January 2008 E-Newsletter

Medical Student Perspectives: How to Prepare for Your Fourth Year

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Unlike the first three years of medical education, most schools have no standardized structure for fourth year. As such, fourth year can be a difficult time to plan. Many students may find themselves with questions about sub-internships, away rotations, electives, residency applications, and the USMLE Step 2 exam. With the help of several resources, including advice from the ACP Council of Associates (COA), I will attempt to answer some of these questions.

Sub-Internship
Doing a sub-I in medicine is generally encouraged for a number of reasons. "First, to ensure you actually like medicine, secondly for letters of recommendation, and lastly for the experience" explains Chris Allen, MD, a COA representative from Case Western University. When to do one? Generally, the most important factor is to complete the sub-I before you finalize your residency applications in order to utilize letters of recommendation—usually by the end of September. Most people will do theirs in the beginning of fourth year or the end of third. There are advantages and disadvantages of both, but one advantage of doing it at the beginning of fourth year is that you will stand out more compared to other students, many of whom will be at the beginning of their third years. Dr. Allen adds that a good way to stand out on your sub-I is to "pick something interesting about a patient you are caring for and do a 5 minute or so presentation."

Away Rotations
Away rotations are more controversial than sub-internships. The issue is that the benefit of doing an away rotation and making a good impression does not necessarily outweigh the risk that you might not make a great impression. Therefore, conventional wisdom dictates that you should only do an away rotation if you are very interested in the program and if you work very hard to make a good impression. "The best time to do an away rotation might be after a sub-I at your own school, so you’re really on top of your game," notes Sara Selig, MD, an intern at Brigham and Women’s. It is also important to complete it before you might interview at the place of the rotation—usually before February. To find an away rotation that interests you, visit the American Association of Medical Colleges Extramural Electives Compendium.

Electives
"There are no electives that will prepare you for your internship," Dr. Selig warns. "You can have all the book-knowledge in the world and still not be completely prepared. That being said, we all know our weak spots, so if you feel you are weak in something, doing an elective in that might help build your knowledge base." Dr. Allen adds, "Two weeks of radiology would be helpful, some time in the ICU would be helpful as well … To be a good general internist, you need to know a lot, so consider electives you think you might be weak in or not have much exposure to."

Residency Applications
Ask for letters of recommendation soon after your interaction with whoever will be writing them. Remember that it may be better to have a junior faculty who knows you very well write you a letter than a full professor who does not. You can network with people in residencies you are considering through the ACP, or through your school’s alumni. Another option is to talk to your medicine program director, since most program directors have connections in multiple schools that might be of interest to you. When interviewing, remember to be yourself. "Interviews should be an opportunity for both you and the school to see how well you fit," Dr. Selig explains. To find more information about internal medicine residency programs, visit ACP’s Residency Programs and Selection Web page.

Step 2 Exam
Although Step 2 is widely considered to be easier than Step 1, it may be more important for your residency applications, so it’s best to start preparing early. As for timing, "the general rule of thumb is that a student with a high Step 1 score might not need to take the test early in the year, fearing that a lower score might only hurt his or her application," Erin Dunnigan, MD, a COA representative from Duke University explains. "For those students who have an average to borderline low performance on Step 1, Step 2 is actually very important--taking this exam early and doing better may convey to program directors a special aptitude in clinical medicine and positive trajectory in future performance." Dr. Dunnigan also notes that the exam "is actually very helpful in forming the knowledge base that a new doctor needs for the first day on internship, or more specifically, the first night on call!" Most people prepare for the exam in very similar ways as they did for Step 1, with emphasis on questions such as those in Kaplan’s QBank. ACP’s MKSAP for Students 3 can also supplement your question bank.

General Advice
Dr. Allen suggests taking fourth year easy, but not too easy. There are a number of things you can do with your time that will help strengthen your residency applications. Research, away or international rotations, volunteer work in clinics, and summer scholarships are all helpful, both for your applications and for preparing for internship. "If you want to specialize or go to a top program, you need to show interest in research and plan to remain in academics," Dr. Allen adds.

Aliza Monroe-Wise, MSc
Council of Student Members Representative, Pacific Region
Stanford University School of Medicine, 2009
E-mail: aliza1@stanford.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Jon Brndjar, DO, FACP

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The best doctors have a little bit of everything: a good bedside manner, a sharp mind, a knack for healing and a gift for precision. Internists have these qualities and more. What sets them apart is felt more than it is defined: an intangible ability to read a patient's body, mind and spirit all at once. Dr. Brndjar has this ability, and his patients are grateful for it.

The Sixth Sense
Dr. Jon Brndjar is an osteopathic physician and a believer in holistic care. The similarity in ideology of both disciplines blends well with his personal approach to medicine, which can be described as straightforward with a good dose of common sense. The secret to his success lies in his ability to get to the root of something quickly and simply.

"Sometimes I’ll have patients come in complaining of chest or abdominal pain and while it is important to take into account their age, other medical problems and other factors, I also ask what has been going on in their lives," he explains. Often times he says these types of common ailments are stem from increased stressors, problems at work or at home. "Asking a patient ‘What’s going on with you right now?’ helps you as a physician establish a timeline."

For Dr. Brndjar, there is nothing particularly extraordinary about the way he practices medicine. To him and other physicians like him it is cut and dry, but with today’s health care environment, his simplicity is refreshing. His ideology and methodology as a physician are guided by an inner compass, something he says he struggled to find. When Dr. Brndjar was finishing college, he found himself at a crossroads, unsure of what he wanted to do with his life. It was down to two choices: medicine or the seminary. His decision reflected the better choice for him intuitively. "I wanted to help people live a better quality of life and being an internist is for me the best way to serve that purpose," he says.

He is able to do that today in a town called Emmaus, just outside of Allentown, PA, where he operates his own private practice, Brndjar Medical Associates. It is a healthy practice that he has been able to build successfully over the years with a little local pull, having completed medical school at the Philadelphia College of Osteopathic Medicine and residency training with a Penn State program at Lehigh Valley Hospital.

The inspiration for his wanting to help people stemmed from his own family doctor growing up. "In the old days, the family doctor treated everything from A to Z and I remember being really impressed by him. I liked his approach to patients, and I liked his knowledge." He also drew inspiration from the people he worked with at a nursing home while in college. "The experience instilled in me a great deal of respect for them—those who do that kind of work."

Dr. Jon Brndjar with his family

Dr. Jon Brndjar with his family


Reaching Out
Contending with difficult and sometimes painful moments has earned Dr. Brndjar appreciation and recognition from his patients and their families, something he cites as one of his finest achievements. One instance Dr. Brndjar remembers had to do with a patient suffering from congestive heart failure. After three or four hospital stays within two months, the patient decided to decline treatment. "He wanted to go home and just be comfortable," he recalls. The following day, Dr. Brndjar met with the patient and the family—including the patient’s spouse, children and grandchildren—as well as the family minister. He helped them work through the emotions and questions, and the following day, the patient left for home, accompanied by hospice services. He died three days later. At the viewing, the patient’s sister approached Dr. Brndjar and told him how much the patient’s wife and family appreciated what he had done and the time he took. Later, he also received a letter from the patient’s wife echoing the same sentiments. "The biggest reason I love internal medicine is helping families like that one,” he says. “I love taking care of people and their families. It’s very rewarding."

He demonstrates similar generosity toward his colleagues. Currently, he is working with ACP’s Center for Practice Innovation in helping smaller practices identify and improve practice-related issues. "I wanted to become involved," he explains. "As a solo practitioner it’s easy to get too into your own little world—I thought this was a good opportunity to connect with other physicians."

While he dedicates much of his time to others—his patients, their families, his colleagues—he still tries to spend as much time as he can with his own family. He enjoys his time with his four children, Dan, Alexa, Hunter, and Anderson, helping them with schoolwork, watching them in sports or just hanging out with them. He also does volunteer work for the church he attends with his family. His wife Dana has worked as a nurse, which is how he met her in 1996. They were friends for many years before they got married. "Being married to Dana is just plain fun," he says. "She’s bright, intelligent and beautiful and she loves me for me—good points and bad. Not to sound sappy, but I feel lucky and blessed to have her in my life."

As for the future, once again Dr. Brndjar’s instincts point him in the right direction. His plan is to get his master’s degree in business, something he says future internists looking to run their own practice should seriously consider. "I’d encourage students and residents to get additional course work in business because running your own practice is like running a business," he says. "I’ve had to learn it on the fly which has been a challenge."

Something else he thinks they should consider is internal medicine. "What’s exciting about being an internist," he says, "is having challenges every day, always having something new on the horizon." Try as he may to act like a bump on a log, Dr. Brndjar is an example of how internists, today’s unsung heroes, are fast becoming tomorrow’s diamonds in the rough.

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Internal Medicine Interest Group of the Month: University of Hawaii

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SOAP Note: John A. Burns School of Medicine Internal Medicine Interest Group

SUBJECTIVE:
2006-2007 was an exciting inaugural year for the very first Internal Medicine Interest Group (IMIG) at the University of Hawaii (UH) John A. Burns School of Medicine (JABSOM), initiated with hopes of providing resources for current and future students interested in internal medicine. Since the start of the 2007-2008 year, IMIG has charged full speed ahead with the same momentum as the year before, with new officers, fresh ideas, and overflowing energy to maximize the growing potential of the interest group.

OBJECTIVE:
Since the start of the school year in July 2007, the IMIG has already coordinated several activities involving students, faculty, and community physicians. The group kicked off the year with recruiting new first-year medical students during the Student Activities Fair to join the IMIG and American College of Physicians (ACP). To this date, we are proud that 77% of the student body (200 students) are members of the ACP.

October was an exciting and busy month with several activities. The first activity was an EKG Workshop with cardiologist, ACP Master, and former ACP Hawaii Chapter Governor, Dr. Irwin Schatz that was well attended by MS1s and MS2s. The following week, neurologist Dr. Melvin Yee presented A National Geographic Tour of Neurology and Neurologic Diseases. The most successful event was the UH Internal Medicine Resident Panel Mixer held at the home of our UH Department of Medicine Chair. Current UH internal medicine residents shared their pearls of wisdom to an audience of eager MS3s and especially MS4s who are currently in the midst of applying to residency. Students were able to ask the residents not only about the UH residency program, but also about other residency programs, including their own experiences.

The most recent event was the Medicine Pau Hana II held at Canoes Restaurant in Waikiki in November that was co-sponsored by the ACP Hawaii Chapter, University of Hawaii Department of Medicine, and IMIG. The event was organized for students, residents, and practicing physicians to meet the national ACP leadership and delegates to the American Medical Association (AMA) who were attending a conference in Hawaii. At this meeting we heard local and national updates and had the opportunity to congratulate the former Dean of our medical school, Dr. Edwin Cadman, for his election to ACP Mastership. In addition, the event gave students and residents another chance to mingle and network with practicing physicians interested in participating in our developing “Medicine Mentorship Program.” An IMIG website was also created under the UH Department of Medicine website that provides, among other resources, a list of physicians willing to be preceptors and mentors for students.

The IMIG will welcome 2008 with the Annual Hawaii Chapter ACP Scientific Meeting on January 12, 2008 at the picturesque Ko’olau Country Club on the windward side of the island. Students and residents will have the opportunity to present their research as well as to hear about Current Hot Topics, including recent medical advances and local and national issues affecting internal medicine. Future events include a Careers in Internal Medicine panel of invited primary care physicians and subspecialty physicians and another panel with invited hospitalists and physicians practicing in the community.

ASSESSMENT:
JABSOM IMIG is a one-and-a-half-year-old interest group, nurtured under the guidance of elected student officers, class representatives, faculty advisor Dr. Laurie Tam, ACP Hawaii Chapter Governor Dr. Alvin Furuike, FACP, Governor’s Assistant Ms. Sharon Chun, UH Department of Medicine Chair Elizabeth Tam, FACP, and the ACP, that presents with endless energy, motivation, and determination to provide great opportunities for students interested in internal medicine. Its prognosis is excellent, with great events planned and the class of 2008 boasting as many as a third of the MS4s applying for categorical residency positions in internal medicine.

PLAN:
It is the hope of the elected student officers to build on the foundation of IMIG and to continue to provide opportunities for UH students to become further involved and fall in love with the field of internal medicine.

Angelina A. Amian
Secretary, Internal Medicine Interest Group
John A. Burns School of Medicine, University of Hawaii
Class of 2008
E-mail: amian@hawaii.edu

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Winning Abstract from the 2007 Medical Student Abstract Competition: Mosquitoes, Meningitis, and Myocarditis: Another Etiology of Acute Febrile Illness.

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Author:
Kate Pettit, Stanford University

Introduction:
West Nile Virus (WNV) is an increasingly common vector-borne illness. The general internist should be aware of thc cndemic areas for WNV, the multi-system nature of the presenting features of WNV, and the interpretation of diagnostic studies.

Case Presentation:
A 67-year-old male construction worker was admitted with myalgias, sore throat, cough, nausea, vomiting, non-bloody diarrhea, and rash for nine days. He denied sick contacts or recent travel, but did report mosquito exposure. He denied meningismus and photophobia. On admission, the patient had a temperature of 102.9 degrees Fahrenheit, heart rate of 96 bpm, respiratory rate of 22, and blood pressure of 115/65. Physical exam revealed dry mucous membranes and a faint erythematous maculopapular rash on the back, chest, and abdomen. Neurologic exam was within normal limits. Laboratory data was significant for an elevated serum WBC of 13,300/mm3 , elevated troponin of 0.08 ng/ml, and elevated creatine kinase of 405 u/l. Electrocardiogram showed elevated convex ST segments in leads V1-V3, new from prior ECG. Shortly after admission, the patient became somnolent and hypotensive. Emergent transthoracic echocardiogram showed a normal left ventricular ejection fraction (>55%) and no evidence of wall motion abnormalities. Cerebrospinal fluid analysis showed 190 WBC/mm3 with 68% neutrophils and 20% lymphocytes, glucose of 49 mg/dl and protein of 67 mg/dl. Empiric treatment with vancomycin, ceftriaxone, and azithromycin was initiated. Blood, urine, and CSF cultures were later negative. CSF EIA for WNV IgG and IgM was inconclusive. WNV serology was IgM positive by IFA and EIA. The patient received supportive care and was discharged with mild fatigue. Repeat ECG showed resolution of ST segment abnormalities and no pathological Q waves. Further cardiovascular investigation on follow-up concluded that the early electrocardiogram changes and increased troponins were likely secondary to perimyocarditis.

Discussion:
Infection with WNV is asymptomatic in approximately 80% of cases. Only 1 of 150 progress to neuroinvasive disease, with advanced age being the most important risk factor. Since the first cases in New York in 1999, WNV has rapidly become endemic in the U.S., with human cases in 43 of 50 states in 2005. The diagnosis should be considered in any patient with an acute febrile illness after mosquito exposure. The clinical presentation can include fatigue, headache, pharyngitis, gastrointestinal symptoms, rash, muscle weakness, meningitis, encephalitis, myocarditis, pancreatitis, and hepatitis. Serum and CSF assay for WNV IgM remains the most sensitive method of diagnosis, though IgM can persist for up to one year after acute infection. IgG avidity testing is a new method being studied to differentiate stages of infection.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Sports Medicine

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The Discipline
The discipline of sports medicine primarily concerns itself with the emergency assessment and care of acutely injured athletes, diagnosis, treatment and management of common sports injuries and illnesses, management of medical problems of the athlete, rehabilitation of ill and injured athletes, and exercise as treatment.

Training
Sports Medicine fellowship training requires 12 months of accredited training beyond general internal medicine residency.

Certification
The Sports Medicine Certification Program is jointly developed by the American Board of Internal Medicine (ABIM), the American Board of Emergency Medicine (ABEM), the American Board of Family Medicine (ABFM), and the American Board of Pediatrics (ABP).

Major Professional Societies
American Medical Society for Sports Medicine
11639 Earnshaw
Overland Park, KS 66210
Phone: (913) 327-1415
Web site: http://www.newamssm.org/

American College of Sports Medicine
401 West Michigan Street
Indianapolis, IN 46202-3233
Phone: (317) 637-9200
Web site: http://www.acsm.org

Major Publications
Clinical Journal of Sports Medicine

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Advocacy Brief: Enroll in ACP’s Key Contact Program

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ACP’s continued success on Capitol Hill greatly depends on year-round grassroots efforts from the College’s nearly 4,500 Key Contacts. Key Contacts communicate with their local members of Congress on issues of importance to internists and their patients and report the results back to ACP.

To enroll as a Key Contact, ACP members are not required to have existing relationships with members of Congress. ACP provides members with the tools necessary to develop and maintain these relationships. The program is open to all membership categories. Enroll now in the Key Contact Program.

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

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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 register and begin accessing Annals of Internal Medicine Online, please visit the Annals Web site.

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MKSAP for Students 3 Question 1

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A 65-year-old man is admitted to the hospital because of fever and dysuria. Laboratory studies show a leukocyte count of 12,000/µL, a blood urea nitrogen level of 24 mg/dL, a serum creatinine concentration of 1.4 mg/dL, and pyuria. Empiric treatment with trimethoprim-sulfamethoxazole is started. Three days later, the pyuria and fever have resolved. The leukocyte count is 10,000/µL, blood urea nitrogen level is 24, and serum creatinine is 1.8 mg/dL. Urinalysis shows no leukocytes, casts or crystals.

Which of the following is the most likely explanation for the rise in serum creatinine from 1.4mg/dL to 1.8 mg/dL?

A. Acute interstitial nephritis
B. Acute pyelonephritis
C. Acute tubular necrosis
D. Obstructive uropathy
E. Reduced creatinine excretion

MKSAP for Students 3 Question 2

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A 42-year-old woman is evaluated because of 4 months of medial right elbow and forearm pain and associated numbness and tingling in her right fourth and fifth digits. On examination, there is no swelling or redness of the elbow, forearm, or hand, and full range of motion is intact at the elbow. There is no exacerbation of symptoms with shoulder or neck movements or with resisted wrist flexion or extension. She has slight wasting of the hypothenar muscles and tenderness medially at the elbow. Percussion over the tender area at the elbow causes tingling that radiates to the fourth and fifth digits, but does not produce symptoms when repeated.

Which of the following is the most likely cause of her hand and elbow pain?

A. C7 radiculopathy
B. Carpal tunnel syndrome
C. Cubital tunnel syndrome
D. Medial epicondylitis
E. Saturday night palsy

MKSAP for Students 3 Answer 1

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Answer: E, Reduced creatinine excretion

Trimethoprim and other organic cations, such as cimetidine, competitively inhibit creatinine secretion in the distal tubule. Although acute interstitial nephritis can occur secondary to treatment with trimethoprim-sulfamethoxazole, it takes several days to evolve and is less commonly seen in the absence of other systemic allergic symptoms, such as eosinophils in the urine, rash, and fever. Acute pyelonephritis is not likely, given that systemic symptoms resolved. Obstructive uropathy can occur; however, it causes the glomerular filtration rate to decrease and, therefore, the blood urea nitrogen level would also be elevated. Unlike aminoglycosides or amphotericin B, trimethoprim has not been associated with acute tubular necrosis and there is no evidence of acute tubular necrosis in the urinalysis such as muddy brown casts or renal tubular epithelial cells.

Bibliography
Andreev E, Koopman M, Arisz L. A rise in plasma creatinine that is not a sign of renal failure: which drugs can be responsible? J Intern Med. 1999;246:247-52. PMID: 10475992

MKSAP for Students 3 Answer 2

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Answer: C, Cubital tunnel syndrome

Cubital tunnel syndrome is the second most common entrapment neuropathy in the upper extremity, and occurs with compression of the ulnar nerve as it passes through the cubital tunnel at the medial elbow. The floor of the tunnel is formed by the medial collateral ligament of the elbow, and the roof is formed by the two heads of the flexor carpi ulnaris muscle with the associated connecting aponeurosis. Compression can occur if the tunnel is congenitally narrowed, or with repetitive elbow motions. Cubital tunnel syndrome typically presents with numbness or paresthesias in the fourth and fifth digits, and may have associated medical elbow pain. In severe cases, hand clumsiness and reduced grip strength occur due to interosseous muscle weakness.

Carpal tunnel syndrome affects the median nerve, causing numbness or paresthesia in the thumb, index, and middle fingers, and the lateral half of the ring finger. Patients with medial epicondylitis experience well-localized medial elbow pain without radiation into the hand; elbow pain is exacerbated by lifting or use of the forearm or wrist. Saturday night palsy occurs with compression of the radial nerve in the spiral groove of the humerus. Ensuing symptoms include sensory loss over the dorsum of the hand and weakness in the brachioradialis muscle, wrist extensors, and finger extensors. C7 radiculopathy, the most common form of cervical radiculopathy should cause sensory changes in digits 2 through 4, motor weakness in the triceps, forearm pronation, and wrist flexion and extension. Additionally, one might expect symptoms to be exacerbated by neck movement.

Bibliography
Posner MA. Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect. 2000;49:305-17. PMID: 10829185

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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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Announcing the Internal Medicine Essentials for Clerkship Students 2007-2008 Textbook

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The Internal Medicine Essentials for Clerkship Students 2007-2008 textbook is now available. Created by the American College of Physicians and the Clerkship Directors in Internal Medicine, Internal Medicine Essentials is written by 68 authors who direct internal medicine clerkships around the country, who help design the internal medicine curriculum, and who are actively involved in teaching students during their internal medicine clerkships.

This invaluable guide demonstrates to students how to care for patients, prepare for clinical rounds, and study for the end of rotation examination. Internal Medicine Essentials covers the common problems and disorders that students are expected to understand and likely to encounter during their clerkship. The printed content is enhanced online with clinical photographs, tables, screening tools, and other instruments. This is a unique resource that provides medical students with the skills they need to enhance learning during the third-year internal medicine clerkship.

List Price: $49.95
ACP Student Member Price: $39.95
Product #: 330361030
ISBN: 1-930513-82-8

Order online or call ACP Customer Service at 800-523-1546, extension 2600 or 215-351-2600 (M-F, 9 a.m.-5 p.m. ET).

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Articles for Medical Students from ACP Internist and ACP Hospitalist

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ACP Internist (formerly ACP Observer)

  • Mindful Medicine: Discover the art of medical diagnosis and decision making through a series of case studies suggested by readers.
  • Ethical Dilemmas: Examine the ethical dilemmas that occur in everyday practice.

ACP Hospitalist

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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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