October 2006 E-Newsletter

IMpact Adds Several New Features to Keep You Better Informed about Careers in Internal Medicine

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Now that we are several months into the new school year, I wanted to take this opportunity to welcome our new Medical Student Members to the American College of Physicians (ACP). The ACP Council of Student Members (CSM) strives to provide you with timely and pertinent information related to the specialty of internal medicine. Toward that end, we have made many updates to our monthly newsletter, IMpact.

Hopefully you are enjoying the new features that debuted last month. One of the new pieces we are most excited about is “My Kind of Medicine: Inspirational Stories from Practicing Internists.” This piece highlights the career and life of an internal medicine specialist. Through articles such as last month’s interview with Dr. Jacqueline Fincher and this month’s interview with Dr. Nirav Shah, we hope to show you a glimpse into real life as an internist.

We also have incorporated some regular items to mark the strengths of ACP Medical Student Members. We have started to publish the winning abstracts from the National Medical Student Abstract Competition to highlight student research activities and growth into clinical practice. We will also continue to cover the activities of one Internal Medicine Interest Group each month. This month we invite you to see what your peers are doing at the University of Vermont College of Medicine.

At ACP, we strongly believe in advocating for the needs of physicians and medical students. In an effort to keep you informed of current issues we have instituted a regular column titled “Advocacy Briefs.” Through this column, you will be kept abreast of issues that will affect you and your career. We will focus on pressing legislation and changes in government programs that will affect you as a student and as a future physician.

Other changes in IMpact include the addition of a “Medical Student Perspectives” section designed to highlight topics such as writing a personal statement, tips to succeed in an interview, selecting a residency, and other important issues you will face as a medical student. We will regularly examine the diverse subspecialties of internal medicine in the feature “Subspecialty Careers: Highlights about Careers in Internal Medicine Subspecialties.” Last month’s issue covered cardiology and this month features endocrinology, diabetes, and metabolism. We hope the above mentioned features, combined with the new “Residency Fast Facts” section, will better prepare you for making the career decision that is right for you.

As always, the CSM is responsive to your needs as a Medical Student Member of ACP. If you have ideas regarding a particular topic you would like to see in IMpact, or if you would like to submit an article or a response to an article, please contact the Medical Student Coordinator, Patty Moore, at pmoore@acponline.org. We look forward to a great year ahead.

Jim Small
Chair, Council of Student Members
Emory University School of Medicine, 2007
E-mail: jfsmall@emory.edu

Internists Top Most-Recruited List

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For the first time in a decade, general internists are number one on the list of most recruited specialists. Recruitment of general internists and family physicians spiked last year due to a shrinking supply of primary care physicians and growing demand from aging Baby Boomers, according to a survey from physician recruitment firm Merritt Hawkins. Other highlights of the survey that tracked 3,000 searches between March 31, 2005 and April 1, 2006 included:

  • Requests for internists rose by 46%.
  • Requests for family physicians increased by 55%.
  • Signing bonuses were offered in 58% of searches compared with 46% last year.
  • The average bonus offer increased from $14,030 to $20,480.
  • Top salaries were $250,000 for general internists and $220,000 for family practitioners.

Medical Student Perspectives: Making the Most of Your Options: What Will You Do Between Your First and Second Years of Medical School?

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The first year of medical school is challenging. You will put in more effort and focus in this year than you ever have before. Late nights, study groups, flash cards, and brain cramps are the norm during the first year, and you deserve a break when the summer comes. While you are relaxing, however, you should keep in mind the current trends in medicine.

The break following the completion of the first year of medical school provides students with a unique opportunity. This short recess from traditional studies presents students with a chance to explore interests or obtain experiences that they would not otherwise have during medical school. You should think seriously about both relaxing and working hard.

Most students choose to participate in some type of research or community health project during the summer months. These types of projects are opportunities to learn methods of research and statistics, become acquainted with prominent physicians and researchers, and possibly get published. You can also use this opportunity to present your research in ACP national or chapter abstract competitions, as well as at many other venues. To get a better idea of what many medical students do during their first summer off, I surveyed students at the University of Utah School of Medicine. The following are some of the responses.

“I worked for most of the summer doing research supported by a National Institutes of Health (NIH) grant for medical students. I worked on a number of different projects related to the genetics of various eye diseases. I also spent three weeks in Prague to gain some experience in medicine outside of the U.S. The program in Prague is called a Summer Selective which is equivalent to a clinical rotation for many medical schools on the East Coast. The program offers a great opportunity to not only gain exposure in different fields of medicine as a second year medical student, but to learn about a completely different medical system. To learn more, you can check out the Web site. I highly recommend this program, it was a great experience.” - Nate Faulkner

“I just got back from Nigeria, with Deseret International. We set up an operating room and performed anesthesia for some eye cases and a cleft palate repair. I also did the Kaplan Summer Research Project with the Orthopedic Department.” - Chad Turner

“I did a student rotation in rural Idaho with local family physicians.” - Peter Crane

“I did cerebral malaria research in Ghana, Africa.” - Melinda Liddle

“I spent three weeks in China at the Western School of Medicine learning about their views of western medicine, as well as the basics in traditional Chinese medicine. I also did some research in autism.” - Matt D'Haenens

“I went to Belize and did an indigenous medicine program with traditional Mayan.” - Lisa Ryujin

“I worked in rural Alaska in an emergency room (ER).” - Cherie McCabe

“I had a great time doing research with Hispanics in the Salt Lake area, focusing on identifying perceived barriers to healthcare. I worked on it with the Department of Family and Preventive Medicine, since they promoted student research projects.” - Nate Gilmore

“I spent a month in Ghana. We worked in a teaching hospital there in the microbiology lab as well as in the pediatric intensive care unit. We rounded with residents there and spent time learning in the ER.” - Neil Argyle

“I went to Guatemala for two months and worked most days in the local hospital in Santiago Atitlan. This was a small hospital that just got re-opened by a couple American physicians. They had a few overnight beds, a clinic, and an ER service. I stayed with a local family while I was there and did some traveling on the side. I did not speak the local’s language, and having very little clinical experience prior to going meant I spent a lot of time shadowing. But I did get to do some cool stuff, delivered a few kids, took out stitches, and saw lots of parasites. I found out about it by talking to every physician I knew and asked if they knew of physicians in other countries willing to take on students. I happened to run across the name of one of the physicians who re-opened the hospital and they encouraged me to come down.” - Wyatt Rivas

“I worked as a full time student on my MPH degree so that I could do the MD/MPH in four years.” - James Bartlett

For ideas about other possibilities, visit ACP Online. Many schools have research programs set up for students or programs to travel internationally. Talk to your Dean’s Office or the upper classmen to find out. Many students figure out what they are interested in and then talk to physicians in that field to find out if there are clinics that need help and are accepting students. Many physicians and researchers are glad to have you in the lab! You just need to ask around.

There are also NIH and Howard Hughes research opportunities available for interested medical students, either through the NIH or at your local institution. See http://www.hhmi.org/cloister/ and http://www.training.nih.gov/ for information. Another example is geriatric research through the American Federation for Aging and the National Institute on Aging or the Hartford Foundation. You could also do cardiology research through the American Heart Association . Click on funding and then select your region on the left side. Many of the national medical societies offer funding for medical student research.

Another option is to participate in a community health project, arranged through one of the departments. You could work on a secondary degree, like MPH or Informatics, or travel and do a medical mission of some type. Many groups take medical students during the summer. For example, Child Family Health International travels all over the world. The Asian Pacific American Medical Student Association has fellowships and internships available. You could also find a government-relations internship through the American Medical Association.

The possibilities are endless, but you must put substantial effort into planning and preparing. No matter what path you choose during the summer, remember to take time to study and review. The boards come quickly and it is difficult to go back and try to remember what you learned during the first year. Here’s my recipe for a successful summer: research during the workweek, six hours of study and review on Saturdays, fun for the rest of Saturday, and then just relax on Sunday.

Landon Dickson
CSM Representative, Midwest Region
University of Utah, 2008
E-mail: Landon.Dickson@hsc.utah.edu

My Kind of Medicine: Inspirational Stories from Practicing Internists: Nirav Shah, MD

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When it comes to New York City, there are two kinds of people—those who can live there and those who cannot. To be a true New Yorker, you have to thrive on the hustle and bustle, the never-ending cycle of action. There is never a dull day in NYC, and the people who make it their home would not have it any other way. That is how Dr. Nirav Shah feels about being a New Yorker. It is also how he feels about being an internist.

Dr. Nirav Shah and his wife, Nidhi

Dr. Nirav Shah and his wife, Nidhi.


“I enjoy being in the middle of the action, dealing with the most important issues facing medicine today,” said Shah. “Right now, internal medicine is the best place—the most exciting place—to be in medicine, because we are on the threshold of significant change and we are already seeing it happen.”

A Desire for More

A conversation with Shah, 34, gives you the sense that he is exactly where he wants to be in life. Though clearly motivated and hard working, his demeanor lacks the hurriedness or impatience you might expect to find in someone so driven. His speaking voice is steady and pleasant, yet confident and authoritative. He also has a sense of humor. In other words, he seems like just the kind of doctor you would want to have.

Shah began his medical career at Harvard College and the Yale School of Medicine, where he graduated with Honors with a concentration in the Epidemiology of Chronic Diseases. He completed residency training in internal medicine at Yale-New Haven Hospital and followed with a fellowship in health services research at UCLA in the Robert Wood Johnson Clinical Scholars Program. He is currently practicing at Manhattan’s Bellevue Hospital and is also completing his PhD in Epidemiology from UCLA. He has learned many lessons along the way. While he might be different today than he was as a fresh-faced medical student, one thing has always been a constant, which is his love of being an internist.

“I made the decision to pursue internal medicine in the beginning of medical school,” he said. “Right away I saw all of the interesting questions I would face every day and I was drawn in. I recognized that being an internist would allow me to research across a broad realm and then apply my research to the practice. One week I would be asking research questions about medication adherence in asthma and the next week I would be treating an asthmatic patient. I liked that—it appealed to me.”

Like many physicians practicing internal medicine, Shah craves stimulation and diversity, which is another reason he cites for his choice. “My brother, who is an epileptologist in White Plains, New York spends most of his day looking at electroencephalograms. For him it is great and he loves it, but it would drive me crazy,” he said.

“Working in internal medicine gives you the most options and frankly, the most interesting options. You have much more flexibility because your skills are transferable. It provides you with an enviable quality of life, more exposure to a wide range of diseases and disorders, and camaraderie with a broader range of people.”

On the Docket

As you might expect of any young and ambitious physician, Shah has something to say about the direction of internal medicine and how he plans to be a part of it. The most pressing issues right now according to Dr. Shah are determining what constitutes appropriate care and finding the most resourceful, or as he puts it, “creative” ways to treat patients according to their needs, preferences and abilities. “We have always had a focus on inpatient, acute care and most of our attention and resources are directed toward a patient’s hospitalization,” he said. “Now we are becoming more focused on ambulatory settings, and as a result the acute care model no longer works.

“We are moving toward an outpatient model where chronic diseases are determining how to best organize the delivery of care,” he continued. “Disease progression and disability are preventable in patients who suffer from chronic conditions. Efforts to prevent progression fail in part because patients are not adequately guided, educated or motivated to manage their own care and risk factors. We are really transforming how we think of the doctor-patient relationship to include things like patient-centered care, electronic health records, and utilizing other health care team members such as a specialized nurse practitioner.”

Another integral part of this school of thought, Shah explained, is the role of community and family. “The new models of health care encourage interaction between the community and the health system,” he said. “The idea is for communities to work interactively with the health system. Individuals need to promote health care awareness while encouraging and assisting patients in taking charge of their own care.”

Real Patients, Real Challenges

“During my residency, I had a patient named Mrs. Calderon who was elderly and did not speak any English, so she would bring her daughter with her to translate. What I learned from her goes beyond the textbook—medical adherence and the importance of family dynamics and how they can affect a patient’s well being. The medical adherence lesson I learned the hard way, when she ended up taking twice the dose of a medicine I had prescribed for her by starting on a refill early. After that, I had a new appreciation for how critical a patient’s understanding is and how you can not take it for granted.

“The other thing I noticed while I was treating her was how happy and healthy she was in general, despite her overall economic and living situation, which was poor. She described her quality of life as good because she had a strong network of close family and friends who kept her in good spirits. She never appeared or acted sick. This is a great example of why the new models of care involving community and family are so effective.

“I have a similar experience with another patient, Mrs. Gonzoles,” he continued. “Although she understands everything I say, whether or not she follows my direction is another story. She is Haitian and lives in Haiti six months out of the year, during which she lives a very different lifestyle than the one she lives in New York. She has many chronic conditions, poor social support and low health literacy. I see her for thirty minutes three times a year and just when I think I have her on track with everything she goes to Haiti for six months. When I say that she has poor health literacy I mean she does not understand the consequences of her actions and lifestyle choices.

“I counteract this by getting the whole team on board while treating her—a diabetes education specialist, a nutritionist and a social worker. We have a team-based approach at Bellevue and it works,” he said. “I have a great support staff and all the resources I need.”

One area he thinks could stand improvement is our understanding of health literacy, which he said he deals with on a daily basis. “Mrs. Calderon and Mrs. Gonzoles are exactly the reason why there needs to be more attention directed toward health literacy,” he points out. “Poor health literacy means a poor understanding of what promotes good health and what encourages disease. We need to direct messages to patients through different media that actually reach them, like radio and Spanish television.”

More than Dollar Signs

These days, the Buffalo, New York native divides his time between practicing internal medicine at Bellevue, teaching at the New York University School of Medicine and doing research at the Geisinger Health System, where he is an investigator in health services and outcomes research.

On the issue of an impending primary care crisis, he believes internists should be in the driver’s seat. “The big question is whether we are going to shape the debate ourselves or if we are going to let others decide for us,” he said.

For right now, Shah’s plate is full enough. His wife, Nidhi, recently gave birth to the couple’s first son, Vir, in September. Reshaping internal medicine may have to wait for another day, but Shah is not complaining. “I love the fact that when I come to work at Bellevue I may hear up to twelve different languages spoken in one day,” he said. “Internal medicine is so rewarding because of the relationships you have, not only with patients but with other doctors. You really get much more exposure to people as an internist. I lead a good life. While compensation may be an issue for many, I think it is truly shortsighted to look at medicine, or any profession, strictly in financial terms. Being an internist cannot be quantified in terms of a paycheck.”

Internal Medicine Interest Group of the Month: University of Vermont College of Medicine

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This has been an exciting new year for the University of Vermont College of Medicine Internal Medicine Interest Group (UVM COM IMIG). The group kicked off the year with two “Careers in Internal Medicine” discussion panels with physicians. The events were very successful and approximately 150 students attended. The first panel focused on general internal medicine and featured a hospitalist, a geriatrician and several internists who primarily work in outpatient medicine. The second panel featured subspecialists in cardiology, pulmonology and critical care medicine, nephrology, infectious disease and hematology/oncology.

In addition to providing helpful career planning resources, the UVM COM IMIG is actively involved in medical student education. We have invited a cardiologist to speak to the first year students who are currently studying gross anatomy to stress the importance of anatomy in internal medicine. We are also helping first and second year students gain clinical experience early in their education by arranging rounds with physicians on Saturday mornings.

The UVM COM IMIG is also addressing social, economic, and political issues in medicine. We have been planning an extended primary care week with the pediatrics, family medicine, and obstetrics/gynecology student interest groups as well as the American Medical Student Association which will culminate in students drafting a primary care advocacy letter to the state governor. We will be developing a workshop this fall on motivational interviewing, a non-judgmental step-wise approach to encouraging patients to make positive behavioral changes. We have also invited a speaker who will be sharing her insights on dealing with HIV and substance abuse in Native American populations in culturally sensitive ways. Finally, we will be hosting a documentary screening and discussion session regarding cultural barriers recent immigrants encounter in the American medical system.

Lastly, the UVM COM IMIG members enjoyed participating in the Vermont ACP Scientific Chapter Meeting which took place on October 13 in Vergennes, Vermont.

Mimansa Sharma and Emily Glick
Student Leaders, UVM COM Internal Medicine Interest Group
E-mail addresses: mimansa.sharma@uvm.edu and emily.glick@uvm.edu

Winning Abstracts from the 2006 National Medical Student Abstract Competition: A Delayed Diagnosis of Chronic Inflammatory Demyelinating Polyneuropathy

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Author: Rachelle Huang, Michigan State University, 2007

Introduction:

Chronic inflammatory demyelinating polyneuropathy (CIDP) is an underdiagnosed neuropathy. CIDP has a chronic presentation similar to Guillain-Barre. CIDP can be easily misdiagnosed due to its protean presentations. Corticosteroids have been a mainstay treatment of CIDP. Recently, intravenous immunoglobulin (IV Ig) has been used to treat CIDP.

Case Presentation:

A 56 year old Caucasian man was brought to the emergency room because of bilateral proximal leg weakness. In two weeks, the weakness had increased to the extent that he could not even lift his legs off of his bed. Complaining of baseline weakness since the 1980s, he had lost his job as a machinist due to this weakness. After that initial episode, symptoms eventually improved after he was treated with steroids for two years. He continued to have periods of improvement after he received single doses of steroids before he returned to baseline weakness. Subsequently, he suffered from herniated discs (lumbar 3-5) in the 1990s, and after disectomy developed right foot drop and permanent weakness. His neurological deficits were attributed to the disectomy and occupational exposures. At this presentation, his weakness was worse than baseline. The patient was given Decadron 8mg on his second day of admission and throughout his hospitalization. Electromyography revealed chronic reinervation and denervation. A lumbar puncture showed an absolute increased and relative increased protein from a previous lumbar puncture. Based on the objective findings and chronic history of waxing and waning weakness, CIDP was diagnosed. Since CIDP is an autoimmune demyelination disorder, the patient was started on IV Ig 2g/kg. His symptoms improved dramatically. His legs “felt warmer” by the second day of IV Ig. Previously areflexic, a patellar reflex of 1/5 was present on the third day. By the fourth day, the patient was lifting his legs off the bed, able to stand, and walk around his room. One week after the cessation of IV Ig, the patient was walking upstairs.

Discussion:

CIDP can often be misdiagnosed due to the broad differential diagnosis of weakness. In this patient, his occupational hazards, and weakness following disc surgery confused the diagnosis. His intermittent treatment with steroids temporarily ameliorated his symptoms. Currently, a combination therapy of IV Ig and Decadron decreased his symptoms although long term effects of this regimen remain unknown. This combination bolus helped achieve a dramatic improvement.

Conclusion:

A detailed history is important in chronic neurological issues to correctly diagnose CIDP. Symptoms of the disease may not fit the criteria of CIDP initially, but repeated evaluations and a careful examination of history can make the correct diagnosis of CIDP and allow initiation of appropriate treatment.

Subspecialty Careers: Highlights about Careers in Internal Medicine: Endocrinology, Diabetes, and Metabolism

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The Discipline

From the Greek endon, "in, inner, or within" and krinein, "to separate or put apart." A term contrived to describe those glands that "put apart" and secrete substances that are used within the body.

Endocrinology is the diagnosis and care of disorders of the endocrine system. The principle endocrine problems include goiter, thyroid nodules, thyroid dysfunction, diabetes mellitus, hyper- and hypocalcemia, adrenal cortex dysfunction, endocrine hypertension, gonadal disorders, disorders of sodium and water balance, manifestations of pituitary disorders, disorders of bone metabolism, and hyperlipidemia. While not strictly an endocrine disorder, obesity is considered part of the spectrum of endocrinology because it often enters into the differential diagnosis of endocrine disease and is a major element in the management of type 2 diabetes. Prevention focuses on the complications of obesity, diabetes, hyperlipidemias, thyroid disease, and the iatrogenic effects of glucocorticoids.

Procedures

Endocrinologists are expected to perform dexamethasone suppression tests, adrenocorticotropin (ACTH) stimulation tests, home blood glucose monitoring and fine needle thyroid biopsies. Additionally, endocrinologists commonly order and interpret bone densitometry tests, fasting and postprandial glucose determinations, glycohemoglobin concentrations, imaging studies of the sella turcica, serum gonadotropin concentrations, lipid profiles, and thyroid function studies.

Training

Endocrinology fellowship training requires two years of accredited training beyond general internal medicine residency. Of the two years, a minimum of 12 months must include clinical training in the diagnosis and management of a broad spectrum of medical diseases.

Training Positions

As of 2005, there were 122 ACGME-accredited training programs and 486 active trainees in Endocrinology, Diabetes, and Metabolism. 67% percent of the trainees were female and 64% were US medical graduates.

Certification

The American Board of Internal Medicine offers certification in Endocrinology, Diabetes, and Metabolism.

Practice

Approximately 52% of the graduates enter clinical practice in Endocrinology, Diabetes, and Metabolism in the United States and 42% enter academic medicine.

Major Professional Societies

American College of Endocrinology
The Endocrine Society
American Diabetes Association

Major Publications

Endocrine Practice
Endocrinology
Diabetes
Journal of Clinical Endocrinology and Metabolism

Advocacy Briefs: Enroll in ACP’s Key Contact Program

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ACP’s continued success on Capitol Hill greatly depends on year-round grassroots efforts from the College’s nearly 4,500 Key Contacts. Key Contacts communicate with their local members of Congress on issues of importance to internists and their patients and report the results back to ACP. To enroll as a Key Contact, ACP members are not required to have existing relationships with members of Congress. ACP gives members the tools necessary to develop and maintain relationships. The program is open to all membership categories. Enroll now in the Key Contact Program.

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

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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.

MKSAP for Students 3 Question 1

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A 60-year-old man is hospitalized because of dyspnea and leg edema of 7 weeks' duration. He has a 30-year history of essential hypertension treated with a thiazide diuretic and amlodipine. Coronary angiography performed 1 year ago because of chest pain was normal.

On physical examination, blood pressure is 180/100 mm Hg and the heart rate is 110/min. Jugular venous pressure is elevated, and there is pitting edema to the knees. The patient has soft S1 and S2, an S3 gallop, and diffuse pulmonary crackles, but no heart murmurs. Echocardiogram shows a left ventricular ejection fraction of 20%. Serum electrolytes and hepatic and renal function are normal. He receives furosemide and improves rapidly with diuresis of 2200 mL.

Which of the following drugs should be added at discharge to improve this patient's long-term survival?

( A ) Digoxin
( B ) Furosemide
( C ) Lisinopril
( D ) Spironolactone

MKSAP for Students 3 Question 2

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A 56-year-old postmenopausal woman is evaluated in the emergency department because of severe substernal burning pain and progressive dyspnea beginning 3 hours ago.

On physical examination, she appears anxious. Her respiration rate is 30/min, pulse rate is 108/min, blood pressure is 80/60 mm Hg, and oxygen saturation is 90% on 100% O2. Her jugular venous pressure is elevated. She has inspiratory crackles and an S3 gallop, but no murmur. Her electrocardiogram shows sinus tachycardia, with 3-mm ST segment elevation in leads V2 to V6. She is given a chewable aspirin and intravenous heparin, and is started on dopamine.

Which of the following is the most appropriate immediate management for this patient?

( A ) Coronary angiography
( B ) Intravenous angiotensin-converting enzyme inhibitor
( C ) Intravenous β-blocker
( D ) Intravenous nitroglycerin

MKSAP Answer 1

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Answer: C

Educational Objective: Treat a patient with decompensated congestive heart failure with an angiotensin-converting enzyme inhibitor.

Although this patient requires therapy with multiple drugs, treatment with an angiotensin-converting enzyme (ACE) inhibitor should be initiated. ACE inhibitors reduce the rates of mortality and morbidity in patients who have congestive heart failure and systolic left ventricular dysfunction. β-Blockers are usually started on an outpatient basis once the dose of ACE inhibitor is optimized and the patient is considered euvolemic. More recently, efforts have been mounted to validate the safety of also starting β-blockers in the hospital.

This patient requires diuretics to achieve and maintain euvolemia, but diuretics do not improve survival. Long-term treatment with a cardiac glycoside, such as digoxin, has no apparent effect on mortality in this situation. However, when coupled with ACE inhibitors, these agents reduce the incidence of deterioration and hospitalization associated with heart failure. Aldosterone antagonists should be reserved for older patients who have persistent New York Heart Association class III/IV symptoms and are receiving a baseline protocol that includes digoxin, a diuretic, an ACE inhibitor, and a ÿ-blocker. Because calcium channel blockers have no proven benefit in reducing morbidity and mortality rates in patients with systolic left ventricular dysfunction, amlodipine is not a first-line drug in this patient.

References

ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2001;38:2101-13. PMID: 11738322 [PubMed]

MKSAP Answer 2

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Answer: A

Educational Objective: Recognize the role of primary angioplasty in the management of cardiogenic shock.

This patient is admitted with cardiogenic shock due to ST segment elevation acute myocardial infarction. Patients with cardiogenic shock have an in-hospital mortality rate of roughly 50%. The single most important intervention involves establishing patency of the infarct-related artery. In such patients, coronary angiography, followed by immediate reperfusion therapy with primary angioplasty, is superior to fibrinolysis. In patients with cardiogenic shock, it is believed that there is insufficient blood flow to deliver the fibrinolytic agent to the coronary occlusion. In a randomized trial of patients with cardiogenic shock due to acute myocardial infarction, those assigned to an immediate angioplasty strategy had better outcomes than those assigned to medical therapy, which included thrombolysis.

Nitroglycerin, β-blockers, and angiotensin-converting enzyme inhibitors should be withheld for patients with cardiogenic shock.

References

Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med. 1999;341:625-34. PMID: 10460813[PubMed]

Hochman JS, Sleeper LA, White HD, Dzavik V, Wong SC, Menon V, et al. One-year survival following early revascularization for cardiogenic shock. JAMA. 2001;285:190-2. PMID: 11176812[PubMed]

Internal Medicine Residency Program Fast Facts

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Program Name: Wilson Medical Center
Location: Johnson City, New York
Hospital Type: University Affiliated Community Hospital
Program Size: 10 First Year Positions, 26 Positions Total
First Year Salary: $45,000
Web Site Address: http://www.uhs.net/meded/im/

Program Name: University of Illinois College of Medicine, Peoria
Location: Peoria, Illinois
Hospital Type: University Affiliated Community Hospital
Program Size: 21 First Year Positions, 49 Positions Total
First Year Salary: $45,000
Web Site Address: www.uicompim.org

Program Name: Tulane University
Location: New Orleans, Louisiana
Hospital Type: University Based
Program Size: 28 First Year Positions, 69 Positions Total
First Year Salary: $41,000
Web Site Address: www.tulanemedicine.com

Program Name: Wayne State University/Detroit Medical Center
Location: Detroit, Michigan
Hospital Type: University Based
Program Size: 32 First Year Positions, 96 Positions Total
First Year Salary: $42,000
Web Site Address: www.med.wayne.edu/intmed

Program Name: Mercy Catholic Medical Center
Location: Darby, Pennsylvania
Hospital Type: University Affiliated Community Hospital
Program Size: 24 First Year Positions, 62 Positions Total
First Year Salary: $42,000
Web Site Address: www.mercyhealth.org/gme

Medical Student Fellowship Opportunity: The CDC Experience

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Are you a medical student looking for something different to do next year?

Are you curious about how public health really works? For example,

  • Would you be interested in investigating outbreaks of tuberculosis among the homeless, or in a prison population?
  • Or investigating an outbreak of leptospirosis among adventure racers in a Florida swamp?
  • What about assessing risk factors for reproductive-health visits to emergency departments?
  • Perhaps you would like to be at the forefront of cardiovascular health policy development?

Do you want an experience that offers an opportunity to enhance your research skills, build your leadership potential, and improve your clinical acumen via a population health perspective, all by working on real-life problems?

Then consider applying to The CDC Experience!

The CDC Experience is a one-year fellowship in applied epidemiology tailored for rising 3rd and 4th year medical students, designed to increase the pool of physicians with a population health perspective. Eight competitively selected fellows spend 10-12 months at the Centers for Disease Control and Prevention (CDC) offices in Atlanta, Georgia, where they carry out epidemiologic analyses in areas of public health that interest them. Examples of previous and current areas of concentration include parasitic diseases, cardiovascular health, birth defects, sexually transmitted diseases, foodborne diseases, and air pollution and respiratory health.

CDC’s challenging and intellectually stimulating environment provides multiple opportunities to enhance skills in research and analytic thinking, written and oral scientific presentations, and preventive medicine and public health. All fellowship assignments offer opportunities to complete epidemiologic analyses which may lead to scientific publications.

You don’t have to have experience in public health to apply for this program. CDC staff will help you acquire practical tools useful for approaching population-based health problems, whether in an entire community or just among your community of patients. The first class of fellows entered in 2004 and graduates have followed varying paths—residencies in clinical specialties, even anesthesia and orthopedics. Graduates of The CDC Experience have an appreciation of the role of epidemiology in medicine and health and are able to apply their knowledge and skills to enhance their clinical acumen and to work within the larger health system. The CDC Experience graduates have the potential to become future physician-leaders and substantially contribute to the quality of the health care system.

If you think The CDC Experience is for you, learn more by visiting the fellowship Web site.

Applications for next year's fellowship class must be postmarked by Monday, December 4, 2006. Questions may be sent to cdcexperience@cdcfoundation.org.

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.

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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