March 2009 E-Newsletter

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Women in Medicine: Work Life Balance

In honor of Women’s History Month, ACP members Kimberly Bates, MD, FACP, Cecily Peterson, MC USA, FACP, and Janis Blair, MD, shared with us their experience, insight and wisdom of what it means to be a physician, wife, and mother all at once. Between them they have served in the U.S. Army, survived breast cancer twice, and led the next generation of female physicians in their careers. They are as diverse as they are the same, but all are an example of how female physicians can enjoy a balanced, fulfilling life without compromising their professional careers.

Why “No” Means “Yes”
Career Day in 1988 at Bishop Hartley High School in Columbus, Ohio may have passed without much consequence for many of her fellow students, but not for Kimberly Bates, who made the decision to become a doctor. Fast forward 21 years, and the petite Dr. Bates, still in the Columbus area, has accomplished that goal and so much more. She is a wife, a mother of a two and a half-year-old son who she describes as “opinionated,” an internist, a pediatrician, and a medical director of an HIV clinic. She is also a survivor of breast cancer, diagnosed in her third year of residency, and again in January 2008. Instead of dwelling on the negative, however, Dr. Bates turned the experience to her advantage. “It made me a better physician,” she explains. “Being the patient for once taught me the true meaning of empathy. It has changed the way I talk to patients.” Something else that has helped her become a better physician she says is learning how to say no. “It can be tough to say no as a woman,” she says, “because you feel as though it might counteract all of your efforts to move up the academic ladder, and you also don’t want to feel like you are asking too much, but it’s the right thing to do.” After deciding to make schedule changes and cut back on administrative work a few years ago, Dr. Bates says she knows for a fact that it was the right decision. “People who are happy in their professional lives are happy in their personal lives,” she says.

Dr. Janis Blair, a seasoned internist and infectious disease specialist at the Mayo Clinic in Phoenix, Arizona, agrees. After running herself nearly ragged as one of two partners in a two-physician practice earlier in her career, her decision to cut back hours proved to be the right move. Now at Mayo, she puts in a full day consulting with patients on infectious disease cases and working with colleagues, but the workload still allows her time to lead a well-rounded existence. For example, before she even sets foot in the hospital each day, she has gone for a swim and driven her two teenage boys to school. She eats dinner with her family every night—no exceptions. It is a full and demanding life to be sure—she hits the sheets at 9:30 to start the whole thing over again the next day—but it’s exactly the life she wants to lead. “My kids make fun of me because I go to bed earlier than they do!” she jokes, “but it is a marathon, not a sprint. The decision to rearrange and prioritize has served me well and helped me balance things.”

The Unlikely Advisor
For Dr. Peterson of Olympia, Washington, the need for change came after she had her second child. As a Lieutenant Colonel in the Army (from which she is recently separated), she was used to pushing herself, but knew something needed to give. “You have to take a long look at who you are and what your strengths are,” she says. “At the time, I was one of those people who put everything before home life. I had to be honest with myself.” She was unsure how to go about it. Ironically, she learned how to do it not from another woman, but from her own husband, also in the Army and an urologist. Dr. Peterson says he is a model of efficiency. “He conducts meetings standing up.” But more than that she says, he is not afraid to ask for what he needs. “I learned from my husband that it is reasonable to ask,” she says. “He’s not afraid to say ‘I need this’ and be insistent on it and state it as a fact.” She took her husband’s advice when she moved into hospital medicine, asking for limitations in administrative work and negotiating for personal time. Her advice for women physicians unsure about how to approach asking for maternity leave is to be up front. “You can get further in negotiations when you talk about your own strengths and weaknesses,” she explains. “When I got my current job I said at the outset ‘this is what I need to be the most effective doctor for you. If you give me “x,” I will be more effective.’”

Dr. Bates learned this important lesson from her own boss. “My boss is a wonderful female physician who is really at the top of her game,” she says. “At one point she said to me ‘tell me everything you’re doing.’ After I finished, she said, ‘now tell me how you are going to move some of it off your plate so you have more time for what’s important to you both professionally and personally.’ I still think about that conversation a lot,” Dr. Bates continues. “She’s someone I respect, so it was very helpful for me.”

Her advice to younger women is similar to Dr. Peterson’s. “Decide what is non- negotiable to you and speak to that,” she recommends. “For me, it is putting my son to bed every night. I also enjoy my work with the HIV clinic very much, and wanted to make room for that. If I didn’t do these things I would be very unhappy. So I made some changes so I could do them, and it’s been worth it.”

Dog and Pony Show
At the Mayo Clinic, Dr. Blair is one of four women who mentor groups of younger colleagues on professional advancement topics such as medical publishing or starting a career in research. Often times the meetings start out with other topics, as she explains. “It’s our own little dog and pony show,” she jokes, “each meeting always starts out with a little therapy—we’re talking about kids, husbands, whatever crisis has popped up during the week.” The purpose of the mentoring groups, she says, is to lend a helping hand to other women physicians looking to advance in their careers. For example, one group focuses on grant writing. She helps the women when they get into trouble, whether it is writing block or something on a personal level. Slowly but surely, the women have begun to advance. “By the time we’ve overseen a group for a year or two, they understand what it takes to get beyond the instructor level to assistant professor.” The groups have been so successful that the Mayo Chairman of the Board has allotted time for the mentors to meet, and the meetings benefit the women in more ways than one. “When someone is out on maternity leave or for other family or personal related things, others will pick up for them and the group stays motivated,” explains Dr. Blair. “There’s always someone who can carry the group. It has really turned out to be a great concept and is hugely supportive.”

A Full Life
In different jobs, in different parts of the country, at different stages in their careers, Drs. Bates, Peterson and Blair have more in common than meets the eye, mainly, the satisfaction of knowing they have made the right choices along the way. “I am doing things now that I never had anticipated doing because of the career path I chose,” says Dr. Bates. “I teach, I run a clinic…and as time goes on I know I will do something else. I’ve had incredible flexibility.” Dr. Blair says she is most fulfilled when she feels she is doing her best to fulfill her purpose in life, which she says is ministering to others. Her deep faith motivates her. “Sometimes when you get so busy, you can forget the main thing…I try to remind myself that each patient I come in contact with is someone who needs to be listened to and cared for.” The fun-loving Dr. Peterson derives her fulfillment from work and family as well, but also from the different activities in her life—a part time job as a fitness instructor at a YMCA, volunteering at her church, having lunch with girlfriends. She says being an internist has given her the opportunity to do it all. “I love to practice medicine,” she says. “It’s part of the fun of my life!”

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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White House Health Summit: An ACP Officer's Perspective

ACP President thanks Obama for addressing Medicare's flawed payment formula

ACP President thanks Obama for addressing Medicare's flawed payment formula


HealthDay News -- For Dr. Jeffrey Harris, whose year-long tenure as president of the American College of Physicians (ACP) comes to an end in April, attending the recent White House Forum on Health Reform was a privilege and a pleasure.

"This clearly is one of those momentous memories of what has been a memorable year," said Harris, an ACP fellow since 1981.

Harris was one of more than 120 people invited to attend the March 5 health care summit at the White House, which brought together stakeholders from across the entire health care spectrum -- providers, payers, consumer advocates and manufacturers, business and labor groups and members of Congress.

Harris briefly spoke with President Obama, thanking him on behalf of the ACP for his candor regarding the SGR -- the sustainable growth rate formula used to calculate Medicare payments. In recent years, the formula has dictated sharp cuts in physician fees that have required an eleventh-hour solution. Obama, unlike his predecessor, acknowledges the problem upfront by including in his budget proposal some $400 billion over 10 years to offset the cost of providing payment relief to doctors.

At the start of the summit, the president addressed the entire audience before attendees split into five separate "breakout" groups for discussion. Later everyone reconvened in the East Room for what was essentially a "town hall" meeting with the president.

Harris postulates one of the objectives of the summit was to demonstrate that those who opposed the Clinton administration's failed health reform initiative of 1993 and 1994 are now in support of Obama administration's efforts.

In 1993, the Health Insurance Association of America (HIAA) sponsored the gripping "Harry and Louise" ad campaign credited with helping to defeat the Clinton health reform proposal. Harry and Louise, a fictional married couple, were featured as they poked holes in the Clinton plan, basically alleging that private insurance plans were far superior. HIAA merged with the American Association of Health Plans in 2003, forming America's Health Insurance Plans (AHIP), which represents the nation's health insurers.

During the town hall portion of the meeting, President Obama recognized AHIP President and CEO Karen Ignagni, who reiterated her members' interest in helping to foster health reform. Dan Danner, president and CEO of the National Federation on Independent Business, another outspoken opponent of the Clinton reform effort, expressed small business' interest in working with the administration toward a solution.

"So it was apparent that they were calling on the people that they wanted to make everyone realize were on board now," Harris observed.

"I think they (the Obama health care team) took lessons from the Clinton administration," said Harris, referring to the outcry that occurred because reform proposal was crafted, essentially, behind closed doors.

Harris was gratified that the president recognized the need to expand the nation's supply of primary-care physicians. Afterward, though, Harris told a member of the Obama administration that he was concerned that there wasn't more discussion about the crisis in primary care. Harris was assured that the administration understands the problem. The issue, he was told, is one of cost.

Indeed, President Obama underscored the point about the need to control expenses as part of the reform initiative when he told attendees, "If we don't address costs, I don't care how heartfelt our efforts are, we will not get this done."

Rather than squabble over the details, summit attendees used the opportunity to show support for what the administration is trying to accomplish, noted Harris, acknowledging that the process of ironing out details will require some give and take.

"Already the discussions one hears -- I don't know the details -- are: 'What are you willing to give up to the insurance industry and the medical device manufacturers, to the pharmaceutical industry, to the hospitals, to the physicians?' What are you willing to give up in order to make this work?" Harris said. "And that's the next chapter."

March 17 2009
Copyright © 2009 ScoutNews, LLC. All rights reserved

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Medical Student Perspectives: How to Find a Mentor

With all the training, challenges and responsibilities that come with becoming a physician, it is difficult to traverse this arduous path alone. A mentor can help serve as a guide, assist with choosing specialties, and facilitate the transition into one’s future career choice.

First Step: Know Thyself
The most important question you need to ask yourself is, “What do I want from a mentor?” Make a list of the qualities, specialties/professions, and areas that appeal to you, whether they are clinical, academic or research related. If you have clear goals, then these will greatly narrow down your search criteria and ultimately help direct you to a mentor who best suits your interests. Some questions you may wish to consider are:

• What are my interests?
• Can I see myself doing this?
• Am I interested in working in [insert practice setting, i.e., hospital, clinic, private practice, health care management, public policy, public health, academia doing research/teaching or a combination of the above]?

However, even if you cannot answer all of the aforementioned questions, the answers to the questions that you can answer will help narrow down your search criteria.

If you are undecided, a great way to test the waters is to shadow a physician in a specialty that has intrigued you and see whether it fits you. If it does, you already have the advantage of knowing the people in the department and if not, you can cross that specialty off your list and search for another one. Shadowing during the first and second years of medical school is a terrific way to get your foot in the door and gives you the ability to explore a particular career without committing yourself to a mentor.

Be picky and do your research. Ideally you want to choose a mentor who is supportive and well-connected in the field, as he or she may become a potential letter writer for you in the future when application season comes around. Mentors are an ideal source for letters of recommendation (LOR), because they have worked with you for some time and know you personally so that the letters they write tend to carry more weight than the perfunctory ones from your third-year rotations. Most programs prefer LOR writers to be MDs, so finding a physician mentor will be beneficial.

Second Step: Identify Potential Mentors
Do your homework. Pay attention to those professors whom you respect as well as those professions which intrigue you. You can also approach your advising dean, academic advisor or even the alumni office for advice on finding mentors. Your school may already have a mentoring program set up to help students navigate through the process. Ask third- or fourth-year students at your school who are matching in your specialty of interest to get their opinions about which physicians are good mentors. Referrals from friends and family can be another source of potential mentors.

Do not limit yourself to only choosing professors who have taught you or clinicians affiliated with your institution. If you cannot find any mentors within your institution who fulfill your criteria, talk to a faculty member, program director or an advisor to see if he or she can help you make some referrals. Finally, if you do not mind traveling, clinicians from other hospitals around your medical school may be great candidates as well.

Last but not least, you can look through the hospital directory for physicians related to your discipline of interest and contact them. However, exercise caution and do not send out too many emails at once, because you may place yourself in an uncomfortable predicament if perchance everyone you contacted responds positively. It is advisable to personally meet with your potential mentor before seriously committing to him or her.

Several professional societies also have mentoring databases that allow members to search for mentors within their membership, such as ACP’s Mentoring Database. Students interested in learning about internal medicine can access the ACP Mentoring Database for free after signing up for ACP membership (which is also free!). Apply for student membership online. The Mentoring Database is comprised of College members, including Program Directors, Clerkship Directors, Chairs of Medicine, practicing internists, and residents. Possible mentors can be narrowed down by specialty, type of practice, country of residence, state of residence, gender, ethnicity, as well as medical school location. Alternatively, ACP can help pair you with a mentor. Email your name, chapter and specific questions or areas of interest to mbrdev@acpmembship.org.

In addition, annual national conferences usually provide opportunities for students to network with physicians in the field as well as talk to various residency programs. ACP’s annual scientific meeting, Internal Medicine 2009, will offer a Medical Student Mentoring Breakfast as well as an Internal Medicine Residency Fair. You may register for Internal Medicine 2009 online.

Third Step: Contact Your Mentor
Send your prospective mentor an e-mail introducing yourself and stating your interests. Give a brief (1-2 sentences) but personal synopsis of what draws you to the field and set up a time to meet and talk about the opportunities for you to become more involved.

Do not forget to be persistent and follow up in a courteous manner. Remember that your mentors will most likely be busier than you are so it will be up to you to keep in touch. However, be careful to not overburden your mentor by demanding too much time or attention. Be patient and do not become discouraged if you do not find a mentor right away.

Great mentors are out there. Know yourself, be appreciative of their guidance and most importantly, be honest with your mentor. Good luck!

Wendy Ho, MS
North Atlantic Region Representative, Council of Student Members
Albany Medical College, Class of 2010
Email: HoW@mail.amc.edu

Check out more volunteer opportunities.

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Internal Medicine Interest Group of the Month: Rush Medical College

The Rush Medical College Internal Medicine Interest Group (IMIG) has been a key resource for medical students for many years and has recently become the largest interest group at our institution, with over 225 members. Over the last four years, our chapter has continued its momentum and growth in advocating for students in regards to issues concerning internal medicine. One of the reasons for the club’s success is clearly the participation from our executive board (all 16 members) and our advisor, Dr. Elizabeth Baker, ACP Member. Mandatory monthly executive board meetings, in addition to a diverse representation of the executive board from all four classes, have facilitated a robust forum in which new ideas are conveyed and brought to fruition.

During this academic year, we were excited about the introduction of new events for our colleagues. After our introductory IMIG event, which had participation of over 200 students, we were successful in orchestrating an EKG workshop where medical students from all levels appreciated a two-hour seminar on this vital skill of interpretation. In addition, our chapter has created a myriad of lunch lectures on various areas of internal medicine, such as careers in medicine workshops, subspecialty lectures, transgender medicine workshops, a series of lectures on the impact of pharmaceutical companies in healthcare, and more. We will hold more than 8 lunch lectures which have an average attendance of about 150 students. These events were aligned with the existing structure of our traditional events, which synergized our ability to gather student interest and maintain strong attendance.

One of the more challenging events to organize is our annual residency director forum. In the past we have had an open question-and-answer forum where students could ask internal medicine program directors and associate program directors questions about the residency application process. Students leave this event with ideas about how to strengthen their applications, prepare for interview questions, and much more. This year we are pleased to expand this forum to include a more regional representation. In the past we have been fortunate to gather program directors from Rush and Cook County Hospital, but this year we will be attempting to expand to other schools in the area such as Loyola, University of Illinois in Chicago, Northwestern, University of Chicago and more by collaborating and working together with the IMIG groups at those schools.

The Rush Medical College IMIG, in partnership with ACP, has seen great strides in enthusiasm and participation over these last few years. We hope to continue to inspire the minds of future internal medicine physicians for years to come.

Ajay Yadlapati
President, Rush Medical College Internal Medicine Interest Group
Rush Medical College, Class of 2009
Emails: Ajay_yadlapati@rush.edu

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Winning Abstracts from the 2008 Medical Student Abstract Competition: Cocaine-induced Hepatotoxicity

Authors: Monica Dandona and Adam Mitchell, MD

Introduction
Cocaine is the second most commonly used illicit drug in the United States. Hospital-related admissions have predominantly been due to complications from cardiovascular, central nervous system, neuromuscular, renal, and pulmonary injury. Recent clinical evidence, however, demonstrates that the liver is also a target organ of cocaine-related toxicity.

Case Presentation
A previously healthy 28 year-old man with a ten-year history of polysubstance abuse was brought to the emergency department with cocaine intoxication. His abdomen was diffusely tender to palpation with localization to the right upper quadrant. Liver-related tests upon admission showed an ALT of 759 U/L (30-65 U/L), AST of 2280 U/L (15-37 U/L), and prothrombin time of 17.3 s (10.9-13.1 s). Total and direct bilirubin peaked four days after admission to 3.8 mg/dL (less than 1.0 mg/dL) and 1.5 mg/dL (0.0-0.3 mg/dL), respectively, with an albumin of 2.7 g/dL (3.4-5.0 g/dL). Serologic tests for viral, autoimmune, metabolic, and hereditary causes of liver dysfunction were negative. Infectious workup was also negative. The urine drug screen was positive for cocaine metabolites, benzodiazepines, and phencyclidine hydrochloride (PCP). Ethanol was not detected in serum, but the patient did admit to drinking 2-4 ounces of hard liquor every other day. Abdominal ultrasound showed normal liver size and echogenicity. Aggressive IV hydration was immediately initiated secondary to the patient’s elevated creatinine. The patient was discharged after 9 days with downward trending serum creatinine and liver-associated enzymes. At 14-day follow-up, his complete blood count and metabolic panel returned to within normal limits. His ALT was 149 U/L and AST was 66 U/L, still slightly elevated from baseline.

Discussion
This case illustrates an uncommon presentation of cocaine-induced hepatotoxicity. Biomechanistic studies on this phenomenon have increased our understanding of the causality between the formation of reactive cocaine intermediates and acute hepatocyte injury. Animal studies have confirmed that risk factors contributing to liver injury include concurrent alcohol, phencyclidine, and/or phenobarbital use. Other predisposing factors are glutathione deficiency, glucose-6-phosphate dehydrogenase deficiency, and low plasma pseudocholinesterase activity. It is therefore thought that the concurrent use of PCP catalyzed the hepatotoxicity observed in our otherwise healthy young patient. The follow-up ALT/AST elevation found in our patient is commonly noted in chronic PCP and alcohol users. Of note, no studies to date have been performed investigating the contribution of prior liver disease to cocaine-induced hepatotoxicity. The question thus remains whether the presence of metabolic defects, hereditary liver disease, and viral or autoimmune hepatitis play a significant role in contributing to cocaine-associated liver injury. Further investigation is needed to determine whether such testing is necessary in patients presenting with cocaine-induced hepatotoxicity.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Medical Oncology

The Discipline
The word oncology is derived from the Greek word ongkos, meaning “a bulk or mass,” which later was changed to mean “a tumor.” Medical oncology is the subspecialty which involves the diagnosis and management of benign and malignant neoplasms. Oncologists typically identify individuals at risk for malignancy and counsel them regarding risk reduction and screening, investigate clinical symptoms and syndromes suggestive of underlying malignancy, identify and treat neoplasms with a potential for cure, and undertake the care of patients with solid and hematologic tumors to prolong life and/or palliate symptoms.

Procedures
Important procedural skills for the oncologist include bone marrow aspiration and biopsy and, for some oncologists, fine needle aspiration of the thyroid and breast. In addition, the oncologist is an expert in interpreting bone marrow cytogenetics and immunophenotyping, cytology and pathology, estrogen and progesterone receptor assays, and serological molecular markers for tumors.

Training
Medical oncology 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 tumors. In addition, a minimum of one half-day per week must be spent in a continuity outpatient clinic for the entire two-year curriculum.

Dual certification in hematology and medical oncology requires three years of full-time combined fellowship training which must include: (a) a minimum of 18 months of full-time clinical training with patient care responsibility; (b) a minimum of 12 months in the diagnosis and management of a broad spectrum of neoplastic diseases including hematological malignancies; and (c) a minimum of six months of training in the diagnosis and management of a broad spectrum of non-neoplastic hematological disorders. During the entire three years the trainee must attend at least one outpatient clinic for a minimum of one half-day per week and be responsible for providing continuous care to a defined cohort of patients being managed for neoplastic and hematological disorders.

Certification
The American Board of Internal Medicine, ABIM, offers certification in medical oncology, and hematology and oncology.

Training Positions
As of August 2005, there were 125 ACGME-accredited training programs that offered 1,164 combined fellowship training positions in hematology/oncology. There were also 18 ACGME-accredited training programs in medical oncology with 160 active training positions. 42% of the trainees were female, and 54% were United States medical school graduates.

Practice
Approximately 50% of the graduates from combined training programs enter clinical practice in hematology and oncology in the United States, and 42% enter academic medicine. Approximately 35% of the graduates who receive only medical oncology fellowship training enter clinical practice in the United States, and 49% enter academic medicine.

Major Professional Societies

  • American Society of Clinical Oncology

    • 1900 Duke Street, Suite 200
    Alexandria, VA 22314
    (703) 299-0150
    asco@asco.org

Major Publications

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Advocacy Brief: Make Your Voice Heard on Capitol Hill

Key Contacts are asked to communicate with their members of Congress regarding issues of importance to internists and their patients and report the results back to ACP. As key issues approach the decision-making stage on Capitol Hill, the College e-mails or faxes legislative alerts to Key Contacts. Legislative alerts include all of the necessary information (including sample messages that can be easily personalized) to send informative communications to members of Congress.

There are currently 575 Medical Student Members of the College who serve as Key Contacts.

ACP members are not required to have existing relationships with their members of Congress before becoming a Key Contact. Please help ACP with its efforts on Capitol Hill and encourage your fellow classmates to enroll today.

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Did You Know ACP Medical Student Members attend Internal Medicine 2009 for free?

ACP’s annual meeting, Internal Medicine 2009, will be held in Philadelphia, PA, from April 23-25, 2009. Internal Medicine 2009 is the premier scientific meeting for internal medicine and features over 250 scientific sessions and is free for ACP Medical Student Members. For details regarding the meeting, including information on discounts, housing and travel arrangements, visit: Internal_Medicine_2009.

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MKSAP for Students 4 Question 1

A 50-year-old man is evaluated in the office for substernal chest pain. The pain is not consistently associated with exertion, nor is it always relieved by rest; it sometimes occurs when he is eating or when he is anxious. The patient has a history of hypertension treated with hydrochlorothiazide and a 15-pack-year history of cigarette smoking.

On physical examination, blood pressure is 148/92 mm Hg and heart rate is 78/min. The cardiac rhythm is regular; heart sounds are normal with no murmurs, gallops, or rubs. The lungs are clear.

The patient's probability of having coronary artery disease is estimated from these findings to be 40%. A nuclear stress test is scheduled to evaluate the chest pain further. This test has a positive likelihood ratio of 5.0 and a negative likelihood ratio of 0.1. The patient's nuclear stress test is positive.

Which of the following values best approximates the patient's post-test probability of having coronary artery disease?

A. 5%
B. 25%
C. 50%
D. 60%
E. 75%

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MKSAP for Students 4 Question 2

A 50-year-old man is evaluated in the office for the recent onset of pruritus while showering. He has previously been in excellent health, eats a normal diet, is an occasional smoker, and does not take any medications.

On physical examination, he has a ruddy face and a palpable spleen tip. Results of fecal occult blood testing are negative. The arterial oxygen saturation is 99% on room air.

Laboratory studies show a hematocrit of 61.0% compared with a value of 44.5% documented 5 years ago, leukocyte count of 11,100/µL, mean corpuscular volume of 79 fL, and platelet count of 650,000/µL. Serum chemistry studies are normal except for a reduced ferritin concentration.

Which of the following is the most likely diagnosis?

A. Myelodysplastic syndrome
B. Polycythemia vera
C. Relative erythrocytosis
D. Secondary erythrocytosis related to smoking

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MKSAP for Students 4 Answer 1

Answer: E: 75%

The patient's post-test probability of having coronary artery disease is 77%. The patient's pretest probability, which is based on his chest pain, age, and sex, is estimated to be 40%. To calculate the patient's post-test probability of disease, the pretest probability is first converted to pretest odds as follows: Pretest probability / (1 – pretest probability) = pretest odds = 0.4/0.6 = 0.67

Because the nuclear stress test had a positive result, the pretest odds value is then multiplied by the test's positive likelihood ratio to obtain the post-test odds as follows: Pretest odds × positive likelihood ratio = post-test odds = 0.67 × 5.0 = 3.35

The post-test odds is then used to calculate the post-test probability as follows:
Post-test odds / (post-test odds +1) = post-test probability = 3.35/4.35 = 0.77 or 77%

If the result of the nuclear stress test had been negative, the test's negative likelihood ratio would be used with the pretest odds to calculate the post-test probability of disease as follows:
0.67 × 0.1 = .067
.067 / 1.067 = .06 or 6%

Bibliography
1. Jaeschke R, Guyatt GH, Sackett DL. Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA. 1994;271:703-7. [PMID: 8309035] [PubMed]

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MKSAP for Students 4 Answer 2

Answer: B: Polycythemia vera

This patient's presenting symptom of pruritus while showering and the elevated hematocrit value are typical of polycythemia vera. Major diagnostic criteria for this disease include an elevated red blood cell mass, normal arterial oxygen saturation, and the presence of splenomegaly. It is currently difficult to obtain a red blood cell mass study in many places in the United States; therefore, the diagnosis of polycythemia vera is frequently established by identifying an elevated hematocrit value in the absence of secondary causes of erythrocytosis. The presence of a low serum ferritin concentration in this patient reflects the increased use of endogenous iron stores as a consequence of increased bone marrow erythroid activity rather than iron deficiency caused by blood loss or decreased dietary iron consumption. A major cause of morbidity in patients with polycythemia vera is thrombosis, which can be alleviated by reducing the hematocrit to less than 45% with phlebotomy or by administering hydroxyurea. Patients with polycythemia vera may also have a mildly increased leukocyte or platelet count.

Myelodysplastic syndrome is a definitional diagnosis requiring cytopenia of at least one lineage. The differential diagnosis of cytopenia of any single lineage is broad (especially in patients with anemia), but the finding of cytopenias of more than one lineage increases the probability of a diagnosis of myelodysplastic syndrome. This patient does not have cytopenia and therefore does not have myelodysplasia.

Relative erythrocytosis is not associated with a true increase in red blood cell mass. The hematocrit or hemoglobin concentration in patients with relative erythrocytosis appears to be increased because of a reduction in plasma volume. This finding may occur as a result of dysentery, heat exhaustion, profound perspiration, capillary leak syndrome, vomiting, and diuretic use and rarely may be idiopathic. Patients with relative erythrocytosis do not have pruritus or increased platelet and leukocyte counts.

Secondary erythrocytosis is a true increase in red blood cell mass that is often mediated by erythropoietin. In rare circumstances, however, a mutation in the erythropoietin receptor may cause secondary erythrocytosis. Erythropoietin-mediated secondary erythrocytosis may be either congenital or acquired. Examples of congenital secondary erythrocytosis include high-oxygen-affinity hemoglobinopathy (autosomal dominant), familial 2,3-diphosphoglycerate deficiency (autosomal recessive), benign familial erythrocytosis (autosomal dominant), or autosomal recessive familial erythrocytosis. Examples of acquired secondary erythrocytosis include either central hypoxia (chronic obstructive pulmonary disease, intracardiac shunts, smoking) or peripheral hypoxia (renal vascular disease). Acquired secondary erythrocytosis may also result from pathologic production of erythropoietin by tumors (hepatoma, hypernephroma, cerebellar hemangioblastoma). The normal arterial oxygen saturation rules out secondary erythrocytosis due to smoking in this patient.

Bibliography
1. Tefferi A. Polycythemia vera: a comprehensive review and clinical recommendations. Mayo Clin Proc. 2003;78:174-94. [PMID: 12583529] [PubMed]

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Attend the Fifth Annual Internal Medicine Residency Fair

The Fifth Annual Internal Medicine Residency Fair will be held during ACP’s national scientific meeting, Internal Medicine 2009, on Saturday, April 25th. We have acquired a better location and time slot for the Residency Fair this year, which will be held from 11:30 a.m. to 1:30 p.m. in Exhibit Hall B of the Pennsylvania Convention Center, next to the Medical Student-Associate Poster Area and the action on the Exhibit Hall Floor.

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.

You may register for Internal Medicine 2009 online. If you have questions about the Residency Fair please e-mail Membership Development at mbrdev@acponline.org.

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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, and polls and surveys (including our cartoon caption contest). Go online for the following stories:

  • Intimate partner violence
    Unexplained bruising or injuries are red flags for intimate partner violence, but less obvious signs might include chronic pain, depression or anxiety. Experts advise how to help victims at risk.
  • Sjögren's syndrome explained
    Lack of awareness compounds a condition that is exceedingly difficult to diagnose. Experts offer signs and symptoms for ruling it out or diagnosing it more quickly.
  • Mindful Medicine
    Would you pass "the eyeball test" if a patient with chest pain presented in your hospital's emergency room? Find out how one physician pressed for a better answer on a patient who presented with cardiac pain but no evidence of a heart attack.

ACP Hospitalist

The relaunched ACP Hospitalist is the place to find all of our print and online content, including ACP HospitalistWeekly, our upcoming blog, and polls and surveys (including our cartoon caption contest). Go online for the following stories:

  • New field offers opportunities
    The American Board of Medical Specialties last fall began offering board certification in palliative care, opening up an exciting new career path for hospitalists.
  • Giving hospitalists their space
    More hospitals are implementing an assignment tool known as “geographic rounding,” where hospitalists are assigned to cover patients on a by-unit basis.
  • Recognizing hyponatremic encephalopathy
    In our latest Expert Analysis, two clinicians offer tips for diagnosis, prevention and treatment of this life-threatening disorder.

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Students: Join ACP for Free

Benefits of Membership for Students: ACP's free Medical Student Membership includes benefits designed especially to meet students' needs.

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

MKSAP 15 Discount 10% Off

MKSAP 15 Discount 10% Off

Get ready for the New Year with the newest edition of MKSAP. Enjoy a 10% discount off MKSAP 15 for a limited time. You must order by December 11, 2009 and use priority code E9048 to get the discount.

Holiday Gift offer - 10% off

Holiday Gift offer - 10% off

A great gift for a colleague or yourself - Landmark Papers in Internal Medicine: The First 80 Years of Annals of Internal Medicine. Enjoy a 10% discount when you order by December 11, 2009 and use priority code E9049.

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