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September 2005 E-Newsletter

• Excelling in Your Internal Medicine Clerkship
• Internal Medicine Interest Group of the Month: University of Minnesota
• Letter to the Editor: Response to "The Match Revealed" in August 2005 Issue
• MKSAP Questions (1,2)
• MKSAP Answers (1,2)

Excelling in Your Internal Medicine Clerkship

The internal medicine inpatient clerkship is a unique experience—an opportunity to care directly for patients, see first-hand a variety of acute and chronic illnesses, and develop the skills that are the basis of competent physician’s practice. It’ll be one of the first times you’ll really appreciate that the second year of medical school is behind you, and your life as a physician has finally begun. But navigating through the complexities of the hospital system, interacting with a myriad of different health care personnel, using your time efficiently to learn about and manage an array of different diseases, and ultimately succeeding in your rotation can be difficult. Here are some tips from former students to help you on your journey and excel in your internal medicine clerkship.

Be a Professional

You’re now part of an expert team delivering quality health care, and patients as well as your colleagues will expect maturity and commitment. Sounds simple, but don’t underestimate the value of commonsense on the wards.

Be on time and be prepared for all activities. If you’re going to be late or absent, notify the whole team in advance.

Look presentable at all times. Wear appropriate attire, and be well groomed. Here is a side note: the “post-call look” is not a good one. If you’re on overnight call, bring a little travel bag with a toothbrush, hairbrush, razor, etc. You might not be a doctor yet, but a disheveled look will not make a good impression on your team.

Apprise your team of substantive updates concerning your patients throughout the day. Remember that establishing good communication skills with your team early in the rotation will save you from plenty of miscommunications later on. Be sure to return all pages promptly.

Take the necessary time to write legible notes (assuming your hospital uses paper charts) and dispose of confidential materials appropriately.

Ask your intern, resident, and attending for constructive feedback early in the clerkship. If you ask too late there will be no time to change. It’s your responsibility and it’s to your benefit to do so.

Self-reflect on your day, your behavior, and what you’ve learned. This will help you evaluate what you can do to be better tomorrow.

Organization is Everything

Without excellent organizational skills and attention to details during your clerkship, you will mix up patient information, forget small but important tasks, look unprofessional, and ultimately sacrifice patient care. On the wards you have to stay on top of all the little things, and for that you’ll need a system.

Utilize notecards, patient data sheets, or sign-out sheets to keep track of your patients. A sample notecard system is detailed at this University of California, San Diego, School of Medicine website, “A Practical Guide to Clinical Medicine”. When you first start your clerkship, try out different systems to find out which works best for you. Regardless of the system, make sure you write down every little “to do” task throughout the day, and check them off as you complete each.

Remember to see the big picture. Don’t forget to think about discharge planning early on, including setting follow-up appointments, obtaining phone numbers to follow the patient’s progress, ordering any vaccinations that might be necessary upon discharge, and coordinating with social workers or case managers concerning the patient’s discharge destination.

Call in requests for consults as early in the day as possible. Not only will that allow the consult to be completed sooner, but it’s more courteous to the consultants, who won’t appreciate receiving a late afternoon consult request.

The Three Es: Energy, Enthusiasm, and Eagerness

What you lack in knowledge, you can make up for with a strong work ethic. Be a productive member, and your team will recognize your contributions.

Volunteer for small tasks to help the team when possible (i.e., a little scut work). Although you are there to learn, helping out a little can go a long way toward building good rapport with your team.

Ask questions. From your readings on a given illness, ask thoughtful questions that will increase your understanding. Attendings like students who demonstrate interest in and take an active part in their education by asking insightful questions.

Develop your physical examination skills in real-life settings by asking interns or residents to demonstrate focused parts of the physical examination. For example, with a patient suffering from progressive weakness of the extremities, ask your resident to show you how to perform and document a good musculoskeletal strength exam. If there is a patient on the wards who has a II/VI systolic ejection murmur and you can’t hear it, ask your attending to help you identify that physical examination finding.

After looking up learning issues, if you discover some interesting facts, share them with the team the next day on rounds. Not only does it show you’re committed to your own learning, but it helps make you a productive member of the team by increasing everyone’s knowledge and understanding.

Be an Advocate for Your Patients

Your patients are exactly that—yours. Never forget that at the heart of the hospital system is a patient, vulnerable and acutely ill, who needs your help.

Some patients will be uncooperative; some will be obese; some will smell bad; some will be drug abusers; some will practice sex in a manner you may not condone; some will carry HIV or tuberculosis. You must strive to deliver the same level of quality of care regardless of how you feel about the patient’s background.

Know your patients. You may not know how to treat your patient yet, but you should spend enough time with your patients that you know them well. Make sure you know how these patients physically came to the hospital (walked in, ambulance, driven by family member, etc.), and their residence prior to admission (home, rehab, prison, or shelter). These two items will be important when planning for your patient’s discharge.

Don’t forget to update your patients. Let your patients know what you are doing to care for them. This will both alleviate their fears and uncertainties and form the beginnings of a good doctor-patient relationship based on trust. It’s when patients don’t know what is going on that they get upset or worried. Save sensitive negative information (such as CT results indicative of cancer) for your resident or attending to communicate to the patient, because they are more equipped to answer subsequent questions.

Be proactive. Find out when the results of a particular test or procedure will be available, or call radiology for a preliminary reading if needed. Don’t forget to utilize the nurses—they spend a lot of time with your patient, tend to a lot of details, and can answer questions concerning secretions, changes in mental status, outputs (urinary, bowel, or other), and the like. When it comes to interacting with consultant services, know not only their recommendations, but also make sure you understand the rationale for those recommendations. Be prepared to call or talk to anyone you need to in order to take better care of your patient.

Read with a Purpose

The amount of information encompassed by internal medicine is astronomical, and its mastery will not be completed in a short clerkship. So, you’re going to need a game plan in order to sift through the mountain of material, and learn and retain it effectively. Picking up a review book on internal medicine and reading it from cover to cover is likely not the best method.

Read about the medical conditions and problems directly relating to the patients you’re caring for. This way you’ll be more involved with the patients’ medical conditions and be able to retain more. Try to read for at least a solid 30 minutes nightly, and use reputable internal medicine textbooks, or online resources such as “PIER" or “Up to Date”. All that focused reading will pay dividends over time.

With that said, in a relatively short clerkship you are not going to see all the diseases and develop all the skills that are going to be tested on the shelf or clerkship examination. So, augment your learning by also reading about conditions similar to those of your patients’. For example, if you have a patient with ulcerative colitis, initially read about ulcerative colitis and Crohn’s disease, and then also read about irritable bowel or infectious colitis. Similarly, if you’re treating a patient for chronic obstructive pulmonary disorder (COPD) exacerbation, read about emphysema and chronic bronchitis initially, and then read about asthma the next day. This strategy will help with assimilating areas of information in a logical and more methodical manner than trying to memorize a review book.

Write down quick questions and little learning issues as they come up throughout the day, and make it a point to find the answers to those questions and learning issues on a daily basis. Keep in mind that answering the same question incorrectly two days in a row will not make a good impression on your team.

Carry a pocket internal medicine book to look up quick questions as the day progresses. This will come in useful while on walking rounds as well. Some suggestions include Practical Care of the Medical Patient by Ferri and Pocket Clinical Medicine, among others. Ask your team or students at your school who have finished their internal medicine clerkship what they recommend. Also, the must-have Maxwell’s Guide will prove to be a valuable commodity throughout all of your third-year rotations.

Other valuable resources include:

• “Epocrates” or “Micromedex” for your PDA. Both are free and provide up-to-date drug information. Learn to use either program and it will become indispensable to you.

• Dubin’s Rapid Interpretation of EKGs. Its easy to read, step-by-step approach will help you become comfortable and confident in reading EKGs, and it can be read in a weekend.

• Question and answer books—helpful to test your fund of knowledge and prepare for examination. MKSAP for Students 2 was designed specifically for the internal medicine clerkship and was developed with the help of many clerkship directors.

Nail Your Oral Presentations

Whether it’s a daily progress report (commonly known as a SOAP note) or a full history and physical exam (H&P), when you’re presenting about a patient the spotlight is on you, and it’s your chance to shine. For three to seven minutes you’re a storyteller, telling an engrossing tale about a patient and their acute illness. But it’ll take time before you are fully comfortable presenting and understand how much and which particular details are relevant to the presentation. Here are some tips to help start you on that path.

Present with the same format each time. Your clerkship may give you a sample guide. Also, ask your attending or resident for guidance on the format they prefer. Some specifics about the formal H&P:

• Chief Complaint: always start with a one-liner identifying the patient, relevant medical conditions, reason for the hospital visit, and duration of symptoms. This is the teaser.

• History of Present Illness: this is the meat of the presentation. Present in chronological fashion and describe each symptom in detail (quality, onset, location, duration, radiation, intensity, exacerbating/alleviating factors, and associated symptoms). Learning which symptoms are associated and relevant to the present illness will, unfortunately, take time and experience.

• Review of Systems: include pertinent positives and negatives.

• Past Medical History: include medical conditions and past surgeries and when these conditions were diagnosed and surgeries performed. Also include obstetric/ gynecological history if applicable.

• Allergies and Medications: if a patient has an allergy, find out what actually happens when the patient takes the offending agent. Make sure you look up any medications you are not familiar with. Attendings love to “pimp” you on medications (meaning they love to ask you hard questions hoping you don’t know the answer to embarrass you), so be sure you know the indications, mechanisms of action, adverse effects, etc., of the drugs your patients are taking.

• Social History: mention current and past use of tobacco, alcohol, or other substances. Include current living situation and developmental history if relevant.

• Family History: include family history that is pertinent to patient’s condition(s).

• Physical Exam: start with the vital signs, then general appearance, and then proceed from head to toe. Initially, present full physical examinations, and once you and your team are more comfortable with your level of communication, present pertinent positive and negative findings only.

• Labs and Studies: learn to present important labs and results without getting bogged down in minutia. Examples: “Liver-associated enzymes were all within normal ranges,” or “Chem 7 was remarkable only for hyperkalemia of 5.6,” rather than reading all the individual lab results.

• Assessment/Plan: recap the patient’s information, organize the important findings, and build a differential diagnosis. At this stage, nobody expects you to know exactly what’s going on with a given patient; rather, focus on verbalizing your thought process and explain what you’re thinking, and look for a unifying diagnosis when possible.

When it comes to SOAP notes, start with a one-line description of the patient and the patient’s ongoing status during admission, mention any overnight events, any new complaints or issues, physical examination data including vitals, shortened assessment, and then the ongoing plan.

Do not read straight from your H&P or SOAP note. Speak clearly and enunciate, take your time, and speak loudly enough for the whole team to hear.

Practice your presentations. Take a few minutes prior to presenting to practice your delivery. A good presentation will be detailed but succinct, logical and organized, and be presented smoothly and with confidence. The only way to achieve this is by presenting over and over again, learning from your past presentations and that of other team members, and striving to present better.

Remember, if you don’t know the answer to a question, reply honestly, “I don’t know, but I’ll find out.”

Hopefully you’ll find some of these tips helpful as you begin your clerkship. Good luck!

Deepak Pradhan
Council of Student Members Representative, North Central Region
Jefferson Medical College, 2006
E-mail: drp002@jefferson.edu

Internal Medicine Interest Group of the Month: University of Minnesota

I would like to share some of the things that have worked well for our internal medicine interest group (IMIG) at the University of Minnesota. If other IMIG leaders would like to organize similar activities at their schools, feel free to e-mail me and we'd be happy to provide further information.

One of our staple activities is the “M&Ms with Peanuts” series, in which first- and second-year students are encouraged to attend the Department of Medicine's weekly morbidity and mortality conference. After the presentation and discussion, students hang around and discuss the cases with the chief residents for about 15 minutes. No preparation is required for either the students or the chiefs, making it easy to plan and run. The cases are usually very complicated, so the key is to let the students know that it is expected that they will not understand everything. Then the students are requested to ask questions and not feel as if they are asking "dumb" questions, so that the group can learn some basics of medicine. This is a great activity for learning the vocabulary of medicine and to get to see how the material from the first two years of medical school is applied on a daily basis on the wards.

The second activity that we’ve run over the past two years is a journal club series. Our sessions are designed for students to learn some evidence-based medicine methodology while also getting to know some practicing doctors in an informal setting. To do this, we've held one or two sessions per month on Saturday mornings at a faculty member's home, with bagels, juice, and coffee provided by the IMIG. We’ve used our journal club sessions as a way to interact with faculty members from other hospitals that we might not otherwise have had a chance to work with. Rather than seeking out noted researchers to lead these sessions, we’ve instead focused on finding good teachers who are enthusiastic about working with students. The relaxed environment allows our discussions to go beyond the scientific aspects of the articles, to some of the important but rarely addressed topics in medicine, such as how practicing physicians implement research findings, how they discuss difficult topics with patients, why they chose their field, and how to balance family and career.

The other major type of activity we’ve run is a lunchtime lecture series on internal medicine topics. Two workshops that have been popular are a panel on subspecialty careers and "The Match Demystified." We try to hold the subspecialty panel workshop in the fall and use it as a chance to educate students about the variety of careers available through internal medicine training. For "The Match Demystified," we ask senior medical students who have just matched to internal medicine residency programs to explain the basics of the Match, what it was like applying and interviewing, what they thought was important to consider about various programs, and how best to arrange clerkships. We also plan to hold a workshop on "Rotations Demystified" for second-year students, to help relieve the anxiety about scheduling and beginning rotations.

Andrew Calvin, MPH
Past President, Internal Medicine Interest Group
University of Minnesota Medical School, Minneapolis, 2007
Student Representative, Minnesota ACP Chapter Executive Council
E-mail: acalvin@med.umn.edu

Letter to the Editor: Response to "The Match Revealed" in August 2005 Issue

To the Editor:

The Match Algorithm has a tremendous impact on our professional careers when it assigns young physicians to their residency programs. Making the Match favor students has long been a goal of the American Medical Student Association (AMSA). Prior to 1996, the Match algorithm favored residency programs. AMSA pushed for change so that the algorithm now favors students. Student-friendly changes to the Match only happen when medical students demand them, and AMSA has always been in the forefront of these movements.

After successfully leading the movement to improve the Match algorithm in the 1990s, AMSA again improved the system for students and residents when we worked to have contract disclosure prior to the ranking. It used to be that students did not know the details of the contract for their internship year until after they had already accepted the hospital's offer of a position, at which time it was too late to change their minds if they were not satisfied with the contract. AMSA changed that so now students are able to see the contracts that they will sign before they submit their rank lists.

AMSA has also been instrumental in increasing the number of student voices on the National Residency Matching Program (NRMP) board. This ensures that the Match continues to work for students, rather than seeing students as resources to be distributed to the participating residency programs. Medical students have the most at stake in the medical education process, and we must be active participants in the system to shape it to further our goals.

Sincerely,

Leana S. Wen, National President, AMSA
E-mail: pres@www.amsa.org

Chris McCoy, Legislative Affairs Director, AMSA
E-mail: lad@www.amsa.org

Krishna Rao, Universal Health Care Coordinator, AMSA
E-mail: krishna_rao@rush.edu

MKSAP Question 1

A 35-year-old man is evaluated because of shortness of breath and fatigue with exercise. He has been well most of his life but has never been able to participate in sports due to lack of energy.

On physical examination, his vital signs are normal except for a pulse rate of 100/min. Head and neck examination is normal. Lungs are clear to percussion and auscultation. Cardiac examination reveals a widely fixed, split-second sound in the pulmonic area, with the second component louder. A soft grade 2/6 systolic murmur is heard over the left sternal border.

A pulmonary arteriogram reveals a pulmonary artery pressure of 60/30 mm Hg with a mean of 42 mm Hg and a normal wedge pressure.

Which of the following is the most likely diagnosis?

( A ) Primary pulmonary hypertension
( B ) Mitral valve stenosis
( C ) Multiple pulmonary emboli
( D ) Atrial septal defect

MKSAP Question 2

A 28-year-old woman with a history of HIV is evaluated because of a 2-day history of fever, coughing, shortness of breath, and right-sided pleuritic chest pain. The cough produces yellowish-green phlegm. HIV infection was diagnosed 5 years ago when she was hospitalized with Pneumocystis carinii pneumonia. She has not had any other complications. The most recent CD4 cell count, obtained 1 month ago, was 190/µL. She is taking effective anti-retroviral therapy.

The temperature is 38.5 °C (101.3 °F). The pulse rate is 125/min, respiratory rate is 25/min, and blood pressure is 110/70 mm Hg. Examination of the chest shows dullness to percussion and decreased breath sounds at the right base with bronchial breath sounds and egophony just above the region of dullness. A chest radiograph shows consolidation of the right lower lobe and a large, right pleural effusion.

What is the next step in the care of this patient?

( A ) Empiric antimicrobial therapy
( B ) Diagnostic thoracentesis
( C ) Chemotherapy for tuberculosis
( D ) Bronchoscopy
( E ) Induce sputum for Pneumocystis carnii

Answer - Question 1

Answer: D

Educational Objective: Evaluate the cause of hypoxemia and pulmonary hypertension.

The patient has had a problem all his life, and a systolic murmur on examination suggests a congenital cause. Of the choices, the one that best fits the results of the tests is an atrial septal defect. The shunt is left-to-right for the bulk of the patient's life; however, when the increased flow in the pulmonary circuit leads to pulmonary hypertension, the shunt reverses and becomes a right-to-left shunt.

Primary pulmonary hypertension is more common in women than in men. It may show enlarged central pulmonary arteries on chest radiograph, but the peripheral vasculature is "pruned" and not increased. Arteriography should show an abrupt decrease in the vessel size, and the right-to-left shunting should not be present unless an incidental, atrial septal defect is opened by the pulmonary hypertension.

Multiple pulmonary emboli would be diagnosed by the limited arteriogram. Because this is not positive, there is no evidence for multiple pulmonary emboli. Mitral stenosis would produce a diastolic not systolic murmur, ruling out this diagnosis.

References

1. Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol. 2001;38:613-23.
2. Palevsky HI, Schloo BL, Pietra GG, Weber KT, Janicki JS, Rubin E. Primary pulmonary hypertension. Vascular structure, morphometry, and responsiveness to vasodilator agents. Circulation. 1989;80:1207-21.

Answer - Question 2

Answer: B

Educational Objective: Recognize and manage the distinguishing features of bacterial pneumonia and pleural effusion in a patient with HIV infection.

Patients with HIV infection have a wide variety of respiratory complications. Bacterial pneumonia has now replaced Pneumocystis carinii pneumonia (PCP) as the leading cause of death due to infection among persons with HIV infection. Investigators from the Pulmonary Complications of HIV Infection Study Group have reported that persons with HIV infection contract pneumonia at the rate of 5.5 episodes per 100 person-years. The incidence of pneumonia is only 0.9 per 100 person-years among persons without HIV infection. The more advanced the stage of infection, as documented with CD4 lymphocyte count, the greater is the risk of bacterial pneumonia. The most common pathogens isolated were Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae.

HIV infection confers increased risk of complications of pneumonia, including a higher rate of bacteremia, a twofold higher frequency of parapneumonic effusions, and more frequent need for tube thoracostomy drainage than among persons without HIV infection. The patient in this case has a syndrome of abrupt-onset pneumonia strongly suggestive of bacterial infection with radiographic studies that suggest the presence of lobar consolidation and pleural effusion. Regardless of HIV status, a parapneumonic effusion of this size in the acute presentation of pneumonia warrants thoracentesis. Empiric antibiotic therapy without thoracentesis can allow a complicated effusion to progress. Tube thoracostomy drainage is indicated if thoracentesis shows gross pus or features of a complicated effusion, including pH less than 7.0, glucose level less than 40 mg/dL, or positive result of fluid Gram stain or culture.

Pulmonary tuberculosis is always an important diagnostic consideration in the care of patients with HIV infection and respiratory disease. However, this patient has a clinical syndrome highly suggestive of acute bacterial pneumonia rather than the subacute presentation of pulmonary tuberculosis. If other historical or clinical features were to make the possibility of pulmonary tuberculosis more likely, four-drug chemotherapy for tuberculosis might be instituted early. However, it is not needed before diagnostic sputum and pleural studies are obtained and other diagnostic possibilities are evaluated.

PCP is still a prevalent and potentially lethal complication of HIV infection. This patient has a history of PCP, which puts her at greater-than-average risk of PCP. However, trimethoprim-sulfamethoxazole is extremely effective in the secondary prevention of PCP, and the acute, focal pneumonitis with a pleural effusion is atypical of PCP. Bronchoscopy or induced sputum for this unlikely possibility would not be the best initial management.

References

1. Gil Suay V, Cordero PJ, Martinez E, Soler JJ, Perpina M, Greses JV, et al. Parapneumonic effusions secondary to community-acquired bacterial pneumonia in human immunodeficiency virus-infected patients. Eur Respir J. 1995;8:1934-9.
2. Hirschtick RE, Glassroth J, Jordan MC, Wicosky TC, Wallace JM, Kvale PA, et al. Bacterial pneumonia in persons infected with the human immunodeficiency virus. Pulmonary Complications of HIV Infection Study Group. N Engl J Med. 1995;333:845-51.

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