ACP American College of Physicians - Internal Medicine - Doctors for Adults

Medical Students

• Career Paths
• Residency
• Find a Mentor
• Student Products
• Competitions & Activities
• Additional Resources
  • Newsletter
    • Archive
    • Reader Submissions
    • Staff
  • IM Interest Groups

June 2006 E-Newsletter

• Focus on Internal Medicine Careers: Cardiology
• Internal Medicine Interest Group of the Month: Yale School of Medicine
• Stafford Loan Interest Rates Will Increase in July
• Single Holder Rule Repealed
• MKSAP Questions (1,2)
• MKSAP Answers (1,2)

Focus on Internal Medicine Careers: Cardiology

Following is an interview with William Hopkins, MD, FACP, Associate Professor of Medicine at University of Vermont College of Medicine and the Director of the Adult Congenital Heart Disease and Pulmonary Hypertension Program at Fletcher Allen Health Care. The interview was conducted by Talia Ben-Jacob, a fourth-year medical student at University of Vermont College of Medicine and the Vice Chair of the ACP Council of Student Members.

IMpact: Why did you decide to go into internal medicine?

Dr. Hopkins: The very first clinical rotation I did as a third year student was internal medicine. I did it first because I had no interest in the field, and I thought it would be a way to improve my skills for the rotations I was more interested in, such as surgery. But then a funny thing happened; I fell in love with internal medicine. I really enjoyed the organ-based approach and the emphasis on pathophysiology. I think many students have little or no understanding of internal medicine until they are exposed to it in their clinical training.

IMpact: Would you please give our readers a brief introduction to your career, fellowship training, and some of the things you have done?

Dr. Hopkins: I grew up in the Chicago area and attended the University of Chicago Medical School. I thoroughly enjoyed my time in medical school at the University of Chicago. Then I did my internship and residency at the Brigham and Women’s Hospital in Boston. I completed residency training in 1988. During residency, I confirmed my love of cardiology. We moved from Boston to St. Louis, where I was a cardiovascular fellow at Washington University’s Barnes Hospital from 1988 to 1992. While I was a fellow, I developed an interest in congenital heart disease and did some of my training at St. Louis Children’s Hospital. At the completion of my fellowship training, I joined the cardiovascular faculty at Washington University. Burton Sobel, MD, MACP, who was Chief of the Cardiovascular Division at that time, gave me the opportunity to start and develop the Adult Congenital Heart Disease Program. I also worked very closely with the lung transplant team at Washington University. It was through the adult congenital and lung transplant programs that I developed an interest in Down Syndrome and pulmonary hypertension. I joined the faculty of the University of Vermont College of Medicine in 1995. Dr. Sobel had become Chairman of the Department of Medicine at University of Vermont the year prior.

IMpact: If you could go back in time would you still choose internal medicine?

Dr. Hopkins: Absolutely.

IMpact: You have a multitude of experience in internal medicine. What led to your decision to become a cardiologist?

Dr. Hopkins: As I mentioned, my first clinical rotation as a third year medical student was internal medicine. Third year students did three separate blocks during the internal medicine rotation at the University of Chicago—one block in general internal medicine and two in subspecialty rotations. The very first block I did was cardiology. I was immediately attracted to the field. I thoroughly enjoyed the pathophysiology, clinical exams and the fast pace of the field. My attending was a phenomenal teacher as were the resident and intern on the team. I pretty much knew then that I wanted to be in the “cardiovascular field”. It was a question of whether I would pursue it through internal medicine, pediatrics, or surgery. Early in my fourth year, I decided on internal medicine.

IMpact: I was in the first class that had you as a basic science teacher. What made you decide to return to the classroom and get more involved with medical education after so many years of being a clinical professor?

Dr. Hopkins: I have always enjoyed teaching. I was frustrated by my lack of involvement with the medical school. Changes in the curriculum provided an opportunity for me to increase my involvement. I have thoroughly enjoyed the experience.

IMpact: What was the biggest challenge that you had to overcome as an internal medicine doctor?

Dr. Hopkins: I think there are many challenges. One important one is death. Some of our patients don’t get better and some die. It is important to know how to work with patients who are dying. I have found that when you deal with death in an honest and compassionate way that you can have an enormous positive impact on a patient’s family.

IMpact: Who is your most memorable patient?

Dr. Hopkins: I have many memorable patients. My most memorable patients are young ones that died because of congenital heart disease or pulmonary hypertension. I not only had a chance to connect with the patient, but also with their families.

IMpact: What advice would you give to third years who want to excel on their internal medicine clerkship?

Dr. Hopkins: (1) Learn to present well on rounds. Do it without reading off cards and do it “crisply”. Everyone notices a good presentation and everyone notices a bad presentation. (2) Know the details about your patient and know them well. (3) Be enthusiastic, show that you’re interested. (4) Improve your understanding of pathophysiology and how it applies to your patients.

IMpact: Do you have any advice for medical students who may be interested in becoming cardiologists?

Dr. Hopkins: Take things one step at a time. To get a good fellowship you need to do well in residency. To get a good residency, you need to do well as a student. Try your best to excel at each step in the process.

IMpact: What is the lifestyle like for a cardiologist?

Dr. Hopkins: It is variable and it often depends on an individual’s own priorities. Cardiologists can coach, teach Sunday school, go to school activities, etc. Alternatively, they can spend all their time at work if that is what they choose to do.

IMpact: Do you recommend that students who are interested in internal medicine fill their elective clerkship time with internal medicine-related rotations or is it preferable to gain experience in other areas of medicine?

Dr. Hopkins: I would do enough time to make sure that internal medicine is truly the field for you and to get letters from supportive faculty. However, it may be the last time you will have to spend time in other fields. I think it would be unfortunate to miss this opportunity. I have never believed that the purpose of medical school, especially the clerkship years, is to prepare students to be good interns. I don’t care if you become a good intern. I care if you become a good doctor.

IMpact: What would you say to medical students who are not choosing internal medicine as a career choice due to decreased salary, difficulty dealing with managed care, and lifestyle issues?

Dr. Hopkins: I never try to talk anyone into internal medicine or cardiology. I think everyone needs to determine their own priorities and make their own decisions. I want all of our students to be the best they can and ultimately to reflect well on the University. Students should remember that the issues mentioned above are potentially applicable to all fields of medicine.

IMpact: Where do you see the field of internal medicine growing, expanding, or changing in the next 20 years?

Dr. Hopkins: This answer could go on forever!! We will have far more genetic-based diagnostics and therapeutics in the future. We will also have therapies that are more directed to individual needs.

IMpact: Where do you see the field of cardiology growing, expanding, or changing in the next 20 years?

Dr. Hopkins: This could also be a very long answer. Cardiovascular disease is far and away the number one killer in the United States and the developed world. I look forward to the day when we have eradicated atherosclerotic-based disease.

IMpact: Is there any advice you would like to share with our medical student readers?

Dr. Hopkins: I hope they end up in a field that they enjoy and feel passionate about. Try to excel and continue to grow. We cannot afford to be mediocre, because we have been given the privilege of being doctors. With this privilege comes great responsibility.

Internal Medicine Interest Group of the Month: Yale School of Medicine

Over the past two years, the Yale School of Medicine (YSM) Internal Medicine Interest Group (IMIG) has reached out to students and faculty through mentoring and shadowing programs, under the capable leadership of Mila Rainoff ’08, Melissa Wollan ’08, Shane Lloyd ‘08, and Lucy Goddard ’07, with the guidance of faculty advisor Barry Wu, MD, FACP. Transitioning into 2006, leadership has passed to members of the class of 2009: Caroline Engel, Janelle Moulder, Neil Vasan, Heather Wachtel, and Qi Zheng.

The Yale IMIG had a strong start this past year with a very well attended meeting discussing career opportunities in internal medicine and accompanied by an ACP student membership drive. Following the October meeting, 33% of the class of 2009 elected to participate in the IMIG mentoring and shadowing program. Students were matched with faculty mentors in internal medicine subspecialties, including cardiology, critical care, general internal medicine, hematology, infectious disease, nephrology, oncology, preventive care, pulmonary, sports medicine, and tropical medicine. Shadowing has continued throughout the year, and follow-up surveys have reported very positive student experiences.

During the coming year, the Yale IMIG is seeking to expand its role by introducing an Internal Medicine Research Open House. YSM is unique in its thesis requirement, an opportunity for students to undertake basic science, clinical, public health, or medical humanities research under the tutelage of a faculty member. The goal of the thesis is to provide a forum through which students can actively, through research, learn the tools of the scientific method; the thesis is a pivotal part of the "Yale System". In order to facilitate this student-faculty partnership, the Yale IMIG plans to implement an Internal Medicine Research Open House. We envision coordinating a day during which medical and clinical faculty would have office hours and would be available to discuss their research with interested students. Currently, students independently seek out advisors throughout the year. We hope that providing a forum for students and faculty to converge will increase the amount of collaboration between students and faculty, help to facilitate more personalized mentoring relationships, and increase the awareness and participation of medical students in internal medicine-related research.

Additionally this coming year, we plan to run a dinner symposium series where internal medicine faculty and interested medical students can discuss current topics within a particular specialty or have a glimpse at “a day in the life” of a doctor or group of doctors in the department. This approach has been quite successful when used in other venues at YSM, and Yale IMIG hopes the dinner symposium series will strengthen the interactions between students and faculty by facilitating relationships earlier on in the medical curriculum. Through our work in developing more integrative programs and forums, we hope to accomplish what internal medicine has always emphasized: meeting many different needs in a variety of ways.

Janelle Moulder, Neil Vasan and Heather Wachtel
Yale School of Medicine, Class of 2009

Stafford Loan Interest Rates Will Increase in July

Interest rates for Stafford loans will increase by nearly 40 percent on July 1. For loans that have not yet been consolidated, the variable interest rate will increase from 4.7 percent to 6.54 percent while enrolled in school, and from 5.3 percent to 7.14 percent during repayment. After July 1, new loans will have a fixed interest rate of 6.8 percent. You must consolidate your loans by June 30 to lock in your current rate. For more information about Stafford loans and consolidation, visit online.

Single Holder Rule Repealed

Congress passed the Emergency Supplemental Appropriations bill on June 15, 2006, which includes a provision repealing the controversial “single holder” rule. The rule required that borrowers with multiple federal student loans who wished to consolidate do so only through the original lender. This was one of the provisions that ACP's medical students and residents lobbied for during Leadership Day 2006 and will provide much needed relief to those with debt.

The single holder rule is considered anti-competitive because of the way it limits options in the student loan marketplace. Under the single-holder rule, a borrower had to refinance through his or her current lender if all student loans were obtained through a single lender. Without the single-holder rule in place, borrowers will now be able to find the best interest rates, customer service, and loan packages available. This change will help debt-burdened graduates obtain the best interest rates and borrower benefits so they can ultimately save more money.

The President is expected to sign the bill into law during the week of June 19, 2006.

MKSAP Question 1

A previously healthy 74-year-old man is hospitalized with cough and chest pain. On physical examination, the blood pressure is 148/92 mm Hg, heart rate is 75/min, respiration rate is 18/min, and temperature is 37.8 °C (100 °F). The left lower lung field has scattered basilar crackles. The hematocrit is 34% and leukocytosis is present. The serum creatinine concentration is 2.3 mg/dL. Urinalysis shows a pH of 6.0, 1+ proteinuria, and no hematuria or ketonuria.

Which of the following is most useful in distinguishing acute from chronic renal failure in this patient?

( A ) A previous hematocrit
( B ) A previous serum creatinine concentration
( C ) Blood urea nitrogen to creatinine ratio
( D ) Microscopic urinalysis
( E ) Renal ultrasonography

MKSAP Question 2

A 77-year-old man is evaluated because of a low energy level of 8 months' duration. He notes that he has not been exercising regularly or sticking to his diet since his wife, who had cooked all of his meals, died 6 months ago. He spends most of his time alone, and has lost interest in his favorite activities.

Which of the following is the most likely explanation of his symptoms?

( A ) Atypical depression
( B ) Dependent personality type
( C ) Normal bereavement
( D ) Post-traumatic stress disorder

MKSAP Answer 1

Answer: B

Educational Objective: Diagnose acute renal failure.

Although many evaluations remain to be performed to establish a diagnosis in this patient with a decreased glomerular filtration rate, the first step must be to determine whether he has a history of renal insufficiency. This allows the clinician to distinguish between acute and chronic renal failure. A previously elevated serum creatinine concentration can establish the diagnosis of chronic renal disease. Ultrasonography provides information on size and symmetry of the kidneys and evidence for obstruction including hydronephrosis; however, renal ultrasonography may be normal in the presence of mild chronic renal disease. The ratio of blood urea nitrogen to creatinine is not diagnostic of renal disease but when elevated suggests the possibility of pre-renal azotemia. The previous hematocrit may suggest chronic renal disease, but it is also not diagnostic. The urinalysis may be helpful in establishing the nature of the renal insufficiency but not its chronicity.

References
Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med. 1996;334:1448-60. PMID: 8618585[PubMed]

MKSAP Answer 2

Answer: A

Educational Objective: Recognize the risk of depression associated with age and death of a spouse.

Depression among the elderly, especially after the loss of a spouse, is common (15%–35% in the first year). The presentation of depression in ambulatory care is often atypical and consists of physical rather than psychosocial symptoms. This often contributes to the difficulty of assessing patients for depression and getting them to accept the diagnosis when it is made. Although the patient may have been dependent on his wife to cook for him, there is not enough evidence to assess whether the patient's personality type is dependent. There is no mention made by the patient of recurrent reliving of the loss; thus, post-traumatic stress is not a likely explanation. Normal bereavement is short-term and is associated with mild impairment. No such marker event is present in this case. Depressed feelings during bereavement are brought on by particular triggers, and the symptoms are circumscribed to these episodes.

References
Casarett D, Kutner JS, Abrahm J; End-of-Life Care Consensus Panel. Life after death: a practical approach to grief and bereavement. Ann Intern Med. 2001;134:208-15. PMID: 11177334[PubMed]

• Careers at ACP
• Contact Us
• Privacy
• Site Map
• For Advertisers
• For Media
• For Governors
• For Regents