October 2008 E-Newsletter

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College Leader Barbara Turner, MD, MSEd, FACP Presents at ACP’s “Brown Bag” Lunch Series for September: Women in Medicine

ACP honored Women in Medicine month in its “brown bag” lunch series in September, featuring Barbara J. Turner, MD, MSEd, FACP as the headline speaker. Christine Laine, MD, MPH, FACP, Vice President and Senior Deputy Editor of Annals of Internal Medicine, introduced Dr. Turner, whom she referred to as a mentor. “She taught me a lot about balancing life and career,” said Dr. Laine, “I wanted to be like her.”

Dr. Turner, who has served on ACP’s Board of Regents since 2007, currently holds the position of Professor of Medicine and Director, Primary Care Physician-Scientist Fellowship, at the University of Pennsylvania. She graduated from the University of Pennsylvania School of Medicine in 1978 and completed her internal medicine residency at the Hospital of the University of Pennsylvania. She is board-certified in internal medicine and has been a Fellow of ACP (FACP) since 1991. She has authored over 100 peer-reviewed articles and specializes in research on quality of care.

Dr. Turner’s presentation focused on the changing role of women in medicine and how ACP supports it. She began with a brief overview and used her personal perspective to frame the historical significance. “During my first year of medical school at the University of Pennsylvania in 1974, the first woman made it to a leadership position—assistant to the President,” she said, “and by the end of the decade, women comprised 28 percent of the medical school.”

Yet while women represent roughly half of the nation’s medical school student population, Dr. Turner went on to explain that there still remains a significantly smaller percentage of women compared to men achieving academic advancement and leadership roles. “Women are not reaching the higher ranks academically,” she said, “because it’s difficult to measure progress through the educational track and also because women aren’t publishing as much.”

The real challenge for women, Dr. Turner said, is effectively balancing family and career and reaching higher level positions both academically and in leadership in higher numbers. To reach these goals, she suggested women pursue training and resources to further develop public speaking, time management, and salary negotiation skills. She said that spending time with female mentors, learning how to manage money, and taking advantage of resources for women at meetings can also be greatly beneficial to women.

She concluded her presentation with a Q&A discussion period, during which she spoke to attendees about the challenges of pursuing a part-time career, negotiating, and racial and ethnic disparities in medicine.

ACP’s brown bag lunch series is held for ACP employees featuring speakers from different areas of the College.

ACP offers several resources for Women in Medicine, including annual meeting programming and activities, which include workshops and a luncheon, chapter-level activities, a part-time employment guide, and more.

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Medical Student Perspectives: The Truth about Taking Time Off from Medical School

Every August, aspiring doctors across the country enter their first year of medical school with hopes of practicing the art of medicine in some capacity, although most have not completely figured out the logistics. Regardless of the means, the end result is the same as student doctors embark upon their medical school journeys and navigate through unfamiliar territory in search of a path which will eventually lead them to a fulfilling career in medicine. Along the way, various events may cause deviations from the typical four-year path. Some students face trials and tribulations in their personal and/or family lives, some consider partaking in dual-degree educational programs, conducting research, or volunteering, while others enter the realm of parenthood.

Many students are under the impression that taking time off from medical school will hinder their chances of matching into a desired residency program, a notion which has little truth. In general, several facts must be taken into consideration when deciding whether or not to take time off from school. First and foremost, students should speak to the school’s administration or refer to the student handbook in order to understand the school’s policy about granting students time off. Each institution has its own policies and often students are required to fill out numerous forms or meet with various deans, all of which requires time, making advanced notice an essential element. Next, one must examine his or her true reasons for taking a break and set personal goals to be achieved; after all, what one accomplishes during that time off is particularly important to residency program directors. Another important factor to consider is the timing of the break, as interruptions at various time points along the typical four-year medical school timeline have different implications and pose different pros and cons. Once the decision has been made, the next question is what should one do during the year off?

Research
Some students opt to take a year off from school in order to do research in a particular field of interest, which not only allows them to take a break from school but also serves as a means of enhancing their CVs. In fact, many students feel that research experience is necessary to be considered for more competitive specialties. There is a bit of truth in that, although students should realize that research experience, whether clinical or bench-top, is a plus and will always boost a CV, regardless of the specialty; however, it is not a prerequisite for matching into the residency of your choice. More importantly, when one engages in research there is the possibility of publication, which is the icing on the cake as it adds more merit and prestige to your work.

Dual Degrees
There are those students who have always had other interests outside of medicine and for some, medical school offers an opportunity to obtain a second degree. For example, those interested in medical litigation or public policy may pursue a JD, those interested in medical research may pursue a PhD, those interested in medical administration may pursue an MBA, and those interested in focusing on population health problems may pursue an MPH. Students may apply for these degree programs separately or apply for combined degree programs, which have some perks such as exemptions from entrance exams if the students’ MCAT scores are sufficient or advanced class standing. In the case of a dual MD-JD degree, most institutions allow students to complete the second degree in two years versus the traditional three-year course while some PhD programs tend to aim for a three-year stint versus the average five years required for obtaining the degree. In addition, some of these programs allow students to work toward their second degree while simultaneously completing their medical school training. Finally, some PhD combined programs will waive medical school fees and provide students with a stipend for the duration of the program in an effort to promote the program and make the typical seven-year commitment more appealing.

Volunteering
As with any other application process, the addition of volunteer work is another beneficial supplement to your CV. Some students partake in volunteer efforts in underserved areas or third-world countries where they help set up hospitals or work in local health clinics. Some apply for positions in acclaimed programs such as Operation Smile or Doctors without Borders and work alongside world-renowned doctors and surgeons, while others opt to stay local and aid by working for a non-profit agency, a homeless shelter, or a soup kitchen. Activities such as these will prove particularly beneficial as they allow students to become exposed to eye-opening experiences that can make lasting impressions.

Personal Reasons
The most common situations in which people take time off for personal reasons are to start a family, to find one’s self, to handle personal and family issues, and unfortunately, deal with emergencies and illnesses. These are all justifiable reasons for taking a break from school and the notion that one must conduct research or volunteer during an off year is not valid. There are no easy answers to the question of what constitutes a legitimate reason, although some residency program directors might beg to differ. The truth of the matter is that life happens and we just have to roll with the punches. At the end of the day, the reason you took time off becomes less relevant if you can thoroughly depict your experience and put a positive spin on it.

In conclusion, the key thing to remember regardless of the reasoning behind your decision to take time off from school is that a break in your CV denotes a flag and raises concerns, so be prepared to honestly answer questions about what you did during your time off when going on residency interviews. Remember, all the residency program director sees is a blurb about your time off on your CV. It is your job to paint a clear and concise picture of the experience and the profound impact it has had on your life. Taking time off from school should not hinder your chances of landing the residency spot of your dreams as long as you can illustrate the fact that the break has not negatively affected your clinical acumen but has instead enhanced your skills and preparedness to train and practice the art of medicine.

Shabnam Zarrabi
Osteopathic Representative, Council of Student Members
University of Medicine and Dentistry of New Jersey
School of Osteopathic Medicine, 2010
Email: zarrabsh@umdnj.edu

Check out more Volunteer opportunities.

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My Kind of Medicine: Real Lives of Practicing Internists: Vineet Arora, MD, FACP

Vineet Arora, MD, FACP

Dr. Arora and her husband, David Meltzer, MD, PhD, at the underground “basilica cistern” in Istanbul in September.

Vineet Arora spent the better part of her 32nd birthday sitting on an uncomfortable wooden bench surrounded mostly by strangers. She was nervous and her stomach was growling, as she had arrived at 9 a.m. without having eaten breakfast, and had been there for five hours since. Finally, it was her turn. She stood up and introduced herself to the U.S. House of Representatives Health Subcommittee of the Energy and Commerce Committee and urged them to consider legislation that would halt Medicare payment cuts. She spoke of her love for internal medicine and how much it meant to her to have ongoing relationships with her patients. “It was a big moment,” she remembers. “I was there to represent the voice of the future—of so many young people who don’t have a voice. It was an honor.” Her boyfriend at the time, unable to attend because of a work obligation, had been intermittingly leaving a meeting to watch her on CSPAN. After she finished her testimony, he sent her an e-mail. “He said that I looked really hungry!” she recalls with laughter.

The Advisor
In 1996, physicians Robert Wachter and Lee Goldman published an article in the New England Journal of Medicine about the emerging role of physicians practicing general medical care of hospitalized patients. A “hospitalist” they called it—a foreign term for a brand new concept in U.S. health care. As she read the article from her apartment in St. Louis, where she was in her third year of medical school at Washington University, Vineet Arora was intrigued. Today, the energetic 34-year-old is a practicing hospitalist at the University of Chicago. She is also a researcher, an Assistant Dean of Curricular Innovation and an Associate Program Director of the Internal Medicine Residency Program at University of Chicago’s Pritzker School of Medicine. It is an expansive, diverse and busy career that fits the lively, quick, and energetic Dr. Arora like a glove. Her training as an internist in many ways served as a catalyst for all of it.

Dr. Arora values each role for different reasons and says they complement each other. For example, while working her rounds as a hospitalist, she can see first-hand how a program is or is not working, or pick up on things that would interest her as a researcher, such as “transitions in care”—the transferring of patient care from one shift to the next—that she has recently begun to pursue. “What I like about research is thinking about a problem and coming up with a systematic way to deal with it,” she says. “So my clinical work helps me to define problems and develop programs to address them. In her role of Assistant Dean and Associate Program Director, she thrives from her work with students. “As a career advisor, I get to know students really well in the role,” she says, “and everyone is so different. The most important thing I need to teach them is to look past the immediate and to see the long run. I have to make sure they are really passionate about what they’re doing.”

It is in this role in particular that Dr. Arora seems to shine brightest. In a video on doctorschannel.com, she is all at once informative, authoritative, accessible, and likable as she rattles off tips for applying for residency. She gives off a positive energy and a youthful air, and when she talks about mentoring it is obvious that she takes it to a higher level, beyond the few token “words of advice.” She draws upon her own experience when appropriate to do so, for example, encouraging residents to pursue public policy, as she did herself at the Harris School at the University of Chicago. “In residency, the goal is to become the best doctor you can be,” she says, “but people have other interests, too. I try to keep a resident’s spirit alive. If someone has an interest in something like that, I try to cultivate it and make it grow.”

Would she recommend hospital medicine for a career? “My job is to advise medical students on their career choice, and while I think hospital medicine is a great career, I have to add that it is important to know who you are,” she says. “People also go through a lot of personal changes and you have to take that into consideration. It can be intense at times, which is why I advise on a case-by-case basis.”

Bread and Butter

Dr. Arora’s experience with her own mentors helped shape her decisions to pursue both internal medicine and hospital medicine. “It was from a mentor who was an endocrinologist that I first learned about internal medicine,” she says. “She was my clinical skills preceptor and I remember she would review our videos and give us feedback on them. Looking back on it I think how bad we must have been! But she was very patient with us.” Dr. Arora says what set her apart was her willingness and enthusiasm to share with the students. She cites a patient case in which the patient had been suffering from an enlarged thyroid, caused as they eventually learned, by a viral infection—a fairly uncommon occurrence for the presenting symptoms. “It’s one of those things you read about,” she explains. “And I thought it was great that she took the time to explain that to us. It’s nice when someone goes out of their way to teach you.”

From another mentor, she learned about hospital medicine. “The hospitalist who I spent my rounds with was very solid in evidence-based, bread-and-butter topics, and I learned a lot from him. There was one time in particular I remember when he really taught us something interesting. We had several patients come in with a high fever, and since many of them were diabetic and elderly, we began treating them with broad spectrum antibiotics. Well, this hospitalist suggested doing an influenza nasal swab and they came back positive. Three or four cases of flu were discovered on the ward. It was a great moment of ‘Wow, you can really make a contribution by making the right diagnosis.’”

During residency, Dr. Arora was named chief resident which she considered an honor. Later, instead of subspecializing, she chose to pursue the systems and public policy training that she had developed an interest in while in college at Johns Hopkins in Baltimore, Maryland. She says knowing how to get the right training in public policy and combining it with research can be confusing. “During college I took health administration courses but at no point did I think that I should dive into another degree. I didn’t know how to integrate it into my career. I think there’s some confusion about this path…one thing students and residents should keep in mind is that getting additional training is important.”

A recent example of how she combines her public policy training with research work is a study she recently published with colleagues in the September 10 issue of the Journal of the American Medical Association on the effect of reduced shift lengths for first-year medical residents. The study concluded that cutting shift lengths is not effective in reducing fatigue-related errors by first-year medical residents if the workload is not reduced as well, but instead packed into fewer hours. “While people have been focusing a lot on the number of hours and resident fatigue, it’s also important to focus on workload and on handoff errors and communication around shift change,” Dr. Arora said in an interview on the study. She explains how the study is a good example of policy-relevant research. “One policy can lead to multiple projects,” she says, “with all of the policies being released on a regular basis, there are boundless opportunities.”

Far Sighted

Dr. Arora’s personal experience has taught her important lessons. “One of the most difficult things as a researcher has been getting rejected from grants or publications,” she explains. “Rejection is a major part of life as a researcher, so early rejections, while tough, are an important part of growing and moving forward in your career. If you don’t have the experience of failure, you can never really enjoy success.”

She recalls being told this while listening to the introductory remarks of a senior investigator at a grant competition. “He talked to us about the grant application process and said that it was how you handle rejection that ultimately defines your ability to succeed in your long term career,” she says. About a week afterwards, the investigator called Dr. Arora and informed her that she would not be receiving the grant she had recently applied for, but that he hoped she would remember his words from the week before. When he called, Dr. Arora happened to be with one of her research fellows. When she hung up the phone and told her research fellow that she had not gotten the grant, they were dumbfounded by her response. “She said that if it had happened to her she would have been in tears,” remembers Dr. Arora. “And I just repeated what he had told me.” Later, when the same fellow was both awarded with her first big grant and rejected for another within a week, Dr. Arora says she was impressed by how well she had taken this advice to heart. “She was excited about her success but also took her failure really well and learned from it. It was rewarding for me to observe that.” Dr. Arora’s work with people from high school all the way up to co-faculty has made it a learning process on both ends, as she explains. “One of my most rewarding career experiences has been training and mentoring others in research,” she says. “I may teach others but I also learn how to be a better mentor and how to help people succeed to their fullest. I’d say it is definitely the best part of my job.”

In her down time, Dr. Arora likes to travel with her husband of two years, David, who is also a researcher and a health economist. They traveled to Turkey in September. “We try to take one big trip a year—it’s our getaway time,” she says. They met at work and were colleagues for about a year and half before they started dating. “We don’t have an interesting story!” she insists, but later adds that her most favorite quality of her husband’s is that he knows how to have a good time. She says he’s “really smart” but qualifies that while everyone sees this side of him, as his wife, she appreciates other things. “He makes me laugh!” she says. For Dr. Arora’s hectic life laughter must be the perfect remedy, just as it was three years ago on that fateful birthday. Sometimes the best stories are the simplest ones.

Check out previous articles as physicians share what motivated them to become physicians as well as why they chose their particular type of practice.

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Internal Medicine Interest Group of the Month: University of Pennsylvania

The William Pepper Internal Medicine Society at the University of Pennsylvania School of Medicine was founded in 1886. Our Society is named for Dr. William Pepper, who as Provost of the University from 1881-1894, enhanced Penn's research capabilities by increasing faculty and class sizes, added more than 40 acres and twenty new buildings to the campus, and was a strong supporter of the Hospital of the University of Pennsylvania. Our mission is to enhance the interest in the practice of internal medicine by fostering educational and research opportunities for medical students through interactions with the Department of Medicine.

The backbone of our Society is our yearly internal medicine dinner speaker series. We invite physicians from different specialties and subspecialties, backgrounds, and locations to have open dialogues with medical students. These talks are always well attended and spark great discussions. Recent topics have included Interventionalism, Women in Internal Medicine, and Work-Life Balance. New topics for the 2008-09 year will include Primary Care, Global Health Opportunities in Internal Medicine, and Veterans’ Health.

Last year, the Pepper Society began an exciting partnership with the American College of Physicians Pennsylvania Chapter to introduce more Penn medical students to the opportunities available in internal medicine. In November 2007, a dinner was held at a Philadelphia restaurant where 60 students and more than 15 internal medicine physicians from all over the Philadelphia area were able to meet and talk about training, career planning, and life as an internal medicine doctor. We followed up this groundbreaking event with a spring happy hour, offering more opportunities to mingle with practicing internists. We look forward to working with Charles Cutler, MD, FACP, the ACP Southeastern Pennsylvania Region Governor, and John Derrickson, the ACP Pennsylvania Chapter Executive Director, to plan more successful events this coming year.

This year, the Pepper Society is becoming involved with several new and exciting projects, including a partnership with the United Church of Christ Volunteer Clinic in West Philadelphia, to improve the patient services offered and enhance the teaching and mentoring of medical students. We will hold the first annual Internal Medicine Specialty Fair in Spring 2009 to introduce first and second year medical students to the various internal medicine specialties and subspecialties. Finally, in April 2009, we will sponsor a “Preparation for Internal Medicine Internship,” with the goal of teaching, reviewing, and practicing procedures in the simulation lab that are commonly done during internal medicine residency.

Our co-presidents are Rebecca Adler, MS4; Amy Imawaye, MS4; and Greg Peterfreund, MS2. Our faculty advisor, Jennifer Kogan, MD, FACP, and our group coordinator, Ann Marie Hunt, are instrumental in helping us plan successful events. We look forward to an exciting new academic year!

Rebecca Adler
Co-President, William Pepper Internal Medicine Society
University of Pennsylvania School of Medicine, Class of 2009
Email: adlers@mail.med.upenn.edu

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The CDC Experience Applied Epidemiology Fellowship - Call for Applications

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

• Are you curious about how public health and the CDC work?

• Do you want to work with state, local and international public health partners?

• Would you be interested in investigating outbreaks of tuberculosis among the homeless, or in a prison population?

• Or traveling to Southeast Asia to help set up a surveillance program for avian influenza?

• What about assessing risk factors for birth defects using national data bases?

• Or perhaps you would like to be at the forefront of injury prevention research?

Do you want an experience that offers an opportunity to enhance your research skills, build 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 Applied Epidemiology Fellowship is a one-year fellowship tailored for rising 3 rd 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, GA where they carry out epidemiologic analyses in various areas of public health. Examples of previous and current areas of concentration include viral diseases, cardiovascular health, birth defects, STDs, food borne diseases, injury prevention, and air pollution and respiratory health.

To learn more about the CDC Experience visit us online at CDC Experience. Applications for next year’s fellowship class must be postmarked by Friday December 5, 2008. Questions? Ask us at cdcexperience@cdcfoundation.org.

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Winning Abstracts from the 2008 Medical Student Abstract Competition: Physiologic Effect of Relaxation Therapies on Autonomic Tone Early After Acute Coronary Syndromes.

Author: Rachel Summer Claire Friedman, Yale University

Introduction
Post-MI patients are at increased risk of arrhythmic sudden death. Stress and sympathetic activation are known to influence arrhythmogenesis. While relaxation therapies improve psychological well-being in multiple medical illnesses, whether these therapies can positively influence sympathovagal balance in the post-MI population is unknown. We explored the physiologic effects of Reiki, a light-touch relaxation therapy, and music on post- acute coronary syndrome (ACS) inpatients, using heart rate variability (HRV) to assess changes in cardiac autonomic function during treatment.

Methods
Forty-eight patients with ACS within the last 72 hours were randomized to received a single 20-minute session of either Reiki, classical music, or a control “minimal distraction environment”. All subjects underwent ambulatory ECG holter monitoring. Emotional state was assessed by Likert scale. HRV was analyzed by spectral analysis via fast Fourier transformation during the baseline, intervention, and post-intervention periods and high-frequency power (log-normalized) compared via ANOVA with repeated measures. Adequate holters were recorded in 12 control, 13 music, and 12 Reiki patients.

Results
As shown in the table below, high frequency (HF) component of HRV, an index of parasympathetic tone, increased significantly during Reiki but not during music or control. RR interval increased significantly with Reiki and control, but not with music. Reiki significantly reduced reported anxiety and increased sense of relaxation compared to control, whereas music did not. ? Reiki (R) ? Music (M) ? Control (C) P value P value P value C vs. R M vs. R C vs. M Ln HF HRV 0.58±0.16 -0.1±0.16 0.06±0.16 0.025* 0.007* 0.5 RR (msec) 46.49±11.3 0.22±10.9 41.40±11.3 0.79 0.002* 0.01* Anxious -1.91±0.7 -0.39±0.8 0.54±0.8 0.04* 0.13 0.41 Relaxed 3.03±0.6 1.71±0.7 0.5±0.7 0.005* 0.21 0.18 Change in physiological and psychological parameters with intervention. * P value significant, p < 0.05.

Conclusion
Reiki increases vagal activity and decreases anxiety in patients after ACS. Whether longer-term use of this therapy can improve outcomes requires further study.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Gastroenterology

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

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

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

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

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

Certification
The American Board of Internal Medicine, ABIM, offers certification in Gastroenterology.

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

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

Major Publications

Major Professional Societies

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Advocacy Brief: Congress Approves Conrad Visa Waiver Program Extension

The House and Senate recently approved legislation to extend the Conrad 30 State J-1 visa waiver program through March 6, 2009. The bill also includes a provision that doubles to 10 the program's "flex-slots," the number of physicians per state who may serve in facilities, often teaching hospitals, that are located outside medically underserved areas but that treat patients from those areas.

The State Conrad 30 program allows state departments of health to request waivers of the J-1 visa home country service requirement for up to 30 foreign physicians per year to work in federally designated health professions shortage or medically underserved areas. The House originally passed the bill in May with a 5-year authorization to 2013, but the Senate shortened the extension to 6 months by amendment and the House concurred with that change.

Sen. Kent Conrad (D-N.D.) had proposed more extensive reforms in a bill S. 2672 introduced Feb. 27 which the College endorsed.

ACP recently released a position paper on the contributions of international medical graduates and the need to support their role in the U.S. health care system.

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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 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 December 8, 2008. Complete details and instructions for submitting an abstract can be found online.

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MKSAP for Students 3 Question 1

A 45-year-old man develops a symptomatic deep venous thrombosis of the left leg 1 week after arthroscopic surgery. Doppler ultrasound examination shows a thrombus in the left posterior tibial vein extending to within 2 mm of the popliteal vein.

The patient has mild hypertension, for which he takes an angiotensin-converting enzyme inhibitor. He has no other medical problems and is a nonsmoker. There is no family history of thromboembolic disease

Which of the following treatments is the most appropriate?

A. Enoxaparin and warfarin
B. Ibuprofen
C. Observation
D. Placement of an inferior vena cava filter

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MKSAP for Students 3 Question 2

An 80-year-old woman comes to the emergency department because of an acute episode of painless lower gastrointestinal bleeding. Physical examination discloses tachycardia and orthostatic hypotension.

With the exception of hyperactive bowel sounds, the abdominal examination was normal. Anorectal examination is normal, except for the presence of gross blood in the rectal vault. Nasogastric aspirate contains bile, but no blood.

Which of the following is the most likely diagnosis?

A. Bleeding internal hemorrhoids
B. Colorectal adenoma or adenocarcinoma
C. Diverticulosis
D. Ischemic colitiss
E. Vascular malformation

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MKSAP for Students 3 Answer 1

Answer: A, Enoxaparin and warfarin

The incidence of symptomatic venous thrombosis after arthroscopic surgery is not nearly as high as that after total knee replacement. Arthroscopic surgery is, however, a risk factor, and venographic studies have shown an incidence of 4% to 17% after such procedures. If it is feasible to treat the patient entirely in the outpatient setting, symptomatic calf vein thrombosis that has been objectively documented should be treated with therapeutic doses of low-molecular-weight heparin, followed by warfarin for a period of 3 months.

Approximately 20% of patients develop clot extension if anticoagulation is not undertaken; therefore, observation alone or the use of anti-inflammatory agents would not be appropriate treatment. There is no indication for placement of an inferior vena cava filter, such as inability to undergo therapeutic anticoagulation or clot extension at a therapeutic level of anticoagulation.

Bibliography
1. McRae SJ, Ginsberg JS. Initial treatment of venous thromboembolism. Circulation. 2004;110:I3-9. PMID: 15339875[PubMed]

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MKSAP for Students 3 Answer 2

Answer: C, Diverticulosis

In large clinical series, diverticular disease and, less commonly, vascular malformations and neoplasms were among the most common causes of acute lower gastrointestinal bleeding. Hemorrhoids and ischemic colitis rarely produce the massive bleeding that this patient is experiencing.

Bibliography
1. Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol. 1998;93:1202-8. PMID: 9707037[PubMed]

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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 links directly into the program’s Web site.

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Succeed on your IM Clerkship Rotation!

ACP continues to help students prepare for clinical rounds and the end-of-rotation examination with the fully revised and updated Internal Medicine Essentials for Clerkship Students 2 and MKSAP for Students 4! Available individually or as a set, these fully integrated new editions ensure success on the IM Clerkship rotation! Check it out.

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Articles for Medical Students from ACP Internist and ACP Hospitalist

ACP Internist (formerly ACP Observer)

ACP Hospitalist

  • Do you really want to be your own boss?
    Small hospitalist groups have independence, financial struggles.
    Hospitalists face issues as they decide whether to start up or join a local hospitalist group, become part of a large group or management company, or be a hospital employee.
  • When hospitalists marry.
    A boon for work-life balance.
    On-call hours and the unpredictability of many medical specialties can leave married physicians as ships passing in the night—or the front hallway. Yet by working as hospitalists in the same practice, some doctors are able to take care of families and spend quality time together.
  • The House of God revisited.
    Jamie S. Newman, FACP, offers a hospitalist’s hilarious perspective on a classic book.

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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