October 2007 E-Newsletter

Win a 128 MB Flash Drive from ACP! IMpact Contest Question for October

.

If you are among the first 30 respondents to answer the following question correctly you will receive a 128 MB flash drive from ACP. E-mail your answer to ImpactContest@acponline.org. The correct answer to October’s contest question will be included in the November issue of IMpact. You must be an ACP Medical Student Member to be eligible to win. Contest winners are not eligible to win again for 4 months.

A 36-year-old woman is admitted to the intensive care unit from the emergency department after ingesting an intentional overdose of a long-acting barbiturate. Endotracheal intubation was performed in the emergency department. Other than being drowsy and minimally arousable, the patient seems to be doing well. The gastric tube used to irrigate her stomach is still in place and is being used for feedings.

Which of the following additional measures is appropriate to prevent complications in this patient?

( A ) Prophylactic antibiotics as long as the endotracheal tube is in place.
( B ) Nasal placement of the endotracheal tube.
( C ) Semi-erect positioning in bed.
( D ) Changing the endotracheal tube every 2 to 3 days.
( E ) A cooling blanket to prevent a rise in temperature above 37.0 ° C (98.6°).

Top

Answer for September Contest Question

.

Click here to see September’s question.

Answer to September Contest Question: ( A ) Enterotoxigenic Escherichia coli (ETEC)

Strains of enterotoxigenic Escherichia coli (ETEC) are among the most commonly implicated causes of diarrheal disease in international travelers. Various other enteric bacterial, viral, and parasitic pathogens have also been reported to cause some form of diarrheal syndrome in travelers. Of the potential pathogens included for this case presentation, ETEC is by far the most common organism causing typical traveler's diarrhea.

Clostridium difficile is not associated with episodes of diarrhea in travelers. Entamoeba histolytica and Strongyloides stercoralis are only rare causes of traveler's diarrhea. In addition, the usual clinical presentation of disease due to these pathogens differs markedly from that of ETEC-associated diarrhea. Salmonella enteritidis is a possibility but is a much less common cause of diarrhea.

Traveler's diarrhea can be prevented by strict attention to food and water precautions. In addition to oral rehydration therapy, medical treatment of traveler's diarrhea usually consists of an antimotility agent (such as loperamide) administered in conjunction with a short course of an appropriate antibiotic (usually a fluoroquinolone). In certain areas of the world, antibiotic resistance to fluoroquinolones is increasing. In these situations, a macrolide antibiotic (for example, erythromycin or azithromycin) may be substituted.

References
1. Lima AA. Tropical diarrhoea: new developments in traveller's diarrhoea. Curr Opin Infect Dis. 2001;14:547-52.
2. Ramzan NN. Traveler's diarrhea. Gastroenterol Clin North Am. 2001;30:665-78, viii.
3. Traveler's diarrhea. Health Information for International Travel. The Yellow Book Online 2002; www.cdc.gov/travel/yb/index.htm

Top

.

Medical Student Perspectives: Acing the Residency Interview

We all remember our medical school interview. Nothing quite compares to the horror of having your entire future hanging in the balance. Fortunately, the hard part is over. The interview process for residency is, with few exceptions, a much friendlier experience.

Interviewing for residency can actually be legitimately fun if you approach it with the right perspective. As an applicant, you will find the residency interview is an opportunity to learn more about each individual program. In general, it is not necessary to convince the powers that be that you belong. There is a detailed review process that every program conducts with each application, and programs only offer interviews to applicants they feel are qualified to match there. The most important piece of advice I can offer is to be yourself. Your interviewers only know you as an application file. The interview is an opportunity for them to get to know the real you. Show them who you are. Have a conversation and answer their questions candidly. Be prepared when they ask you if you have any questions. You should definitely have a list of questions prepared, and do not be afraid to ask the same question many times over to different people in a residency program. If you receive several inconsistent responses to the same question, that may be a red flag. Ask about didactic sessions, resident pass rates on the boards, procedural training, research opportunities, and fellowship success rates. Most important, ask questions relevant to your interests and show them that you are critically analyzing the program.

Probably the most valuable time you will spend during a residency interview is time with the residents. The residents are a barometer of life in that residency program. Are they happy? Can they barely stay awake enough to answer your questions? Do they have a life outside of residency? Pay attention to what they say and how they act. You will get no better insight into what it is like to be a resident at a given program. Remember that your ultimate goal as you interview is to determine where each program will fall on your rank order list in February. Find a place where you can be happy and where your personality fits in with the other residents.

The structure of the interview day itself varies by program and specialty, but there tends to be a general theme to most residency interviews. There will probably be a display of their didactic presentations, which will involve sitting through a morning report or noon conference. Pay attention to the interaction between residents and attendings. This is one of your few opportunities to see this interaction during the course of a typical interview day. Perhaps most important, no matter how boring the lecture do NOT fall asleep! Believe it or not, this actually happens! There will be anywhere between two to five interviews with staff, residents, or both. Interviews with residents offer an opportunity to ask questions about resident life, call schedules, or things to do around town. There will be the dreaded tour, which comes with more opportunities to ask questions of the residents. Most interviews will also include a discussion of benefits, including vacation time, maternity/paternity leave, and health benefits.

Dress professionally. Men should wear a suit and tie, and get a garment bag. You certainly do not want to show up in a hopelessly wrinkled suit. Women should wear a suit with a jacket and either slacks or a longer skirt. Dress conservatively. Your goal for dress should be blending in, not standing out.

Perhaps the most difficult aspect to interviewing for residency is determining how to communicate your level of interest in the program. The best advice is to be honest. If you know you are going to rank a program first and you want them to know it, tell them. If you know a program is among your favorites, you can tell them that too. However, do not tell ten different programs they are your top choice. Program directors tend to know one another, and they may have conversations about prospective residents. Be professional and try to be honest when you discuss your level of interest in a given program.

As you prepare for your residency interviews, the following are the most important tips to remember: Have fun, be yourself, watch the residents carefully, and bring a list of questions. Remember the final product of the interview process will be a rank order list, where you will determine which programs fit you best. If you approach each interview with these thoughts in mind you will have great success.

Brian Freeman, MD
Third Year Internal Medicine Resident, University of Iowa – Des Moines
Council of Associates Representative, Midwestern Region
E-mail: brian-freeman@uiowa.edu

Top

My Kind of Medicine: Real Lives of Practicing Internists: Michael Mignoli, MD, FACP.

.

Every year, Dr. Michael Mignoli visits a different baseball park. So far, he has been to 16, roughly half in the country. Baseball has long been an interest of Dr. Mignoli’s, something he says most of his patients know. And it was baseball that he and one of his patients, an elderly man with congestive heart failure, talked about one evening in the hospital, as the man neared the end of his life. Dr. Mignoli had been at the hospital for another patient, but decided to check on him to see how he was doing. Having been the patient’s internist for eight years, Dr. Mignoli had seen him through countless tests, procedures, office visits and hospital stays, but after it was all said and done, it was not any of those things that stuck with him. During a visit by the patient’s daughter shortly after the patient had passed away, she told Dr. Mignoli that of all the things he had done for her father, what he had remembered most was how much he enjoyed their conversation about baseball that evening.

Dr. Michael Mignoli at the Los Angeles Angels of Anaheim game

Dr. Michael Mignoli at the Los Angeles Angels of Anaheim game


Wise Medicine

Dr. Mignoli says one thing he becomes more cognizant of as he treats more patients is how significant a part of his treatment is dependent on knowing his patients. "I can take care of my patients better than anyone because I know them," he says. "I know their history, I know how I’ve treated them, and I know how they’ve reacted to the treatment. That kind of knowledge is indispensable."

He says he enjoys all aspects of his job and knows he made the right decision for himself. "No day is the same. Each individual patient presents a new challenge, which I love," he says. "Plus, the more I’ve been in practice, the more I’ve come to understand how much medical knowledge changes. I love keeping up to date with the latest research and information. I also chose internal medicine because it presented so many opportunities. You have to love what you do," he continues. "If you don’t like what you do, no matter how much money you make, no matter what the perks or advantages are, if you don’t love what you do, you will never find enjoyment in your career. I love what I do." He says medical students who are unsure of which path to follow should tune in to what their gut is telling them. "Try on all of the hats you possibly can and see if there is something you like. Pay attention to how you feel when you’re doing it, which will tell you."

One of the biggest lessons he has learned as a practicing physician is learning what he is not comfortable doing. The proliferation of information that is constantly being channeled to patients everywhere via the internet and media creates a very serious challenge for physicians in their treatment decisions. "Patients will come to you and ask you about something they saw on Oprah or heard from a cousin or read on the Internet," he explains. "That’s where you have to really take a step back and consider everything at stake: your own sense of right and wrong, the patient’s desires and whether or not they parallel their needs, the payer’s authorization, and how much of a stand you’re going to take if you do in fact decide it’s a good decision for the patient and the payer doesn’t authorize. There are whole sets of competing principles."

The Oprah-watching, self-prescribing trend is a prime example of the downside of information overload, as he explains. "You may have a situation where another doctor prescribes something to a patient of yours without consulting the patient’s current medication list, which can lead to trouble. Without an internist, it’s like having fifteen chefs in the kitchen with no kitchen manager. It doesn’t work."

The Local

Dr. Mignoli is from Texas, but there is not a trace of an accent in his voice. He called it home for a long time too—all the way through medical school at the Baylor College of Medicine in Houston. He then decided to take his internship at the University of Colorado, and ever since he has called Colorado home. "I tell people I liked it so much that I decided to stay," says the 42-year-old, "which is great because I don’t need to leave. Being an internist, I can practice anywhere I want."

Colorado suits him—five years ago he learned how to snowboard and he is also a cyclist. He has a host of other hobbies and interests: photography, cycling, and traveling. He also invests his time in what he calls "pet projects," which to most sound like part-time jobs: he is a regular speaker on the subject of electronic medical records with local medical societies and has acted as the medical director for a local hospice for several years. He has integrated himself into his community, doing what he loves and is passionate about, which for him, is the only way to live.

Dr. Mignoli’s private practice that he shares with one partner in Highlands Ranch, Colorado, gives him many things: flexibility, satisfaction, and control. "It has allowed me to be the captain of my own ship," he says. "I can control my work and my productivity. I determine how much I work and how I actually do the work. I like being in charge of my own destiny."

But being the captain of his own ship requires more than calling the shots, as Dr. Mignoli is well aware. "A lot of times, my job is just about listening and offering human support. As an internist, you’re taking care of people, not conditions," he explains. "It’s rewarding to watch patients grow older, to see a patient survive cancer, or grow stronger and healthier after quitting drinking. You don’t get to see that in a lot of positions in the medical profession. I get to see the good stuff! There’s a lot of life between 18 and 80—I get to see my patients live it."

Top

Internal Medicine Interest Group of the Month: Drexel University

.

The Drexel Internal Medicine Interest Group (IMIG) has been an active organization at Drexel University for many years. Today it remains one of the largest and most successful groups at Drexel. The goal of the IMIG is to provide both informational and experience-based opportunities to students who are interested in the field of internal medicine. Throughout the year we organize meetings that provide a better picture of what the field of internal medicine entails, not just the well-known subspecialties such as cardiology and pulmonary medicine, but also the lesser-known subspecialties such as endocrinology, infectious diseases, and geriatric medicine. In addition, we have had a lot of success in developing a mentoring program that allows students opportunities to shadow doctors in our affiliated hospitals. These opportunities are especially rewarding for first and second-year students who can use these experiences to bridge the gap between what they study in their textbooks and what they want to do in the clinical world. We also hold discussion sessions on a range of topics. One of the most interesting of these discussions is the surgery vs. medicine debate, consisting of a panel of doctors weighing in with their opinions. Our meetings also focus on informing students about available research opportunities and providing advice on how to successfully navigate the match process.

The key to the success of the IMIG at Drexel has revolved around having motivated, enthusiastic, and inquisitive students. In addition, the Pennsylvania ACP Chapter has been invaluable to our organization in both providing resources and information. We work closely with the Chapter, which has a large student membership, thereby keeping students involved. Student representatives also, when schedules permit, attend Pennsylvania Chapter Council meetings and help provide a different perspective in discussions, especially those pertaining to escalating costs of education. The local ACP Chapter leaders also participate in our informational meetings to give a broad view of current issues that face aspiring doctors. The Pennsylvania ACP Chapter helps us organize small focus group sessions. These sessions consist of twenty students who meet with doctors from a specific subspecialty field for dinner. These informal, smaller group meetings allow students to ask questions and receive advice from doctors in the subspecialty in which they are interested.

So far this year we have participated in the Drexel University Activity Fair, where we increased awareness and exposure of our club. We used a variety of props to generate interest. For example, we had a mannequin that allowed students to practice inserting a central line. In addition, we raffled off several items including a new stethoscope. This was also an opportunity for us to increase ACP Medical Student Membership. We recently had our first IMIG meeting, which focused on clarifying for medical students what internal medicine really is. With the help of the local ACP Chapter, we invited doctors in primary care, infectious disease, gastroenterology, nephrology, and cardiology to speak to the IMIG about their experiences in medicine.

Darren Wong dww34@drexel.edu and Lance Hale lh54@drexel.edu
Co-Presidents of the Drexel Internal Medicine Interest Group
Drexel University School of Medicine, Class of 2010

Top

Winning Abstracts from the 2007 Medical Student Abstract Competition: Porphyria Cutanea Tarda (Pct): Mutations and Sequence Variants in the Uroporphyrinogen Decarboxylase (Uro-D) Gene in Sporadic Patients.

.

Author:
Eric Gehrie, Mount Sinai School of Medicine

Introduction:
Porphyria cutanea tarda (PCT), the most common disorder of heme biosynthesis, typically presents with characteristic light-induced blistering skin lesions. Familial PCT (F-PCT) is an autosomal dominant disorder and patients have germline uroporphyrinogen decarboxylase (URO-D) mutations, half-normal erythrocyte and decreased hepatic URO-D activities. In contrast, sporadic PCT (S-PCT) patients have normal UROD genes and erythrocyte URO-D activities, but have decreased hepatic URO-D activity presumably due to the specific inhibition of the hepatic enzyme. Both familial and sporadic forms are precipitated by environmental factors including alcohol, iron overload, and viral infections (e.g., HCV). S-PCT and F-PCT can be diagnosed biochemically by markedly elevated urinary heptacarboxylate porphyrin levels.

Methods:
To determine if URO-D single nucleotide polymorphisms (SNPs) or rare sequence variants predispose to S-PCT, the entire ~3.5 kb URO-D gene and 1000 bases upstream and downstream were sequenced in 24 sporadic patients who had no affected relatives, and 25 unrelated normal individuals.

Results:
Surprisingly, two previously identified URO-D coding mutations, R142X and a complex mutation (g645del1053ins10), were identified in 2 (8.3%) unrelated S-PCT patients, indicating that they actually had F-PCT. At-risk relatives have been counseled and offered testing. In addition, studies of a known F-PCT family revealed a novel URO-D mutation (H331R). Among the 22 S-PCT patients, 8 SNPs were identified at gDNA -293 (4 patients), -263 (9), -175 (1),496 (9), 1562 (2), 1772 (2), 1835 (9), and 2892 (9). The three F-PCT patients had 5 SNPs at gDNA -263 (2), 496 (10), 1835 (2), 2892 (2), and 3236 (1). In the 25 control patients, 7 SNPs were identified at gDNA -293 (6), -263 (10), 496 (10), 1562 (2), 1772 (2), 1835 (10), and 2892 (10).

Conclusion:
This is the first report of germline mutations in presumed S-PCT patients, indicating that these manifesting patients either had de novo mutations or F-PCT that masqueraded as S-PCT due to the low penetrance of the germline mutations. Therefore, biochemically confirmed S-PCT patients should be screened by mutation analysis. In addition, no sequence variants or SNPs were identified in the URO-D gene that predisposed patients to S-PCT.

Top

Subspecialty Careers: Highlights about Careers in Internal Medicine: Adolescent Medicine

.

The Discipline
Adolescent medicine focuses on the physical, psychological, social, and sexual development of adolescents and young adults. Multidisciplinary and comprehensive in approach, this specialty encompasses the full spectrum of acute, chronic, and preventive health care. Adolescent medicine evaluates medical and behavioral problems within the context of puberty and tailors management to the individual's developmental needs. Problems typically encountered include abnormalities in growth and development, vision and hearing disorders, learning disabilities, musculoskeletal problems (often sports related), allergies, acne, eating disorders, substance abuse, psychosocial adjustment problems, sexually transmitted diseases, contraception and pregnancy, and sexual identity concerns. In addition, adolescent medicine emphasizes the management of chronic diseases that begin in childhood and continue into adulthood, such as diabetes, asthma, cystic fibrosis, congenital heart disease, and inflammatory bowel diseases.

Opportunities for physicians to practice exclusively in this discipline are relatively few but growing in the private sector and are generally found within academic medical centers or in the public health sector. Adolescent medicine is an important part of general internal medicine, pediatrics, and family medicine.

Training
While most fellowship programs in adolescent medicine are clinically oriented, most fellowships do provide significant background in research, prevention, and education. Adolescent Medicine fellowships vary from one to three years in length. Candidates for fellowship programs must have completed an approved residency in internal medicine, pediatrics, family practice, or combined medicine-pediatrics.

Certification
The American Board of Internal Medicine and the American Board of Pediatrics have agreed to award certification in adolescent medicine on the basis of performance on an examination developed jointly by both Boards. The admission requirements are similar and the standard for certification by the two Boards is identical. The examination is offered in the fall of odd numbered years.

Training Positions
As of 2007, there were 26 training programs in Adolescent Medicine. Sixty-six percent of the trainees were female and 77% were US medical graduates. The Society of Adolescent Medicine annually publishes a list of available fellowships in the Journal of Adolescent Health.

Practice
The practice and procedures performed in this specialty are very similar to those of a general internist; however, additional gynecological procedures such as colposcopy and IUD implantation may be performed.

Major Professional Societies
The Society for Adolescent Medicine
1916 NW Copper Oaks Circle
Blue Springs, MO 64015
Phone: (816) 224-8010
Web site: http://www.adolescenthealth.org/

Major Publication
Journal of Adolescent Health

Source: This information came from the American College of Physicians’ Subspecialty Brochure.

Top

Advocacy Briefs: Economic Hardship Deferment at Risk: Contact Congress Now

.

The "College Cost Reduction and Access Act" (H.R. 2669) was signed by the President on September 27. Unfortunately, H.R. 2669 eliminates the economic hardship deferment qualification criterion that most medical residents rely upon to defer their student loan debts while completing residency training.

Prior to the passage of H.R. 2669, a resident could qualify for economic hardship deferment if he or she was employed full-time and his or her federal education debt burden was equal to or greater than 20 percent of his or her monthly income, and his or her income minus the education debt burden was less than 220 percent of the greater of the minimum wage rate or the federal poverty line (FPL) for a family of two ("20/220 pathway").

Now, instead of the "20/220 pathway", borrowers will have the option of participating in a debt repayment program that caps payments at 15 percent of the borrower’s income that is above 150 percent FPL. The effective date of H.R. 2669 was October 1, 2007, but the new debt repayment program does not go into effect until July 1, 2009. The October 1 deadline leaves forbearance as the only option for residents-in-need to avoid payment for their first three years of training. Tell your members of Congress exactly how eliminating the economic hardship deferment will impact you. Visit the Legislative Action Center now.

Top

Did You Know You Can Enter the ACP’s National Medical Student Abstract Competition?

.

Did you know the ACP offers Medical Student Members the opportunity to present their research and interesting cases at the national annual meeting? If you are involved in a research or community service project through your medical school, or have come across an interesting case during your internal medicine rotation or preceptorship program, you should take advantage of the ACP’s National Medical Student Abstract Competition. For the past fourteen years, hundreds of Medical Student Members have presented their work to College members at ACP’s annual scientific meetings.

The time to act is now! The deadline for the National Medical Student Abstract Competition is November 1, 2007. Complete details and instructions for submitting an abstract can be found online.

Top

MKSAP for Students 3 Question 1

.

A 22-year-old man with sickle cell disease has four to six painful crises per year that require parenteral hydration and narcotics. Two weeks ago, he was diagnosed with an acute chest syndrome that responded rapidly to exchange transfusions and broad-spectrum antibiotics; he has been asymptomatic for 1 week.

Which of the following should be done to reduce the recurrence of sickle cell crisis in this patient?

( A ) Bone marrow transplantation
( B ) Gene therapy
( C ) Hydroxyurea
( D ) Long-term, continuous oxygen
( E ) Long-term exchange transfusions

MKSAP for Students 3 Question 2

.

A 71-year-old woman is evaluated because of progressive fatigue, weakness, and dyspnea on exertion of 3 months’ duration. A former smoker, she has a history of advanced emphysema and is on continuous long-term oxygen therapy. She currently uses a long-active bronchodilator twice per day, theophylline and an inhaled corticosteroid twice per day, ipratropium four times per day, and albuterol four to six times per day.

Physical examination is normal. Heart and lung examinations are consistent with long-standing, advanced emphysema. Her laboratory and radiographic findings are unremarkable.

Which of the following will result in improved exercise tolerance and exertional dyspnea in this patient?

( A ) Amoxapine (tricyclic antidepressant)
( B ) Corticosteroids, 500 mg/day, for 3 consecutive days
( C ) Digoxin
( D ) Pulmonary rehabilitation program

MKSAP for Students 3 Answer 1

.

Answer: C, Hydroxyurea

Hydroxyurea, a ribonucleotide reductase inhibitor, has been shown to increase the level of fetal hemoglobin (hemoglobin F) in patients with sickle cell disease. Increased concentration of hemoglobin F may inhibit the polymerization of sickle hemoglobin and the incidence of sickle cell crisis. Hydroxyurea is an antitumor drug that is relatively nontoxic. Its myelosuppressive effects are reversibly, but it appears to increase the incidence of acute myeloid leukemia when used in patients with the malignant myeloproliferative disorder polycythemia vera. While taking hydroxyurea, the patient can be easily monitored though periodic complete blood counts.

Although bone marrow transplantation might be a consideration for this patient, it is attended by substantially higher toxicity than hydroxyurea therapy. Gene therapy approaches for the treatment of sickle cell disease remain investigational. There is no role for either long-term transfusion therapy or oxygen therapy for this patient.

References
1. Charache S, Terrin ML, Moore RD, Dover GJ, Barton FB, Eckert SV, et al. Effect of hydroxyurea of the frequency of painful crises in sickle cell anemia. N Engl J Med. 1995;332:1317-22. PMID: 7715639.

2. Steinberg MH, Barton F, Castro O, Pegelow CH, Ballas SK, Kutlar A, et al. Effect of hydroxyurea on mortality and morbidity in adult sickle cell anemia: risks and benefits up to 9 years or treatment. JAMA. 2003;289:1645-51. PMID: 12672732.

MKSAP for Students 3 Answer 2

.

Answer: D, Pulmonary rehabilitation program

Pulmonary rehabilitation is a critical adjunct to pharmacologic therapy in patients with chronic obstructive pulmonary disease. Severe dyspnea leads to a sedentary lifestyle and subsequent deconditioning. Pulmonary rehabilitation increases the patient’s strength, quality of life, sense of well-being, and exercise tolerance. Pulmonary rehabilitation is indicated for patients with chronic respiratory impairment who, despite optimal medical management, are dyspneic, have reduced exercise tolerance, or experience a restriction in activities. Although pulmonary rehabilitation may improve symptoms and exercise tolerance, often there is no improvement in pulmonary function, oxygenation, or survival.

There is no role for high-dose corticosteroids in the treatment of this patient. Prescribing antidepressant medication may be helpful in patients with depression, but it will not improve exercise tolerance or dyspnea. There is nothing in the physical examination to support the diagnosis of heart failure; therefore, a digoxin is not indicated. In any event, digoxin would not be a first-line drug for the treatment of cor pulmonale, even if present.

References
1. Pulmonary rehabilitation-1999. American Thoracic Society. Am J Respir Crit Care Med. 1999;159:1666-82. PMID: 10228143.

Top

ACP Internal Medicine Residency Database

.

Interested in obtaining more information about residency programs? 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 Web site.

Top

Student Members Receive a 30% Discount When Ordering MKSAP for Students 3

.

MKSAP for Students 3 includes over 400 patient-centered self-assessment questions and their answers in print and on CD-ROM. Designed for medical students participating in their clerkship rotation, the questions help define and assess a student’s mastery of the core knowledge base requisite to internal medicine education in medical school. The questions reflect the daily management dilemmas faced by internal medicine physicians and when coupled with the answer critiques, provide a focused, concise review of important content.

New in MKSAP for Students 3:

  • All new questions and critiques
  • More topics and chapters
  • 12 electrocardiogram questions
  • 24 color figure dermatology questions

List Price: $44.50; Student Member Price: $30.00

To order your copy of MKSAP for Students 3 please visit us online.

Top

Stories for Medical Students from ACP Observer

.

Top

[PDF] Acrobat PDF format. Download Acrobat Reader software for free from Adobe. Problems with PDFs?

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.

Advertisement