July 2008 E-Newsletter

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Medical Student Perspectives: How to Succeed During Your Clerkship Year

The third year of medical school will set the stage for your medical career. It is a year full of promise; it is a year full of hard work. You may start the year thinking that you already know which field you intend to pursue, but for most medical students, that idea will change at least once. You will have opportunities this year to experience and to see first-hand everything that goes on in the hospital, so take advantage! Now in my fourth year and looking back at my third year of medical school, I am utterly amazed at how quickly it goes by and how much I learned in what seemed like a very short year. Since hind-sight is 20/20, here are my thoughts on how to rock during your clerkship year, how to impress your attendings, and how to stay sane.

The Intimidation Factor
Do not worry! Every medical student is going to feel totally clueless at least 100 times this year. Remember, every great attending and resident that you work with started as a medical student. Most likely, they made the same mistakes that you will, they felt just as lost, and they were just as embarrassed about their lack of knowledge. The key is to remember that they got to where they are through a lot of hard work and a whole lot of studying, and so can you. No one expects you to know everything at the beginning of your rotation. Rather, the key is to demonstrate an increased knowledge base over the course of the months, reflecting that you are paying attention on teaching rounds and that you are avidly reading about the diseases you see when you get home.

Ask Questions
When you do not understand something that is being discussed, speak up. The number one reason that you are on the clerkship is to learn, so do not waste your time or the time of the team. Teaching rounds are not for the good of the attending – they are for you! This is your best chance to learn how to build a differential diagnosis, to interpret physical and laboratory findings, and to develop an assessment and plan. Questions will reflect active listening, interest in the subject being discussed, and will clarify difficult topics thus lightening the load of studying that you will have to do when you get home.

Show Interest
Get excited! This year is your chance to see what being a doctor is all about, and to see all of the aspects of medicine in its continuity. Try to approach each rotation with a positive attitude no matter which field you may already plan to pursue. Most important, do not express any disinterest you may have for your current rotation, as this attitude will be clear to your residents and attendings. A bad attitude will reflect itself in less interest on the part of the attendings and residents to teach you, a lower score on the shelf exam, and poorer evaluations. No matter how long some rotations may seem to drag on, especially during those cold winter months of perpetual darkness, keep in mind that this is an experience with opportunities to teach you something applicable to your later clinical practice. Stay positive, even if you have to feign it every once in a while.

The Early Bird Catches the Worm
The adage especially holds true in third year. See your patient, check in with the nursing staff covering your patient, check for new labs and imaging, and get your notes written before anyone else on your team has seen the patient. Then, check in with your resident before rounding with the attending. Find out if your patient will be having any tests or undergoing any procedures that you did not know about, and make sure that both of you are on the same page concerning the management of the patient. This is the single easiest way to avoid embarrassing moments while rounding.

Know Your Patient Better than Anyone Else
The medical student is the go-to-person when there is a question about a patient’s past medical history. Memorize the patient’s history, commit it to your memory, or write it on the inside of your sleeve if you cannot seem to remember it. This is a really easy way to shine, to appear interested, and to look like a hard worker. Also, if your patient is in the hospital for a COPD exacerbation but has a past medical history of rheumatoid arthritis, know the current status of both conditions and any physical findings that the patient has for either condition. This is a great way to practice the physical exam as it relates to different pathologies, and an even better way to reinforce the patient’s information in your memory.

Make an Impression
It is one thing to try and make an impression on your residents and attendings, but do not forget to put just as much effort into making an impression on your patient. Check back in with your patient frequently throughout the day, ask them if there is anything that you can do to make them more comfortable, and make sure that they know your name. If your patients feel that you provide excellent care, then your attendings will definitely hear about it. This kind of feedback is priceless.

Perseverance
Everyone will make mistakes and look foolish during their third year, but the key is to bounce back. Remember that it takes a lot more than one bad day to hurt your evaluation grade, and that your failures will be small in comparison to your accomplishments if you continue to show up and work hard every day. The most successful students are those who learn from their failures and who do not make the same mistake again.

Dress the Part
If you do not know the answer, at least you can look like you do. Being a professional requires dressing like one, and many residents and/or attendings will assume a lot about the effort you will put into the rotation and your level of seriousness based solely on the way you physically present yourself. A sloppy dresser earns less respect and tends to receive poorer evaluations, despite how well he or she may answer questions on rounds.

Set Aside Time for Yourself
This year will be the hardest that you will have ever worked, and you need to schedule free time just as you schedule study-nights for yourself. Whether it is at the gym, watching your favorite television show, or participating in a recreational sports league, maintaining an outlet for yourself is going to make the difference between loving your third year and hating it. Moreover, staying sane will help you focus more clearly when it is time for work or study. Do not forget that residents/attendings are partially evaluating you as someone they may have to work with one day, so maintaining outside interests and hobbies often provides another opportunity for you to make a good impression. Most important, if you find yourself really struggling to handle the stress and emotion that the clerkship year can place on you, do not hesitate to seek help. Countless resources are available to help students in this situation.

The Take Home Message
Third year is going to transform you from a medical student to a soon-to-be clinician faster than you can imagine. Appreciate the year for what it is: a chance to figure out what you want to do with your medical career. Study hard, work hard, and keep in mind that the year will only be as fulfilling as you make it. As the year continues on, keep putting your best effort into each of your clerkships. Good luck, and I am sure that you will enjoy the year!

John Paul Henao
North Central Region Representative, Council of Student Members
Drexel University College of Medicine, 2009
Email: jph32@drexel.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Lori Minasian, MD, FACP

“No one goes into medical school thinking ‘I’m going to work for the federal government,’” says Dr. Lori Minasian, Chief of the Community Oncology and Prevention Trials Research Group Program at the National Cancer Institute (NCI) of the National Institutes of Health (NIH). Yet as improbable as the idea seemed to her at the time and later as a practicing oncologist in Augusta, Georgia, all it would take to change her mind would be an innocent conversation with a friend from Washington, DC. The friend worked for NCI and wanted to know if Dr. Minasian would be interested in a position there that had opened up. “I remember asking him ‘what exactly do you do?’” she recalls. She liked what she heard and decided to give it a go. “I took a leap of faith,” she says; one year later she was running the program.

Sharing the Limelight
NIH is the primary agency of the United States Department of Health and Human Services, responsible for biomedical and health-related research. There are 27 Institutes and Centers within NIH, NCI being one of them. The majority of NIH’s $27.8 billion dollar budget goes to investigators in academic centers for peer-reviewed projects. To put this in perspective, the agency is responsible for approximately 28 percent of the total biomedical research funding spent annually in the U.S. NIH focuses on facilitating the kinds of important medical discoveries that improve people’s health and save lives through the work of their scientists, or “investigators,” who investigate ways to prevent disease as well as the causes, treatments and cures for common and rare diseases. NCI funds basic and clinical research in cancer, and sponsors a national network of academic and community physicians to participate in clinical trials. Dr. Minasian manages and oversees the Community Clinical Oncology Program, a community-based trials network that is nested into NCI’s overall clinical trials program. ”

NIH is a high profile organization, yet much of the work takes place behind the scenes. Managing research, unlike patient care, as Dr. Minasian explains, can be hard to define. “It’s difficult to show what you’ve done because all of the real work is executed by the funded investigators,” she says. “You have to be able to step back and let someone else take the limelight.” The real star of the show is the community physician, who Dr. Minasian says is the focus of the program’s efforts. The relationship is mutually beneficial—NIH can evaluate treatment regimens and prevention strategies in real settings, and the community physicians who participate gain access to state of the art cancer care through clinical trials. “I really feel like what we do is a wonderful approach to translating science into medical care on the level of the community physician,” she says. “I like to think that we create fluidity between academia and community.”

Dr. Minasian has received a lot of positive feedback about her commitment and passion for her job, which she says was not always a natural fit. She had growing pains during the first two years and cites the time as one of her most taxing. Realizing how much she missed clinical work, despite spending one day a week as a volunteer at NCI’s cancer clinic, she left and returned to the world of academics and clinical care. But instead of confirmation that she was not cut out for government work, returning to the clinical world accomplished exactly the opposite—it made her want to go back. “In an odd way I came to realize the value and importance of what I had been doing,” she says. “It was as if I needed to go back and get my bearings again to realize that my role at NCI could have value in a way that I hadn’t seen before.”

She adds that working for the government entails a desire to work in science for the public interest. “There is a significant need to have people within the government understand science and medicine in order to move the research into a framework that has a public health benefit.”

Early Aspirations
As a girl growing up in southern California, Dr. Minasian read a lot of books, one of her favorites of which was “Florence Nightingale.” She liked the combination of the romantic story and the theme of helping people, so much so that it shaped her choice to pursue medicine for a career. “After I finished the book I told my father that I wanted to be a nurse. He said that if I wanted to do medicine, I should become a doctor, instead. ”

In medical school, she considered both internal medicine and surgery, but by her third year she realized she felt most comfortable with internal medicine. Her choice was more intuitive than anything else. “It comes down to where you feel most comfortable,” she explains, “and by that I mean, where is it that your thinking most closely matches those around you? I think different groups have different mindsets. If you like to problem solve, internal medicine is perfect for you.”

Her decision to pursue oncology was deeply personal. When Dr. Minasian was a second year medical student, her father died of cancer. In the 1980s colorectal cancer screening had yet to exist, so when her father was diagnosed, the family was told he had less than three weeks to live. “It was a roller coaster ride,” she remembers, “everyone dealt with it differently. I know for me personally, it really changed how I approached my last year of medical school. I had a different appreciation for what families go through.”

The experience touched her professionally as well. During her residency, she realized that her own personal experience with cancer had left her with a keen sensitivity for patient-family dynamics, and she found herself helping the family members as well as patients cope with having cancer. To her surprise, she discovered she was not alone. “If you take a close look you’ll find that many oncologists have had some kind of personal experience with cancer,” she says. “Many of my oncology fellowship group had personal experience with cancer. It became clear to me that I was not unique.”

A Perfect Marriage

When it comes to job satisfaction, Dr. Minasian does not suffer. “I get to work with some of the best people in the country—wonderfully committed physicians in both academia and the community,” she says. “It’s a combination of bright, interesting people.” Her happiness on a professional level is mirrored in her personal life. When she’s not working, she and her husband enjoy spending time outdoors with their son and daughter. They frequent state parks and often travel together, which she refers to as some of the best times she has ever had.

Lori Minasian, MD, FACP

Lori Minasian, MD, FACP

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Internal Medicine Interest Group of the Month: University of Texas Medical Branch at Galveston

The Alliance in Internal Medicine (AIM) at the University of Texas Medical Branch (UTMB) in Galveston, Texas has been excited to be involved in promoting internal medicine to our students over the past year. Since its inception, AIM has been devoted to helping students realize the breadth and potential of a career in internal medicine. Several of the more popular faculty from the internal medicine department have been engaged in helping us achieve this mission. In the past, this has been done through clinical skills practice sessions, show-and-tell meetings in the form of division showcases, and lectures that expand on classroom topics for first and second year students.

In 2007-2008 we focused on specialty specific discussions. Faculty members from cardiology, gastroenterology, nephrology and primary care presented interactive discussions that focused on their careers, steps to success in their specialties, and advances in technology associated with what they do. These provided a non-curricular look at the actual life of the practice of medicine during the appropriately matched organ system courses in the second year medical student curriculum. For example, the nephrology seminar discussed relevant career details for aspiring nephrologists and included a review of some of the complex acid-base problems a week before the renal course exam.

AIM has also been involved with the Texas Academy of Internal Medicine during the past year. The TAIM meeting was held in Galveston, and UTMB students helped host visiting students and faculty members at the conference. Our students also participated in local and state case presentation competitions. In fact, one of our senior students won the state award for her presentation of a case seen on the wards at the John Sealy Hospital. We also worked with TAIM to encourage our students to participate in the Texas General Internal Medicine Preceptorship Program that pays students a stipend to work in the clinic of a general internal medicine physician for the summer. We also sponsored our own preceptorship program that helped students get credit for spending summer elective time with mentors in subspecialties around the country.

AIM has been heavily involved in a number of community service events. In previous years, we have sponsored a booth at the Galveston County Health Fair to help educate community members about the risks of smoking and the benefits of diet and exercise. This year, we encouraged members to be involved in our local student run clinic, St. Vincent’s House, to provide access to health care for community members who would otherwise be unable to afford it. We also got involved with a student proposal to review our university’s policy on access to cancer care. Our students were warmly welcomed by the administration as part of a group that held brainstorming and discussion sessions about the importance of maintaining our mission to be “here for the health of Texas.” Our president was one of two students present at the meeting where the group’s proposal was presented to the oversight committee. Through this activity, AIM was excited to be a part of encouraging students to increase their focus on patient advocacy.

In sum, UTMB AIM is involved in working to help medical students at all levels understand and appreciate internal medicine. We provide interactions with energetic faculty, opportunities to practice the art of internal medicine, and encouragement to get involved in the broader social context of caring for patients.

Patrick Aguilar
President, Texas Academy of Internal Medicine
University of Texas Medical Branch at Galveston, Class of 2010
E-mail: praguila@utmb.edu

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Winning Abstracts from the 2008 Medical Student Abstract Competition: Hemodynamic Differences in the Infra-renal Aorta in Mice and Men: Implications for the Localization of Abdominal Aortic Aneurysms.

Author: Smbat Amirbekian, Emory University School of Medicine

Introduction
In humans, abdominal aortic aneurysms (AAA) develop inferior to the renal arteries. The aorta superior to the renal artery is remarkably spared. Conversely, mouse models exhibit AAA formation exclusively in the supra-renal aorta. Oscillatory wall shear stress (WSS) has been shown be important in the localization of atherosclerosis and AAA pathogenesis. Humans have a triphasic flow pattern in the infra-renal aorta that results in oscillatory WSS. The purpose of the current work was to investigate the hemodynamic environment of the supra& infra-renal abdominal aorta of normal mice using in-vivo MRI. We hypothesized that there is no reversal of blood flow in the infra-renal aorta of mice due to the lack of AAA formation in this segment.

Methods
In-vivo imaging was performed using a 4.7 Tesla Varian INOVA MRI. ECG-gating was used to acquire ten frames over the cardiac cycle. Using a phase contrast magnetic resonance imaging (PCMR) sequence, we obtained cine images, which allow measurement of both blood flow velocity and assessment of aortic wall motion. Ten images per cardiac cycle were obtained in a plane perpendicular to the aorta at the supra-renal and infra renal levels of 18 normal C57BL/6J mice. Flow vs. time curves were created at both locations.

Results
Supra-renal and infra-renal velocity measurements were successfully obtained in 18 of 20 mice. Time averaged infra-renal blood flow was 7.4±4.4ml/min. Through the entire cardiac cycle, flow was in the forward direction and there was no evidence of flow reversal at any time point. This difference in flow pattern between mice and humans may suggest differences in renal vasculature resistance and/or lower limb vessel capacitance. Supra-renal flow in mice, measured similarly as described above was 15.2±7.9ml/min and no reversal of flow was detected.

Conclusion
The absence of blood flow reversal in the mouse infra-renal aorta is a major difference in flow patterns between humans and mice. This difference in hemodynamic patterns between these two species may have important consequences for the etiology of AAA development. Performing similar hemodynamic studies in mouse AAA models may elucidate the effects of flow reversal on AAA formation. In conclusion, the mouse has become a commonly studied animal model for many cardiovascular diseases such as atherosclerosis and aneurysm development. However, there are differences that exist between many of these human diseases and their murine counterparts. Investigating these differences is a crucial part of determining the initiating factors in the pathogenesis of these diseases.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Combined Internal Medicine and Pediatrics

The Discipline
Combined Internal Medicine and Pediatrics (Med-Peds) is the dual training in and dual practice of Internal Medicine and Pediatrics. Physicians practicing Med-Peds see both adults and children in a wide variety of practice settings and practice styles. Practice settings range from outpatient primary care to inpatient hospitalist practice, and practice styles range from urgent acute illness care to the longitudinal chronic illness care of patients with congenital heart disease.

Recognizing the need for physicians with in-depth skills in the provision of care to adults and children, the American Board of Internal Medicine and the American Board of Pediatrics approved combined training leading to dual board eligibility in 1967. Since then, combined internal medicine-pediatrics residency programs have flourished, especially since the mid-1980s. Med-Peds attracts bright, capable physicians desiring a challenging career path either in primary care or further subspecialty fellowship training.

With their in-depth knowledge of internal medicine and pediatrics, Med-Peds physicians can synthesize their clinical knowledge onto a life’s spectrum from birth until death. They encounter a wide variety of patients and clinical scenarios: well baby visits, high risk deliveries, newborn assessments, common childhood illnesses, adolescents, emergency room visits, basic gynecology care, inpatient adult and pediatric patients, outpatient adult and pediatric patients, adult and pediatric intensive care.

Procedures
Important procedural skills include those necessary for both an internist and a pediatrician. Med-Peds physicians report competence in the wide range of procedures commonly performed in outpatient and inpatient settings.

Training
Med-Peds trainees and physicians receive the same in-depth training as their categorical pediatric and internal medicine colleagues. Recognizing a shared knowledge base, a Med-Peds residency is streamlined into 4 years of residency training. Residents change between their internal medicine and pediatric rotations every 3-4 months, depending on the residency program. By the end of 4 years, residents will have completed core requirements for both categorical internal medicine and categorical pediatrics, including some elective time.

Certification
At the completion of residency training, Med-Peds graduates are board eligible for certification by the American Board of Pediatrics, APB, and by the American Board of Internal Medicine, ABIM.

Fellowship
Med-Peds residents may choose to enter a subspecialty fellowship in either or both internal medicine and pediatrics. Having dual board eligibility may prove more competitive to fellowship directors. Many residents choose a fellowship where their expertise in both specialties will be beneficial. Med-Peds trained physicians have pursued nearly every type of fellowship training; cardiology, endocrinology, and infectious disease are among the most popular fellowships. Combined internal medicine and pediatrics subspecialty fellowships can be streamlined via special arrangements with the fellowship directors and the boards.

Practice
Med-Peds physicians practice in the wide variety of settings and styles available to internists and pediatricians. Primary care, inpatient care, subspecialty practice, and urgent care are among the most popular practice styles. Practice settings range from solo practice to large multi-specialty groups to academic medical centers. Some Med-Peds physicians pursue international health careers in the U.S. or other countries.

Major Professional Societies

Official Resident Website

Student Involvement
If you are interested in writing for the quarterly student Med-Peds newsletter or if you have any questions, please contact either Gitanjali Srivastava, MD at gitanjali.srivastava@mssm.edu or David Kaelber, MD at david.kaelber@case.edu, who head the National Student/Resident/Young Physician Med-Peds Subcommittee. They are actively recruiting interested medical students.

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Advocacy Brief: Ask Your Members of Congress to Prevent the Elimination of the 20/220 Economic Hardship Student Debt Deferment

The Higher Education Act (HEA) has been extended yet again until July 31. There is still time to contact your members of Congress to include 20/220 as part of HEA Reauthorization.

The 20/220 pathway allows medical residents to qualify for economic hardship deferment and postpone repayment of their student loans (without penalty). A resident has been able to qualify for economic hardship deferment through the 20/220 pathway if he or she was employed full-time and his or her federal education debt burden was equal to or greater than 20 percent of his or her monthly income, and his or her income minus the education debt burden was less than 220 percent of the greater of the minimum wage rate or the federal poverty line (FPL) for a family of two.

Currently, the House and Senate education committees are working to reconcile (in “conference committee”) the Senate’s "Higher Education Amendments of 2007" (S. 1642) and the House’s "College Opportunity and Affordability Act" (H.R. 4137). They are expected to produce a final bill before the end of July. Right now, they have the opportunity to include in the final House-Senate conference HEA reauthorization agreement, provisions to reinstate the 20/220 pathway.

Send an email to your members of Congress using this link: Congress.

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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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