October 2005 E-Newsletter

Focus on Internal Medicine Careers: Hospitalist/Medical Education

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Following is an interview with Robert Trowbridge, MD, ACP Member, Assistant Professor of Medicine at University of Vermont College of Medicine, and the Associate Director of Medical Student Education for the Department of Medicine at Maine Medical Center in Portland, Maine. The interview was conducted by Talia Ben-Jacob, a third-year medical student at University of Vermont College of Medicine and the New England Representative to the ACP Council of Student Members.

IMpact: Why did you decide to go into internal medicine?

Dr. Trowbridge: Perhaps the most important reason was the career possibilities that internal medicine opened up—there is just so much one can do within the field. Training in internal medicine is integral and necessary to everything from the procedure-based practices, such as interventional cardiology, to rural primary care, to public health. Another important reason was that internists are both experts and generalists; they have varied practices and you’re never quite sure who will walk in the door next. Finally, internists get to participate in what I think are the most the most appealing aspects of medicine in general: great intellectual challenge and rewarding patient relationships.

IMpact: If you could go back in time, would you still choose internal medicine?

Dr. Trowbridge: Without question. Although I only finished residency a decade ago, I’ve already had many interesting career experiences as a primary care physician, an academic researcher, a rural internist with the Indian Health Service, and now as a clinician-educator. I can’t imagine any other career choice in medicine being able to provide the training necessary to follow a career path with that degree of choice and variety.

IMpact: What is your special interest within internal medicine and why did you choose it?

Dr. Trowbridge: I have several special interests, including venous thromboembolic disease and rural medicine. I have a special appreciation for pulmonary embolism, since it is the quintessential “internists’ problem,” because it is difficult to diagnose and manage. Although I now practice in a relatively urban setting, I also have a great interest in rural medicine, especially as it relates to the internist’s role in that setting.

IMpact: Who is your most memorable patient and why?

Dr. Trowbridge: A patient from my time on the Navajo Reservation is perhaps the one I remember most keenly. He was an older medicine man with severe coronary artery disease and greatly limiting congestive heart failure as a result. He was a fascinating man who had lived a long interesting life as medicine man, champion rodeo rider, and patriarch. He was tenuous physiologically, but strongly grounded spiritually. He taught me much about medicine and its limitations.

IMpact: You have a multitude of experience in internal medicine. What led you to the decision to become a hospitalist?

Dr. Trowbridge: A large part of the reason I became a hospitalist was the increased teaching opportunities that often come with being a hospitalist at an academic medical center. I've been involved with teaching throughout my career and medical education remains a major interest of mine. I also enjoy the pace and complexity of inpatient medicine, although I greatly miss the longitudinal patient relationships that I enjoyed as a primary care physician. I wouldn't be surprised if at some point in my career, I return to primary care, hopefully in a rural setting.

IMpact: What made you decide to start an internal medicine interest group at Maine Medical Center?

Dr. Trowbridge: We want the students to know how great a career in internal medicine can be. There is just so much one can do with internal medicine training and we want to be sure that students are aware of this.

IMpact: What was the biggest challenge that you had to overcome as an internal medicine doctor?

Dr. Trowbridge: By far the biggest challenge has been balancing career and family. My wife is also an internist and juggling our careers and family has been difficult at times. Because of the flexibility that we’ve found in internal medicine, however, we’ve been able to settle into a routine that provides a good amount of time for all that is important.

IMpact: What advice would you give to third-year students who want to excel on their internal medicine clerkship?

Dr. Trowbridge: Probably the most important things are also the most obvious ones: work hard and become an integral and valued member of the team. As a third-year clerk, you will often have a lighter clinical load than other members of the team and you should take advantage of that by getting to know the patient and his or her problems extremely well. Try to recognize that the patients will teach you quite a bit, if you let them. Above all, take advantage of the opportunity, know your limitations, and enjoy learning while not being overly stressed about how you're being perceived. If you know your patients, work hard, and are truly a member of the team, things will go well.

IMpact: What advice would you give to students who are preparing for the residency application process?

Dr. Trowbridge: Choose a specialty that doesn’t limit your choices, unless you are completely certain of your interest in a specialty field. I would also make a career choice based on your level of interest, not on the relationships you had with the specific attendings and residents during your clerkships. Finally, choose a residency program that fits your personality and your personal preferences, including geographic locations. You will get out of residency what you put into it and if you choose a residency program which does not take into account your personal needs it is likely to make you miserable.

IMpact: Do you recommend that students who are interested in internal medicine fill their elective clerkship time with medicine-related rotations, or is it preferable to gain experience in other areas of medicine?

Dr. Trowbridge: A bit of both. Doing an acting internship in medicine is a great way to be sure that you’re making the right choice and to make the transition to internship a bit easier. In addition, doing a medical subspecialty rotation in an area where you feel your experience is lacking can also be helpful. But doing several rotations in areas outside of internal medicine can also be useful and enjoyable. I completed rotations in ophthalmology and autopsy during my fourth year and loved them both.

Articles from Annals of Internal Medicine

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

Influenza A (H5N1): Will It Be the Next Pandemic Influenza? Are We Ready?

Bartlett J and Hayden F. Ann Intern Med 2005; 143:460-462 Sept 20

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Influenza experts have predicted the next pandemic flu for many years. What they fear most is an event like the Spanish flu of 1918 to 1919—the largest outbreak of fatal infectious disease during the past century. Avian influenza (influenza A [H5N1]) appears to have that potential. Dramatic response strategies have been undertaken in some countries, but the response in others has been far more measured. For example, the United Kingdom has committed to stockpile enough oseltamavir to treat 25% of its population in an effort to be prepared; the United States has enough in its Strategic National Stockpile for less than 1% (1). So how real is this risk?

The Costs of a National Health Information Network

Kaushal R, et al. Ann Intern Med 2005; 143:165-173 Aug 2

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Background: The use of information technology may result in a safer and more efficient health care system. However, consensus does not exist about the structure or costs of a national health information network (NHIN).

Objectives: To describe the potential structure and estimate the costs of an NHIN.

Design: Cost estimates of an NHIN model developed by an expert panel.

Setting: U.S. health care system.

Measurements: An expert panel estimated the existing and the expected prevalence in 5 years of critical information technology functionalities. They then developed a model of an achievable NHIN by defining key providers, functionalities, and interoperability functions. By using these data and published cost estimates, the authors determined the cost of achieving this model NHIN in 5 years given the current state of information technology infrastructure.

Results: To achieve an NHIN would cost $156 billion in capital investment over 5 years and $48 billion in annual operating costs. Approximately two thirds of the capital costs would be required for acquiring functionalities and one third for interoperability. Ongoing costs would be more evenly divided between functionality and interoperability. If the current trajectory continues, the health care system will spend $24 billion on functionalities over the next 5 years or about one quarter of the cost for functionalities of a model NHIN.

Limitations: Because of a lack of primary data, the authors relied on expert estimates.

Conclusions: While an NHIN will be expensive, $156 billion is equivalent to 2% of annual health care spending for 5 years. Assessments such as this one may assist policymakers in determining the level of investment that the United States should make in an NHIN.

Editors’ Notes

Context: The United States needs a national health information network (NHIN). To build one, we need realistic estimates of costs.

Contribution: An expert panel conceptualized a model NHIN and determined the costs of implementing the model throughout the United States. The model NHIN would require $156 billion in capital investment over 5 years and would incur $48 billion in annual operating costs.

Cautions: The authors used expert opinion to estimate some costs and assumed fixed prices for hardware and software and no major new technological developments.

Implications: The United States probably needs to spend more now if we want to implement an NHIN in the next decade.

Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge

Roy C, et al. Ann Intern Med 2005; 143:121-128 Jul 19

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Background: Failure to relay information about test results pending when patients are discharged from the hospital may pose an important patient-safety problem. Few data are available on the epidemiology of test results pending at discharge or on physician awareness of these results.

Objective: To determine the prevalence, characteristics, and physician awareness of potentially actionable laboratory and radiologic test results returning after hospital discharge.

Design: Cross-sectional study.

Setting: Two tertiary care academic hospitals.

Patients: 2644 consecutive patients discharged from hospitalist services from February to June 2004.

Measurements: The main outcomes were the prevalence and characteristics of potentially actionable test results returning after hospital discharge, awareness of these results by inpatient and primary care physicians, and satisfaction of inpatient physicians with current systems for follow-up on test results. The authors prospectively collected data on test results pending at the time of discharge and, as results returned after discharge, surveyed hospitalists, junior residents, and primary care physicians about those results that were potentially actionable according to a physician-reviewer.

Results: A total of 1095 patients (41%) had 2033 test results return after discharge. Of these results, 191 (9.4% [95% CI, 8.0% to 11.0%]) were potentially actionable. Surveys were sent regarding 155 results, and 105 responses were returned. Of the 105 results in the surveys with responses, physicians had been unaware of 65 (61.6% [CI, 51.3% to 70.9%]); of these 65, they agreed with physician-reviewers that 24 (37.1% [CI, 25.7% to 50.2%]) were actionable and 8 (12.6% [CI, 6.4% to 23.3%]) required urgent action. Inpatient physicians were dissatisfied with their systems for following up on test results returning after discharge.

Limitations: The authors were unable to determine whether physicians' lack of awareness of test results returning after discharge was associated with adverse outcomes.

Conclusions: Many patients are discharged from hospitals with test results still pending, and physicians are often unaware of potentially actionable test results returning after discharge. Further work is needed to design better follow-up systems for test results returning after hospital discharge.

Editors’ Notes

Context: Poor communication between inpatient and outpatient providers precedes many preventable adverse events that occur shortly after discharge.

Contribution: Forty-one percent of 2644 patients on the hospitalist services of 2 academic hospitals had pending laboratory or radiology results at discharge. Physician-reviewers deemed approximately 9% of these results potentially actionable. Physician surveys done 14 days after results were first available showed that physicians were unaware of many results and thought that about 13% of them required urgent action.

Cautions: Findings may not apply to nonacademic or nonhospitalist settings. Implications: We need good integrated systems to assure follow-up of tests that are pending at discharge.

A Randomized Clinical Trial of Acupuncture Compared with Sham Acupuncture in Fibromyalgia

Assefi N, et al. Ann Intern Med 2005; 143:10-19 Jul 5

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Background: Fibromyalgia is a common chronic pain condition for which patients frequently use acupuncture.

Objective: To determine whether acupuncture relieves pain in fibromyalgia.

Design: Randomized, sham-controlled trial in which participants, data collection staff, and data analysts were blinded to treatment group.

Setting: Private acupuncture offices in the greater Seattle, Washington, metropolitan area.

Patients: 100 adults with fibromyalgia.

Intervention: Twice-weekly treatment for 12 weeks with an acupuncture program that was specifically designed to treat fibromyalgia, or 1 of 3 sham acupuncture treatments: acupuncture for an unrelated condition, needle insertion at nonacupoint locations, or noninsertive simulated acupuncture.

Measurements: The primary outcome was subjective pain as measured by a 10-cm visual analogue scale ranging from 0 (no pain) to 10 (worst pain ever). Measurements were obtained at baseline; 1, 4, 8, and 12 weeks of treatment; and 3 and 6 months after completion of treatment. Participant blinding and adverse effects were ascertained by self-report. The primary outcomes were evaluated by pooling the 3 sham-control groups and comparing them with the group that received acupuncture to treat fibromyalgia.

Results: The mean subjective pain rating among patients who received acupuncture for fibromyalgia did not differ from that in the pooled sham acupuncture group (mean between-group difference, 0.5 cm [95% CI, –0.3 cm to 1.2 cm]). Participant blinding was adequate throughout the trial, and no serious adverse effects were noted.

Limitations: A prescription of acupuncture at fixed points may differ from acupuncture administered in clinical settings, in which therapy is individualized and often combined with herbal supplementation and other adjunctive measures. A usual-care comparison group was not studied.

Conclusion: Acupuncture was no better than sham acupuncture at relieving pain in fibromyalgia.

Editors’ Notes

Context: A substantial number of patients use acupuncture to treat the symptoms of fibromyalgia, but previous randomized trials of this intervention are inconclusive, in part because of control groups that did not permit adequate blinding of the patients.

Contribution: This study randomly assigned 100 patients with fibromyalgia to 12 weeks of either true acupuncture treatment or one of 3 types of sham acupuncture. No differences in pain were identified between acupuncture and sham acupuncture.

Cautions: The study had too few patients to detect small differences between the groups. Patients could use other fibromyalgia therapies, so this study evaluates acupuncture as adjunctive treatment.

Internal Medicine Interest Group of the Month: Kansas City University of Medicine and Biosciences

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The Kansas City University of Medicine and Biosciences (KCUMB) recently changed its name from the University of Health Sciences. This marks a new beginning to better represent our emerging position as both a community advocate and a partner in biomedical research endeavors, as well as the oldest medical school in Kansas City and the largest in Missouri. The KCUMB internal medicine interest group (IMIG) is also experiencing a new beginning this year; a new group of students with a great new interest in internal medicine. While the IMIG has long been a recognized organization, we are now working on stepping up our efforts in supporting students with an interest in internal medicine and providing them with access to information to prepare them for decisions they will have to make as they pursue their medical careers.

One of the great traditions of osteopathic medicine is a hands-on approach to education. An emphasis on mentoring provides a close relationship between osteopathic physicians in our community and the student body. This strong tie to practicing physicians continues to meet our needs in finding guest speakers for our meetings and programs. I continue to be surprised by how many are willing to participate and I have found that one of the best ways to recruit speakers is simply by asking!

Our Department of Internal Medicine faculty takes great interest in the students. They continually foster an interest in medicine by encouraging students to participate in shadowing programs. Students are invited to participate in rounds with them each weekend morning at the hospital. Students are given a chance to experience first-hand what their clinical years will be like as they join a small group of residents, interns, and rotating students in a no-pressure setting to directly observe patient care. Additionally, the faculty participates in the university’s summer practicum program, which allows students to work with local physicians for 2 to 8 weeks during the summer after their first year of medical school.

The following is an example of a recent program in which the IMIG participated. During the month of September, the University celebrates women in medicine. In doing its part, the IMIG joined with the National Osteopathic Women Physicians Association in hosting Anne Winkler, MD, FACP, Governor of the ACP Missouri Chapter. She presented an informative and humorous look at the role women have played in the history of the practice of medicine. After the lecture, Dr. Winkler participated in a panel of faculty and alumni women physicians, mostly internists or internal medicine specialists, in answering questions that students had about their careers in medicine.

We also have several other programs we’d like to get started. To help new students as they begin medical school, we’d like to create a presentation that would help explain the medical education process. What we’ve found is that many students spend so much time just getting to medical school that they really don’t understand what’s ahead of them. We would like to help ease students’ confusion by providing them information about the various options for internships, residencies, and fellowships that will be available to them during their medical education. Additionally, medical professionalism has come to the forefront in medical education curriculum. The University has implemented a professionalism evaluation program, and in connection with this, the IMIG would like to help demonstrate professionalism needs in internal medicine. Appropriate to this field is a discussion of professionalism between medical and surgical professions and also between specialists and primary care providers. These activities will be added to the IMIG’s current offerings, which include providing various internist and specialist physician speakers who can give insight into their lives as physicians.

We appreciate any input from other groups as we strengthen our activities and would like to share ideas as we all attempt to generate interest in internal medicine and provide the best possible learning environments for ourselves and our classmates.

Richard Rattin
President, Internal Medicine Club
Kansas City University of Medicine and Biosciences, 2008
E-mail: rrattin@kcumb.edu

Medical School Awards Program 2005-2006

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The Council of Student Members (CSM) is pleased announce the seventh year of its awards program for internal medicine interest groups at U.S. and Canadian medical schools. There are two types of awards. The first award is based on increasing Medical Student Membership in the ACP. This award will be given to all schools whose Medical Student Membership increases by 15% or more of the total medical student body at each school during the time frame beginning July 1, 2005 and ending March 15, 2006. The internal medicine interest group at each winning school will receive a Certificate of Merit and will be identified at the Medical Students and Associates Recognition Reception during the 2006 Annual Session in Philadelphia. In addition, the two schools having the greatest increases in Medical Student Membership based on percentage of the total medical student body at their school during this time frame will receive monetary prizes.

The second group of awards is based on having high overall Medical Student Membership in the ACP. This award will be given to all schools whose Medical Student Membership meets or exceeds 40% of the total medical student body at each school for the entire membership year, beginning July 1, 2005 and ending June 30, 2006. The internal medicine interest group at each winning school will receive a Certificate of Merit and will be announced in the Summer 2006 issue of IMpact. In addition, the two schools with the highest overall Medical Student Membership based on percentage of the total medical student body at their schools during the same time frame will receive monetary prizes.

For more details regarding this program, please contact Patty Moore, Medical Student Coordinator, by e-mail at pmoore@acponline.org.

MKSAP Question 1

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A 24-year-old man is evaluated because of a swollen right calf. The calf has been swollen for 1 day. He had a deep venous thrombosis of the opposite leg when he was 17 years old, for which he took warfarin for 3 months. He has never smoked cigarettes. His father also had a deep venous thrombosis, but he is currently in good health. Physical examination shows a tender, swollen, right calf. Doppler studies confirm a deep venous thrombosis.

Which of the following is the most likely risk factor for hypercoagulability in this patient?

( A ) Antiphospholipid antibodies
( B ) Occult malignancy
( C ) Paroxysmal nocturnal hemoglobinuria
( D ) Factor V Leiden mutation
( E ) Homocysteinemia

MKSAP Question 2

A 45-year-old woman is evaluated because of an elevated serum cholesterol level. She is otherwise healthy and has no other risk factors for atherosclerotic cardiovascular disease. Her total serum cholesterol after a 12-hour fast is 260 mg/dL.

Which one of the following should be done next?

( A ) Repeat total cholesterol measurement
( B ) Perform fasting lipoprotein analysis
( C ) Dietary modification
( D ) Prescribe an exercise program

Answer - Question 1

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Answer: D

Educational Objective: Select appropriate testing in patients with primary (genetic) versus secondary (acquired) hypercoagulability.

This patient requires an evaluation for hypercoagulability state because he has a recurrent thrombosis and because of his young age. The patient's history suggests a genetic cause of hypercoagulability. The most common inherited cause of hypercoagulability in white patients is factor V Leiden mutation, which leads to resistance to activated protein C. Approximately 5% of white patients have this mutation. There are many other inherited causes of hypercoagulability, including genetic deficiencies of protein C, protein S, and antithrombin III. This patient could have had an acquired cause of hypercoagulability, the most common of which is the antiphospholipid antibody syndrome, but this is rarely familial.

References

  • Petri M. Pathogenesis and treatment of the antiphospholipid antibody syndrome. Med Clin North Am. 1997;81:151-77.
  • Nachman RL, Silverstein R. Hypercoagulable states. Ann Intern Med. 1993;119:819-27.

Answer - Question 2

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Answer: B

Educational Objective: Recognize proper management of a patient with elevated fasting total serum cholesterol level.

The National Cholesterol Education Project recommends that in all adults aged 20 years or older, a fasting lipoprotein profile (total cholesterol, low-density lipoprotein [LDL] cholesterol, high-density lipoprotein [HDL] cholesterol, and triglyceride) should be obtained once every 5 years. If the testing opportunity is nonfasting, only the values for total cholesterol and HDL cholesterol will be usable. In such a case, if total cholesterol is 200 mg/dL or HDL is <40 mg/dL, a follow-up lipoprotein profile is needed for appropriate management based on LDL. Values between 200 mg/dL and 239 mg/dL (borderline elevated) in the absence of established coronary heart disease, or two risk factors (one of which is male sex) should prompt dietary instruction and annual reassessment. The presence of risk factors, established coronary heart disease, presence of diabetes mellitus or a cholesterol level of 240 mg/dL or higher is an indication for fasting lipoprotein analysis. Additional fasting past 12 hours is unlikely to lower cholesterol levels further. Exercise or family testing may be appropriate parts of a risk modification program, but specific recommendations are not indicated until after a fasting lipoprotein analysis reveals abnormal cholesterol subfractions.

References

  • Executive summary of the 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). JAMA. 2001;285:2486-97.

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