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March 2005 E-Newsletter

• Focus on Internal Medicine Careers: Internal Medicine/Medical Education
• MKSAP Questions (1,2)
• MKSAP Answers (1,2)

Focus on Internal Medicine Careers: Internal Medicine/Medical Education

Following is an interview of Maj. Steven Durning, MC USAF, FACP, a practicing Internist and Associate Professor of Medicine at the Uniformed Services University of the Health Sciences (USUHS). Dr. Durning is the recipient of the American College of Physicians (ACP) Herbert S. Waxman Award for Outstanding Medical Student Educator. This award honors the late Herbert S. Waxman, MD, FACP, recently the ACP Senior Vice President for Medical Knowledge and Education. The award recognizes a physician, internal medical interest group leader, clinical clerkship director, program director, or faculty member who spends a significant amount of time teaching medical students. The award will be presented for the first time at the April 2005 Annual Session in San Francisco.

Dr. Durning is an Associate Professor in the Department of Medicine, Director of the Introduction to Clinical Reasoning Course for second-year medical students, and Faculty Advisor to Club Med, the USUHS Internal Medicine Interest Group. 2Lt. Javed Nasir, a third-year medical student at USUHS and the Military Liaison to the ACP Council of Student Members, conducted the interview.

IMpact: Congratulations on winning the inaugural Herbert S. Waxman Award for Outstanding Medical Student Educator. Having been involved with your nomination and working with you for several years, I am familiar with your resume, but our readers likely are not. Could you please briefly describe your training?

Dr. Durning: I am honored to receive the inaugural Herbert S. Waxman award! I went to college at Pennsylvania State University and received a degree in pre-medicine with a minor in business. Next, I attended the University of Pittsburgh School of Medicine from 1991-1995. Finally, I went on to complete an internal medicine residency at Wright-Patterson Air Force Base in Dayton, Ohio, from 1995-1998. I am a Board certified general internist.

IMpact: Why did you choose internal medicine?

Dr. Durning: I chose internal medicine for a variety of reasons. I feel that one of the distinguishing characteristics of internal medicine as a discipline is its breadth and versatility. Internists combine the attributes of a caring clinician, master diagnostician, expert in a variety of procedures, and medical consultant to other specialties. The scope of practice involves treating patients in the clinic, hospital ward, intensive care unit, in a hospice, and in a patient's own home or a nursing home. I enjoy seeing patients in these practice settings. The internist is the specialist who is often called in the hospital or clinic to aid in diagnosing complex adult patient presentations involving multiple organ systems. Internists provide advice regarding both wellness and disease. Long-term relationships with patients are also a core feature of practice that I likewise find very rewarding. Indeed, for me and many other internists, no two days are alike.

IMpact: How did you get involved in undergraduate medical education?

Dr. Durning: Upon completion of my residency training, I expressed interest in staying at Wright-Patterson Air Force Base as an attending, as I enjoyed the teaching opportunities I experienced as a resident working with medical students and interns. As a staff internist at Wright-Patterson, initially I was quite heavily involved in the internal medicine residency training program. When my colleague separated from the military to go into private practice, I expressed interest in serving as his replacement, as the on-site internal medicine clerkship director for the third- and fourth-year students at Wright-Patterson and Wright State University. I was fortunate to be selected for this position and served as the clerkship director for several years. Then I took a position at USUHS as the course director for the Introduction to Clinical Reasoning (Clinical Concepts) second-year medical student course.

IMpact: In addition to your duties as a clinician, researcher, and teacher, I know you are involved with leadership activities. Could you please describe some of the activities you are involved in with the ACP?

Dr. Durning: I have greatly enjoyed the opportunity to serve the ACP, and this organization provides numerous opportunities to lead and be mentored by exemplary physicians and scholars. Since I was a resident at Wright-Patterson, I have been involved with the Society of Air Force Physicians (SAFP), the Air Force ACP Chapter. I am currently serving as a member of the SAFP Board of Governors. After moving to Maryland to work at USUHS, I also became involved with the Washington, DC, Chapter of the ACP and have recently been selected to chair the Medical Student Committee and serve on their Governors Council. Involvement with the DC ACP Chapter has also afforded additional opportunities, including serving as the faculty mentor for the First and Second Annual Washington, DC, Steps to Success medical student meetings. This program was devised to give students from USUHS, Georgetown, George Washington, and Howard Universities the chance to learn about careers in internal medicine, meet mentors in internal medicine, and learn about research in internal medicine through participation in a poster competition. The DC Chapter is are also arranging experiences for medical students in outreach activities, such as shadowing at a local hospice and a tobacco prevention and cessation program with area public school students. Finally, as the Faculty Advisor for USUHS Club Med, I have also become involved with the Army and Navy Chapters of the ACP, as students at USUHS are from all three branches of service.

IMpact: Are there opportunities for research and teaching in this field?

Dr. Durning: There continue to be numerous opportunities for teaching and research in internal medicine. As a physician, you will educate patients on their medical conditions. If you would also like to teach medical residents and students, opportunities are abundant. At many medical schools, the majority of clinical faculty are internists or subspecialists. Teaching interns and residents involves setting up your practice within or near an internal medicine residency program. Likewise, many research opportunities exist in internal medicine, such as identifying outcome measurements for patient care, identifying ways to more effectively teach and assess medical students and residents, and conducting symptom-based research and meta-analyses.

IMpact: Do you have time for family or hobbies?

Dr. Durning: Absolutely. I have a lovely wife, Kristen, and two boys-Andrew (age 9) and Daniel (age 7). I have the chance to play with my kids after school, help them with their homework, see their sports events, and I often "step in" as their coach. I also have the time to pursue a variety of hobbies, like long-distance running. I am very content with choosing a career in internal medicine and medical education and value the time that I have for my family.

MKSAP Question 1

A 45-year-old man is evaluated because of a persistent cough. He is a lifelong nonsmoker without a history of lung disease. He has had a cough productive of clear sputum for approximately 6 months. The cough is particularly troublesome at night and toward the end of the workweek. The patient works in an automobile repair shop spray-painting cars. He has worked in his present job for 2 years. He denies a history of allergies, and there is no family history of asthma or allergies. The chest examination shows a few expiratory wheezes. Spirometry shows moderate airflow obstruction and substantial improvement after inhalation of a bronchodilator.

Which of the following is the best management option for this patient?

( A ) Measure carbon monoxide diffusing capacity
( B ) Advise him to change jobs
( C ) Prescribe an inhaled bronchodilator
( D ) Measure IgE antibody to anhydrides

MKSAP Question 2

A 56-year-old man with a 15-year history of active rheumatoid arthritis is evaluated because of left lower leg pain that began suddenly while he was climbing stairs 2 days ago. In recent years, his arthritis has been reasonably well controlled with a combination of disease-modifying agents. His principal symptom has been continual swelling in his knees, for which arthrocentesis has been done twice in the last year on the left knee with concurrent injection of glucocorticosteroids. The last injection was done 2 weeks ago.

On physical examination, he has a temperature of 37.5 ºC (99.5 ºF). Fluid is palpable in both knees, but more so in the right than the left, with fullness in both popliteal fossae. The left calf is tender, and at 25 cm below the patella the circumference is 3 cm greater than on the right. Dorsiflexion of his left foot with the knee extended elicits sharp calf pain.

What step should be taken next in managing this patient?

( A ) Venography of the left leg
( B ) Ultrasonography of the left thigh, knee, and calf
( C ) Arthrocentesis of both knees
( D ) Anticoagulation
( E ) Inject triamcinolone hexacetonide into the left knee

Answer - Question 1

Answer: B

Educational Objective: Review common clinical features of occupational asthma and understand the best management of occupational asthma.

The patient has adult-onset asthma. He is middle-aged, does not smoke, has no history of allergies or asthma, and has a cough, wheezing, and reversible airflow obstruction. The exposure to chemicals in the workplace suggests occupational asthma. Auto-body repair with spray painting is an occupation commonly associated with asthma induced by workplace exposure. In this environment, urethane paint containing isocyanates is the likely sensitizing agent. Once someone is sensitized, smaller and smaller inhalational exposures can trigger asthmatic reactions. It can be stated with relative certainty that with continued exposure to the offending asthmagen in the workplace, this patient's symptoms will worsen over time. Coughing often is an early manifestation of occupational asthma; chest tightness, wheezing, and shortness of breath are likely to follow if exposure continues.

Withdrawal from the workplace exposure is an important first step both in diagnosing occupational asthma and in controlling it. Symptoms of occupational asthma routinely improve during a week away from work and then recur when the person returns to work. Occupational asthma often resolves entirely after removal from the workplace. However, it does not always do so. Prognostic indicators favoring recovery after cessation of exposure include short duration of symptoms before diagnosis and withdrawal, less severe abnormality of lung function at time of diagnosis, and, in some studies, a milder degree of bronchial hyperresponsiveness.

Standard antiasthma therapies, such as bronchodilators and inhaled glucocorticoids, are effective in controlling occupational asthma and constitute standard care. Radioallergosorbent tests to detect specific IgE antibodies are unreliable in assessing occupational asthma. The test often is not available for the specific, suspected sensitizing agent. Even when the tests are available, a positive result indicates only sensitization and does not give conclusive evidence of disease caused by the agent. In any case, the suspected agent for this patient, who is exposed to spray paint, is isocyanates, not anhydrides. Measuring carbon monoxide diffusing capacity has no role in the management of occupational asthma.

References

1. Chan-Yeung M, Malo JL. Occupational asthma. N Engl J Med. 1995;333:107-12.

Answer - Question 2

Answer: B

Educational Objective: Differentiate between rupture of a popliteal cyst and thrombophlebitis.

The probable diagnosis in this man is a rupture of a popliteal cyst (Baker's cyst) into the calf, an event that can mimic thrombophlebitis. It is important that the diagnosis be made because anticoagulation in such a patient can lead to excessive bleeding in the calf muscles and adjacent tissues. Ultrasonography is the best and least expensive technique for displaying a popliteal cyst and its rupture or extension into the lower leg; it will also identify deep venous thrombosis. A helpful sign for diagnosis, when it is found, is the appearance of a crescentic ecchymosis beneath one of the malleoli of the ankle. Before recognizing the usefulness of ultrasonography in making the diagnosis, arthrography (radiographic injection into the knee) was used. If ultrasonography results are equivocal, MRI and CT would be additional techniques for imaging a popliteal cyst. Venography is not indicated.

Although joint aspiration and injection of glucocorticoids into the joint would not harm the patient, it would not help in discerning between phlebitis and rupture of a popliteal cyst. Rarely, both thrombophlebitis and a rupture of a popliteal cyst can occur concurrently.

When the diagnosis of a ruptured popliteal cyst is made, intra-articular glucocorticoids can be used to suppress the inflammation and decrease the volume of fluid in the joint. Popliteal cysts develop when excessive intra-articular pressure causes a posterior herniation, often with formation of a one-way valve effect, whereby fluid forced into the cyst cannot return to the joint space. Rarely, synovectomy of the knee is necessary for recurrent cysts. Surgical excision of popliteal cysts is rarely done because the rate of recurrence is high.

References

1. Hench PK, Reid RT, Reames PM. Dissecting popliteal cyst simulating thrombophlebitis. Ann Intern Med. 1966;64:1259-64.
2. Kraag G, Thevathasan EM, Gordon DA, Walker IH. The hemorrhagic crescent sign of acute synovial rupture. Ann Intern Med. 1976;85:477-8.

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