November 2005 E-Newsletter

Fall 2005 IMpact PDF

Adventures Await--A Simple Guide to Medical Electives Abroad

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Many medical students entertain the idea of doing an elective abroad, but many never actually make it to the airport. In order to turn a great possibility into a reality, I will offer some answers to the basic questions that surround international medical electives.

Why Should I Go?

Medical students pursue international rotations for a variety of reasons. Some want to learn a foreign language, some want to try out a totally different practice environment, and some are looking for a way to travel to a country they have always dreamed of visiting while still earning credit towards their degree. Whatever your reason, there are opportunities available for you! Many students return from their rotations abroad re-inspired about medicine and healthcare, and some may even return to those countries as volunteer physicians in the future. Rotations in rural areas and different climates also allow students to witness pathology they may not encounter very often at home, giving their medical education a greater breadth. Practicing in a different healthcare system can also give students insight into how to improve care in the United States, as well as open their eyes to healthcare needs around the world.

Who Should Go?

You! Any medical student can go abroad for an elective, and opportunities abound. Don't let your language abilities (or lack thereof) hold you back, because there are plenty of opportunities in English-speaking countries. You could be even more adventurous and include language learning in your experience!

When Should I Go?

Pick a time, most likely during your fourth year, when you do not need to be in the States. Most important is to take residency interviewing into consideration. Many students choose to go in October, since applications should be in and interviews haven't yet gotten into full swing. Many others wait until February, once interviews are over, or even April, when the Match is finished. Most rotations operate on a monthly basis, so look at your schedule and pick a good month for you. You will also want to take the climate of the country you are traveling to into consideration. Doing a rotation in a tropical locale during monsoon season may be less than enjoyable!

Where Should I Go?

Location, location, location! Your experience abroad will undoubtedly be shaped by your choice of destination. Maybe you want to experience healthcare in a country with a national socialized system like England or Canada, or you would rather work in a clinic in a small African village. Most international university medical schools offer elective credit for away rotations. Don't be afraid to organize your own experience. Maybe a doctor you have worked with at home regularly volunteers abroad. Try to arrange elective credit to join his group on their next trip. Also, if you choose to go to a country whose language you do not speak, be sure to inquire about the availability of translators. Better yet, take a language course before you go and/or during the elective. The possibilities are endless!

How Can I Go?

This is the part that most students let get in the way of going abroad: money. Travel is not cheap, and many elective programs charge a fee that is not covered by your medical school tuition. You should also take cost into consideration when choosing a destination. Countries in the developing world will be much cheaper to live, eat, and travel in than European countries.

So, be creative about finances. Many medical schools have travel scholarships for research abroad, so think about incorporating a research project into your elective. For example, a student at my school is currently in Nepal doing research on altitude sickness awareness and preparedness at the Mt. Everest base camp. Simple projects that can be completed in a few weeks, such as surveys or health education project development, are often well suited to an elective abroad. In addition, fellowships exist for international health work that various organizations offer. Often, these may require a multiple-month stay, but your travel expenses are usually covered. For airfare, try to use frequent flyer miles or find cheap off-season flights, one of the benefits of traveling during the school year. Another way to subsidize your trip is to sublet your apartment for the month you are away to another student coming to do a visiting elective at your school. If you are committed to going, there are always ways to find the finances.

So, I've Decided to Go . . .

Here are some great web resources to begin your search.

Ashley Starkweather, Pacific Region
University of Southern California School of Medicine, 2007
E-mail: starkwea@usc.edu

Check Out ACP's PIER for FREE!

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Have you ever wanted a quick answer to a clinical question just minutes before rounds start (and not had time to sift through a twelve-page article from Up-to-Date)? Or needed a hand-out to leave with a patient on rounds as your attending explains an upcoming procedure? Or just wanted a quick reference guide to anti-retroviral therapies for your upcoming pharmacology class?

If so, don't forget to check PIER (Physicians' Information and Education Resource), ACP's online educational reference, which provides physicians and medical students with evidence-based, peer-reviewed clinical recommendations on the diagnosis, treatment and management of over 400 diseases. PIER includes information such as lists and flow diagrams to help you perform targeted histories and physicals, work up undifferentiated patients, create thorough differential diagnoses, and find complete treatment information, including advice on counseling patients, non-drug therapies and complementary-alternative medicine. The information is updated continuously, easy-to-access, thorough, and concise. Strength of recommendation ratings are also included based on the quality of the underlying evidence.

To make your search even easier, PIER is linked to additional articles in Annals of Internal Medicine, ACP Medicine, ACP Journal Club, MKSAP (Medical Knowledge Self-Assessment Programs), sections of ACP books, PubMed abstracts, Clinical Evidence, Cochrane Reviews and other Web resources-giving you information that will help you shine during your clerkship and make you stand out to your attending physician and residents. You can also find related information on screening and prevention, procedures, and legal and ethics issues. Video clips, illustrative figures, and supplemental tables are available, which can be printed out as handy pocket references or loaded onto your PDA.

Best of all, PIER is provided FREE to ACP Medical Student Members as a benefit of belonging to the College! To access PIER, you need to register at the College website. This will allow you to create your online username and password-a thirty-second process. The link to PIER is provided from the College homepage, giving you immediate access and fast searching capabilities with each subsequent visit. So, the next time you're wondering how to tackle a clinical question, check out PIER and put your ACP membership to use to help you find the right answer!

Erin Dunnigan, Vice Chair
Ohio State University College of Medicine, 2006
E-mail: dunnigan-1@medctr.osu.edu

Internal Medicine Interest Group of the Month: University of Massachusetts Medical School

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After spending so much time in the classroom as first and second years, it's important for medical students to catch a glimpse of that light at the end of the tunnel. The lectures on physiology, biochemistry, and pathology will all help us become great physicians, but what type of physicians will we become? The ACP gives us the chance to see what a career in internal medicine or one of its subspecialties is like. The ACP has lots to offer, and at the University of Massachusetts Medical School (UMass), we felt it was important to make our Internal Medicine Interest Group's events appealing to our fellow students so they too could learn about the field. The UMass recipe for a well-attended ACP event is actually quite simple:

1. Entertaining, well-liked speakers. We chose physicians with whom students were familiar from classes, who were admired, and who were, above all, amusing. One of our speakers included a popular infectious disease doctor who, while wearing his distinctive bow tie, would review slides of numerous intestinal parasites, while also quizzing us on pop culture and classic 50's movies during his lectures. Another was a cardiologist who would always somehow incorporate cartoons of giraffes and photos of beach scenes into his lectures, while he helped us understand cardiac output and the pathophysiology of the heart. These doctors are committed to teaching and are willing to speak at our events. Students appreciate getting to know their favorite instructors on a more personal level and finding out why they chose their subspecialty, what they like and dislike about their field, and how they balance life and work.

2. An appealing advertisement for the event. First and second years are in class all day, so a little humor can really catch their attention. An example of one of our e-mails includes: "Cuénoud on Cardiology: Learn about the Wacky World of MedicineTM and how to pronounce that extra accent "é" thing on Cuénoud's name". The underlying message is that medicine is fun, and in order to be good at what we do, we have to enjoy it, no matter what level we are at in our training.

3. Good food. This seems obvious, but should never be understated. There are plenty of creative ways to break away from the traditional pizza or cafeteria pre-made sandwiches. Our school's student activities board struck some deals with local restaurants for catering, which helped keep costs reasonable. We were able to serve Indian food, an Italian spread, or make-your-own sundaes (ice cream as well as frozen yogurt to please everyone) at various events.

1 + 2 + 3 = a great student event! Of course, there are other components to maintaining an active group with successful events. The ACP faculty advisor at UMass, who is also the internal medicine clerkship director, was very approachable, friendly, and eager to help out in any way. The student leaders were all very involved in the activity planning and shared responsibilities well, each taking ownership of their role.

ACP events at UMass included a sign-up booth at the activities fair, which occurred during the first few weeks of school, an introductory meeting covering an overview of possible careers in internal medicine, and a series of subspecialty talks where students could hear more about the training, daily challenges, and lifestyles which accompany specific subspecialties. We also offered a panel discussion with fourth-year students who recently matched in internal medicine, giving students an idea of what the interview process entailed, and what makes an application appealing to residency directors. The group also arranged shadowing opportunities in the endoscopy suite and cardiac catheterization lab and held a raffle for a free copy of MKSAP for Students 2 for ACP members.

ACP leaders at UMass also have had the opportunity to get to know ACP leaders at the other Massachusetts medical schools (Tufts, Harvard, and Boston University), which allows us to share ideas and to work jointly on events like the Massachusetts Residency Fair. ACP leadership has been a lot of fun. It has also been a great opportunity to learn more about internal medicine and meet internal medicine physicians. And if you use the recipe provided above, planning a great event is really quite easy!

Lael Yonker
University of Massachusetts Medical School, 2007
E-mail: lael.yonker@umassmed.edu

MKSAP Question 1

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A 45-year-old man with alcoholic cirrhosis is admitted to the intensive care unit for evaluation of hematemesis. On the morning of admission, he developed nausea and dizziness followed by a liquid, maroon stool. He subsequently vomited "a quart" of bright red blood.

The patient's hemodynamic condition was stabilized. Upper gastrointestinal endoscopy shows large esophageal varices, one of which has adherent clot. No other bleeding site is seen. Sclerotherapy is administered to all visible varices. Twenty-four hours later he suddenly vomits a large volume of bright red blood. His pulse rate is 140/min, respiration rate is 36/min, and blood pressure is 70/40 mm Hg. Despite fluid resuscitation, he continues to be hypotensive and vomit bright red blood.

Which of the following is the most appropriate next step?

( A ) Portosystemic shunt procedure
( B ) Balloon-tamponade of the bleeding varices
( C ) Intravenous vasopressin
( D ) Transjugular intrahepatic portosystemic shunt (TIPS) procedure

MKSAP Question 2

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A 63-year-old woman comes to the emergency department because of nausea, vomiting, shaking chills, fever, and abdominal pain of 4 hours' duration. Physical examination reveals a temperature of 39.2 °C (102.5 °F), scleral icterus, and epigastric tenderness.

Ultrasonography of the abdomen reveals gallstones and dilatation of the common bile duct. The liver and pancreas appear to be normal.

Which of the following is the most likely diagnosis?

( A ) Viral hepatitis
( B ) Ascending cholangitis
( C ) Hepatic abscess
( D ) Gallstone ilieus
( E ) Pancreatic pseudocyst

Answer - Question 1

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Answer: B

Educational Objective: Select the most appropriate emergent management for bleeding esophageal varices.

The most appropriate next procedure is insertion of a balloon-tamponade tube and inflation of the gastric balloon. This patient is in extremis from probable recurrent esophageal variceal bleeding despite his earlier sclerotherapy, and he requires urgent stabilization. Balloon tamponade will control variceal bleeding in 90% of patients. Inflation of the gastric balloon alone and subsequent tamponade at the gastroesophageal junction will stop bleeding in most patients due to pressure on feeding venous radicles that course along the cardia to the distal esophagus. Inflation of the esophageal tube is often unnecessary and is associated with excessive morbidity. Emergent surgical therapy is associated with at least a 50% mortality rate in patients with this condition. Intravenous vasopressin may decrease the bleeding rate, but it is unlikely to control severe hemorrhage and may result in intestinal ischemia in hypotensive patients. A transjugular intrahepatic portosystemic shunt (TIPS) may eventually be useful for this patient, but it is not appropriate in this urgent situation.

References

  1. Terblanche J, Burroughs AK, Hobbs KE. Controversies in the management of bleeding esophageal varices (1). N Engl J Med. 1989;320:1393-8.
  2. Terblanche J, Burroughs AK, Hobbs KE. Controversies in the management of bleeding esophageal varices (2). N Engl J Med. 1989;320:1469-75.
  3. Infante-Rivard C, Esnaola S, Villeneuve J. Role of endoscopic variceal sclerotherapy in the long-term management of variceal bleeding: a meta-analysis. Gastroenterology. 1989;96:1087-92.

Answer - Question 2

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Answer: B

Educational Objective: Recognize ascending cholangitis.

This patient clearly has acute ascending cholangitis due to common bile duct stones. Prospective, controlled trials have shown that endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and either removal of a common duct stone or placement of a stent are more effective therapy than emergency surgery. The morbidity and mortality rates are lower and the success rates higher with emergency endoscopic treatment than with surgery. Similar controlled trials have shown that emergency endoscopy in the critically ill patient with gallstone pancreatitis is better than conservative therapy, such as antibiotics and supportive care.

The duration and severity of this patient's illness are not consistent with viral hepatitis or hepatic abscess. Jaundice would not be present in gallstone ileus or pancreatic pseudocyst.

References

  1. Johnston DE, Kaplan MM. Pathogenesis and treatment of gallstones. N Engl J Med. 1993;328:412-21.
  2. Lai EC, Mok FP, Tan ES, Lo CM, Fan ST, You KT, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med. 1992;326:1582-6.

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