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New for 2015! ACP members in low income/low middle income countries and upper middle income countries, as defined by the World Bank Economic Indicators, will be offered special discount registration rates for ACP Internal Medicine 2015 in Boston. These discounts will apply to individual registrations as well as group delegations. Watch your e-mail for announcements regarding the individual registration rates. The discounted group delegation rates will be as follows:
ACP Internal Medicine 2015 International Delegation Rates
*Members in high income countries pay ACP dues of $220.
**Members in upper-middle income countries pay ACP dues of $160.
***Members in low and low-middle income countries pay ACP dues of $110
If you have questions, please contact firstname.lastname@example.org.
ACP will be holding its first national conference in India September 5-6, 2014, at the Le Meridien Hotel, New Delhi. The national conference will focus on "The Burden of Non-communicable Diseases," and will feature update sessions on hypertension, diabetes, gastroenterology & hepatology, hematology & oncology, infectious diseases, and cardiology. These updates will be presented in a panel format comprised of 1 U.S. and 1 Indian speaker per session. A pre-session focusing on Gerontology issues will be held on September 4 in collaboration with Fortis Hospital, Gurgaon.
ACP's International Fellowship Exchange Program (IFEP) provides opportunities for early to mid-career physicians from outside the United States and Canada to gain expertise in a focused area relating to the prevention, diagnosis, and/or management of a clinical problem in internal medicine and the subspecialties. Through observation, mentorship, and study of the work of senior faculty physicians, fellows will be funded to acquire knowledge, experience, and skills that they can apply, utilize, and disseminate to colleagues upon return to their home country. Faculty mentors will engage fellows in individual and group clinical and educational experiences and discussions, and facilitate the design of an independent project to be implemented in each fellow's own country upon his or her return. Fellowships are observational and expected to last four weeks. Candidates must be internists or subspecialists of internal medicine and must be ACP Members or Fellows. Residents in training will be considered if they reside in an ACP Chapter.
Three scholarships will be awarded for the 2014-2015 program year. The deadline for submitting an application is August 1, 2014. Information about the program may be found on ACP's website at www.acponline.org/IFEP. If you have any questions please contact Emily Seeling, Program Coordinator, International Programs at email@example.com.
Taiwan is an island state in East Asia governed by the Republic of China. Neighboring states include the People's Republic of China to the west, Japan to the east and northeast, and the Philippines to the south. The population of Taiwan numbers more than 23 million. The city of Taipei is the seat of the central government and New Taipei, encompassing the metropolitan area surrounding Taipei proper, is the most populous city with almost four million inhabitants.
During the latter half of the 20th century, Taiwan experienced rapid economic growth and industrialization. It now ranks as the 19th-largest economy in the world, with its high-tech industry playing a key role in the global economy.
Dr. Yang, what made you pursue medicine? Why did you want to become a doctor?
My father is a primary care physician. When I observed him treating patients, I felt it was wonderful to help patients, and so it was natural for me to choose medical school in college.
In what area of medicine do you spend most of your time? What do you enjoy most about the work that you do?
After completion of general internal medicine and gastroenterology subspecialty training, I decided to stay at the National Taiwan University Hospital, one of the most prestigious medical centers in Taiwan, and become an attending physician. My major goal was to conduct medical research, however, I found that practicing medicine greatly helped me in my research; therefore, I also enjoyed clinical practice a lot.
Furthermore, I have been teaching in medical school for many years as a Professor in Medicine and have devoted myself to nurturing the future generation of young doctors. Clinical service, education, and research have been the 3 pillars of my career. In the past 30 plus years, the distribution varied at different stages of my career, but I loved them all.
What is the role of the internist in Taiwan? What are the education and training requirements needed to practice internal medicine?
Most internists (approximately 80%) are specialists and the remaining 20% are primary care physicians. The required training and exams for an internist in Taiwan are the following:
What illnesses and problems do internists in your country treat most often? Are there any trends in chronic illness or disease that you are particularly concerned about?
Since most internists are specialists, the problems they encounter vary significantly by sub-specialty. Overall, however, there are rising rates of metabolic syndromes and cancers for the entire country.
Do internists work most often in private offices or in hospital settings? To what extent do physicians and hospitals use electronic health records?
Most internists (approximately 70%) work in a hospital setting and most physicians and hospitals use electronic health records to a certain degree.
Does everyone in Taiwan have access to health care? Who pays for health care services-patients, employers, or the government?
Nearly 99% of Taiwan's entire population is covered by the National Health Insurance (NHI). The NHI monthly premium is shared among patients, employers and the government. Individual contribution ratios can vary from 0 to 30% depending on a person's income or employment.
Are enough young physicians choosing to be internists? What makes them choose (or not choose) to practice internal medicine?
Recently, not enough young physicians are choosing to be internists. For the past 2-3 years, only 70% of resident training vacancies were filled. The major obstacles are that most internists have heavy duty calls during residency training. As attending physicians in hospitals, they are taking care of patients during the day and then many are on call overnight. The long hours contribute to a poor quality of life for young physicians.
Is access to the internet or social media influencing the patient-physician relationship?
It is a somewhat complicated issue. Nowadays, patients and their families may get fragmented medical information through the internet or social media. Compared to older generations, they are more likely to ask questions of physicians and challenge their medical management. However, most people still highly respect physicians and doctor-patient relationships are generally quite good. At the same time, interpersonal communication has been highly emphasized in recent medical education in Taiwan.
What are some of the most significant challenges that physicians in your country face? What are your thoughts on the best way to meet those challenges?
Decreasing payments and high work stress are commonly faced by all physicians in Taiwan. Because of the NHI system, most physicians do not have bargaining powers with the payer (government).
We will need opinion leaders as well the congress to understand the challenges we face to make policy changes. For example, recently there were some payment increases for internists, surgeons, pediatricians, OB/GYNs, and physicians from emergency medicine as incentives to encourage more young physicians to choose or stay in those specialties.
What can other countries learn from your health system?
Taiwan has one of the most affordable universal health care plans with unrestricted access to care for most patients. The healthcare expenditure is only 6-7% of the entire GDP. We are good at controlling the budget while providing relatively high quality care.
As President of the Taiwan Society of Internal Medicine (TSIM), what are your goals? What do you find most challenging? Most rewarding?
The major objectives of TSIM include creating a reasonable working environment for all internists in Taiwan and serving as a platform for acquiring new knowledge in the field of internal medicine. Since internal medicine is the cornerstone of modern medicine, we also aim to promote the service quality of our discipline as a strategy to enhance the health of the entire population in Taiwan.
Another goal of TSIM is to foster well-trained young internists and increase their competency. One of the major challenges we face is the relatively low reimbursements by NHI to general internal medicine. Through a collective effort, we are fighting for more reasonable payments from NHI, as an incentive to recruit young doctors to specialize in internal medicine. As the president of TSIM, it will be most rewarding to watch batches of young physicians complete their residency programs in internal medicine and become practicing physicians.
Why is it important for physicians in Taiwan to belong to professional organizations like the Taiwan Society of Internal Medicine (TSIM) and ACP?
To ensure high quality of care, we believe that all physicians trained in internal medicine in Taiwan should be evaluated and certified by an independent body, i.e., the TSIM. TSIM serves as the accreditation organization of all internal medicine training programs and provides many continuous medical education courses and annual scientific meetings to update current knowledge in internal medicine and prepare internists for recertification. All trainees and board certified internists are mandated to join TSIM so they can benefit from the resources we provide.
TSIM is one of the largest academic associations in Taiwan. It has a strong impact on medical practice and can influence policy changes. We believe it is important for physicians in Taiwan to join organizations like TSIM or ACP to increase professionalism in medicine and their careers.
The new Medical Knowledge Self-Assessment Program® (MKSAP® 16) provides you with the most current and critical information in the core of internal medicine and its subspecialties so you can stay aware of what you need to know as a practicing physician in internal medicine today.
For more information on MKSAP 16, or to order your copy, visit http://www.acponline.org/products_services/mksap/16/
A 33-year-old woman is evaluated for chronic lower pelvic pain. It has been persistent for the past year but has worsened in recent months. She describes it as a constant, aching discomfort centered over her lower pelvis that persists during her menstrual cycle and has prevented her from being sexually active with her partner. She also reports a 4-month history of urinary urgency and frequency. She has been empirically treated twice for urinary tract infections, but her urinary symptoms improve for only a few days and then recur. She has no history of pelvic surgeries or pelvic infections and has never been pregnant. She has no associated constipation, diarrhea, abdominal distention, or flank pain. She currently takes ibuprofen as needed for pain.
On physical examination, vital signs are normal. BMI is 24. There is mild tenderness to palpation over the pelvic floor muscles with significant tenderness over the anterior vaginal wall. External genitalia are normal in appearance; there is no tenderness to palpation over the vulva. There is no cervical motion tenderness, adnexal tenderness, or discomfort with palpation of the uterus.
Laboratory studies show normal electrolytes, kidney function, and a complete blood count. Erythrocyte sedimentation rate is 4 mm/h. Urinalysis is without erythrocytes or leukocytes and is negative for nitrite and leukocyte esterase. Urine culture is negative. Tests for chlamydial infection and gonorrhea are negative.
Transvaginal/transabdominal ultrasonography is negative for endometrial or ovarian masses and no abnormalities are noted.
Which of the following is the most likely diagnosis?
B. Interstitial cystitis
C. Irritable bowel syndrome
D. Pelvic adhesions
Click here for the answer and critique.
My first major trip of the year as President of ACP was to Geneva, Switzerland to attend the Swiss and European Congress of Internal Medicine (European Federation of Internal Medicine and Swiss Society of General Internal Medicine) May 14-16, 2014. It was a large venue, much like the Annual Internal Medicine Conference for ACP, with 2600 attendees and 500 poster presentations. The majority of participants were very young, very energetic, very smart, and mostly female. There also seemed to be many residents and young physicians early in their careers, either in academia or practice.
The questions and issues of the day were very similar to those we are dealing with in the US: physician and resident burnout, workforce concerns with too few primary care physicians, changing demands of internal medicine training, migration health, the high cost of health care, and the usual updates on a variety of scientific and clinical topics, including the emerging threat of MERS CoV. Of interest were a series of "Trend" presentations, of which mine was one on "Future if Internist Training", sharing the podium with a colleague from England.
The venue was new and modern and with all presentations being precise and on time (it being in Switzerland, after all). There were several speakers from the US, besides myself. The internal medicine leaders from around Europe were unified in their concern for the future of health care and how internists would be positioned to deal with the many present and future challenges being confronted: ongoing expansion of global population, emerging health threats (some related to migratory spread), maintaining strong and relevant training and continuing education for internists, and the rising cost of health care.
This was a dynamic, educational, energetic, informative and an all-around wonderful meeting. This trip also offered broad opportunities for collaboration and for meeting new colleagues and friends from around Europe and beyond. I am deeply grateful for the opportunity to attend and contribute to this conference and to be able to become better acquainted with internal medicine colleagues and friends from around the globe.
Dr. Fleming speaking at the meeting.
Invitations to speak at meetings of the ACP Chile Chapter and the Uruguay Society of Internal Medicine provided a wonderful opportunity for my wife Janet and me to take our first trip to South America. Throughout the trip, we were blessed by incomparable hospitality from our hosts, travel arrangements that went without a hitch (something I am not used to with my frequent domestic travels!), and excellent weather. We arrived in Santiago a day before the meeting started, allowing us to have several advance social events with current and former ACP leaders from Chile. We started with a VIP-level private tour and wine tasting at the Concho y Toro vineyard, accompanied by former ACP Regent Dr. Jose (Pepe) Rodriguez-Portales and his wife Isabel, as well as the Chair of the Scientific Program, Dr. Helia Morales. Dinner that evening provided a wonderful opportunity to spend time with several luminaries of the Chile Chapter: Dr. Guillermo Conte (Governor of the ACP Chile Chapter) and his wife Maria; Dr. and Mrs. Rodriguez-Portales; and Dr. Maria Pinto (Past Governor of the ACP Chile Chapter) and her husband.
The Chile Chapter meeting was held on April 24-25. I estimated the attendance as approximately 500, including large numbers of residents and students. I gave talks on diffuse lung disease and high value care, as well as a presentation of what's happening nationally at ACP. I also had the privilege of presenting Dr. Conte with a Chapter Excellence Award. Dr. and Mrs. Conte hosted two wonderful dinners at a private club, where we had opportunities to socialize with ACP Fellows on one evening and with residents and students on another. I was also delighted that Dr. Aron Benzadon-Cohen, ACP Central America Chapter Governor, was another guest speaker at the meeting, accompanied by his wife Lelia.
Dr. Weinberger presenting the Chapter Excellence Award to Dr. Conte.
I cannot end a description of the Chile Chapter meeting without thanking Dr. Conte and his wife Maria for being such gracious hosts throughout Janet's and my stay in Santiago. Similarly, I must recognize what a wonderful job that Dr. Conte and his wife Maria are doing as the Governor and "First Lady" of the Chapter. Their successful efforts at increasing membership, coordinating the activities of the Chapter, and developing enthusiasm about the Chapter and about ACP have made the Chile Chapter such a vibrant and exciting Chapter.
Our next stop was in Montevideo, Uruguay, where I was invited to speak at the Uruguay Society of Internal Medicine. Our host was Dr. Juan Carlos Bagattini, whom we first met when he came to Santiago for the Chile Chapter meeting. Although ACP does not currently have a Chapter in Uruguay, Dr. Bagattini has an infectious enthusiasm that has generated significant interest in ACP among his colleagues in Montevideo. He could not have been a more attentive, gracious, and warm host! In addition to two lectures I presented on diffuse lung disease and on high value care at the meeting, which was held at the Hospital Britanico, Dr. Bagattini arranged for us to have a day-long visit to Punta del Este, a well-known resort about 90 minutes from Montevideo. The social high point was a magnificent dinner reception at Dr. Bagattini's house - a truly elegant and elaborate feast in a beautiful setting and with a wonderful group of other physicians from Montevideo.
After this week of most enjoyable "work," Janet and I took a week of vacation in Peru, visiting Machu Picchu, the Sacred Valley, and Cusco. For those who have not visited Machu Picchu and the surrounding areas, this itinerary must be added to everyone's "bucket list" - photos cannot capture the beauty of the setting, combined with the magnificence of the Incan ruins.
Last month I spent an engaging four days in Auckland representing the College at the Annual Meeting of the Royal Australasian College of Physicians. Leslie Bolitho, MD, FACP, whose term as president of the Royal Australasian College of Physicians (RACP) was concluding and Nick Talley, MD, PhD, the incoming president, were most gracious hosts. The meeting began with the induction of Fellows. Australia and New Zealand are, of course, on the British system, with a six year medical school beginning directly after high school. After medical school, graduates proceed to a two-year period of general medical training. Again, this is like the British two-year Foundation Programme; the content is similar to the old rotating internship. After the two years, physicians can practice as general practitioners or they can pursue further training as registrars (residents). People who complete their advanced training in good standing become Fellows and can practice their specialty or subspecialty. The RACP is a bit more complex as an organization than ACP. In addition to internal medicine and its subspecialties, it includes pediatrics, public health (as practiced by physicians), preventive medicine, sexual health, addiction medicine and a couple of other small specialties.
The plenary sessions were diverse and excellent. In particular, Dame Silvia Cartwright gave a moving presentation describing her experiences serving as a commissioner on the Cambodian "killing fields" tribunal and the role of the testimony of victims. In addition to attending the general sessions, I was asked to speak on two topics, one of my choosing - Medical Education: Shift the Focus from Teaching to Learning - and one selected by the organizers - Revalidation: Where from Here? Revalidation is the British term for "maintenance of certification" but, because there is no equivalent of our initial certification exam at the end of registrar training, they are taking a very different approach to the challenge of verification of maintenance of competence of physicians in practice. MyCPD is the name of the RACP¹s initiative. The requirements are attending 'collegial meetings¹ - six in the first year then four annually, one clinical audit per year, peer review of 10 hours annually, and CME of 20 hours per year. Again, there are no examinations in place or contemplated.
The social events were lovely as well. The second evening, Drs. Bolitho and Talley hosted a small dinner for the plenary speakers and international guests and a tour was provided to Waiheke Island where we were treated to tastings of both olive oil and locally produced and very tasty wine. Auckland sits on an isthmus bounded on the west by the Tasman Sea and on east by the Pacific Ocean. On my last I walked from the sea to the ocean, a seven mile hike primarily through parks and open space.
My visit to the Japan chapter meeting was interesting and informative. The Governor, Shotai Kobayashi, MD, MACP, had organized an interactive meeting with sessions in diverse formats, including case discussions. The plenary talks and at least one of the concurrent sessions each cycle were conducted in English so I had no trouble staying involved. A major theme of the meeting was the workforce challenge that is right around the corner resulting from a confluence of factors: a demographic inversion with far more aging people than young people, the strong preference of Japanese physicians to subspecialize, and a health system that is built around hospital care. The first day of the meeting concluded with a two-hour panel discussion considering how primary care could be developed in Japan in order to allow the care of frail elderly patients to take place in their homes and communities. In addition to participating in this panel, I had the chance to address an audience of young clinician-educators on the topic of emerging trends in residency education in the US, and to preside over the oral presentations of the winning abstract in each of three categories, medical student, resident, and young physicians.
It was a delight to reconnect with Shunichi Fukuhara, MD, FACP, who was a resident at UCSF when Paul and I were junior faculty members and who is now Dean, Kyoto University School of Public Health in the Graduate School of Medicine and Vice-President, Fukushima Medical University, as well as being the vice-chair of the Japan ACP chapter. We were beautifully taken care of from beginning to end. The first day in Kyoto, Dr. Fukuhara's charming assistant served as our guide, taking us to several temples and the beautiful gardens of Shugakuin Rikyu. Kyoto is famous for the quality of its tofu and we had a delicious lunch at a tofu specialty restaurant. Our first official event was the chapter council dinner that concluded with a tea ceremony conducted by Dr. Fukuhara's wife, Naoko.
I was impressed by the scientific rigor of the presentations and the enthusiasm of the participants. The Japanese Society of General Internal Medicine has picked up the cause of high-value care and I was presented with a Japanese version of "Choosing Wisely". Kyoto is a lovely city - I look forward to coming back.
Dr. Cooke (center) stands with the 2014 ACP Japan Chapter Abstract Competition winners and former ACP Japan Chapter Governor Kiyoshi Kurokawa, MD, MACP (far right).
Upcoming meetings will be held in Guatemala, Colombia, Argentina, and India. Also, don't forget the World Congress of Internal Medicine in Seoul, Korea.
A complete list of other Future Worldwide Internal Medicine Meetings is available here.
ACP is pleased to announce the following newly elected International Fellows, who were recommended by the Credentials Committee and approved for election by the Board of Regents as of July 1, 2014. They are listed by current location and may have been credentialed through a different Chapter.
Marcelo Zonensein, MD, FACP - Rio de Janeiro
Lenley S. Adams, MD, FACP - Charlottetown
Clement S. Yeung, MD, FACP - Winnipeg
Zoltan Berger Fleiszig, MD, FACP - Santiago
Ronald Wainstein Gewolb, MD, FACP - Santiago
Marcela Granados, MD, FACP - Cali
Mandalanayagam Chellappah, MBBS, FACP - Kent
Mahendra P. Samal, MD, FACP - Chhatisgarha
Ajmal Khan, MBBS, MD, FACP - Lucknow
Mangesh Harihar Tiwaskar, MD, MBBS - Mumbai
Erni Juwita Nelwan, MD, FACP - Jakarta
Nawfal M. Sheaheed, MBChB, FACP - Baghdad
Fawaz Masalha, MBBCh, FACP - Amman
Jose Antonio Fernandez Vera, MD, FACP - Mexico
Joel Rodriguez Saldana, MD, FACP - Mexico
Diosdado Jovian E. Domingo - Tuguegarao City
Maria Gina C. Nazareth, MD, FACP - Sto Tomas Batangas
Abdulsalam M. Al Matari, MBChB, FACP - Al Ahsa
Naeim G. Salah, MD, FACP - Khamis Mushait
Dragan Lovic, MD, FACP - Niska Banja
Berty M. Jayakody, MBBS, FACP - Kandy
Thilak Priyantha Weerarathna, MD, FACP - Galle
Franco G. Cavalli, MD, FACP
ACP Internist June 2014
ACP Hospitalist May/June 2014
Answer: B, Interstitial cystitis
Educational Objective: Diagnose interstitial cystitis as a cause of chronic pelvic pain.
Critique:This most likely diagnosis in this patient with chronic pelvic pain is interstitial cystitis. Chronic pelvic pain is defined as noncyclic pain of at least 6 months' duration that localizes to the anatomic pelvis, the anterior abdominal wall at or below the umbilicus, the lumbosacral back, or the buttocks, and is of sufficient severity to impair quality of life. Potential causes of chronic pelvic pain include interstitial cystitis, endometriosis, pelvic adhesions, and irritable bowel syndrome. In this patient, the combination of chronic pelvic pain in association with unexplained urinary symptoms is most consistent with a diagnosis of interstitial cystitis. Interstitial cystitis is a chronic inflammatory condition of the bladder that causes symptoms of urinary urgency, frequency, and pelvic discomfort. The pelvic discomfort may be worsened by sexual intercourse, and patients may urinate numerous times per day. Although urinalysis and urine cultures are almost always negative, most women with interstitial cystitis have been treated empirically several times for urinary tract infections.
Endometriosis is a common cause of chronic pelvic pain, and patients typically report severe dysmenorrhea, cyclic pain, and dyspareunia. The absence of severe dysmenorrhea and the noncyclic nature of this patient's pelvic pain make endometriosis a less likely diagnosis. Similarly, irritable bowel syndrome is unlikely to explain her symptoms in the absence of any associated gastrointestinal symptoms.
Adhesions are diagnosed in 25% to 50% of women with chronic pelvic pain. Pelvic adhesions typically form in the setting of acute or chronic inflammatory processes, such as infection, or surgery. This patient has no history of pelvic infection and has never had pelvic surgery, making this an unlikely cause of her symptoms.
Key Point: Interstitial cystitis is a likely diagnosis in women with chronic pelvic pain associated with unexplained urinary symptoms; most women with interstitial cystitis have been treated empirically several times for urinary tract infections.
Vercellini P, Somigliana E, Viganò P, Abbiati A, Barbara G, Fedele L. Chronic pelvic pain in women: etiology, pathogenesis, and diagnostic approach. Gynecol Endocrinol. 2009;25(3):149-158. [PMID: 19347704]