April 2009 E-Newsletter

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Medical Student Perspectives: Money Management: A Medical Student Financial Guide

Whether you are deep in six-figure debt or obliviously swiping your parents’ credit card with every purchase, all of us are concerned about money at some point. The financial burdens placed on medical students, the budding physicians of the future, are at levels previous medical graduates did not endure. Many medical students are not sure how to tackle a budget or a HUGE loan lump sum at the beginning of the semester. Not everyone can watch CNBC or Fox Business for the latest financial news and “wealth management” advice. So here are some tips that I have used and gathered from my other medical school friends. Why should you listen to me, though? While I am admittedly not a financial analyst, I did get my undergraduate degree in business management and I have sat through many seminars on financial planning. So listen up, this might just change your life!

Starting out, one of the worst mistakes students make financially is also the most popular crime committed. At the beginning of the year or semester, most students get a loan or large sum of money and place it all in their checking account. They then proceed to just spend as needed until the next large sum will be available. Meanwhile, at the end of the semester their account balance gets smaller and smaller until it reaches zilch, or worse, the feared overdraft. This is a terrible plan for several reasons. You have no way to track how much money you are spending each month. You may spend all of it upfront getting ready for school and housing, but as the semester goes on you have less and less to pay off your commitments. Many students find themselves at the holidays with little money for that plane ticket home or presents for family and friends. This is bad fiscal policy and frequently causes you to make tough financial decisions when you absolutely need the money. Not to mention this is also the time when you are taking the hardest finals of your lives. Even if you know ahead of time that you will need to save some money for the end of this period, it is hard to be certain you will have enough when you are not even sure how much you spend each month. When you see that large amount just hanging out in your checking account, it is really easy to be loose with your money and spend without consideration.

How can you tackle the relentless draining of your checking account? The following is what I do and it has been working great for three years now. First, I take the lump sum that I get at the beginning of each semester and divide it by the number of months it will be until the next precious check arrives. So to make it easy, let us say that you get $12,000 in loans and funds from your parents for a six-month time period. That means you have $2,000 a month to survive on. I recommend placing the entire $12,000 in a savings account. Then at the beginning of each month you give yourself an allowance of $2,000 that you transfer into your checking account. This is really easy and ensures that you will have enough for each month. Using this method teaches you to budget as well. It will force you to look at whether you are over or under spending each month. If you under spend, that money just gets added to your next allowance at the beginning of the month. You might have $2,234 to start out the next month. Residency programs and businesses do not give you half your salary at the beginning of the year. So training yourself to be disciplined now can only help you when you actually get a salary in a few years.

For some people, this method is too overwhelming and does not fit their personality. That is fine as long as you are trying to balance the same amount of expenditures each month so you do not blow it all before the end. Another method I have heard my friends use is to pay off all the expenses they know they are committed to at the beginning when they get their lump sum. That includes rent, car payments, insurance, and fixed bills like cable/internet or Netflix. This way they know that all of the required bills are taken care of and the remaining balance is free to spend on whatever they like. I think this is a good plan for those who easily forget that the rent is due until it seems to sneak up on them. Whatever plan works for you, being organized with your money is extremely important. We will be making financial decisions for the rest of our lives and now is the best time to start being responsible for your spending.

An equally important part of being responsible with your money is saving for splurging and having fun. Make sure you plan for shopping, dining, and bar tabs that always seem higher than expected. We all need vacations throughout medical school to unwind on the beach or see our family and friends. Do not let your financial burdens detract from living a full life. While having fun and going on vacation is not in the “official medical school loan budget,” the right amount of planning and saving will allow you to have extra money to use at your leisure. You never know when your car will break down or your computer will crash, so be ready for the fun surprises in life.

A quote that I have read is, “The worst financial decision you will ever make is the daily decision to spend money on things you don’t need.” Be smart with your money and enjoy spending it. How you spend your money says a lot about your values and priorities in life, and people take notice.

Gates Colbert, MSIII
Southwestern Representative, Council of Student Members
University of Texas Medical School at Houston, 2010
University of Oklahoma, 2006, BBA
Email: Gates.B.Colbert@uth.tmc.edu

Check out more volunteer opportunities.

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My Kind of Medicine: Real Lives of Practicing Internists: Gregory Kane, MD, FACP, FCCP

Gregory Kane, MD, FACP, FCCP

On a rainy and damp March day in Philadelphia in the Hamilton auditorium at Jefferson Medical College, Gregory Kane circulates through an anxious and excited crowd of fourth year medical students. Some he knows quite well, stopping to chat or give a pat on the back; others he knows not at all, but he is there to support all of them as they wait for their envelopes announcing their residency matches. During the ceremony as the voices rise in excitement, he stands at the back of the room, tall and fit, in a white doctor’s coat, remembering his own Match Day as a Jefferson student. He exudes contentment. “I’m lucky I picked the perfect career,” he says.

The Professor
Dr. Kane, 47, is the Residency Program Director and a Professor at Thomas Jefferson University’s Medical College. As such, he spends a good deal of time teaching and mentoring students. He teaches specifically on lung diseases and conducts small group seminars. He loves working with students. “I love their enthusiasm and energy, and their thirst for knowledge,” he says. He explains how students are at a unique juncture in their training that highlights their ability relating to patients. “The younger students who haven’t learned yet how to make the next step or diagnosis, they focus on connecting with the patient,” he says. “I like watching this innate skill come out. When they are good at this, and they also enjoy the diagnostic process, doctoring, and answering patients’ questions, I know they’ve made the right decision to go into internal medicine.”

As a former Jefferson student, Dr. Kane says he had many physician role models of his own during medical school and residency. One in particular who Dr. Kane worked with during his third-year clerkship made a big impact on him. “He would take us to lunch and talk about how satisfied he was with the patient aspect of his career,” he says, “and it was obvious how much he enjoyed it.” Recognizing the unique value in his mentor’s ritual, he now practices it himself, often taking students to lunch or for a coffee or snack break. He says these unguarded moments when students aren’t consumed with performance are telling. “It’s nice to have down time with them…those are the times when you really get to know them.”

The Swimmer
From the treacherous southeast lanes of I-76, or as locals call it, “the Schuylkill,” the Schuylkill River strikes a picturesque image with the colorful Boathouse Row on the left and the stately Art Museum farther up. For Dr. Kane who regularly competes in triathlons, the river is home. “Oh, the Schuylkill is my favorite swim by far,” he says. “Temperature wise, it’s just amazing—better than lakes and the ocean, and it also flows downstream which helps.” The training is cathartic and satisfying for Dr. Kane, and the swimming, often seen as the most difficult leg of the event, is his strong suit.

Another difficult thing he loves to do is treat patients in the Intensive Care Unit. “I love working in the hospital and the ICU because I use the entire breadth of internal medicine,” he explains. “In the ICU, communication and goal setting are very important, which I enjoy. I also like being there for someone’s most critical point in life.” Sometimes these critical points occur not in the hospital, but in a patient’s home, as it did with one of his longtime patients and her husband.

His relationship with the couple began in 1990 when he treated the wife for an unusual lung infection. The infection was cured, but Dr. Kane continued to care for her for other minor problems for about ten more years, at which point her husband became severely ill with cancer. The husband became Dr. Kane’s patient. During the later stages while the man was receiving hospice care, Dr. Kane paid a home visit to the couple. After visiting with the husband, Dr. Kane sat down with the wife in the kitchen, where they talked while drinking tea and coffee. It was a difficult time for the family, but Dr. Kane embraced it and says students should know how moments like these can mean the most, not only to the patients and their families, but to physicians as well. “It is particularly gratifying to know a patient for this long, getting to know their family, going through a sensitive and difficult experience with them,” he says. “There is a special kind of reward in that.”

It was his appreciation for living life that drove Dr. Kane to make the decision to go into internal medicine, changing direction from his initial choice of engineering in college. “I enjoyed the technical work and found it challenging enough but the personal rewards just weren’t there,” he says. Now, as a husband and father of four, he is reaping the benefits of this long ago decision and the professional satisfaction he has found as an internist has overlapped into personal fulfillment. “Internal medicine gave me great flexibility,” he says. He uses his down time to run, bike, and swim, and spend time with his family, which has included coaching the soccer teams of three of his kids. He says he usually signs up to be the head coach so he can choose the days for practice, allowing him to get home early to pick them up. He recognizes the same priorities in his patients. He talks of one patient in particular with whom he connected, a man in his 50s who had battled life-threatening pneumonia. The man was on a respirator in the hospital for an entire month before Dr. Kane and his team were able to cure him. When the patient returned to the office for follow-up after rehabilitation and further recovery at home, Dr. Kane was grateful to be able to see him in that setting. “Now when I talk to him I get to hear about how he went hunting with his son in New Jersey,” he says.

Back in the auditorium after the Match Day ceremony, as the newly anointed first year residents sip champagne, laugh and cry, Dr. Kane is long gone—likely back to work to see a patient or instruct a student—but it won’t be long before he’s back.

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: University of Texas Health Sciences Center at San Antonio

The University of Texas Health Sciences Center at San Antonio (UTHSCSA) Internal Medicine Student Interest Group (IMSIG) is one of the most well known student organizations on campus and boasts the highest membership rate of all the specialty interest groups within the medical school. The attendees at the monthly lunch meetings are mostly first and second year students. We have added variety to the meetings this year, ranging from subspecialty panels to a meeting on the business of medicine with an office manager, a doctor, and a lawyer. IMSIG aims to provide a wide range of perspectives for medical students, especially for those unsure of what awaits their future.

Our main project this year has been in conjunction with a new organization on campus, the Preventative Medicine Interest Group, as well as the Center for Medical Humanities and Ethics. This year-long community service project consists of monthly diabetes screenings at a local grocery store or Wal-Mart, directed toward the heavily Hispanic population of San Antonio. Utilizing a mini-grant from the Morehouse School of Medicine, we have funded the entire project. At each 2-3 hour screening, we screen about 100 people, young and old, healthy and diabetic. The first and second year medical students were trained on how to screen and counsel patients with diabetes by a registered dietitian.

One month after the screening, we call each patient who had a blood sugar reading within the pre-diabetes or diabetes range. We ask them questions based on the Stages of Change model, to determine if they have made any progress toward lowering their high reading. Have they visited a physician? Have they changed their diet? Have they started to exercise? Have they discussed diabetes and its risks with friends and family? After the phone interview, we send them information packets containing local clinic and prescription information as well as ACP’s Living with Diabetes guide. If the patient does not have access to a glucometer, we send them a free glucometer as well. We will present our findings at the 2nd Annual Community Service Learning Conference at UTHSCSA this month.

Feedback from the patients as well as the students demonstrates how effective this project has become. Many patients are grateful to receive care and attention from the students, especially since many of them do not receive the same attention from their primary care provider, if they even have one. On the other hand, the students are in awe of the value of continuity of care. We do not have the opportunity to follow up with the patients we see on our ward service at school. For next year, we have been in contact with a regional manager of Wal-Mart’s pharmacy. We are working to establish a partnership to screen exclusively at Wal-Marts around San Antonio while they provide us with supplies and publicity.

Our final big event this year will be a dinner at the home David Hillis, MD, FACP, the Chairman of the Department of Medicine, which will be open to all student members of ACP. The dinner will enable students to interact with Dr. Hillis, in addition to several internal medicine faculty members, including Dr. Kristy Kosub, ACP Member, our faculty advisor. It will be a great event to end a very productive year from UTHSCSA IMSIG.

Ha Lam
Student Leader, Internal Medicine Student Interest Group
University of Texas Health Sciences Center at San Antonio, Class of 2011
Email: lamhn@uthscsa.edu

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Winning Abstracts from the 2008 Medical Student Abstract Competition: The Efficacy Of Tenofovir Plus Emtricitabine Or Lamivudinecontaining Regimens In HIV-infected Patients With A Preexisting m184V Reverse Transcriptase Mutation

Authors: Cheryl K Conner, Anthony LaRocco MD, and James Paulson PhD

Introduction
Background: The goal of antiretroviral therapy is to suppress HIV replication, improve immunologic function, and decrease morbidity and mortality due to opportunistic infections and malignancy. HIV can mutate and develop resistance to a given regimen. Numerous studies have shown and the general consensus remains that, for optimal results, failing regimens should be replaced by three new active antiretroviral agents or three drugs not likely to be affected by pre-existing mutations. The M184V reverse transcriptase mutation develops in response to lamivudine or emtricitabine. However, recent in vitro research has shown hypersensitization of HIV to tenofovir in the presence of M184V.Objective: The goal of this retrospective descriptive study is to examine the clinical outcomes of patients whose HIV genotype contains M184V and who subsequently received tenofovir plus lamivudine or emtricitabine.Rationale: The majority of HIV-infected patients who initiate antiretroviral therapy will experience virologic failure at some point during treatment. As lamivudine and emtricitabine are common in first line regimens, clinicians are faced with devising an effective salvage regimen in the presence of M184V. Effective, non-toxic nucleoside/nucleotide reverse transcriptase inhibitor combinations are limited. Therefore, demonstrating that retention of lamivudine or emtricitabine in a salvage regimen with tenofovir is effective in restoring virologic suppression will provide additional treatment options for patients who fail their first or second antiretroviral regimens, especially in resource-limited settings.

Methods
Retrospective chart review (paper and electronic medical records) of all HIV-infected patients at an infectious disease clinic who have: 1) failed a lamivudine-containing regimen, 2) have a documented M184V mutation on genotype, or lamivudine resistance on phenotype, and 3) subsequently received a regimen containing tenofovir plus either lamivudine or emtricitabine.

Results
Analysis: Standard descriptive statistics will be used to summarize demographic and case characteristics of subjects and these methods will be extended to examine time-linked disease endpoints (e.g. CD4, viral load). To account for the variations in patients’ follow-up data, hierarchical linear modeling will be used. Within this modeling framework, both raw and demographic-adjusted endpoint growth curves will be estimated.

Conclusion
Results will be reported. Preliminary queries of the electronic medical databases used in the clinic have identified 300 patients that fit the drug regimen criteria. Due to the frequency of genotyping and phenotyping of HIV in the clinic, it is predicted that at least 100 patients will be identified.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Nephrology

The Discipline
The word nephrology comes from the word nephros, the Greek word for kidney. Nephrology involves the diagnosis and management of diseases of the kidneys, the contiguous collecting system, and the associated vasculature.

The commonly encountered conditions in nephrology include disorders of fluid, electrolyte, and acid-base balance. Other problems include disorders involving the glomerulus, asymptomatic urine abnormalities, tubulointerstitial disorders, renal vascular diseases, renal failure, nephrolithiasis, tubular defects, and infections and neoplasms of the kidney, collecting system, and bladder. The nephrologist must understand how systemic diseases affect the kidneys, and recognize the potential toxicities of various therapeutic and diagnostic agents.

Procedures
Important procedural skills for the nephrologist include peritoneal dialysis, percutaneous kidney biopsy, and temporary placement of vascular access for hemodialysis. In addition, the nephrologist is expert at interpreting 24-hour urine excretion of minerals and electrolytes, serological tests for evaluating glomerulopathies, acid-base studies, and studies of sodium and water balance.

Training
Nephrology 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 renal diseases.

Certification
The American Board of Internal Medicine, ABIM, offers certification in nephrology.

Training Positions
As of August 2005, there were 135 ACGME-accredited training programs with 822 active positions in nephrology. 295 of the trainees were female and 54% were US medical graduates.

Practice
Approximately 61% of the graduates enter clinical practice in nephrology in the United States and 29% enter academic medicine.

Major Professional Societies

  • National Kidney Foundation

    • 30 East 33rd Street, 8th Floor
    New York, NY 10016
    800-622-9010
    http://www.kidney.org

Major Publications

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Advocacy Brief: Legislation to Reinstate 20/220 Introduced in Congress

Legislation to reinstate the 20/220 loan deferment pathway was introduced in both the House and Senate in late March. This pathway is the economic hardship deferment qualification criterion that 67% of the nation’s medical residents have relied upon to defer their student loan debts while completing residency training. Without this deferment option, starting on July 1, 2009, the majority of medical residents, who previously would have otherwise been able to defer repayment for up to three years time during their residency, will be forced to begin repayment immediately or seek forbearance. The legislation will permanently restore the 20/220 pathway and expand the current economic hardship qualifications. ACP endorsed the legislation last week and is working hard to have this important loan deferment pathway reinstated.

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Did You Know You Can Take Advantage of ACP's 50% Product Discount: Clinical Skills Collection on DVD?

For the first time, ACP offers its popular Clinical Skills video series on one low-priced DVD. This extensive series is intended for health care professionals who wish to expand their knowledge of various procedural, examination, and communication skills. The seven titles in this collection represent skills that can easily be incorporated into one's practice to help physicians and other care providers improve patient care.

Clinical Skills Collection on DVD

The ACP Clinical Skills Collection includes:

    • Arthrocentesis and Joint Injection
    • Counseling for Behavior Change
    • Sports Medicine Musculoskeletal Examination
    • Using Skin Biopsy in the Office
    • The Pelvic Examination
    • Efficiency through Effective Communication
    • Clinical Breast Examination

    Product #180450010

    ACP Medical Student Members and Associates may take advantage of this educational discount at ACP's Internal Medicine 2009, where they may view and purchase the DVD set at the Waxman Learning Center for $49.95. Original price is $99.95! You may also order online.

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    MKSAP for Students 4 Question 1

    A 36-year-old man is evaluated in the office because of frothy, watery stools that are found to be positive for Giardia lamblia antigen. This is his third episode of giardiasis in the past 10 months. Previous episodes were treated with metronidazole, following which symptoms resolved and G. lamblia antigen was no longer found in stool specimens. The patient has also had two episodes of bronchitis and three episodes of sinusitis over the past 2 years. He is HIV negative and is a lifelong nonsmoker.

    Metronidazole is prescribed.

    Which of the following diagnostic studies should be done at this time?

    A. Bone marrow biopsy
    B. Colonoscopy with biopsies
    C. Measurement of cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA)
    D. Measurement of serum IgG levels
    E. Upper endoscopy with duodenal aspirates for pathogens

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    MKSAP for Students 4 Question 2

    A 69-year-old man is evaluated during a routine physical examination. He has a history of hypertension, hyperlipidemia, osteoarthritis of the knees, and a 40-pack-year smoking history. Medications are hydrochlorothiazide, atenolol, simvastatin, and acetaminophen as needed. Physical examination is unchanged from 1 year ago.

    Laboratory Studies:

    Blood urea nitrogen 12 mg/dL
    Creatinine 1.1 mg/dL
    Sodium 138 meq/L
    Potassium 4.2 meq/L
    Bicarbonate 25 meq/L
    Urinalysis pH 5.0, specific gravity 1.015, 2+ blood, 5–10 intact erythrocytes/hpf without casts

    Repeated urinalysis 14 days later is unchanged. Spiral CT scan of the abdomen is normal.

    Which of the following is the most appropriate next step in the management of this patient's hematuria?

    A. Ciprofloxacin
    B. Cystoscopy
    C. Renal biopsy
    D. Repeat urinalysis in 6 months

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    MKSAP for Students 4 Answer 1

    Answer: D: Measurement of serum IgG levels

    Common variable immunodeficiency (also called acquired hypogammaglobulinemia) should be suspected in a patient with recurrent gastrointestinal infections (especially giardiasis) and respiratory infections. The diagnosis is established by the presence of decreased serum IgG levels. Patients may also develop malabsorption secondary to villous atrophy that does not respond to a gluten-free diet.

    Patients with common variable immunodeficiency may also develop small bowel bacterial overgrowth; however, upper endoscopy with duodenal aspirates would not identify a specific diagnosis for the underlying condition. Although patients with common variable immunodeficiency are at risk for autoimmune or neoplastic diseases, there is no indication for bone marrow biopsy in this patient at this time. Wegener's granulomatosis, which is diagnosed by a positive cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) assay, may be associated with recurrent respiratory infections. However, patients with Wegener's granulomatosis rarely develop gastrointestinal complications, and there is no association with recurrent episodes of giardiasis. Unless other gastrointestinal disorders are present, patients with common variable immunodeficiency will have normal colonoscopic examinations. In addition, disorders that are diagnosed by colonoscopy (e.g., inflammatory bowel disease, microscopic colitis, colonic neoplasia) would not be associated with a prodrome of recurrent giardiasis.

    Bibliography
    1. Bonilla FA, Bernstein IL, Khan DA, Ballas ZK, Chinen J, Frank MM, et al. Practice parameter for the diagnosis and management of primary immunodeficiency. Ann Allergy Asthma Immunol. 2005;94:S1-63. [PMID: 15945566] [PubMed]

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    MKSAP for Students 4 Answer 2

    Answer: B: Cystoscopy

    Cystoscopy is the most appropriate next step in the management of this patient's hematuria. Hematuria is a common finding that occurs in 1% to 3% of all patients and in as many as 10% of all men. One of the most important initial steps in the evaluation of microscopic hematuria is microscopic analysis of urine sediment to assess erythrocyte morphology to distinguish between glomerular and nonglomerular hematuria of the urinary tract. Monomorphic or intact erythrocytes characterize nonglomerular hematuria, whereas dysmorphic erythrocytes are associated with glomerular hematuria. In men >50 years of age with persistent hematuria, genitourinary tract malignancy must be excluded by cystoscopy, especially in the setting of associated risk factors such as cigarette smoking, analgesic abuse, benzene exposure, or a history of voiding abnormalities.

    Repeated urinalysis is not indicated, and the associated risk factors for genitourinary tract malignancy mandate further evaluation. Urinary tract infection is commonly associated with pyuria and bacteriuria but not persistent hematuria. Moreover, a treatment course with antibiotics may delay diagnosis of urinary tract malignancy. Renal biopsy is the procedure of choice for patients with glomerular disease but has a low yield in identifying the cause of hematuria in the absence of demonstrable glomerular bleeding, proteinuria, or renal insufficiency.

    Bibliography
    1. Cohen RA, Brown RS. Clinical practice. Microscopic hematuria. N Engl J Med. 2003;348:2330-8. [PMID: 12788998] [PubMed]

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    Succeed on your IM Clerkship Rotation!

    ACP continues to help students prepare for clinical rounds and the end-of-rotation examination with the fully revised and updated Internal Medicine Essentials for Clerkship Students 2 and MKSAP for Students 4! Available individually or as a set, these fully integrated new editions ensure success on the IM Clerkship rotation! Check it out.

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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, including ACP InternistWeekly, our blog, and polls and surveys (including our cartoon caption contest). Go online for the following stories:

    • The timing is right, and possibly expandable, for giving tPA
      Tissue plasminogen activator (tPA) was the star of the show at International Stroke Conference 2009, with much discussion of expanding its treatment window, and several studies presented on gender differences in tPA treatment.
    • Twitter: a medical help, hindrance or hype?
      Imagine a future where you can with a click of the mouse see what your patients and colleagues read on the Internet this morning, what they ate for lunch, and what they’re working on right now. Whether that sounds to you like a potential practice innovation or a disaster of oversharing probably indicates whether you’ll have any use for Twitter, the most hyped Internet innovation of the year.
    • Do placebos have a place in clinical practice?
      Placebo use is common in internal medicine. But is it ethical? Experts examine the disconnect between the standards of medicine, and how it's actually practiced in the office.

    ACP Hospitalist

    The relaunched ACP Hospitalist is the place to find all of our print and online content, including ACP HospitalistWeekly, our upcoming blog, and polls and surveys (including our cartoon caption contest). Go online for the following stories:

    • Work hour limits: No gain without pain
      Nobody would want their child riding on an icy road at 70 miles per hour in a school bus driven by someone whose head keeps nodding. Similarly, who would want to be cared for by a physician who is so fatigued he can’t remember the difference between the cranium and the cremaster?
    • Melding intuition with deliberation to sidestep diagnostic traps
      Would you pass "the eyeball test" if the patient in this case study presented in your hospital's emergency department? Find out how one physician pressed for a better answer on a patient who presented with cardiac pain but no evidence of a heart attack.

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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.

MKSAP 15 Discount 10% Off

MKSAP 15 Discount 10% Off

Get ready for the New Year with the newest edition of MKSAP. Enjoy a 10% discount off MKSAP 15 for a limited time. You must order by December 11, 2009 and use priority code E9048 to get the discount.

Holiday Gift offer - 10% off

Holiday Gift offer - 10% off

A great gift for a colleague or yourself - Landmark Papers in Internal Medicine: The First 80 Years of Annals of Internal Medicine. Enjoy a 10% discount when you order by December 11, 2009 and use priority code E9049.

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