February 2010 E-Newsletter
- Advocacy Brief: Epocrates 2009’s Best Health Policy/Ethics Blog
- Medical Student Perspectives: Why Should You Attend Leadership Day?
- My Kind of Medicine: Real Lives of Practicing Internists: Leslie Saltzman, DO
- Internal Medicine Interest Group of the Month: West Virginia School of Osteopathic Medicine (WVSOM)
- Winning Abstracts from the 2009 Medical Student Abstract Competition: Humate P for Treatment of Persistent, Life Threatening Epistaxis in a Patient with Glanzmann’s Thrombasthenia: A Case Report
- Subspecialty Careers: Highlights about Careers in Internal Medicine: Transplant Hepatology
- Ask the Program Director
- Did you Know that ACP Medical Student members attend Internal Medicine 2010 for free?
- MKSAP for Students 4 Questions (1,2)
- MKSAP for Students 4 Answers (1,2)
- Top Five Internal Medicine Interest Group's (IMIG) at Program Close
- Articles for Medical Students from ACP Internist and ACP Hospitalist
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Advocacy Brief: Epocrates 2009’s Best Health Policy/Ethics Blog
Want to learn the latest about what is going on in Washington? Check out the ACP Advocate Blog by Bob Doherty, Senior Vice President of the College's Division of Governmental Affairs and Public Policy, recently voted the "Best Health Policy/Ethics" blog in the Epocrates 2009 Medical Blogs Award Program.
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Medical Student Perspectives: Why Should You Attend Leadership Day?
Since President Obama took office just over one year ago, the health care debate in Washington has brought to center stage what many physicians have known for some time. The American health care system is broken and in need of thorough reassessment. Major players in health care reform range from insurance companies to professional medical societies, but it is critical that, as the future of medicine, students take an active role in shaping the future of health care. ACP Leadership Day offers just such an opportunity, as well as providing valuable advocacy training and leadership experience.
Leadership Day 2010 will be held May 18-19 in Washington DC and is designed to provide ACP members with an update on the College's priority legislative issues, briefings from members of Congress and White House officials, and an opportunity to meet with your state's elected officials. A special briefing for medical students is also provided, so you should not feel overwhelmed or intimidated. Whether this will be your first ACP Leadership Day or if you are a seasoned veteran to this annual event, you will find that your voice is needed more than ever to help improve the future of medicine. We have an opportunity to be a voice for our patients and fellow students, sharing first-hand experiences about the necessity for changes in health care.
Because our professional careers are just beginning, no matter what the outcome of health care reform, we will be the ones dealing with the aftermath and any impact it will have on our patients. Take advantage of this incredible opportunity to improve our medical system!
Tips for Leadership Day:
1. Contact your state ACP chapter to learn about possible funding opportunities to support your attendance at Leadership Day. You will be traveling with your state delegation, so it is important that you coordinate your participation through your chapter.
2. Visit the ACP Leadership Day Website to learn more about our planned events and read up on College priorities and issues.
3. Become an ACP Key Contact to receive timely updates on health care legislation and stay involved in advocacy throughout the year.
4. If you have questions, contact your regional representative on the ACP Council of Student Members.
Matt Rudy
Southeastern Region Representative, ACP Council of Student Members
Medical College of Georgia School of Medicine, 2010
E-mail: mattrudy@gmail.com
Check out more volunteer opportunities.
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My Kind of Medicine: Real Lives of Practicing Internists: Leslie Saltzman, DO
Leslie Saltzman’s first job was fairly important for a ten-year-old. She didn’t hold an official title—she and her mom didn’t think it was necessary—but her help filing the billing and storing the Pap smears for her mother’s family practice in West Philadelphia, PA, was greatly appreciated, and young Leslie was glad to do it. She looked up to her mother—who is still practicing and has yet to see a malpractice suit—and says she was the role model she sought to emulate. “My mom’s patients love her,” she explains. “Having a person like that to look up to meant a lot.” Over the next twenty years, Dr. Saltzman would take her mother’s inspiration, step outside the world of medicine long enough to live a different life, and then come back full circle to realize her personal vision of being a physician. Today, Dr. Saltzman has her dream job, one that she created all on her own, with a little help from a loving mother, a handsome guy named Bob, and internal medicine.
The French Major
As an undergrad at Wellesley College just outside of Boston, MA, Dr. Saltzman loved science, yearned to do something intellectual, and knew that she wanted to help people. She began as a biology major, but things at home were tough: Dr. Saltzman’s father was dying of pancreatic cancer, and she knew deep down that she would not have the mental or emotional strength to pull off pre-med and medical school while going through it. So she switched to French and Economics and studied abroad in Paris before returning to Philadelphia to complete her Post Baccalaureate studies at the University of Pennsylvania. It was then when she knew it was time to return to medicine. “By this time I knew I was going to medical school,” she says, “and I knew early on that it would be primary care that I would go into. I wanted to focus on helping people because I had seen how my mother’s relationships with her patients were the most rewarding part of her job.”
During her training at Bryn Mawr Hospital and Pennsylvania Hospital, she focused on rotations conducive to outpatient care. She was drawn to internal medicine because she felt it was interesting. “The great part about internal medicine is the variety,” she says. It was also around this time when Dr. Saltzman met her husband, Bob. “He’s had a good influence on me,” she says, “and I’ve tried things because of him, like answering health questions for the local CBS station. I was nervous the first time I did it, but I’ve found that if you do something you are uncomfortable with, you are no longer afraid of it anymore.” They have been married seven years and have a two-year-old little girl. With her training complete, a loving partner by her side, and a beautiful daughter, Dr. Saltzman was ready to begin the next chapter of her life.
Her Baby
As a business planning and marketing consultant, Bob Saltzman was the perfect person to help his wife realize her vision for an internal medicine practice. The two worked hard, researching and planning, and Dr. Saltzman had her hands in everything that went into building the practice, from creating all of the forms to the billing to writing copy for the web site. “The thing that I’m proudest of is the fact that this practice is mine,” she says. “There is so much satisfaction in developing something and creating it…and then as time goes by to have people tell you how amazing it is. It’s like your baby.”
Rittenhouse Internal Medicine of Philadelphia opened in October, 2008. The practice is focused on adult primary care with an emphasis on women’s health, as well as evidence-based preventive care and endocrinology. Dr. Saltzman also serves as the medical director of the Rittenhouse Women’s Wellness Center, which is part of the practice. At the Wellness Center, women can receive fitness evaluations, stress management support, and nutrition education and planning. It’s common for patients to receive several of these services in a half-day visit.
The practice provides personalized, comprehensive care, and since opening has attracted over 1,000 patients and is growing quickly. “The patients here are almost like groupies,” says Bob Saltzman, “they’ve found a place where they get everything they need and where someone will listen to them and they love it. We’re already looking for another physician to handle the patient load.”
The Onion Peeler
Much of the practice’s appeal, as Dr. Saltzman explains, has to do with the fact that she runs it the way she wants to. This is centered on one central component—time spent with patients. “My shortest visit time is 15 minutes and for every new patient, I spend an hour,” she explains. She invests a lot of that time practicing preventive care and keeps a keen eye on what is going on in the lives of her patients. “Things like relationships and jobs affect health in a big way,” she says. “People come in all the time with something that they think is viral, and it’s not, it’s anxiety or depression. Treating patients is like peeling an onion; you have to peel one layer back at a time to see what the story is. You have to let patients tell the story.”
“Being an internist and working here is so great,” she continues, “I treat families, groups of friends…it’s like a community right here in my own practice. The thing about financial compensation…sure you might do better in a subspecialty, or in some other specialties, but I just think it comes down to ‘why did I become a doctor in the first place?’ It’s because it’s an interesting career and I want to do good things with my life. You can have that as an internist.”
Another thing Dr. Saltzman can do as an internist is live a full life. She loves to travel—she and Bob visited Portugal this year—exercise, and spend time with her daughter. She says being an internist lets her do all. “If I want to take an art class with my daughter, I can do that,” she explains. “If I want to exercise in the morning, I can do that, too.”
Things may have changed since the days when she used to organize Pap smear slides for her mother in West Philadelphia, but one thing that remains in spades for the multi-tasking Dr. Saltzman is the timeless bond between doctor and patient that permeates everything she does. “I love coming to work,” she says.
Check out previous articles as physicians share what motivated them to become physicians as well as why they chose their particular type of practice.
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Internal Medicine Interest Group of the Month: West Virginia School of Osteopathic Medicine (WVSOM)
The Internal Medicine Club at the West Virginia School of Osteopathic Medicine (WVSOM) is proudly one of the largest and most active clubs on campus, extending memberships to 30% of the student body. Our mission is to bring together students who share an interest in internal medicine and educate them about the many opportunities available in this diverse field. The club promotes leadership, education, and service to the community to foster the development of skilled and compassionate osteopathic physicians.
Under the guidance of ACP Member, Patrick Ryan, MD, the club leadership includes Rebecca S. Barrett, OMS-II (President), Matt Pugh, OMS-II (Vice President), Calvin Yang, OMS-II (Treasurer), and Wynee Lou, OMS-I (Secretary).
This year we hosted our Second Annual Blood Drive open to WVSOM and the greater community of Lewisburg, WV. Dubbed “The Bleed Off”, the blood drive was a competition between the first and second-year students for the most units of donated blood. Through the combined efforts of our volunteers, donors, and partnership with the American Red Cross, 75 units of blood were donated. The second-year students won the competition and received a pizza party on the house.
In October, a pioneering team of third-year students entered into the Medical Student Doctor’s DilemmaTM competition at the 2009 WV Chapter Scientific Meeting of the ACP. Our students competed with fourth-year students from WVU and Marshall medical schools. This marked the first year that WVSOM was represented at the ACP statewide competition, and we hope to continue our participation at future meetings.
In November, we hosted our Second Annual Internal Medicine Club Week. In line with our mission, the week was comprised of a variety of activities to cater to students interested in internal medicine and to benefit the greater community. Dr. Ryan played Alex Trebek in a Jeopardy competition that was designed as a Step 1 Board Review for first and second-year students. We also hosted a chili cook-off, in which 26 chilies prepared by students, their families, and faculty were judged. Prizes were graciously donated by John Garlitz, DO and the WVSOM Bookstore. Proceeds were allotted to host future guest speakers and to benefit the local Children’s Home Society. To conclude the week, we had the distinguished honor of hosting ACOI Board member John B. Bulger, DO, FACP, FACOI. Dr. Bulger’s presentation was a case-based lecture that focused on analyzing liver function tests. He was highly energetic and his insight into the field of internal medicine was very beneficial.
The Children’s Home Society (CHS) is our year-long community service project. The CHS is an emergency shelter for at-risk adolescents who are usually housed for no more than 90 days. Each week, volunteers go the CHS as mentors and engage the adolescents in learning activities to promote leadership, positive behavior, critical thinking, and communication skills.
students at WVSOM show an increasing interest in internal medicine each year. The spring semester looks promising, with several guest speakers and board review Jeopardy competitions being planned. It is our hope to continue to provide ample opportunities and resources to these students interested in such a diverse field.
Rebecca S. Barrett, OMS-II
President, WVSOM Chapter of SOIMA/IMIG
West Virginia School of Osteopathic Medicine, Class of 2012
Email: rbarrett@wvsom.edu
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Winning Abstracts from the 2009 Medical Student Abstract Competition: Humate P for Treatment of Persistent, Life Threatening Epistaxis in a Patient with Glanzmann’s Thrombasthenia: A Case Report
Authors: Richard A Zinke and Chris E Holmes, MD PhD
Introduction:
Glanzmann’s thrombasthenia is a rare inherited disorder of platelet function caused by a deficiency or abnormality in the platelet glycoprotein (GP) IIb/IIIa complex. Treatment of Glanzmann’s thrombasthenia with transfused blood products and desmopressin (DDAVP) is effective in many patients. Recombinant factor VIIa (rFVIIa) is often used in severe, refractory bleeds. We report on the successful use of Antihemophilic Factor VIII/von Willebrand Factor Complex (Humate P) in a Glanzmann’s thrombasthenia patient with active bleeding who had failed to respond to aggressive prior management including recurrent rFVIIa dosing.
Case Presentations:
A 54-year-old woman with Glanzmann’s thrombasthenia presented with persistent posterior epistaxis of three to four weeks duration unresponsive to platelet transfusions, multiple doses of rFVIIa, and local electrocautery and nasal packing at an outside institution. Despite aggressive therapy including repeated packed red blood cell transfusions, the patient was admitted to the ICU with a hemoglobin level of 4.2 mg/dl and active nasal bleeding leading to mild airway compromise. Treatment was continued with multiple platelet and packed red blood cell transfusions and two 90 mg/kg doses of rFVIIa were given. Epistaxis persisted and she remained hemodynamically unstable despite intranasal aminocaproic acid and phenylephrine four times daily. The patient periodically experienced severe transfusion reactions which were later found to likely be related to her development of GPIIb/IIIa alloantibodies. DDAVP therapy was contraindicated due to this patient’s chronic hyponatremia (Sodium = 128 mEq/L). Factor VIII (434%, ref 61-192) and von Willebrand factor (352%, ref 50-200) levels were elevated; however, the decision was made to proceed with Humate P therapy given the tenuous clinical situation. Humate P (2450 ristocetin cofactor (RCoF) units, 25 units/kg) resulted in cessation of her epistaxis within four hours. A maintenance regimen of intranasal aminocaproic acid, estrogen nasal cream, and isoflavones has prevented recurrent hemorrhage.
Discussion:
Despite already elevated levels of factor VIII and von Willebrand factor (vWF), our patient had an abrupt response to Humate P infusion after more than five weeks of continuous, life threatening epistaxis. Humate P may offer an additional therapeutic option for patients with Glanzmann’s thrombasthenia and may provide insight into potential mechanistic functions of vWF in these patients.
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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: www.abim.org/certification/policies/imss/thep.aspx.
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. For more on certification requirements, visit the ABIM’s Web site: www.abim.org/certification/policies/imss/thep.aspx.
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
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Ask the Program Director
IMpact is developing a new feature that will focus on providing medical students practical advice to help them navigate the process of obtaining a residency position in internal medicine. Issues to be covered include CV development, writing a personal statement, the Match process, residency program interviews, and more. At this time, we are collecting questions and issues that medical students would like addressed by program directors. We will then recruit volunteer program directors to answer those questions in a series of monthly columns that will be included in the newsletter beginning in spring 2010. Please send your issues and questions to Katie Buell, Programs and Services Coordinator, at kbuell@acponline.org.
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Did you Know that ACP Medical Student members attend Internal Medicine 2010 for free?
ACP’s annual meeting, Internal Medicine 2010, will be held in Toronto, Ontario, from April 22-24, 2010. Internal Medicine 2010 is the premier scientific meeting for internal medicine and features over 250 scientific sessions and is free for ACP Medical Student Members. For details regarding the meeting, including information on discounts, housing and travel arrangements, visit www.acponline.org/im10.
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Top Five Internal Medicine Interest Group's (IMIG) at Program Close
The 2009 ACP IMIG program closed on December 31, 2009. The top five schools this year were:
| Medical School | % of Medical Student Members |
| University of Cincinnati College of Medicine | |
| University of Hawaii | |
| University of South Alabama | |
| Wright State University School of Medicine | |
| University of Mississippi School of Medicine |
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MKSAP for Students 4 Question 1
A 32-year-old woman who has had type 1 diabetes mellitus for 20 years is evaluated during a routine office follow-up visit. She is using 32 units of premixed insulin twice daily (75/25 neutral protamine lispro/lispro mix) at her morning and evening meals. Most premeal capillary glucose readings range between 100 and 200 mg/dL. Fasting glucose readings average approximately 170 mg/dL. She does, however, have hypoglycemic reactions about once or twice a week, usually between 1:00 and 3:00 AM. The most recent hemoglobin A1c was 7.4%. Examination reveals normal weight and blood pressure and no evidence of diabetic complications.
Which of the following would be most appropriate to improve her glucose control?
A. Change to insulin glargine at bedtime with three premeal injections of insulin lispro during the day
B. Change to three premeal injections of insulin lispro during the day
C. Increase the dose of both the morning and the evening premixed insulin
D. Reduce caloric consumption
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MKSAP for Students 4 Question 2
A 30-year-old woman is evaluated in the office because of an abnormal total bilirubin level detected when she had a life insurance examination. Medical history is unremarkable. Her only medication is an oral contraceptive agent. Physical examination is normal.
Laboratory Studies
| Hemoglobin | 13.9 g/dL |
| Mean corpuscular volume | 88 fL |
| Red cell distribution width | 10.8% (normal) |
| Total bilirubin | 2.4 mg/dL |
| Direct bilirubin | 0.2 mg/dL |
| Aspartate aminotransferase | 23 U/L |
| Alanine aminotransferase | 22 U/L |
Which of the following is the most appropriate management at this time?
A. Discontinue the oral contraceptive agent
B. Evaluate for the presence of hemolysis
C. Repeat the liver chemistry tests in 3 months
D. Schedule abdominal ultrasonography
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MKSAP for Students 4 Answer 1
Answer: A: Change to insulin glargine at bedtime with three premeal injections of insulin lispro during the day
This patient's glucose control will improve by switching to insulin glargine at bedtime with three premeal injections of insulin lispro during the day. Generally, more complex regimens with more frequent injections of both short/rapid–acting and long/intermediate–acting insulins result in better glucose control, as long as the patient has the required motivation and capabilities. This patient has suboptimal glucose control on premixed (intermediate plus rapid-acting) insulin administered twice daily. Premixed insulins, although convenient, lack the more precise dosing flexibility of self-mixed or individually administered insulins. High glucose levels during the morning fasting period suggest the need for greater insulin exposure to a long-acting insulin during the night. However, the overnight hypoglycemic episodes prevent increasing the patient's premixed evening insulin dose. Indeed, these episodes likely reflect the peak action of the intermediate-acting insulin protamine lispro administered before dinner.
Increasing the dose of both the morning and the evening premixed insulin may result in better glucose levels during the day but will probably increase the hypoglycemic episodes overnight. Reducing caloric consumption is an inappropriate recommendation for a normal-weight person with type 1 diabetes, although proper food choices may improve control to some degree. This patient will derive the most benefit from switching to a regimen of the long-acting insulin glargine at bedtime, providing 24 hours of basal insulin, with three adjusted doses of the rapid-acting insulin lispro at mealtimes to prevent postprandial glucose excursions.
Bibliography
1. Flood TM. Appropriate use of insulin analogs in an increasingly complex type 2 diabetes mellitus (T2DM) landscape. J Fam Pract. 2007;56:S1-S10; [PMID: 17217893] [PubMed]
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MKSAP for Students 4 Answer 2
Answer: C: Repeat the liver chemistry tests in 3 months
This patient has indirect (unconjugated) hyperbilirubinemia, which in an asymptomatic patient with a normal hemoglobin level and otherwise normal liver chemistry tests is suggestive of Gilbert's syndrome. Gilbert's syndrome is the most common inherited disorder of bilirubin metabolism. In adults, it is a benign disorder, and a presumptive diagnosis can be made based on repeated testing showing only mildly elevated indirect bilirubin.
Cholestasis due to an oral contraceptive agent will cause conjugated (direct) hyperbilirubinemia, which is not present in this patient. Patients with hemolysis significant enough to cause unconjugated hyperbilirubinemia generally have a low hemoglobin level and abnormal values for mean corpuscular volume and red cell distribution width as a result of reticulocytosis. Abdominal ultrasonography may be a helpful study for patients with direct hyperbilirubinemia, which is usually associated with hepatobiliary disease, but is not indicated in this patient who has indirect hyperbilirubinemia.
Bibliography
1. Roche SP, Kobos R. Jaundice in the adult patient. Am Fam Physician. 2004;69:299-304. [PMID: 14765767] [PubMed]
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Articles for Medical Students from ACP Internist and ACP Hospitalist
ACP Internist (formerly ACP Observer)
Find all of our print and online content, by going online for the following stories:
- Calmer talk needed about mammography
Controversy about implementing new mammography guidelines shouldn’t cloud talks between doctors and the women they counsel. Clarify what the guidelines really say, and share the decision-making with patients, experts counsel. - Expert lays out controversies for cardio care
February is National Heart Disease Awareness Month, and the field is wide open to controversies seemingly without resolution when it comes to invasive versus therapeutic regimens. Bill Kussmaul, FACP, an associate editor of Annals of Internal Medicine, addressed some of the hottest controversies in cardiology. - Med schools promoting care for underserved
To encourage primary care careers, medical schools are offering students shortened specialty rotations in favor of fast-track graduation, half-tuition forgiveness and having students follow patients wherever they go in the health system. Different teaching models emphasize continuity of care over snapshots of diagnoses, and place students in the clinics where they can fulfill the nation’s need for rural care. - Army physicians on the front line of infectious disease research
Walter Reed’s infectious disease unit travels the globe to identify and combat the world’s deadliest infectious diseases. Initiated to find vaccines that protect troops stationed overseas, the work quickly benefits civilian populations, too.
ACP Hospitalist
The relaunched ACP Hospitalist is the place to find all of our print and online content, including ACP HospitalistWeekly, our polls, and surveys (including our cartoon caption contest). Go online for the following stories:
- More than a mentor
Mentors play a crucial role in helping less experienced physicians develop their careers. A good coach can provide needed perspective and guidance. - Helping patients kick the habit
In the face of recent reports that U.S. smoking rates are no longer declining, hospitalists may be ideally situated to help patients quit.
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