The Patient that Made the Difference

Her initials were the same as mine, and we greeted one another after a few phone conversations with "Hi, BB, it's BB." 

We had this connection. Two grown women. Both single and young. The big difference was that I was her home health pharmacist in charge of her pain pump and she had terminal cancer.

When you are halfway through your life (and maybe your career) there comes a time when you look back and remember the patients that change your life and maybe even validate the half-ass "I want to be a pharmacist" decision made by a young twenty-something with no idea how profound the decision would have on every aspect of your life. 

B wanted to go to Florida and be in the ocean one more time.  Her boyfriend was in Florida and since she knew her time was short, the ocean was on her bucket list... with the dilemma of a pain pump. That's where I fit into the story, finding a creative way to make it happen along with a couple home health nurses and some supplies. She was a nurse, too, and was a big part of her own end-of-life care.

It has been eleven years ago. B was 33 years old. I had been a pharmacist for only four years; a baby in the working world with little idea of how that year would change my life.

I had these biweekly chats with her concerning supplies she might need, including the intravenous pain medication itself but we often left the rigid discussion of how we were connected through pharmacist and patient to human conversation of "please do monthly self breast exams," to "live a full life and travel Beth!" to "who cares what people think about you, you certainly won't care when you are at the end of your life" and "I wish I could have been a mother." It was almost as if I had been granted insight into the world of a life ending way too soon and maybe learning my own lesson along the way. I sure did.

I finally went to meet her the last few days of her life. I waited much too long to meet my friend and that is my only regret. There is a professional line you have to keep in place with your patients, but sometimes that looks a little different patient to patient.  She squeezed my hand and had a picture of her vibrant former self before cancer ravaged her body sitting on her nightstand. "You are beautiful," I had said although wishing I had arrived months before.

Pharmacists and nurses along with other healthcare providers can make a difference. 

I witnessed the same thing with my father-in-law's nurse at the VA in Nashville caring for a man that had no family at bedside because of a lack of a relationship with his family. His nurse was amazing and was not only his nurse but his friend.  

I saw it again in Memphis on a hospice rotation where I saw different patients in different stages of terminal illness along with their families in different stages of grief. 

My life changed with each of these moments and patients who touched my life and maybe that young twenty-something college student knew more than I thought about selecting a career?

A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition

Click on image to order A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition (no paid link on this, just for your information)

            As a pharmacist and a clinician at my local hospital, there have been times where I am starting a new PN (total parenteral nutrition) and needed help beyond the usual formula or write-up that we use. In the information age, we have a diverse amount of information online at our fingertips; however sometimes this information can be from sources that are not legitimate. I can google PN and a disease state and hope for something relevant, or I can seek out material that is tried, true and tested.

            The A.S.P.E.N. Parenteral Nutrition Handbook, 2nd Edition is a pocket-sized handbook or quick reference that covers many parenteral nutrition topics with students in dietetics, nursing, medicine and pharmacy in mind. There are 10 fully revised chapters from the 2009 1st edition including: 

1.  Chapter 1: Nutrition Screening, Assessment, and Plan of Care

2.   Chapter 2:  Overview of Parenteral Nutrition

3.   Chapter 3:  Parenteral Nutrition Access Devices

4.   Chapter 4:  Parenteral Nutrition Formulations and Managing Component Shortages

5.   Chapter 5:  How to Prescribe Parenteral Nutrition Therapy

6.   Chapter 6:  Review and Verification of Parenteral Nutrition Orders, Preparing Parenteral Formulations, and Ordering

7.   Chapter 7:  Parenteral Nutrition Administration and Monitoring

8.  Chapter 8:  Complications of Parenteral Nutrition

9.  Chapter 9:  Medication-Related Interactions

10.  Chapter 10:  Home Parenteral Nutrition Support

These chapters cover many of the relevant topics for the patient receiving parenteral nutrition (PN) including some newer topics on order review, compounding, and drug shortage management. Also this handbook contains evidence-based guidelines from the A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations (JPEN, March 2014) and A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing (JPEN, March 2014).

I have taken the time to utilize this handbook while dosing PNs in the past few weeks and have found this reference accurate while covering many of the topics I needed.  I especially enjoyed the chapter on parenteral nutrition complications.  I found the topics succinct and spot-on for finding quick information on a couple of questions I had on a patient’s PN.

If you are looking for a guide with a broad range of topics related to PN that will help your student, resident or even new pharmacist managing PN, this guide will help you tremendously.

10 Rules of Email Etiquette at Work

One of the most frustrating things about pharmacy jobs today, for me at least, is the lack of email etiquette at work.  I know it sounds crazy to even bring this up, but I have been pondering this post for years.  You see, I have been guilty of not being the best at email, but over the years it is becoming crystal clear the errors people make every single day that not only make the sender look badly, but can actually fracture a team.  Without further ado, the email changes I would like to see in the pharmacy and hospital world with a disclaimer that since I have been practicing for almost 15 years, these examples go way back in time. 1.  REFRAIN FROM REACTIVE EMOTIONAL EMAILS.  If you find yourself getting worked up over what you are reading, do your best to avoid pressing reply and firing off a response.  Avoid sending emails when you’re feeling any type of negative emotion. These types of emails will ALWAYS make you look unprofessional and maybe even unstable.  Before you send off that email rant or reply to an email that angers you, try cooling off overnight.  Or, write an uncensored draft that you never actually send. Remember that all emails are forwardable.  If you don't want your whole department to read it, do not send it.

2.  RESIST THE REPLY ALL BUTTON.  This is the one that literally will make my entire head explode at work.  I have seen coworker after coworker make this mistake and it is not pretty.  This can make you look totally clueless all the way up the chain.  Coworkers don't let coworkers reply all.  In fact, I would love to see the day when reply all is no longer an option in Outlook, Gmail, or any other email client.  Why?  Because it creates mindless replies when all of the discussion could be tabled and then ONE single email sent out to a team.  Time after time in all of my jobs have seen emails go out - an official type declaration of what we are going to be doing - and someone else will reply all and jump in with something else essentially calling out critically all the things wrong with the initial.  Take the time to call the person that sent the email and give them the professional courtesy to make any corrections.  Don't shoot the messenger!

3.  UNDERSTAND WHAT CC AND BCC MEAN.  The recipients listed in the To field are the direct addressees of your email. These are the people to whom you are writing directly.  CC, which stands for “carbon copy” or even “courtesy copy,” is for anyone you want to keep in the loop but are not addressing directly in the email. The person(s) in the CC field is being sent a copy of your email as an FYI. Commonly, people CC their supervisors to let them know an email has been sent/an action has been taken or to provide a record of communications. The general rule of thumb is that recipients in the To field are expected to reply or follow up to the email, while those in the CC field do not.  So many times I see the ones in the CC field adding in their two-cents and then the whole thing becomes a reply-all festival.

4. IF YOU ADD SOMEONE IN THE CC OR TO FIELD, LET THE OTHERS KNOW.  Guess what?  There are times when people are added willy-nilly for no good reason and you look back and notice it a couple of emails later.  Let people know.  Professional courtesy and politeness go a long way.

5.  BCC IS GOOD FOR ONE THING ONLY.  Let's say that only half in your department contributed to the annual walk fund.  Rather than sending out an email to all those that contribute in the TO field where each of them can see who did contribute and who did not, put your own name in the TO and the rest in the BCC.  That way, gossip about who gives and doesn't is stopped before it can even begin.  Don't use the BCC field to add someone random to eavesdrop on the email.

6.  PICK UP THE PHONE.  If you notice that you are going back and forth on an email and getting nowhere, the phone still works.  Guess what?  Voices can convey so much more than words and rarely are misinterpreted as much as typed words.  I remember an email I saw that was sent for the third time.  The second time it was heavily highlighted with quotes from the manager's email weeks before.  The third send apologized for resending the email yet again but someone was not doing it correctly.  Because of the sender's frustration, more time was wasted from the entire department reading about some small piece in the whole operation, and worse, half of the department had nothing to do with the infraction.

7.  DON'T PUT A QUOTE IN YOUR SIGNATURE.  There is no reason for it.  From The Wordsmith:

******Avoid quotes, witty sayings and colors in the signature.

8.  DON'T ASSUME EVERYONE READS THEIR EMAIL IMMEDIATELY.  If something is important and needs to be communicated quickly, pick up the phone.

9.  DO NOT FORWARD AN EMAIL UNTIL YOU ASK PERMISSION.  This is just plain common professional sense.

10.  DO NOT USE UNPROFESSIONAL FONTS OR BACKGROUND PAPERS.  They only distract.  This means NO comic sans.

Hope that helps.  And, by the way, I do mess up on some of these myself.

Ativan Drips and Precipitation

If you happen to run short of the lorazepam 2 mg/mL vials to compound your ativan drips, be mindful of the possibility of precipitation when using the lorazepam 4 mg/mL vials.  AHFS Drug Info states:

Precipitation-- The choice of commercial lorazepam concentration to use in the preparation of dilutions is a critical factor in the physical stability of the dilutions. Both the 2- and 4-mg/mL concentrations utilize the same concentrations of solubilizing solvents. On admixture, the solvents that keep the aqueous insoluble lorazepam in solution are diluted twice as much using the 4-mg/mL concentration than if the 2- mg/mL were used, resulting in different precipitation potentials for the same concentration of lorazepam. Care should be taken to ensure that the compounding procedure that is to be used for lorazepam admixtures has been demonstrated to result in solutions in which the lorazepam remains soluble.

Lorazepam concentrations up to 0.08 mg/mL have been reported to be physically stable, while occasional precipitate formation in admixtures of lorazepam 0.1 to 0.2 mg/mL has been reported. The precipitate has been observed in both containers and in administration set tubing.

In one case, a visible precipitate formed in a lorazepam 0.5-mg/mL admixture in sodium chloride 0.9% in a glass bottle.  However, a 0.5-mg/mL concentration may remain in solution longer if prepared from the 2-mg/mL concentration, yielding a higher concentration of organic solvents in the final admixture.

Concentrations of 1 and 2 mg/mL have been reported to be physically stable for up to 24 hours as well as concentrations below 0.08 mg/mL.

Concentrations in the middle range of 0.8 to 1 mg/mL may be problematic.  In one report, use of lorazepam 2 mg/mL to prepare lorazepam 1-mg/mL admixtures in dextrose 5% or sodium chloride 0.9% was acceptable but use of the lorazepam 4-mg/mL concentration to prepare the same solutions resulted in almost immediate precipitation.

Lorazepam solubility in common infusion solutions has been reported. Its solubility in sodium chloride 0.9% is approximately half that found in the other tested solutions. This result was attributed to the pH of the sodium chloride 0.9% (pH 6.3) being essentially the same as the isoelectric point of lorazepam (pH 6.4), where aqueous solubility would be the lowest. Dextrose 5% was the best diluent for lorazepam.

If you are a hospital or facility that mixes the middle range of 0.8mg to 1 mg/mL you have to be more mindful of other factors.  This is the reason I had no idea of this problem since other facilities where I have worked we mixed a much less concentrated solution.  I found out the validity of this information and wasn't too pleased.

The bottom line is that it would be nearly impossible for a pharmacist to know every single intricacies of different hospitals and compounding practices.  If knowledge like this is indeed something we should all 100%  know, then someone somewhere dropped the ball on training and/or education.  I am mostly wondering, how does your facility compound ativan drips?  What scenarios caused precipitation?

For more about this issue read here.

New Year's Resolutions for the Pharmacist

Most of the time, the New Year ushers in thoughts of dropping 15-20 lbs and signing up for a few road races.  No, not to race, but just to finish.  This year, I have been much more introspective thinking about life and career and all the above.  Maybe some of these pharmacy related resolutions will be similar to yours.

1. Begin studying for another certification.  I am heavily learning toward the BCNSP.  I am in no hurry because quite honestly, there is no reason professionally to obtain.  I would just accomplish something that has interested me in the past.  I used to work for a home infusion company and there was a pharmacist (JB) who was quite fabulous.  I am sure he still is today, but I noticed he has this designation and is probably running circles around most in the area when it comes to nutrition.  It is quite an in-depth topic from enteral to parenteral nutrition, and I am predicting another 1-2 year study.  I have purchased the material and have started though not nearly as much gusto as the BCPS so far.  If you are not certified, consider it.  IT MATTERS.
2. Stop worrying about what other pharmacists think about you.  You cannot live your professional life trying to beat out or outsmart the guy/gal next to you.  Yes, you may be in fact more qualified and more experienced, but you cannot control how a company decides to utilize your experience or knowledge.  Perhaps a position in a different area will open up and any type of learning on the side you have pursued will open doors!?  Sometimes it is just timing and sometimes just sheer luck.  In the meantime, focus on being a better pharmacist.  Focus on remaining competitive and the go-to person for all things current.  If you keep up with the current practice and move forward, the people who win are your patients.
3. Look to the future.  Prepare for the future so that when it happens, you will be ready to step right into the role without any problems.

Those are my resolutions for pharmacy this year.  I hope 2014 holds many wonderful things for you in your career whether it is pursuing a board certification or attending an update to begin the process to do more for your patients than last year.

Cheers!

Why Should You Become Board Certified?

I enjoy brainstorming with other pharmacists and asking them their opinions on becoming board certified.  I remember back in 1998-1999, the assistant dean of my alma mater, University of Tennessee at Memphis stressed how important it was for us to consider residency and board certification.  At the time, I was a 25-26 year old making decisions that would impact me for life.  You see, I decided back then to decline that path.  I only saw the dollars that were before me and the student loan debt piling up.  I quipped, "Why would I want to work for half-pay or less for a whole year?" Why?  Hindsight is 20/20.  Fast forward to a 40 year-old in the profession for over 14 years experiencing all sorts of different experiences, and after trying most, I have a couple of regrets as far as my tenure in pharmacy school.  I regret not doing a rotation overseas.  I regret not doing an residency.  I regret that I dismissed more learning inferior to money.

I know not everyone feels like me, and that is understandable.  Perhaps I am just a different sort who becomes stir-crazy when bored.  Whatever the reason, I decided to pursue BCPS last year.  I missed it barely the first time and immediately jumped back up and started studying again.  I work in a small community setting in a smaller city and though it is nothing like Memphis was in terms of clinical opportunities, these opportunities can be found with a little thought.  Passing the test was probably up there with other accomplishments in life - like the time I finished my first marathon (26.2 mile run) in 2002.  Victory!

Why should you become board certified?

1. BPS website quotes:  "From patient to provider, the value of the BPS-certified practitioner registers throughout the health care continuum. For pharmacy professionals, documentation of specialized experience and skills yields the additional benefits of personal satisfaction, financial rewards and career advancement."  I definitely agree with most of this though most I have talked with did not receive a raise unless they changed jobs.  In the past where BCPS maybe helped with landing a clinical job, today it may be the thing to separate you from a PharmD without BCPS.
2. If you have been out of school for over four to five years, you can be sure you have already forgotten some of what you have learned and have not learned new material being presented to new graduates.  You can depend on your local hospitals' computer system to remind you of every little thing (trusting those that program such systems) OR you can take charge of what you know and remain committed to being the best you can be.  Think of it like this, if you work in a hospital and you are commanding larger salaries than new graduates with fresher knowledge, there comes a point where you are replaceable.  Be your best to remain competitive in your field.  This means utilizing continuing education to really learn something and not last-minute cramming to renew your state license.  (Guilty, by the way).
3. A paper wrote in 2006 (seven years ago) states that "Future Clinical Pharmacy Practitioners Should Be Board-Certified Specialists."  In the past clinical pharmacists have not made board certification a priority, but this is changing rapidly with not only clinical positions but in staff positions.  Clinical faculty and preceptors MUST be board certified, I believe.  As pharmacists move toward the direction of becoming reimbursed professionals for optimizing medications, there will be a trend toward licensing agencies requiring board certification in certain scenarios.  Sure, it is not TODAY, but if you would have asked me in 2000 if I thought the market would be in the shape it is with oversaturation, I would have done things VERY differently in 1999-2002.  Direct patient care IS coming.
4. The PharmD curriculum is not enough to be able to interact in sync with other healthcare professionals.  Experience in dealing with physicians and their assistance along with board certification will take you to the next level in recommending appropriate treatment.  Placing a new graduate in a clinical position without experience and expecting them to build relationships with clinicians is not the best case scenario for the patient.  Requiring a board certification ensures a higher level of expertise and should be a requirement of all hospitals (in my opinion).  I know, I know.  Not something anyone wants to enforce, but wow!  The benefits in just preparing and studying for the test are immense.
5. Last, but not least, you should become board certified to give your patients the best care possible.  This was my number one reason.  I remember the day I sat at my desk years ago and realized I had no idea about new guidelines (and even some not-so-new) and that centralized order entry had essentially turned me into a robot at a computer verifying at will, I realized it was time to make some personal changes that would cost me both dollar and more importantly time but result in amazing benefits for my patients.  BCPS.

I hope that you will consider these reasons.  For the most part most people are reluctant because no one wants to fail, much less fail twice.  Yes, it is humbling to fail once, but it is euphoric to pass (even the second time).  Especially for someone like me, I prove you can teach an old dog new tricks.  I hope to inspire more of you to seek to be your best in our profession, stop worrying about your coworkers and if you fail, and realize that any amount of learning that happens will significantly change how you practice pharmacy.

In the future, I am thinking about tackling another certification.  I hope you will, too!

CV Risk Calculator - American Heart Association and American College of Cardiology's Changes

Guidelines change, and recently new material was released concerning cardiovascular risk.   The spreadsheet enables health care providers and patients to estimate 10-year and lifetime risks for atherosclerotic cardiovascular disease (ASCVD), defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke, based on the Pooled Cohort Equations and the work of Lloyd-Jones, et al., respectively. The information required to estimate ASCVD risk includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status. However, the more I play with different patients' numbers, even my own mother's, the more it is very obvious the calculator overestimates risk fairly significantly.  We can expect, I guess, statin snack machines to pop up everywhere since most will now be candidates to be on a statin.

Read more about this in a fabulous NY Times article that really goes in-depth concerning the embarrassment and application in the future.

The controversy set off turmoil at the annual meeting of the American Heart Association, which started this weekend in Dallas. After an emergency session on Saturday night, the two organizations that published the guidelines — the American Heart Association and the American College of Cardiology — said that while the calculator was not perfect, it was a major step forward, and that the guidelines already say patients and doctors should discuss treatment options rather than blindly follow a calculator.

Doing What You Love

There is this paradox of thought that creeps in most days (if I allow it) and most of the time I will even ask a fellow coworker, "Do you love what you do?"  or "If you could go back in time, would you choose pharmacy again?" This article by Paul Graham found its way to my feed this morning through another reading, and though it took me all morning to read and digest the whole thing, I feel validated.  There are moments when I look at myself from another's point-of-view and think, "Is she happy?"  Happiness is the thing that I tend to search for... you see I couldn't tell you exactly how much money I make to the penny.  I have no idea to the hour how much PTO I have built up.  I can tell you I have been a drug expert since 1999 and only recently so feel I can use that term and MEAN it.

Would I do my job without pay?  That, according to the article, seems to be one of the qualifiers of finding and doing what you love.  Would I do right now for money for free?  Maybe.  I mean, I would definitely change the job.  First, I wouldn't sit in a room and just enter orders all day.  I would probably do more of a clinical job but not clinical that is defined in my current job today.

What would that look like?  More patient contact.  More ER contact.  More of a presence where knowledge is valued and needed in a moment's notice.  I have that to offer.  It would make me happy, even if momentarily in that the Sallie Mae bill I continue to pay monthly would see more worthy.

But, if I was really honest with myself I would stop and say I may find something else someday.  Even if it is something on the side.  Being in-demand was a lovely time when district managers valued your license (not so much your credentials) and would throw new cars, sign-on bonuses and time off your way.  They would appear like vultures outside the retail pharmacy with a suit on and ready to beg.

Today?  The students are graduating and learning the art of begging.

The creative life doesn't seem to coincide with making money.

"The most important thing a creative per­son can learn professionally is where to draw the red line that separates what you are willing to do, and what you are not.

Art suffers the moment other people start paying for it. The more you need the money, the more people will tell you what to do. The less control you will have. The more bullshit you will have to swallow. The less joy it will bring. Know this and plan accordingly.” - Hugh McLeod

And this one by him:

"The best way to get approval is not to need it.

This is equally true in art and business. And love. And sex. And just about everything else worth having.”

What about approval from myself because I am so excited to face the day and go to work because it is not work but my passion?  Is that possible?

Steve Jobs:

Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when you find it. And, like any great relationship, it just gets better and better as the years roll on. So keep looking until you find it. Don’t settle.

What if that looking takes more than 20 years because quite honestly I am THERE.  20 years and able to say apologetically I am still seeking.

The bottom line is start doing the things you love.  What do I love?  Well, I do love medicine.  I would be lying if I didn't admit that.  I do like how convoluted and complicated it can get.  Throw in another disease state and another medication and a genetic tendency to metabolize differently and weight changes.  Throw in some food or no food or grapefruit juice (though in some medications you would have to drink about a quart a day maybe?) and complicate the black and white definition.

Then give it some time because years ago hormone replacement therapy was all the rage and now it's not.  Thank you Women's Health Initiative for that one.

Back to the question at hand...

The realization:  A 21-year-old chose this career path for me.  She, in her silver spoon mentality felt it was prestigious but not to a fault.  She could forsee perhaps having a family and not being on call.  Oh, and Todd Gean's house was close to the biggest house in Adamsville, TN.  He owned and still owns his own drugstore.  Guess what?  I never spent ONE SINGLE DAY in his pharmacy prior to going to pharmacy school.  I am not even sure I was aware what went on except he put pills in a bottle all day.

“If one wanted to crush and destroy a man entirely, to mete out to him the most terrible punishment,”wrote Dostoevsky, “all one would have to do would be to make him do work that was completely and utterly devoid of usefulness and meaning.”

Yes, I am searching.

Pills, Thrills and Methadone Spills!

I have an exciting giveaway to mention!  A fellow twitter pharmacist has written a book available on amazon kindle!

Mr Dispenser is  a community pharmacist from England and has written a funny book about pharmacy called ‘Pills, Thrills and Methadone Spills: The Adventures of a Community Pharmacist’.

It’s a collection of the best blogs, tweets and anecdotes about the wonderful world of pharmacy.

There is a chapter of American anecdotes in there.

Get your Kindle version here: Paperback copy 

5% of sales are going to  Pharmacist Support which is a UK pharmacist charity.

Want to follow the author?

Blog

Facebook Page

Twitter

Facebook Profile

LinkedIn

Retweet this post or share on Facebook for a chance to win a free copy!  Winner will be decided this coming Monday at noon!  Post a comment on THIS POST saying you retweeted or shared.  Drawing will be random!

The Best Health Blogs You Must Read in 2013

1.  Health Beat by Maggie Mahar - Maggie Mahar created HealthBeat in 2007. Earlier this year, she began posting regularly at the healthinsurance.org blog and she’ll continue to write on both websites. The author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006), Mahar also served as the co-writer of the documentary, Money-Driven Medicine (2009), directed by Andrew Fredericks and produced by Alex Gibney.

Before she began writing about health care, Mahar was a financial journalist and wrote for Barron’s, Time Inc., The New York Times and other publications. (Her first book, Bull: A History of the Boom and Bust 1982-2003(Harper Collins, 2003) was recommended by Warren Buffet in Berkshire Hathaway’s annual report. For more on her books, click here.

In an earlier career, Mahar was an English professor at Yale University where she taught 19th and 20th century literature.

2.  HealthBlawg  - David Harlow is a seasoned health care attorney and consultant recognized as an accomplished, innovative and resourceful thought leader in health care law, strategy and policy.  His experience in both the public and private sectors over the past twenty-five years affords him a unique perspective on legal, policy and business issues facing the health care community.

3.  But Doctor I Hate Pink - Breast Cancer? But Doctor, I hate pink is a brutally honest, laugh out loud funny, raw account of navigating life with metastatic breast cancer. Breast cancer is not all pink ribbons and fun runs and survivorship memorabilia, and Ann tells it like it is, what it's like to live life when you know you are going to die.

4.  The Health Care Blog - You can think of us as a little bit like the Huffington Post with a focus on medicine, science and the business of medicine.  Since passage of the Obama administration’s health reform law, we’ve paid close attention to the Affordable Care Act, tracking the implications of the landmark legislation for the industry and consumers, as well as the looming legal battle over the law’s future in Washington.

5.  Health Care Informatics - Mark Hagland's blog about informatics.

6.  Simply Healthy - Marta Montenegro has been inspiring people to live healthy lives by giving them the tools and strength to find one’s inner athlete. Inspired by her father’s last words to her, “Find your victory,” she dedicated herself to living a healthy lifestyle and sharing her personal journey with others. Her personal website MartaMontenegro.com combines health and fitness advice, first-person stories, and tips on nutrition, beauty and fashion.

7.  Runblogger - The best running blog out there (running is health right?) and you can read more about the author.

8.  Wall Street Journal Health Blog - Great resource from the WSJ.

9.  Jay Parkinson + MD + MPH - If I had gone to medical school instead of pharmacy school, THIS is the kind of doctor that I would want to be.  Love this blog.

After completing a residency in pediatrics and one in preventive medicine at Johns Hopkins, I started a practice for my neighborhood of Williamsburg, Brooklyn in September 2007. People would visit my website; see my Google calendar; choose a time and input their symptoms; my iphone would alert me; I would make a house call; they'd pay me via Paypal; and we'd follow up by email, IM, videochat, or in person.

Fast Company calls me The Doctor of the Future. I've got a startup called Sherpaa. Read more about me here.

10.  NPR's Shots - fascinating daily information about health around the world

So there is my top ten list of blogs I enjoy at the moment.  Hope you enjoy!