I write this while sitting in our sailing catamaran, swaying in the wind and current eight feet above sand and sea grass.  I know this because I can see right through the water in the Bahamas.  There is clarity here. When I started this journey thirteen months ago, I was burning with anger.  I was angry at insurance companies for developing complex, mutable formularies, coverage policies, and appeal procedures, maximizing my ...

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 61-year-old man is evaluated for a 10-month history of generalized weakness. He reports no pain or myalgia. History is significant for hypercholesterolemia treated with a stable dose of simvastatin for the past 3 years. On physical examination, temperature is normal, blood pressure is 138/74 mm Hg, pulse rate is 70/min, and ...

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We are assembling too many panels of people in the name of health these days. Too many. They usually seem like a good idea. I’ve been supportive before. I assumed we needed them. More of them. I might have been wrong. There was a day when I believed my food would be toxic, my medicine harmful, and my safety gone without them. But, I’ve come to believe I was mistaken. I was wrong because ...

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 26-year-old woman is evaluated for a 10-year history of recurrent episodes of acute-onset feelings of fear and anxiety. These episodes initially occurred approximately 4 times per year but for the past 3 months have been occurring once or twice per month, especially when she is under stress. She describes the ...

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Ronald Reagan’s last letter to the American people, penned with his own hand in November, 1994, went directly to the point: “My fellow Americans, I have recently been told that I am one of the millions of Americans who will be afflicted with Alzheimer’s disease.” In this deeply poignant moment, the former president explained that he decided to share his diagnosis “to promote greater awareness of this condition,” with the hope that doing ...

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My husband, Mark, called me at my practice. “I’ve been working on something; I need you to come home now.” He spoke definitively, urgently. “Is it the kids?” I was instinctively anxious. “No, not the kids, just come home now.” 6 p.m., a cool evening, an ordinary day. The life before the fact. And then life afterward, irrevocably and catastrophically changed. A tense ride home, then the revelation. “I've been having difficulty ...

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. An 86-year-old woman is evaluated in her assisted-living facility for pain. Four weeks ago, she developed herpetic lesions on her right posterior thorax in a T7 distribution. She was treated with acyclovir, and the lesions healed; however, she has persistent severe burning pain. The pain is so severe that she is ...

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USMLE Step exams are a rite of passage in medical education. They mark the  transition from pre-clinical years to clinical years, from medical school to residency and from intern to resident. One of the more difficult aspects of the transition to residency was convincing myself that I really was a doctor. The habits of explaining my role as a student, of hedging every statement with “I’ll need to ask the ...

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 50-year-old man is evaluated for a 1-year history of increasing urinary frequency and urgency and occasional urge incontinence. He has no symptoms of urinary hesitancy or incomplete emptying. The patient has primary progressive multiple sclerosis. Medications are dalfampridine and vitamin D. On physical evaluation, temperature is 36.8 °C (98.2 °F), blood pressure ...

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 77-year-old woman is evaluated 4 months following a left middle cerebral artery ischemic stroke. The severity of her stroke required prolonged initial hospitalization and a 3-month stay in a rehabilitation center before returning home. Residual deficits include dense right-sided hemiparesis and dysphagia requiring oral feeding with thickened liquids. Medical history is ...

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