August 2008 E-Newsletter

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Medical Student Perspectives: Staying Balanced as a Medical Student

Do you remember when you started medical school? I remember it well. I was sitting in an orientation session for first-year medical students at my school, listening to administrators tell us about the importance of remaining well-rounded. I felt a curious combination of excitement, motivation, and idealism. There was no doubt in my mind that I would easily heed their advice while still excelling in school.

Fast forward two weeks later, when I found myself overwhelmed by the sheer volume of material being thrown at me each day. I was stressed out, feeling like there was not enough time in the day to address all of my academic obligations such as classes, labs, small group sessions, and of course studying. My non-academic interests frequently became an afterthought. I often wondered if it was even possible to have an enjoyable, balanced life and avoid being a slave to medicine. What I ultimately discovered was that balance is possible in medical school, but it takes dedication to make it happen.

Why Balance is Important
With our busy schedules, it is easy to allow medical school to consume us. We are around it all the time, whether in class, the library, or a study group. The temptation is there for us to make it the epicenter of our existence, and as a result lose the very things that make us unique and interesting people. I have seen this happen to some of my classmates, and wonder how it will impact their lives in the future.

I have also talked with peers who intend to temporarily put their outside interests aside until they have completed their training. They reason that their other interests will still be there several years down the road. I worry that the person who once enjoyed those interests will be nowhere to be found.

Medicine changes people, and not always for the better. Medical school is a wonderful opportunity to learn and grow. It is also a time when we can lose our identities and become shells of our former selves. We do ourselves a great disservice by learning all about how to help others, yet failing to help ourselves in the process.

Priorities
We must start by examining our priorities. For 99% of medical students, school must be the number one priority. It was very liberating for me once I accepted the fact that, for most of my day, my time was not my own. Gone were the days when much of my time was spent doing what I wanted to do.

Let’s be honest, medical school often involves doing things we would rather not do. Most people do not enjoy sitting in class for 6-8 hours every day during the basic science years, or getting up at 4:00 a.m. during the clinical science years in order to be at the hospital. But we do it because we believe that the temporary discomfort is worth it for the long-term gain. There are patients who will need us, and we must possess the clinical and basic science knowledge to effectively treat them.

So with that said, my question for you is: what are your non-medical school priorities? What are the 4 or 5 things you must have in your life? Take time now to examine what those priorities are, and make a commitment to devote time to them on a regular basis. Perhaps friends and family are priorities to you. Maybe you love photography and are your happiest when taking photos, or enjoy a favorite television show or two every week. Or perhaps you cannot let more than a few days pass without going for a jog. Consider the several aspects of your life that you cannot live without, and write them down on a piece of paper. If you have a hard time thinking of a handful of things that are important to you, now is the perfect time to develop them! Make a commitment now to give those things an important place in your routine, even if it means putting your studies aside from time to time.

It’s a Matter of Degree
Depending on where you are in your training, it might seem nearly impossible to be a balanced person. Let me assure you that with good time management skills, you can enjoy those outside interests on a fairly regular basis – even though you might not get to do so as often as you would like. Hopefully, you will find that you learn to appreciate those interests and activities even more than before. Truly maximizing the moment will result in a much higher level of satisfaction at work and at play. And who knows, you might even develop new interests and hobbies in the process!

Nurture Your Support System
No matter how independent you are, chances are very good that there are times when you want someone to talk to. Perhaps you have great news to share, or maybe you are frustrated and need to vent. Regardless, it is important that you have a support system you can rely upon. Your support system can be family or close friends, but it is vital that you choose these people carefully! Whoever you choose, they should know you well enough to be aware of what you need and when you need it.

Relaxation Techniques
Stress has a way of sneaking up on us, even when we think we have everything under control. We are all aware of the dangers of stress as well as the need to minimize it. I have found it extremely beneficial to devote at least 10-15 minutes a day to focus my thoughts and clear my mind. I highly recommend that you try something like this for yourself.

The technique you choose is up to you, but it must fulfill several requirements. First, it must take place in an environment that you find calming. Second, it should allow you the ability to take slow, deep, cleansing breaths. Third, it should provide you an opportunity for reflection. In other words, you want these 10-15 minutes every day to be your escape from everything else. What you do during this time is up to you. Many people use this time for prayer, meditation, and reflection. Do not allow your mind to dwell on negative and worrisome topics, but rather concentrate on the great things that lie ahead. Studies have shown real therapeutic value in using such techniques – even in those who are fighting devastating terminal illnesses! Make this time an important part of your regular routine.

The Carryover Effect
In addition to an improved quality of life, one of the benefits of being well-rounded is that it will actually enhance the time you spend on medical school. You will find that you have better concentration when you study and clearer thinking when solving complex medical problems. You will likely accomplish as much academically – if not more – despite spending less time studying. As busy medical students, I think we can all appreciate that!

Doctor, Heal Thyself
It is up to each of us to examine our own lives and evaluate the balance contained within. You now have all the necessary tools to continue your current accomplishments while also reaching for new goals. I wish you all the best as you strive for more balance!

Jonathan D. Stegall
Vice Chair, Council of Student Members
Medical University of South Carolina College of Medicine, 2010
Email: stegallj@musc.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Kavita Patel, MD

Kavita Patel, MDOn the steamy Wednesday afternoon of July 9, 2008, members of the Senate waited anxiously in the Senate chamber as the votes were cast. Hanging intangibly yet precariously in the air was H.R. 6331—“the Medicare bill”—vetoed by President Bush and in danger of slashing Medicare payments to doctors by 10.6 percent. Then the door opened and through it, escorted by Senator and presumptive Democratic presidential nominee Barack Obama, Senator John Kerry, and Representative Patrick Kennedy, came the man of the hour, Senator Edward Kennedy of Massachusetts. Applause rang out and the tense atmosphere dissipated as Republicans and Democrats alike greeted Kennedy’s first return to the chamber since becoming ill in May. “I return to the Senate today to keep a promise to our senior citizens,” Kennedy said in a statement, “to protect Medicare. Win, lose or draw, I wasn’t going to take the chance that my vote could make the difference.” It was an engaging scene befitting of a movie, but the work that went into it was anything but—hours upon hours of researching, drafting, editing and deliberating. As Deputy Director of Kennedy’s Health Subcommittee, it is the kind of thing that Dr. Kavita Patel, 34, does on a daily basis. She is not complaining, though. “I love that I get to think about an issue that’s important and put together something that might be meaningful that will actually have an effect on how medicine is practiced,” she says enthusiastically. “I consider it a privilege.”

Going to Bat
Dr. Patel’s job is to advocate on issues important to Senator Kennedy, which she says generally fall into one of two categories: quality of care and chronic disease. She does this any number of ways, for example, drafting legislation or looking into proposed regulations on a health training program. All of it involves a lot of talking to people, which bodes well for Dr. Patel, who is quick, easygoing and pleasant to talk to all at once. She makes a partner in conversation feel at ease and comfortable, undoubtedly a desirable and necessary skill for a job working in the office of one of the nation’s most prominent legislators. A typical day for her begins early with emails, followed by meetings and phone calls, which take up the majority of her time. Around 5 or 6 p.m., she gets to work on legislation, something she enjoys very much, as it is one of the more tangible parts of her role. “The best thing so far I would say has been working on a cancer bill for Senator Kennedy,” she says energetically. “It’s probably one of my proudest moments, putting together the hearing that Senator Kennedy chaired on it,” she says. “It’s amazing how a tweak here or there can make a difference.”

For the Medicare bill (H.R. 6331), Dr. Patel’s efforts focused on protecting low income beneficiaries as well as addressing the concerns of constituents from the Commonwealth of Massachusetts. “I worked on some of the issues related to quality and I talked with our staff director about whether we were supportive of the changes,” she says. “And I worked a great deal with a number of other Senate offices making sure that low income beneficiaries remained protected.” She worked in conjunction with other staff members, who like Dr. Patel, were chosen for their respective areas of expertise. “We all come from different backgrounds—neuroscience, public health, research—and we translate it into a desire for action, to push things forward.” She says this passion is a common thread among Hill staffers, and adds that working with other Senate offices is not as partisan as people might suspect. “Some of the best conversations we have are with our colleagues on the other side,” she explains. “It doesn’t matter who you work for, we all more or less want to put people’s needs first.”

The commitment shown by Dr. Patel and others is reciprocated by Kennedy. “It’s not uncommon for him to ask me a question and then repeat my answer later on during a meeting or conversation,” she says. “He really believes in us and will go to bat for us if he needs to.” Despite the pressures, she considers her role incredibly rewarding. “All of the times that I’ve had the opportunity to actually be around Kennedy, watching him do what he does are some of the more rewarding moments I’ve had in my career,” she says. “He’s really just magical, the way he talks to other members or listens to a constituent. People love to be around it.”

In the Club
From the time she was a little girl, Dr. Patel was enthralled with the idea of being a doctor. To her, the world of medicine represented a mysterious and exclusive club or society to which only precious few could gain access. “No one in my family had gone into medicine and I was fascinated by this area of science that to me was held in secrecy,” she says. “It seemed really important, and I wanted to be a part of it.”

She graduated from medical school at the University of Texas Medical School at San Antonio and followed with a residency at Oregon’s Health and Science University Program. Following residency, a job as a research fellow at UCLA laid the foundation for her to hone her talent for examination and investigation; it was not long before she landed a job with RAND, the high profile non-profit organization once considered a global policy “think tank” in its early years when it serviced the U.S. military. Since expanding to work with other governments, private foundations, international organizations, and commercial organizations, RAND has built a reputation for rigorous, quantitative, and non-partisan analysis and policy recommendations. Her duties there included participating in several health service research projects, including a community based participatory research project in south Los Angeles looking at novel ways to expand access to mental health services.

While at RAND, an acquaintance of hers who also knew Senator Kennedy approached her about a staff position. Even though it would mean relocating across the country, she decided to try for it. Getting into that club, however, would prove to be a bit more challenging. “I interviewed with five different people before I got to him,” she recalls. She was intimidated at first, she says, since Kennedy can seem larger than life, but was soon at ease once she sat down with him. “I was impressed with how giving he was,” she recalls. “He was really interested in what I was excited about. He’s a gracious employer and he has a sense of respect for medicine in general.”

Since being hired a little over a year ago, Dr. Patel has enjoyed the ride and says she plans on staying put. “I came on board knowing that if and when there is health care reform, Senator Kennedy is going to be a major player,” she explains. “That’s what I signed up for and moved across the country for.” She says trading California for Washington has been a good trade, aside from “the horrible weather.” And surprisingly, she says working in Washington has provided her with more structure than her previous career in research. “I can actually relax … read a book or do some yoga,” she says, “I like it, it’s a balanced life.”

Dr. Patel credits her experience as a practicing physician, and in part, her internal medicine training, as the basic building block of her career. “My perspective as a practicing physician has allowed me to do all of this,” she says. She adds that she would encourage students to pursue internal medicine, but with a caveat. “If you are going to pursue a career in internal medicine, think through what kind of practice setting would best suit your strengths and lifestyle balance, and then pursue that aggressively.” Her recommended approach sounds much like her own, which might not be bad advice to follow. Afterall, it worked pretty well for her.

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Internal Medicine Interest Group of the Month: Indiana University School of Medicine

The Internal Medicine Student Interest Group (IMSIG) at Indiana University School of Medicine is one of the largest and most active student interest groups at the medical school. In addition to having a strong presence at the main Indianapolis campus, Regional IMSIGs have been established at three of our school’s satellite campuses last year, with more to come. We are fortunate to have the current Governor of the ACP Indiana Chapter, Michael Sha, MD, FACP, and the Director of the Indiana University Integrative Pain Center, Palmer MacKie, MD, as our faculty advisors.

The annual kick-off event each new school year for IMSIG is the “Top Ten Reasons to Be a Big Doctor” lunch talk presented by the past ACP Indiana Chapter Governor, Robert Lubitz, MD FACP. This talk is always very well attended as Dr. Lubitz shares what he has found to be most meaningful to him in the practice of medicine over the years. We also offer a series of “Bagel Lunch Talks” featuring a variety of topics. Last year, topics included how to arrange an international health elective, acupuncture, and how to approach care of a terminally ill patient. These talks are aimed primarily at first and second year students and provide them an opportunity to interact with clinical faculty and learn about aspects of medicine not emphasized in the basic science courses. A popular event with third and fourth year medical students is our annual Residency Program Fair. Last year, we hosted directors from six different programs and provided a forum for directors to talk about the strengths of their programs and for students to ask questions.

A recent addition to our lineup of events is a monthly journal club, presented by third and fourth year students. After the main points of the article have been presented, students discuss the results, the strengths and weaknesses of the study design, and its applicability to clinical practice. Through the IMSIG Journal Club, students gain experience in critically evaluating medical literature in a relaxed environment. This year, we are expanding the scope of the IMSIG Journal Club by inviting academic and community physicians to join us for these discussions.

In addition to many educational offerings, IMSIG has a proud tradition of extensive volunteerism. Our largest undertaking is organizing the Westside Health Fair, which has the distinction of being the only student-run health fair as well as one of the biggest health fairs in Indianapolis. Now in its eleventh year, the fair continues to grow. Last year, over 150 volunteers from many student interest groups and disciplines joined forces to provide free health screenings, immunizations, and education to 700 people. Health fair attendees, public health officials, physicians, and hospital directors all came together to discuss the ACP National Primary Care Week theme “Community-Based Primary Care: Promoting Justice in Health Care,” at the fair’s Town Hall Meeting.

Finally, our group is privileged to be closely involved with the Indiana ACP Chapter. Our local chapter sponsors several students to attend ACP Leadership Day as well as the ACP national scientific meeting each year. Additionally, our co-chairs sit on the Chapter’s ACP Governor’s Council and Associate’s Council. This year we are excited to have been given the opportunity to assist in planning the annual ACP Indiana Chapter Meeting.

The students who are involved in our group are motivated to continue with the great things established in past years, further develop our relationship with ACP, and initiate new and innovative ideas to get students involved in internal medicine. The upcoming year is bound to be exciting as we expand our impact on both our school and community.

Laura Hinkle, MSIII and Laila Saied, MSIV
Co-Chairs of Indiana University School of Medicine IMSIG
IMSIG Web Site: http://medicine.iupui.edu/imsig/

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Winning Abstracts from the 2008 Medical Student Abstract Competition: Acute Disseminated Encephalomyelitis Presenting Without Clinical Encephalitis

Author: Sheena Sahota, University of Missouri, Kansas City

Introduction
Acute disseminated encephalomyelitis (ADEM) is a nonvasculitic demyelinating disease diagnosed by clinical signs of encephalitis and myelitis with corresponding MRI findings on brain and spinal cord. We report a patient who presented with myelitis, but no clinical signs or symptoms of encephalitis, while MRI brain and spine showed hyperintensities on T2/FLAIR which later resolved on follow up imaging. The MRI demonstrated reversible lesions in both brain and spinal cord.

Case Presentation
A 50 year old male presented with acute onset of urinary retention, low grade fever, followed by bilateral lower extremity weakness one month after his flu vaccination. Examination demonstrated flaccid paraparesis with decreased rectal tone and sensory loss below the T3 dermatone. MRI T2 images with no contrast enhancement were done of the cervical and thoracic spinal cord and showed multi-focal high intensity signals in the anterior and central cord. FLAIR images were seen in both white and grey matter that did not enhance on T1. No flow voids or cord swelling were seen. Diffusion weighted MR showed no restricted diffusion. CSF analysis was remarkable for lymphocytic pleocytosis and elevated protein. Workup for infectious and toxic causes were negative. Patient was treated with IV steroids for presumptive diagnosis of ADEM and showed marked clinical improvement. Repeat MRI showed resolution of signal changes in brain and spinal cord. He was subsequently discharged to inpatient rehabilitation.

Discussion
ADEM is an immune-mediated inflammatory disorder characterized by extensive, multifocal, subcortical demyelinating lesions throughout the central nervous system on MRI. Neuromyelitis optica (NMO), multiple sclerosis, and acute transverse myelitis (ATM) are hallmark demyelinating diseases; the first two of which have characteristic brain imaging abnormalities. This patient presented with acute onset myelitis with no features of encephalopathy iterating the fact that brain lesions in ADEM can be present without clinical findings. Our patient had unremarkable infectious workup and his MRI lesions reversed after steroid therapy making ADEM more likely diagnosis. Transverse myelitis alone could explain his symptoms, but identification of an encephalitis component in ATM, if found, gives credence to the hypothesis that this disease entity is actually a subset of ADEM or a part of continuum of neuroimmunological demyelinting disorders including NMO and ADEM.

ADEM by iself has favorable prognostic outcomes as compared to other etiologies of myelitis because it is reversible. The need for developing diagnostic criteria for ADEM and the question of if brain imaging should be done in all patients who present with transverse myelitis is one that must be answered.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Cardiology

The Discipline
From the Greek kardia, meaning heart, as used in the Hippocratic treatises.

Cardiology is the prevention, diagnosis, and management of disorders of the cardiovascular system, including ischemic heart disease, cardiac dysrhythmias, cardiomyopathies, valvular heart disease, pericarditis and myocarditis, endocarditis, congenital heart disease in adults, hypertension, and disorders of the veins, arteries, and pulmonary circulation. Management of risk factors for disease and early diagnosis and intervention for established disease are important elements of cardiology.

Procedures
Important procedural skills in cardiology include: cardioversion; arterial catheter insertion; balloon-tipped pulmonary artery catheter insertion; temporary and permanent pacemaker insertion; implantable cardiac defibrillator insertion; ambulatory electrocardiographic monitoring; echocardiography; left ventricular catheterization, coronary angiography and percutaneous vascular interventions; nuclear scan wall motion studies; stress electrocardiography; thallium perfusion scanning; and tilt-table physiology studies.

Training
Cardiovascular fellowship training requires three years of accredited training beyond general internal medicine residency. Of the three years, a minimum of 24 months must include clinical training in the diagnosis and management of a broad spectrum of cardiovascular disease.

Training Positions
As of 2005, there were 173 ACGME-accredited training programs in Cardiovascular Disease and 2,142 active trainees. Eighteen percent of the trainees were female and 65% were US medical graduates.

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

Practice
Approximately 82% of the graduates enter clinical practice in cardiology in the United States, and 16% enter academic medicine.

Major Professional Societies

Major Publications

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Advocacy Brief: Senate Approves National Health Service Corps Reauthorization

On July 21, 2008 the Senate unanimously approved S. 901, a bill that reauthorizes the National Health Service Corps (NHSC) through fiscal year 2012. The bill authorizes funding from $131.5 million increasing each year to $185.6 million in fiscal year 2012. The Consolidated Appropriations Act of 2008 provided $123.5 million for the NHSC. The bill removes the current provision that requires health centers and clinics to demonstrate eligibility as a health professions shortage area every 6 years. The bill also requires that each qualifying site demonstrate "willingness to support or facilitate mentorship, professional development, and training opportunities for Corps members," and directs the Secretary of Health and Human Services to facilitate professional relationships among Corps members and other health professionals. The reauthorization is part of a package that also reauthorizes the Community Health Centers Program and the Rural Health Care Programs.

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Did You Know You Have Access to Annals of Internal Medicine Online?

The most widely cited medical specialty journal in the world, Annals of Internal Medicine delivers major review articles, incisive original research, topical clinical reviews, thought-provoking editorials, and a spirited exchange of medical opinion. To access your Annals Online subscription, register on the Annals web site at Annals.

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MKSAP for Students 3 Question 1

A 51-year-old man is evaluated because of severe epigastric pain, nausea, and vomiting. He occasionally takes ibuprofen for low back pain, but has not taken any medication in the last 10 days. Abdominal examination discloses epigastric tenderness. On rectal examination, a stool specimen is positive for occult blood. Computed tomography scan of the abdomen shows thickened gastric mucosa. Upper endoscopy discloses multiple duodenal ulcerations extending into the second portion of the duodenum and thickened gastric folds in the fundus. A fasting gastrin level is 520 pg/mL. Basal acid output is markedly elevated.

Which of the following is the most likely diagnosis?

A. Alcohol-associated ulcers
B. Helicobacter pylori-associated duodenal ulcers
C. Gastrinoma
D. Nonsteroidal anti-inflammatory drug-induced ulceration

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MKSAP for Students 3 Question 2

A 76-year-old man comes to the office because of decreasing exercise tolerance of 6 months’ duration. He has dyspnea with chest tightness when he walks briskly or uphill. He denies lightheadedness or syncope. He underwent single-vessel percutaneous transluminal coronary angioplasty 3 years ago. Medication includes aspirin, 81 mg/d, and atorvastatin, 20 mg/d.

On physical examination, his heart rate is 82/min and blood pressure is 142/84 mm Hg. A harsh 3/6 crescendo-decresendo systolic murmur is noted at the right upper sternal border and radiates to the carotids. The murmur diminishes with the Valsalva maneuver. The carotid upstroke is diminished and delayed.

Which of the following is the most likely cause of his chest pain?

A. Acute coronary artery syndrome
B. Aortic dissection
C. Aortic stenosis
D. Chronic pericarditis
E. Hypertrophic cardiomyopathy

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MKSAP for Students 3 Answer 1

Answer: C, Gastrinoma

The elevated fasting gastrin level and the marked elevation in basal acid output are diagnostic of gastrimnoma (Zollinger-Ellison syndrome). Approximately 65% of gastrinomas are malignant, with the potential for metasis. Postbulbar ulcers are uncommon and can be caused by Crohn’s disease, lymphoma, and Zollinger-Ellsion syndrome (as in this patient). An octreotide scan is the most effective sturdy for demonstrating a gastrinoma. This study can show not only the primary lesion, but also any metastases to the liver or lymph nodes.

All of the incorrect options are capable of producing gastric ulceration; however, only gastrinoma is associates with a high serum gastrin level and markedly elevated basal acid output.

Furhtermore, multiple duodenal ulcerations are not commonly found in any of the options listed other than gastinoma. Alcohol may induce superficial erosions of the gastric mucosa, but not duodenal ulceration. Nonsteroidal anti-inflammatory drugs are a common cause of gastric, but not duodenal, ulcers. Helicobacter pylori is associated with a single duodenal ulcer, but not multiple ulcers.

Bibliography
1. Li ML, Norton JA. Gastrinoma. Curr Treat Options Oncol. 2001;2:337-46. PMID: 12057114

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MKSAP for Students 3 Answer 2

Answer: C, Aortic Stenosis

The physical findings of a loud, crescendo-decrescendo systolic murmur that is best heard at the base, with radiation to the carotid arteries, and diminished and delayed carotid pulsation strongly support the diagnosis of aortic stenosis. Because symptomatic aortic stenosis is associated with a poor 3-to-5 year prognosis, intervention with aortic valve replacement is warranted.

Acute coronary artery syndrome is not compatible with a 6-month history of progressive chest pain and dyspnea and does not explain the heart murmur. The murmur of Hypertrophic cardiomyopathy increases with the Valsalva maneuver and is associated with bisferious (two impulses) apical pulsation, not delayed and diminished carotid pulsation. Chronic pericarditis is not associated with chest pain, but is associated with dyspnea and signs of right-sided congestive heart failure. Aortic dissection is not compatible with a 6-month history of chest pain or the murmur of aortic stenosis.

Bibliography
Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA. 1997;277:564-71. PMID: 9032164

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ACP Internal Medicine Residency Database

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

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Announcing the MKSAP for Students 3 and Internal Medicine Essentials for Clerkship Students Package

ACP introduces the essential book set for medical students. Get both titles for one low price. Log in with your member ID for member pricing or call ACP Customer Service at 800-523-1546, extension 2600 (M-F, 9 a.m.-5 p.m. ET).

Price: $84.95

Learn more: MKSAP Package.

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Articles for Medical Students from ACP Internist and ACP Hospitalist

ACP Internist (formerly ACP Observer)

ACP Hospitalist

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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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