April 2007 E-Newsletter

Win a 128 MB Flash Drive from ACP! IMpact Contest Question for April

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If you are among the first 30 respondents to answer the following question correctly you will receive a 128 MB flash drive from ACP. E-mail your answer to ImpactContest@acponline.org. The correct answer to April’s contest question will be included in the May issue of IMpact. You must be an ACP Medical Student Member to be eligible to win. Contest winners are not eligible to win again for 4 months.

A 45-year-old woman presents with pruritus of her chest, back, arms and legs of 4 weeks' duration. She has no significant medical history, takes no medications, and has not used any new soaps, detergents, or cosmetics.

Physical examination reveals scattered excoriations but no rash. Skin examination is otherwise normal. The patient follows your recommendation regarding bathing and limited use of soaps and cosmetics and to use an emollient twice daily. On follow-up in 2 weeks, her pruritus is minimally improved.

What would you do next in the management of this patient?

( A ) Skin biopsy of an excoriation
( B ) Topical medium-potency corticosteroid cream
( C ) Hydroxyzine hydrochloride
( D ) Laboratory evaluation for systemic illness
( E ) Patch testing for contact allergens

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Answer for March Contest Question

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Click here to see March’s question.

Answer to March Contest Question: D

Risk factors for stroke in patients who have atrial fibrillation include a history of stroke, a history of myocardial infarction, a history of hypertension, age older than 65 years, and diabetes. Echocardiographic findings of left ventricular dysfunction and left atrial enlargement are additional risk factors. Because this patient has multiple risk factors for stroke, anticoagulation is indicated. The decision as to whether to pursue sinus rhythm must be made. Recent data suggest that clinical outcomes are similar in patients who are treated to achieve sinus rhythm compared with those who receive maintenance therapy for rate control and anticoagulation. Amiodarone may provide rate control but may also result in pharmacologic cardioversion. Therefore, initiating amiodarone therapy in the absence of established, effective anticoagulation is inappropriate. Aspirin does not provide adequate protection against thromboembolic events. Amlodipine has no effect on ventricular rate in atrial fibrillation.

References

Krahn AD, Manfreda J, Tate RB, Mathewson FA, Cuddy TE. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med. 1995;98:476-84.
Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation): developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol. 2001;38:1231-66.
Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med 2002:347:1825-33.
Goldschlager N, Epstein AE, Naccarelli G, Alshansky B, Singh B. Practical guidelines for clinicians who treat patients with amiodarone. Arch Intern Med. 2000;160:1741-48.

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Medical Student Perspectives: Ask Good Questions

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I am reaching the end of medical school and one of the tips for success I have been offered by every clerkship director, every resident, every small-group facilitator and even a couple of books is, “Ask good questions.” Every time, I wanted to ask, “Could you please be more specific?”

What constitutes a good question? I am sure you have been told, “There is no such thing as a dumb question.” While that is almost true, you should not ask a question that is so simple that it makes it obvious you were not paying attention or you did not understand what was going on.

I recently returned from a global health rotation in Brazil where I learned about infectious diseases that affect Brazilians but do not occur (or are extremely rare) in the U.S. About 4 weeks into my 8-week rotation, I went to a dermatology clinic at the university hospital and worked with a new attending physician. Granted, I speak very little Portuguese but I should have been paying closer attention. While the residents and attending were talking, I picked up these words: Mycobacterium, dapsone, peripheral neuropathy, and Hansen’s, among others. I should have thought to myself, “What do these words have in common?” Instead, I blurted out, “What was wrong with that patient?” The resident looked at me a little confused and said, “Hansen’s disease. You know, leprosy. This is a leprosy clinic.” Now that was a dumb question! For those of you who will start your rotations on the wards in the upcoming months, much of what will be said may as well be in a foreign language. I suggest that you retain the words you know and look up the words you do not know and occasionally play the game, “What do these words have in common?” before you ask, “What is going on?”

Asking good questions requires four things: background knowledge, some interest in the topic, context and timing.

Background knowledge requires more than just having survived or even done well in your pre-clinical years. Background knowledge requires constant work. For instance, if you have a patient who is admitted with hyponatremia then you need to look up the causes and treatment for hyponatremia. You should be prepared to talk about hyponatremia for approximately 30 seconds during rounds and you need to be able to finish your 30-second talk with, “But what I didn’t understand from what I read is…” Make sure it is something you actually didn’t understand; doctors can always tell when you are asking a question to which you already know the answer. Please, don’t be that student. I know this sounds like a lot of work (and a little “gunnerish”), but there are many complex topics in medicine; your residents will probably appreciate a quick refresher before your attending starts asking them questions.

Demonstrating interest in a topic has a lot to do with being a good conversationalist. If you cannot express your thoughts on a particular topic you will never be able to convey your interest in it. While this can be difficult sometimes, there is always going to be something that you can take from your current rotation to use in the future. How do you get interested in a topic you find rather boring? Daydream. Yes, you read correctly: daydream. Think ahead to the days in the future when you are a real doctor. Imagine you are not a student sitting behind the radiologist in the dark trying to stay awake while she reads a head CT. Imagine you are in private practice and a patient comes to your clinic with mental status changes and you do not have a radiologist in-house. Now you have a question: “If I have a patient with mental status changes and I have to do a preliminary read on a head CT, what things should I be looking for?” Then, you can follow up with, “Which window would be best for me to see that?” The follow-up question is very important for demonstrating interest. If you have trouble with thinking of questions, try this: at your next family reunion, go to the person with whom you have the least in common and talk about that person’s hobbies for 10 minutes. It is great practice.

Before you ask the thoughtful question demonstrating your interest in a topic, consider the context. Those of you who are studying for your USMLE Step 1 have a lot of background knowledge, and you may even have an interest in the topic, but it is unlikely that your attending physician is going to be able to explain the biochemical mechanism behind doxorubicin-induced hemolysis in a patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency in detail. A more appropriate question might be, “If a patient has G6PD deficiency, what would be a good alternative chemotherapy regimen?” (This question is best when asked to a hematologist.) Try to keep things as clinically relevant as possible. Also, try to avoid asking a question in such a way that it will put a physician in the position of knowingly contradicting the treatment decision of another physician. This is something that we, as professionals, should try to avoid. As professionals, we should respect our colleagues and the decisions they make, regardless of whether or not we agree with them.

Finally, consider the timing. This is probably the most important. There is, without a doubt, a right time and a wrong time to ask a question. For instance, during surgery try not to ask, “What are you doing now?” immediately after a major artery has been severed. In every clinical situation, you will be asked, “Do you have any questions?” Use the time before this question is asked, to think of a question and then save it for when the time is right. If you find that you have many questions, and you are not in a surgery, it is okay to write them down so you remember them. Writing your questions down is particularly important during a busy clinic. You can preface your question with the explanation, “I was curious about this when Mr. So-and-So was here, but I wanted to wait to ask you about it until we had time to discuss it a little more.” Saving the questions that are not vital to your understanding of the immediate situation will demonstrate to your attendings that you have respect for their time and their patients’ time.

To those of you who will start your clinical rotations this summer, good luck and ask good questions!

Heather Strah
Council of Student Members Representative, Central Region
University of Iowa College of Medicine, 2007
E-mail: heather-strah@uiowa.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Kathleen Sandness, MD, FACP

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Kathleen Sandness, MD, FACP If you had to use a single word to describe what Dr. Kathleen Sandness does for a living without making any reference to the field of medicine, it would be “connect.” In an increasingly isolated world, Dr. Sandness shares her life in spades. In a small town like Pittsburg, Kansas, it comes with the territory, particularly if you are one of the community’s most popular doctors. “I have the opportunity to participate in people’s lives in many ways,” she says. “In a time when people are growing more and more distant from one another, I interact with people and sometimes I get to make a difference in their lives. As their primary physician, I am given responsibility for the most precious thing they have, their health. It’s like holding an egg … they hand it to me with the hope that I will handle it with care. I consider that an honor.”

The Communicator

In 16 years of practice, Dr. Sandness has held a lot of eggs. It has earned her a reputation within the community of respect and dependability. It has also guaranteed her job security. “As an internist, especially in a smaller community like mine, you’re sought after,” she explains. For most of her patients, she is an executor of sorts, giving the final word on treatments and diagnoses. “My patients often will come to me after they’ve seen a specialist or gone to the Mayo Clinic and say ‘What do you think?’” She says patients do this as much out of need as out of trust because they need someone to talk to them about their overall health. “Patients like to be talked to,” she says. “Sometimes doctors can make the mistake of focusing on just the organ or the symptom, rather than the patient as a whole—there’s a lack of communication. Having several doctors with no primary physician is a lot like trying to run an airport without an air traffic control tower.”

One of the joys of practicing internal medicine is having long-lasting relationships with patients, which in some cases can last a lifetime. Several years ago, Dr. Sandness visited with a new patient, an elderly woman who was very quiet and reluctant to engage in conversation. Dr. Sandness was having trouble striking a common chord with the woman until one day when she learned that the woman had a dog named Horatio, whom she adored. Dr. Sandness, an animal lover herself, was finally able to make a connection. Things were smooth sailing from there, and the two quickly became good friends. Then one day the woman had a bad fall and suffered fractures in her back. When she needed someone to take in Horatio while she recovered, Dr. Sandness was the first in line. She is also the first one her patients call in the middle of the night. “Sometimes it can be a challenge, in the middle of the night when something goes wrong and it’s something you’re not specifically trained to handle, and you wish you had a consultant nearby to call but you don’t, so you have to be prepared for things,” she explains. “But it is good for me because it makes me keep my skills honed.”

She says she feels as though she has a fulfilling life as an internist because of the positive interactions she has with people, but that there are times when dedication is accompanied by heartache. “Sometimes it’s hard to let go, to say goodbye,” she says. “Probably the hardest thing is to lose a younger patient before you thought you would. Sometimes it just happens because you didn’t know a patient was at risk. You have to accept the fact that you’re not always going to know, that you’re not God.”

A Free Life

When she isn’t treating patients, Dr. Sandness enjoys her life on the farm that she shares with her husband. They have horses, cattle, dogs, and even their own fox hunt. She enjoys riding and fox hunting, and says being an internist allows her the freedom to spend time doing each. Her office is located just a few minutes from where she lives. Dr. Sandness is indeed living “the good life,” and when you talk to her, you can hear the happiness in her voice. Her decision to pursue internal medicine was not one she made alone. Originally from Texas, Dr. Sandness moved to Kansas to train horses, but her path soon changed when she met Wesley Sandness, the Dean of the School of Education at Pittsburg State. After marrying, Sandness guided her back to college to complete her undergraduate degree in Science with the goal of going to medical school. Dr. Sandness then attended medical school at the University of Kansas, where she also completed her residency. She says she revered the internists who taught her. “I had incredible teachers, and I was totally in awe of how smart they were,” she recalls. “I remember during my residency, when they had a difficult problem and needed it sorted out, it was always the internists they called in. That’s when I knew that internists were the best and the brightest. These were the people I thought were the greatest and I wanted to emulate them.”

For Dr. Sandness, the satisfaction of practicing internal medicine has only grown stronger through the years. She has an air of pure contentment, as though she is exactly where she wants to be in life. “Practicing internal medicine is a grand and fulfilling career,” she says, “and with knowledge comes freedom. Because I’m Board certified, I could go anywhere in the world, have a job and be respected. It’s a wonderful way to live.”

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Internal Medicine Interest Group of the Month: University of Mississippi

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The internal medicine interest group at the University of Mississippi School of Medicine, named Club Med, was formed in October of 2000. Club Med has planned many exciting activities and experienced much growth over the past six years.

The majority of Club Med’s activities consist of bringing in monthly lunchtime speakers from the university and the city of Jackson. All participants enjoy lunch provided by the Department of Medicine while interacting with the speakers. Subjects such as private practice medicine, academic medicine, critical care medicine, history and physical taking skills, and gastroenterology are just a few of the many topics students have heard over the past two years. These meetings offer students an excellent source of information as well as an opportunity to ask questions.

One of the most popular meetings is a standing debate between the residency and fellowship program directors on the subject of the differences between various subspecialties and primary care. Students always have questions and enjoy interacting with the program directors.

Another favorite meeting occurs each April and is conducted by junior medical students. “How to Be a Good M3” provides information about all of the junior medical rotations. Students are given hints on how to exceed the expectations of residents and faculty on the varying services. Handouts are provided covering subjects such as general order writing, pediatric intake and output calculating, and a two-hour labor and delivery progress note. This meeting is well attended by the sophomore students.

This year Club Med will try a new afternoon topic for students and their significant others: tips for a couple to survive during medical school and beyond. We are eagerly anticipating this event.

Club Med also began to participate in community service projects this year. Three service committee co-chairs organized a project in which we signed and delivered Christmas cards to internal medicine inpatients. Cards were also sent to patients at a local hospice. We hope to continue participating in service and community projects in coming years.

The leadership in our group consists of a president from the senior class, president-elect from the junior class, 2 representatives from each class, and up to 4 service committee co-chairs. The officers receive wonderful support from our faculty advisor and 2 Department of Medicine staff members who assist in an advisory capacity. The president and president-elect also sit on the Mississippi ACP Chapter Council of Students and Associates. This group provides a wonderful bridge between the students and the Associate members of the ACP. Club Med is currently considering ways in which to encourage future ACP participation among students.

Among the many student activities at the University of Mississippi, Club Med continues to be a favorite among the students. We anticipate sustained growth and involvement in the years to come.

Lindsey B. McMullan
President, Club Med
University of Mississippi School of Medicine, 2007
E-mail: klmcmullan@som.umsmed.edu

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Winning Abstracts from the 2007 Medical Student Abstract Competition: Lambl’s Excrescence: A Poorly Defined Source of Cerebral Emboli

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Author:
Henry Ho-jin Ra, Michigan State University College of Human Medicine, 2008

Introduction:
Lambl’s excrescence are small filiform processes found on the closure lines of aortic and mitral valves; formed by the organization of microthrombi on the valve’s contact margins. Discovered by transesophageal echocardiography (TEE) and often dismissed as an incidental finding, the frequency and clinical significance of these structures remains poorly defined. We present a case where Lambl’s excrescence is the most likely etiology of an ischemic stroke.

Case Presentation:
A 53-year-old female with multiple sclerosis was found unresponsive on her living room floor by her family. She had been unconscious for an unknown length of time. Her family history included stroke, diabetes mellitus, and myocardial infarction. Her brother died after a myocardial infarction at age 57. She had no other major medical problems. Physical examination showed expressive aphasia, right-sided hemiparesis and horizontal nystagmus. A brain MRI revealed moderate-to-large areas of left thalamic, left temporal and external capsule infarcts. Ultrasound and Doppler studies of her carotids and lower extremities were normal. TEE showed a filamentous density on a trileaflet aortic valve with fibrous dense and light areas suspicious of either Lambl’s excrescence or endocarditis. Antiphospholipid studies were normal, including the lupus anticoagulant and cardiolipin antibodies. Infective endocarditis seemed unlikely in the absence of fevers and chills; negative blood cultures; and an unremarkable physical examination. In light of no other source of emboli, the densities found on TEE were presumed to be Lambl’s excrescence, and the most likely cause of this patient’s stroke. Warfarin was started.

Discussion:
Lambl’s excrescence has been suspected as a cause of cerebral embolic events in a few studies. It has been identified more commonly in patients undergoing TEE assessment for cardiac sources of embolism versus patients referred for other indications (6.3% vs 0.3%). One report of 50 patients with cerebral emboli revealed 11 (22%) with Lambl’s excrescence of the mitral valve on TEE examination. Despite this association between Lambl’s excrescence and stroke, the literature on this phenomenon is limited A Pubmed search using the term “Lambl’s” returned only 34 articles—many of them only mentioning Lambl’s excrescence in comparison to cardiac papillary fibroelastomas (CPE). More importantly, research and recommendations on management of patients suspected of embolic stroke caused by Lambl’s excrescence is nearly non-existent. In cases of CPE, the current recommendation is to remove any tumors. Should this recommendation be applied to Lambl’s excrescence despite a different hypothesized mechanism of formation from CPE? Is anticoagulation therapy an alternative? If so, does it need to be life-long? Finally, can the etiology of previously identified cryptogenic strokes be attributed to Lambl’s excrescence?

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Medical Oncology

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The Discipline

The word oncology is derived from the Greek word ongkos, meaning “a bulk or mass,” which later was changed to mean “a tumor.” Medical oncology is the subspecialty which involves the diagnosis and management of benign and malignant neoplasms. Oncologists typically identify individuals at risk for malignancy and counsel them regarding risk reduction and screening, investigate clinical symptoms and syndromes suggestive of underlying malignancy, identify and treat neoplasms with a potential for cure, abd undertake the care of patients with solid and hematologic tumors to prolong life and/or palliate symptoms.

Procedures

Important procedural skills for the oncologist include bone marrow aspiration and biopsy and, for some oncologists, fine needle aspiration of the thyroid and breast. In addition, the oncologist is an expert in interpreting bone marrow cytogenetics and immunophenotyping, cytology and pathology, estrogen and progesterone receptor assays, and serological molecular markers for tumors.

Training

Medical oncology fellowship training requires two years of accredited training beyond general internal medicine residency. Of the two years, a minimum of 12 months must include clinical training in the diagnosis and management of a broad spectrum of tumors. In addition, a minimum of one half-day per week must be spent in a continuity outpatient clinic for the entire two-year curriculum.

Dual certification in hematology and medical oncology requires three years of full-time combined fellowship training which must include: (a) a minimum of 18 months of full-time clinical training with patient care responsibility; (b) a minimum of 12 months in the diagnosis and management of a broad spectrum of neoplastic diseases including hematological malignancies; and (c) a minimum of six months of training in the diagnosis and management of a broad spectrum of non-neoplastic hematological disorders. During the entire three years the trainee must attend at least one outpatient clinic for a minimum of one half-day per week and be responsible for providing continuous care to a defined cohort of patients being managed for neoplastic and hematological disorders.

Certification

The American Board of Internal Medicine (http://www.abim.org/) offers certification in medical oncology, and hematology and oncology.

Training Positions

As of August 2005, there were 125 ACGME-accredited training programs that offered 1,164 combined fellowship training positions in hematology/oncology. There were also 18 ACGME-accredited training programs in medical oncology with 160 active training positions. 42% of the trainees were female, and 54% were United States medical school graduates.

Practice

Approximately 50% of the graduates from combined training programs enter clinical practice in hematology and oncology in the United States, and 42% enter academic medicine. Approximately 35% of the graduates who receive only medical oncology fellowship training enter clinical practice in the United States, and 49% enter academic medicine.

Major Professional Societies

American Society of Clinical Oncology
1900 Duke Street, Suite 200
Alexandria, VA 22314
(703) 299-0150
E-mail: asco@asco.org

Major Publications

American Journal of Clinical Oncology
CA: A Cancer Journal for Clinicians
Cancer
Journal of Clinical Oncology

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Advocacy Briefs: ACP Endorses Student Loan Deferment Legislation

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ACP has endorsed the “Medical Education Affordability Act,” a bill proposed in the U.S. Senate that would allow physicians-in-training to defer repayment of their student loans while they complete their residency or fellowship. Current law relating to the economic hardship deferment option allows physicians who meet specific debt-to-income ratios to defer repayment of federal educational loans for up to three years. The new proposed legislation would extend this deferment to include the entire length of “postgraduate medical or dental internship, residency, or fellowship programs.” To view a copy of the ACP’s letter of support, see ACP online.

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

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ACP’s continued success on Capitol Hill greatly depends on year-round grassroots efforts from the College’s nearly 4,500 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

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A 70-year-old female resident of a nursing home is evaluated in the emergency department because of decreasing mental status and hypothermia. She has a history of stroke and is currently taking only aspirin. She has been able to eat on her own, and there have been no witnessed aspirations. She has not been treated recently with antibiotics.

Her leukocyte count is 12,000/μL, and her hemoglobin is 12 g/dL. Serum electrolytes are within normal limits. Chest radiograph shows a small interstitial infiltrate in the right lower lung field.

Antibiotic therapy for which of the following organisms should be included in her treatment?

( A ) Anaerobic bacteria
( B ) Aspergillus fumigatus
( C ) Enteric gram-negative organisms
( D ) Pseudomonas aeruginosa

MKSAP for Students 3 Question 2

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A 53-year-old woman with a history of mild persistent asthma is evaluated because of a recent increase in her symptoms, with dyspnea and cough occurring daily and a cough that awakens her once a week. She is currently using low-dose inhaled corticosteroids. She has no symptoms of rhinitis or gastroesophageal reflux. On physical examination, she has wheezing bilaterally.

Which of the following is the most appropriate addition to her therapy?

( A ) Azithromycin
( B ) Inhaled ipratropium bromide
( C ) Inhaled long-acting β-agonist
( D ) Leukotriene inhibitor
( E ) Nebulized short-acting β-agonist

MKSAP Answer 1

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Answer: C

Educational Objective: Recognize risk factors for gram-negative pathogens causing nursing home–acquired pneumonia.

This patient has risk factors that suggest that additional coverage is necessary for drug-resistant Streptococcus pneumoniae and enteric gram-negative organisms. She does not need additional coverage for anaerobes or Pseudomonas aeruginosa.

Treatment guidelines for community-acquired pneumonia are based on the likelihood of specific pathogens. In general, there should be coverage for the most common organisms, such as Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae. For some patients with specific risk factors, there should be consideration given for other specific pathogens.

Risk factors for drug-resistant S. pneumoniae include age greater than 65 years, use of β-lactam antibiotics within the past 3 months, immunosuppression, multiple medical comorbidities, and regular exposure to a child in day care. Risk factors for anaerobic infections include significant witnessed or suspected aspiration. Risk factors for enteric gram-negative organisms include all of those for S. pneumoniae listed earlier, as well as regular alcohol consumption and residence in a nursing home. Risk factors for P. aeruginosa include bronchiectasis, daily corticosteroid therapy, recent broad-spectrum antibiotic therapy, and severe malnutrition. Risk factors for Aspergillus pneumonia include prolonged neutropenia or other significant immunosuppression, including human immunodeficiency virus infection.

References

Niederman MS, Mandell LA, Anzueto A, et al. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med. 2001;163:1730–54. PMID: 11401897
Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis. 2000;31:347–82. PMID: 10987697

MKSAP Answer 2

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Answer: C

Educational Objective: Recognize and treat poorly controlled asthma.

This patient's symptoms are classified as moderate persistent asthma. Adding long-acting β-agonists to an adequate inhaled corticosteroid dose is the recommendation of the National Asthma Education and Prevention Program Expert Panel. The improvement in control afforded by adding the long-acting β-agonist appears to be greater than that of doubling the dosage of inhaled corticosteroids.

Antibiotics have not been shown to improve asthma control. Nebulizers can increase the dose of β-agonist, usually equivalent to four to six puffs of a metered-dose inhaler, but nebulizers do not lead to increased asthma control. Adding ipratropium bromide is recommended in an acute exacerbation in an emergency situation, but has not been shown to add to the long-term control of asthma. Adding a leukotriene receptor antagonist is an alternative approach, but not the preferred approach in this setting.

References

National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics--2002. J Allergy Clin Immunol. 2002;110(5 Suppl):S141-219. PMID: 12542074

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Internal Medicine Residency Program Fast Facts

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Program Name: St. Vincent’s Medical Center Program
Location: Bridgeport, Connecticut
Hospital Type: University Affiliated Community Hospital
Program Size: 19 First Year Positions, 30 Positions Total
First Year Salary: $45,000
Web Site Address: http://www.svmc-meded.org/residencyprograms/
internalmedcategorical.html

Program Name: University of Arizona Program
Location: Tucson, Arizona
Hospital Type: University Based
Program Size: 28 First Year Positions, 72 Positions Total
First Year Salary: $41,000
Web Site Address: http://www.meded.arizona.edu/applicants/
overview.htm

Program Name: Aurora Health Care Program
Location: Milwaukee, Wisconsin
Hospital Type: University Affiliated Community Hospital
Program Size: 13 First Year Positions, 39 Positions Total
First Year Salary: $45,000
Web Site Address: http://www.aurorahealthcare.org/aboutus/
meded/programs/internalmedicine/index.asp

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

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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 here.

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Students: Join ACP for Free

Benefits of Membership for Students: ACP's free Medical Student Membership includes benefits designed especially to meet students' needs.

Join Now: Sign-up today and begin enjoying the benefits of ACP Medical Student Membership.