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ACOI American College of Osteopathic Internists
August Resident News
AUGUST 2010
TABLE OF CONTENTS



WHAT CAN ACOI DO FOR YOU?

A new training year is underway and the ACOI extends a warm welcome to all new and returning residents and fellows. There are more than 1000 of you in osteopathic internal medicine and subspecialty training programs, which is greater than any other specialty in the profession. We are very proud of the growth in osteopathic internal medicine and in the numerous excellent training opportunities available to osteopathic college graduates.

All residents and fellows are Candidate members of the ACOI at no cost to the resident. As you complete your training, the ACOI can be a true resource for you. The College is responsible, with the AOA, for all of the training standards guiding the operations of your programs. Through the Council on Education and Evaluation, program quality undergoes continuous scrutiny. The Council also is responsible for assuring that your individual training is completed successfully. The Council is comprised of nine internists who are deeply involved with and committed to osteopathic education. Residents have a voice on the Council, as well, in the person of Belinda Kakos, D.O. a second-year resident at Henry Ford Health System Macomb-Warren Campus.

The ACOI website (www.acoi.org) includes many of the documents that are essential to your training. In addition to the Basic Standards for internal medicine and all subspecialty training, there is a Model Curriculum which outlines the education content that internal medicine residents are responsible for learning during the course of your training. The American Osteopathic Board of Internal Medicine, which administers the internal medicine and subspecialty certifying examinations, draws the test content directly from the Curriculum.

Residents and fellows also complete required annual reports via the ACOI website. The website also is the portal to your ACOI membership record and the numerous listservs available to residents, fellows and all other members.

The ACOI invites you to consider the College as the first source for answers or assistance with any questions or concerns about your training. Christina Smith (Christy@acoi.org) is the primary staff contact for training matters. Keisha Oglesby (Keisha@acoi.org) can help with certification questions. Susan Stacy (Susan@acoi.org) and I (bjd@acoi.org) are also available to help. It is ACOI policy that all phone calls and e-mails will be acknowledged and responded to within 24 hours of receipt. Please take advantage of the wealth of information that is available to you now and throughout your careers as osteopathic internists.

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.




CAREER OPPORTUNITIES AS AN INTERNIST

This is an exciting time to be an Internal Medicine Resident. Health care reform and the latest trends in primary care make it a "buyers market" for Medicine residents looking for their first jobs. Over the past few years, the demand for Internal Medicine trained physician's has greatly increased and the shortfall of needed primary care physicians is becoming more apparent, this has lead to a number of good things for Internists. Demand for well-trained Internists has resulted in positions that provide better pay, a better lifestyle, and therefore more physician job satisfaction. Recent articles in the New England Journal of Medicine also look at how the current presidential administration has recognized the need for a strong primary care backbone in health care reform, and has made an effort to adjust the health care system to reward the primary care physicians of the country.

There are many options for an Internist who chooses not to subspecialize, but I thought I would take a quick look at three of the most common options.

The Hospitalist is usually an Internist who has chosen to work only in the inpatient hospital setting, only treating patients who are ill enough to require inpatient care. This is a high stress job, treating high acuity patients. With the resident work hour rules, as well as overworked outpatient clinicians the need for Hospitalists has grown greatly over the past 10 years. As the country ages, there are more people in need of medical care. Outpatient clinicians, find that their day is full with only the outpatient work and getting to the hospital is hard to fit into the day. Now that residents can only work a restricted schedule, this leaves many patients in need of inpatient care and fewer physician to see them. The Hospitalist position a very attractive option for a new graduate because the job entails work very similar to work done during residency, and the lifestyle tends to be attractive. Most Hospitalists work 12 hour shifts, 26 weeks a year. No pager call outside of the 12-hour shift, no calls at home when not working. Compensation tends to better than average for an internist, as well. There are trade offs with being a "hospital-only physician." Most patients do not see you as "their doctor." If you are looking for a practice with patient continuity and a long-standing relationships with your patients, this is likely not the job for you.

The outpatient clinical practice continues to be a great place to see "your patients." Most outpatient practices nowadays are strictly outpatient. In this type of setting you can focus all of your time and efforts on the patients scheduled that day without getting calls from the hospital, or having to do hospital rounds in the morning and evening on top of a full clinic schedule. Workdays tend to be slightly shorter than the hospitalist, and the traditional "work week" of Monday thru Friday is also more common in this type of practice. The "Clinic Doc" is a good example of an Internist as a primary care physician.

The traditional practice of clinic duties and some hospital work is also available. This is what most people still envision when they think of "Internal Medicine,", but this type of practice is becoming more rare. Most group practices now work with Hospitalists groups for inpatient duties and have physicians that work outpatient practice only. This allows each physician adequate time to provide care for their patients, but does not provide the continuity of care that many patients and physicians desire. There is still a place for the traditional practice and indeed, some Internists will only feel satisfied with the ability to see their patients in both the clinic and when they need to be in the hospital.

No matter which type of Internal medicine position you choose, you should take your time and find the place and type of practice that suits you. You are in demand currently and you can have your pick positions.

Quick Tips for the Job Search:
  • Start looking and interviewing early (February of your third year is not too early)
  • It takes longer than you think to start a job (three months to get all of the paperwork together and reference checks done is not unheard of).
  • Find an area that is right for you and your family.
  • Try to get a feel for the other people in the practice when you interview. Are these people that you want to work with?
  • Ask about sign-on bonuses, loan forgiveness, etc.
Please contact me with any questions or comments.

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 III

This is my last installment in this series of articles. As stated before, one of the main motivations for me as a physician is the education of students and house staff. It has been the primary motivation for choosing my place of residency and the driving force for my involvement in professional organizations. As such, I am constantly looking for better ways to interact with professionals in training. This has led me to explore research in interpersonal communication and self perception. Most recently I have begun to concentrate my studies on the four personalities: Director, Socializer, Thinker, Relator.

Before delving into details, I need to make a couple things abundantly clear:
  1. There is no such thing as a good personality type and a bad personality type.
  2. Almost everyone has one personality type as their norm (Primary personality type), but a different personality type when responding to stress (Secondary personality type).
  3. A person's personality type can change, but that rarely happens unless there is a major life changing event.
  4. Effective utilization of this information requires that an individual make changes in their own method of communication, in an effort to meet the needs of those with whom they are communicating. Avoid the temptation to pigeon-hole individuals.
The Relator Weaknesses: Relators are seen by other as being too compliant, soft-hearted, and acquiescent. They often seek security and "belongingness," which makes decision making very difficult for the Relator. This procrastination stems from the desire to avoid risky and unknown situations. They will only make a decision after knowing how other people feel about it. They dislike interpersonal conflicts so much that they sometimes say what they think other people want to hear, rather than what is really on their mind. Relators are so adverse to change that they will tolerate unpleasant environments rather than risk trying something new.

Relating to the Relator: Relationships are the most important thing to the Relator. They want interaction and desire to get to know the people around them. They will tend to have a set schedule and appreciate when others make it easy for them to maintain. If a Relator asks you to make a decision about just about anything, you do them a great service by offering up your opinion.

In the Medical Realm: Relators are drawn to service type professions, which includes every aspect of medical field. They are nurses, doctors, therapists, technicians, and aides. Physician Relators will be drawn to fields that allow them to get to know their patients and allow for a team approach to patient care. This includes: family practice, internal medicine, and neuromuscular medicine. Relators are found in every field, but these fields really do allow for the development of relationships that are essential to this personality type. Relator physicians who have a support staff that keep them on task can be very successful and are some of the least-sued doctors. Relators are great teachers and are attracted to these opportunities. As administrators, Relators rely heavily on their supporting staff. They are great public relation coordinators and are good at providing a humanistic perspective to any meeting.

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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AN END, A NEW BEGINNING

Many of you have begun a new chapter in your training. Whether it is a new year in residency or entering into practice/fellowship, it is a new beginning. And no doubt, new beginnings are exciting! For the graduates it may seem as though you have finally reached the end, but in truth while we may accrue many degrees on the wall, walk across the stage a few times, we never truly graduate. The reality, of course, is that as physicians we will be spending the rest of our lives in the dynamic state of life long learning and training.

Reading philosophical and literary works happens to be one of my pleasurable pastimes. I make an effort to read a non-medical book at least once a month, sometimes more, in the hopes of gaining a different perspective than my chosen vocation. In the last few years, two books have caught my attention and have made it to the top of my must read list. Jerome Groopman's How Doctors Think and Atul Gawande's Better: Surgeon's notes on performance. Both authors are physicians who write for the New Yorker and who provide thoughtful insight in medical training, education and the doctor/patient interaction. Dr. Groopman provides memorable and relatable cases on the different cognitive biases that we develop as a result of our human and medical training experiences. For example, he shows examples of confirmation bias, where one develops an inclination to search for information that supports preconceptions despite evidence to the contrary, or anchoring bias, where the tendency to rely on one sign or symptom leads to a rapid decision/diagnosis and an inability to entertain a differential. By becoming aware of our cognitive biases, we can develop systems that prevent harm and improve upon patient safety as we deliver healthcare. It is no secret that I am passionate about patient care and education. This book provides a refreshing take on our role as physician. Next month, I will discuss Dr. Gawande's Better and the ethical conundrums for the physician.

Roughly 4000 years ago, the ancient Babylonians began documenting an 11-day springtime celebration, bringing in the harvest of a new year. Since that time, it has become a common motif seen throughout all cultures with various institutions adopting the concept of a New Year, a mark in the timeline for change, growth and new beginnings. I can remember in late August, standing in line at the store with a fresh set of pencils, new folders and notebooks in tow, both anxious and excited for the academic year's coming events. In the Jewish faith, the New Year, Rosh Hashanah usually falls in late September (depending on the lunar cycle) and is a time for the people to reflect on the past year, identify mistakes and make plans for amends. October marks our government's fiscal year, where budget plans and thoughts on spending occur for the following year.

Yet all these New Years, briefly pale in comparison for the medical student that becomes a resident in July. All across the country in academic and teaching hospitals alike, July is the New Year for the incoming residents. After 20 plus years of learning in a classroom, where teacher and students are on opposite sides of the room, where theory is hotly discussed and mildly practiced, the first year resident is now the responsible doctor. Standing side by side with your attending, you will present your patient's case, discuss a plan of action and most importantly, execute...no pun intended!

Not to place fear in your hearts or overstate the obvious; our actions on the wards have consequences. Medical students will now look to you to model behavior with patients; nurses will turn to you for direction on the most mundane and serious of issues. Your decisions will directly influence the life of someone's loved one.

For the seniors July is the month where we are truly exposed to the finer nuances in the art of negotiation. Effectively leading a service not only requires academic and clinical knowledge, there has to be an understanding of the steps in the delicate dance of motivation. There will be residents on your service that are both eager and disinterested. Finding the balance between the two while ensuring safe, efficient and effective healthcare becomes the mark of the excellent resident.

On behalf of the ACOI Council on Education and Evaluation, I would like to welcome you all...to a new role, a new responsibility...welcome to a new beginning. Happy New Years! Belinda Kakos, DO

Belinda Kakos, DO, is the Resident Representative on the ACOI Council on Education and Evaluation. She is a third year internal medicine resident at Henry Ford Health System-Warren Campus. She may be reached via email at bkakos1@hfhs.org.

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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 infomation these questions are testing. In order for residents to better understand the process, the ACOI has asked several former certifying board members to write this feature. This month's question is by Joanna R. Pease, DO, FACOI, a Past President of the ACOI and former chair of the AOBIM.

An 80 year old man is evaluated for a 2 month history of black stools. He had 2-3 day periods where his stools are black and then followed by normal stools. He has developed anemia during these episodes requiring transfusions. He has no abdominal pain and no vomiting. Between episodes he feels well. His other medical history is positive for hypertension and hyperlipidemia for which he takes lisinopril and simvastatin. He has had two EGD’s and a colonoscopy in the past two months which showed no bleeding source. On exam, his BP is 120/70, pulse 86, respiratory rate 12. His abdominal exam is normal. Rectal exam reveals hemoccult positive stool. Lab studies show a hemoglobin of 9 gm/dl with and MCV of 80. Metabolic panel, platelet count, PT and PTT were all normal. What test would you recommend next to determine the bleeding source?

  1. Small bowel barium exam
  2. Repeat routine esophagogastroduodenoscopy
  3. Double-balloon enteroscopy
  4. Wireless capsule endoscopy
  5. CT angiography

The answer is 4. The most likely reason for melena in this case is small bowel angiodysplasia as the episodes are recurrent and previous EGD and colonoscopy have not shown a source. A third EGD is unlikely to identify any new pathology. Barium small bowel exam is too insensitive to identify a source and CT angiography is also too insensitive and only likely to identify a site when there is brisk bleeding. Double-balloon enteroscopy is an option but only after the wireless capsule endoscopy has already identified the source to then determine if the double-balloon procedure should be peroral or per rectum.




INTERESTING CASE OF THE MONTH

Presented by Ramneet Wadehra, DO, a third-year internal medicine resident and Alan Rey Lucerna, DO, Chief Resident, at Kennedy Memorial Hospital, Cherry Hill, NJ, University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine.
Click the case title to view the report.





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IRS ANNOUNCES TAX INCENTIVE FOR THOSE WHO WORK IN UNDERSERVED AREAS

The Internal Revenue Service (IRS) announced efforts to strengthen the healthcare workforce in underserved areas on June 16. The IRS announced that, "Under the Affordable Care Act healthcare professionals who received student loan relief under state programs that reward those who work in underserved communities may qualify for refunds on their 2009 federal income returns as well as an annual tax cut going forward." Prior to the enactment of the "Patient Protection and Affordable Care Act" (PPACA, Pub. L. 111-148), only amounts received under the National Health Service Corps Loan Repayment and Forgiveness Program were eligible for the tax benefit. As a result of this legislation, the tax exclusion applies to any state loan repayment or loan forgiveness programs intended to increase the availability of healthcare services in underserved or health professional shortage areas. Additional information is available from the IRS at www.irs.gov/newsroom/article/0,,id=224387,00.html.

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

Dr. Coupet First DO to be RWJ Clinical Scholar

Sidney Coupet, DO, an internal medicine resident at Geisinger Medical Center in Danville, PA, was recently named a clinical scholar by the Robert Wood Johnson Foundation. He is the first DO to be named to this position. Dr. Coupet will begin this prestigious two-year fellowship in July, 2011 at the University of Michigan. The Clinical Scholars Fellowship provides training on how to conduct innovative research and work on important health care issues. Dr. Coupet recently completed the Training in Policy Studies (TIPS) program sponsored by the American Association of Colleges of Osteopathic Medicine.

ACOI provided a grant to support a portion of Dr. Coupet's expenses for the program.




UMDNJ-SOM Mobilizes Medical Residents to Provide Food for Area Needy

Alan Lucerna, DO (left) and Chien Wei, DO (right) posing with the staff from
the Food Bank of South Jersey during the delivery ofover 2000 pounds of donated food items.

Responding to the needs of more than 90,000 people in South Jersey who go hungry each week, the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine (UMDNJ-SOM) Postdoctoral Training Institute medical residents worked with the South Jersey Food Bank to collect non-perishable food items at five area locations this May. Participants in the food drive included medical residents from the Internal Medicine and Emergency Medicine departments at UMDNJ-SOM, the nursing and ancillary staff from all three divisions of Kennedy University Hospital and Our Lady of Lourdes Medical Center- Camden and students and staff from UMDNJ campus in Stratford. "The medical residents wanted to give back to the people of our community that have played a large role in our education through the years," said Dr. Alan Lucerna, a fifth-year emergency medicine/internal medicine resident at UMDNJ-SOM. "We have a large network with tremendous resources to help our neighbors. During this time of the year when there aren't any major holidays, food stores reach critical lows. Additionally, during these tough economic times, more and more people are in need. We are proud to have collected over 2,000 lbs of non-perishable food goods for the Food Bank of South Jersey." Dr. Lucerna and Dr. Anthony Wehbe, a senior internal medicine resident, were the chief organizers of the successful event. "We were so thankful for the overwhelming support of the medical and nursing staff, as well as the support of our administration and program directors,"ť said Dr. Wehbe, who will be practicing medicine in Nigeria after graduation this June. Beth Reichman, AVP of Medical Administration at Kennedy University Hospital, was also instrumental in promoting the event at multiple campuses of the Kennedy Health Systems.

The residents in emergency medicine and internal medicine at UMDNJ-SOM have historically worked closely together, but this food drive was the first coordinated community outreach project from the two residencies. Dr. Adrienne Williams, DO, a graduating EM resident, served as the public relations officer for the drive. Dr. Chien Wei, DO, an incoming senior resident, headed the sub-committee for the emergency residents.

The University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine Osteopathic Postdoctoral Training Institution provides medical school graduates with opportunity, support and encouragement to complete residency training in a myriad of medical specialties. These programs are completed at full-service urban and suburban community hospitals. The strong alliance of the school and the hospitals began over 20 years ago and continues to provide trainees with excellent educational opportunities in one of the nation's largest osteopathic graduate medical education programs.

UMDNJ is the nation's largest free-standing public health sciences university with more than 5,900 students attending the state's three medical schools, its only dental school, a graduate school of biomedical sciences, a school of health related professions, a school of nursing and its only school of public health, on five campuses. Annually, there are more than two million patient visits to UMDNJ facilities and faculty at campuses in Newark, New Brunswick/ Piscataway, Scotch Plains, Camden and Stratford. UMDNJ operates University Hospital, a Level I Trauma Center in Newark, and University Behavioral HealthCare, a statewide mental health and addiction services network.

Article written by Adrienne Williams, 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