March 2008 E-Newsletter
- Legislative Action Alert: 20/220 Economic Hardship Student Debt Deferment
- Medical Student Perspectives: Cultural Differences in Patient Care
- My Kind of Medicine: Women in Medicine Panel Discussion
- Internal Medicine Interest Group of the Month: Uniformed Services University of the Health Sciences
- Winning Abstracts from the 2007 Medical Student Abstract Competition: Neutropenic Fever and Thrombocytopenia in a Returning Traveler.
- Subspecialty Careers: Highlights about Careers in Internal Medicine: Hospice and Palliative Medicine
- Advocacy Briefs: Enroll in ACP’s Key Contact Program
- Did You Know there are Special Events for Medical Students at Internal Medicine 2008?
- Learn about residency programs at the Residency Fair.
- Attend the Clinical Skills Review Course.
- Volunteer to work during the meeting.
- MKSAP for Students 3 Questions (1,2)
- MKSAP for Students 3 Answers (1,2)
- Announcing the Internal Medicine Essentials for Clerkship Students 2007-2008 Textbook
- Articles for Medical Students from ACP Internist and ACP Hospitalist
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Legislative Action Alert
Contact your members of Congress now to stop the elimination of the 20/220 economic hardship student debt deferment pathway. Go the Legislative Action Center to take action. You do not have to be a Key Contact or ACP Member to use the Legislative Action Center. Please forward this link to as many medical students as you can.
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Medical Student Perspectives: Cultural Differences in Patient Care
In 2006, the United States spent over $2 trillion, or 16% of its GDP, on healthcare expenditures, the world’s highest. Despite this, minorities tend to have less access to healthcare; and when they do, their health outcomes are worse when compared to whites with similar diseases, age, socioeconomic status, and other potential confounding factors (Smedley, Stith, & Nelson, 2002) (see Figure 1). Cultural and linguistic barriers in the health care setting are thought to be among the top causes for these disparities. The American College of Physicians (ACP) has outlined cultural competency as one of the major methods of addressing these barriers.
Cultural competence is defined as “the ability of health care providers and institutions to deliver effective services to racially, ethnically and culturally diverse patient populations.” But how do we as a medical community, and specifically as medical students, even begin to approach this?
As we begin our clinical years, we are already faced with many challenges as we transition our knowledge into practice. An additional layer of complexity is added when we consider the extremely diverse backgrounds from which our patients come. It may be easier in these instances to focus on “the medicine” and disregard the psychosocial aspects of a patient’s life. However, these may be some of the most important factors that contribute to how your patients view health and healthcare and can therefore influence their adherence to treatment/lifestyle changes, satisfaction with their healthcare, and ultimately, their overall well-being (see Figure 1). Addressing these psychosocial aspects moves us toward becoming culturally competent and, therefore, more effective physicians.
Figure 1. Factors that Seem to Independently Contribute to Health Behaviors (Bigby, 2003)
1.) Exposure to biomedical and popular standards of care as determined by:
b. Generational status c. Level of encapsulation within ethnic and family social network d. Experience of medical treatment e. Previous experience with particular diseases f. Age at immigration (if applicable) g. Degree of migration back and forth to country of origin (if applicable) 3.) Occupation 4.) Area of origin in native country (if applicable) 5.) Religion |
It is reasonable to assume that most providers would find it morally and professionally objectionable to be prejudiced or biased against certain minority groups. However, whether conscious or not, and despite best intentions, “healthcare providers’ diagnostic and treatment decisions, as well as their feelings about patients, are influenced by patients’ race or ethnicity” (Smedley, Stith, & Nelson, 2002).
An excellent starting point to untangle and understand the origins of these biases is to consciously analyze what makes up your own culture and beliefs. Only after a thorough analysis of your own biases and prejudices can you begin to deconstruct them. These values are what make up your relative assessment of others. Careful self-assessment and critique are the first steps towards cultural competence (Bigby, 2003).
Several models and strategies have been developed to improve patient interactions and can be applied in the setting of cultural differences (see Figures 2 and 3).
Figure 2. Models for Improving Patient Interactions
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LEARN Model 1 RESPECT Model 2
1 (Berlin & Fowkes, 1983) |
Figure 3. Some Additional Strategies for Clinical Cultural Assessments
(Adapted from Diversity Rx Website; Bigby, 2003)
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1.) Patients should be considered as individuals first. 2.) Do not assume that ethnic identity indicates specific cultural values or behavior. 3.) Most people from racial and ethnic minority groups are bicultural in American society; however, the degree of acclimatization varies. 4.) Some aspects of a patient’s cultural history, values, and beliefs are relevant to clinical situations and some are not. Do not prejudge which are relevant; let the patient tell you. 5.) Identify strategies taken from the patient’s cultural orientation that you both can use to enhance the therapeutic alliance. Acknowledge those that seem counter-productive. |
In addition to culture, another major barrier to the reduction of healthcare disparities is linguistic barriers. According to Title VI of the Civil Rights Act of 1964, “no person in the United States shall on ground of race, color or national origin be excluded from participation and be denied the benefits or be subjected to discrimination under any program or activity receiving federal financial assistance.” For patients who have limited English proficiency, it is the responsibility of the physician to find a way to overcome these language barriers in order to provide an equivalent level of care as would be received by an English-speaking patient.
This can be achieved through trained professional interpreters, or an interpretation phone system. It is not acceptable to use patients’ family members or friends for many reasons. The ability of the interpreter is unknown, as are their potential personal agendas. It also may hinder the collection of accurate data, particularly on sensitive topics. Additionally, one should note that physicians often overestimate their fluency in other languages. Research has shown that providers usually overestimate their language proficiency and patients often do not understand what the provider is communicating (Bigby, 2003). This can be dangerous as misunderstandings can easily occur. Therefore, physicians should be certain of their fluency, and err on the side of caution and use a professional interpreter when in doubt.
When using an interpreter, there are some general guidelines that should be followed for effective communication in these settings. In an ideal situation, the physician should meet with the interpreter before the patient encounter to determine whether the interpreter is bicultural as well as bilingual. Those that are bicultural can be used as a resource during the interview. The style of interpretation (phrased, simultaneous or summary) should also be discussed and determined based on the type of interaction taking place. And lastly, it should be stressed that physicians should still make an effort to establish rapport with their patient through the interpreter. Patients who require interpreters should not be treated differently from the patient care or personal perspectives.
I hope that you can begin to see some of the issues and challenges involved in eliminating the disparities in minority healthcare. Articles, books and documentaries abound studying cultures and their beliefs and practices. It was not the goal of this article to familiarize you with all of these or provide a comprehensive manual for how to approach your patients of various backgrounds. However, I hope that it did serve to familiarize you with the concept and importance of cultural competency, provide some general models for approaching patients of different cultures, unearth some of your personal or professional prejudices and serve as a springboard from which to begin your own changes and pursuit of knowledge based on your unique practice and patient population.
For a more detailed discussion and additional information on these topics, I highly recommend the book Cross-Cultural Medicine edited by JudyAnn Bigby, MD. Also, many ACP policy papers abound, and provide interesting discussions on policies and curriculums to reduce disparities in healthcare.
Andrew A. Chang, MA
North Atlantic Representative, Council of Student Members
Health & Public Policy Committee Representative
New York Medical College, MD/MPH in Health Policy & Management
Class of 2008
Co-Founder, La Casita de la Salud,
The NYMC Student-Run Clinic in East Harlem, NY
E-mail: andrew_chang@nymc.edu
References
American College of Physicians. (2004). Racial and ethnic disparities in health care: a position paper of the American college of physicians. Philadelphia: Annals of Internal Medicine, 141, 226-232.
Berlin EA, Fowkes WC. A teaching framework for cross-cultural health care.West J Med. 1983;139:935.
Bigby, JudyAnn, Cross Cultural Medicine. Philadelphia: American College of Physicians, 2003.
Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57 Suppl 1:181-217.
Brach C, Fraser I. Reducing disparities through culturally competent health care: an analysis of the business case. Qual Manag Health Care. 2002;10:15-28.
Harwood A. Guidelines for culturally appropriate health care. In: Harwood A, ed. Ethnicity and Medical Care. Cambridge, MA: Harvard University Press: 1981:483-507.
Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-8.
Smedley BD, Stith AY, Nelson AR, eds. (2002). Unequal treatment: confronting racial and ethnic disparities in health care. Institute of Medicine. Washington, DC: National Academies Press.
Smith WR, Betancourt JR, Wynia, MK, Bussey-Jones J, Stone VE, Phillips CO, Fernandez A, Jacobs E, Bowles J. Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med. 2007; 147:654-665.
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My Kind of Medicine: Women in Medicine Panel Discussion
Ruth Parker, MD, FACP; Christine Reimer, MD, FACP; Susan Hingle, MD, FACP; and Karen Hsu Blatman, MD
To commemorate Women’s History Month, this month’s IMpact profile features four of our female physician members who recently came together for a panel discussion. Our panelists were a diverse group, representing different areas of the country and ranging in experience: Dr. Ruth Parker, a general internist and professor of medicine at Emory University School of Medicine in Atlanta GA; Dr. Susan Hingle, a general internist, internal medicine clerkship director, and associate residency program director at Southern Illinois University School of Medicine in Springfield, IL; Dr. Christie Reimer, a hospitalist and associate program director with the University of Iowa in Iowa City, IA; and Dr. Karen Hsu Blatman, a resident at the University of Virginia in Charlottesville, VA.
During the discussion, panelists talked about what they love about their jobs, as well as what some of their challenges have been, and shared everything from being a new mom, to showing emotion on the job, to being the only woman at the table. Below are highlights.
To listen to the panel discussion in full length or to access ACP’s additional resources about women in medicine, please visit the Women in Medicine Web site.
Q: The percentage of women entering the medical field has increased significantly, particularly in the last 20 years. In your opinion, is discrimination even an issue anymore for women in the workplace?
Dr. Parker: “I think it’s probably still there to some degree, but there’s definitely been a shift. For one thing the numbers of women who are in medical school and medical school training are up enormously. There’s no question that the critical mass has had an impact. But we definitely don’t see those kinds of numbers in leadership roles at high levels—whether it be in academic medicine as Dean or Chair or in leadership roles of big private practice groups and multi-specialty groups. And I think it’s probably for a combination of reasons. There probably are some barriers that have been related to gender and other issues, but I think for some it might be a matter of lifestyle choices.”
Dr. Reimer: “I agree that there are fewer women in leadership positions than in other places in medicine, and I also think that’s multi-factorial. I think it may include things like lifestyle choices, and the fact that only recently have medical students been nearly 50 percent women and it takes a while for that class of women to rise up through the ranks.”
Dr. Hingle: “I don’t feel that my gender has been detrimental in any way as far as me achieving what my goals are. I think if we want more women in leadership positions, I don’t know that I would say it’s lifestyle choices, I think maybe it’s redefining expectations.”
Dr. Hsu Blatman: “I don’t think it’s an issue of discrimination, I think what it is is ‘time off the clock.’ What’s interesting to me is that my husband has actually gotten a lot more flak from being at Harvard Medical School to now being a part-time dad and working what may be perceived as a less prestigious job. But he feels fulfilled—being able to do the teaching and clinical stuff, and being able to take care of the family, which has allowed me to be full time in residency and do additional things that I’ve wanted to. There is no way I would be able to do this if it weren’t for my husband.”
Q: How do you balance everything?
Dr. Reimer: “I had a conversation yesterday in the hall with one of my colleagues here about this. I think by the nature of the profession we’re in, most of us are used to giving 100 percent of our time to what we want to do and what we’re good at, and that’s medicine. And then particularly when you have a child that changes, because you want to give 100 percent of the hours in your day to your child and your family…and 100 percent to your career and job. And I think that’s a hard lesson learned by a lot of people in our profession, that you just can’t give all of your hours to more than one thing.”
Dr. Parker: “I would be the first to say there are only so many hours in a day, and it took me a long time to realize that. On top of that, a couple can only do so much, a family, parents….you have to figure out what you really are going to do and how you’re going to make it happen. But at the end of the day, what really matters is feeling good about your kids and your family and what you’re doing and realizing you can only do so much. But I didn’t start out knowing that. I grew into it.”
Dr. Hsu Blatman: “I have a great husband. He actually chose to leave an excellent institution and was willing to come down to a place where I found was much more family-friendly. He also went part-time so I can finish out residency. We’ve recently realized just how stressful it’s been for both of us to be full time and to not have any family around, because he’s actually had to go full time for the last couple of months. We’ve realized that it’s just not doable.”
Q: The issue of assertiveness is a tricky one for women. Women are encouraged to be assertive and have to be in certain fields, but yet if you’re too assertive or aggressive, a woman can seem difficult or demanding. What has your experience been with this?
Dr. Hingle: “I think in general that assertiveness is looked favorably upon, and being overly emotional is harder for people to deal with in women. Occasionally when I’ve gotten emotional in discussions, sometimes that’s harder to deal with than when you’re assertive. Have I ever had the experience where being assertive has not been well taken? Yes. Is it because I’m a female? That I’m not sure. Sometimes, I suspect it might be. Other times I may suspect that it’s just the person on the receiving end, that it’s their position and not really anything in what I did. And when that happens, I just try to step back and think of if there’s a different way I could present the point that I’m trying to make.”
Dr. Reimer: “I’m still working on my communication skills and I’m not sure if that’s a function of my gender. But I think as we learn to interact with patients, we learn to interact with peers and other people with whom we work, and we all have communication skills to learn. I admittedly have had to learn to be a little more assertive, as I’ve become more involved in some administrative roles.”
Dr. Parker: “I would add that I think as more women become part of the infrastructure of the care teams, academic teams and everything around patient care, that I do think there is a greater emphasis on getting the voice of everybody at the table heard. I can remember when on so many committees where I was the only woman at the table. Now there are several women on a lot of them.”
Q: Did you have a female mentor who has made a difference for you?
Dr. Reimer: “I was lucky enough to have Donna Sweet who is well known in the ACP circles as one of my faculty as a resident and also when I worked with her as a junior faculty peer. She was probably my first career mentor and she was great. I’ve learned so much from her, from things ranging from patient care and always putting the patient first to communication skills to how to deal with administrative things that I hadn’t dealt with before.”
Dr. Hingle: “I actually have not had a female mentor—I’ve had excellent mentors throughout my career so far who have been very supportive. But to this point, they’ve all been men. And I feel like it probably would have made things a little bit easier, had I had a strong female mentor. But one important thing I did learn from them was learning how to say no, and I think this is something that Dr. Parker was alluding to. You’re going to be most effective when you aren’t overwhelmed and you’re able to fully put forth your effort into the projects you have. And that’s been a difficult thing for me to learn, and I don’t know if it is gender related. That may be an area where having had a strong female mentor might have made an impact.”
Dr. Hsu Blatman: “I have been able to encounter a lot of different people and tailor my experience with them to the specific questions I’m interested in. One thing that’s really helped me is hearing people’s stories and how they’ve gotten to where they are, and thinking about those stories and taking some of those lessons and making them personal.”
Q: What do you love about being an internist? What do you love about being a woman physician?
Dr. Parker: “I have a great job—I love my job. Internal medicine has given me enormous flexibility—I have four kids and a husband who works way too much, and I have a lot of other passions and interests outside of practicing medicine that I’m able to pursue. So it’s been incredible to be able to have that kind of flexibility.”
Dr. Reimer: “I feel like I’ve been very lucky. I have had very supportive division chiefs and department chairs and mentors. I feel like I’ve had a fair chance at everything that I’ve wanted to do or tried to do. I think residents—women and men have so many opportunities open to them.”
Dr. Hingle: “I feel like I’m in a very supportive environment. I don’t think I could ask for a better place to work.”
Q: If you were talking to a younger woman colleague or medical student and she asked you for a piece of take-away advice, what would it be?
Dr. Parker: “Don’t take it too seriously. Enjoy yourself and laugh and have fun. Find the joy. I think that’s the key to it all. It’s all right there for you.”
Dr. Hingle: “Find your passion. And allow yourself to be a full person and not just a doctor.”
Dr. Reimer: “I feel the same way. I try to encourage people to find multiple passions and work to be able to do all of those things that make them happy and make them a whole person.”
Dr. Hsu Blatman: “I remember when I told my husband I was going to be going to medical school him saying, ‘The problem is the way the system is. You take all of these fascinating people who get into medical school and then you make them into very boring people!’ Life is more than just work and you have to find the things that you’re interested in doing as opposed to maybe picking the specialty that’s most prestigious. Go back and think ‘Is this something I’m going to be happy doing for the rest of my life?’”
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Internal Medicine Interest Group of the Month: Uniformed Services University of the Health Sciences
The Uniformed Services University of the Health Sciences (USUHS) is proud to host the 2008 Medical Students’ Steps to Success Meeting on Saturday, April 5th. This unique event brings together medical student leaders from local internal medicine interest groups at USUHS, Howard University, Johns Hopkins University, George Washington University, Georgetown University, Rush University, and University of Maryland. Working in conjunction with the Maryland, District of Columbia, Army, Navy, and Air Force chapters of the American College of Physicians (ACP), the meeting provides medical students an opportunity to interact with internists representing the diversity of this field, such as generalists, academicians, and subspecialists.
The Steps to Success Meeting represents the fruition of several unique and innovative ideas. Founded as a way to bring medical students from local schools together with a common interest in internal medicine, the meeting has grown in success and popularity with each passing year. Sponsored by the ACP and dedicated to medical students, the Steps to Success Meeting enables students to present their research not only to their peers, but physician experts in the field of internal medicine. Students also gain valuable experience in applying these findings to clinical medicine.
In addition to the robust research experience, students have the opportunity to ask interns, residents, and physicians in the field of internal medicine tough questions on topics ranging from finances to lifestyle to universal healthcare to the future of internal medicine through a series of panel discussions. The meeting hosts specialty session workshops that provide hands-on teaching exercises, such as a simulated code, transthoracic echocardiography, and joint injections. Students are also provided with useful tips for success in clerkships and in the match from experienced faculty. Another panel discussion will focus on the different issues facing single and married medical students as they transition into residency. The meeting will end with a social event complete with food, drink, and music. We encourage all medical students in the Maryland, DC, and Virginia areas to attend and learn about the nearly limitless opportunities the field of internal medicine has to offer. If you are interested in attending, please register using the link below by March 24th, 2008.
For more information, please see:
2008 Steps to Success Meeting General Information
Register for the 2008 Steps to Success Meeting
USUHS Club Med Faculty Advisors
Capt. Jeff LaRochelle, MD, USAF MC, jlarochelle@usuhs.mil
Dr. Steve Durning, MD, FACP, sdurning@usuhs.mil
USUHS Club Med Student Leaders
2LT Daniel Lee, MS, USA, s10dlee@usuhs.mil
2LT Grigory Charny, MS, USA, s10gcharny@usuhs.mil
2LT Samuel Holmes, MS, USA, s10sholmes@usuhs.mil
ENS Brad Williams, MC, USN, s10bwilliams@usuhs.mil
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Winning Abstract from the 2007 Medical Student Abstract Competition: Neutropenic Fever and Thrombocytopenia in a Returning Traveler.
Author:
Ryan Hollenbeck, University of Iowa Carver College of Medicine
Introduction
Tropical diseases are rarely seen in the Midwest, and fever in the returning traveler often poses a significant diagnostic challenge.
Case Presentation
A 26-year-old male medical student presented to the student health department four days after returning from the Riviera Maya on Mexico's Yucatan Peninsula. Two days prior to presentation he began to experience severe abdominal cramping and watery diarrhea. He was given ciprof1oxacin as empiric treatment for traveler's diarrhea, which resolved that day. On the morning of presentation he became symptomatic with chills, fevers to 104°F, severe myalgias, and burning eye pain. Physical exam was unremarkable except for diffuse nontender lymphadenopathy. Complete blood count revealed leukocytopenia, thrombocytopenia, and neutropenia. Blood cultures, stool cultures, stool ova and parasite, and malaria thin and thick smears were negative. Electrolytes, BUN, creatinine, and liver function tests were all within normal limits. He was treated with ceftriaxone for suspected enteroinvasive bacterial infection and sent home. Over the course of the three days following presentation he continued to experience intermittent fevers from 101-103°F despite receiving ceftriaxone infusions daily. His leukocyte, platelet, and neutrophil counts continued to drop. He was hospitalized for neutropenic fever of unknown origin. The differential diagnosis included typhoid fever, enteroinvasive salmonella, shigella, campylobacter, or yersinia, EBV mononucleosis, CMV, dengue fever, and ehrlichiosis. He was treated with cefepime and doxycycline. The fevers abruptly stopped on the second day of hospitalization, his blood counts began to normalize, and he was discharged feeling well. Serologic tests were significant for reactive heterophile antibody, CMV and EBV serologies consistent with past exposure and no acute infection, negative ehrlichia serologies, and strongly positive dengue fever IgM. The diagnosis of dengue fever was confirmed.
Discussion
Dengue fever is an acute febrile viral disease caused by one of four serotypes of f1avivims transmitted by the Aedes aegypti mosquito. The acute infection is characterized by headaches, GI disturbances, myalgias, arthralgias, prostration, lymphadenopathy, leukocytopenia, high fever, and retroorbital eye pain. Dengue fever is the most significant arthropod-born viral disease worldwide, found in over 100 countries and causing 50-100 million cases of infection annually. However, the patient described represents only the second confirmed case in Iowa since 2001 . This case illustrates several important points including the classic signs and symptoms of dengue fever, the diagnostic challenge posed by diseases not endemic to an area, and the spreading epidemic of dengue fever in the tropics.
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Subspecialty Careers: Highlights about Careers in Internal Medicine: Hospice and Palliative Medicine
The Discipline
Palliative medicine aims to relieve symptoms and pain a patient suffers due to a serious illness. Goals of palliative care include reducing suffering, improving the quality of life for a patient, and supporting the patient and family throughout the treatment process.
Hospice care is provided for patients facing a terminal diagnosis who no longer wish to undergo curative treatment. Goals of hospice care include relieving symptoms and supporting patients in the end-of-life stages.
Training
Hospice and Palliative Medicine fellowship training requires an additional year of accredited training beyond general internal medicine residency in a Hospice and Palliative Medicine fellowship training program.
Certification
The American Board of Medical Specialties approved the creation of Hospice and Palliative Medicine (HPM) as a sub-specialty of ten participating boards in September 2006. The American Board of Internal Medicine is one of these boards. The first certification exam will be held in October 2008, and will then be offered every other year.
Major Professional Societies
American Academy of Hospice and Palliative Medicine
4700 W. Lake Ave.
Glenview, IL 60025
Phone: 847-375-4712
Fax: 847-375-6475
Web site: http://www.aahpm.org/
Major Publications
American Journal of Hospice and Palliative Medicine
Journal of Palliative Medicine
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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 nearly 4,500 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 with 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 there are Special Events for Medical Students at Internal Medicine 2008?
ACP's annual meeting, Internal Medicine 2008, held May 15-17 in Washington D.C., contains a variety of events and courses geared toward Medical Student Members. Please visit ACP's Web site for a complete listing of these events.
.Learn about residency programs at the Residency Fair.
The Fourth Annual Internal Medicine Residency Fair will be held during ACP’s national scientific meeting, Internal Medicine 2008 on Saturday, May 17th from 2:00 to 5:00 p.m.
At the Residency Fair, you will learn about internal medicine residency programs throughout the United States, while you gather essential information about the residency application process and the Match. You will also have the opportunity to practice your networking skills while introducing yourself to internal medicine residency program staff and meeting fellow medical students.
Register now for Internal Medicine 2008. If you have questions about the Residency Fair please e-mail Membership Development.
.Attend the Clinical Skills Review Course.
Students can prepare for the USMLE Step 2 Clinical Skills Examination by participating in the Waxman Clinical Skills Center Step 2 Practice Session. This workshop consists of four stations that simulate the experience of the USMLE Step 2 Clinical Skills Exam. Professional teaching patients (standardized patients) will present you with common problems and provide expert feedback on your history and physical examination skills, communication skills, and written note. A checklist score will be generated and shared with you in addition to other verbal feedback on your global performance. You will be provided with a written note summarizing the feedback, highlighting areas of strengths and weaknesses. Two students will be paired for the four station workshop, allowing each student two "hands-on" experiences and two observation experiences.
Features include:
I. Assessment orientation
II. 4 Station Clinical Skills Assessment
- 15 minutes per patient visit
- 10 minutes immediate feedback for 2 stations
- 10 minutes for 1 patient note
III. Detailed performance profiles of scores for each of the areas of a Clinical Skills Examination:
- conducting a relevant patient history
- performing a focused physical examination
- providing diagnosis
- communication and interpersonal skills
- 1 graded patient note for accuracy and completeness
- English proficiency
Here are representative comments from previous medical student participants in this highly rated workshop:
- These teachers are excellent! Want more time with them!
- The training was desperately needed. I've really gained insight on my strengths and weaknesses in the clinical setting.
- Best activity so far in the conference.
- Feedback was key!
Activities in the Herbert S. Waxman Clinical Skills Center are free of charge but require onsite advance registration. Please visit our Web site to learn more.
.Volunteer to work during the meeting.
The College needs medical students with basic to intermediate computing skills to help in our medical informatics workshops. Students will be paid a small honorarium ($100 per half-day, $200 for a full day).
If you are attending Internal Medicine 2008 and would like to help, please contact Lisa Rockey at (800) 523-1546 ext. 2588 or lrockey@mail.acponline.org.
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MKSAP for Students 3 Question 1
A 63-year-old woman is hospitalized because of refractory cellulitis. An intravenous cephalosporin is started, and she appears to be improving. On the fifth hospital day, she develops profuse diarrhea and a low-grade fever. Her abdomen is soft, with minimal diffuse tenderness to deep palpation and normal bowel sounds.
Which of the following is the most likely diagnosis?
A. Clostridium difficile infection
B. Cryptosporidium infection
C. Drug fever
D. Enterotoxigenic Escherichia coli toxin ingestion
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MKSAP for Students 3 Question 2
A 21-year-old woman is evaluated for a murmur that was discovered during a sports physical examination. She has no significant medical history. She runs 3 to 8 miles daily and participates in moderate-intensity resistance training. She has no exertional chest pain, unusual exertional dyspnea, lightheadedness, or syncope. She has no family history of premature cardiac disease or sudden cardiac death.
On physical examination, her heart rate is 52/min and blood pressure is 98/60 mm Hg. Cardiac auscultation shows a 2/6 systolic, crescendo-decrescendo murmur that is loudest in the left upper sternal border.
Which of the following additional findings warrants an echocardiogram?
A. Murmur that decreases in intensity during Valsalva maneuver
B. Murmur that peaks in intensity late in systole
C. S2 that splits only during inspiration
D. S3
E. Split S1
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MKSAP for Students 3 Answer 1
Answer: A, Clostridium difficile infection
This patient is at high risk for Clostridium difficile infection on the basis of her hospitalization and treatment with antibiotics. In high-risk patients with suspected C. difficile infection, empiric contact isolation should be instituted until the pathogen can be ruled out, as C. difficile is easily spread by contact and may cause outbreaks of nosocomial diarrhea. Treatment of C. difficile diarrhea requires discontinuing the causative antibiotic and starting metronidazole or oral vancomycin.
Cryptosporidium is a protozoan parasite that produces sporadic cases of self-limited diarrhea in healthy individuals and intractable diarrhea in immunocompromised patients. It is a watery, noninflammatory diarrhea. The association of fever argues against Cryptosporidium infection as a cause of diarrhea, and the close association with recent antibiotic treatment more strongly suggests C. difficile as the source of infection.
Drug fever can be the sole manifestation of an untoward drug event, and risk factors include older age and multiple drug use. Fever may be the only manifestation of a drug reaction, or it can be part of a hypersensitivity syndrome, with skin, renal, joint, or pulmonary involvement. Diarrhea is rarely, if ever, a manifestation of drug fever.
Enterotoxigenic Escherichia coli is typically associated with nausea and vomiting, followed by diarrhea, within 12 hours of ingestion of the preformed toxin, making this etiology quite unlikely in this patient.
Bibliography
Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1996;17:53-80. PMID: 8789689
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MKSAP for Students 3 Answer 2
Answer: B, Murmur that peaks in intensity late in systole
This patient likely has a flow murmur, an innocent murmur that reflects normal cardiac outflow without concomitant cardiac disease. Flow murmurs may be more prominent in young, thin patients, in whom heart sounds are well heard, and in athletes, in whom stroke volume may be increased. Flow murmurs peak in the first half of systole.
The decision to perform echocardiography is affected by the characteristics of the murmur and the presence of accompanying symptoms or signs. A late-peaking systolic murmur suggests left ventricular outflow obstruction, and further testing should be considered. A soft S3 is common in children and young adults, and does not indicate underlying cardiac disease. Similarly, dynamic splitting of S1 and splitting of S2 during inspiration are normal, and do not require additional evaluation. Murmurs of dynamic subvalvular left ventricular outflow obstruction associated with hypertrophic cardiomyopathy increase during Valsalva maneuver. Murmurs of aortic and pulmonic stenoses and those of mitral and tricuspid regurgitation diminish during Valsalva maneuver. The intensity of an innocent flow murmur also diminishes during Valsalva maneuver.
Bibliography
ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol. 1998;32:1486-588. PMID: 9809971
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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 online with clinical photographs, tables, screening tools, and other instruments. 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 or call ACP Customer Service 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)
- Mindful Medicine Case Study: Patient’s doubts about diagnosis prompt a second opinion.
- Diabetes project narrows gap between theory and practice.
ACP Hospitalist
- It’s not an admission, it’s an experience. Cleveland Clinic’s chief experience officer leads the way in improvements for patients.
- E-learning for everyone. Virtual patients expose students and physicians to a wide range of clinical scenarios.
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