November 2007 E-Newsletter

Answer for October Contest Question

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Click here to see October’s question.

Answer to October Contest Question: (C) Semi-erect positioning in bed

Prevention of infections in an intensive care unit (ICU) is difficult. There are relatively few proven interventions to help reduce the risk of infection in an ICU. However, there are interventions for preventing ventilator-associated pneumonia. Even when a cuffed tube is in place, bacteria from the stomach can reach the lungs and cause pneumonia. Semi-erect positioning in bed is useful because it prevents the excursion of bacteria from the stomach into the upper airways.

In many patients in ICUs, use of H2-receptor blockers permits a high density of bacteria in the stomach. These organisms are frequently pathogenic and resistant to standard antibiotics. Reducing the density of gastric bacteria by use of prophylactic antibiotics is tempting. However, this approach is ineffective and serves to select for even more resistant strains.

Oral placement of endotracheal tubes is currently believed to be superior to nasal placement because nasogastric and nasotracheal tubes cause some degree of obstruction of the ostia in the nose, which can predispose to nosocomial sinusitis. Whether all nasal tubes should be replaced by oral tubes is unclear. However, no benefit will be gained by changing from an orotracheal to a nasotracheal tube.

Changing endotracheal tubes seems logical, but reintubation is associated with certain risks (intubating the esophagus, precipitating hypoxia during the procedure, and so on). Reintubation may also increase the risk of nosocomial pneumonia. Careful inspection and management of the tubing can help reduce infections slightly. Because the tubing has a tendency to collect water, careful drainage of accumulated condensate into patient-specific drainage containers is advocated.

Cooling blankets are often used to control body temperature in patients who are critically ill. However, there is little support for this measure. In addition, cooling blankets are uncomfortable for awake patients and do not prevent complications related to infections.

References

Torres A, Gatell JM, Aznar E, el-Ebiary M, Puig de la Bellacasa J, Gonzalez J, et al. Re-intubation increases the risk of nosocomial pneumonia in patients needing mechanical ventilation. Am J Respir Crit Care Med. 1995;152:137-41. PMID: 7599812

Nelson LD, Choi SC. Kinetic therapy in critically ill trauma patients. Clin Intensive Care. 1992;3:248-52. PMID: 10148407

Orozco-Levi M, Torres A, Ferrer M, Piera C, el-Ebiary M, de la Bellacasa JP, Rodriguez-Roisin R. Semirecumbent position protects from pulmonary aspiration but not completely from gastroesophageal reflux in mechanically ventilated patients. Am J Respir Crit Care Med. 1995;152(Pt 1):1387-90. PMID: 7551400

This is the final answer in the IMpact contest question series. Thank you to all of the medical students who submitted answers to these contest questions, we appreciate your support!

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Medical Student Perspectives: What Should You Do During Your First Summer in Medical School?

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The summer after your first year of medical school presents a unique opportunity to explore various areas of medicine through shadowing, research, and travel. Most medical schools provide resources to assist students in deciding how to spend their summer, and there are many societies accessible through a simple search on Google that have programs for medical students.

Traveling is certainly an exciting option. Many of my classmates traveled during their summer off, including trips to Africa, Central America, and South America, where they not only helped to provide care at the local hospitals, but also had time to have fun. I have received many e-mails with pictures of my classmates exploring rainforests, rafting down the Nile, and spending time with groups of local children.

The American Medical Student Association Web site provides a wealth of information about various travel opportunities. At this Web site you will find a search engine where you can find opportunities for medical students in any region of the world you choose. There is also information about how to fund your trip, a checklist of items to bring with you, and worksheets to help you compare programs.

Many students choose to do research during their summer off. If you have never done research before, or want to try to publish a paper during medical school, research is a good option. Finding a research project that you are interested in can be a daunting task, but there are plenty of resources to help you. If you are attending a research-oriented medical school, first find out what research opportunities are available. Do not worry about finding a project in the area of medicine in which you plan to specialize, just find a project that interests you. Many schools provide a list of available projects to students, and by contacting researchers directly you might find a project not on these lists. There are also numerous national research programs set up for students. I found the pamphlet created by the American Medical Association Committee on Scientific Issues to be helpful.

There are two key points to keep in mind about your summer during medical school. First, this is your last summer off, probably for the rest of your life (until you retire that is), so whatever you end up doing, make sure that it is something you will enjoy. Secondly, you will have plenty of time during your fourth year of medical school to practice medicine abroad, or to do research, so do not put too much pressure on yourself at this point to beef up your resume. If you want to travel with friends or spend time with family, then do it! No one says you need to do something related to medicine during your summer off. I wish everyone the best of luck, and please feel free to e-mail me with any questions or comments.

Joseph Sivak
Council of Student Members Representative, Central Atlantic Region
University of Virginia School of Medicine, Class of 2009
E-mail: jasivak@virginia.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Christopher Mays, MD.

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As a teenager, Dr. Christopher Mays had long blond hair that hung to the middle of his back, little academic ambition, and notions of becoming a rock star or professional athlete. But by the time he graduated from high school, that boy was long gone, replaced by a reflective, deeply faithful, and purposeful young man who dreamed of doing something useful with his life. That something turned out to be internal medicine.

The catalyst for the transformation was a failing kidney which landed him in the hospital for four major operations between the ages of 12 and 18. The experience was trying yet defining, as it served as his introduction to the field of medicine. "I was in the hospital a lot," he says, "and so I ended up developing a relationship with my surgeon. I liked him and knowing him had a positive effect on me. Around the same time I also began to grow in other ways. Religious faith became important to me, and I saw in medicine the opportunity to serve people and utilize my faith as well."

Dr. Christopher Mays with his family

Dr. Christopher Mays with his family


Embracing Stereotype
Dr. Mays says one of the best things about practicing internal medicine is being tested. As he explains, most of what an internist faces every day is the result of multiple systems interacting with each other, creating multiple problems. "There is a stereotype—they say that internists think and surgeons do," he says, "and that’s fine with me. I like the fact that I am the one who is able to figure it out."

Getting to that point required commitment. For Dr. Mays, that meant medical school at the University of Maryland followed by residency at the Washington Hospital Center in Washington, D.C. As is the case with most physicians, his training was not one-dimensional. For example, it was one of his mentors during his introduction to clinical practice, whom he credits for teaching him how to perform a physical exam and conduct a patient interview. "It was because of him that I really began to understand how to integrate all of the systems in the body and put them all together," he says. "I admired this guy because of his ability to teach us this in a way we understood."

Dr. Mays practices medicine in the same area where he grew up and went to school, in Gaithersburg, Maryland, a suburb of Washington, D.C. His familiarity with the community has been a benefit to him as an internist who owns his own practice, allowing him the unique opportunity of knowing many of his patients well, something he cherishes greatly. "I like the continuity of the care I give," he explains, "I like the stimulation the work gives me. I like having relationships with my patients, treating the whole family, and being there for all of the major events in their lives."

His affectionate and generous nature extends beyond the office. He works with local hospital leadership staff and also as medical director for a local nursing home. He recognizes the very real need for quality care in such facilities, and he sees patients as people, not cases. "A lot of people still need care when they leave the hospital," he explains. "And the elderly have many medical needs—some have many needs, while others are just frail. I’m glad I can be a part of that."

Growing Up
As a teenager and later as a medical student, Dr. Mays was influenced and guided by mentors and others who had a positive effect on him. For example, during his junior year rotation, he identified strongly with his attending. "He was kind of a younger guy so I related to him because of his age," recalls Dr. Mays. "I thought he was very, very smart and he possessed a genuine compassion for patients. I was still very impressionable at this point, you know, and I thought he was awesome."

Now, as a well established physician running his own private practice, the 46-year-old is filling the role himself. Eight years ago, a senior high school boy named Luke came to Dr. Mays and asked him if he could observe him at his practice. He was outgoing, had an easy smile, and aspirations to be a physician. Dr. Mays agreed, and soon recognized qualities in the 18-year-old that impressed him. "Even at that time, I could see qualities in him that would make him a great internist," he says. "His thinking processes were logical, he had compassion for others, and he was a skilled communicator." Luke went to college and when it was time to apply to medical school, he again returned to Dr. Mays, asking him to write a recommendation letter to the admissions director, who ironically had been a mentor of his. He was happy to oblige. "I said in the letter that you couldn’t ask for a better student," he recalls. Three years later, Luke has returned to Dr. Mays as he prepares to apply for internship and residency.

His commitment to young people resonates on more personal levels: as a youth group leader with his church, a role he shares with his wife, Jean, and as a father to three daughters. The middle daughter, 14-year-old Janelle, is a cross country runner, just like her dad used to be when he was her age. He admits he enjoys this because it reminds him of a time in his own life that was so special. Some thirty years ago when Dr. Mays himself was on the team, he and his teammates had to run a daily route that took them past a house across the street from the school. There was a girl named Jean who lived inside the house, who was two years younger than Dr. Mays. Although she remembers seeing him running past her house every day, Dr. Mays insists she did not think much of him at the time. Eventually however, he won her over and the two began dating while in high school. Just as surely as he decided on medicine as his chosen profession, he knew that Jean was a keeper. "She was pretty, fun to be around and made me laugh," he says.

Personal Practice
Now currently in his senior year of medical school and newly married, Luke, Dr. Mays’ protégé, is ready to pick a career. Dr. Mays hopes it will be as an internist. "It’s been so rewarding just to watch him, all the way from high school until now," he says. "It’s been nice to know him in other ways as well—my wife and I even give them advice about marriage. I would like to see him pursue internal medicine since he is such a great physician—and my dream is that he would come work with me in my practice, but we’ll see."

Dr. Mays leads a full life, surrounded by and working with people he loves and enjoys. He tries his best to bring something unique to each of their lives, and seems to be rewarded for it with happiness. He says being an internist has allowed him to live the life he wants, which for Dr. Mays is a life shared with others. "I could talk for hours about what I find rewarding about being an internist," he says, "but knowing someone like Luke and being able to teach him and watch him grow has been one of the best rewards."

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Internal Medicine Interest Group of the Month: Cornell University

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One of the more troubling trends in health care today is that medical students have increasingly chosen to match into surgical subspecialties to the exclusion of more generalist specialties, including pediatrics, primary care, geriatrics, and of course, internal medicine. This is not some minor "Scrubs-style" J.D. versus Turk, medicine versus surgery debate. In fact, those going into internal medicine are also not immune to this growing affliction, since many who enter internal medicine residencies end up subspecializing. What is disturbing about this trend is that as the over 70 million baby boomers in the United States develop multiple chronic conditions, there might not be enough generalists to meet the nation’s growing needs.

Perhaps as an effect of this growing disinterest in primary care, the Internal Medicine Interest Group (IMIG) at Cornell had not been active for a while and was only recently restarted two years ago, similar to our peers at Stanford and Columbia. Although no one person or one group can single-handedly reverse this trend, we hope that by exposing more students to the diversity of internal medicine, we can at least stem the tide.

The new leadership of the IMIG at Weill Cornell—composed entirely of the Class of 2010—took over in late April just as the Class of 2009 was beginning to study for the dreaded boards. For our first event we assembled a panel of fourth-year students that had recently matched into internal medicine and had them give a talk entitled "How to Match into Internal Medicine." We made sure to represent several locations (rural and metropolitan as well as different regions of the country) and several programs with different focuses (that is, more research versus more clinical). One of the most pervading themes of the panel was that there was in fact no one right way to match into internal medicine, as the students on the panel had such different experiences in medical school. For example, during the summer after first year, some went to Africa, a few did basic science research here in the city, and others did clinical research related to geriatrics on a Weill Cornell-specific scholarship. Another important take-home point was that neither grades nor board scores define an applicant. That is, most programs take a holistic approach to the match process, perhaps echoing the holistic way in which internists practice.

To celebrate National Primary Care Week in mid-October, we teamed up with the interest groups in pediatrics, geriatrics, primary care, and OB/GYN to bring together a panel of primary care physicians to speak on why they went into primary care and to discuss the joys and frustrations they have experienced. We will soon be screening the movie Sicko by Michael Moore and use it as a springboard to discuss the current health care system in the United States and to highlight possible improvements that can be made. And in the spring, we have planned a talk on the subtleties of immigrant health and a panel on the many career paths of internal medicine. We are also outlining plans on a "meet and greet" with internal medicine faculty, shadowing opportunities, a talk on going into academic medicine, and developing a database of past students who matched into internal medicine.

Every step of the way we have been supported intellectually by our interest group advisor, internist Suzanne Wenderoth, MD, FACP, and supported financially by the ACP. We hope that through our efforts and through subsequent iterations of our interest group, we can help shift students back to practicing medicine in the Oslerian tradition.

Dan Ly
Co-President, Weill Cornell Medical College Internal Medicine Interest Group
Weill Cornell Medical College, Class of 2010
E-mail: dpl2001@med.cornell.edu

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Winning Abstracts from the 2007 Medical Student Abstract Competition: An Old World Disease Finding its Place in the Modern World.

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Author:
Anna Karina Celaya, MPH, Charles R. Drew University of Medicine and Science

Introduction
Hansenis disease is an uncommon condition encountered in the United States. In patients of Mexican ancestry there is an ulcerative vasculitis form called Luciois leprosy that may be confused with diseases caused by bioterrorist infectious agents.

Case Presentation
A 51-year-old Mexican male presented to the emergency room with an 8 day history of painful facial lesions. The first lesion began at the left mandibular angle as a small, red papule which over a few days enlarged and centrally ulcerated. Similar lesions developed over the face but sparing the eyes, nose, and ears. Patient denied a past medical history, is originally from southern Mexico, and has lived in the U.S. for 30 years where he works as a factory assembly person. On admission, patient was febrile (102°F) and vital signs stable. He was noted to have multiple ulcerative lesions throughout the face, the largest being 8cm in diameter, with a central eschar, a rim of surrounding erythema, and a lack of pustular discharge (images available). The rest of the exam was found to be normal. The lack of a medical history and the aggressive, unusual lesions caused concern for bioterrorist agents. Given the potential for bioterrorism we have seen in recent years, the concern for anthrax, tularemia, and bubonic plague were entertained. Wound scrapings obtained at admissions were sent promptly to the public health department laboratory. PCR of the wound specimens were negative for the above. Wound swabs eventually revealed AFB + organisms which subsequently were identified as Mycobacterium leprae. A biopsy of the deltoid was then performed which also revealed the M. leprae bacilli (histopathology images available). The patient was treated with thalidomide and at a 9-month follow up visit the patientis lesions had resolved.

Discussion
Luciois leprosy was first described by Lucio and Alvarado in 1852 in Mexico. Luciois phenomenon is common only in the diffuse lepromatous leprosy of Mexicans. It is clinically manifested by painful, violaceous, and hemorrhagic plaques followed by ulcerated, necrotic, irregular-shaped skin lesions. It has an aggressive and rapid clinical course that can be fatal. Histopathologic characteristics include colonization of the endothelial cells by acid fast bacilli, ischemic epidermal necrosis, necrotizing vasculitis of small vessels in the upper dermis, or a leukocytoclastic vasculitis along with lymphocytes and foamy macrophages throughout the dermis. The treatment of Luciois phenomenon is the same as that used for other type 2 reactions in leprosy: high dose clofazimine (200-300 mg/day) and prednisone (40-60 mg/day) or low-dose thalidomide (50-100 mg/day).

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Interventional Cardiology

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The Discipline
From the Latin word intervenire, "to come between." Interventional Cardiology is the branch of Cardiology responsible for catheter-based interventions in the management of ischemic heart disease, congenital heart disease, and acquired valvular disease.

Procedures
Important procedural skills include coronary artery catheterization, angioplasty, intra-coronary thombolysis, valvuloplasty, coronary artery stent placement, and intra-aortic balloon counterpulsation.

Training
Interventional Cardiology fellowship training requires 12 months of accredited training beyond three years of general cardiology training.

Certification
The American Board of Internal Medicine offers certification in Interventional Cardiology.

Major Professional Societies
The Society for Cardiovascular Angiography and Interventions
2400 N. Street, NW
Washington, DC 20037-1153
1-800-992-7224
Web site: http://www.scai.org

Major Publications

Journal of Vascular and Interventional Radiology

Journal of Interventional Cardiology

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

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Advocacy Briefs: Education Regulations Preserve Economic Hardship Debt-to-Income Ratio

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The Department of Education recently published final regulations that address certain provisions of the "College Cost Reduction and Access Act of 2007" that became effective October 1, 2007.

Of particular importance to medical students and residents, the regulations preserve the current definition of the economic hardship deferment debt-to-income ratio. The debt-to-income ratio allows medical residents to qualify for economic hardship deferment and postpone payment of their educational loans for up to three years. ACP supported postponing the elimination of the debt-to-income ratio in a letter to Congress.

The regulations also include a change in another provision of the economic hardship deferment that will increase the debt-to-income ratio by 50 percent, allowing more residents to qualify for the deferment. Previously, a resident's monthly income less monthly loan payments could not exceed 220 percent of the federal poverty line for a family of two. Under the new regulations, a resident's monthly income less monthly loan payments can reach up to 330 percent of the federal poverty line for the borrower's family size.

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Did You Know You Have Access to ACP's Online Mentoring Database?

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ACP recognizes that the years of an internist's education, training, and early career are those of excitement, challenge, and anxiety. With so many important decisions to be made, providing opportunities for medical students and early career physicians to seek out more experienced colleagues for guidance and advice is important.

Our online Mentoring Database was developed to provide you with personal and professional guidance from College members, including Program Directors, Clerkship Directors, Chairs of Medicine, practicing internists, and residents. Use the Mentoring Database to find a mentor who is right for you and who can provide the guidance and information you need. If you prefer we pair you with a mentor, please e-mail your name, chapter and medical school to mbrdev@acpmembership.org and ACP Membership Staff will match you with an appropriate mentor.

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MKSAP for Students 3 Question 1

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A thin, 19-year-old woman is evaluated because of chronic cough productive of green sputum. She reports a long-standing history of loose bowel movements and intermittent abdominal bloating. Physical examination is notable for bilateral nasal polyps, crackles in the upper lung zones bilaterally, and digital clubbing.

Which of the following is the best initial test to diagnose the cause of this patient’s chronic cough?

( A ) Gene mutation test (buccal swab or blood test)
( B ) 72-Hour fecal fat test
( C ) Quantitative pilocarpine iontophoresis sweat chloride test
( D ) Sputum culture

MKSAP for Students 3 Question 2

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A 50-year-old woman requests hormone replacement therapy for severe hot flashes. She had never had a thrombotic event. Because her daughter had a history of deep venous thrombosis in association with the use of oral contraceptives, screening for factor V Leiden mutation was undertaken. The patient was found to be heterozygous for the factor V Leiden mutation. The results of her physical examination are within normal limits.

Which of the following is most appropriate management of this patient?

( A ) Initiate hormone replacement therapy along with low-dose warfarin
( B ) Initial hormone replacement therapy along with full-dose warfarin
( C ) Recommend against the use of hormone replacement therapy
( D ) Initiate hormone replacement therapy along with aspirin therapym

MKSAP for Students 3 Answer 1

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Answer: C, Quantitative pilocarpine iontophoresis sweat chloride test

Although cystic fibrosis is most commonly diagnosed in childhood, diagnosis can be delayed until adulthood. Features suggestive of cystic fibrosis include chronic sinopulmonary disease, gastrointestinal and nutritional abnormalities, salt-loss syndromes, and male infertility. The diagnosis of cystic fibrosis is made by clinical history and documentation of dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The most appropriate initial test is the quantitative pilocarpine iontophoresis sweat chloride test, which should be performed at an accredited laboratory.

Gene mutation testing might be helpful, but patients who present initially as adults often have unusual genotypes that are not detected by many commercially available test batteries. Although fecal fat testing is helpful for establishing whether the patient has fat malabsorption due to pancreatic insufficiency, fat malabsorption is symptomatic of disease states other than cystic fibrosis and is not specific for cystic fibrosis.

Although cystic fibrosis should be suspected in any outpatient with a sputum culture positive for mucoid-strain Pseudomonas aeruginosa, this organism is now increasingly also recovered from outpatients who have bronchiectasis without cystic fibrosis. While cultures may be helpful in treating this patient, evaluation for the underlying cause of the chronic cough is the key to long-term management and will not establish the diagnosis of cystic fibrosis.

References
1. Stern RC. The diagnosis of cystic fibrosis. N Engl J Med. 1997; 336:487-91. PMID: 9017943

MKSAP for Students 3 Answer 2

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Answer: C, Recommend against the use of hormone replacement therapy.

Heterozygotes for factor V Leiden have roughly an eightfold increased relative risk for the development of thromboembolic disease. Therefore, not only should this patient be advised against the use of hormone replacement therapy (HRT), but she should also use anticoagulant prophylaxis at times of increased risk. HRT has been shown to increase the risk of venous thromboembolism, and the risk is compounded in patients with an underlying hereditary thrombotic defect.

Although warfarin therapy is likely to be highly effective in reducing the risk of venous thromboembolism, it is associated with a risk of major bleeding, and for that reason, its use prophylactically is contraindicated. Aspirin provides minimal, if any, protection against the development of venous thrombosis.

References
1. Rosendaal FR, Vessey M, Rumley A, Daly E, Woodward M, Helmerhorst FM, Lowe GD. Hormonal replacement therapy, prothrombotic mutations and the risk of venous thrombosis. Br J Haematol. 2002;116:851-4. PMID: 11886391.

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ACP Internal Medicine Residency Database

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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.

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

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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 during their clerkship. The printed content is enhanced with clinical photographs, tables, screening tools, and other instruments 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.

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)

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Stories for Medical Students from ACP Observer and ACP Hospitalist:

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The CDC Experience Applied Epidemiology Fellowship - Call for Applications

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Are you a medical student looking for something different to do next year? 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 3rd 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 areas of public health that interest them. Examples of previous and current areas of concentration include viral diseases, cardiovascular health, birth defects, STDs, food borne diseases, and air pollution and respiratory health.

Visit the CDC Web site to learn more about the CDC Experience. Applications for next year’s fellowship class must be postmarked by Monday, December 3, 2007. Please send any questions to, cdcexperience@cdcfoundation.org.

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ACP Issues Comprehensive Guidelines for Diagnosis and Treatment of Stable COPD

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Don't miss ACP's Steven Weinberger, MD, FACP, Senior Vice President, Medical Education and Publishing, in the latest Internal Medicine Report broadcast news story.

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