April 2008 E-Newsletter

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Important Information for Internal Medicine 2008 Attendees!

ACP's annual meeting, Internal Medicine 2008, held May 15-17 in Washington D.C., contains a variety of events and courses geared toward Medical Student Members. Register now to attend Internal Medicine 2008.

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Visit the Special Events for Medical Students.

If you are attending Internal Medicine 2008, you are invited to participate in the special events listed below. Please pre-register for one or more of the following sessions.

  • Volunteerism Networking Luncheon, Thursday, 12:45–2:15 p.m., Convention Center, Room 150
  • Reception for African American Physicians, Friday, 6:00–8:00 p.m., Renaissance Washington DC Hotel, Grand Ballroom South
  • Medical Student Mentoring Breakfast, Saturday, 7:00–8:30 a.m., Grand Hyatt Washington DC Hotel, Constitution Rooms C/D/E

You are also invited to participate in the following events at Internal Medicine 2008.

  • Leadership Day Closing Ceremony and White Coat Event/graphics/new/pdf.gif, Wednesday, approximately 5:00–5:30 p.m.
  • Medical Student–Associate–Young Physician Hospitality Area, Thursday–Saturday, 8:00 a.m.–5:00 p.m., Convention Center, East Registration Hall
  • International Reception, Thursday, 9:00–11:00 p.m., Renaissance Washington DC Hotel, Grand Ballroom
  • Fourth Annual Internal Medicine Residency Fair, Saturday, 2:00–5:00 p.m., Convention Center, Ballroom Prefunction Area
  • Medical Student, Associate, & Young Physician Recognition Reception, Saturday, 6:30–7:30 p.m., Grand Hyatt Washington DC Hotel, Wilson/Roosevelt Rooms

We look forward to seeing you in Washington, DC!

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Attend the Clinical Skills Review Course.

Students can prepare for the USMLE Step 2 Clinical Skills Examination by participating in the Waxman Clinical Skills Center Step 2 Practice Session. This workshop consists of four stations that simulate the experience of the USMLE Step 2 Clinical Skills Exam. Professional teaching patients (standardized patients) will present you with common problems and provide expert feedback on your history and physical examination skills, communication skills, and written note. A checklist score will be generated and shared with you in addition to other verbal feedback on your global performance. You will be provided with a written note summarizing the feedback, highlighting areas of strengths and weaknesses. Two students will be paired for the four station workshop, allowing each student two "hands-on" experiences and two observation experiences.

Features include:

I. Assessment orientation

II. 4 Station Clinical Skills Assessment

  • 15 minutes per patient visit

  • 10 minutes immediate feedback for 2 stations

  • 10 minutes for 1 patient note

III. Detailed performance profiles of scores for each of the areas of a Clinical Skills Examination:

  • conducting a relevant patient history

  • performing a focused physical examination

  • providing diagnosis

  • communication and interpersonal skills

  • 1 graded patient note for accuracy and completeness

  • English proficiency

Here are representative comments from previous medical student participants in this highly rated workshop:

  • These teachers are excellent! Want more time with them!

  • The training was desperately needed. I've really gained insight on my strengths and weaknesses in the clinical setting.

  • Best activity so far in the conference.

  • Feedback was key!

Activities in the Herbert S. Waxman Clinical Skills Center are free of charge but require onsite advance registration. Please visit our Web site to learn more/graphics/new/pdf.gif.

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Volunteer to work during the meeting.

The College needs medical students with basic to intermediate computing skills to help in our medical informatics workshops. Students will be paid a small honorarium ($100 per half-day, $200 for a full day).

If you are attending Internal Medicine 2008 and would like to help, please contact Lisa Rockey at (800) 523-1546 ext. 2588 or lrockey@mail.acponline.org.

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Medical Student Perspectives: Tips for Applying to Internal Medicine Residency Programs.

The fourth year of medical school is quite an exciting time, but the residency application process can be daunting. Once you have decided to pursue internal medicine, it is time to do your research, begin selecting individual programs, and complete the Electronic Residency Application Service (ERAS) application. The following timeline should keep you right on track throughout the process.

June 2008

  • Prepare your personal statement. This is one of the most difficult stages of the application process and time for editing is essential, so start early.
  • Check the Fellowship and Residency Electronic Interactive Database (FREIDA) to view all accredited residency programs participating in the Match. You can search by specialty or location. This site will give you detailed information regarding each residency program, including the number of residents, call schedule, salary, number of recommendation letters required, and whether or not a Chairman’s letter is required.
  • You can also visit ACP’s Residency Database, to learn more about internal medicine residency programs in the U.S and Canada.

July 1, 2008

  • MyERAS Web site opens to applicants. Your school will distribute a MyERAS token to you so that you may begin working on your application.

July through August

  • Ask for letters of recommendation. Once you have asked someone to write a letter for you be sure to send him or her an up-to-date copy of your curriculum vitae, a copy of your personal statement, and a MyERAS cover letter.

July 15, 2008

  • ERAS opens for students. Begin to download your application files.

August 2008

  • Medical Student Performance Evaluation (MSPE) electronic drafts are due.
  • National Resident Matching Program (NRMP) registration opens. You must register and pay NRMP fees in order to submit a rank list in February. This fee is separate from the ERAS application fees.

September 1, 2008

  • Accreditation Council for Graduate Medical Education (ACGME)-accredited programs can begin to download application files.
  • Transmit your applications via ERAS to residency programs.

November 2008

  • MSPE letters are released to ACGME programs.
  • At the end of November NRMP registration officially closes.

December 2008

  • Military Match results are released.

February 2009

  • Submit Rank Order List (ROL) via NRMP website.
  • Osteopathic Match results are released.

March 2009

  • Allopathic Match results are released.

Visit http://www.aamc.org/students/eras/resources/start.htm, to download helpful resources. Resources include:

  • ERAS 2008 Applicant Manual.
  • MyERAS 2008 Application Worksheet.
  • ERAS 2008 Residency Applicant Information Sheet.
  • ERAS 2008 Residency Applicant Information Sheet for Osteopathic Applicants.
  • A Guide to the Preparation of the Medical Student Performance Evaluation.

In addition to the plethora of resources available on the Web, there are many individuals who will be willing to help you during the residency application process. Meet with them and seek the advice of faculty and residents in your department of medicine to get information regarding specific programs. There is one last point I would like to share with you: no program is beyond your reach. Best of luck!

Kerry Massman
Council of Student Members Representative, Midwestern Region
University of Missouri, Columbia, Class of 2008
E-mail: klm9f9@mizzou.edu

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My Kind of Medicine: Real Lives of Practicing Internists: L. Clifford McDonald, MD, FACP

Working as a “foot soldier” for the Centers for Disease Control and Prevention (CDC) has its moments, the first of which for a young L. Clifford McDonald was terrifying and thrilling all at once. Three weeks after landing the job, he found himself stepping off a plane in the Caribbean and greeting the nation’s Minister of Health. His task was to figure out why eight infants had unexpectedly passed away at a local nursery. People were watching, too. One of the infants happened to be a nephew of a major local politician. Daunting? Yes he says, but worth it. As he puts it, “It was the best job in the world.”

A Global Point of View
Ten years later as Chief of the CDC Prevention and Response Branch, Dr. McDonald has grown into his responsibility, but is every bit as challenged today as he was on that day on the Caribbean tarmac. His job and that of the branch he oversees is to study the causes of health care associated infections and ways to prevent them. This includes overseeing investigations of outbreaks in hospitals and the use of science to guide national policy on prevention. He loves the job and says his decision to pursue internal medicine made it possible. “When I look back I can see how my training has contributed to where I am now—without it I would not have had the opportunity to subspecialize in infectious diseases,” he says. And although his father was a physician, Dr. McDonald attributes his passion for medicine to an inner awareness he discovered in high school. “I enjoyed science a lot but I wanted to help people, too,” he explains. “And I am so glad I chose internal medicine because it has opened up so many different opportunities and has been a platform for so many things for me in public health.”

After finishing medical school at Northwestern University’s Feinberg School of Medicine, Dr. McDonald began his career as a hospitalist at Blodgett Hospital, near Grand Rapids, Michigan. A short stint as a missionary physician followed in Taiwan, and then work as an infectious disease fellow at the University of South Alabama and a microbiology fellow at Duke University. Upon completing his fellowships, Dr. McDonald was accepted into CDC’s elite Epidemic Intelligence Service (EIS), which he says provides the ‘foot soldiers’ for CDC. It would take him to four continents and far-reaching parts of the world—South America, the Caribbean, Thailand and Africa—in two years. “It was exciting and challenging,” he says, but adds that it was not all fun and games. “It could be anxiety provoking. For example, my first investigation in the Caribbean when I was thrust into being the sole investigator of a high profile outbreak—the pressure was definitely on.”

L. Clifford McDonald, MD, FACP with his family.

L. Clifford McDonald, MD, FACP with his family.

He says working in public health has been the opportunity of a lifetime. “For me it has been an opportunity to understand how to control the spread of disease and also how policies can have a major impact on making patients safer,” he says. His work overseas has also given him the perspective to appreciate what our own health care system offers in comparison to those abroad. “Working overseas I have realized how glad I am to live in a place where information is shared freely across various levels of experience,” he says. “I think the way we share information here with students is really beneficial, as well as the ways in which teachers can learn from students. The fact is sometimes we don’t have all the answers. Sometimes the patient has the answer and we need to take on the role of directing the traffic as we lead teams of other professionals.”

A Sensitive Soul
Working with a team is something Dr. McDonald has come to value more and more, having weathered a handful of difficult situations alone, as he did one evening while working his evening shift at Blodgett Hospital. A man in his 60s with apparent pancreatitis and evidence of a large myocardial infarction had come under Dr. McDonald’s care from the day shift. When the man’s condition started to decline, Dr. McDonald started to struggle. “Despite my best efforts to keep him alive and to keep him supported, he was deteriorating rapidly,” he remembers. “Despite intensive support, the patient died that evening. The particularly hard part was interacting with a family I did not know; the patient and his family had recently moved to the area and did not have a local physician to consult, so it came as a shock to the family. What I learned from it was how to not be afraid to ask for help. I faced the care of that patient largely alone, thus I appreciate having a team to work with now.”

The experience touched him as it would have any physician, but for Dr. McDonald the incident resonated deeply. “I could see and hear their anguish. I had been through residency and all that by this point, and there had been other times I had gone through a similar process with other patients, but in this situation I was very much alone. I cried with them.” Empathetic would be the word to describe people like Dr. McDonald, but the 45-year-old also seems to have an extra layer of sensitivity built in. It is apparent when he talks of his wife and his experience coping with Hodgkin’s disease since the age of 17.

“Having been diagnosed with Hodgkin’s at a young age, I’ve experienced medicine from the other side,” he explains. “It’s been intense at times. I underwent chemo and radiation therapy as an undergrad and since then I’ve been having little complications here and there. Recently I had to have a pacemaker put in.” But the difficulties of his disease are minimized by the joys in his life—his wife Lisa, a nurse, and six children. Dr. McDonald met Lisa at a Christian clinic for the poor in Chicago. She clearly has an enormous impact on him. “She keeps me young in more than one way,” he says. “She keeps me very active and she’s just very positive. Her faith in God inspires those around her; she is not someone who sits around feeling sorry for herself.”

Dr. McDonald knows a thing or two about life as well. He says students need to consider the long term when making a career choice. “Don’t let temporary situations dictate your future—consider both lifestyle and the purpose you want to have in life that extends beyond the material,” he says. “In hindsight I know that some of the other careers I was considering I wouldn’t be satisfied with now. I also feel like internal medicine has altruism at its very core and that is something to be proud of. Yes we do get to do science, but we also have the chance to help people. We don’t know the future of health care, but it’s why I went into medicine in the first place. People always respect that and they’ll always come back to it.”

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Internal Medicine Interest Group of the Month: University of North Dakota

The University of North Dakota (UND) School of Medicine’s Internal Medicine Interest Group (IMIG) has been very active for the past 6 years. This year, along with the usual panels and presentations, we decided that we would like to provide some service to the community. This, in turn, allowed us to offer first and second year students experiences that did not solely involve standardized patients or the infamous medical mannequin, Harvey. From these activities, we have three tips that we hope other IMIGs might find valuable.

Tip #1: Partner With Other Organizations
By partnering with UND’s Chapters of the American Medical Association, American Medical Student Association, and our community hospital, we were able to provide free glucose, vision, and blood pressure screenings, along with cholesterol screenings to the community. In providing the screenings, we helped first and second year students gain confidence in patient interactions while we provided a valuable service to the community. By partnering with the two other student organizations, we were able to present this opportunity to students with a variety of interests. Therefore, this partnership allowed members of other student groups to gain a better understanding of our IMIG, which allowed us to gain a few new members.

Tip #2: Find a Passionate Faculty Advisor and Hold on to Her or Him.
At UND, third and fourth year students are spread throughout the state for their clinical experiences to enable greater one-on-one faculty-student interactions. Due to this fact, our IMIG is composed solely of first and second year students, with second year students serving as officers. This yearly turnover of officers provides a challenge to maintaining continuity in our IMIG. In combating this issue, we have been lucky to have LaVaun McCann, MD, FACP, our tireless faculty advisor, at our side. With her invaluable help and the help of twenty-one other local internists, we were able to set up a mentoring program for first and second year students. Through this program, first and second year students spend as many afternoons as they would like observing internists and sharpening their physical exam techniques. Students have been able to shadow general internists, hospitalists, and a variety of specialists. This program has allowed our IMIG to provide students with early exposure to internal medicine, while preparing us for the thousands of questions we will get pointed our way during third and fourth year. Also, by taking into consideration which specialties our members are most enthusiastic about, we can develop more effective and applicable panels and presentations for our class.

Tip #3: Match Your Topic to What is Currently Being Taught
The events with greatest attendance were presentations that put an interactive spin on information previously presented in class. By offering gastroenterology shadowing during the portion of the curriculum dedicated to gastrointestinal physiology and pathology or offering an interactive ECG refresher while cardiac physiology and pathology are being presented in class, we have been able achieve high attendance, while showcasing the breadth of internal medicine.

In summary, we started off the year with a panel of four internists explaining the answer to the question we most often face: “What is Internal Medicine?” This was followed up by a presentation entitled “Basic ECG Interpretation” presented by cardiologist Joshua Wynne, MD, MBA, MPH, which was attended by nearly 100% of the first and second year students. In the future, we are planning a presentation by an oncologist/hematologist, coinciding with our cancer therapeutics lectures. Finally, we are ending the year with a panel of residents and fourth year students to offer advice for our future years and elections to help ensure our continued success.

Miran Blanchard
President, Internal Medicine Interest Group
University of North Dakota School of Medicine,
Class of 2010
E-mail: mblanchard@medicine.nodak.edu

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Winning Abstracts from the 2008 Medical Student Abstract Competition: Acute Staphylococcus Aureus Endocarditis: Early/rapid diagnosis by recognition of the classical peripheral manifestations of infective endocarditis.

Author:
Sudy E. Jahangiri, BS. Northeastern Ohio University

Introduction:
The current incidence of infective endocarditis is 1 case per 1,000 hospital admissions and has not changed since the 1970’s. Classic peripheral manifestations of infective endocarditis (IE) have a decreased historical prevalence of 50% to current day prevalences of 10-23% for Osler’s nodes, 15% for splinter hemorrhages, and less than 10% for Janeway lesions. It is therefore uncommon for current medical students and residents to have seen these lesions in a patient with IE. We present a patient with acute Staphylococcus aureus IE due to injection drug use (IDU) with these classic peripheral manifestations in order to better acquaint current student and resident physicians with these classic manifestations.

Case Presentation:
A 24 year-old male with a history of IDU presented to the emergency department with left shoulder pain and fever of 102.3. On examination he was found to have left sternoclavicular (SC) joint tenderness and his white blood cell count was 13.1. He was admitted with suspected SC joint infection, started on vancomycin, piperacillin/tazobactam, and gentamicin, and scheduled for joint aspiration. Blood cultures were also drawn. The aspiration fluid was sterile with no neutrophils. The next day, the patient’s left second toe and left index finger were ecchymosed and tender. A transesophageal echocardiogram was completed and read as normal. At this time, the patient left against medical advice. Three days later, the patient returned to the hospital with increasing lesions. By this time his original blood cultures were positive for Staphylococcus aureus. On examination, he had multiple Janeway lesions, Osler’s nodes on his left second toe and left fifth metatarsal joint, splinter hemorrhages on his left index finger, and right subconjuctival petechiae. No murmurs were audible. Intravenous vancomycin and rifampin were begun but the patient again signed out against medical advice and was lost to follow-up.

Discussion:
This patient with acute IE diagnosed by physical diagnostic signs and positive blood cultures provides a potent visual and clinical review of the classical but now uncommon presentation for this widely recognized disease process. The negative TEE results in this case serve as a reminder that an echocardiographic abnormality is not required for the diagnosis of IE. Physical diagnosis is still a potent means of recognition of a potentially life-threatening infectious disease.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Transplant Hepatology

Training
Transplant Hepatology training involves one year of additional clinical training after completion of both residency in internal medicine and fellowship training in gastroenterology. Candidates must also complete the following procedural requirements: performance of at least 30 percutaneous liver biopsies, including allograft biopsies; interpretation of 200 native and allograft liver biopsies; and knowledge of indications, contraindications, and complications of allograft biopsies. For more on training requirements, visit the ABIM’s Web site.

Certification
The American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) jointly developed the Transplant Hepatology Certification Program. Before becoming certified in Transplant Hepatology, physicians must be ABIM certified in internal medicine and maintain a current, underlying certificate in gastroenterology. Registration for the Transplant Hepatology Certification exam is open until May 1, 2008. For more on certification requirements, visit the ABIM’s Web site.

Major Professional Societies

American Association for the Study of Liver Diseases (AASLD)
1001 North Fairfax, Suite 400
Alexandria, VA 22314
Phone: (703) 299-9766
Fax: (703) 299-9622
E-mail: aasld@aasld.org
Web site: https://www.aasld.org

International Liver Transplantation Society (ILTS)
15000 Commerce Parkway, Suite C
Mt. Laurel, NJ 08054
Phone: (856) 439-0500
Fax: (856) 439-0525
Web site: http://www.ilts.org

Major Publications

Hepatology, official journal of AASLD
Liver Transplantation, monthly journal of AASLD and ILTS.

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Advocacy Brief: Department of Education to Increase Health Professions Student Loan Limits

In response to a September 2007 group letter/graphics/new/pdf.gif from ACP and other medical organizations, Secretary of Education Margaret Spellings, the Department of Education has agreed to raise the combined aggregate Stafford loan limit for health professions students from $189,125 to $224,000. Secretary Spellings sent a letter to AAMC President and CEO Darrell G. Kirch, M.D., last month, in which she announced the increase in student loan limits and promised to provide additional information as soon as possible. This increase is entirely in unsubsidized Stafford loans and will allow medical students to borrow at a 6.8 percent interest rate. The Secretary's letter/graphics/new/pdf.gif is available online.

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Did You Know You Can Enroll in ACP’s Key Contact Program?

ACP’s continued success on Capitol Hill greatly depends on year-round grassroots efforts from the College’s nearly 5,000 Key Contacts. Key Contacts communicate with their local members of Congress on issues of importance to internists and their patients and report the results back to ACP.

To enroll as a Key Contact, ACP members are not required to have existing relationships with members of Congress. ACP provides members with the tools necessary to develop and maintain these relationships. The program is open to all membership categories. Enroll now in the Key Contact Program.

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MKSAP for Students 3 Question 1

An inactive, overweight, 43-year-old man with a strong family history of type 2 diabetes mellitus seeks advice to help prevent diabetes. His body mass index is 29.5, blood pressure is 138/86 mm Hg, and fasting plasma glucose level is 104 mg/dL.

Which of the following interventions is associated with a decreased incidence of new-onset diabetes mellitus?

A. Atenolol therapy
B. Amlodipine therapy
C. Hydrochlorothiazide therapy
D. Exercise and a low-calorie, low-fat diet

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MKSAP for Students 3 Question 2

A 67-year-old obese (body mass index, 34) man who has had type 2 diabetes mellitus for 8 years is evaluated because of an increased hemoglobin A1C level. His diabetes originally responded well to a nutrition and exercise plan. The hemoglobin A1C value decreased from 8.8% at diagnosis to 6.9% after 6 months of nutrition therapy and a 5.5-kg (12-lb) weight loss. After 2 years, hemoglobin A1C increased to 8.1%; therapy with glyburide, 10 mg daily, decreased the hemoglobin A1C level to 6.6%, and it remained at less than 7% until 1 year ago. At that time, the patient noted a 7 kg (15-lb) weight gain. The hemoglobin A1C level had increased to 7.7%.

In addition to weight loss and exercise, what is the most appropriate additional intervention?

A. Add metformin to glyburide
B. Discontinue glyburide and begin glipizide
C. Discontinue glyburide and begin metformin
D. Increase glyburide to 10 mg twice daily
E. Continue glyburide and begin insulin

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MKSAP for Students 3 Answer 1

Answer: D, Exercise and a low-calorie, low-fat diet

In the Diabetes Prevention Project, a prospective randomized trial, a combination of regular exercise and a low-calorie, low-fat diet significantly decreased the incidence of new-onset diabetes in overweight patients who lost 7% of their body weight and exercised regularly. ß-Blockers may increase the likelihood of developing diabetes. Amlodipine does not affect the onset of diabetes. Diuretics may worsen glucose tolerance and do not prevent the onset of diabetes.

Bibliography
Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403. PMID: 11832527

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MKSAP for Students 3 Answer 2

Answer: A, Add metformin to glyburide

The goals of therapy for type 2 diabetes include an ideal hemoglobin A1C level of less than 6.5% to 7%. Because the patient is not achieving this goal, a change in the therapeutic regimen is indicated. Multiple studies have demonstrated the advantage of adding synergistic therapies rather than substituting therapies. The addition of metformin to sulfonylurea is considerably more advantageous than replacing the sulfonylurea in the case of secondary sulfonylurea failure. The pathophysiology of type 2 diabetes suggests a benefit associated with the combination of an insulin secretogogue, such as glyburide, with an insulin sensitizer, such as metformin. This combination of drugs is more weight-neutral and thus would have a relative advantage in a patient with progressive weight gain.

Substituting one sulfonylurea for another is unlikely to improve glycemic control. Increasing the does of glyburide is likely to fail because the maximal effective dose of sulfonylureas is less than the maximally approved dose; glycemic control rarely improves with sulfonylurea dosing beyond approximately 50% of the approved maximum amount. While insulin is an option and may be required for the patient in the future, adding an insulin sensitizer remains a better choice than adding insulin to an insulin secretagogue.

Bibliography
Inzucchi, SE. Oral antihyperglycemic therapy for type 2 diabetes: scientific review. JAMA. 2002;287:360-72. PMID: 11790216

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ACP Internal Medicine Residency Database

Interested in obtaining more information about residency programs? ACP offers the Internal Medicine Residency Database which contains information about all internal medicine residency programs in the United States. The Internal Medicine Residency Database provides a description of each program as provided by its internal medicine department or links directly into the program’s Web site.

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Student Members Receive a 30% Discount When Ordering MKSAP for Students 3

MKSAP for Students 3 includes over 400 patient-centered self-assessment questions and their answers in print and on CD-ROM. Designed for medical students participating in their clerkship rotation, the questions help define and assess a student’s mastery of the core knowledge base requisite to internal medicine education in medical school. The questions reflect the daily management dilemmas faced by internal medicine physicians and when coupled with the answer critiques, provide a focused, concise review of important content.

New in MKSAP for Students 3:

  • All new questions and critiques

  • More topics and chapters

  • 12 electrocardiogram questions

  • 24 color figure dermatology questions

List Price: $44.50; Student Member Price: $30.00

To order MKSAP for Students 3 please visit the ACP catalog.

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Articles for Medical Students from ACP Internist and ACP Hospitalist

ACP Internist (formerly ACP Observer)

  • Is the generation gap a growth opportunity? Younger physicians enter medical school and their careers with a much different take on work-life balance than their teachers, mentors and employers. But each generation brings strengths to the workplace.

ACP Hospitalist

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Internal Medicine 2008

Internal Medicine 2008, May 15-17, 2008
May 15-17, 2008 Washington, DC
Take advantage of free registration and events especially for medical students.

Learn more