May 2008 E-Newsletter

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Medical Student Perspectives: Living with a Chronic Illness During Medical School.

As we go through medical school the amount of information we learn is spectacular. We learn about so many illnesses in books and then on the wards we apply this knowledge to the patient. The patient is the one who helps us incorporate all the information into a useful and memorable lesson. For some medical students, this lesson hits a little too close to home. Living with a chronic illness during medical school can be a difficult yet rewarding experience.

Adapting to the lifestyle of a medical student is one of the most dramatic changes anyone can experience. Making that adjustment while also having a chronic illness makes it even more challenging. Throughout your life, adapting to different situations will seem easier when compared to those first months of medical school. The level of stress during the first semester of medical school can seem overwhelming when compared to life before first-year orientation. That being said, open discussion regarding managing stress is critical, particularly for those who must balance medical school with chronic illness.

There are many resources to help along the way. The student affairs office at your school is the perfect place to talk to someone about the issues that are disrupting your transition into your new and wonderful life as a medical student. You may also want to speak to the dean about the challenges you are facing. Being honest with your school’s administration will be helpful should you need flexibility in making up class requirements due to unexpected absences.

Find out if it will be possible to get in contact with other people at your medical school who may be dealing with the same illness. Sometimes being able to talk to someone who has faced similar challenges can be comforting and can give you hope.

Find out if your school has a disability resource center. Most schools have a center that oversees students with illnesses and disabilities and their right to have equal opportunities. This office is responsible for providing testing accommodations for a variety of students with different ailments. Whether you need extended time during test taking or a scribe or reader for a test, the disability resource center is a great tool to utilize. Some of these same accommodations are also available through the National Board of Medical Examiners for the USMLE tests.

One aspect of having a chronic illness is that it is difficult to find the resources to provide you with the proper care. It is ironic that medical students with chronic illnesses spend so many hours learning in the hospital and often find themselves struggling to access the healthcare system within which they are educated. Student health insurance is generally good for providing emergency care but not the best when it comes to providing care for chronic illnesses. Many times the prescription drugs required are far more expensive than the insurance program is willing to cover. To avoid this burden, many pharmaceutical companies offer prescription drug assistance programs for which most students can be approved. Assistance programs are also offered by hospitals to patrons whose income is lower than a certain amount. These programs exist to ensure access to care and provide an invaluable resource to patients—be sure to use them if you need them.

Having a chronic illness is challenging but it can also be a blessing in disguise. Empathy cannot be easily taught. Knowing what it feels like to be on the other side of the stethoscope can provide invaluable perspective. The best way to understand what a patient needs and cherishes is by being one yourself. By being in this position, when you get to the wards you will be able to relate to the patients and their families.

For some, personal experience with chronic illness also sparks an interest in their future career. By speaking to their physicians, a mentoring relationship can be built within the field which can lead to a great educational opportunity. Living with a chronic illness does not mean that you have to let go of this opportunity. There may be some bumps in the road and some mornings when it seems like the work is not worth the reward, but hold on. The proof is when you can look into the eyes of your patient and truly say you understand.

Viral Patel
Central Region Representative, Council of Student Members
University of Kentucky College of Medicine, Class of 2010
E-mail: vdpate2@uky.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Kalpalatha Guntupalli, MD, MACP

Texas is a long way from Kay Guntupalli’s childhood home in Hyderabad, India, but there are certain things she has kept close to her heart since leaving years ago. The most significant of these were the memories of growing up with her sisters. As the youngest of five, she looked to her older sisters and brother for guidance and inspiration, so when all three of her sisters decided to pursue medicine as a career, she was quick to fall in line. “I used to go through their books to get an idea of what medical school was about,” she recalls. “I was awed when they discussed diseases and approaches for diagnosing and treating. At one point when all four of us were in medical school, our house was like a girls’ dorm with everyone talking and discussing different topics.”

Today as a professor, fellowship director and ICU director, her environment is anything but that of a girls’ dorm, but the spirit is much the same. “I am surrounded by young and enthusiastic medical students, residents and fellows all day,” she says. “I love the stimulation it provides me being questioned and challenged by young minds. I couldn’t imagine myself working in any other setting.”

The Making of a Doctor
As a student at The Institute of Medical Sciences, Osmania Medical College in Hyderabad, Dr. Guntupalli was drawn to internal medicine because as she puts it, internal medicine “paused to dig deeper into a problem.” Watching internists at work was also a persuasive factor for her and she credits a former professor with inspiring her to become an internist. “As a student I saw outstanding internists diagnosing complicated cases with a methodical approach. It seemed to be a specialty that would let me grow in other fields by providing me with a solid foundation.”

Following medical school and residency at District of Columbia General Hospital, Dr. Guntupalli completed a pulmonary fellowship. Then she and her husband prepared to pursue further training—he in nephrology and she in critical care. His plan was to attend the University of Michigan; hers the University of Pittsburgh, where she knew the training program for her fellowship was excellent. The problem, however, was the fact that they now had a six-week-old son. Everyone urged them not to do it, but Dr. Guntupalli says she and her husband knew it would work. “We were apart for two years which was most difficult because we were trying to raise an infant,” she says, “but we knew that to get what we wanted, we had to make some sacrifices. Not many of our family or friends agreed with the decision but we do not regret it. We have a very strong marriage. In fact, both of our children have decided to go into medicine which I think is a testimony to the fact that they did think what my husband and I did was important.”

Dr. Guntupalli has also learned valuable lessons from her patients. One patient in particular stands out to her, a young woman who had been suffering so badly from severe asthma that she was being admitted repeatedly to the ICU on a ventilator. “She had many stressors in her life,” explains Dr. Guntupalli, “and she was difficult to treat and deal with for a few years. But by working with her steadily, we not only got her asthma under control but also motivated her to volunteer in our ICU. She enriched my life in many ways—from her I learned how determination can overcome many odds.” Dr. Guntapalli would need that determination more than she would know soon enough.

Dr. Guntupalli with her family.

Dr. Guntupalli with her family.

The One
The moment a thin and tall young man named Prakash walked into Dr. Guntupalli’s office one morning Dr. Guntupalli’s career would never be the same, although it would be weeks before she knew it. Prakash explained to her how his brother, Prem, just 40 years old, was critically ill at Apollo Hospital in New Delhi, India. The patient’s doctor had given Prakash Dr. Guntupalli’s name and Prakash wanted to know if she could help. The case summary of the patient was dire: post influenza pneumonia, complicated by acute respiratory distress syndrome. “I wondered what I could contribute,” she says, “but I made the decision, went home and told my husband and children that I was going to India.”

On the flight spanning the 10,000 miles to India, Dr. Guntupalli made hourly calls, during which she learned that while the patient had not deteriorated, he also hadn’t improved. “I told Prakash that things were ok but did not use terms like “stable” or “out of danger,” she says. When she arrived at the hospital at 3 a.m., Prem was pharmacologically paralyzed, heavily sedated and on a ventilator. She also learned that he had tested positive for a resistant variety of Staphylococcus. Complicating matters was Prem’s agitation. If not sedated adequately, he would fight the ventilator, yet if too sedated he would be unable to be assessed. “By the end of the day I had new worries,” Dr. Guntupalli admits. “Finding the right balance was a delicate task. How neurologically intact was he? My worry was for the head.” An echocardiogram was ordered and returned positive for possible involvement of the heart. “My heart sank,” she says.

As impossible as the situation seemed, however, Dr. Guntupalli knew people were counting on her. “I had to keep going,” she says. “I had to keep going because of his two young children…because of the faith the family had in me.”

The Academic
Dr. Guntupalli’s day begins with rounds in the ICU of Ben Taub Hospital in Houston, TX from 7 a.m. until noon. This is followed by a teaching session in the ICU for residents and more “rounding.” She meets with patients’ families in the afternoon, and follows that with administrative work before finally calling it quits for the day around 6 or 7 p.m. Once home, she does her academic reading and writing. When asked what the benefits of working in her setting are, she talks of satisfaction and stimulation. “I have worked in an academic teaching setting all my professional life,” she explains. “I love working with all of the different personalities and experience level of residents, fellows, faculty and other colleagues. Through my career I have gained many opportunities. I would like to continue teaching not only physician trainees but also contribute more to family and patient teaching.”

She also has a passion for humanism and social responsibility, which she mentions repeatedly. “Humanism and social responsibility in medicine are very important,” she says. “I have been developing materials for patient education and public education for many years and would like to continue these efforts in the future.” One such effort of Dr. Guntupalli’s includes tobacco prevention education, for which she developed anti-tobacco materials in seven languages, which have been distributed to over 150,000 children in several countries.

Homeward Bound
Back in the ICU in Delhi, India, Prem was weak going into surgery. Dr. Guntupalli knew she had to level with the family. She explained to Prem’s younger brother, Padam, what the complications and risks were and how the level of support needed had escalated by several notches. “From over 20 years of experience, I know that one of the important aspects of taking care of critically ill patients is not only to convey the realistic picture honestly, but also not to leave the loved ones ignorant to form their own interpretations,” she says.

Prem pulled through the surgery well enough and Dr. Guntupalli was confident of a satisfactory recovery. Everything was going according to plan, until Dr. Guntupalli’s phone rang at 11 p.m. It was the respiratory therapist, Rajender. Prem was bleeding heavily from the nose and an incision wound in the neck. When Dr. Guntupalli reached the hospital, the ENT surgeon had derailed the emergency by re-exploring the wound, putting in deep stitches, and packing the nose, but Prem’s condition had declined again.

The next 24 hours were tense for patient, family and doctor. “That night I asked myself, ‘Did I come all this way to convey bad tidings to this family?’” Dr. Guntupalli recalls. They waited and watched. Gradually, the bleeding stopped and Prem began waking up. Dr. Guntupalli had at this point been in Delhi for over a week, but even despite his recent turnaround, Dr. Guntupalli knew that she could not leave. “I could not leave him in unknown hands,” she says. “I had to get someone who thought like me and was dedicated to the patient. So I stayed another week.”

During that last week, Prem became fully awake. Dr. Guntapalli went to his bedside to introduce herself. She said, “Prem, although I have been around for about ten days, you don’t remember anything that transpired. I am a professor at Baylor College of Medicine in Houston, TX and also an Intensive Care Specialist. I have been asked to care for you.” “He smiled, extended his hand and mouthed ‘thank you,’” she says, “and then, ‘take me to America,’” and we both laughed. “It was a good moment. I was able to catch a glimpse of the person everyone knew apart from me.” Prem has since recovered fully and remains friends with Dr. Guntupalli. “Whenever I see his family, I get a great sense of satisfaction,” she says.

Dr. Guntupalli has accomplished much in her life and has made the most of her education and professional career in the U.S. Yet she longs for the same opportunity and progress in her native country. “India has come a long way since I left to pursue higher education in the U.S.,” she says, “and it is possible to do the right things to save lives there now. The question is, how do we take these services to those who need them most?” As far as she has come, Dr. Guntupalli is still very much the young girl lying on her bed in Hyderabad, India, peering into a medical book with eyes wide open, searching for a way to heal the world of its ills.

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Internal Medicine Interest Group of the Month: UMDNJ New Jersey Medical School

Club Med, the Internal Medicine Interest Group at UMDNJ-New Jersey Medical School, was founded in the spring of 2004 by Tony Tarchichi in his freshman year. Dr. Tarchichi, who humbly asks to be called Tony, is currently in his first year of a dual Internal Medicine-Pediatrics residency at UMDNJ-University Hospital. He continues to be an important resource for Club Med, always offering to help in any way possible. Dr. Jo-Ann Reteguiz, FACP, Program Director for the Department of Medicine and former Club Med advisor, along with Dr. Neil Kothari, Associate Program Director for the Department of Medicine and current Club Med advisor, are very actively involved with our organization. Their assistance in helping run the Club Med non-credit elective has been invaluable. Club Med is headed by Haroon Shahid (MSII) and Kingsuk Ganguly (MSII). The rest of the executive board includes Janet ElGallab, Manisha Reddy, Neel Desai, Ruchi Kumari, and Shyam Patel, who are also second year medical students. Leadership is passed on to rising second-year medical students who have shown genuine interest in the organization and have participated in various Club Med activities.

In order to also involve the third- and fourth-year medical students, we created a liaison between upperclassmen and underclassmen this year. Our liaison, Angela Gomez-Simmonds (MSIV) has been integral in arranging various activities to prepare third- and fourth-year students for life as a resident. These include EKG review sessions as well as a mentorship program where third- and fourth-year medical students are paired up with residents at University Hospital. Also, we plan to hold a talk where some of the upperclassmen can give first- and second-year students tips on what to expect during rotations and can explain the process of applying to residencies.

As mentioned earlier, Club Med also runs a year long non-credit elective. This elective is broken into lectures and ATM (“Attendings Teaching Medical students”) sessions. The lectures cover a wide variety of topics including “What is an Internist?”, “Developing a Differential Diagnosis”, and “An Overview of Common Procedures in Medicine.” We also have had separate lectures on the various specialties within internal medicine, including pulmonology, gastroenterology, cardiology, nephrology, and endocrinology. These lectures provide students with some insight into the field of internal medicine and the various subspecialties. The ATM sessions, on the other hand, provide clinical exposure. ATM sessions are clinical teaching rounds offered five to six times per month. During each session, about four to five medical students meet with an attending physician or the chief resident and have the opportunity to observe some of the more interesting clinical cases in the hospital. This allows students to apply what they have learned in class and become more proficient at physical diagnosis.

This year, we also started a pilot program to allow one to two first- and second-year medical students the chance to go on rounds with the teams on the hospital floors. This gives the students a peek into what third and fourth year will be like. At the end of this year, the program will be evaluated based on members’ reactions and experiences and then the decision will be made whether or not to incorporate this into the non-credit elective.

Club Med is also very active in the urban Newark community. This year, we have participated in many health fairs where club members were actively involved in blood pressure and blood glucose screenings. These health fairs provide a free service to the poor and disadvantaged residents of Newark, while at the same time reminding overworked and overstressed medical students why they chose to become physicians.

Club Med has grown by leaps and bounds since its inception in the spring of 2004. Currently 360 out of 680 medical students (53%) at New Jersey Medical School are members of the American College of Physicians. I hope this growth continues as new students enter our medical school and bring innovative, fresh ideas. I would like to thank the American College of Physicians for all the support it has provided our organization.

Haroon Shahid
Co-President of Club Med, 2007-2008
UMDNJ-New Jersey Medical School
Class of 2010
E-mail: shahidha@umdnj.edu

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Winning Abstracts from the 2008 Medical Student Abstract Competition: Medical Hide and Seek...With A Twist!

Author:
Chun Chin Huang, Medical College of Georgia

Introduction:
Small Leukocytic Lymphoma/Chronic Leukocytic Leukemia (SLL/CLL) is a low grade lymphoma usually characterized by slow clinical progression. However, in patients with concurrent malignancy or who later develop another primary malignancy, the clinical progression of SLL/CLL can be somewhat unexpected.

Case Presentation:
A 59 y/o WF with a prior history of SLL/CLL was diagnosed with Non-Small Cell lung Cancer (NSCC) in 1996. She underwent surgical resection, radiation and chemotherapy with cisplatin and etopiside. Her original laboratory studies at the time of diagnosis with NSCC showed minor peripheral lymphocytosis but subsequent labs failed to show clinical evidence of SLL/CLL. Therefore this diagnosis was not further pursued and the patient was followed by the cancer clinic primarily for her NSCC. In November 2006 she presented to the clinic with worsening back and shoulder pain Bone scan showed focal uptakes in T5 and the coracoid process of the L scapula. Subsequent thoracic spine MRI showed findings consistent with metastatic lesions in T4, T5, and T7. She described a chronic cough, shortness of breath and an 8lb weight loss, but denied night sweats, fatigue, anorexia, or hemoptysis. Needle biopsy of the lesion from T5 vertebrate was done for evaluation of possible recurrence of NSSC vs metastatic tumor of unknown primary. Surprisingly, the final pathology report showed that the lesion was composed of lymphoid cells. Morphology and immunophenotype were most consistent with SLL/CLL. CT scan of chest, abdomen, and pelvis showed no lymphadenopathy or hepatosplenomegaly. Based on the pathology report and past medical history, the patient was diagnosed with recurrent SLL/CLL.

Discussion:
Although spontaneous remissions SLL/CLL have been reported prior to the development of a second malignancy, this case is particularly unusual because the patient went into prolonged clinical remission at the time of the treatment of her NSSC. It is unclear whether this is one of the rare spontaneous remissions documented or an unintended benefit of the chemotherapy and XRT. In addition, the patient’s disease presented itself in an unusual location for SLL/CLL– the thoracic vertebral body, with no other lymphadenopathy or hepatosplenomegaly. The patient was very fortunate in that her past medical history made the presenting symptoms of thoracic back pain much more alarming, which prompted a bone scan that revealed the lesions.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Sleep Medicine

The Discipline
Physicians who specialize in Sleep Medicine are trained to detect, treat, and prevent sleep disorders, such as jet lag, sleep walking, snoring, insomnia, and obstructive sleep apnea. Sleep Medicine was recognized as a medical subspecialty by the ACGME in 2003.

Procedures
According to the ABIM, Sleep Medicine specialists should be trained to interpret results of maintenance of wakefulness testing, polysomnography, multiple sleep latency testing, actigraphy, and portable monitoring related to sleep disorders.

Training
The ACGME began accrediting Sleep Medicine fellowship training programs in 2005. Sleep Medicine fellowship training involves one year of additional clinical training after completion of the internal medicine residency.

Certification
Sleep Medicine’s board certification exam is administered every two years by the following institutions: American Board of Family Medicine, American Board of Internal Medicine, American Board of Otolaryngology, American Board of Pediatrics, and the American Board of Psychiatry and Neurology. The first certification exam was held in the fall of 2007.

For additional information regarding the training and certification required for Sleep Medicine, please visit the ABIM Web site.

Major Professional Societies
American Academy of Sleep Medicine (AASM)
One Westbrook Corporate Center, Ste. 920
Westchester, IL 60154
Phone: (708) 492-0930
Fax: (708) 492-0943
Web site: www.aasmnet.org

Major Publications
Journal of Clinical Sleep Medicine, the official publication of AASM

SLEEP, the official publication of the Associated Professional Sleep Societies, LLC.

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Advocacy Brief: Department of Education Increases Stafford Loan Limit

The Department of Education has issued a "Dear Colleague" letter announcing an increase in the combined aggregate Stafford loan limit for certain health professions students (including medical students) from $189,125 to $224,000, effective immediately. This increase is entirely in unsubsidized Stafford loans and will allow medical students to borrow at a 6.8 percent interest rate, avoiding higher rates available through GradPLUS and other private loan programs. The loan limit increase comes in response to a September 2007 sign-on letter sent to Secretary of Education Margaret Spellings by medical organizations including ACP.

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Did You Know You Have Access to the Physicians’ Information and Education Resource (PIER®)?

PIER is ACP’s electronic, web-based decision-support tool designed for rapid point of care delivery of up-to-date, evidence-based guidance. PIER offers more than 480 modules focusing on the diagnosis and treatment of diseases, as well as an extensive drug database and valuable patient information.

ACP Medical Student Members have free online access to PIER after they register online.

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MKSAP for Students 3 Question 1

A 68-year-old woman is evaluated because of worsening pneumonia and respiratory failure. She has been in the hospital for 11 days following a cerebrovascular accident. She developed a nosocomial urinary tract infection that was treated with ceftazidime. Two days ago, she developed increasing purulent sputum, and a tracheal aspirate showed many leukocytes and Acinetobacter baumannii resistant to ceftazidime. Today she has a temperature of 38.5 °C (101.3 °F). A chest radiography shows two new areas of consolidation in the right lung, compatible with a hospital-acquired pneumonia.

Which of the following is the most reasonable choice of antibiotics for this patient?

A. Azithromycin
B. Ceftazidime
C. Doxycycline
D. Gentamicin
E. Imipenem

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MKSAP for Students 3 Question 2

The wife of a patient with type 1 diabetes mellitus calls because he had a severe hypoglycemic reaction last night that required a visit to the emergency department. She had administered intramuscular glucagon, and although it seemed to revive her husband at first, he became unconscious again in less than 10 minutes.

What is the likely cause of the recurrence of hypoglycemia?

A. Expired (ineffective) glucagon
B. Failure to provide oral carbohydrates after glucagon
C. Improper administration of glucagon
D. Ineffectiveness of intramuscular glucagon

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MKSAP for Students 3 Answer 1

Answer: E, Imipenem

Resistant gram-negative bacillary infections are common in very ill hospitalized patients. Many of these infections begin by colonization of patients in intensive care units. Each hospital tends to have certain organisms that predominate, although these change over time. Acinetobacter baumannii is seldom found in ambulatory patients, but it is one of the most commonly isolated gram-negative organisms in some hospitals. Differentiating between colonization and infection can sometimes be difficult since infection is almost always preceded by a variable duration of colonization. However, not all patients who are colonized will become infected.

Some Acinetobacter strains are broadly susceptible to antimicrobials, but many are multidrug-resistant and difficult to treat. Usually, the potent carbapenems (for example, imipenem and meropenem) and some of the aminoglycosides (for example, amikacin and tobramycin) are most active in vitro. Some of the ß-lactamase inhibitors (especially sulbactam) also demonstrate activity. Cephalosporins, such as cefepime, and fluoroquinolones, such as levofloxacin, are usually ineffective. Azithromycin and doxycycline have no activity against most causes of nosocomial pneumonia, and are not indicated. Although there is no substitute for knowing all of the in vitro data, early use of an active drug is strongly recommended when an infection is highly likely.

Aminoglycosides may not be well suited for treating lung infections, due to poor lung tissue penetration, despite having good minimal inhibitory concentrations. A combination of drugs may be better for the most critically ill patients, but this issue is unresolved.

Bibliography
Marques MB, Brookings ES, Moser SA, Sonke PB, Waites KB. Comparative in vitro antimicrobial susceptibilities of nosocomial isolates of Acinetobacter baumannii and synergistic activities of nine antimicrobial combinations. Antimicrob Agents Chemother. 1997;41:881-5. PMID: 9145838

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MKSAP for Students 3 Answer 2

Answer: B, Failure to provide oral carbohydrates after glucagon

Intramuscular glucagon has an effective half-life of only several minutes. Unless carbohydrates are ingested or another method is used to increase the glucose level in a sustained manner, hypoglycemia is likely to recur.

Intramuscular glucagon is less effective in type 1 than in type 2 diabetes, but is useful nonetheless. The current glucagon injection kit has no expiration date because the active ingredient is in a powdered form before reconstitution with the provided diluent. Depth of injection into the muscle has not been shown to significantly affect the action of glucagon.

Bibliography
Inzucchi SE. Oral antihyperglycemic therapy for type 2 diabetes: scientific review. JAMA. 2002;287:360-72. PMID: 11790216

Lebovitz HE. Oral therapies for diabetic hyperglycemia. Oral therapies for diabetic hyperglycemia. Endocrinol Metab Clin North Am. 2001;30:909-33. PMID: 11727405

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ACP Internal Medicine Residency Database

Interested in obtaining more information about residency programs? ACP offers the Internal Medicine Residency Database which contains information about all internal medicine residency programs in the United States. The Internal Medicine Residency Database provides a description of each program as provided by its internal medicine department or links directly into the program’s Web site.

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ACP Launches an Online, Mobile Game based on the Popular ACP Doctor's Dilemma™ Competition

Test your knowledge in a variety of disciplines with this new online game based on the popular ACP Doctor's Dilemma™ Competition from the ACP's annual Internal Medicine meetings. The game is simple to play and all you need is a web browser.

Because this product was designed using standards for mobile web content, all devices equipped with a Web browser are supported, including mobile smartphones and PDAs like Windows Mobile devices and Palm OS devices. An active Internet connection is required to play, but there is nothing to download or install.

Visit ACP's Web site to learn more.

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Articles for Medical Students from ACP Internist and ACP Hospitalist

ACP Internist (formerly ACP Observer)

ACP Hospitalist

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The College Issues Guideline for Screening for Osteoporosis in Men: View the latest ACP Internal Medicine Report

Osteoporosis is often viewed as a women's health issue, but few men are currently tested or diagnosed. Because of the aging population, a dramatic increase in osteoporosis among men is expected in the near future. New recommendations from ACP call for physicians to screen for osteoporosis in older men, especially those over the age of 65.

Osteoporosis is significantly under-diagnosed and under-treated in men, and studies show that osteoporotic fractures result in substantial disease, death, and health costs in men. Risk factors for osteoporosis in men include older age, low body weight, weight loss, physical inactivity, previous fractures not caused by substantial trauma, ongoing use of certain drugs (such as corticosteroids like prednisone or drugs that are sometimes used to treat prostate cancer), and low-calcium diets. Physicians should obtain a DXA (dual-energy x-ray absorptiometry) scan for men who are at increased risk for osteoporosis and may be candidates for drug therapy.

For more information or to view the report in streaming video format, please visit ACP Online.

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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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