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ACOI American College of Osteopathic Internists
April Resident News
APRIL 2010
TABLE OF CONTENTS



UNDERSTANDING THE ANNUAL IN-SERVICE EXAMINATION

The annual ACOI Resident In-Service Examination was administered on Friday, March 5 at all osteopathic internal medicine training sites. The following information is provided to help explain the examination and why it should be viewed as a useful experience for residents and their programs.

The In-Service Examination consists of 200 items in 11 subtest areas which comprise 10 subspecialties and general internal medicine. About 70 to 75% of the exam questions are ambulatory-based in accordance with current health delivery and medical practice. The remaining 25% of questions focus on inpatient and critical care areas. Over 50% of the questions are case-based.

The content of the exam is based on the ACOI Model Curriculum for Internal Medicine Residency Training (available at www.acoi.org), as is the content for the Internal Medicine Certifying Examination administered by the American Osteopathic Board of Internal Medicine (AOBIM). It should be noted that the item writers for the In-Service Examination are a different group of individuals than the AOBIM members who write the Certifying Exam. The certifying board has no information regarding what items appear on the In-Service Examination and vice versa for the In-Service Exam question writers. Residents should also be aware that there is a high correlation between performance on the In-Service Examination when taken during the last year of residency and performance on the Certifying Examination.

The purposes of the In-Service Examination are: 1) to evaluate each resident's knowledge base in comparison to the expectation at that level of training and relative to the national average at the same level of training; 2) to determine progress of the resident from one training year to another; 3) to assist the resident in identifying personal areas of strength and weakness; and 4) to assist the ACOI Council on Education and Evaluation in evaluating individual training programs, and in identifying programs that may need assistance from the Council.

It is not the purpose of the examination to grade residents or determine promotion in residency. Program directors are required to review scores individually with each resident and assist the resident in identifying strengths and weaknesses. This must occur at the end of each academic year, in late June or early in the new year in July. Residents and program directors are cautioned regarding placing significant emphasis on the scores in the individual specialty areas unless they are markedly above or below the average. This is due to the impact that occurs by changing only one or two correct or incorrect answers. It is recommended that the "total score" and overall average, in comparison to others at the same training level, be utilized to evaluate performance. Individual specialty scores should be used to direct study needs.

Brian J. Donadio, FACOI

Brian J. Donadio, FACOI, is the Executive Director of the American College of Osteopathic Internists. He may be reached via email at bjd@acoi.org.




TAKE A SPRING BREAK

Around the country the winter doldrums are slowly passing and hopefully your life in general is looking better. Those of you who are in your intern year and the medical students have learned how to be to be efficient (or at least are able to keep your heads above water) and you are starting to trust some of your clinical abilities. Second year residents have matched for fellowship and third years are either interviewing for a first job or have found one. Things should be falling into place; the day-to-day job of being a resident or student is still very stressful, but now makes sense.

I wanted to use this small article to think about how to mix a personal and professional life and to address the stresses and joys of being a physician. I will touch on each group separately to try to address some of the specific stressors for each type of physician in training.

To be quite honest, it has been shown in numerous studies that these stressful years of becoming a physician can lead to depression, divorce, and drug/alcohol abuse.

Students
The clinical years are a joy, after the first two years in a classroom, but these last two years of training have their own issues. The hours can be very long on clinical rotation, but this allows you to understand what it is like to be a resident. Patients who are ill begin to see you as someone who is there to help them get well, and they will begin to ask things of you (your time, your knowledge and your compassion). This can be very rewarding, but the time and stress can be draining. In addition, as a student you are always "auditioning" for an Internship spot, so you always have to make a good impression.

My main advice to you at this point is to make the most of your time off. Take vacation when you can. If you can imagine, it gets harder; you will be an Intern soon and will be working up to 80 hours a week.

Take the time off now, because you may not have much free time in the near future. Take lots of breaks when studying for COMLEX and for rotations. This is the time when you begin to feel like you are becoming a physician and, hopefully, you are beginning to enjoy the work.

Residents
Internship and Residency have to be the most stressful part of these training years. Eighty-hour work weeks; days and nights of little sleep; sick patients requesting your time; some of them getting better, others dying despite your best efforts. It is difficult to imagine a harder job. Don't get me wrong, I still believe I have the best job in the world, but the day-to-day struggle can sometimes get you down.

This is a time for you to be vigilant. It is easy to become depressed. Most programs are aware that residents are highly stressed, sleeping little, and are at high risk for depression. You would not be the first one to feel stressed or depressed during residency, and most programs are ready to help you in any way that is needed. Along these same lines, we need to be careful of alcohol and drugs. It is natural to try to find a way to treat ourselves and try to make ourselves feel better; but alcohol and drugs cannot only make things worse in the short term, they can also mean problems for the rest of your professional career.

So how can we avoid all of this during these years of hard work and learning? Most programs have a few "easy months" per year. Take full advantage of these. Get away from the hospital, visit family, go to the beach, and sleep in. Get outside; exercise if you can. Get out of the hospital. Another good idea is to stay active with friends, both inside your residency and outside. Your fellow residents understand what you are going through and there is something cathartic about going out and comparing notes over dinner with people who are going through it with you. There is also something great about going out with people who are not in the medical field and spending the whole night not discussing anything medical. Just let your mind be free from work.

First Job
Once you have gotten your first real job things get better. No one will tell you that being a physician is easy, particularly your first year. It can be full of stress and self-doubt, but things get better every day. There is no work hour rule for staff physicians and the long days are not over, but there are positions available (particularly in Internal Medicine) that fit every lifestyle. You can work as a hospitalist and work only 26 weeks a year, 12 hours a day, or have shorter days with a clinic job and be able to do things with friends and family after work. What is better is that you start getting paid for your long hours, and are more appreciated for your work. You can now find a nice home and start doing some of the things that you have been putting off for the past seven or eight years. Finding someone you can trust or a mentor may help during this first year, a seasoned physician who you can discuss difficult cases with, who will provide you with advice and not judge you.

This is my advice for enjoying the training years. Obviously these are not comprehensive, and are my opinions, alone. If you would like any further advice, feel free to email me, I am available anytime.

Scott Girard, DO

Scott Girard, DO, is a hospitalist in Danville, PA. He completed his internal medicine training at Geisinger Medical Center in Danville in July, 2008. During his training, Scott served for two years as the resident representative to the ACOI Board of Directors. He now serves as liaison and advisor for residents and the College. He may be reached at slgirard@geisinger.edu.



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WHAT IS YOUR PERSONALITY? PART II

Last month I introduced the four primary personality types: Director, Socializer, Thinker, and Relater. I told you that these personality types help to guide us in our communication with those around us. In the medical field, we are called upon to utilize active communication as much as possible. Active communication involves not just the verbal, but also the non-verbal. Being perceptive enough to recognize the personality type of the people that we work with, are taught by, and serve allows us the unique opportunity to really make an impact.

As stated last month:
  • There are neither "good" personality types, nor "bad" personality types
  • Almost everyone has one personality type as their norm (Primary personality type), but a different personality type when responding to stress (Secondary personality type)
  • Personality types can change, but that rarely happens unless there is a major, life-changing event
  • Effective utilization of this information requires that individuals make changes in their own methods of communication, so that they might meet the needs of those they are communicating with. It is not effective if you only focus on whether your own needs are being met
The Socializer

Strengths Socializers are quite talkative and work well with others. These folks are very outgoing, responsive, warm, friendly, enthusiastic, compassionate and gregarious. They are good at keeping a work environment relaxed and can make decisions in an almost spontaneous fashion, with what they and others describe as "intuition."

Weaknesses Socializers have a tough time concentrating on one project and will often shift from one activity to another more often than their attending physician may appreciate. They will occasionally be described as undisciplined, unproductive and unstable. They are also prone to exaggeration and have a tough time getting people to take them seriously. Socializers tend to like everyone, but can be very difficult for task-oriented personalities to work with.

Relating to the Socializer - People are the primary focus of a Socializer's existence. These individuals often relate topics of discussion to people they know or similar experiences. They want to be known and liked by others. Socializers prefer discussions in social settings, such as during a meal or a round of golf. Getting to know Socializers in these types of environments will help increase rapport and build trust. Other traits common in Socializers include being outgoing, flexible, lighthearted, easily distracted, enthusiastic and spontaneous.

In the Medical Realm Socializers in medicine are a great asset and constant source of frustration. With the Millennial Generation now in medical school, there has been a rise in the number of Socializers graduating from medical school. Some of this increase is secondary to the rise of a new generation of "ultra-connected" graduates and the environment in which these students have been raised. The other aspect is that our interview process favors the Socializer. These applicants stand out because they can be good multi-taskers and, if they can direct their energies in a positive fashion, are more willing to do a lot of job shadowing and volunteer work. These students can, however, be very difficult to educate in the traditional "lecture" format. They have a tendency to learn better when working in small groups in a problem-based format. Ultimately, Socializers will be drawn to fields of medicine where they can interact with lots of people. Primary care and hospitalist internal medicine, and family medicine pediatrics provide a lot of patient interaction and select for individuals that have the ability to see a large number of people in a relatively short period of time. Socializers that pick areas of medicine like the surgery specialties or anesthesia are often attracted to the unique bond between staff that is present in the operating room. Socializers able to reign in their tendency to be distracted can become very important in the hospital leadership and make for great health policy advocates in both the state and national arenas.

The Thinker

Strengths The Thinker is very analytical. They are self-disciplined and are often the person that keeps projects organized and meetings running on time. Thinkers take pride in being knowledgeable and accurate in their areas of interest. Because they are very careful about not expressing their opinion until the data has been examined, they are often able to give good insight. They are logical, but can also appreciate an item s aesthetic value.

Weaknesses Thinkers are typically not people persons. They are often classified as self-centered and moody. People around them tend to see them as negative and hard to relate with. The Thinker takes so much pride in considering all the facets of a problem before presenting a solution that they can be very critical when someone else gives another possible solution. If presented with an obvious error or a miscalculation, a Thinker will have a tendency to blame others and lessen their involvement. Thinkers are also the most likely to seek revenge for perceived injustices done to them.

Relating to the Thinker - These individuals usually are numbers-oriented, seek a lot of information before making decisions, and use methodical processes when drawing conclusions. Making it a point to have as much information about a patient (Current Labs and Vitals, Trends, Old Admission Notes, Previous Procedure Notes, Medication Lists, etc.) is an effective strategy for dealing with Thinkers. In general, Thinkers ask a lot of questions and need to be asked to share their feedback. Communication with the Thinker should take place at their slower pace, with a good deal of emphasis on showing proof. Approaching this person with ideas for changes in his or her practice should be accompanied with facts and data about how the change would move their practice along to the next step.

In the Medical Realm Without Thinkers in medicine we wouldn't have the advances that we take for granted. Thinkers do very well in medical school and score very well on standardized exams. They will be the last people out of a test, but will often have done the best. Thinkers are drawn to areas of medicine where they can collect data or work as an individual. Pathology, Radiology, and Specialty Medicine are the most likely areas of medicine to find a Thinker. Because of their individualism, they do not frequently take on strong leadership roles, but they are a necessary part of any committee and tend to be the people that run meetings.

Next newsletter: The Relater and final thoughts.

Mat Hardee, DO

ACOI Board of Directors Resident Representative Mat Hardee, DO, is a third year internal medicine resident at Northeast Regional Medical Center in Kirksville, MO. He may be reached via email at ACOIResidentRep@gmail.com.

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BOARD QUESTION OF THE MONTH

This series of questions is to help residents understand how board questions are written and what kind of information these questions are testing. In order for residents to better understand the process, the ACOI has asked several former AOBIM members to write sample questions, explain how the questions are constructed and demonstrate some of the concepts that will enhance test taking. This month's question is by Joanna R. Pease, DO, FACOI, a Past President of the ACOI and former chair of the AOBIM.

A 32 year old women presents to the ED for evaluation. Her husband had heard an unusual sound and found the patient lying in the bed looking dazed and acting confused. Her husband became very concerned and brought her to the ED. By the time they reached the hospital, the patient had returned to normal behavior. She has no memory of the event and did not remember getting into the car. She was not incontinent. She has no past medical history and has never had a previous similar episode. She uses no medications, illicit drugs or alcohol. On exam, she is alert and oriented and her vitals are normal. She has a normal neurologic and cardiac exam. CT of the head is normal. All labs including liver function tests, electrolytes, renal function tests and complete blood count are normal. The patient is placed in 23:59 observation status and you are consulted to give an opinion about further management. What would you recommend?

  1. Safe to discharge and obtain outpatient MRI and EEG
  2. Obtain inpatient MRI and EEG before any further treatment recommendations can be made
  3. Load with IV fosphenytoin, then discharge on phenytoin 300mg/day orally and obtain MRI and EEG as outpatient
  4. Obtain inpatient neurology consult
  5. Start lamotrigine 25 mg/day then follow in office in one week to instruct on titration and determine if further testing is needed.
The answer is 1. Although this patient probably did have a seizure, medication treatment is not recommended for an initial seizure unless the patient is in a high risk category for recurrence. As her initial screen in the ED is negative, it is appropriate to send her home and finish the evaluation as an outpatient. CT of the head is a good screening tool but MRI is more sensitive to identify structural abnormalities that could cause epilepsy so should be performed. EEG should be performed as it can show abnormalities but neither a normal EEG nor one that shows interictal abnormalities refute or confirm a diagnosis of epilepsy so performance does not need to be done inpatient.




INTERESTING CASE OF THE MONTH

Presented by Alan Lucerna, DO, a senior resident in combined emergency medicine/internal medicine at UMDNJ-Kennedy Health System in Stratford, NJ.
Click the case title to view the report.





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HEALTH CARE REFORM LEGISLATION SIGNED INTO LAW

Health Care Reform Legislation Signed into Law History was made when President Obama signed into law the "Patient Protection and Affordable Care Act" (PPACA)(H.R. 3590)(Pub.L. 111-148) on March 23. The signing of the PPACA into law was the culmination of over a year of debate and political wrangling.

H.R. 3590 was first introduced in the House as the "Service Members Home Ownership Tax Act of 2009" on September 17, 2009. It was approved under suspension of the rules by a vote of 416-0 and sent to the Senate for consideration. The Senate amended the bill stripping the original legislative language and inserted the text of the "Patient Protection and Affordable Care Act." In a rare Christmas Eve vote, the Senate approved H.R. 3590 as amended by a vote of 60-39. The House agreed to the Senate amendments by a vote of 219-212 on March 21. The legislation was approved in both chambers along party-lines.

As part of the negotiations to attain the needed votes in the House to approve the Senate-passed H.R. 3590, the House moved and approved a "corrections" package to further amend the health care reform package once it was signed into law. The corrections package, entitled the "Healthcare and Education Reconciliation Act of 2010" (H.R. 4872), was signed into law on March 30.

The non-partisan Congressional Budget Office estimates the PPACA and H.R. 4872 will cost $938 billion over ten years. Further, the CBO estimates that the combined bills will reduce the federal deficit by $118 billion over the same time period. Following is a summary of the key provisions of the PPAC as amended. Additional information will be made available at www.acoi.org as regulations are advanced to implement the legislation.



Tim McNichol, JD

Timothy McNichol, JD, is the Deputy Executive Director of the ACOI and is responsible for the College's advocacy efforts. He may be reached via email at tmcnichol@acoi.org
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NEWS OF NOTE

Research Symposium 2010 - Research Abstract Contest
The ACOI is pleased to announce the 2010 awards for Research Abstract Posters prepared by residents and fellows in internal medicine and its subspecialties.

Cash awards of $1,500, $1,000, and $500 will be made for the 1st, 2nd, and 3rd place posters as judged at the 2010 Convention, October 23-27, 2010 in San Francisco, CA. In addition, the top three finishers will present their work at a plenary session of the Convention and receive reimbursement of their travel costs (1-2 nights at hotel and coach air travel), if not paid by your program.

Abstract subjects are to be related to internal medicine and its subspecialties. There are no restrictions as to content, and the entry may represent, but is not limited to: original research, a retrospective analysis, a prospective analysis, etc.

A second category for competition will include an interesting case or several cases analyzed with a review of the literature and supporting or refuting contemporary attitudes in literature. There will be separate cash awards of $500, $250 and $100 for the top three case presentations. Unfortunately, funding constraints do not allow reimbursement for travel for the top three finishers in the competition.

Instructions for the Submission of Abstracts are included with this mailing. Please clearly specify in which category (Research abstracts or Case presentations) you are submitting your entry. The deadline for submission is July 26, 2010.

I would strongly encourage you to enter this contest. In addition to the judging in San Francisco, a first-rate convention is planned. Residents may attend the convention at no charge for registration.

Please feel free to call the ACOI at any time you may need assistance.




Largo Medical Center Internal Medicine Program

Residents at the Largo, Florida Medical Center met with Robert G. Good, DO, late in March. Dr. Good, a member of the ACOI Board of Directors from Champagne, IL, is a graduate of the program. He was in town for an ACOI Board meeting.
From front of photo left side going around the table: Nicholas Strobbe, DO, Asma Talukdar, DO, Ernest DiGiovanni, DO, Weston Connell, DO, Joseph Namey, DO, program director, standing, and Jeanine Martin, DO. Back to camera: Amber Tas, DO, Imran Ismail, DO, and Jarvis Tzeng, DO.



ACOI Staff Resources for Residents and Fellows
The ACOI staff and the Council on Education and Evaluation are important sources of information and assistance for osteopathic internal medicine residents and fellows. Two staff members are available on a daily basis to address questions and concerns. Christy Smith serves as postdoctoral administrative coordinator and can answer questions about general training requirements and specific individual training issues. Keisha Oglesby is the ACOI certification liaison. Residents and other certification candidates are urged to contact her to clarify questions about completion of certification requirements.
ACOI policy is that all phone calls and e-mails are acknowledged and returned within 24 hours of receipt. Please take advantage of these resources available to you.




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ACOI Contacts
Michael B. Clearfield, DO, FACOI
President
michael.clearfield@touro.edu
Thomas F. Morley, DO, FACOI
President-Elect
tmorley@comcast.net
Matthew R. Hardee, DO
Board of Directors Resident Representative
ACOIResidentRep@gmail.com
Brian J. Donadio, FACOI
Executive Director
bjd@acoi.org
Timothy W. McNichol, JD
Deputy Executive Director
tmcnichol@acoi.org
Susan B. Stacy, FACOI
Director of Administration and Finance
susan@acoi.org
Christina A. Smith
Post-Doctoral Training Coordinator
christy@acoi.org
Keisha L. Oglesby
Membership Coordinator/
Certification Liaison
keisha@acoi.org



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Council on Education and Evaulation
John B. Bulger, DO, Chairman
jbulger@geisinger.edu
Thomas J. Mohr, DO, Vice Chair
tmohr@rockyvistauniversity.org
Gary L. Slick, DO (AOBIM)
aobim@mail.com
Robert A. Cain, DO
racain@sbcglobal.net
Susan M. Enright, DO
senright@genesys.org
Joanne Kaiser-Smith, DO
jksdoc@aol.com
Robert T. Hasty, DO
hasty@nova.edu
Joanna R. Pease, DO
strixvaria@sbcglobal.net
Frederick A. Schaller, DO
frederick.schaller@touro.edu
Belinda Kakos, DO - Resident Representative
bkakos1@hfhs.org