we came there to make, especially the last one about elections. What was just as surprising was the ease with which we got into see everyone and how well we were received. Only afterward was it clear why this was the case. We heard from most of the Congressmen and Senators that they need to hear from doctors and that they would like to see an organization of doctors that truly represents us and our patients. They appreciate when doctors come to Washington because they understand that we are sacrificing quite a lot to be there. They know that the AMA has failed to do its job, and that specialty societies have a limited focus and narrow interests. We believe that Docs 4 Patient Care can fill this void and we believe that they do too. These exchanges gave us hope for the future. Although there is a healthcare law that looms large and is shaking things up, everyone in Washington is unsettled. The fight is far from over, but the only way to get rid of this law which will have profound and negatives effects on patients and doctors is to change control of the Senate and White House. Only then is there a chance that we can throw this law out before it is too late. With the help of people like those who came to Washington with me, we can help to create and implement a plan that makes sense for the majority of Americans without destroying everything which is great about the American Healthcare system. ### Dr. Scherz is the Founder and President/CEO of Docs 4 Patient Care (www.docs4patientcare.org).

Obamacare One Year Later: Happy Anniversary, Doctor

Physicians News — Tue, 29 Mar 2011 13:36:24 +0000

[caption id="attachment_3980" align="alignleft" width="251" caption="The health care law recently passed the one year mark. Opinions are mixed. (Photo: SAUL LOEB/AFP/Getty Images)"][/caption] By Hal C. Scherz, MD Twelve months after the passage of one of the most controversial laws in American history, healthcare is still an unsettled issue. Never before has a president needed to go around the country to defend and sell a bill that he signed into law. America has been subjected to a law that over 1000 groups, representing 2.4 million people has been exempted from because they discovered that they could not afford the increased costs associated with it. This is before the law has even gone into effect. The bitter irony is that many of these groups who have received waivers were the most vocal proponents for this law, including the SEIU. This is cronyism at its worst and just a taste of things to come when the Federal Government, under the watchful eye of the Secretary of HHS decides what treatments doctors may deliver to their patients. As physicians, we are already beginning to see the profoundly adverse effects of the Accountable Care Act (ACA) on us and our patients. This year, the Medicare SGR (sustainable growth rate), which required a 23% reduction in physician reimbursement, was postponed 5 times. The final reprieve, resulted in Congress “kicking the can down the road” until January 2012, when the reduction becomes 29%. Meanwhile, the new Medicare fee schedule goes into effect in October, with across the board cuts of approximately 7%. During 2011, CMS (Centers for Medicare and Medicaid) withheld payments to physicians on TWO occasions, for as long as 45 days. This presented tremendous hardships for doctors whose practices are largely made up of patients on Medicare and where these payments represent a large portion of their income. Many doctors needed to take personal loans to meet payroll. Many doctors did not take home a paycheck even though they had provided services. Some doctors needed to down size, which meant layoffs of employees, and still others needed to close their practices. And thousands of doctors, who have been caring for Medicare patients for over 40 years, simply had enough and either stopped taking new Medicare patients or left the Medicare system entirely. And who could blame them? Any business needs to have some degree of predictability in order to survive, and Medicare has become too unpredictable to base future decisions upon. The losers are not so much the doctors as are the seniors. They have paid into a system during their working lives, and now many struggle to find a doctor. With 0 billion slated to be cut away from Medicare, the benefits that seniors will receive will diminish as well. The care that these seniors and others receive will not be as good as the care that patients currently get. One reason is that the ACA makes it easier for non- physicians to deliver healthcare. The new law emphasizes the concept of “medical homes”, which will be the gatekeeper in future healthcare delivery models. Nurse practitioners and physician assistants are elevated to physician status by virtue of this law. It is the attempt on the part of the federal government to convince the public that there is equivalency between all healthcare providers, but sadly that is just not so. It is the beginning of the attempt on the part of the government to condition the public for a lower standard of healthcare. This statement is not meant to be derogatory to this group of professionals, but simply stated, they are not doctors; they are physician extenders. It takes 7-15 years of education and training, long hours and personal sacrifice to become a doctor. A physician cannot simply be created by a legislative edict. Yet, this is precisely what is happening around the country. Clinical psychologists in California are being giving hospital admitting and prescription writing privileges, optometrists in some states are given eye surgery privileges, including laser surgery privileges in Oklahoma, and nurse anesthetists are designated as equals to board certified anesthesiologists. Pharmacists are lobbying for the ability to change prescriptions written by physicians not to generics, but to entirely different drugs, if they think that it is warranted. And nurse practitioners are now able to do an extra year of training and come out with a doctorate degree in nurse practice, so that they can call themselves “doctor” as they populate primary care clinics and medical homes. The HITECH Act which was actually in the Stimulus Bill of 2009, was essentially activated by passage of ACA, so that now, all doctors who wish to receive the highest levels of reimbursement for the services that they will have already provided, will need to have a health information system in place that meets federal standards. This is not an entirely bad concept, were it not for the fact that the systems currently available are not yet ready to accomplish the integration of clinical information between doctors, hospitals, pharmacies and other sectors of the healthcare spectrum. We will get there at some point, but to force doctors to spend money now on systems that cannot meet these goals is absurd. The systems are pricey, and the costs cannot be passed along, so doctors have to assume them all themselves. Consequently, less money will be available to spend on patients whether that means fewer personnel in doctors’ offices to care for them or less sophisticated tools available for the doctors. The systems that doctors are being forced to adopt will soon be surpassed by better systems that will be developed that can do what we expect from them, and then doctors will have to incur the costs to retool their offices once again. The problem is that when the technology is developed, every doctor will want to adopt it and not before, just because it has been decreed. The money that is supposedly available to doctors who implement these systems and who demonstrate “meaningful use” will barely cover the incurred costs, assuming that there is money available to begin with. The government and insurance companies are looking for alternative healthcare delivery models and the ACA supports one such model- the Accountable Care Organization (ACO). This organization is intended to be a vertically integrated healthcare delivery system consisting of physicians of all specialties working together, by following clinical protocols and best practice models, so that care can be coordinated and waste can be eliminated, while delivering improved care. This medical utopia would work with the hospitals as partners, but what is instead happening around the country is that hospitals are buying up physician practices at a record pace so that they can control as many patients as possible and hence control the medical market in their community. The physicians in this “super HMO” are employees and they then have to choose between doing what is right for their patients and what their employers instruct them to do. This is already happening in hospitals across the country, but will escalate as more physicians, especially specialists, leave private practice because they fear that their practices will have no value if the hospitals control the flow of patients to them. Besides encouraging the formation of ASOs, the ACA has other provisions which are aimed directly at doctors, in an attempt to destroy the private practice of medicine; a necessary first step to get to a single payer, government run healthcare system. Working with a willing accomplice, the American Hospital Association (AHA), provisions were put into the ACA that eliminates future physician owned hospitals and surgery centers, imaging centers and laboratories. The exemptions to these ventures occur when they are connected to and are a part of the physicians’ direct practice, but these exemptions are being challenged as well. The AHA is a very powerful lobby and as we have come to see, doctors have no effective lobbying group and are easy targets for every group that wants to push us around. Finally, the worst part of the ACA lies in the limitless power granted to the Secretary of HHS when it comes to healthcare matters. The Secretary determines what the clinical protocols are which doctors must follow if they wish to see patients who have insurance that is offered through the healthcare exchange. According to the ACA, there will be no insurance offered outside of the exchange. So if you want to see insured patients, you must follow the protocols approved by the HHS Secretary. If this wasn’t bad enough, the Federal Coordinating Council for Comparative Effectiveness, a 15 person board appointed by the President and with no Congressional oversight, will decide what treatments doctors may offer to patients and which cannot. Simply, this is the beginning of medical rationing, and if the issue of waivers bothers you, then this should really scare you. “trial balloons” have already been sent up in this regard. We have seen it with mammogram recommendations and with limiting Avastin for breast cancer patients. You can be certain that It will escalate as new ways to limit care are explored. ### Dr. Scherz is the Founder and President/CEO of Docs 4 Patient Care (www.docs4patientcare.org).

Doctors: Doing Nothing Is No Longer An Option

Physicians News — Wed, 23 Mar 2011 14:30:02 +0000

By Hal C. Scherz MD There is a truism that every physician needs to constantly remind themselves of; there is no healthcare without doctors. So why do so many of us feel so powerless and why are so many of us unwilling to do something about it? Most of us do what we do professionally because we enjoy helping people. That is our collective strength but also our weakness. What we do is special, but other entities have staked out their “turf” in our professional world; the government, insurance companies, and hospitals. They need doctors to remain an active player in this world, but have learned to exploit us in business matters, counting on the fact that our sense of morality and responsibility would supersede our fiduciary capabilities. For the most part, this is exactly what has happened and what said entities are counting on in the future. Simply look at the model under which most of us receive payment for services rendered to patients. In almost all cases, someone else pays us, whether it is the government or the insurance companies. To make matters worse, someone else has decided how much your service is worth, not you. There is no other business model in existence quite like this. Does anyone think that lawyers would allow someone else to set their fees and wait for someone other than the client to pay them, often having to fight for their reimbursement and having to continuously resubmit their claims to get paid because the payment form was improperly filled out? The healthcare industry is a vibrant and booming sector of our economy. Between 2008-9, when every sector of our economy was in recession and losing jobs, the only part of our economy (besides the federal government) that had added jobs was healthcare. It is not the “black hole” that politicians in Washington would have the public believe. Healthcare is an 0 billion annual part of the economy, which accounts for over 25 million jobs. So it should come as no surprise that lots of people want in on it. Doctors’ professional fees account for approximately 12% of the healthcare dollar. That means that 88% goes elsewhere -- pharmacy, hospitals, insurance, management, legal, etc. In difficult economic times, when everyone is getting squeezed, and when doctors are already perceived as pushovers in the business world, how do you think that they will fare? Couple this with the fact that all of the other players in healthcare spend billions on lobbyists and are well organized, while doctors have essentially no organized representation. The future looks bleak for doctors if we continue down this same path. It is interesting that talks about healthcare reform play to packed auditoriums. Doctors are eager to get news “from the front.” They want to know what is going to happen, and after hearing the news of what is in store for them, many will be motivated to act, but most will settle into the ennui that characterizes their professional lives these days as it relates to their business. There are basically five groups of doctors that I have encountered: those who are angry about what they hear and are stirred to action; those who are angry but are convinced that there is nothing that they can do; those who think that they can game the system and what is coming will not affect them; those who are looking for an exit strategy; and those who welcome the change that is coming (for whatever reason that may be). The average doctor spends less than 0 annually on advocacy for themselves, whether it is on a PAC, or some other group that is trying to defend their interests. Contrast this with trial lawyers who spend 100 times that amount. Most doctors will become defensive when confronted with this fact, claiming that they already give to their specialty societies and state medical associations. Unfortunately, that has failed to protect us from the sharks that constantly swim around us. The American Medical Association is perceived by the public as the lobby for doctors, but they have become part of the problem, looking out for their own special interests, and have failed doctors in general. We are a profession at a crossroad. The massive federal expansion over control of our healthcare system, and quite frankly, over doctors, is beginning to show cracks in the wall. Beginning with a shaky foundation, it fails to support the massive superstructure on which it rests. The mandate to purchase health insurance is being challenged in court and the entire law is at risk of being thrown out. The new majority in the House of Representatives is vowing not to fund portions of the law that require new agencies and expanded bureaucracies to function. However, there are parts of the law that will remain in effect. These provisions threaten to place more burdens on doctors and will limit our ability to remain economically solvent. Doing nothing and just hoping that this will go away or be acceptable is simply no longer an option. Doctors who are already struggling to keep their practices open because of decreasing reimbursement from insurance companies, or the constant threat of Medicare cuts to physicians (a new round of across the board cuts goes into effect in October, separate from the SGR postponement or “doc fix” due to expire in January 2012) are now facing further financial burdens. The mandate requiring health information systems in their offices means that doctors who have not implemented such a system will get lower levels of reimbursement from the government, if they get anything at all. Thus doctors are forced to divert money that could be spent on new staff or on salary increases for existing employees, and instead spend it on technology which is not currently configured to improve medical care, but to comply with government regulations. In fact, in many situations, these systems may negatively impact care. The new law contains provisions which favor special interests such as hospitals, who lobbied to get restrictions placed on physicians who own surgery centers, hospitals, and imaging centers, which limit or restrict physician ownership in these entities. And how are doctors responding to all of this? Too often, in fear and desperation, they are selling their practices to hospitals and relinquishing financial and professional control to entities whose only concern is the bottom line. These organizations have proven over the years that they desire to work with doctors, but only on their terms. We are now seeing the newest iteration of HMOs, the Accountable Care Organization, which is a group of doctors who get together to manage care and make it better by coordinating care, sharing information and driving the cost curve down. Payment is delivered in a lump sum for an episode of care, left to be divided by the ACO; frequently controlled by a hospital. The reality is that this is an attempt to have doctors manage risk, get paid less, take on liability, and allow insurance companies and hospitals to reap the financial rewards. As bleak as this may appear, the solution is closer than we may think. Doctors still control healthcare, and they are still the most respected profession in the eyes of the general public; 89% rate their doctors favorably in a Gallup poll in 2010, compared to 11% for politicians. Doctors need to consolidate their power into a single, strong unified voice that can deliver the message that things are not working well under this model. We need to begin to take personal responsibility for our profession because it has been, and continues to be, under attack. Doctors need to open up their pocket books and understand that it will take money to keep our profession safe from all of the intruders who want what we have. If we do not act soon, private practice medicine will be a distant memory and we will all be federal, state or hospital employees. There will be no one to blame but ourselves. Doing nothing is not an option. ### Dr. Scherz is the Founder and President/CEO of Docs 4 Patient Care (www.docs4patientcare.org).

The HEALTH Act Brings Protection Back to Patients

Physicians News — Tue, 07 Feb 2012 16:14:45 +0000

Resolutions Reflect the Changing Influences On Our Profession

Physicians News — Thu, 17 Nov 2011 14:59:06 +0000

By Lynn Lucas-Fehm, MD, JD

Going mobile: How EHRs and mobile technology are shaping one physician’s practice

Physicians News — Fri, 28 Oct 2011 13:38:51 +0000

Watson: Extreme Evidence Based Medicine

Physicians News — Thu, 13 Oct 2011 14:44:46 +0000

Hospitalists: A Consumer’s-Eye View

Physicians News — Tue, 27 Sep 2011 17:23:27 +0000

Christopher P. Noel, “The Emerging Role of the Hospitalist.” Physicians News Digest (February 1998): p. 298.
Niraj Sehgal and Robert M. Wachter, “The Expanding Role of Hospitalists in the United States.” Medicine Weekly 136 (2006): pp. 591-596.
http://www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm [accessed June 22, 2011].

Doctors Will Remain a Target Until They Wake Up

Physicians News — Tue, 06 Sep 2011 15:42:32 +0000

Dr. Smith Goes To Washington (Again)

Physicians News — Thu, 05 May 2011 14:26:00 +0000

Obamacare One Year Later: Happy Anniversary, Doctor

Physicians News — Tue, 29 Mar 2011 13:36:24 +0000

Doctors: Doing Nothing Is No Longer An Option

Physicians News — Wed, 23 Mar 2011 14:30:02 +0000

The HEALTH Act Brings Protection Back to Patients

Physicians News — Tue, 07 Feb 2012 16:14:45 +0000

Physicians News » Physician Blog

Physicians News — Tue, 07 Feb 2012 16:14:45 +0000

Resolutions Reflect the Changing Influences On Our Profession

Physicians News — Thu, 17 Nov 2011 14:59:06 +0000

By Lynn Lucas-Fehm, MD, JD

Going mobile: How EHRs and mobile technology are shaping one physician’s practice

Physicians News — Fri, 28 Oct 2011 13:38:51 +0000

Watson: Extreme Evidence Based Medicine

Physicians News — Thu, 13 Oct 2011 14:44:46 +0000

Hospitalists: A Consumer’s-Eye View

Physicians News — Tue, 27 Sep 2011 17:23:27 +0000

Christopher P. Noel, “The Emerging Role of the Hospitalist.” Physicians News Digest (February 1998): p. 298.
Niraj Sehgal and Robert M. Wachter, “The Expanding Role of Hospitalists in the United States.” Medicine Weekly 136 (2006): pp. 591-596.
http://www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm [accessed June 22, 2011].

Doctors Will Remain a Target Until They Wake Up

Physicians News — Tue, 06 Sep 2011 15:42:32 +0000

Dr. Smith Goes To Washington (Again)

Physicians News — Thu, 05 May 2011 14:26:00 +0000

Obamacare One Year Later: Happy Anniversary, Doctor

Physicians News — Tue, 29 Mar 2011 13:36:24 +0000

Doctors: Doing Nothing Is No Longer An Option

Physicians News — Wed, 23 Mar 2011 14:30:02 +0000

The HEALTH Act Brings Protection Back to Patients

Physicians News — Thu, 17 Nov 2011 14:59:06 +0000

By Lynn Lucas-Fehm, MD, JD

Physicians News » Physician Blog

Physicians News — Tue, 07 Feb 2012 16:14:45 +0000

Resolutions Reflect the Changing Influences On Our Profession

Physicians News — Thu, 17 Nov 2011 14:59:06 +0000

By Lynn Lucas-Fehm, MD, JD

Going mobile: How EHRs and mobile technology are shaping one physician’s practice

Physicians News — Fri, 28 Oct 2011 13:38:51 +0000

Watson: Extreme Evidence Based Medicine

Physicians News — Thu, 13 Oct 2011 14:44:46 +0000

Hospitalists: A Consumer’s-Eye View

Physicians News — Tue, 27 Sep 2011 17:23:27 +0000

Christopher P. Noel, “The Emerging Role of the Hospitalist.” Physicians News Digest (February 1998): p. 298.
Niraj Sehgal and Robert M. Wachter, “The Expanding Role of Hospitalists in the United States.” Medicine Weekly 136 (2006): pp. 591-596.
http://www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm [accessed June 22, 2011].

Doctors Will Remain a Target Until They Wake Up

Physicians News — Tue, 06 Sep 2011 15:42:32 +0000

Dr. Smith Goes To Washington (Again)

Physicians News — Thu, 05 May 2011 14:26:00 +0000

Obamacare One Year Later: Happy Anniversary, Doctor

Physicians News — Tue, 29 Mar 2011 13:36:24 +0000

Doctors: Doing Nothing Is No Longer An Option

Physicians News — Wed, 23 Mar 2011 14:30:02 +0000

The HEALTH Act Brings Protection Back to Patients

Physicians News — Fri, 28 Oct 2011 13:38:51 +0000

Physicians News » Physician Blog

Physicians News — Tue, 07 Feb 2012 16:14:45 +0000

Resolutions Reflect the Changing Influences On Our Profession

Physicians News — Thu, 17 Nov 2011 14:59:06 +0000

By Lynn Lucas-Fehm, MD, JD

Going mobile: How EHRs and mobile technology are shaping one physician’s practice

Physicians News — Fri, 28 Oct 2011 13:38:51 +0000

Watson: Extreme Evidence Based Medicine

Physicians News — Thu, 13 Oct 2011 14:44:46 +0000

Hospitalists: A Consumer’s-Eye View

Physicians News — Tue, 27 Sep 2011 17:23:27 +0000

Christopher P. Noel, “The Emerging Role of the Hospitalist.” Physicians News Digest (February 1998): p. 298.
Niraj Sehgal and Robert M. Wachter, “The Expanding Role of Hospitalists in the United States.” Medicine Weekly 136 (2006): pp. 591-596.
http://www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm [accessed June 22, 2011].

Doctors Will Remain a Target Until They Wake Up

Physicians News — Tue, 06 Sep 2011 15:42:32 +0000

Dr. Smith Goes To Washington (Again)

Physicians News — Thu, 05 May 2011 14:26:00 +0000

Obamacare One Year Later: Happy Anniversary, Doctor

Physicians News — Tue, 29 Mar 2011 13:36:24 +0000

Doctors: Doing Nothing Is No Longer An Option

Physicians News — Wed, 23 Mar 2011 14:30:02 +0000

The HEALTH Act Brings Protection Back to Patients

Physicians News — Thu, 13 Oct 2011 14:44:46 +0000

Physicians News » Physician Blog

Physicians News — Tue, 07 Feb 2012 16:14:45 +0000

Resolutions Reflect the Changing Influences On Our Profession

Physicians News — Thu, 17 Nov 2011 14:59:06 +0000

By Lynn Lucas-Fehm, MD, JD

Going mobile: How EHRs and mobile technology are shaping one physician’s practice

Physicians News — Fri, 28 Oct 2011 13:38:51 +0000

Watson: Extreme Evidence Based Medicine

Physicians News — Thu, 13 Oct 2011 14:44:46 +0000

Hospitalists: A Consumer’s-Eye View

Physicians News — Tue, 27 Sep 2011 17:23:27 +0000

Christopher P. Noel, “The Emerging Role of the Hospitalist.” Physicians News Digest (February 1998): p. 298.
Niraj Sehgal and Robert M. Wachter, “The Expanding Role of Hospitalists in the United States.” Medicine Weekly 136 (2006): pp. 591-596.
http://www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm [accessed June 22, 2011].

Doctors Will Remain a Target Until They Wake Up

Physicians News — Tue, 06 Sep 2011 15:42:32 +0000

Dr. Smith Goes To Washington (Again)

Physicians News — Thu, 05 May 2011 14:26:00 +0000

Obamacare One Year Later: Happy Anniversary, Doctor

Physicians News — Tue, 29 Mar 2011 13:36:24 +0000

Doctors: Doing Nothing Is No Longer An Option

Physicians News — Wed, 23 Mar 2011 14:30:02 +0000

The HEALTH Act Brings Protection Back to Patients

Physicians News — Tue, 27 Sep 2011 17:23:27 +0000

Christopher P. Noel, “The Emerging Role of the Hospitalist.” Physicians News Digest (February 1998): p. 298.
Niraj Sehgal and Robert M. Wachter, “The Expanding Role of Hospitalists in the United States.” Medicine Weekly 136 (2006): pp. 591-596.
http://www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm [accessed June 22, 2011].

Physicians News » Physician Blog

Physicians News — Tue, 07 Feb 2012 16:14:45 +0000

Resolutions Reflect the Changing Influences On Our Profession

Physicians News — Thu, 17 Nov 2011 14:59:06 +0000

By Lynn Lucas-Fehm, MD, JD