May 2009 E-Newsletter

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Announcing the 2009-2010 Council of Student Members

The Council of Student Members (CSM) was formed in 1998 to address the needs of medical students and represent the interests of ACP’s Medical Student Members. Following is a list of Council members including their position and regional responsibilities. For more information about the CSM, click here.

Chair
Jonathan Stegall, MS, Medical University of South Carolina School of Medicine, Charleston, SC

Vice Chair
Viral Patel, University of Kentucky College of Medicine, Lexington, KY

Central Region Representative
Celine Goetz, University of Chicago – Pritzker School of Medicine, Chicago, IL

Central Atlantic Region Representative
Dana C. Mueller, University of Virginia School of Medicine, Charlottesville, VA

Midwestern Region Representative
Ryan C. VanWoerkom, University of Utah School of Medicine, Salt Lake City, UT

Military Representative
Lavanya Viswanathan, Uniformed Services University of the Health Sciences, Potomac, MD

New England Region Representative
Cedar Fowler, Tufts University School of Medicine, Cambridge, MA

North Atlantic Region Representative
Wendy Ho, Albany Medical College, Albany, NY

North Central Region Representative
Vance L. Albaugh, Penn State University College of Medicine, Hershey, PA

Osteopathic Representative
Shabnam Zarrabi, UMDNJ School of Osteopathic Medicine, Voorhees, NJ

Pacific Region Representative
Munveer Bhangoo, University of California, San Diego, San Diego, CA

Southeastern Region Representative
Matthew Rudy, Medical College of Georgia School of Medicine, Augusta, GA

Southwestern Region Representative
Gates Colbert, University of Texas Medical School at Houston, Houston, TX

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Medical Student Perspectives: Alternative Career Choices for Physicians

As medical students, we have chosen to enter a profession that holds endless opportunities and remarkable stability. As this year’s fourth year class matched into different specialties, we saw a vast array of people entering fields of medicine which will enable them to provide healthcare to tens of thousands of patients over their lifetime. One topic of discussion in medical schools that is often overlooked is that of alternative careers in medicine. There are various physicians across the world that put their skills and knowledge to use without encountering traditional patients. Even though the following list of ideas is not all encompassing, we will address pursuing careers with biotechnology and pharmaceutical companies, consulting firms, hospital administration, and public health opportunities.

Medical advances are consistently made in the medical industries of biotechnology and pharmaceutical companies. These companies need physicians to design new studies and write protocols. Physicians also initiate and monitor studies while juggling the tasks of interpreting data and preparing medical reports for company shareholders. They also work with administrators to develop strategies to bring new drugs or technologies to the market. Entrepreneurial opportunities are available to those physicians with bright and innovative ideas that include starting up companies in their respective fields.

Consulting firms also offer an intriguing spin to a career in medicine. With your alternative professional degree you can have experiences you could never have working in a conventional medical setting. Countries all around the world seek consultation about their health care systems and infrastructure. Pharmaceutical companies also demand services in analyzing market strategies for their drugs. Analysis of Medicaid programs is needed on a state-by-state basis and funding issues need to be resolved. Essentially, consulting leads you to think outside of the box and create efficiency standards in areas of health care while helping corporations and people do their jobs better.

Hospital administration is needed in every corner of your community. There are few physician leaders in health care and more are needed if the future of health care is to brighten. There is a multitude of opportunities in administration to make sure that hospitals operate efficiently and provide quality health care to patients. Hospital administrators are communicators between governing boards, medical staff, and department heads while integrating everyone’s expertise to ensure proper functioning of the hospital. A top official at a local hospital told me the easiest way to become an administrator is not to get an MBA but rather to fix a problem. Find a problem in the clinic where you work or the hospital you round in and provide a solution. When others notice your problem-solving skills, they will give you another to solve, and another. In this manner, your administration skills will develop naturally and people will learn that you are a problem solver.

Last, but definitely not least, are public health opportunities. Working in an underserved area, whether in the United States or abroad, provides rewarding experiences. The fruits of your labor are quite evident when working with indigent communities due to lack of health care and supplies. Immense opportunities exist, including the National Health Service Corps working in “mountain villages, bustling cities, desert townships, and along waterfronts.” They provide primary care to 50 million Americans living in health professional shortage areas. If you are looking for an international flavor of public health improvement, Doctors Without Borders or Médecins Sans Frontières (MSF) is an international medical humanitarian organization that provides essential health care in response to armed conflict, epidemics, malnutrition, and natural disasters. There are also public health opportunities with agencies such as the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH).

The opportunities available after medical school are endless and exposure to many career options is critical. Alternative careers provide different lifestyles and experiences not available to physicians practicing in traditional settings. Some of these options have less stability than others but provide something else if that is what you are looking for. Medicine is a career path that leads you to create whatever you want from it. Shape it, experiment with it, and have fun with it; as it is yours for the making.

Viral Patel
Vice Chair, Council of Student Members
University of Kentucky College of Medicine, 2010
Email: viral.patel@uky.edu

Check out more volunteer opportunities.

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My Kind of Medicine: Real Lives of Practicing Internists: Mark D. Anderson, MD, FACP

Mark D. Anderson, MD, FACP

On the farm where Mark Anderson grew up in Mississippi, there were always things that needed fixing, and Mark was terrible at it. His brother on the other hand, was a whiz—effortlessly saving the day time and time again with a gracefully held pair of pliers or a wrench. In “hill country” in a family that had worked in farming for multiple generations, this was not a desirable position to be in, but it wasn’t long before he would become quite good at solving problems on his own.

The Orderly
As a college student, Dr. Anderson knew he wanted a job working with people but that also challenged him as well. He chose pre-med at the University of Mississippi and took a job after college at a hospital as an “attendant,” cleaning up soiled patients and doing things like performing what were referred to as “tap water cleansing enemas,” which prepared patients for gastrointestinal procedures. It wasn’t a glamorous job to say the least, but Dr. Anderson didn’t complain. “I was an orderly, really,” he recalls, “but I actually enjoyed the work. The nurses explained to me the importance of what I was doing, which was a great experience to have before becoming a doctor.” After performing a tap water cleansing enema on one man, the young Dr. Anderson remembers being stunned when the patient turned around and thanked him. “He said ‘I don’t want you to think I enjoyed that but I thank you for being cheerful and helpful,’” he recalls. “It made a big impression on me that if you do something well people will appreciate you for it.”

In medical school at Tulane University in New Orleans, internal medicine drew Dr. Anderson in from the start. Always a voracious reader, the cognitive aspects of the discipline appealed to him, and he liked the idea of gaining a history of a patient to figure out a diagnosis. He made the definite decision to pursue internal medicine during a rotation with a cardiologist, whom he describes as gifted. “He was just extremely good at everything that is internal medicine—getting the history, the physical exam, the talking to the patients…and his examination skills were just amazing—he could put his hand on a patient’s chest and tell you what their cardiac cycle was.”

Today, in Chattanooga, TN working as an infectious disease specialist, a vice chief medical officer and quality officer for a health care system, a volunteer at an HIV clinic, and a control oversight consultant for health care-related infectious disease for several area hospitals, Dr. Anderson uses many of the same skills he admired in his mentor. He thrives on the difficulty of the job and loves all of his roles for the interaction he has with patients. “Most people don’t know what an infectious disease specialist is,” he says, “when I tell them they say it sounds like detective work, and it is. I love detective work!”

Farmer at Sea
An infectious disease can be a tough egg to crack. There are many times for example, when a patient goes to the hospital, very ill with a high fever, only to be sent home days later, completely recovered without any diagnosis. It’s the not knowing that can be hardest for families, as Dr. Anderson explains. “Generally speaking, people are more stressed out by uncertainty than they are by bad news.” But most of the time, Dr. Anderson is able to figure it out, as he did five years ago with a patient with a mysterious and persistent case of pneumonia that left the man so weak that he could barely get out of bed. The patient, a man in his late forties, had been to five physicians before going to see Dr. Anderson. After talking to the patient at length about his medical history, lifestyle and home environment, Dr. Anderson arrived at a diagnosis—Q Fever—a name coined in Australia because of its elusiveness. “The Q stands for query, as in a question, because for a long time they couldn’t figure out what it was,” he explained. “When they eventually did, they found a connection between the bacteria and close animal contact. I had learned from my patient that he lived on a farm raising goats.”

Just as his time on the family farm gave him a keen awareness of lifestyle-related illnesses, his time working as a medical officer in the U.S. Navy gave him the confidence to handle crisis situations. Dr. Anderson’s nine year career with the Navy based in San Diego proved to be an outstanding and unique training experience with unusual and severe infections. He also gained management experience, which he draws on today. In addition to his consultant and practice work, Dr. Anderson also works part time as the chief quality officer at a nearby hospital. Together he and the staff work on implementing quality programs and identifying the need for such programs. He enjoys the progress he sees from their efforts. “It’s very rewarding, doing this kind of work, and being an internist allows me to do it,” he says. “For example, one program we implemented was effective in decreasing medical errors. The real value of internal medicine for me is coordinating care. It’s very interesting, the variety of problems I address on a daily basis. My work is never routine. I’ve never known an internist who was bored, myself included.”

Working in the Navy also proved to be a crash course in quick-fire decision making, as it was in one instance during a two-year appointment as Medical Officer aboard the USS Vancouver. A young man had come to Dr. Anderson with a painful swelling underneath his jaw, which Dr. Anderson suspected was a deep head and neck infection. He was anxious about the diagnosis, however. If he made the decision to treat based on his theory, it would mean calling in a transport for the man to be flown to shore—a very disrupting operation. “We were in the middle of the Pacific Ocean, days from shore-based help,” he recalls. “My only option for a second opinion was to radio a more experienced doctor on a neighboring ship, which I did.” After discussing the symptoms, the physician told Dr. Anderson that he thought it wasn’t an infection at all, but rather a blocked salivary gland, which had a very simple treatment. “Here I was ready to call the helicopters in for a dramatic emergency trip across the Pacific, and the next thing I know I’m squirting lemon juice into the guy’s mouth. Problem solved—I’m glad I got his input!”

The Reader
In addition to physician, infectious disease specialist, chief quality officer, and volunteer, Dr. Anderson has taken on even more roles: course director and president. “My wife says if I say yes to one more thing, she’s going to kill me!” he jokes. However, Dr. Anderson chooses his activities carefully, picking only those which interest him the most, like the course director position for a reading retreat for physicians—an annual trip he looks forward to each year. His responsibilities include choosing the reading material for each retreat, something that comes easily to him as an avid reader. He also relishes his time as president of the Chattanooga Arts and Education Council and as the Chair for the Southern Writers Conference every year. The rest of his time he spends attending activities of his five children. And in the spare time he has left after all of that, he likes to sit on his front porch and relax with his wife, a pediatrician turned full-time mom. Like her husband, she is very busy herself. When she’s not with the kids she has her work cut out for her on their 20-acre farm, but these days when something needs fixing, he can handle it just fine.

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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Internal Medicine Interest Group of the Month: University of Nebraska

The Internal Medicine Interest Group or “Club Med” is going strong after eight years at the University of Nebraska Medical Center (UNMC) in Omaha. Our Advisor and Internal Medicine Chief Resident, Dr. Katie Hanson (ACP Associate Member), along with the internal medicine residency office staff, including Shirene Seina, Erin Blaszak, Lynette McKenny, and Sheila Rosenberg, are crucial to the club’s success. They allow us to run smoothly and adopt a different type of student-led organization. Club Med is organized by three second-year medical students, known affectionately as the “Tri-Pres.” We like to think of ourselves as a tripod – without all three legs we fall. The Tri-Pres is collectively responsible for directing luncheon meetings and club activities.

The first activity of the year was the UNMC Interest Group Fair, where we had a very strong showing of students and our ACP student membership recruitment was the highest it has been in years. The lunch meeting that followed focused on what it means to be an internist. Dr. Hanson eloquently discussed the many facets of internal medicine and primary care. After the meeting surveys were collected detailing what students wanted to learn from Club Med throughout the year. We hoped to show students both an enthusiastic glimpse into the life of an internal medicine doctor as well as the future career specialty opportunities available after internal medicine residency training.

In order to spark our classmates’ interest in our club and internal medicine, we decided to have themed meetings. During the week of Halloween we had an infectious disease fellow talk about “scary flesh eating bacteria”- with plenty of terrifying pictures to make us cover our eyes! Shortly after the “pregnant man” made the news, an endocrinologist talked to us about the physiology involved in gender transition as well as fertility issues post-transition. In response to all the discussion about the stimulus bill and health care reform, we are planning a “future of medicine” discussion, stressing the importance primary care providers such as internal medicine doctors will have in the new health care model.

A popular meeting was one we collaborated with the Pediatric Interest Group in which we invited a medicine-pediatrics doctor to talk about the highlights of her growing career field. We also invited a hospitalist to discuss the unique aspects of his job, another rising internal medicine pathway. Traditionally our interest group has had “Case Files”: presentations where an internist shows a challenging case they managed in an interactive way, promoting student participation and interest. We look forward to hosting a few more of these case files before the year comes to a close.

In the past year, the Tri-Pres has tried to put an exciting new spin on the way our classmates view internal medicine. We have certainly learned much about all the opportunities internal medicine has to offer and are looking forward to where it takes us in the future.

Ariana Astley, Tyler Ptacek, and Brett Malchow
Club Med Tri-Presidents
The University of Nebraska College of Medicine, Class of 2011
Emails: aastley@unmc.edu, tptacek@unmc.edu, bmalchow@unmc.edu

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Winning Abstracts from the 2008 Medical Student Abstract Competition: Decreased Pain Of IV Catheterization Via Jet Injection

Authors: Matthew V Satterly, Anikumar N Vinayakan MD, Heidi M. Koenig MD

Introduction
IV catheterization can be a painful procedure.

Case Presentation
A 57 year old white female presented to the University of Louisville Outpatient Day Surgery Unit for a skin graft to her left lower extremity post dog bite and subsequent infection. During her routine pre-operative preparation, she was to have an intervenous catheter placed for administration of fluids and medication during and after her procedure. After expressing a dislike of needles, she elected to have delivery of local anesthesia via jet injection technology. The patient received 0.2ccs of 1% carbonated lidocaine via J-Tip; jet injection on the dorsum of her hand. An immediate 7 to 8 mm skin wheal was produced and with no delay an 18 gauge IV catheter was placed without incident. The patient reported no pain whatsoever (0 out of 10) for both the administration of lidocaine and the IV catheter placement.

Discussion
With pain often referred to as the 5th vital sign and a JCAHO mandate to “recognize the right of patients to appropriate assessment and management of pain” minimizing the pain generated secondary to procedures or treatment administered by healthcare professionals is a high priority. Moreover, with roughly 10% of the population having some degree of “needle-phobia” jet injection avoids the need to subject patients to undue stress and discomfort. Initially developed for mass vaccinations, jet injection is gaining interest in a variety of arenas, from insulin delivery to local anesthesia for vasectomy. By also eliminating the risk of needle stick injuries and reducing sharps waste, jet injection offers a safer working environment for healthcare providers and a more humane experience for patients.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Critical Care Medicine

The Discipline
Critical care medicine encompasses the diagnosis and treatment of a wide variety of clinical problems representing the extreme of human disease. Critically ill patients require intensive care by a coordinated team. The critical care specialist (intensivist) may be the primary provider of care or a consultant. The intensivist needs to be competent not only in a broad range of conditions common among critically ill patients but also with the technological procedures and devices used in the intensive care setting. The care of critically ill patients raises many complicated ethical and social issues, and the intensivist must be competent in areas such as end-of-life decisions, advance directives, estimating prognosis, and counseling of patients and their families.

Procedures
Important procedural skills for the critical care medicine specialist include advanced cardiac life support, arterial blood gas sampling and interpretation, bedside pulmonary function, mechanical ventilation, placement of arterial and central venous lines, insertion of temporary pacemaker, endotracheal intubation, and placement of pulmonary artery catheter.

Training (via Internal Medicine)
Training in critical care medicine is most commonly pursued as part of a combined 3-year subspecialty fellowship in pulmonary and critical care medicine, after which the trainee is eligible for subspecialty certification in both pulmonary medicine and critical care medicine. In addition, a physician interested in critical care medicine can pursue training by alternative routes besides linking critical care with pulmonary medicine training. Such alternative routes include: (1) a two-year accredited fellowship in critical care medicine after internal medicine residency; (2) two years of fellowship training in advanced general internal medicine (that include at least six months of critical care medicine) plus one year of accredited fellowship training in critical care medicine; or (3) two years of accredited fellowship training in a subspecialty of internal medicine (three years for cardiovascular disease or gastrointestinal disease) plus one year of accredited clinical fellowship training in critical care medicine.

Certification
The American Board of Internal Medicine, ABIM, offers certification in critical care medicine. Certificates of Added Qualifications are also awarded from the American Board of Surgery, American Board of Pediatrics, and the American Board of Anesthesiology.

Training Positions
As of August 2005, there were 31 “stand-alone” ACGME-accredited training programs in critical care medicine with 126 active positions. 30% of the trainees were female and 36% were US medical graduates. There are also approximately 130 programs that offer combined training in pulmonary medicine and critical care.

Practice
Approximately 48% of the graduates enter clinical practice in critical care medicine in the United States, and 20% enter academic medicine.

Major Professional Societies

  • Society of Critical Care Medicine

    • 701 Lee Street, Suite 200
    Des Plaines, IL 60016
    Phone: 847 827-6869
    www.sccm.org/sccm

  • American Thoracic Society

    • 61 Broadway
    New York, NY 10006-2755
    Phone: 212-315-8600
    www.thoracic.org

  • American College of Chest Physicians

    • 3300 Dundee Road
    Northbrook, Illinois 60062-2348
    Phone: (847) 498-1400
    www.chestnet.org

Major Publications

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Advocacy Brief: Preserving Patient Access to Primary Care Act Introduced

This week Rep. Allyson Schwartz (D-PA) introduced the Preserving Patient Access to Primary Care Act of 2009 (H.R. 2350). This bill, based largely on ACP policies, is designed to help reverse the growing shortage of primary care physicians by increasing payments to internists and other primary care physicians, providing scholarships and loan forgiveness, and making the Patient Centered Medical Home a permanent covered benefit under Medicare. As a sign of the support that primary care has in Congress, the bill already has 9 cosponsors. ACP has endorsed the legislation and College leadership will be participating in a press event with the Congresswoman next week.

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Did You Know You Have Access to the Internal Medicine Residency Database?

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 a link directly into the program’s own Web site.

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MKSAP for Students 4 Question 1

A 60-year-old morbidly obese man becomes difficult to arouse 12 hours after undergoing elective right knee replacement. He has a history of osteoarthritis, hypertension, and sleep apnea. Outpatient medications are acetaminophen and hydrochlorothiazide. He also uses nocturnal bilevel positive airway pressure ventilation. His surgery was uncomplicated, and he has received regularly scheduled doses of intravenous morphine sulfate for pain.

On physical examination, temperature is 36.6 °C (97.8 °F), heart rate is 80/min, respiration rate is 10/min and shallow, and blood pressure is 130/85 mm Hg. Cardiac examination is normal and unchanged from his examination on admission. Pulmonary examination reveals distant breath sounds without wheezes or crackles. He is moderately responsive to sternal rub. Oxygen saturation is 90% by pulse oximetry with the patient breathing oxygen, 2 L/min, by nasal cannula. The pupils are equal, round, and reactive to light. Neurologic examination is normal.

Which of the following diagnostic studies is most likely to determine the cause of this patient's diminished level of consciousness?

A. Arterial blood gas measurement
B. CT scan of the head
C. Finger-stick blood glucose
D. Lumbar puncture

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MKSAP for Students 4 Question 2

A 30-year-old woman is evaluated in the office during a routine examination. Her medical history is significant for Hodgkin's lymphoma that was treated successfully with radiation therapy to the chest and abdominal lymph node sites 10 years ago; she never received chemotherapy. The patient has never smoked, has no family history of cancer, and has no current medical problems. Her physical examination is normal.

The patient is at the most increased risk for developing which of the following cancers?

A. Acute myeloid leukemia
B. Breast cancer
C. Hodgkin's lymphoma
D. Lung cancer
E. Non-Hodgkin's lymphoma

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MKSAP for Students 4 Answer 1

Answer: A: Arterial blood gas measurement

Measurement of arterial blood gases is likely to determine the cause of this patient's diminished consciousness. His history of obesity and sleep apnea and the recent general anesthesia and regular narcotic therapy make the obesity hypoventilation syndrome likely. If he has obesity hypoventilation syndrome as well as obstructive sleep apnea, he is likely to be very sensitive to the respiratory depressant effect of narcotics. Pulse oximetry is useful in monitoring oxygenation but does not adequately assess ventilation in patients receiving supplemental oxygen. Measurement of blood gases in patients who are hypoventilating shows an elevated PCO2 and a decreased pH (respiratory acidosis). In narcotic-related hypoventilation, intravenous naloxone, a short-acting opioid antagonist, can quickly reverse the effects that narcotic agents have on ventilation.

Brain imaging is used in patients with a history of head trauma or evidence of focal neurologic impairment on clinical examination. Finger-stick blood glucose measurement is rapid and simple and is most likely warranted in this patient. However, without a history of diabetes mellitus or liver disease, the level of suspicion for hypo- or hyperglycemia is low. Lumbar puncture is rarely helpful in diagnosing the cause of diminished consciousness in the absence of clinical signs supporting a diagnosis of meningitis or subarachnoid hemorrhage, such as fever, nuchal rigidity, or focal neurologic signs.

Bibliography
1. Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med. 2005;142:187-97. [PMID: 15684207] [PubMed]

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MKSAP for Students 4 Answer 2

Answer: B: Breast cancer

Hodgkin's lymphoma survivors who receive extended-field radiation therapy have a 1% risk/year for developing solid tumors. Young women are particularly prone to developing breast cancer in this setting, with an actuarial lifetime risk for a 20-year-old patient treated with mediastinal radiation therapy of 50% to 60%.

If this patient were a smoker, her history of radiation therapy would put her at increased risk for lung cancer. After 10 years, this patient's risk for developing recurrent Hodgkin's lymphoma is very low (2% lifetime risk). Radiation therapy does not increase the risk for acute myeloid leukemia, but alkylating-agent chemotherapy does. Finally, this patient's lifetime risk for developing non-Hodgkin's lymphoma after a previous diagnosis of Hodgkin's lymphoma is low (5%), and its occurrence would probably be unrelated to prior therapy.

Bibliography
1. Dores GM, Metayer C, Curtis RE, et al. Second malignant neoplasms among long-term survivors of Hodgkin's disease: a population-based evaluation over 25 years. J Clin Oncol. 2002;20:3484-94. [PMID: 12177110] [PubMed]

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Internal Medicine 2009 Feedback

The Council of Student Members wants to hear your opinions of Internal Medicine 2009. If you attended ACP’s annual meeting, please send your feedback on the meeting to Membership Development mbrdev@acponline.org. Your feedback will be carefully considered as the Council plans the Student sessions and events for future meetings.

What scientific sessions did you enjoy? What sessions did you not find useful?
What did you learn from the meeting that you could take home?
Was there anything you were hoping to come away with but did not?
What is the one thing that the College could do to make the conference more appealing to Medical Students?

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

ACP Hospitalist

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

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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.

New ACP Online Clinical Information Page

New ACP Online Clinical Information Page
Sneak a peek at ACP's new and improved Clinical Information page! Test drive the beta version of our redesigned Clinical Information landing page, give us your feedback, and help us make it as easy to use as possible.

Your Opinion Counts

Your Opinion Counts

Twice a year, ACP participates in a journal readership survey of random internists. If you receive one of these surveys in the mail, please indicate if you read our journals and answer the questions about your reading habits of our journals.

Your voice in these surveys is very important to ACP and enables us to continue to produce the high-quality publications that you expect.
Find out more.

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