June 2009 E-Newsletter

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Medical Student Perspectives: Interpersonal Communication: Resolving Conflicts

Heraclitus wrote in On the Universe, “You could not step into the same river twice; for other waters are ever flowing on to you.” Medical students are ever the product of our rapidly swirling experiences–no two events are alike. So are the encounters we have with our patients, classmates, residents, allied health-care staff, and attendings. Four principles of interpersonal communication may allow insight into a more efficient manner in resolving the ebb and flow of conflict: interpersonal communication is intricate, irrevocable, inevitable, and contextual. Because of variance involving both personality and circumstances no single solution or formula can be applied to all arising conflicts; however, if we build upon a foundation of patience, understanding, integrity, and empathy, we may better weather difficult situations.

If you would, allow me to indulge in my own experience and thus illustrate. I attend medical school in a region of the country with relatively little ethnic or racial diversity. A young immigrant woman presented to my internal medicine service in excruciating pain. She had battled many previous crises caused by a hereditary blood disorder. Due to her transient social status, she had a record of visiting many physician offices around the valley seeking pain relief. The team resident doubted the reality, severity, or urgency of her condition. In my mind, there were great risks which may have led my team to misunderstand her suffering due to differences in our culture, gender, ethnicity or race, and relative inexperience in treating this disease. I felt that we needed to aggressively manage the pain contrary to my resident’s opinion. At this point, I had a few options. I could acquiesce and focus on other clinical duties or tactfully (or tactlessly for that matter) demonstrate my dissension. During rounds, I presented several papers to our team and made what I hoped to be a compelling case for my patient; while also recognizing the concerns of my resident, who was certainly more experienced and knowledgeable than I.

This was stressful and required meticulous selection of words. In the end, my suggestions were not adopted into the patient’s care-plan. Did I lose overall? Absolutely not! I learned from quality, peer-reviewed literature about a common medical problem, demonstrated to my team that I could discreetly disagree, and most importantly made a case to more fully alleviate human suffering. To me this was a sticky complicated situation, primarily because I knew my resident’s thoughts before I presented my plan to the team attending. The words I spoke were irrevocable — that is to say, once I had spoken the words I could not take them back. Inevitably, I had to either accept or reject my resident’s plan. Understanding given to my words was highly contextual. The better the team knew me as a both a student and a person, the more likely my message would be fully understood. The chance that my words would be successfully received by my team members depended highly on cultural and psychological similarities.

Many other encounters existed during my rotations. I have acquiesced to “easy ways out” and blundered through many an attempt to share a tasteful difference of opinion. On that note, during my class’s first year of medical school, we collectively developed a code of professionalism to help us navigate through these medical conundrums. A portion of the preamble for our class code reads as follows:

  In the presence of ignorance, I will strive for knowledge.
When intolerance knocks, I will answer with patience.
May I always find time to care and make time to teach –
for that is a doctor.

 

To some these lines may be simple platitudes, but instead I’ll mark them as aptitudes, on my journey to become a physician.

Ryan VanWoerkom
Council of Student Members Representative, Midwestern Region
University of Utah School of Medicine, 2010
Email: ryan.vanwoerkom@hsc.utah.edu

Check out more volunteer opportunities.

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My Kind of Medicine: Real Lives of Practicing Internists: Erica Scavella, MD, FACP

Erica Scavella, MD, FACP

The Test Taker
At the Lower School of University of Chicago Laboratory Schools in Chicago, IL, Erica Scavella liked science class the most. Her love for it followed her to New Jersey where she chose pre-med at Rutgers University, and later to the University of Medicine & Dentistry of New Jersey - Robert Wood Johnson Medical School where she fell in love with internal medicine. “Figuring out the cases was exciting,” she remembers, “and I liked how broad and different the opportunities were for patient care.” Today at 38, Dr. Scavella has a career any young woman would covet—she is a practicing physician at the VA Medical System in Maryland, a medical director at one of the VA community-based primary care clinics, and an ACP Fellow—a distinction she earned at the age of 35. But it hasn’t been an entirely easy ride—she struggled with test-taking for years, all the way through medical school. Eventually she learned what worked for her—charts, graphs and tables. Yet while these difficulties made life as a medical student a challenge, it also made the experience of earning her fellowship all the more meaningful. She says becoming a Fellow gave her not only external validation, but internal validation as well. “It was important to me,” she says. “I worked hard to get it and I did it.”

Action Junkie
When Dr. Scavella and her college sweetheart and husband Darryl, also an internist, aren’t working, they can be found doing something active—running, biking, skiing, or camping. “We love physical activity in general,” she says. They also volunteer for the Boy Scout Troop that their sons, Darryl Justus, 11, and Jordan Grant, 10 belong to. The patients at the VA clinic where Dr. Scavella spends about half of her time keep her equally busy and happy. “I like the day-to-day interactions and meeting new people,” she says. “The veterans are a great group to learn from and they are grateful for the care received…I find the interactions I have with them extremely rewarding. They are the reason I love this job.” She says that being an internist allows her the flexibility to spend time with family and to also pursue other professional interests, including educational and administrative programs that she attends across the country. She also works in an administrative role in a more permanent setting, for the VA Maryland Health Care System, working to improve quality and performance.

She loves how the job allows her to work with other professionals, such as nurses and social workers, to improve quality. She is excited and animated when discussing it and it is clear that she puts her heart into it. “It’s exciting to come up with action plans, help roll them out, and see them work,” she says. One example she cites is the group’s success improving the access to care. Dr. Scavella and her team examined the entire enrollment process, broke it down into small pieces, identified specific areas of wasted time, and created ways to eliminate waste. “I feel passionate about finding more effective ways to deliver care,” she says. “I think that the solution to many problems lies in the ability to put yourself in the patient’s place. Oftentimes we’re not thinking the way a patient thinks.”

And her work as a medical director at the Glen Burnie VA Community-Based Outpatient Clinic has given her valuable insight to management and problem solving. “Working with other primary care physicians and specialists is a wonderful experience,” she says. All in all, Dr. Scavella’s different roles provide her with the stimulation and excitement she craves. “Internal medicine is a great field—students should consider it in terms of the marketability it gives you in your career. My career is a perfect example of how interesting and varied a job you can have every day as an internist.”

The Weekly Gift
Dr. Scavella once told a colleague at the VA Medical Center that each week, she looks forward to what she knows will be a unique patient experience. “At least once a week I meet a patient who is like a gift to me,” she says. She talks of one patient in particular, an elderly African American man, about six-foot-four, with a long goatee and light grey eyes. He would often entertain her with his military stories, and over the years, the two shared many laughs. “There was something magical about him,” she recalls. He had one request for her: “He said to me, ‘I want you to do something for me. I want you to get me to 100,’” she recalls, “and I said ‘no problem!’ It was relatively easy since he was in pretty good health, but we did do a lot for him to prevent him growing sicker whenever he was ill.” After ten years of treating the man, Dr. Scavella finally delivered on her promise, and the patient celebrated his 100th birthday in good health. She continued to treat him until he passed away recently at the age of 101.

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 Iowa

The mission of the Internal Medicine Interest Group (IMIG) at the University of Iowa Carver College of Medicine, named Club Med, is to increase the understanding and enthusiasm for internal medicine amongst medical students as well as to act as a service organization.

Activities start as early as first-year orientation to inform medical students of the benefits of a career in internal medicine. Most of these students enroll in ACP, which becomes both a source of career mentoring as well as a spring of clinical knowledge through the monthly IMpact newsletter and ACP Internist Weekly. Through our recruiting at the first-year orientation, ACP membership has grown 30% over the past two years to a current total of 217 members. These members, with other students, also sign up for the Club Med listserve during orientation, through which they are kept abreast of the many activities throughout the year.

Through the generous support of the ACP IMIG Sponsorship Program, the Iowa ACP Chapter, and the University of Iowa Hospitals and Clinics (UIHC) Internal Medicine Department, we sponsor a lunchtime discussion series. The topics for these informative lunch meetings include “A Day in the Life of an Internist,” “Insider’s Perspective on IM – Panel of IM Residents and Fellows,” and “Career Pathways in Internal Medicine”. In the spring we hold a lunch meeting for all second-year students where we teach them the process of scheduling their third year clerkships. In the early summer, we put together a fourth-year student panel to instruct third-year students on how to maneuver the match process successfully.

Another service we provide students at the Iowa Carver College of Medicine is our mentoring program. Physicians from general medicine and eight subspecialties participate in the program. We begin each year with a “Meet the Mentors” lunch meeting where students have the chance to introduce themselves to the physician members and network in their particular areas of interest. At the luncheon, students are given the list of mentors, which they use to set up shadowing experiences, one-on-one conversations, and similar activities.

As do most medical students, we believe that it is our duty not only to serve each other in the medical community but to also to look outside ourselves for service opportunities elsewhere. Each year we hold a blood drive in collaboration with the entire student body as well as the Department of Internal Medicine. Next year we are planning on participating in service activities through the Habitat for Humanity organization.

One of the highlights of the academic year is a chili dinner social held in January. Prior to the event the Club Med presidency taps into the career interests of our student members in order to provide a useful spread of faculty. Internal medicine faculty with a variety of interests and clinical backgrounds enjoy the chance to sit down with eager medical students to discuss the joys and challenges of their particular career paths.

Together with faculty, medical student leaders, the Iowa ACP and the UIHC Internal Medicine Department, we strive to enlighten the future leaders of health care at the University of Iowa Carver College of Medicine. Each year we reevaluate our progress and make plans to improve the operations of our interest group going forward. This has led to a consistent increase in student membership and activity. With sustained improvement, we are confident this trend will continue.

J. Ben Robbins
Co-President, Club Med
University of Iowa Carver College of Medicine, Class of 2009
Email: j.benjamin.robbins@gmail.com

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Winning Abstracts from the 2009 Medical Student Abstract Competition: Use Of The Monoclonal Antibody Rituximab For Refractory Thrombotic Thrombocytopenic Purpura

Authors: Amie Jackson, MD, Gregory Monohan MD
Dr. Jackson recently graduated the University of Kentucky and will begin her Internal Medicine residency at Barnes Jewish Hospital in St. Louis

Introduction
A 53 year old female presented for elective aorto-bifemoral bypass secondary to atherosclerotic infrarenal aortic occlusion. Her past medical history was significant for idiopathic thrombocytopenic purpura at age 20, and hemolytic uremic syndrome with refractory thrombocytopenia requiring plasma exchange at age 49.

Case Presentation
The bypass was successful, with no intraoperative complications. Postoperatively, the patient experienced a rapid decrease in platelet count, from 400K/cmm preoperatively to 15K on postoperative day (POD) three, which persisted for over one week without recovery. At that time platelet factor 4 antibody was detected in the patient’s serum by ELISA and she was initiated on argatroban for heparin-induced thrombocytopenia. This was followed by a marked increase in schistocytes on peripheral smear, with persistent thrombocytopenia and anemia. A diagnosis of thrombotic thrombocytopenic purpura (TTP) was made, argatroban was discontinued, and the patient was initiated on plasma exchange utilizing fresh frozen plasma as the replacement product. She had a good clinical response with recovery of platelet count to 377 K/cmm. She was discharged home, but relapsed on post-discharge day five with platelet count of 22K. Her count recovered to supratherapeutic levels with five days of plasma exchange followed by a three week taper. However, after completion of the taper, her platelet count steadily declined over 4 weeks to 112K/cmm. Plasma exchange was initiated a third time, again with resolution of her thrombocytopenia. Because of her relapsing course, it was decided to give the patient four weekly doses of Rituximab at 375 mg/m2 during the tapering phase of plasma exchange. This was successful in maintaining the patients’ platelet counts within normal limits. She has since remained in remission from TTP for over one year from her last plasma exchange.

Discussion
TTP is a rare disorder that was almost universally fatal prior to the use of plasma exchange therapy. Plasma exchange has dramatically improved prognosis for TTP, with an attendant decrease in mortality from 90 to less than 20 percent. However, 10 to 20 percent of patients have absent or poor response to plasma exchange. Numerous therapeutic options have been tried for patients with exchange refractory disease, with variable success. The association of idiopathic TTP with auto-antibody inhibitors to a protease known as ADAMTS-13 has prompted trials of the anti-CD20 antibody Rituximab for treatment of refractory TTP. We report a case in which a patient with refractory TTP achieved durable remission with the addition of rituximab to plasma exchange.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Rheumatology

The Discipline
From the Greek word rheuma, "that which flows as a river or stream." In ancient medical writings, "rheuma" was used to describe any thin discharge from a body surface or orifice. This term was eventually applied to an infection of the joints, presumably because an effusion of the joint space marks the various forms of arthritis.

Rheumatology deals with the prevention, diagnosis, and management of crystalline diseases, systemic rheumatic diseases, spondyloarthropathies, vasculitis, inflammatory muscle disease, osteoporosis, osteoarthritis, recreational sports injury, soft-tissue diseases and trauma. The goal of the rheumatologist is the early diagnosis and treatment of these conditions to prevent disability and death.

Procedures
Important procedural skills include diagnostic and therapeutic joint aspiration, and joint and soft tissue injection of corticosteroids. Rheumatologists are expert in the interpretation of joint fluid analysis, including crystal identification, and the interpretation of serology associated with rheumatological disorders.

Training
Rheumatology fellowship training requires two years of accredited training beyond general 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 medical diseases. Dual certification in Rheumatology and Allergy and Immunology requires a minimum of three years of training which must include (a) at least 12 months full-time clinical rheumatology, (b) weekly attendance for 18 consecutive months in a rheumatology ambulatory care program which must include continuity of patient care, and (c) at least 18 months of full-time allergy and immunology.

Certification
The American Board of Internal Medicine ABIM offers certification in Rheumatology. Dual certification in Rheumatology and Allergy and Immunology requires completion of the entire three-year program.

Training Positions
As of August 2005, there were 108 ACGME-accredited training programs in Rheumatology. 61% of the trainees were female, and 62% were US medical graduates.

Practice
Approximately 65% of the graduates enter clinical practice in Rheumatology in the United States, and 26% enter academic medicine.

Major Professional Societies

  • American College of Rheumatology

    1800 Century Place, Suite 250
    Atlanta GA 30345
    Phone: (404) 633-3777
    www.rheumatology.org

  • American College of Allergy, Asthma, & Immunology

    85 West Algonquin Road, Suite 550
    Arlington Heights IL 60005
    http://www.acaai.org

Major Publications

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Advocacy Brief: Duty Hours

An editorial in the New England Journal of Medicine's May 21 edition on the IOM's duty hours recommendations:

A study in the NEJM estimated that it would cost $1.6 billion per year to implement the Institute of Medicine's recommendations in its December report. Further, the authors state that the patient safety implications are unknown.

An editorial in the same issue of NEJM, "To Nap or Not to Nap: Residents' Work Hours Revisited," stated: "The IOM committee urged rapid implementation of their recommendations. We strongly disagree. In this era of evidence-based medicine and comparative effectiveness, such a major policy change should be based not only on the recommendations of an expert committee but also on careful studies and evidence that improvements in both patient and educational outcomes will result. To date, the necessary research has not been done and the evidence of benefit is lacking."

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Internal Medicine Essentials for Clerkship Students 2 Review

Doody’s Book Reviews™ evaluates books and electronic products across a wide range of clinical specialty areas. The highest rating a title can receive is 100 and the lowest is 20. The stars correlate to the numerical ratings that are derived from an 18-point questionnaire completed by the reviewer in the course of assessing the title. The reviewer must rate each element essentially on a 5-point scale.

NEW REVIEW -- ALGUIRE / Internal Medicine Essentials for Clerkship Students 2. American College of Physicians, 2009, $54.95.

If you've read Internal Medicine Essentials for Clerkship Students 2, please share your review on ACP's Medical Student Group discussion board on Facebook.

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!

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Did You Know You Have Access to ACP Online’s Mentoring Database?

ACP recognizes that the years of an internist's education, training, and early career are those of excitement, challenge, and anxiety. With so many important decisions to be made, providing opportunities for medical students and early career physicians to seek out more experienced colleagues for guidance and advice is important.

Our online Mentoring Database, was developed to provide you with personal and professional guidance from College members, including Program Directors, Clerkship Directors, Chairs of Medicine, practicing internists, and residents. Use the Mentoring Database to find a mentor who is right for you and who can provide the guidance and information you need. If you prefer we pair you with a mentor, please e-mail your name, chapter and medical school to mbrdev@acpmembership.org and ACP Membership Staff will match you with an appropriate mentor.

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MKSAP for Students 4 Question 1

A 36-year-old woman is evaluated in the office for an uncomfortable, occasionally burning feeling in her legs for the past year. The symptoms are most pronounced when she drives long distances and are relieved when she gets out of the car and starts walking.

The symptoms also occur at night and interfere with her ability to fall sleep. Getting up and walking around the house help relieve the discomfort. Physical examination is normal.

Which of the following is the most likely diagnosis?

A. Hypothyroidism
B. Multiple sclerosis
C. Restless legs syndrome
D. Wilson's disease

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MKSAP for Students 4 Question 2

A 28-year-old woman is evaluated in the office for pain in her arms and legs of 7 years' duration that has recently worsened. She has a 7-year history of rheumatoid arthritis that had been well controlled with methotrexate and etanercept. She has pain in her shoulders, back, elbows, wrists, hips, and knees. She does not have fever, rash, or weight loss. The patient also has increased fatigue, particularly the day after any increased activity, such as grocery shopping.

On physical examination, there is mild interosseous muscle wasting but no synovitis, swelling, or warmth. On musculoskeletal examination, range of motion of the joints is full. Her pain is reproducible on palpation of the midpoint of the trapezius muscles, upper outer buttocks, 2 cm below the lateral epicondyles, bilateral trochanteric bursae, medial fat pads of the knees and second costochondral junctions.

Complete blood count, erythrocyte sedimentation rate, creatinine, alanine aminotransferase, aspartate aminotransferase, and thyroid-stimulating hormone values are normal.

Which of the following is the most likely diagnosis?

A. Fibromyalgia
B. Polymyositis
C. Rheumatoid arthritis flare
D. Systemic lupus erythematosus

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MKSAP for Students 4 Answer 1

Answer: C: Restless legs syndrome

Abnormal sensations in the legs and restlessness relieved by movement are consistent with restless legs syndrome, a neurologic movement disorder that is often associated with a sleep complaint. The diagnosis of restless legs syndrome is based primarily on the patient's history of a compelling urge to move the limbs, usually associated with paresthesias/dysesthesias accompanied by motor restlessness associated with activities such as floor pacing, tossing in bed, and rubbing the legs. Symptoms are worse or exclusively present at rest with variable and temporary relief by activity. Symptoms are worse in the evening and at night. The disorder is treated with dopamine agonists, but it is essential before initiating treatment to check serum iron levels. Oral iron therapy can alleviate symptoms and is recommended if serum ferritin levels are less than 50 ng/mL. Nerve conduction velocity studies can be performed and at times can be consistent with peripheral neuropathy but are not essential to make the diagnosis.

The clinical presentation of this patient is not consistent with Wilson's disease or hypothyroidism. Wilson's disease is characterized by fatigue, anorexia, abdominal pain, tremors, poor coordination, spastic dystonia, and psychiatric or behavioral disorders. Hypothyroidism can present with a wide range of clinical symptoms, including fatigue, weakness, and paresthesias, but not leg dysesthesias that improve with movement. Multiple sclerosis is associated with highly variable signs and symptoms and can overlap with a number of other conditions. Generally, neurologic symptoms develop over hours to days, sometimes years, can spontaneously remit, and are not relieved by movement. Common symptoms and signs of multiple sclerosis include diplopia, hemiparesis, hemisensory deficit, urinary retention or hesitancy, cognitive problems, and fatigue. Many patients also have a history of painful optic neuritis.

Bibliography
1. Kushida CA. Clinical presentation, diagnosis, and quality of life issues in restless legs syndrome. Am J Med. 2007;120:S4-S12. [PMID: 17198769] [PubMed]

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MKSAP for Students 4 Answer 2

Answer: A: Fibromyalgia

Generalized pain in the setting of a normal complete blood count and erythrocyte sedimentation rate and normal joint examination is consistent with fibromyalgia. Characteristic manifestations of fibromyalgia are widespread musculoskeletal pain and stiffness, nonrestorative sleep, and fatigue. On physical examination, there are multiple symmetrical painful tender points; a diagnosis of fibromyalgia may be established in patients with pain at 11 or more of 18 tender points defined by the American College of Rheumatology. Laboratory and joint examination findings are normal. Management of fibromyalgia is multimodal and includes interventions to improve sleep and conditioning with a graded aerobic exercise program. Treatment for anxiety and/or depression, if present, also is indicated. Amitriptyline effectively improves general disease activity in patients with this condition. This agent also improves sleep habits in patients with fibromyalgia with associated sleep disturbances.

Because this patient has no evidence of synovitis or muscle weakness on examination, a diagnosis of active or flaring rheumatoid arthritis or polymyositis is unlikely. While many patients with systemic lupus erythematosus (SLE) experience fatigue, other manifestations are present as well, including active synovitis, serositis, rash, aphthous ulcers, cytopenia, and an abnormal urinalysis. In the absence of these findings, SLE is unlikely.

Bibliography
1. Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician. 2007;76:247-54. [PMID: 17695569] [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:

  • Same job, fewer hours
    Part-time options are growing, but finding or creating the right job still can be a challenge. Recruiters, employers and part-time hospitalists offer tips for making part-time hospital medicine work for physicians and practices.
  • Job hunting in a down economy
    Employers have stepped up efforts to maximize productivity in new hires and existing staff, while hospitalists are focused on the perils of switching jobs in a gloomy housing market.

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

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Your Opinion Counts

Your Opinion Counts

Twice a year, ACP participates in a journal readership survey of random internists. If you receive one of these surveys in the mail, please indicate if you read our journals and answer the questions about your reading habits of our journals.

Your voice in these surveys is very important to ACP and enables us to continue to produce the high-quality publications that you expect.
Find out more.

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