November 2006 E-Newsletter

My Kind of Medicine: Real Lives of Practicing Internists: James McCallum, MD

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Boxwoods are impressive, stately looking bushes. They are fairly substantial in size; large enough to serve as a barrier or hedge, for which they are often used, but they need to be trimmed often, and the trimming takes a lot of time. However, that does not bother 32-year-old Dr. James McCallum. That is where you will find him on any given evening—outside trimming his boxwoods. For him it is a cherished way of life and one he says is possible because of his decision to go into internal medicine.

Dr. James McCallum

Dr. James McCallum


“I think it is very important to have balance in your life, otherwise you will end up getting burned out,” he says. “A mentor of mine once told me that during his busiest years as a physician, he rarely saw his children. He said he regretted that, and I did not want the same thing to happen to me.”

Learning to Lead

Dr. McCallum currently works as a hospitalist and as Assistant Director for the third year internal medicine clerkship program at the U.S. Department of Veterans Affairs (VA) Hospital in Columbia, South Carolina. He completed medical school at the University of South Carolina in 2001 and followed with a residency with the Palmetto Health Alliance Program, which is affiliated with the university. Aside from taking in the large volume of knowledge students are expected to obtain, he says his main challenge in medical school was learning to believe in himself.

“The most challenging aspect of medical school is understanding that you have a great deal of knowledge and that you are capable of being a good doctor,” he says. “I see a lot of insecurity in both the medical students and the residents. They come in with a façade of bravado, but they are really terrified underneath. I know, because it happened to me. I can remember being truly scared that I was a fraud and that surely someone was going to figure that out sooner or later.”

For Dr. McCallum, experience was the key for overcoming fear. He says the confidence came gradually, as he continued to take on additional responsibility. He also says a big part of banishing self-doubt is the experience of teaching newer students and residents. “When a second year resident takes an intern under their wing they realize they have learned what they were supposed to and that they are good doctors.”

Dr. McCallum decided to pursue internal medicine in his third year of medical school, because as he says, “it just fit.” He was intrigued by the thought process it demanded and likens being an internist to being a detective in the medical world. When asked why he would recommend a medical student pursues internal medicine, Dr. McCallum says it boils down to opportunity.

“There are a tremendous number of options involved,” he explains. “Internal medicine is always challenging because there is so much information and knowledge we need to know in order to do our jobs. We look at a bunch of clues and try to make a diagnosis of it. It’s never boring, because every patient is different.”

Letting Go

Trying to practice perfect medicine in an imperfect world has its frustrations. Dr. McCallum will tell you, despite the best of intentions or effort, that sometimes the outcome is not what you had envisioned. He says one patient in particular stands out in his mind as a learning experience.

“The patient suffered a large stroke and had appropriately been given thrombolytics at another facility. He subsequently developed a huge cerebral hemorrhage and was transferred to me because we had neurosurgical support available at our facility. When the patient arrived, there was nothing that the medicine service or the neurosurgery service could do for him, and he died later that day. It was a difficult situation for me because even though everything had been done correctly, the patient still had a dramatically bad outcome.”

In the “business of saving lives” as they say, becoming aware of your own mortality can be a strange and unwelcome event. Dr. McCallum experienced that feeling already, when he was in a room full of doctors. “I was at a medical school banquet when I suffered an episode of supraventricular tachycardia,” he explains. “My heart rate shot up to 240 beats per minute. After a trip to the emergency room and some testing, they determined I was fine. I spent several sleepless nights worrying about it however; even though intellectually I knew it was relatively benign.”

The episode gave Dr. McCallum a strong glimpse of the patient experience and a keen understanding of the physician-patient relationship. “I love what I do because I feel like I am really doing something to help patients. It is easy to come to work every day—I get to be the good guy.”

A Balanced Life is Good Medicine

For this native southerner, a balanced life is a better life. “I love my job,” he says, “but I think that it is unbelievably important to go to my four-year-old’s dance recital as well.” Dr. McCallum says being able to do things like that makes him a better doctor. He says he believes he is more productive at work when he is able to put it out of his mind when he goes home.

“I like to go home, spend time with my wife, mow the lawn, fix the dishwasher, and push my two-year-old on the swing,” he says. “I get to put my children to bed every night, and that is what I hope they remember in 20 years.”

His mentor would be proud.

Internal Medicine Interest Group of the Month: Louisiana State University, New Orleans

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The Edgar Hull Society, the internal medicine interest group at Louisiana State University Health Sciences Center (LSUHSC) School of Medicine in New Orleans, is glad to be back in the city after a rough year. Our medical school spent its post-Katrina days dispersed. The first and second year medical students were displaced to a research center in Baton Rouge while the third and fourth year students spent last year in the clinics of neighboring cities. LSU is proud to mark the advent of the 2006-2007 school year with the first and second year medical students back in their own classrooms in New Orleans. While our own University Hospital is not yet open, the New Orleans community hospitals have absorbed our Charity Hospital patients along with our medical students. Upperclassmen are still rotating through hospitals in neighboring cities, but as the patient base is moving back to New Orleans, the LSUHSC clinical experience is reestablishing a greater position in the city. The Edgar Hull Society has adjusted to these changes as well and has begun this year on a note representative of our legacy.

Our internal medicine interest group was established in 1999 and was named the Edgar Hull Society (EHS) to honor the late Dr. Edgar Hull, past chairman of LSU’s Department of Medicine and renowned physician. Since its inception, the EHS has grown tremendously and now occupies a place among the largest campus organizations. Currently, large monthly meetings are held each semester in which various speakers discuss their experiences in the field of internal medicine or specialties. Past meetings have covered topics including general internal medicine, cardiology, gastroenterology, student research opportunities, and case presentations that bring the “Morning Report” experience to first and second year students. In addition, the EHS coordinates an annual party, “A Taste of New Orleans,” for senior and junior medical students who intend to pursue internal medicine residencies. The party is hosted by Charles Sanders, MD, MACP, Edgar Hull Professor and Chairman of the Department of Medicine, and his wife, Julia. The EHS has also been engaged in helping its community. In the past, members presented health-related topics to residents of the Brantley House, a homeless shelter in New Orleans. Since shelters have been forced to take on a larger load of homeless citizens, the EHS expanded this program to include visits to more homeless shelters.

Last year, the EHS earned the honor of becoming part of the 2005-2006 Forty Percent Medical School Awards Program sponsored by ACP. LSUHSC, New Orleans was ranked third in the nation with sixty percent of its student body maintaining membership in ACP for the 2005-2006 academic year. In fact, our group has earned ACP recognition every year for the past six years. Our Department of Medicine will be hosting the Louisiana ACP Annual Scientific Meeting in January 2007. All of our students are strongly encouraged to submit abstracts to the local and national ACP abstract competitions and abstract writing workshops are offered to all EHS members. Out of the highest ranked abstracts presented at the Louisiana ACP Annual Scientific Meeting last year as part of the Louisiana ACP Associates Program, three belonged to LSU medical students.

The EHS owes its success to a very supportive Internal Medicine Department and to the club advisors, Charles Sanders, MD, MACP, and Fred Lopez, MD, FACP. The EHS and the university as a whole persevered last year despite the disadvantages, and wish to continue improving and moving forward this year.

Clifford Courville and Sarah Jolley
Edgar Hull Society Co-Presidents
University of Louisiana School of Medicine, New Orleans

Winning Abstracts from the 2006 National Medical Student Abstract Competition: Adherence to the American Heart Association Guidelines for Telemetry Monitoring on a General Medicine Telemetry Unit

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Author: Christopher J. Varughese, Howard University College of Medicine, 2007

Introduction:
The advent of telemetry allowed health care professionals to monitor inpatients that were considered high risk for developing serious cardiac complications. However, studies have shown that not all patients admitted to telemetry units benefit from monitoring and that telemetry monitoring significantly increases the cost of caring for patients (Estrada et. al., 2000).The American Heart Association (AHA) has instituted guidelines for the use of telemetry with patients admitted to non-intensive care units. Cardiac monitoring is indicated for patients with Class I diagnoses. Patients with Class II diagnoses may benefit from cardiac monitoring, though it is not essential. Those patients with Class III diagnoses have low risk for cardiac events and it has been shown that monitoring has no benefit. This study reviews patients admitted to a general medicine telemetry unit and classified their illnesses based on the AHA guidelines.

Methods:
We reviewed reasoning for admission of 127 patients placed on a non-intensive care unit monitored telemetry ward. A record was kept of the admissions for 30 days. The patients' diagnoses were classified as either Class I, II or III based on the admission information. We then determined the most common diagnosis found in each class.

Results:
49 out of 127 patients (38%) were classified as Class I with the most common reason being decompensated congestive heart failure. 43 of the 127 patients (34%) were admitted to the telemetry ward with the most common reason being chest pain and they were identified as Class II. Finally, 35 out of the 127 patients (28%) admitted to the telemetry unit were most consistent with Class III recommendations. Many of the non-cardiac reasons for admission, which include hemodynamically stable lower GI bleeding, and hemodynamically stable anemia were classified into Class III.

Conclusion:
In this study, we found that patients in a monitored general medicine ward were not admitted based on AHA recommendations. These results support previous studies that suggest that low risk patients are inappropriately assessed for telemetry monitoring (Estrada et. al., 2000) and may be admitted more as a reassurance tool for both the physicians and health care team (Estrada et al., 2005). In addition, a recent study by Hollander and colleagues has suggested that the routine use of telemetry monitoring for low risk patients with chest pain is of limited utility (Hollander et. al., 2004). This suggests that many of the patients who were categorized into Class II and III should be re-evaluated before they are admitted to monitored beds. The data also suggests and that the role of telemetry in guiding patient management may be overestimated by physicians (Estrada et. al., 1995). Implementation of a checklist for admission to a telemetry unit for the emergency department physicians and staff may be helpful in reducing unnecessary admissions to monitored beds.

Subspecialty Careers: Highlights about Careers in Internal Medicine: Gastroenterology

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The Discipline

From the Greek word gaster, "the paunch or belly," and the word enteron, "the gut or intestine," this relating to the Greek enteros, "within."

Gastroenterology encompasses the evaluation and treatment of patients with disorders of the gastrointestinal tract, pancreas, biliary tract, and liver. It includes disorders of organs within the abdominal cavity and requires knowledge of the manifestations of gastrointestinal disorders in other organ systems, including the skin. Additional content areas include nutrition and nutritional deficiencies, and screening and prevention, particularly for colorectal cancer.

Procedures

Important procedural skills include flexible sigmoidoscopy, colonoscopy, upper endoscopy, all including biopsy and polypectomy, esophageal dilation, paracentesis, esophageal manometry, and endoscopic retrograde cholangiopancreatography. Other common procedures include 24-hour esophageal pH monitoring, small bowel absorption tests, gastric acid analysis, laparoscopy, liver biopsy, and percutaneous transhepatic cholangiography.

Training

Gastroenterology fellowship training requires three years of accredited training beyond general internal medicine residency. Of the three years, a minimum of 18 months must include clinical training in the diagnosis and management of a broad spectrum of medical diseases.

Certification

The American Board of Internal Medicine offers certification in Gastroenterology.

Training Positions

As of August 2005, there were 159 ACGME-accredited training programs with 1,097 active fellowship positions in Gastroenterology. 26% of the trainees were female, and 71% were US medical graduates.

Practice

Approximately 63% of the graduates enter clinical practice in gastroenterology in the United States, and 23% enter academic medicine.

Major Professional Societies

American Association for the Study of Liver Diseases
1729 King Street
Suite 200
Alexandria, VA 22314
(703) 299-9766

American College of Gastroenterology
P.O. Box 342260
Bethesda, MD 20827
(301) 263-9000

American Society for Gastrointestinal Endoscopy
1520 Kensington Road
Suite 202
Oak Brook, IL 60523
(630) 573-0600

The American Gastroenterological Association
4930 Del Ray Avenue
Bethesda, MD 20814
(301) 654-2055

Major Publications

Gastroenterology
Hepatology
Journal of Clinical Gastroenterology
The American Journal of Gastroenterology

Advocacy Briefs: U.S. Medical School Enrollment up 2.2%

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According to the Association of American Medical Colleges (AAMC), first-year enrollment in U.S. allopathic medical schools edged up slightly—by 2.2%—in 2006 for the second straight year, reaching an all-time high of 17,340. The AAMC, which represents all of the nation’s 125 accredited medical schools, has called for a 30% increase in medical school enrollment by 2015. Twenty-eight medical schools boosted first-year enrollment by 5% this fall. At Florida State University College of Medicine, Tallahassee, the number of freshman increased 36.3% (from 80 to 109) in 2005. At Brown Medical School, Providence, Rhode Island, freshman enrollment was up 24.7% (from 73 to 91) in 2005. Total medical school applicants rose almost 5% to 39,109.

The data also show an increase in medical student diversity. The number of Mexican American and Puerto Rican applicants increased by more than 8% and 6%, respectively. The number of African-American applicants rose by 9%, and the number of African-American enrollees rose to 1,100 (an increase of 8%). Men comprise the majority of medical school applicants and enrollees for the second year in a row. This year, there were 19,812 male applicants compared to 19,297 female applicants, and 8,924 new male first-year enrollees compared to 8,446 new female first-year enrollees.

For details, download the AAMC data here.

Did You Know You Have Access to ACP Online’s Mentoring Database?

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ACP recognizes that the years of an internist's education, training, and early career are those of excitement, challenge, and anxiety. With so many important decisions to be made, providing opportunities for medical students and early career physicians to seek out more experienced colleagues for guidance and advice is important. Our online mentoring program was developed to provide you with personal and professional guidance from College members, including Program Directors, Clerkship Directors, Chairs of Medicine, practicing internists, and residents. Use the Mentoring Database to find a mentor who is right for you and who can provide the guidance and information you need.

MKSAP for Students 3 Question 1

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A 66-year-old woman requests a second opinion. During a recent visit to another physician, her total cholesterol level was 300 mg/dL. She was prescribed a statin, but is reluctant to take a medication. She has no other risk factors, has a healthy lifestyle, and does not have coronary heart disease.

What is the most appropriate recommendation for this patient?

( A ) Begin a bile acid sequestrant
( B ) Begin ezetimibe
( C ) Begin an HMG-CoA reductase inhibitor
( D ) Obtain a fasting lipid profile
( E ) Measure total cholesterol

MKSAP for Students 3 Question 2

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A 46-year-old man is evaluated in the emergency department because of loss of consciousness 2 hours ago. Yesterday, he slipped on ice and fell, injuring his lower back, and developed significant low-back pain. That evening, he awakened to urinate and fainted in the bathroom. His wife heard him fall and found him unconscious. She called an ambulance, and on arrival, the paramedics found him awake and oriented, with a heart rate of 90/min and blood pressure of 140/85 mm Hg. Other than back pain, he has no discomfort.

Physical examination shows no abnormalities, and there is no evidence of a head injury. He has no significant medical history. His electrocardiogram is normal.

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

( A ) Carotid artery ultrasound
( B ) Computed tomography scan of the head
( C ) Exercise electrocardiography stress test
( D ) No further treatment or investigation

MKSAP Answer 1

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Answer: D

Educational Objective: Understand the use of lipid measurement for the management of patients with lipoprotein abnormalities.

The value of the total cholesterol measurement is principally for the purpose of screening persons for cardiac risk. When the concentration is elevated, a full lipid profile should always be measured before pharmacologic therapy is initiated. Therapy should never be based solely on a total cholesterol measurement. The total cholesterol measurement does not represent the cholesterol content of a single lipoprotein moiety, but is the sum of the cholesterol content in all of the circulating lipoprotein fractions: very-low-density lipoprotein (VLDL), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) cholesterol. In this case, the patient had an HDL cholesterol level of 140 mg/dL. Her triglyceride level was 150 mg/dL, and her calculated LDL cholesterol level was 130 mg/dL. She does not require drug therapy. Total cholesterol can also be increased by an elevation of VLDL cholesterol, which is clinically recognized by an increase in triglycerides. The therapy for elevated triglycerides may be significantly different from the therapy for elevated LDL cholesterol. Finally, low HDL cholesterol will lower total cholesterol, potentially masking elevations in LDL cholesterol or triglycerides. Therefore, whenever possible, HDL cholesterol should also be measured to screen for cardiovascular risk.

References

Smith SC Jr, Greenland P, Grundy SM. AHA Conference Proceedings. Prevention conference V: Beyond secondary prevention: Identifying the high-risk patient for primary prevention: executive summary. American Heart Association. Circulation. 2000;101:111-6. PMID: 10618313[PubMed]

National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-421. PMID: 12485966[PubMed]

MKSAP Answer 2

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Answer: D

Educational Objective: Diagnose vasovagal syncope.

Approximately 30% of the population experiences syncope at some point. In the absence of structural heart disease, syncope, near-syncope, and transient lightheadedness are usually benign, but the recurrence rate is high (30%). Obtaining a careful history and performing a thorough physical examination are critical components of the evaluation of syncope and can help to distinguish patients who have benign syncope from those who are likely to have a malignant cause. In approximately 50% of cases, history and physical examination alone can identify the probable cause of syncope. In this case, the most likely cause is vasovagal syncope related to enhanced vagal tone as a result of both the back injury and micturition. In this patient, the history, normal findings on physical examination, and normal electrocardiogram are consistent with a benign cause, and no further evaluation is warranted. Micturition syncope can occur in young men, and is a variant of situational syncope. In older individuals, including women, micturition syncope is often associated with orthostatic hypotension due to medications. Patients who have recurrent micturition syncope should be advised to urinate while sitting down.

This patient has no evidence of a primary neurologic event, and the utility of a computed tomography scan of the head in the evaluation of syncope is limited. Carotid artery stenosis is an unlikely cause of syncope in any circumstance, and a carotid artery ultrasound is not likely to be helpful. Likewise, the patient has no indication of ischemia, and exercise stress testing would not be of use.

References

Alboni P, Brignole M, Menozzi C, Raviele A, Del Rosso A, Dinelli M, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol 2001;37:1921-8 PMID: 11401133[PubMed]

Internal Medicine Residency Program Fast Facts

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Program Name: Penn State University, M.S. Hershey Medical Center
Location: Hershey, Pennsylvania
Hospital Type: University Affiliated Hospital
Program Size: 28 First Year Positions, 65 Positions Total
First Year Salary: $42,000
Web Site Address: http://www.hmc.psu.edu/medicine/residency/

Program Name: Norwalk Hospital
Location: Norwalk, Connecticut
Hospital Type: University Affiliated Community Hospital
Program Size: 19 First Year Positions, 46 Positions Total
First Year Salary: $40,000
Web Site Address: www.norwalkhosp.org

Program Name: University of Hawaii
Location: Honolulu, Hawaii
Hospital Type: University Affiliated Hospital
Program Size: 22 First Year Positions, 64 Positions Total
First Year Salary: $44,000
Web Site Address: www.hawaiiresidency.org

Program Name: UMDNJ, Robert Wood Johnson Medical School
Location: New Brunswick, New Jersey
Hospital Type: University Affiliated Hospital
Program Size: 30First Year Positions, 75 Positions Total
First Year Salary: $45,000
Web Site Address: http://rwjms.umdnj.edu/imrp

Program Name: Beth Israel Medical Center
Location: New York, New York
Hospital Type: University Affiliated Hospital
Program Size: 49 First Year Positions, 120 Positions Total
First Year Salary: $49,000
Web Site Address: www.bethisrealgme.org

Announcing the New Internal Medicine Essentials for Clerkship Students 2007-2008 Textbook

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The new Internal Medicine Essentials for Clerkship Students 2007-2008 textbook is available. Created by the American College of Physicians and the Clerkship Directors in Internal Medicine, Internal Medicine Essentials is written by 68 authors who help design the internal medicine curriculum and who are actively involved in teaching students on internal medicine clerkships. This invaluable guide demonstrates to students how to care for patients, prepare for clinical rounds, and study for the end of rotation examination. Internal Medicine Essentials covers the common problems and disorders a student is likely to encounter. The printed content is enhanced with clinical photographs, tables, screening tools, and other instruments on the Internet here. This is a unique resource that provides medical students with the skills they need to enhance learning during the third-year internal medicine clerkship.

List Price: $49.95
ACP Student Member Price: $39.95
Product #: 330361030
ISBN: 1-930513-82-8

Order online

You can also call ACP Customer Service to order at 800-523-1546, extension 2600 or 215-351-2600 (M-F, 9 a.m.-5 p.m. ET).

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Students: Join ACP for Free

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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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