July 2009 E-Newsletter

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Medical Student Perspectives: Disarming Gunners

During medical school at the University of Vermont College of Medicine, encountering “gunners” was so infrequent that for the most part, the term, “gunner” was used by my classmates almost affectionately for a friend who studies too hard for the boards or crams a lot for a rotation. However, a couple of students, during third year, were rumored to be the real gunners. Gunners are medical students, or students in any professional school (e.g., law, veterinary, business, etc.), who will mow down anyone they perceive to be a threat. They are motivated to get a good evaluation, a good grade and thus a secure lucrative future in their competitive field of choice.

I had an irritating experience with a gunner. I was in a seminar about management of chronic kidney disease and acute kidney injury, given by one of our favorite renal attendings. I was unclear about how to handle volume resuscitation in a septic patient with kidney disease. So I asked the attending my question. However, instead of hearing his explanation, I was appalled by my classmate haughtily explaining what he would do in such a situation. He looked at me like I wasn’t supposed to ask a question. I patiently waited for the attending’s response. I was furious that this guy made me look stupid in front of a group of students and residents. After the attending left the room, I turned to him and let him know I would not permit him to embarrass me publicly ever again, and he apologized.

Being direct and assertive worked in this case. I think it worked because he didn’t even realize he was being a gunner. I think he was keyed into the lecture and was trying to get approval by showing off at my expense. He was desperately trying to get into a special subset of one of the most competitive fields of medicine and he was stressed out, insecure, and having trouble managing his anxiety about an uncertain future. After match day, when he was successfully placed in a program of his choosing, he reverted back to the chap I knew as a first year, amusing, and fun to be around.

Why do nice, sociable, fun folks become gunners? Neil Hyman, M.D., a sage, savvy Professor of Surgery at UVM COM, compared med students’ process of learning to navigate the wards to small children trying to master new tasks. “It’s like the way my kids are…one of them sits by the pool and slowly gets in and the other jumps in and splashes around to get my attention. On the wards, some of you will be splashers and some of you will get in at your own pace. Don’t hate the splashers. That’s just who they are. And frankly, most residents and attendings can see right through it.” I have always tried to keep this in mind: some of us need lots of approval and reassurance when we try new things because we’re nervous. Unfortunately, insecurity may cause gunners to seek approval at other students’ expense.

Outwardly, such students may look like better clerks because they recite every detail from their Step 1 Boards preparation, whether asked a related question or not. However, these students lose sight of the goals of the team and the importance of teamwork according to Joseph Wright, MD, a Beth Israel Deaconess internal medicine resident and writer, who gave an insightful NPR commentary on “gunners” when he was a med student.

Fourth year medical students generally do a couple of sub-internships (aka, acting internship at UVM COM). In these rotations, fourth year med students work with their resident and work on the team as though they are a first-year resident. I did mine in medicine and one time, I saw a more overt type of gunner behavior. A competitive third-year student on my team made her colleague’s time on the rotation rough, by putting him on the spot when he couldn’t answer questions. When he was asked a question by the attending on rounds, she would interrupt his thinking to interject answers. This student’s confidence was shaken during these episodes and it was difficult to watch. I can only imagine how difficult learning was under those circumstances. During this time, I told myself that when I was an intern, charged with teaching and mentoring third year medical students, I would try to help change such uncomfortable, unproductive team dynamics.

One of my mentors, Lewis First, MD, Professor and Chair of our Department of Pediatrics and for the past six years, also our Senior Associate Dean of Medical Education who is stepping down this year to become editor-in-chief of the journal Pediatrics, believes that competitive behaviors among med students can and should be changed. It is important “to refocus them [such students] on their patients rather than their peers and teachers, and have them advocate on behalf of those patients collaboratively as team players rather than focus their priorities on their personal grades or scores in an exam or rotation.”

Although refocusing gunner-type behavior is ideal, what do you do when residents and attendings overlook or actually praise the student who makes learning difficult for others? In those cases, I would ask the clerkship director or another advisor who is neutral for help. I would not focus not on the gunner’s behavior, but rather, the effect it has on your learning. Ideally, the clerkship director can discuss the situation and help mediate in the situation to help colleagues construct a better working relationship.

Ultimately, we all have career goals. The methodology to securing honors can be elusive, but in the end, learning to become the best physician you can be is most important. In trying to impress and “beat the system,” gunners often lose sight of the true goal of training, and ultimately, risk cheating themselves, their teams, and their patients. I hope you never encounter gunners on the wards. But if you do, remember to be assertive, practice empathy, and focus your priorities on taking care of your patients as a member of the care team so the gunner will do the same. And if things are still tough, ask for help.

Emily Glick, MD
PGY-1, Fletcher Allen Healthcare
Former New England Representative, ACP Council of Student Members

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My Kind of Medicine: Real Lives of Practicing Internists: Prerna Mona Khanna, MD, MPH, FACP

Prerna Mona Khanna, MD, MPH, FACP

In the medium speed lane of the swimming pool at Glass Court Swimming Club, Mona Khanna steels herself for the day ahead. With each lap of freestyle, she ponders the near future. The ritual—which she has been doing religiously three times every week for half of her life—has helped her maintain a steady level of mental and physical fitness that has proven invaluable in countless situations, from the ashy Ground Zero after 9/11, to a steamy and stricken post-tsunami[PDF] village in Banda Aceh, Indonesia, in front of the CBS television camera in sunny Palm Springs, California, to the overwhelmed New Orleans airport teeming with tens of thousands of evacuees following Hurricane Katrina, to name a few. As some would say, swimming is an ambitious lifelong exercise, but that is exactly why she chose it. If there’s one thing that can be counted on with Dr. Khanna, or as she’s known in the media world, “Dr. Mona,” it’s that she’s always up for a challenge.

Family Values
After immigrating to Chicago from India in the 1960s, Dr. Khanna’s parents impressed upon their children the importance of education and what it can bring to a life. “Medicine was seen as an über profession,” she says, “doctors had prestige. As a doctor you could secure yourself financially and otherwise and you were revered. That’s what my parents wanted for us, and education was the means by which we could attain it.”

Dr. Khanna and her siblings heeded their parents’ advice—today three out of four are physicians, and Dr. Khanna at just 44, has already collected a lifetime’s worth of achievements, well beyond her years. Her professional bio dazzles—among other highlights, she is triple board-certified, an Emmy award winner, a recipient of commendations from local, state and federal branches of government, and a founding member of the Department of Homeland Security. She says being an internist made it happen. “When you go into internal medicine, it opens the door to everything,” she says. “Students need to know that the opportunities are out there for internists. I get offers all the time. The sky is the limit based on your willingness to work.”

But even after all the awards, accolades and high profile jobs, Dr. Khanna remains focused on the grounding center of her life: empowering patients through health education. For her, it is a universal necessity and as such, her life’s work. She has built a career around it—for example, when she felt that her job as a medical director for the Riverside County Health Department in Riverside, CA was no longer providing enough value on an educational level, she left to pursue a medical reporting job with CBS in Palm Springs, CA. The position combined the early media training that she learned with a bachelor’s in journalism from the Medill School of Journalism at Northwestern University with health education on a broad, public level. It was a perfect fit and she has more or less stayed in the same vein since. Today, she works as a medical editor for an online health network, www.icyou.com, as “Dr. Mona.” She oversees medical content and coverage for the web site, and answers viewer questions via video clip. She writes the scripts herself and travels to Charleston, SC, every month to shoot the videos. Last month she shot 42 videos in 3 days, including answers to “Ask Dr. Mona.” In the clips, Dr. Khanna exudes polish and reassurance all at once as she answers questions about earaches, shingles, heat rash, and vaccinations in a crisp white lab coat. She gestures frequently and raises and lowers her voice expertly at the appropriate times to engage the listener. She’s been in the job for two years and loves it. “This job allows me to do what I love in terms of education and it gives me flexibility,” she says, “and because being an internist gives you incredible credibility, people trust me. I think it is the most respected field in the profession.”

The Born Traveler
Dr. Khanna’s career and interests have taken her around the world, and over time she has found that traveling has become more of a requirement than an indulgence. Following medical school at the University of Illinois, she completed residencies in Internal Medicine and Occupational Medicine in San Francisco at St. Mary’s Medical Center and UCSF, and Public Health and Preventive Medicine at Johns Hopkins University in Baltimore. She has studied terrorism medicine in Jerusalem, Israel, emergency response in L’viv, Ukraine, infectious disease in Hong Kong and Vietnam, and traditional chinese medicine in Japan. She has trained at the Clinica del Lavoro in Milan, Italy, and completed a Rotary scholarship in Switzerland.

Over the years, Dr. Khanna has volunteered with national and international humanitarian agencies, as well as the Texas State Guard and the National Disaster Medical System (NDMS), providing and promoting voluntary emergency medical services. She has staffed medical clinics at Ground Zero, the Fort Worth Alliance Air Show, the crash of Alaska Airlines Flight 261, Kosovo refugee headquarters, and Hurricanes Katrina, Rita, Dolly and Edouard.

When it comes time for vacation, she also travels. This summer, she traveled to Spain in early July for the running of the bulls and then shortly afterwards to Paris. Last year she went to the Olympics in Beijing, Germany, and India. “Traveling is a huge love of mine,” she says, “and my job lets me do it. Internal medicine has allowed me to do what I want to do. It has shaped my life.”

In the Field
The chaos began immediately after Dr. Khanna and a fellow physician were barely three steps off the bus. It was 2:30AM on August 31, 2005. Dr. Khanna and a team of 40 (only four of whom were physicians) from the NDMS were the first medical team to arrive at the New Orleans airport. A police officer drove over to them and said, “Where do you want me to put her?” He pointed to a young woman in labor in the back seat of his cruiser. The woman was ready to deliver and said that she had given birth before, which was relief to Dr. Khanna, but it didn’t last long. All of the births had been c-sections, the woman said, because she was incapable of dilating. Dr. Khanna instantly knew that she would need to get the woman flown out to the nearest hospital immediately. The incident was the beginning of an intense week. Dr. Khanna worked triple duty for two weeks with her team. During that time, showers and cots were not available for the first week; Dr. Khanna slept on a conveyer belt. The temperature hovered somewhere around 100 degrees with 80 percent humidity, and roughly 10,000 people came to the airport every day. Additional medical teams were sent for support, but the work was overwhelming and the workforce was inadequate. Conditions were stupefying. “We kept asking each other ‘What is going on? Where are the back-up supplies? The water? The food?’” she recalls. “It was horrendous but fascinating at the same time.” Although her primary purpose while there was to provide medical care, since she was also employed by CBS Television at the time, Dr. Khanna began phoning in reports from the airport every day. The station sent a cameraman and reporter out and Dr. Khanna worked as an impromptu field producer. She was proud of what they did. “We had video footage no one else had,” she says, “not even the cable networks. I was able to give our crew the best information and help show them where to go, since I had an insider’s perspective of what was going on.” When asked if she was ever scared during the week, she replies without hesitation. “Not at all. There is safety in numbers.”

Homeward Bound
Back at the Glass Court Swimming Club, Dr. Khanna flips another lap. With each stroke, her inner compass repositions itself to prepare her for what awaits her when she steps out of the pool—a health education video that might need shooting, a disaster medical clinic that needs staffing, a public speaking engagement, a television interview. Whatever it is, she will be anchored by the values she learned from her parents. “I’ve taken care of people all over the world,” she says, “and I still believe the most important part of any visit to the doctor is health education.” Soon, the jet-setting Dr. Khanna will be off to her next destination, but before she goes, she will likely stop in to visit with her extended family. They live in the vicinity, just minutes away from Dr. Khanna’s own house outside of Chicago, where it all began.

Check out previous articles as physicians share what motivated them to become physicians as well as why they chose their particular type of practice.

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Internal Medicine Interest Group of the Month: University of South Dakota

University of South Dakota

SD ACP Student Interest Group - Sioux Falls, 2009


The South Dakota ACP Internal Medicine Interest Group (IMIG) has had a huge resurgence in activity over the last two years. Our organization’s membership went from just a few student members in 2008 to 90 members this year, 45% of the medical students at Sanford School of Medicine (SSOM) at the University of South Dakota.

In 2008 we sent one of the largest delegations of students and physicians to ACP Leadership Day in Washington, DC. Building on that momentum, we have been a fiery bunch lately trying to develop our organization beyond our regular offerings of one-hour weekday lunch meetings and a few 2-3 hour weekend luncheons.

The IMIG is now actively involved in several community service projects in the state. In 2009 we started the 2M Project, which stands for Muscles for Movement. The goal of this program is to improve the amount of exercise that patients participate in during their daily lives. Our hope is that this project will decrease the number of patients suffering from diabetes and aid in the treatment of those already diagnosed with diabetes. Some research has shown that exercise alone can aid in prevention and treatment of obesity-related diseases. We will be implementing several arms of this project as we increase our funding and membership over the next several years. We have several target populations in mind:

1) Grade-school and middle-school aged children who are still malleable and willing to learn and are not as set in their ways. We are in the process of setting up in-school talks and programs with the local Boys and Girls Clubs in two communities.

2) American Indians on South Dakota reservations. This population is at a greater risk of many diseases in our state. We will work with the tribal leaders to provide education to their members on the benefits of exercise and nutrition.

3) The adult clinic patient population. We will be asking ACP physicians across the state to talk with their adult patients about the benefits of exercise and ask them to sign a contract whereby they agree to exercise for their health.

We have devised a presentation aimed at the younger populations and are also developing an exercise journal that program participants can use to detail pertinent educational facts on nutrition and exercise. We plan to monitor the success of our program via BMI measurements taken before the program and regularly afterwards. Results at the end of three years will be published.

The 2M Project is currently our largest project and we hope to be able to expand it to other states in the future. We are happy to see the rekindling of ACP spirit at SSOM and will continue to grow with increased membership and projects. We would like to thank the leadership of the South Dakota ACP Chapter for making the IMIG an integral part of the Chapter.

Joshua Hughes
President, South Dakota ACP Internal Medicine Interest Group
Sanford School of Medicine (SSOM) at the University of South Dakota, 2013
Email: jehughes@usd.edu

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Winning Abstracts from the 2009 Medical Student Abstract Competition: Combined Targeting of Histone Deacetylases and Hedgehog Signaling Cooperatively Induces Cell Death and Suppresses Proliferation In Pancreatic Cancer

Authors: First Author: Stephen G. Chun, University of Hawaii, Second Author: Weiqiang Zhou, Third Author: Nelson S. Yee

Introduction
Pancreatic adenocarcinoma is almost uniformly fatal and the combination of agents that target distinct cellular signaling mechanisms may improve the efficacy of therapy. Histone deacetylases (HDACs) control cellular functions through epigenetic modulation, and inhibitors of HDACs suppress cell growth in pancreatic adenocarcinoma. The hedgehog (HH) pathway regulates the development of the pancreas, and aberrantly activated HH signaling promotes the initiation and progression of pancreatic neoplasia. Based upon these lines of evidence, we hypothesize that HDACs and the HH pathway cooperatively interact to regulate cellular proliferation of the exocrine pancreas.

Methods
A combination of an HDACs inhibitor (HDACi) and HH pathway inhibitor (HHi) was evaluated for their ability to suppress the growth of the gemcitabine-resistant pancreatic adenocarcinoma cell lines as well as their underlying molecular mechanisms.

Results
Using soft agar colony assay, we showed that the combination of HDACi and HHi supra-additively suppressed cellular proliferation. Flow cytometric analyses indicated a cooperative induction of cell death and accumulation of cells in G0/G1 phases of the cell cycle. Immunohistochemistry revealed ductal epithelial differentiation and altered localization of survivin. Examination of the molecular mechanisms by immunoblotting and real-time polymerase chain reaction demonstrated repression of HH signaling, stimulation of bax expression, up-regulation of the cyclin-dependent kinase inhibitors p21 and p27, and down-regulation of cyclin D1. There was a supra-additive induction of caspases 3 and 7, although the pan-caspase inhibitor z-VAD-FMK failed to abolish the anti-proliferative effects of HDACi and HHi, suggesting that caspase-independent mechanisms are involved.

Conclusion
This translational study elucidates a novel interaction between HDACs and HH pathway that cooperatively regulates pancreatic cancer proliferation and may be required for pancreatic cancer stem cell homeostasis. Based upon this interaction, we have developed a molecular target-based strategy that overcomes chemo-resistance in pancreatic cancer cells by chemically inhibiting HH signaling and HDACs. Ongoing translational in vivo studies will evaluate the therapeutic potential of combining HDACs and HH inhibitors for pancreatic adenocarcinoma.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Pulmonary Disease

The Discipline
From the word, pulmo, Latin for "lung."

Pulmonary medicine is the diagnosis and management of disorders of the lungs, upper airways, thoracic cavity, and chest wall. The pulmonary specialist has expertise in neoplastic, inflammatory, and infectious disorders of the lung parenchyma, pleura and airways; pulmonary vascular disease and its effect on the cardiovascular system; and detection and prevention of occupational and environmental causes of lung disease. Other specialized areas include respiratory failure and sleep-disordered breathing.

Procedures
Important procedural skills include arterial blood gas sampling and interpretation, flexible bronchoscopy and related bronchoscopic procedures, endotracheal intubation, spirometry and peak flow assessment, pulmonary artery catheterization and interpretation, thoracentesis, pleural biopsy, placement and management of chest tubes, ventilator management, progressive exercise testing, and complete pulmonary function testing.

Training
Pulmonary Disease fellowship training can be obtained either through a combined Pulmonary and Critical Care fellowship (the most common path) or through a Pulmonary fellowship alone. Combined programs require three years of accredited training beyond internal medicine residency. The three years must include a minimum of 18 months of clinical training (at least nine months of Pulmonary training and nine months of Critical Care training). Pulmonary Disease fellowship training without Critical Care requires two years of accredited training beyond internal medicine residency. Of the two years, a minimum of 12 months must include clinical training in the diagnosis and management of a broad spectrum of pulmonary diseases.

Certification
The American Board of Internal Medicine ABIM offers separate certificates in Pulmonary Disease and in Critical Care.

Training Positions
As of July 2007, there were 130 ACGME-accredited combined training programs with 1,237 active positions in Pulmonary Disease and Critical Care Medicine, and there were 25 ACGME-accredited training programs with 83 active positions in Pulmonary Disease alone. For combined training programs in Pulmonary Disease and Critical Care Medicine, 27% of the trainees were female, and 56% were US medical graduates. For training programs in Pulmonary Disease alone, 22% of the trainees were female, and 19% were US medical graduates.

Practice
Approximately 48% of the graduates of combined programs enter clinical practice in the United States, and 36% enter academic medicine.

Major Professional Societies

  • American College of Chest Physicians

    3300 Dundee Road
    Northbrook IL 60062-2348
    (847) 498-1400
    www.chestnet.org

  • American Thoracic

    61 Broadway
    New York, NY 10006-2755
    (212) 315-8600
    www.thoracic.org

Major Publications

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Advocacy Brief: Health Care Will Fundamentally Change. Act Now. Act Often.

ACP is stepping up efforts right now to ensure that much-needed improvements for internal medicine are included in comprehensive health care reform legislation. We need your help more than ever to ensure that ACP's top priorities are addressed in the legislation: health coverage for all, and access to an internist or other primary care physician.

Key congressional committees are pursuing a very aggressive timetable. They are working to get legislation through their committees in July, with a target of August 1 for a vote on a final bill. The decisions they make could determine the future of patient care in the United States, and especially, if internal medicine itself has a viable future.

Now is our best chance to ensure that the legislation includes policies to ensure that your future patients will have access to coverage and to care by an internist or other primary care physician.

Please contact Congress now to ask that they ensure that these four provisions are included in the health care reform legislation being drafted right now by Congress:

1. Ensure that all Americans will have access to affordable coverage.
2. Improve Medicare fee for service system payments to make primary care competitive with other specialties.
3. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care.
4. Create a national policy to ensure sufficient numbers of physicians, including general internists and other specialists facing critical shortages.

Get ACP's Priorities Included in Health Care Reform Legislation.

ACP's continued success on Capitol Hill greatly depends upon year-round grassroots support from the College's over 5,000 Key Contacts. Key Contacts communicate with their members of Congress on issues of importance to medical students, internists and their patients, and report the results back to ACP. Sign up to become a Key Contact now. To enroll as a Key Contact, ACP members are not required to have existing relationships with their members of Congress. ACP gives them the tools necessary to develop and maintain relationships. The program is open to all membership categories.

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ACP's Clerkship Bundle

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

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

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. For information about the current advocacy and policy development efforts of the College please click here.

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MKSAP for Students 4 Question 1

A 72-year-old man is evaluated in the office for bilateral leg pain and cramping after walking briskly up an incline. The pain is in the distal thigh and calf and is worse on the right side. He has no pain when walking downhill. The patient has a 100-pack-year smoking history, type 2 diabetes mellitus, hypertension, and heart failure. His medications are captopril, furosemide, atenolol, atorvastatin, metformin, and aspirin.

On physical examination, the blood pressure is 146/68 mm Hg and heart rate 82/min and regular. The lungs are clear. Cardiac examination reveals an S4. There is a right femoral artery bruit with absent pulses and mild dependent rubor. Ankle-brachial index is 0.8.

Which of the following is the most likely cause of this patient's symptoms?

A. Arterial ischemia
B. Osteoarthritis
C. Peripheral neuropathy
D. Right popliteal venous thrombosis
E. Spinal stenosis

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MKSAP for Students 4 Question 2

A 68-year-old woman is scheduled to undergo arteriography of the lower extremities for progressive claudication. She has type 2 diabetes mellitus (hemoglobin A1c 6.4%) that is well controlled with pioglitazone and metformin. On the day of the procedure, she is to receive nothing by mouth all morning except for medications until after the procedure.

Which of the following decisions regarding her medications is most appropriate on the day of the procedure?

A. Continue both medications
B. Withhold both medications
C. Withhold metformin
D. Withhold pioglitazone

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MKSAP for Students 4 Answer 1

Answer: A: Arterial ischemia

The patient's history of exercise-induced leg pain, its relief with rest or walking downhill, vascular bruit and absent pulses on physical examination, dependent rubor, and several major risk factors for atherosclerotic artery disease all point to arterial ischemia as the cause of his symptoms. Determination of the ankle-brachial index (ABI) is a common initial test in the evaluation for peripheral vascular disease. With a Doppler probe, the ABI is measured as the ratio of the highest right/left dorsalis pedis/posterior tibial artery systolic pressure divided by the highest right/left brachial artery systolic pressure. A normal ABI is 1.0 to 1.3. Most patients with peripheral vascular disease have an ABI < 0.9, and those with severe disease (rest ischemia) have an ABI of < 0.4. An ABI >1.3 suggests a calcified, noncompressible vessel, most commonly seen in patients with long-standing diabetes mellitus and hypertension.

Peripheral neuropathy would be unlikely to present as pain with exercise. Spinal stenosis commonly presents as pain with standing and after walking a variable distance, most prominently with spinal extension, and is usually relieved by flexing forward, sitting, or lying down. Like spinal stenosis, osteoarthritis may cause pain on walking but is usually independent of grade; neither condition can account for the patient's other findings including bruit, diminished pulses, dependent rubor, and abnormal ABI. Popliteal venous thrombosis may present with localized pain and erythema, but the pain would not be exertional and cannot account for bilateral pain or the physical examination findings.

Bibliography
1. Khan NA, Rahim SA, Anand SS, Simel DL, Panju A. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA. 2006;295:536-46. [PMID: 16449619] [PubMed]

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MKSAP for Students 4 Answer 2

Answer: C: Withhold metformin

Metformin accumulates in patients with renal insufficiency, which may lead to lactic acidosis. Therefore, because of the potential nephrotoxicity of radiocontrast agents, the current prescribing guidelines for metformin include strict precautions when radiographic procedures employing an intravenous contrast agent are performed. These procedures include pyelography, arteriography, venography, and CT studies. The recommendation is that metformin be stopped on the day of the study and resumed once renal function normalizes 24 to 48 hours after the procedure.

Pioglitazone, a thiazolidinedione, can be continued, as it will not predispose the patient to hypoglycemia during fasting. However, pioglitazone could also be withheld without any untoward effects because of its long duration of action.

Bibliography
1. Setter SM, Iltz JL, Thams J, Campbell RK. Metformin hydrochloride in the treatment of type 2 diabetes mellitus: a clinical review with a focus on dual therapy. Clin Ther. 2003;25:2991-3026. [PMID: 14749143] [PubMed]

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Need Help Finding a Residency?

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 a link directly into the program’s own Web site.

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Articles for Medical Students from ACP Internist and ACP Hospitalist

ACP Internist (formerly ACP Observer)

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

ACP Hospitalist

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

  • Experts debate new glucose goals for the ICU
    The NICE-SUGAR investigators’ finding that intensive control actually increased mortality among their more than 6,000 ICU patients will lead to a dramatic and rapid change in practice for hospitalists.
  • Lunch with Lynch
    Lunch with a former residency director leads to reflections on a career in medicine.
  • Suggest a physician as a Top Hospitalist
    ACP Hospitalist is seeking candidates for its second annual Top Hospitalists issue. Physicians selected as Top Hospitalists will be those who made notable contributions to the field in 2009, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.

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Students: Join ACP for Free

Benefits of Membership for Students: ACP's free Medical Student Membership includes benefits designed especially to meet students' needs.

Join Now: Sign-up today and begin enjoying the benefits of ACP Medical Student Membership.

MKSAP 15 Discount 10% Off

MKSAP 15 Discount 10% Off

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

Holiday Gift offer - 10% off

Holiday Gift offer - 10% off

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

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