December 2007 E-Newsletter

Medical Student Perspectives: Balancing Medical School and Personal Life

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Medical school is challenging and time-consuming. It requires focus and dedication. If the appropriate affection is not provided, medical school will divorce you. And although the school of medicine would like the students’ full attention, by nature, medical students are well-rounded, talented, busy people with full lives outside of medicine. Some students are single and like sports, art, concerts, or volunteering. Others are engaged or married and may like to travel or enjoy unique restaurants. Others are married with children and enjoy spending time with little ones at home when they are not at the hospital. Whoever you are, and whatever your interests or responsibilities outside of medicine are, you are bound with all other students, having the same need of achieving balance and happiness. Medical students excel at most of what they do in life, from the classroom to the ski slopes, from physiology to music. It’s ironic that medical schools require applicants to demonstrate excellence in many areas of life, yet straight away ask for your allegiance to academics only.

The rigors of medical school can, however, be managed with personal life in an effective and satisfying way. Let me give you a personal example. I am married and have two beautiful daughters. In addition, I hold many leadership positions on a local, regional, and national level. I am also currently involved in multiple research activities and enjoy volunteering. And, like everyone else, I have many hobbies outside of medicine that I choose to devote time to. Now as a fourth year student, I can honestly look back and say that medical school was a wonderful experience for both myself and my family. My wife and I have never complained about the difficulty of it or the time away. We have grown through the experience, had remarkable adventures, and have felt satisfied with the process and progress.

I would like to provide a few pieces of advice to make your journey smoother, more balanced, and more enjoyable. And since medical students thrive on learning tools, here are 4 M’s for Medical school.

  • Manage: Make a list. Prioritize activities. Consider the importance of them to you and decide how much time you are going to donate to each. Then, stick to it. It’s ok to go to the movies or golf, but work hard at the library, and be willing to forego less important activities.
  • Modify: Make time count. For example, don’t pass the time in front of the television or gaming, but rather use the time to accomplish multiple needed tasks. Get things done quickly and move on. It will feel satisfying and will open doors down the road for personal time when needed.
  • Moderation: Learn to say ‘no’. You don’t have to be a part of every interest group, sit on every council or committee, or go on every trip. Choose just a few activities that you will enjoy and will enhance your learning experience and let the others pass. This is difficult for medical students to do!
  • Meaningful: Medical school goes too fast. It is a wonderful time of life. Make time to play. Enjoy the friendships and the adventures. And yes, leaving the library to go out for Chinese food for an hour is worth it, provided that you work hard when you return.

I hope these suggestions will help you to find balance in medical school. Remember that life as a physician does not necessarily become simpler when you complete the training. Current important activities and duties will likely be replaced with other important activities and duties later on. Therefore, part of your medical training is to learn how to manage many demanding, important activities and excel in them all—similar criteria that you were judged upon in order to enter medical school. If you learn to balance now, it will benefit you throughout your entire career.

Landon Dickson
Chair, Council of Student Members
University of Utah School of Medicine, 2008
E-mail: Landon.Dickson@hsc.utah.edu

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My Kind of Medicine: Real Lives of Practicing Internists: LuAnn Aquino, MD

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When Dr. LuAnn Aquino got the measles as a little girl, her mother took her to the family doctor. Unlike many children, she wasn’t scared. In fact, she looked forward to it because she had such affection for her doctor. “He was always happy, always smiling and he made you feel good when you were sick,” she remembers. At the end of the visit, he would give her a lollipop from his bottom desk drawer. “I can still see his smile,” she says. Her experience with him, as well as with other family members who were physicians was the catalyst for her pursuing medicine. Her decision to become an internist however, was deeply personal and foreshadowed what would become a uniquely intuitive approach to practicing medicine.

Being Jimmy Stewart
For Dr. Aquino, being an internist means using more than your stethoscope or prescription pad, it means using your heart and mind as well. "My patients share with me their deepest concerns," she says, "so you find yourself dealing with a lot of social issues. Caring for my patients often has a social aspect to it." She says this is especially the case when treating more than one generation of a family, in which changes such as death and divorce can not only impact the health of her patients but also how she interacts with them. "Patients will always tell you their problem if you just listen. I’m there to help them and that’s what I try to do. I kind of look at it like Jimmy Stewart’s character in "It’s a Wonderful Life"—'Am I really changing anyone’s life? Am I helping people?' that’s what I want to be doing and it’s why I chose internal medicine."

Dr. Aquino graduated from the Medical College of Georgia and completed her residency at Atlanta Medical Center. Since then, she has operated her own private practice in Hilton Head Island, SC. Her husband, Jeffrey, has a dentistry practice in the same building. It is an ideal situation, but one she admits might be difficult to realize for internists just starting out in today’s environment. She recommends pursuing group practice, where young physicians can share the cost of a business with other partners. Another promising path she says is hospital medicine. “The hospitalists I know are very happy,” she says. "They like how it improves their personal life because you can schedule it nine to five." Would she make the same decision today that she made as a student to pursue internal medicine as a career? "I absolutely would," she says with enthusiasm in her voice. "It is so important to me to have that ongoing connection with my patients. If I didn’t have that, I wouldn’t do it."

Medicine with a Smile
Dr. Aquino’s affinity for connecting with others comes across as she discusses her work. Instead of drifting into "doctor speak" or avoiding the mention of a patient’s psychological or emotional well being, Dr. Aquino does the opposite. She treats the patient’s emotional and physical experience as one and the same, even from early on in her career. One such example comes from her residency, when she treated an unconscious elderly patient with dangerously low hemoglobin. She transfused the patient, which normally would not have been a problem, except that in this patient’s case, she was a Jehovah’s Witness, with religious beliefs that do not recognize this kind of intervention. "I remember the patient and the case as bright as day," she says, "Once I found out she was a Jehovah’s Witness, I knew that what I had done was against her wishes…yet it saved her life. It was a difficult moment."

Dr. Aquino is humble and saves her accolades for others. When asked what a proud accomplishment is for her professionally, she talks of a patient she admires. "She’s unbelievable," she says of the patient, "I’ve never seen anything like it. She’s legally blind from diabetes, has high blood pressure and a host of other conditions but she has a smile on her face every time I see her. She’s accepted her illnesses and limitations. It really puts things in perspective. Knowing patients like her and treating her make this job worthwhile."

Dr. LuAnn Aquino with her family

Dr. LuAnn Aquino with her family


As for down time, she is equally unassuming. "We’re boring!" she jokes about her home life with husband Jeffrey and eight-year-old daughter Anna Lisa. "On the weekends we just kind of hang out and watch movies. After spending all week talking to people you just want to be with your family, you know?" Her favorites are action films, which she says are great for "taking her mind off things." She also walks every day for stress relief. For all of her warmth and charm, Dr. Aquino is an example of how even the most giving of doctors needs to recharge every once in a while.

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Internal Medicine Interest Group of the Month: Touro University Nevada

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Where the rest of the world comes to live their latest hedonistic ventures, the Nevada campus of the Touro University College of Medicine holds down the fort in medical education. As part of the only medical school in Las Vegas, the Internal Medicine Interest Group (IMIG) of Touro University Nevada College of Medicine (TUNCOM) has taken on a vast responsibility to promote adult primary care in a city that approaches a population of 2 million. Needless to say, we are “betting” on a promising outcome. This is the fourth year our campus has been operational and the first year that the ACP-sponsored IMIG has been in operation. When considering the needs of this community and, indeed, the nation as a whole, it is an obvious connection to work with the ACP to come up with some solutions. The field of internal medicine offers more to the medical community in today’s world than it ever has in the past. There is a growing void of adult care in the community of Las Vegas and we have begun this year to enlighten those around us to the opportunities in internal medicine. Through a campaign of encouragement we strive to help others make an educated decision when applying for residency programs. We feel that the simple matter of understanding the role of internal medicine and its subspecialties will lead to an increase in the number of medical students who decide to enter the field of adult medicine. There has been an overwhelming response.

Under the leadership of our faculty advisor, Paul Kalekas, DO, we have organized recruiting events and talks based on our IMIG goal to educate patients and medical students in the field of internal medicine. In only three months of operation, our group is now the second largest in the school and has a membership of more than 50% of the entire student body. We have already hosted a talk on the gamut of options within internal medicine and the support that ACP can provide to these physicians. We enjoyed participating in National Primary Care Week by hosting talks from local physicians every day of that week. Our most recent meeting was directed by a local cardiologist who told us of the high demands that must be met over the next decade. The student body who attended the talk went away with an increased desire to not simply become a doctor, but to fill the need for competent physicians in specific fields.

The IMIG at TUNCOM is progressing at a rapid rate and we hope to host several more lectures and activities to meet the needs of the Las Vegas area. We are anticipating an excellent response to our current project, a community program to promote immunizations among low income patients. As we look into the future of medicine in the state of Nevada, we feel confident that the IMIG of TUNCOM will play a major role in the development of quality care.

Craig Boyle
Co-President, Internal Medicine Interest Group
Touro University Nevada College of Medicine, Class of 2010
E-mail: craigboyle@gmail.com

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Winning Abstract from the 2007 Medical Student Abstract Competition: Medical Students Have Misconceptions About Standard Precautions And Biosafety Measures

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Author:
Lia Monsalve, University Central de Venezuela

Introduction:
Medical students are at a very high risk of acquiring health-care related infectious diseases. Students represent the third most frequent group with exposure accidents. Students are frequently exposed to blood and other body fluids when they perform invasive procedures during their training, therefore, their knowledge in biosafety measures is essential to prevent such accidents. We propose to evaluate the training of medical students in terms of biosafety to manage these procedures.

Methods:
A descriptive, transversal study was conducted over 115 medical students in the 4th and 5th year from the "Luis Razetti" School of Medicine in the academic period 2005-2006. Both a self-administered Likert-type survey and a knowledge test were given to the students to evaluate their attitude and knowledge on health-associated risks and universal biosafety measures.

Results:
Of the 115 students, 66.95% were females and 33.04% were males, with an average age of 22 years. 41 % percent agreed and 53.09% totally agreed with "being on risk of health-care related accidents". When asked, 54.86% disagreed and 24.77% totally disagreed that the responsibility in preventing accidents rests with their superiors. Half of the medical students had no knowledge of the existence of a Hygiene and Biosafety Commission in their Hospital.

Only 55.65% of the students knew that cerebrospinal, synovial, pleural, peritoneal, amniotic and pericardial fluids are considered potentially infectious for HIV, HBV and HCV; 23.47% knew that in case of accidents with needles or other sharp objects they must wash the skin area vigorously. Only 26.95% of the surveyed knew that needles and other objects in contact with body fluids must be discarded in containers designed for that purpose. Finally, 80% were aware that parenteral transmission is produced by contact of body fluids with injured skin.

Conclusion:
Medicine students in our study showed a great misconception towards biosafety measures and the risks they are exposed to. This issue needs to be addressed by the various education commissions during the medical student training.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Clinical Cardiac Electrophysiology

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The Discipline
Clinical Cardiac Electrophysiology is a branch of Cardiology that manages complex cardiac arrhythmias with the use of implantable pacemakers and cardioverter-defibrillators, and also applies other interventional techniques and treatments.

Procedures
Specialization in Clinical Cardiac Electrophysiology requires a physician to perform and interpret a number of noninvasive diagnostic procedures such as ambulatory ECG monitoring, event recording, telephone ECG transmission, signal-averaged electrocardiography, tilt table testing, assessment of heart rate variability, and other tests of the autonomic nervous system. Advanced expertise in temporary cardiac pacing, transesophageal atrial pacing, cardioversion, interpretation of invasive electrophysiologic study data, and complex arrhythmia ECG interpretation is also needed.

Training
Three years of Cardiovascular Disease fellowship training in a program accredited by the ACGME, including 24 months of clinical training, is required before entering a training program in Clinical Cardiac Electrophysiology. Training in Clinical Cardiac Electrophysiology involves an additional year of fellowship training, ideally pursued immediately following the prerequisite Cardiovascular Disease fellowship training.

Certification
Successful Diplomates will be awarded an ABIM Subspecialty Certificate in Clinical Cardiac Electrophysiology. The certificate will bear dates limiting the duration of its validity to ten years, but is renewable upon successful completion of ABIM’s Maintenance of Certification program.

Major Professional Societies
Heart Rhythm Society
1400 K Street NW Ste 500
Washington, DC 20005
Phone: 202-464-3400
Web site: http://www.hrsonline.org/

Major Publications
Heart Rhythm
Pacing and Clinical Electrophysiology

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Advocacy Brief: Department of Education Reaffirms No Change in Economic Hardship Deferment

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The Department of Education recently confirmed that the debt-to-income ratio (20/220) qualifying pathway for economic hardship will not be changed as a result of the College Cost Reduction and Access Act. The economic hardship deferment allows medical residents to postpone payment of their student loans for up to 3 years, during which time no interest accrues on the subsidized portion of their loan. Most medical residents qualify for economic hardship under the debt-to-income ratio criteria. While the College Cost Reduction and Access Act eliminated the debt-to-income ratio in statute, Secretary of Education Margaret Spellings has used her authority to continue this qualifying pathway. However, medical school financial aid professionals have reported that some lenders are not aware of this continuation and are rejecting qualified applicants. Please be aware that educational loan servicers and lenders currently should be offering – and should never have stopped accepting – applications for the economic hardship deferment from medical residents that qualify under the debt-to-income ratio.

The College previously expressed concern about the elimination of the 20/220 pathway in a letter to Congress and recently endorsed legislation that would make the 20/220 Pathway for Economic Hardship Deferment Permanent and expand the current economic hardship qualifications for medical residents. The official endorsement letter can be located online.

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Did You Know ACP Develops Policy and Advocates for a Better Practice Environment for its Members?

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ACP works directly with government entities and managed care organizations to influence their internal policies and procedures and ensure that the standards for professionalism and quality are upheld. ACP has been a leader in advocating for changes to improve the practice environment for its membership. Information about the current advocacy and policy development efforts of the College is available online.

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MKSAP for Students 3 Question 1

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A 34-year-old woman has had fatigue, a 11.0-lb (5-kg) weight gain, irregular menstrual cycles, and milky discharge from both breasts for 6 months.

Physical examination reveals a small goiter, dry skin, and bilateral expressible galactorrhea. Laboratory results include a negative pregnancy test, a serum thyroid-stimulating hormone of 43µU/mL, and a serum prolactin level of 55ng/mL.

Which of the following is the most likely diagnosis?

A. Adrenal insufficiency
B. Hypothyroidism
C. Premature ovarian failure
D. Prolactinoma

MKSAP for Students 3 Question 2

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A 21-year-old female college student has a 1-week history of malaise, anorexia, nausea, and vomiting. Three weeks ago, she returned from Guatemala, where she had engaged in missionary work. She has never been sexually active, does not use intravenous drugs, and has never had a blood transfusion.

On physical examination, temperature is 37.9°C (100.2°F). There is mild jaundice and a palpable, tender liver.

Serum alkaline phosphatase 110 U/L
Serum aspartate aminotransferase 1100 U/L
Serum alanine aminotransferase 1700 U/L
Serum total bilirubin 3.0 mg/dL

Which of the following laboratory tests is most likely to establish the diagnosis?

A. Antibody to hepatitis B surface antigen
B. Antibody to hepatitis C virus
C. Epstein-Barr virus DNA
D. IgM antibody to hepatitis A virus

MKSAP for Students 3 Answer 1

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Answer: B, Hypothyroidism

There are many secondary causes of hyperprolactinemia that are not associated with pituitary tumor. One of the most common secondary causes of hyperprolactinemia is primary hypothyroidism. Up to 30% of women with primary hypothyroidism have a mildly elevated prolactin level. The reason for this elevation in primary hypothyroidism is thought to be increased stimulation of the pituitary gland by thyrotropin-releasing hormone, the hypothalamic hormone that stimulates thyroid-stimulating hormone and prolactin secretion from the pituitary gland. As in other secondary causes of hyperprolactinemia, serum prolactin levels in primary hypothyroidism are less than 200 ng/mL.

Treatment of primary hypothyroidism with levothyroxine to normalize serum TSH levels will also normalize prolactin levels, and irregular menses, stabilize weight, and the galactorrhea should resolve. None of the other diagnoses can explain the combination of altered menstrual function, weight gain, and galactorrhea. Premature ovarian failure may be associated with irregular periods but is not associated with weight change or galactorrhea. A prolactin secreting pituitary tumor can certainly cause galactorrhea but cannot account for the elevated thyroid stimulating hormone level. Adrenal insufficiency is most likely to cause weight loss, not weight gain, and will not produce an elevated thyroid stimulating hormone level or galactorrhea.

Bibliography
Grubb MR, Chakeres D, Malarkey WB. Patients with primary hypothyroidism presenting as prolactinomas. Am J Med. 1987;83:765-9. PMID 3674063

MKSAP for Students 3 Answer 2

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Answer: D, IgM antibody to hepatitis A virus.

This patient’s clinical and biochemical findings suggest acute hepatitis. She has recently returned from a country where hepatitis A virus is endemic, and testing for IgM antibody to hepatitis A virus is indicated. Acute hepatitis B or C infection is unlikely in the absence of any risk factors, including sexual, intravenous drug, or other sources of parenteral transmission.

A positive test for antibody to hepatitis B surface antigen indicates that the patient has been exposed and is immune to hepatitis B virus (HBV). It does not indicate that she has acute HBV infection.

Determination of antibody to hepatitis C virus is not the appropriate test to diagnose this acute infection, as up to 40% of patients may have a negative test result. Measurement of hepatitis C viral load is the best test to confirm the diagnosis. Acute Epstein-Barr virus infection is usually associated with pharyngeal discomfort, lymphadenopathy, and atypical lymphocytosis, which this patient does not have.

Bibliography
Ryder SD, Beckingham IJ. ABC of diseases of liver, pancreas, and biliary system: Acute hepatitis. BMJ 2001;332:151-3. PMID: 11159575

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ACP Internal Medicine Residency Database

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

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

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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 your copy of MKSAP for Students 3 please visit us online.

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Articles for Medical Students from ACP Observer

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New look for ACP’s newspaper

Readers will notice many changes in the January 2008 issue, which will re-launch as ACP Internist with a new look and expanded content. New to ACP Internist will be a column, “Mindful Medicine” which conveys the importance of creative thinking in medicine, using actual cases submitted by readers.

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Council of Student Members: Call for Nominations

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If you are active in your local chapter, get involved nationally by joining the ACP Council of Student Members (CSM). The CSM is responsible for planning programs for the annual meeting for medical students and providing a student perspective on current issues impacting the field of internal medicine.

More information including time requirements for the Council and application procedures can be located on the CSM Web site.

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New ACP Ethics Paper: Patient Welfare Comes First in Quality and Cost Control Efforts

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A new ethics paper, developed by the ACP Committee on Ethics, Professionalism and Human Rights and released in the December 4th issue of Annals of Internal Medicine, highlights the need for increased sensitivity toward patient care in pay-for-performance (P4P) programs. “Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto,” states that pay-for-performance has the potential to help improve the quality of care, if it can be aligned with the goals of medical professionalism.

Pay-for-performance programs appear to be a part of the future of medicine, and as medical students, it is important to be aware of the potential impact these programs could have on patient care, patient-physician relationships, organized medicine, and internal medicine in particular. Initiatives that provide incentives for a few specific elements of a single disease or condition, however, may neglect the complexity of care for the whole patient, especially the elderly patient with multiple chronic conditions. The authors point to the need to adhere to patients’ welfare, preferences, and best interests first and foremost in the effort to improve quality and control costs. Elderly patients and those with chronic conditions are particularly vulnerable to P4P programs they say, as well as patients who might be dropped because of their inability to meet existing measures or who are unable to comply with treatment plans.

By releasing the paper, ACP hopes to move the pay-for-performance debate forward with a patient centered focus—one that puts the needs and interests of the patient first.

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ACP offers recommendations for U.S. health care system based on review of other countries

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ACP offers suggestions to reform the U.S. health care in “Achieving a High Performance Health Care System with Universal Access: What the USA Can Learn from Other Countries,” a new evidence-based paper published in the December issue of Annals of Internal Medicine. The paper was developed by ACP's Health and Public Policy Committee and approved by the Board of Regents in October, 2007. The paper reflects comments received on an earlier draft from members of the Board of Governors, Board of Regents, ACP Councils, and selected expert advisors.

The paper outlines the ills plaguing the American health care system and proposes evidence-based recommendations addressing each of them, based on findings of a review of 12 industrialized countries. The paper concludes that the current U.S. health care system—which involves multiple payers without guaranteed coverage (pluralistic model) results in the U.S. lagging behind other countries on access, quality and efficiency of care. The paper proposes two different pathways to achieve universal coverage: a pluralistic system with universal coverage or a single payer system. Rather then endorsing either pathway, the ACP calls on the public and policymakers to consider the strengths and weaknesses of each approach. For instance, the paper reports that single payer systems perform well on most measures of quality, satisfaction, access, and administrative costs, but are more likely to result in shortages of services subject to price controls and waiting lists for elective procedures. Pluralistic models with universal coverage do better on giving individuals the freedom to purchase additional services, but less well on measures of equity (access without regard to ability to pay) and administrative costs.

To improve the quality of care, ACP recommends building incentives into the system for both patients and physicians, redirecting federal health care policy toward supporting a patient-centered medical home model of care, and developing a national workforce policy to ensure an adequate supply of physicians. To improve administrative cost and burden, ACP recommends creating a uniform billing system for all services, supporting HIT infrastructure with federal funds, and encouraging public and private investment in medical research.

For links to the paper and other related resources, visit the ACP Web site.

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