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May 2006 E-Newsletter

Spring 2006 IMpact PDF

• You Just Might Be More Competitive Than You Think You Are!
• Internal Medicine Interest Group of the Month: University of Utah
• Articles from Annals of Internal Medicine
• MKSAP Questions (1,2)
• MKSAP Answers (1,2)

You Just Might Be More Competitive Than You Think You Are!

The time of year when fourth years need to decide where to apply for residency is coming up faster than you might think. This is often the point in time when applicants to the Match begin to wonder, “Is it possible for me to match in my dream residency? Am I competitive enough for the big names? What can I do to make myself look better on paper?” The bigger questions that arise include, “What exactly are the residency directors looking for? Do I meet the criteria specified?” In order to find the answers to these questions, I randomly queried internal medicine residency program directors from across the United States in the different types of residencies that exist, including Med-Peds, academic, community, primary care and categorical programs. I asked them two simple questions:

1. What qualities does the ideal applicant have?
2. If an applicant does not have all the ideal qualities, what can he or she do to be more competitive?

The first conclusions I came to were that every program is unique and every program director desires specific qualities, and as a result they assess applicants differently. The multitude and variety of responses I received astounded me. I also learned that the philosophy of programs can differ over time as their respective directors change. Keeping that in mind, I’ve summarized the comments from the different residency directors in the categories listed below. Hopefully, this will bring some clarity to the issues at hand.

1. Personal Qualities: I put this category first because, based on the responses, it seemed that most residency directors placed a substantial amount of importance on this category. The qualities that were suggested by a large percentage of residency directors were:

• Well-rounded
• Superb interpersonal skills
• Positive attitude
• Optimistic personality
• Team player
• Commitment to patients and quality health care
• Intelligence
• A passionate love for medicine
• A strong work ethic
• An affection for and appreciation for fellow human beings
• A capacity for empathy
• Evidence of high motivation
• Enthusiasm to both learn and independently self-study but also to share knowledge with team members
• Community service involvement and leadership, or another unique quality that distinguishes them from other medical students

These are all traits that a strong letter of reference can vouch for and are often cemented during the interview. It is important to remember that in the case of students who are not exceptional academic performers, outstanding research or unique volunteer work will go a long way, but do not always guarantee an interview. On a positive note, there were also program directors who blatantly stated that they did not care whether an applicant had all honors, stellar board scores and did research, as long as the student was able to demonstrate that he or she has the “right stuff.”

2. Academics: The consensus across the board from all the residency directors is that applicants with above average academic performances are more likely to be invited for an interview by their programs. Program directors weigh the individual components of the applicant’s performance differently. The majority of residency directors base the emphasis on performance in clerkships. One needs to do well in his or her clerkships and sub-internships; this is critical and usually will not be overlooked even if the individual was outstanding in the first two years. It is not a good sign if the candidate was required to repeat classes in the first two years of school without a plausible reason. All honors in medicine with less than stellar evaluations in other clerkships is also not well received. The ideal applicant should demonstrate clinical excellence in his or her clinical clerkship grades, sub-internship grades, Dean’s letter and letters of recommendation.

3. USMLE Scores: Once again the jury is out on the board score; however, the residency directors questioned said that they do not give very much importance to board scores. They contend that often board scores are better correlated with test-taking abilities rather than academic performance. However, when evaluating candidates for interviews, applicants who have failed either USMLE Step I or Step II Clinical Knowledge Examination receive a more in-depth screening before receiving an invitation to interview. Having said all that, keep in mind that programs with a large number of applicants will use USMLE scores to determine interview status as well as use them in ranking applicants.

4. Research: This category is clearly more highly regarded at the academic programs. Most programs agree that outstanding research will not compensate for mediocre grades. However, research may be a useful surrogate for those who have average grades early on in their medical school careers and then excelled in the medicine sub-internship and later clerkships. Earning graduate degrees as well as participating in other meaningful scholarly activity such as teaching and tutoring is looked upon favorably. Achievements in research, such as being published, are helpful but the residency directors state that the most important thing is that an applicant needs to be able to talk about his or her research fluently at an interview.

5. Competitiveness: One tool to be used to increase competitiveness at application time is to apply widely (many programs of different types) in order to increase the chances of getting interviews. Applicants who choose to apply widely should be prepared to visit more programs during the months of December and January. Keep in mind that a mediocre performance in a single clerkship should not be a reason to stress, as good grades and evaluations in the majority of clerkships plus good research and/or volunteerism will increase your desirability. Students should know that their extracurricular activities and research are only viewed as favorable as long as they do not affect academic performance. Applicants can become more competitive by getting involved as early as possible in leadership activities and/or research as this can help demonstrate academic potential and productivity. The letters of recommendation should be written by different types of evaluators, such as an attending physician from your sub-internship, someone who can provide useful insight regarding personal qualities, and a scholarly activity preceptor. It is definitely important and useful to have someone inside the program advocate for you if possible. Other ways to get your foot in the door consist of doing an elective at the program you are interested in and letting people know you are interested by either sending correspondence or going back for a second look. Finally, the way you present yourself at an interview should be honest, portray you in a positive yet realistic fashion and be consistent with your application, CV, and personal statement.

In conclusion, it seems that every residency director is looking for something different, so the best advice is just to be yourself and remember you are definitely more competitive than you think. Good luck with the Match!

Talia K. Ben-Jacob
Vice Chair, Council of Student Members
University of Vermont College of Medicine, 2007
e-mail: talia.ben-jacob@uvm.edu

Internal Medicine Interest Group of the Month: University of Utah

The Internal Medicine Interest Group (IMIG) at the University of Utah School of Medicine has made many changes this year to improve our student membership, participation, and interest in internal medicine and its various subspecialties. With new co-presidents and wonderful advisors, we set out to energize students and find new ways to get students involved in the ACP. Some of our great leaders who have made an impact on this year's success are: Becky Kroll (Co-President); Landon Dickson (Co-President); Allyson Pace (Co-President); Michael Battistone, MD (IMIG Advisor); Grant Cannon, MD, FACP (ACP Utah Chapter Governor); and Shauna Gulso (Administrative Assistant).

At Freshman Orientation, we recruited 116 new ACP Medical Student Members (with only 100 incoming freshmen). We have since recruited more and continue to look for opportunities to grow our membership.

In trying to broaden students' understanding of internal medicine and its subspecialties, we set up a series of luncheons with unique guest speakers such as a transplant pulmonologist, the chief of geriatrics, a private practice internist, and an internal medicine match panel.

We also helped plan and participate in this year's ACP Utah Chapter Scientific Meeting. This year, we had more medical students attend than physicians. Medical student winners in the Associates & Medical Student Poster Competition were: Thomas B. Skidmore, MS III, “Disappearing Bone Disease” (3rd Place, Clinical Posters); Eric Glissmeyer, MS II, “Relationship of Bone Morphogenetic Protein Receptor-2 Mutations and Vasoreactivity in Pulmonary Arterial Hypertension” (1st Place, Research Posters); Landon Dickson, MS II, “Heat Shock Protein HSPB2 Expression Reverses Paradoxical Cardioprotection of CRYAB and HSPB2 Deficiency After Severe Ischemia-Reperfusion in Mice” (2nd Place, Research Posters); and Nathan Faulkner, MS II, “Isolated Ectopia Lentis Caused by a Novel Mutation in Fibrillin-1” (3rd Place, Research Posters).

The IMIG at the University of Utah realizes that early exposure and interaction is key in motivating students to pursue an internal medicine career. We try to provide opportunities for students by getting them involved in activities, planning committees for conferences and meetings, and in leadership opportunities. We are also planning exciting new activities for next year, such as an immunization clinic at the VA Hospital in conjunction with the Geriatrics Interest Group.

Landon Dickson, MSII
Becky Kroll, MSII
Allyson Pace, MSII
IMIG Co-Presidents, University of Utah School of Medicine
e-mail: Landon.Dickson@hsc.utah.edu

Articles from Annals of Internal Medicine

Following are summaries and full text articles from Annals of Internal Medicine. Medical Student Members can get full access to Annals Online by registering.

Exercise Is Associated with Reduced Risk for Incident Dementia among Persons 65 Years of Age and Older
Larson EB et al. Ann Intern Med 2006; 144:73-81 January 17
(Access full text of article)

Background: Alzheimer disease and other dementing disorders are major sources of morbidity and mortality in aging societies. Proven strategies to delay onset or reduce risk for dementing disorders would be greatly beneficial.

Objective: To determine whether regular exercise is associated with a reduced risk for dementia and Alzheimer disease.

Design: Prospective cohort study.

Setting: Group Health Cooperative, Seattle, Washington.

Participants: 1740 persons older than age 65 years without cognitive impairment who scored above the 25th percentile on the Cognitive Ability Screening Instrument (CASI) in the Adult Changes in Thought study and who were followed biennially to identify incident dementia.

Measurements: Baseline measurements, including exercise frequency, cognitive function, physical function, depression, health conditions, lifestyle characteristics, and other potential risk factors for dementia (for example, apolipoprotein E ε4); biennial assessment for dementia.

Results: During a mean follow-up of 6.2 years (SD, 2.0), 158 participants developed dementia (107 developed Alzheimer disease). The incidence rate of dementia was 13.0 per 1000 person-years for participants who exercised 3 or more times per week compared with 19.7 per 1000 person-years for those who exercised fewer than 3 times per week. The age- and sex-adjusted hazard ratio of dementia was 0.62 (95% CI, 0.44 to 0.86; P = 0.004). The interaction between exercise and performance-based physical function was statistically significant (P = 0.013). The risk reduction associated with exercise was greater in those with lower performance levels. Similar results were observed in analyses restricted to participants with incident Alzheimer disease.

Limitations: Exercise was measured by self-reported frequency. The study population had a relatively high proportion of regular exercisers at baseline.

Conclusion: These results suggest that regular exercise is associated with a delay in onset of dementia and Alzheimer disease, further supporting its value for elderly persons.

On Being a Doctor: Transport
Gianakos D. Ann Intern Med 2006; 144:216 February 7

I love to see the last patient of the day. I won't deny it: The last patient reminds me that the day is coming to an end and that I will soon be going home to dine with my family. However, there are other reasons. When I see the final patient, I'm in my most relaxed state. There are no time pressures to see other patients. I am not distracted by phone calls, knocks on the door, or overhead pages. The work of the day, except for a few dictations, is almost done. I can sit back and give the patient my full attention. Yes, my nurse may be anxious to get home and may push me to speed up. And there are days when there are more than a few dictations to be done or phone calls to make. Nonetheless, I feel good about finishing, and I look forward to spending time with the patient—as I do with good friends.

My last patient also gives me the best opportunity to break my routine. I am more likely to stray from the typical review of systems and to ask questions, such as "What is the most meaningful experience you've ever had?" and "What would you change about your life if you had to live it over again?" Then I sit back and listen, and usually discover something about my patients that I never knew, something that gives me a deeper understanding of what drives them. Besides that, I enjoy the conversation.

Last Monday, Ray was the last person on my schedule. He was in for a routine follow-up for asthma. I've seen Ray through several asthma exacerbations and assorted minor ailments over the past 9 years. He is a middle-aged man with a slight build, round shoulders, and the beginnings of a potbelly. His beard is neatly trimmed. He talks matter-of-factly and rarely smiles. After 10 minutes or so of routine questions and examinations, I told him that he was in good health and that his asthma was well-controlled. When he had been talking, I tried to recall some personal facts about him. I couldn't recall whether he had children. Wasn't he recently divorced? I couldn't remember. Now was a good time to explore, though I was embarrassed that so many personal details escaped me. He gave me short answers to my questions—yes, he has 3 grown children and yes, he has been dating a woman for 6 months. He didn't open up as I had hoped. I tried one more question:

“Ray, are you a religious person?”

He unfolded his arms and smiled for the first time in the interview. In an animated voice, he said, “Doc, when I was an orderly in a hospital, I met an amputee named Avery. One day I overheard the doctors telling him he had bad vessels everywhere and didn't have long to live. I felt sad when I heard it, 'cause Avery and I had become quick friends in just a few weeks, me being responsible for bathing him and moving him around. Sitting together in his small bathroom, we'd talk about important stuff: money, love, and death. He told me he ran a shuttle service for old folks. He told me he was going to make me a partner one day. That made me feel good—I was poor at the time and looking for new job opportunities.”

“He talked about his kids, how he tried to raise them to help people. One boy's a preacher, another a doctor. He was real proud of them. If he had to do it over again, he told me he would have been a teacher.”

“Anyway, when Avery left the hospital, I told him I'd come see him. A week passed. I dropped by his house and met his wife at the front door. I didn't think she knew me from Adam. Before I could say hey, I knew.”

“She pointed to Avery's van.”

“Take it!’ she cried. She squeezed my hand and shut the door.”

“Yeah, doc, I'm religious all right. I've never told that story to anyone before, not even to my wife. Today seemed like the right time for it to come out, it being the day he died a year ago. Have a good day, doc.”

After that answer, I knew I would never look at Ray in the same way. I discovered a charitable, grateful human being that I previously did not know. I also realized that I, in some hardly perceptible way, had changed. Ray's story lifted me to a higher plane of understanding and commitment than I had previously experienced. His answer was not the answer I was expecting—it never is. And this is another reason why I continue to ask interesting questions at the end of the day.

Appropriateness of Diagnostic Management and Outcomes of Suspected Pulmonary Embolism Roy P et al. Ann of Inten Med 2006; 144:157-164 February 7 (Access full text of article)

Background: International guidelines include several strategies for diagnosing pulmonary embolism with confidence, but little is known about how these guidelines are implemented in routine practice.

Objective: To evaluate the appropriateness of diagnostic management of suspected pulmonary embolism and the relationship between diagnostic criteria and outcome.

Design: Prospective cohort study with a 3-month follow-up.

Setting: 116 emergency departments in France and 1 in Belgium.

Patients: 1529 consecutive outpatients with suspected pulmonary embolism.

Measurements: Appropriateness of diagnostic criteria according to international guidelines; incidence of thromboembolic events during follow-up.

Results: Diagnostic management was inappropriate in 662 (43%) patients: 36 of 429 (8%) patients with confirmed pulmonary embolism and 626 of 1100 (57%) patients in whom pulmonary embolism was ruled out. Independent risk factors for inappropriate management were age older than 75 years (adjusted odds ratio, 2.27 [95% CI, 1.48 to 3.47]), known heart failure (odds ratio, 1.53 [CI, 1.11 to 2.12]), chronic lung disease (odds ratio, 1.39 [CI, 1.00 to 1.94]), current or recent pregnancy (odds ratio, 5.92 [CI, 1.81 to 19.30]), currently receiving anticoagulant treatment (odds ratio, 4.57 [CI, 2.51 to 8.31]), and the lack of a written diagnostic algorithm and clinical probability scoring in the emergency department (odds ratio, 2.54 [CI, 1.51 to 4.28]). Among patients who did not receive anticoagulant treatment, 44 had a thromboembolic event during follow-up: 5 of 418 (1.2%) patients who received appropriate management and 39 of 506 (7.7%) patients who received inappropriate management (absolute risk difference, 6.5 percentage points [CI, 4.0 to 9.1 percentage points]; P < 0.001). Inappropriateness was independently associated with thromboembolism occurrence (adjusted odds ratio, 4.29 [CI, 1.45 to 12.70]).

Limitations: This was an observational study without evaluation of the risk for overdiagnosis.

Conclusions: Diagnostic management that does not adhere to guidelines is frequent and harmful in patients with suspected pulmonary embolism. Several risk factors for inappropriateness constitute useful findings for subsequent interventions.

MKSAP for Students 3 – Question 1

A 34-year-old woman is evaluated because of a 1-year history of increased dyspnea on exertion. She has no symptoms at rest, but has to stop about 15 minutes into her aerobics class because of dyspnea, wheezing, and an occasional cough. She usually recovers fully in about an hour. One year ago, she was able to do aerobics for 45 minutes without difficulty.

Her vital signs are normal, and her physical examination is normal, including clear breath sounds. Baseline spirometry is also normal.

Which of the following is the best next step in the management of this patient?

( A ) Inhaled albuterol prior to exercise
( B ) Inhaled corticosteroids
( C ) Inhaled ipratropium bromide prior to exercise
( D ) Long-acting theophylline
( E ) Oral leukotriene inhibitors

MKSAP for Students 3 – Question 2

A 46-year-old man is evaluated because he has had malaise and intermittent sweats for the past 3 months. Two years ago, he was treated for stage III diffuse large cell non-Hodgkin's lymphoma.

On physical examination, he has lymphadenopathy: a 3-cm right axillary node and a 2-cm right supraclavicular node. His spleen tip is palpable. Laboratory evaluation shows mild normochromic, normocytic anemia and an elevated serum lactate dehydrogenase level.

Which of the following is the most likely diagnosis?

( A ) Reactivation tuberculosis
( B ) Recurrent lymphoma
( C ) Occurrence of a second malignancy
( D ) Opportunistic viral infection

MKSAP Answer 1

Answer = A

Educational Objective: Treat exercise-induced asthma.

This patient's history is most consistent with exercise-induced asthma with no symptoms between periods of exercise. The most appropriate management at this point would be inhaled β-agonists prior to exercise.

Theophylline and ipratropium bromide have no role in this setting, and corticosteroids and leukotriene inhibitors are best used in the background setting of persistent asthma.

References

Anderson S, Seale JP, Ferris L, Schoeffel R, Lindsay DA. An evaluation of pharmacotherapy for exercise-induced asthma. J Allergy Clin Immunol. 1979;64:612-24.

MKSAP Answer 2

Answer = B

Educational Objective: Diagnose relapsed lymphoma.

Relapse occurs in approximately 50% to 60% of patients with advanced-stage (II–IV) aggressive non-Hodgkin's lymphoma treated with chemotherapy. The systemic symptoms, findings on physical examination, and elevated serum lactate dehydrogenase (LDH) level are all consistent with relapsed lymphoma in this patient. Relapse should be documented by a lymph node biopsy, and staging should be completed with bone marrow aspiration and biopsy.

Reactivation pulmonary tuberculosis is not an unreasonable explanation for the patient's symptoms, but does not explain the lymphadenopathy or elevated LDH level. There is no reason to suspect an opportunistic viral infection 2 years out from chemotherapy. Patients treated for Hodgkin's disease do have an increased incidence of second malignancies. The risk may be higher for patients who received combined radiation therapy and chemotherapy. Both blood and solid-organ malignancies are associated with Hodgkin's disease treatment. However, in this patient, who initially presented with a late-stage, aggressive tumor, recurrence of the original disease is more likely than a second malignancy. It is important to diagnose relapsed Hodgkin's disease because half of these individuals can be cured with high-dose salvage therapy plus hematopoietic stem cell transplantation.

References

Ng AK, Bernando MV, Backstrand K, Silver B, Marcus KC, Tarbell NJ, Stevenson MA, Friedberg JW, Mauch PM. Second malignancy after Hodgkin disease treated with radiation therapy with or without chemotherapy: long-term risks and risk factors. Blood. 2002;100:1989-96.

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