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March 2006 E-Newsletter

• Leadership Day and Political Activism for Medical Students
• Internal Medicine Interest Group of the Month: Columbia University College of Physicians and Surgeons
• Announcing a New Activity for Medical Students at the Herbert S. Waxman Learning Center During Annual Session 2006 in Philadelphia
• Student Members Receive a 30% Discount When Ordering MKSAP for Students 3
• MKSAP Questions (1,2)
• MKSAP Answers (1,2)

Leadership Day and Political Activism for Medical Students

Last May, leaders in the field of internal medicine, along with representatives of the ACP Council of Student Members, had the unique opportunity to participate in a day-long campaign of lobbying legislators on Capitol Hill concerning an array of pressing medical legislation as a part of Leadership Day 2005. As Leadership Day 2006 approaches this May, I thought I’d use this occasion to reflect on some thoughts concerning medical students and political activism.

Why is it that the vast majority of medical students are not politically active, or for that matter politically aware of those issues that are germane to our profession and are at the forefront of deliberation locally and/or nationally? As bright and motivated as we are, and as vocal as we are for our patients, why are we not just as vocal when it comes to ourselves and our profession?

One thought is that those who matriculate into medical school are not interested in politics, making a conscious decision to shy away from it and focus their energies rather on patient care. But I don’t believe that medical students are by nature apolitical and unable to vocalize themselves when they see a pressing need. In fact, we are constantly focusing our attention on the medical system, researching methods to better patient care and patient outcomes through clinical trials. We are constantly making system changes, which is exactly what is at the heart of political activism—the ability to determine changes that will better the system, and working incrementally to implement those changes. So, I believe that we as medical students do possess the qualities and abilities to be successful activists.

Maybe medical students are too busy to be politically active? As the tome of basic and clinical sciences continues to expand and thus the information that we have to learn and digest within four years continues to grow, we have less free time to focus on other things, including political activism. But medical school, like life, is a juggling act, where we prioritize the things that are important to us. So, as busy as we are, perhaps the problem is more that medical students don’t recognize political activism to be a priority for them.

The postulate I put forth is that the reason why most medical students are not politically active concerning medical issues is three-fold: 1) a lack of understanding that these current issues are important and do directly affect them and the belief that therefore there are more pressing matters to focus their energies upon; 2) a lack of understanding of the issues, which stems from a paucity of politically savvy role models in the field and a lack of education on these topics within the medical school curriculum; and finally 3) a lack of knowledge of reliable resources to become politically aware and make a difference.

“Medicare cuts, information technology, uninsured, patient safety, tort reform—while these issues are all important, they just don’t affect me, at least not right now. These are issues for current physicians, and when I become one then I’ll worry about them.” Underlying this sentiment of disinterest is the lack of recognition that the ongoing issues do, in fact, directly affect medical students and that their voice is an important one in these ongoing debates. One of the key issues argued during last year’s Leadership Day was a push to halt looming Medicare cuts. But Medicare cuts don’t live in a vacuum—they affect everyone. Physicians, especially generalists, geriatricians, those in rural practices, and those caring for a large percentage of Medicare patients in their practices are the ones hit hardest by these looming Medicare cuts. The result will be that more physicians will refuse to care for Medicare patients, and in the end such patients will ultimately suffer, having to travel increasing distances and wait longer periods of time in order to obtain medical care. The bottom line is that patients will suffer, and that is something that we as medical students do care about, as these patients very well could be our own friends and relatives. Moreover, medical students themselves are being affected even more directly. As physician reimbursement from Medicare declines, coupled with increasing medical student debt, fewer students are choosing to matriculate into primary care specialties, particularly general internal medicine and family medicine residencies. And as fewer students choose primary care and more current primary care physicians leave as a result of economic conditions, there will be a significant shortage of generalists in the future.

When it comes to health information technology, can you imagine a future where medical records will be completely paperless; where medical students will be able to easily read a specialist’s consult without a deciphering kit; where we can obtain inpatient and outpatient records by a click of a button, including records from outside institutions so we don’t have to repeat costly studies that were completed prior elsewhere; where checks and balances will be throughout a patient-centered system to prevent medical errors? All these great technological innovations take investment of time and most importantly money before they can be actualized, money which physicians, particularly in solo or small practices and those in rural settings, don’t have, particularly at a time when Medicare reimbursements are being cut. Instead of cuts, we should provide monetary incentives for such practices to implement these information technologies. And medical students should care about this issue because we want electronic medical records that are easy to use, and a computer system that will protect patients and ourselves from medical errors, and reduce health care costs by reducing unnecessary repeat testing. Bottom line: a better system will make us better.

The issue lobbied for during last year’s Leadership Day that had the most obvious implications for medical students was student loan debt relief. Specifically, we supported acts that allowed the refinancing of student consolidation loans more than once, eliminated loan fees to borrowers, and expanded the tax deductibility of student loan interest. If we as medical students will not be vocal and fight for the reduction of our student debt, who will?

Other issues at the forefront last year included reducing the number of uninsured, professional liability insurance reform, patient safety, and funding for health programs, all of which will have implications on our practice of medicine in the upcoming future. So, why don’t we realize the importance of these issues? One of the reasons stems from a lack of politically savvy residents and attending physicians to serve as role models. There is no doubt that the physicians we interact with have a tremendous impact on the physicians we in turn become. We emulate our predecessors, and if they’re politically naïve then it’s more than likely that we too will be uninterested and uninformed. The second reason, which follows the same line of thought, is that medical students possess a deficient knowledge base, frankly because we are not taught the relevant material during our four years of medical schooling. Health policy should be important, and should be more than just learning the definitions of “HMO,” “PPO,” and “fee-for-service.” It should truly examine the system and equip students with the fundamental knowledge base to then visualize the problems in the system and stimulate system change. Perhaps health policy should be positioned into the curriculum in a longitudinal manner, allowing for the exploration of topics throughout our four years.

Lastly, I believe there are plenty of medical students who are willing to be more politically involved in their futures, but simply lack the understanding of how to become involved. Medical students are smart and passionate, but may not know how to impact the system and voice themselves. The first step is to become aware—aware of the issues that are being deliberated. The best way to do that is to consult reputable resources. The ACP runs a Member Advocacy webpage, which highlights national issues, contains useful links, and details the Key Contact Program whereby members can communicate with their Congressional representatives on issues of importance to internists and their patients. Also on the webpage is a link for the Legislative Action Center (LAC) where ACP members can learn further about national legislation and monitor updates, and help with particular causes. Additionally, you can write directly to your Congressmen from the LAC webpage, as logging onto the site automatically generates a listing with pictures of your Congressional representatives. Another good website to learn about pertinent, ongoing medical issues and legislation is the AMA Health Care Advocacy Agenda website. To find out about more local issues, contact your local ACP chapter through the ACP’s website. Your local chapter will be more than happy to provide you with details of ongoing legislation/advocacy issues, and will be thrilled to have students involved.

In conclusion, one of the best parts of last year’s Leadership Day for me was the ability to offer a student perspective on these complicated medical issues and detail their specific implications on medical students. To my surprise I felt it was a perspective to which most legislators had not been exposed. My point, as I step off the proverbial soapbox, is that we as medical students have an important and unique voice on these matters—so let’s make sure we use it and we are heard.

Deepak Pradhan
Jefferson Medical College, 2006
President, Jefferson Internal Medicine Society
North Central Representative, ACP Council of Student Members
e-mail: drp002@jefferson.edu

Internal Medicine Interest Group of the Month: Columbia University College of Physicians and Surgeons

This year, the Internal Medicine Interest Group (IMIG) at Columbia University’s College of Physicians and Surgeons was started by co-leaders Beverly Johnson '06, Jordan Mossler '08 and Elizabeth Oelsner '08, along with help from faculty sponsors, Drs. David Brenner (Chair of the Department of Medicine), Paul Lee (Chief IMIG Advisor, Associate Residency Program Director and Director of the Hospitalist Service), Nicholas Fiebach (Director of the Residency Program), Katherine Nickerson (Vice Chair for Education and Clinical Operations), and Jaime Rubin (Director for Research Development).

For the first year in operation, the program has been very busy, starting with a well-attended "Meet the Medicine Faculty Mixer" at a local restaurant in the fall. This spring, with a funding received from the ACP, the group ran a "Careers in Medicine Dinner" which was attended by over 100 individuals. The program consisted of 10 themed tables, such as primary care and cardiology, each with an attending physician to lead the discussion.

In addition to these large events, there have been shadowing and teaching opportunities for students. First-year students have had the option to shadow a team in the hospital and second-year students have had the opportunity to shadow specialty rounds such as the infectious diseases team. There is also a teaching elective, "Clinical Correlations", co-organized by the fourth- and second-year students. Each week, the fourth-years advise the second-years as to what aspects of their coursework are particularly clinically relevant and then follow up by identifying an appropriate patient in the hospital for them to examine.

For the research-minded, there are “Research Lunches” throughout the year which focus on how to find research opportunities in internal medicine. Equally important, more than 60 different research funding opportunities are described on our website. Dr. Rubin serves as our funding specialist and research advisor.

For more information on our group, please visit our website.

Finally, we would also like to extend a huge thank you to the ACP and the Columbia University Department of Medicine for their financial support this year, helping us take our ideas and making them a reality!

Beverly Johnson, Jordan Mossler, and Elizabeth Oelsner
Co-leaders of Columbia University College of Physicians and Surgeons

Announcing a New Activity for Medical Students at the Herbert S. Waxman Learning Center During Annual Session 2006 in Philadelphia

Students can prepare for the USMLE Step 2 Clinical Skills Examination by using the Learning Center’s professional teaching patients and receive feedback on their performance from expert faculty. To find out about Annual Session 2006 and to register, visit here. All Learning Center activities are free to Annual Session attendees, but onsite advance registration is required.

Student Members Receive a 30% Discount When Ordering MKSAP for Students 3

MKSAP for Students 3 includes over 400 patient-centered self-assessment questions and their answers in print and on CD-ROM. Designed for medical students participating in their clerkship rotation, the questions help define and assess mastery of the core knowledge base requisite to internal medicine education in medical school. The questions reflect the many management dilemmas faced daily by internal medicine physicians and when coupled with the answer critiques, provide a focused, concise review of important content.

New in MKSAP for Students 3: All new questions and critiques; more topics and chapters; 12 Electrocardiogram questions; and 24 color figure dermatology questions. Order online.

MKSAP for Students 3 – Question 1

A 20-year-old woman seeks help for weight. She has always been heavier than she would like, but she has gained almost 13.5 kg (30 lb) since starting college 2 years ago. She has a diet rich in convenience and snack foods and has several alcoholic beverages on most weekends and finds little time for regular physical activity. Her father is overweight and has type 2 diabetes mellitus and hypertension. She does not have polyuria, polydipsia, blurred vision, changes in her skin or hair, changes in her regular menses, or cold intolerance.

On physical examination, she is 167.5 cm (66 in) tall and weighs 99.5 kg (219 lb); her body mass index is 35. Her blood pressure is 148/92 mm Hg. The remainder of her examination is normal.

In addition to an exercise program, which of the following is the most appropriate management of obesity in this young woman?

( A ) A calorie deficit of 500 kcal/d
( B ) A protein-rich, carbohydrate-restricted diet
( C ) Orlistat, 120 mg with meals, plus a calorie deficit of 500 kcal/d
( D ) Sibutramine, 10 mg/d, plus a calorie deficit of 500 kcal/d

MKSAP for Students 3 – Question 2

A 60-year-old man with severe, crushing chest pain of 15 minutes' duration is evaluated in the emergency department. An electrocardiogram shows the onset of an arrhythmia.

What is the abnormal rhythm seen on the electrocardiogram?

( A ) Atrial flutter
( B ) Atrial fibrillation
( C ) Atrial tachycardia
( D ) Ventricular tachycardia/fibrillation

MKSAP Answer 1

Answer = A

Educational Objective: Recognize the optimal initial medical management of obesity.

This patient is obese, with a BMI of 35, which confers high risk for complications of obesity, including hypertension, type 2 diabetes mellitus, and cardiovascular disease, independent of the presence or absence of other risk factors. The presence of other risk factors, including smoking, existing hypertension, dyslipidemia, or diabetes, would certainly further increase her risk.

The optimal initial management of obesity includes changes in both diet and exercise. Typical physical activity accounts for only 15% of daily caloric expenditure. Exercise may increase this caloric expenditure somewhat, but is not sufficient to achieve sustainable weight loss. Current dietary recommendations include a balanced diet with a negative caloric balance of 500 to 1000 kcal/d. A negative caloric intake of this scale will result in a 0.5 to 1.0 kg (1 to 2 lb) per week weight loss over the initial 6 months of the diet. Diets rich in fat tend to be high calorie, and saturated fats, in particular, are implicated in cardiovascular risk. Recommended diets generally include less than 30% of caloric intake from fat. Convenience and snack foods tend to be rich in fats and refined sugars, and are very calorie-dense. Minimizing these foods is essential for weight loss. Excessive alcohol consumption is incompatible with weight loss. Very-low-calorie diets and rapid weight loss are potentially harmful. Diets rich in protein and fat, and very low in carbohydrates (the Atkins' Diet) are effective for weight loss, largely by limiting caloric intake, but are of uncertain safety in terms of their effect on lipids.

Exercise is an essential component of sustainable weight loss. Patients who succeed with weight loss achieve lasting changes in habits of diet and daily exercise. Exercise has additional salutary effects on cardiovascular risk independent of weight loss.

Pharmacologic therapy with sibutramine or orlistat, although successful in short-term weight loss, is generally reserved for patients who have not achieved weight loss goals after trials of diet and exercise alone. These agents are most successful when coupled with diet and exercise. Weight lost is typically regained following cessation of pharmacologic therapy.

References

Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. NIH publication no. 98-4083. Bethesda, MD. 1998.

MKSAP Answer 2

Answer = D

Educational Objective: Diagnose ventricular tachycardia/fibrillation.

This electrocardiogram shows the degeneration of sinus rhythm into polymorphic ventricular tachycardia. This rhythm, unless treated, will degenerate into ventricular fibrillation. There is a relatively arbitrary distinction between polymorphic ventricular tachycardia and ventricular fibrillation, based on cycle length. Both rhythms are lethal and require immediate correction.

Atrial flutter is characterized by monomorphic P wave morphology in lead V1 and the inferior leads. In addition, a sawtooth pattern is present in leads II, III, and VF. Atrial tachycardia has an isoelectric interval between P waves. However, if the atrial rate is fast enough, the P waves can merge with the T waves, making it impossible identify them. Atrial fibrillation is characterized by the complete absence of P wave activity and an irregularly irregular ventricular rhythm. Atrial flutter, atrial tachycardia, and atrial fibrillation are associated with narrow QRS complexes (unless there is a coexisting conduction block), whereas ventricular tachycardia and fibrillation are associated with bizarrely shaped, prolonged QRS complexes.

References

Hudson KB, Brady WJ, Chan TC, Pollack M, Harrigan RA. Electrocardiographic manifestations: ventricular tachycardia. J Emerg Med. 2003;25:303-14.

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