June 2008 E-Newsletter

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Medical Student Perspectives: Welcome from the Chair of the Council of Student Members

Welcome! As a Medical Student Member of the American College of Physicians (ACP), you have joined over 22,000 of your fellow medical students in the largest medical specialty organization in the United States. The ACP recognizes that the future of internal medicine lies in the strength of its student members, and this is why you are so very important to all the work that we do.

These are exciting times to be involved in internal medicine. Many physicians are working hard to implement new methods of delivering quality healthcare, creating more efficient models to improve patient outcomes, and are working towards reforming training and education. The ACP is at the forefront of this wave of innovation and is calling on you to be part of this movement. Being involved at the national level, I am continually amazed at the ACP’s commitment to medical students, and to helping us thrive and succeed in our futures.

The College offers its Medical Student Members valuable benefits, essential educational tools, and opportunities for involvement in public policy, advocacy, and healthcare reform. I encourage you to join your student colleagues, residents, and attending physicians as we work together to revitalize internal medicine.

As a medical student, you are represented by the Council of Student Members (CSM), which is comprised of 13 students from 11 regions, representing all ACP Medical Student Members. The CSM meets twice a year to discuss issues of particular importance to us as medical students. We welcome your input and feedback, as we aim to enrich the quality of your medical school experience—please do not hesitate to contact me or any CSM member if we can be of help to you and your chapter. Your ideas and feedback guide our Council as we propose policy and plan events that will impact all of our members—please tell us what is on your mind!

On a regional level, each CSM member works to promote activities related to internal medicine and to gather ideas from local Internal Medicine Interest Groups (IMIGs). ACP’s IMIG Sponsorship Program provides funding and support for internal medicine club activities, as well as further financial incentives for increasing the number of ACP Medical Student Members enrolled during the academic year. For more details about this program, visit the IMIG Resource Guide online. Through initiatives such as the IMIG Sponsorship Program, we work to establish stronger bonds between the IMIGs at local schools, the regional ACP chapters, and the national ACP. We want to foster the exchange of ideas and expand activities for you to learn about careers in internal medicine. We distribute lapel pins to our members so you can proudly identify yourself as an ACP Medical Student Member—please join the ACP, and encourage your classmates to become members too!

The Council plans and develops tools to assist students as they progress through medical school. You may have seen some of ACP's educational and clinical resources in your coursework thus far. Resources such as MKSAP (Medical Knowledge Self Assessment Programs) for Students 3, the highly-esteemed Annals of Internal Medicine and our newest and most valuable day-to-day resource, Internal Medicine Essentials for Clerkship Students, are all essential to learning and succeeding during your clerkships. We hope that you will rely on these academic tools during medical school and continue to use them throughout your careers.

Policy-wise, the CSM takes an active role in proposing resolutions that advocate for your interests on a national level. We want to ensure that the leadership of ACP understands the environment in which the contemporary medical student learns and enacts policy that fosters the development of superb physicians. Each May, student members have the opportunity to join physicians and members of the United States Congress in Washington, D.C. for ACP Leadership Day. Leadership Day is a fabulous event during which students and physicians lobby for crucial changes to the future of healthcare in the United States. To learn more, please contact me or any other CSM representative.

Your Council of Student Members is dedicated to a variety of issues in internal medicine, such as public policy, education, and professionalism. With a strong body of Medical Student Members and your active participation in our organization, we can work together to ensure that you have the tools and resources you need from the ACP to succeed in your medical training, career, and life.

I look forward to hearing from you!

Best,

Maya Babu
Chair, Council of Student Members
Harvard Medical School, Class of 2010
Email: mbabu@hms.harvard.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Paul Quartararo, MD, FACP, Medical Director, New York Life Insurance Company

A desk job was the last thing Paul Quartararo, MD, FACP, imagined himself doing, yet it is exactly where he found himself on the heels of a successful run as a practicing physician. And he likes it. Each day as he walks into the New York Life Insurance building between Madison and Park Avenues in New York City, he takes a moment to admire the shining pyramid-shaped gold dome on top of the building, and once inside, the high arches and mosaics of the lobby. “One of my first thoughts when I was considering this position was ‘I’m a physician…am I going to go crazy sitting at a desk all day?’” he says. Fortunately, the answer to that question turned out to be no. “It’s a pleasure coming to work.”

A Perfect Fit
At New York Life Insurance, Dr. Quartararo works as a Medical Director and co-head of medical underwriting. His job is to assign mortality risk to applicants. As a former practicing internist, he is uniquely qualified for it. “We have three goals in this company,” he says. “Integrity, Humanity, and Financial Strength. Being a physician enables you to balance those things well when reading people’s medical records.” While others might find his job tedious, he sees it as quite the opposite and there is an excitement and contentment in his voice as he describes it. “I review 20 to 30 files a day,” he says. “I find it intellectually stimulating and fascinating to see how other doctors are treating their patients, and how that treatment has played out in their patients’ lives.” He also enjoys the people. “I work with a great group of people,” he says. “There are nine physicians in the company and they’re all bright, pleasant, fun and interesting. The employees who aren’t physicians are also wonderful. It’s a huge collegial environment. Dr. Quartararo says the tradeoffs of giving up some degree of authority and autonomy is counterbalanced by the improved quality of life. “Nobody wakes me up at two in the morning,” he says, “and I can call in sick. When you are a practicing physician and you have fifteen patients scheduled for the day, you don’t call in sick. These are the little things that make the difference.”

Paul Quartararo, MD, FACP

Paul Quartararo, MD, FACP

A Long Way from Long Island
Dr. Quartararo knew he wanted to be a physician from the age of four, inspired by his father, an endodontist, as well as friends of the family who were physicians and his own pediatrician. From his father, who continues to work three days a week, he learned a core set of values which would and still guide him through this career: community, education, and a strong work ethic. From both his father and the others, he found inspiration. “I thought they were all personable and intelligent,” he recalls. “I just thought they were great people.”

The path he would take over the next several years would teach him much about his profession as well as his own strengths and weaknesses. He attended medical school at Albert Einstein College of Medicine in the Bronx, where his passion for treating adults and the elderly came alive. “I enjoyed treating the people who were extremely ill because that’s when people show their true colors,” he says. “I also found the interpersonal challenge of that to be a big adrenaline rush. It was high energy, high stress. It fit me then.”

After that, the native New Yorker decided it was time to stretch his boundaries and chose Cincinnati, Ohio to pursue internal medicine training at the University of Cincinnati. It was a period of growth for him, not only as a student of medicine, but also as a newlywed and eventually a father of two children. “It was challenging with neither of our families around.” he says. From Cincinnati, Dr. Quartararo moved his family back to the east coast where he would pursue a fellowship in pulmonary and critical care medicine at Brown University in Rhode Island. There, he realized that general internal medicine would be a better path for him. Upon completion of his fellowship, Dr. Quartararo joined an internal medicine group practice in Stamford, CT. He says group practice was the right choice at the right time.

“When you’re starting out it’s good to be in a group,” he explains. “There’s camaraderie, mentorship, and it’s nice to have experienced physicians around you.” After spending seven years with the group practice, he decided to set up a solo practice a few blocks away. “What made solo practice special to me was being able to practice according to my own style,” he says. “For example, having a person answer the phone instead of voicemail, and having a small staff who the patients know personally.”

But after a few years, the personal sacrifice he was making to treat a large Medicare population was taking its toll. “The time and energy that I was taking to treat my patients were affecting my ability to be a good father and husband,” he says. He also admits that he struggled to “do it all.” “I was never good at working off-shifts,” he explains. “The physicians who are good at it can, for instance, get a call at 2am, talk calmly to a patient about his or her symptoms, then hang up, go back to bed, and get up a few hours later to go to work like nothing happened. There are physicians who are good at that sort of thing—whom I admire—and there are those who aren’t. I’m not one of them. I thought to myself, ‘I won’t make it to 65 or 70 years old like this.’”

He pursued other roles as well during his time in practice, including as a medical director for a local visiting nurse and hospice care organization, as a volunteer for the American Lung Association, and as a physician in a pulmonary clinic at a local corporation. He also taught at Stamford Hospital for ten years, a role he embraced. “As a student I remember how I appreciated the time and energy that were given to me by my teachers, and so I was grateful to be able to give these back as a teacher myself,” he says.

Through and Through
For Dr. Quartararo, there is little delineation between “career life” and “personal life.” To him, they are one in the same. He has a tendency to carry his work home with him and to internalize what goes on during the day. It was this inability to detach himself from his work that led him to make the career-changing decision to leave his practice.

“The hardest part about leaving my practice was knowing that I had taken care of these people for years and now I wouldn’t be,” he says. “The separation was difficult.” He also says he has a heightened awareness of end-of-life issues. “I’ve always been sensitive about these issues,” he says, “what people are faced with when they face their own mortality.” This sensitivity came to a head during his last two years in practice, when he worked in hospice care. One patient in particular had so much of an effect on Dr. Quartararo that he struggles when discussing it. Polly, an elderly woman with end stage COPD, was independent with a strong sense of self, and she worried that her care was too much of a burden for her family. As her condition progressed, it was clear to Dr. Quartararo that the family had indeed reached its limit. “I knew hospice was the solution for this family,” he said. “With end of life care, everything is magnified and can seem like a crisis even when it’s not. I was so relieved to be able to get her into the program because at the time, the majority of hospice patients were cancer patients.” When asked for more detail, he pauses for a long time and finally offers a simple, “We helped her a lot,” before growing quiet again.

Dr. Chocolate
When he’s not working, he spends his time with his wife Carol and his three daughters, and also at his church where he volunteers with his wife. As for the future, Dr. Quartararo has plans that, like his father’s, do not include retiring. “In ten years I’m still going to be a kid,” he jokes. He plans on staying at New York Life, and after that is anyone’s guess, although he is entertaining the idea of opening his own gourmet chocolate shop. An avid chocolate lover, he collects it when he travels and has plans to organize a group from work to go to an international chocolate show in the fall. A nurse he used to work with gave him a plaque that reads, “Give me the chocolate and nobody will get hurt.”

Dr. Quartararo takes everything in his life, from the chocolate to his patients, very personally. “I miss my patients,” he says, “but since I live in the same community as a lot of them I often run into them at the grocery store, on the train or in the park, which has in a way made up for not seeing them anymore as their physician.” Whether in the quiet corporate offices of New York Life, the buzzing activity of a medical practice, the hallways of Stamford Hospital, or the comforting familiarity of Long Island, it’s this quality that makes Dr. Quartararo shine—the fact that he cares and isn’t afraid to show it.

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Internal Medicine Interest Group of the Month: University of Cincinnati

The University of Cincinnati Internal Medicine Interest Group (IMIG) is one of the largest clubs in existence at our medical school. Individual members can participate in varying capacities, whether by attending lunch talks sponsored by the IMIG or participating in shadowing opportunities.

During the orientation fair, we described our club’s mission and introduced students to internal medicine. On the first day of classes, we sponsored a lunch talk entitled “Introduction to Internal Medicine,” given by Eric Warm, MD, FACP, one of our faculty advisors. He presented a lively and entertaining discussion about what goes into being an internist and described the different subspecialties. Our next lunch talk brought in Dr. James Wilkin, a cardiologist who discussed historical as well as current and upcoming cardiac devices. Because of the overlapping interests, this event was co-sponsored with the biotechnology in medicine interest group. The presentation raised several interesting questions regarding which patients should be referred for the newest technologies, such as biventricular resynchronization, while at the same time balancing the cost and long-term prognosis. We have a few more talks scheduled later this year, including a workshop on how to present a case to an attending and a panel presentation of fourth-year students who matched into internal medicine. We hope the panel presentation will give our audience an idea about what motivated these students to choose medicine as their career.

In addition to the lunch talks, our group offers shadowing opportunities. A student can sign up to shadow in the medicine-pediatrics or adult medicine clinics or in the gastroenterology endoscopy suite. First- and second-year students enjoy this experience as a way to see medicine in practice and interact with physicians and patients. The overall response from students has been positive and our group intends to continue such opportunities in the future. In addition, we would like to expand this experience into other internal medicine subspecialties, such as the cardiac catheterization lab.

The leadership of our club consists of five officers: Jared Bentley ’10, C. Callie Coombs ’10, Rob Larke ’10, Kenneth Liu ’10, and Wilson Tong ’10. Each of us has different responsibilities, such as coordinating lunch talks or organizing shadowing. Furthermore, we are grateful that our two faculty advisors, Dr. Warm and LeAnn Coberly, MD, FACP, are able to help us with the planning of various activities and participate as our lunch speakers.

Callie Coombs
University of Cincinnati, Class of 2010
E-mail: coombscc@email.uc.edu

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Winning Abstracts from the 2008 Medical Student Abstract Competition: “Spam Disease”: A Chronic Cutaneous Disease Linked To A Remote Island In Chuuk, Fsm And Associated With Swimming In World War II Era Bomb Craters And Working In Taro Fields.

Author: Gloria Tumbaga, University of Hawaii, JABSOM

Introduction
Since World War II, residents of Satowan (population 650), a remote outer island in Chuuk, FSM have noted a high prevalence of a chronic, progressive, skin disease known locally as “spam disease” due to a resemblance to the popular food product. A Satowanese patient with this condition had previously been diagnosed in Portland, Oregon with culture positive Mycobacterium marinum. He had responded dramatically to treatment with doxycycline.

Methods
We traveled to Satowan to investigate this disease and invited all island residents to be evaluated. Suspect cases of “spam disease” were defined as patients with chronic, progressive verrucous or keloidal plaques on the extremities. Punch biopsies were obtained on several suspect cases for mycobacterial culture and histopathology. A case control study was performed using suspect cases and randomly selected controls. All suspect cases were treated with antibiotics (doxycycline or doxycycline + rifampicin or azithromycin).

Results
We examined 45 persons, identified 39 case-patients, and enrolled 98 controls. Case-patients and controls were similar with regard to age (median age 26.0 vs. 23.0 respectively, p=0.14), but control patients were more likely female (53.1%) vs. cases (25.6%) [p Mean disease duration was 12.5 years (range 3 months to 53 years). All tissue cultures (n=19) were negative for mycobacteria but PCR analysis revealed non-tuberculosis mycobacteria in 2 out of 3 submitted specimens. Histopathologic sections (n=9) showed epidermal and follicular hyperplasia with dense neutrophilic and epitheloid histiocytic infiltrate and dermal fibrosis, a pattern typical of mycobacterial and fungal infections. AFB and PAS staining was negative in all. All cases were taro farmers (OR undefined p Cases were no more likely to have affected family members than controls (OR 1.04, p=0.93).

Conclusion
“Spam” disease" is a chronic skin infection with high prevalence on Satowan, Chuuk, FSM. It is associated with taro farming and swimming in World War II era bomb craters. Histopathology and PCR analysis suggest that it is likely due to M. marinum infection.

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

The Discipline
Internal medicine is a specialty that relies on the basic sciences and a diverse breadth of knowledge to form the foundation for a successful career in a variety of fields. General internists are crucial in filling a vital need in our health care system, serving as the primary or principal providers of care in outpatient (ambulatory) and /or inpatient (hospital) settings.

General internists handle the broad and comprehensive spectrum of illnesses that affect adults, and are recognized as experts in diagnosis, in treatment of chronic illness, and in health promotion and disease prevention—they are not limited to one type of medical problem or organ system.

Procedures
Common procedures for general internists include lumbar puncture, joint aspiration, central venous line placement, paracentesis and thoracentesis.

Training
After successful completion of medical school, those interested in becoming an internist will enter a residency program. Residency in internal medicine usually lasts three years, and residents work in a variety of settings, including university hospitals, community teaching hospitals, hospital outpatient clinics, and community physicians’ offices. Residents assume progressive responsibility as they acquire various skills in treating hospitalized patients and gain competency in ambulatory care.

Certification
The American Board of Internal Medicine (ABIM) offers certification for physicians interested in pursuing the field of internal medicine.

Major Professional Society
American College of Physicians
190 N. Independence Mall West
Philadelphia, PA 19106-1572
Phone: 215.351.2400
Web site: http://www.acponline.org

Major Publications
Annals of Internal Medicine
ACP Internist
ACP Hospitalist

Have questions about training and careers in internal medicine? Search the ACP Mentoring Database to find an internal medicine physician who can answer your questions.

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Advocacy Brief: Enroll in ACP’s Key Contact Program

ACP’s continued success on Capitol Hill greatly depends on year-round grassroots efforts from the College’s more than 5,600 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 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 ACP Journal Club?

Journal Club's editorial team reviews 150 medical journals and identifies the articles most important to internal medicine. Then they summarize these studies in structured abstracts featuring expert clinical commentary. You'll enjoy access to every current Journal Club abstract -- plus a large collection of previously published abstracts still relevant to medical practice -- FREE as a Medical Student Member of ACP.

Access ACP Journal Club now!

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MKSAP for Students 3 Question 1

A 16-year-old girl is evaluated at the request of her mother for help in quitting smoking. She smokes four to five cigarettes some days, and more when stressed or when she is socializing with her friends. She lives at home with her parents, both of whom smoked until her father’s recent myocardial infarction at age 48 years. She believes that she can quit smoking at any time, having done so twice for several weeks in the past year. She is uncertain about quitting now and reports that half of her friends smoke at least occasionally. The patient performs well in school and has no other risk-taking behaviors. Her physical examination is normal.

Which of the following interventions is most likely to influence this patient to quit smoking?

A. Acknowledging that she is too smart to keep smoking
B. Emphasizing her father’s history and her own risk for heart disease
C. Empathizing with her ambivalence and exploring her reasons for smoking
D. Suggesting that she call you for bupropion when she is ready to quit.

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MKSAP for Students 3 Question 2

A 48-year-old man with a long history of alcohol abuse is seen for ongoing care after an inpatient stay for alcohol withdrawal. This is his third episode of acute detoxification, with the longest period of abstinence being 4 months. He denies any current symptoms of depression and states that he is not using any illicit drugs or prescription medications. His last alcohol intake was 2 weeks before his visit to the office, and he is now enrolled in an alcohol treatment program.

Which of the following pharmacologic agents is the best adjunct to his treatment?

A. Buspirone
B. Diazepam
C. Disulfiram
D. Naltrexone
E. Paroxetine

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MKSAP for Students 3 Answer 1

Answer: C, Empathizing with her ambivalence and exploring her reasons for smoking.

Integral to assisting adolescents to quit smoking is understanding their personal beliefs and reasons for smoking. Ambivalence about quitting is common, but does not suggest that the adolescent will not abruptly decide to quite, too frequently without adequate preparation. Smoking is the leading cause of preventable death in the United States. Among adults who have ever smoked daily, 91% tried their first cigarette and 77% became daily smokers before age 20 years. Tobacco companies direct their advertising to young women in particular, emphasizing the association of tobacco use with lower weight; in the United States, the largest group taking up tobacco smoking is adolescent girls. Adolescents consistently underestimate their susceptibility to nicotine addictions, and most who smoke regularly are already nicotine-addicted, including 50% of persons who smoke only one to five cigarettes daily. This patient’s relapses after several weeks of not smoking may, in part, reflect continued nicotine-withdrawal symptoms. Her ambivalence about quitting smoking may reflect her memory of nicotine-withdrawal symptoms, which she may not disclose unless specifically asked; it may also reflect peer pressure, weight pressure, and other reasons that are more relevant to adolescents than they are to adults.

Adolescents are frequently indifferent about the potential morbidity of smoking beyond the near future. Appealing to their intellect or supplying information about the long-term consequences of smoking is unlikely to be effective. It is more useful to stress the short-term consequences, including cough, dyspnea on exertion, decreased fitness, phlegm production, more frequent respiratory illnesses, bad breath, smelly hair and clothes, and cost. Physicians should anticipate adolescents’ impulsive tendency to quit smoking and their reluctance to interact with the medical system by offering bupropion at the current visit and not requiring them to call back to obtain it, regardless of their apparent stage of change.

Bibliography
Sussman S, Lichtman K, Ritt A, Pallonen UE. Effects of thirty-four adolescent tobacco use cessation and prevention trials on regular users of tobacco products. Subst Use Misuse. 1999;34:1469-503. PMID: 10468104

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MKSAP for Students 3 Answer 2

Answer: D, Naltrexone.

This patient presents with a history of alcohol dependence. Brief interventions work for patients with at-risk alcohols use, but more aggressive therapy, potentially including pharmacotherapy, is indicated in both alcohol abuse and alcohol dependence. Naltrexone, an opioid receptor antagonist, has been shown to be effective in short-term treatment as well as in decreasing the frequency of relapse. Benzodiazepines, such as diazepam, would be used in the acute detoxification setting. Antidepressants and anxiolytics may play a role if an underlying psychiatric disorder is present. Disulfiram has been used for years and works by leading to an accumulation of aldehyde if alcohol is consumed, resulting in vomiting, headache, and anxiety. However, studies have been inconclusive on its efficacy in enhancing abstinence.

Bibliography
Fiellin DA, Reid MC, O’Connor PG. Outpatient management of patients with alcohol problems. Ann Intern Med. 2000;133:815-27. PMID: 11085845

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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 Internal Medicine Essentials for Clerkship Students 2007-2008 Textbook

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 with clinical photographs, tables, screening tools, and other instruments available online. 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.

You can also call ACP Customer Service to order 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

ACP Internist (formerly ACP Observer)

  • ACP Internist launches new blog!
    Regular features include “Medical News of the Obvious,” and irregular features include anything, absolutely anything, that crosses our desks but can’t to wait to find its way into print. In upcoming months we'll add new columnists with opinion leaders in internal medicine.
  • Osteoporosis no longer just a woman’s disease.
    ACP guideline recommends screening for older men.

ACP Hospitalist

  • Hospitals tighten rules on gifts, meals, education from pharma.
    Conflict of interest policies go under revision.
  • Becoming a better ward attending.
    Ten modifiable behaviors.

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Suggest a physician as a Hospitalist of the Year

ACP Hospitalist is seeking candidates for its first annual Hospitalists of the Year issue. Physicians selected as Hospitalists of the Year will be those who made the most notable contributions to the field in 2008, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement.

If you know a hospitalist who improved care through a patient safety innovation, led an important cost-savings initiative, or served as an extraordinary teacher or mentor, to name just a few examples, ACP Hospitalist would like to hear about it. Submit your suggestions by completing the online form. All recommendations must be received by July 14, 2008, when the ACP Hospitalist editorial advisory board will pick the winner. Hospitalists of the Year will be profiled in the November 2008 issue of ACP Hospitalist.

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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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