September 2007 E-Newsletter

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

.

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 September’s contest question will be included in the October 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 35-year-old woman had been vacationing in Cancun, Mexico, for the past week. This morning, she noted the sudden onset of crampy, watery diarrhea but has not passed any blood or mucus with her stools. She has no fever, and her only other symptoms are mild nausea and anorexia of 1 day's duration. She has a history of occasional migraine headaches, has no known allergies, and takes no prescription medications.

Which of the following organisms is most likely to be causing this patient's diarrhea?

( A ) Enterotoxigenic Escherichia coli (ETEC)
( B ) Clostridium difficile
( C ) Entamoeba histolytica
( D ) Strongyloides stercoralis
( E ) Salmonella enteritidis

Top

Answer for August Contest Question

.

Click here to see August’s question.

Answer to August Contest Question: (B) Hydoxyurea therapy

Hydroxyurea therapy reduces the incidence of sickle-cell–related events through its capacity to re-activate expression of the developmentally silenced fetal gamma globin. The potential toxicities of hydroxyurea are well described. The patient's levels can be easily monitored through periodic complete blood counts. The patient's current transfusion-related decrease in hemoglobin S should not affect the decision to initiate therapy, because the benefits of hydroxyurea are generally delayed.

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

Top

Medical Student Perspectives: A Canadian Medical Student’s Perspective on Health Care

.

As the Canadian Representative to the Council of Student Members, I wanted to share our perspective about health care. Let me start off with a definition of health care that we can use for our discussion: health care is the prevention, treatment, and management of illness and the preservation of mental and physical well being through the services offered by the medical and allied health professions (reference). As medical students, we are immersed in the health care environment, constantly learning and serving within it, sometimes even oblivious to what is going on around us. This perspective has allowed me to widen the scope of my vision and has led me to look critically at Canada’s health care system. I want to discuss what a health care system needs, how best to deliver care, and Canada’s current health care system.

Health care needs a delivery system that will reach all of its patients; rich or poor, urban or rural, and of every ethnic origin. Discrimination of access based on any of these aspects is a violation of the very definition of health care. What every citizen of the world needs is a system that provides equality of access and ensures prompt delivery of care. Canada has a system such as this: any Canadian or permanent resident can walk into any clinic in any of Canada’s 9.8 million km2 and receive ‘free’ health care. The system is public with each province providing residents with ‘health cards’ allowing every Canadian to have preventative, diagnostic and treatment services. The system is publicly funded by provincial and federal taxes. Doctors are private entrepreneurs and are generally paid on a fee-for-service basis, with a minority practicing as salaried physicians. While this is what most Canadians will tell you about our health care system, allow me to tell you what I saw as a student doing clinical rotations this past year in my home province. I worked in tertiary care centres, community hospitals, and in rural hospitals. I saw all members of the health care team work together for the best of the individual patient. We were encouraged daily to practice evidence based medicine, being challenged on the spot about new medical literature. Patients in our emergency department had timely access to non-invasive procedures, such as CT scans or MRIs, or invasive procedures, such as angioplasties. I saw a patient with metastatic carcinoma diagnosed in the emergency department go for radiation treatment within 24 hours. Patients were always discharged with the proper input from home care, occupational therapy and physiotherapy services.

Canadian patients can see any primary care physician they choose and request to see specialists at will. Physicians are always empowered to have the entire spectrum of treatment options offered to their patients, so that both patients and physicians can make informed decisions as to what fits their beliefs and objectives. Furthermore, the exaggerated wait-times often cited as an argument against our public health care system are taken out of context. Patients who need lifesaving treatments get those in a timely fashion, while those whose interventions are not as time-sensitive have a lower priority. Contrast this to a health care system based on profit, where individual freedoms of a patient and the medical practitioner are limited, in terms of services, which hospitals an insurance provider will cover and which physicians a provider will allow a patient to see.

It is true that in private health care systems wait times are shorter for non-life saving treatments for some patients, however they are an eternity for the millions of individuals without access to health care. Furthermore, the ability to deny patients access to lifesaving treatments because of their inability to pay or the unwillingness of their insurance company to pay is unethical and a crime against the common good of society. I believe every honest practicing physician, resident, and medical student should reject and work to change such a non-sensical framework. As a Canadian medical student, I realize that my perspective on health care may be somewhat different from my American counterparts, but I believe as a future physician, the majority of us have the same core values and principles that have led us to, and keep us in, this wonderous field of medicine. Like most of my Canadian peers, I am looking forward to becoming a fully established medical practitioner within a system where I can have a rewarding professional life.

Umjeet Jolly
Council of Student Members, Canadian Liaison
University of Manitoba Faculty of Medicine, 2008

Note: The views and opinions contained in this article are those of Umjeet Jolly and do not represent an official position of the American College of Physicians (ACP). For more information about ACP's policies about access to care, visit www.acponline.org.

Top

My Kind of Medicine: Real Lives of Practicing Internists: Bill Johnson, M.D.

.

Fifteen years ago, Dr. Bill Johnson set a goal: 100,000 miles by 2012. He chose the year 2012 because it would be the 20th anniversary of when he began cycling. As of August, he has finished 75,000 miles. He has another goal: to keep his patients out of the hospital.

In 22 years of practice, he has done a pretty good job of accomplishing it. According to insurance records, Dr. Johnson’s hospitalization rate is one tenth that of the average internist. Out of a patient base of roughly 3,000, not one of them is currently in the hospital. A figure like that is something many physicians strive for; Dr. Johnson has made it a reality.

A Calling

It was during his last semester of high school that Dr. Johnson, a Lubbock, Texas native, was having difficulty deciding on a career. At first, he considered missionary work and ministry, but after a discussion with a friend of his father’s, he considered another choice. “He was frustrated by my decision because he felt I was strong in my studies and that I should put them to good use. I remember he said, ‘Well if you are going to do missionary work, at least be a medical missionary!’” Dr. Johnson took his mentor’s advice. After graduating college in just three years, he was off to medical school at Texas Tech University.

In medical school he quickly identified with the ideology and approach to internal medicine. “I admired the way the professors taught and the thought processes that went into it,” he says. “I chose internal medicine primarily because of their influence and I knew I would want to have ongoing relationships with my patients.” He took his learning experience very seriously. “I learned how to do a proper physical exam from the head of cardiology,” recalls Dr. Johnson. “He was the first person to get through my thick head the importance of evidence-based medicine and data. Now of course, it is a practice that is prominent and widely taught, but back then we were still warming to the idea.”

At the urging of others, Dr. Johnson found his calling. Once he did, he ran with it, soon becoming a wizard at diagnosing. In the 1980s, he explains, the skill was valued even more than it is today. “Managed care has changed the environment a bit, but internists are still the most skilled at diagnosing a common disease or a condition that is presenting uncommon symptoms.”

A few years ago, Dr. Johnson had a patient case that put these exact skills to the test. A young woman who was pregnant was referred to Dr. Johnson by an Obstetrician/Gynecologist for a swollen leg. The gynecologist had suspected deep vein thrombosis. Dr. Johnson performed an ultrasound and found no clots, but did eventually figure out that the patient had developed factor VIII deficiency which was causing a compartment syndrome. If Dr. Johnson had not recognized the condition immediately, the patient would have likely lost the leg. “That referring gynecologist sent me patients for the next five years!” he says. “That is a testament to how internists are valued in our system.”

A Pure Progressive

Dr. Johnson was a busy man in medical school and during residency training. While studying to become an internist, he met and married his wife, Rhonda, and had two children. Shortly after he finished, he opted to work in a private practice outpatient facility. It fit his professional needs, allowed him the opportunity to work with colleagues he admired, and gave him the time he needed to spend with a growing family. “It was 1985 and my wife and I were in the bathroom as I remember,” he says. “We made the decision right there that I would take a job which would allow me to be with my family; to know my children. That meant working as an internist.”

Dr. Johnson has been practicing in a private practice setting for his entire career. His practice is named “Prevention First,” and the name is not rhetoric; Dr. Johnson has always touted preventive care, long before it became a catch phrase. “My goal has always been to keep patients out of the hospital, that’s my job,” he explains. “There’s an art to it. You have to be able to know when they’re on the edge of running into trouble. As doctors, we’re scientists, but what I do I see more as an art. As much as 70 per cent can be taught, but the rest has to be inherent.” As a devoted religious man, Dr. Johnson has a naturally positive attitude that lends itself well to the business of healing. But the seasoned doctor is also aware of his own limitations, as he was following an unforeseen and sad event involving a longtime patient.

The patient, a woman in her late 50s, had been involved in a car accident, in which she had broken her tibia and was sent to a local hospital. Because it was not the hospital that Dr. Johnson was affiliated with, he did not treat her. Nonetheless, everything appeared fine and afterwards she returned to Dr. Johnson wearing a cast. Four months passed, and her husband died. On the day of the funeral, she contacted Dr. Johnson and told him she was not feeling well, which was to be expected under the circumstances. She came to the office and he measured her blood pressure. It was low, which was odd since she had never been hypotensive. An exam produced normal results and she was not out of breath. The only thing worth noting was the fact that she was on warfarin. The next morning, when she returned to his office, he decided to admit her. While at the office, she threw a massive clot (despite having been on warfarin) and Dr. Johnson rushed her to the emergency room. She died that day. “That has been my biggest disappointment,” he says. “She was one of my favorite patients. I did everything by the book, but it was still too late. If only I had been a little bit better; a little bit faster.”

The Goal Keeper

In 2001, after their adult children had moved out of the area, Dr. Johnson and his wife knew it was unlikely the kids would return to the Lubbock area to work. The decision they had made back in 1985 in their bathroom suddenly resurfaced. They wanted to be a family again. They decided to relocate to the Dallas-Fort Worth area to be closer to their son William and their daughter Meredith, and that Meredith would work as the new office manager once they relocated. The move would mean a major upheaval for Dr. Johnson—after spending decades building a career as a trusted internist, a department chairman overseeing a staff of hundreds, and an internal medicine section chief, he would have to start completely over. The idea would terrify many, but for Dr. Johnson, it was not terrifying at all, but rather something that was already familiar to him: a goal. “It was challenging, starting over,” he admits. “Opening an office—it’s a skill set I had not used in a long time, but ultimately it was very rewarding. My practice is very successful now and we’re planning on opening a second office soon.” In 2001 when the decision to relocate was made, Dr. Johnson had yet to reach his 75,000-mile mark. But he was well on his way, and he had also by this time maintained his enviable hospitalization record for many years. And so he just took to his new goal the only way he knew how: with hard work, seasoned skills, and a little bit of faith.

Top

Internal Medicine Interest Group of the Month: University of Colorado

.

During the spring semester, second-year medical students are notorious for disappearing—and here in Colorado we are no different. So as the USMLE Step 1 (“the Boards”) approached, the class of 2009 leaders of the internal medicine interest group (IMIG) at the University of Colorado School of Medicine decided to pass on their venerable organization to a younger, less-distracted group: the class of 2010. Three of us decided to become co-presidents and run the show. Little did we know what was in store!

While brainstorming activities at monthly planning meetings, we decided to make our three main priorities providing shadowing opportunities, organizing regular lectures, and putting together “field trips” to clinical facilities. As our courses on the cardiovascular, pulmonary, and renal systems commenced, we could not have asked for better timing. Co-President Owen Bowers convinced the directors of the University Hospital Cardiac Catheterization Lab to allow 15 medical students to swarm around his facilities. Co-President Douglas Melzer talked an experienced cardiologist – who had a solo practice in rural Minnesota, then worked at an HMO in a big city, and now teaches at a university hospital – into sharing his experiences as a “workaday” cardiologist. With each medical school course we have had since then, our IMIG has been fortunate to find a great group of physicians to share their experiences and stories with us. Visits to the pulmonary function testing facilities at the specialty hospital down the road and trips to the dialysis unit are examples of other trips we have organized.

Twice a year we organize shadowing opportunities for the first- and second-year medical students. Forty or more students requested physicians to shadow, ranging from hospitalists and general internists to subspecialists at the regional referral centers. Once the students have requested a particular type of physician, we e-mail faculty members in those divisions, always being sure to copy our faculty advisor to add a little credibility to our e-mail requests. Even when we have a large number of requests for a particular subspecialty or type of clinic, it never seems to be a problem finding enough physicians to send our students off to.

Looking toward the coming year, we have set a few goals for ourselves. First, we want to continue to organize lectures and field trips related to what we are learning about in our courses. A panel on careers in internal medicine is coming up, and during National Primary Care Week in October, several general internists will speak about their career choice. Visits to endoscopy, thyroid, and diabetes clinics are on the horizon, as is another round of shadowing opportunities. In January we will put together a “career fair,” with representatives from different divisions within the department of medicine as well as representatives from residency programs. After that is finished, it will be time to pass the IMIG along to the class of 2011—the Boards will be approaching, and for some reason I think we might all be going M.I.A. for a bit.

Max Cohen
Co-President, University of Colorado Internal Medicine Interest Group
University of Colorado, 2010
E-mail: max.cohen@uchsc.edu

Top

Winning Abstracts from the 2007 Medical Student Abstract Competition: Cloning and Transfection of Heat Shock Protein 90 (Hsp90) Isoforms Alpha and Beta.

.

Author:
Mark Gilbert, Universidad de Anahuac Escuela de Medicina, 2007

Introduction:
Heat Shock Proteins (Hsp) have a key role in cytoprotection during inflammatory processes, oxidative stress and ischemia. Hsp90 has been recognized as a critical part of the nitric oxide (NO) synthesis cascade, which is very important in the maintenance of organ perfusion and function during renal injuries. These observations suggest that inhibition of Hsp90 would be detrimental to kidney function, while overexpression of this protein might be beneficial in a pathological process. There are two isoforms of Hsp90 that differ in their basal and stress-induced expression.

Methods:
Primers were designed to amplify Hsp90a and Hsp90b by PCR. Both isoforms were then cloned into an expression vector (pcDNA 3.1) fused with Green Fluorescent Protein (GFP) and lastly supercompetent XL-Blue E. Coli bacteria were transformed with this DNA. The reading frame and orientation were corroborated by gene sequencing. After confirming successful cloning liposomes were used as DNA carriers to transfect Human Embryonic Kidney (HEK) cell cultures in vitro. Finally, transfection and overexpression were confirmed by Western Blot and epifluorescence microscopy.

Results:
The fragments corresponding to Hsp90a and Hsp90b were isolated and had a size of ~2318 bp and ~2220 bp respectively, as expected. The reading frame and orientation were correct, with a 99% identity to the reported sequence in the gene bank. Western Blotting showed protein expression of the transfected DNA, and epifluorescence microscopy demonstrated positive fluorescence of cells transfected with GFP.

Conclusion:
So far it has been proven that the cloned and transfected Hsp90 gene is transcriptionally and translationally active. This will ultimately allow us to proceed with in vivo transfection of rat kidneys. We suggest that overexpression of Hsp90 will have a protective effect in a renal ischemia-reperfusion process. With the distinction of both Hsp90 isoforms it will also be possible to determine if they have different roles in renal pathophysiology.

Top

Subspecialty Careers: Highlights about Careers in Internal Medicine: Pulmonary Disease

.

The Discipline

From the word pulmo, Latin for "lung."

Pulmonary medicine is the diagnosis and management of disorders of the lungs, upper airways, thoracic cavity, and chest wall. The pulmonary specialist has expertise in neoplastic, inflammatory, and infectious disorders of the lung parenchyma, pleura and airways; pulmonary vascular disease and its effect on the cardiovascular system; and detection and prevention of occupational and environmental causes of lung disease. Other specialized areas include respiratory failure and sleep-disordered breathing.

Procedures

Important procedural skills include arterial blood gas sampling and interpretation, flexible bronchoscopy and related bronchoscopic procedures, endotracheal intubation, spirometry and peak flow assessment, pulmonary artery catheterization and interpretation, thoracentesis, pleural biopsy, placement and management of chest tubes, ventilator management, progressive exercise testing, and complete pulmonary function testing.

Training

Pulmonary Disease fellowship training can be obtained either through a combined Pulmonary and Critical Care fellowship (the most common path) or through a Pulmonary fellowship alone. Combined programs require three years of accredited training beyond internal medicine residency. The three years must include a minimum of 18 months of clinical training (at least nine months of Pulmonary training and nine months of Critical Care training). Pulmonary Disease fellowship training without Critical Care requires two years of accredited training beyond 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 pulmonary diseases.

Certification

The American Board of Internal Medicine offers separate certificates in Pulmonary Disease and in Critical Care.

Training Positions

As of July 2007, there were 130 ACGME-accredited combined training programs with 1,237 active positions in Pulmonary Disease and Critical Care Medicine, and there were 25 ACGME-accredited training programs with 83 active positions in Pulmonary Disease alone. For combined training programs in Pulmonary Disease and Critical Care Medicine, 27% of the trainees were female, and 56% were US medical graduates. For training programs in Pulmonary Disease alone, 22% of the trainees were female, and 19% were US medical graduates.

Practice

Approximately 48% of the graduates of combined programs enter clinical practice in the United States, and 36% enter academic medicine.

Major Professional Societies

American College of Chest Physicians
3300 Dundee Road
Northbrook IL 60062-2348
(847) 498-1400
http://www.chestnet.org

American Thoracic Society
61 Broadway
New York, NY 10006-2755
(212) 315-8600
http://www.thoracic.org

Major Publications

American Journal of Respiratory and Critical Care Medicine
Chest: The Cardiopulmonary and Critical Care Journal

Top

Advocacy Briefs: ACP Urges Stafford Loan Limit Increase

.

ACP joined a group of almost 60 health professions associations to urge U.S. Secretary of Education Margaret Spellings to increase the aggregate combined Stafford loan limit for health professions students from $189,125 to $223,793.

Students in programs leading to a degree in allopathic medicine, osteopathic medicine, dentistry, veterinary medicine, optometry, podiatric medicine, and naturopathic medicine are eligible for additional annual unsubsidized Stafford loans beyond that of a graduate/professional student. However, many students require more than this aggregate limit and are forced to seek less favorable options.

The letter points out that "the aggregate combined Stafford loan limit for health professions students has remained stagnant for over a decade, does not account for recent increases in annual unsubsidized Stafford loan limits or reflect programs of different duration, and is not defined in regulation."

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 thousands of College members at ACP’s annual scientific meetings.

To find out more about the competition and win a chance to present at Internal Medicine 2008 in Washington, D.C., please check out www.acponline.org/abstracts. All of the details and instructions for submitting an abstract are located on this site.

Top

MKSAP for Students 3 Question 1

.

A 35-year-old woman is begun on anticoagulation therapy for pulmonary emboli. She had been using oral contraceptives for the past 10 years, but stopped when the pulmonary emboli were detected. There is no family history of thrombosis.

What is the best recommendation for this patient regarding anticoagulation?

( A ) Warfarin, indefinitely
( B ) Warfarin and aspirin, indefinitely
( C ) Warfarin for 6 months, with resumption of oral contraceptives
( D ) Warfarin for 6 months, with avoidance of oral contraceptives

MKSAP for Students 3 Question 2

.

A 22-year-old woman is evaluated in the office because of lower abdominal pain. She has had symptoms since childhood, with a tendency toward diarrhea during times of stress. When symptomatic, the pain can keep her up at night and is often progressive during the day. She has abdominal distention and gas after eating. Symptoms may be worse during her menstrual period, which she describes as regular, but painful, and she is often confined to bed on the first day of menstruation. She denies fever, rectal bleeding, or weight loss, and she has no other symptoms.

She has seen several physicians over the years for these symptoms, and has had an upper gastrointestinal barium study and two barium enemas; all test results were normal. Her only medication is ibuprofen for dysmenorrhea.

Physical examination shows diffuse lower abdominal tenderness, but no palpable mass. The pelvic examination is unremarkable, and the rectal examination is painful for the patient, but otherwise normal; stool is negative for blood.

Which of the following is the most important diagnostic procedure for this patient?

( A ) Abdominal/pelvic computed tomography scan
( B ) Colonoscopy
( C ) Laparoscopy
( D ) Pelvic ultrasonography
( E ) More detailed social history

MKSAP for Students 3 Answer 1

.

Answer: D

Educational Objective: Treat a first episode of pulmonary embolism provoked by a transient risk factor.

All patients with documented thromboembolism require anticoagulation. The duration of anticoagulation therapy for a first episode of “provoked” thromboembolism is 3 to 6 months. An episode of pulmonary embolism that is associated with a transient risk factor (such as oral contraceptive use) carries a substantially lower annual risk of recurrence than one that is “unprovoked.” This patient should never resume taking oral contraceptives and must be made aware of the symptoms of recurrent thromboembolism.

The recurrence prevention benefits of anticoagulation at an international normalized ratio of 2 to 3 for more than 3 to 6 months have not been demonstrated to outweigh the bleeding risk associated with extended treatment. Aspirin, or a combination of aspirin and warfarin, has not been shown to decrease the risk of recurrent venous thromboembolism, but does increase the risk of bleeding.

References
McRae SJ, Ginsberg JS. Initial treatment of venous thromboembolism. Circulation. 2004;110:I3-9.

MKSAP for Students 3 Answer 2

.

Answer: E

Educational Objective: Diagnose irritable bowel syndrome.

This patient has classic irritable bowel syndrome. The absence of weight loss, in combination with bleeding, inflammatory symptoms, and negative findings on prior examinations, excludes other important diseases, such as cancer, collagen vascular disease, and inflammatory bowel disease. The association of irritable bowel syndrome with menstrual cycle complaints is common. Additional invasive or costly diagnostic studies are unnecessary until a more careful social history, exploring the patient's psychological triggers for the symptoms, is completed.

Criteria are available (Rome II) to assist in making this clinical diagnosis. Irritable bowel syndrome is one of the most common disorders for which patients consult general internal medicine physicians. The pathophysiology is not completely understood, but the three factors most often implicated are altered gastrointestinal motility, visceral hypersensitivity (heightened sensory awareness), and psychological factors.

References
Camilleri M. Management of the irritable bowel syndrome. Gastroenterology. 2001;120:652-68.
Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut. 1999;45:II43-7.

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

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

.

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

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

Order online:
https://www.acponline.org/atpro/timssnet
/products/tnt_products.cfm?action=long&primary_id=330361030

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

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