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ACOI American College of Osteopathic Internists
Resident News August 2011
Click here to register now for the Annual Convention and Scientific Sessions to be held October 12-16 in San Antonio, TX.

AUGUST 2011
TABLE OF CONTENTS



ACOI's ROLE IN QUALITY RESIDENCY TRAINING

As the 2011-12 academic year gets into full swing, I would like to extend a warm welcome to all returning and new osteopathic internal medicine residents.

The American College of Osteopathic Internists devotes a significant proportion of its resources to assuring the quality of your residency and fellowship programs. Working with the AOA, the ACOI establishes training standards, evaluates new and existing programs for continuing approval, provides faculty development for program directors and trainers, and maintains records of all residents and fellows documenting progress in satisfactorily completing training requirements.

The Council on Education and Evaluation (CEE) is the primary body responsible for these activities. Importantly, there is resident representation on the CEE in the person of Maryanne Samuel, D.O. At this time of year, one of the Council's most significant responsibilities is to review the year-end Annual Reports required of every resident, fellow and program director. With more than 1200 trainees in 150 internal medicine and subspecialty programs, this is a daunting responsibility.

The Annual Reports serve two important purposes: the first is to mark the individual trainee's progress in the training year; the second is to provide an overall picture of the quality of training in each program. These reports provide an opportunity for you to offer candid comments on your program in a completely confidential setting. All comments are seen by Council reviewers and discussed by the Council as a whole. Where appropriate, programs are provided an opportunity to respond, but the identity of those who have raised concerns is closely guarded.

Issues raised are tracked from year-to-year and are one of many factors considered when decisions must be made on the continuing approval of each program. Trainee feedback is an important part of assuring quality and one that I hope you take seriously.

The ACOI wishes each of you success. As you work through the new training year, please consider the CEE and ACOI staff as a resource for you. Each Council member's e-mail address is linked in this newsletter, as are those of the ACOI staff. We are always interested in hearing from you.

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.




ETHICS LESSONS BEGIN AT HOME

Don't worry that children never listen to you; worry that they are always watching you. ~Robert Fulghum

Lucky is the child that comes from a good home with loving parents to guide and support him. I am talking about the parents that teach their children how to handle awkward situations and moral dilemmas---not by telling them what to do--- but by living as an example. Parents who model this behavior for their young children provide a foundation that can never be taught in medical school, internship and residency. I have tried as a post-graduate trainer to model and encourage these traits. I have come to the conclusion that they are much more difficult to acquire after childhood.

These past seven years as an Osteopathic Program Director have given me the wonderful opportunity to observe something about the many young doctors I come into contact with on a personal and professional basis. The young doctors who come from homes where manners are expected, education and open discussion is encouraged and social acceptance and communication are modeled do much better than those who are not as fortunate as to experience this type of upbringing. In addition to these ideas, however, the more successful young residents have confidence, believe in themselves and are able to accept new ideas. They can readily incorporate suggestions and encouragement into their tool box of training. These young doctors move toward fellowships and private practices with ease. The more successful residents have had mothers and fathers who closely observed them, carefully guided them and provided strong support and love with encouragement to them to reach their dreams. These doctors have confidence in themselves. This is something they bring to their training. I could never teach them to behave appropriately and believe in themselves in a million years. I do know that a good upbringing will aid in the success of a young doctor who must navigate ethical issues daily.

From his blog entitled, “The Manners Mother Taught Us,” Jim Saben, a medical ethics teacher at Harvard notes:
“Bad interpersonal behavior creates patient safety risks. Nurses and young physicians stop raising questions or sounding alerts. The most corrosive form of bullying isn’t the loud tantrum--- its passive---like not answering pages or phone calls.”

He also notes:
“In the feedback I received from patient surveys over the years I was impressed with how many of the comments focused on behaviors that ultimately derived from the lessons in “good manners” that my mother (and father) taught me a as a young child. I remember their saying, “If you make an appointment, don’t be late.” There was no occasion to teach about returning phone calls promptly, but when the mother of my best friend in fourth grade died, they insisted that I call him. And the one time I remember my father spanking me was after I’d treated someone doing housecleaning for the family with disrespect.”

He continues:
“This isn’t the ethics taught in medical ethics classes. It’s closer to the good manners we’re taught, or should have been taught, as kids. If we were lucky, the behaviors have become second nature, automatic. But the right kind of example among our teachers and peers can reinforce or reduce our propensity to treat patients and colleagues with ordinary human decency.”

My mother and father are not around for me to be able to thank them for all the lessons I learned. I can tell you from my heart though; this has made me a much better parent to my three young children.

This article is provided by Laura M. Rosch, DO, FACOI, program director at Mount Sinai Hospital in Chicago and a member of the ACOI Ethics Committee. She may be reached at roslau@sinai.org




BECOMING THE TEACHER

The beginning of the new academic year brings about a lot of changes. No matter who you are, your day-to-day role has changed. A student becomes a teacher of students as the Intern (while trying to maintain sanity and help patients), the Intern now plays a large role as teacher as the upper level Resident, and the third year resident, who just became staff, now has the responsibility of caring for patients while helping craft the next generation of Internists.

Not all of us are gifted teachers, but we all have something to teach those around us. Here are some things to remember.

Be patient. Your pupil is trying to understand you. If they don’t get it, or become anxious or even agitated because they are unable to understand your teaching point, then it is time to try a different approach. Not everyone thinks or learns like you do. Try your best to understand your audience and find the best way to bring the information to them.

Every patient has a “teaching point.” When I first became teaching staff, I made it a point to discuss at least one important teaching point for each patient. It could be as complex as the pathogenesis of acute heart failure, or as simple as how to replete potassium.

Teaching is done informally as much as formally. A lecture is nice, but few people can retain information that is given in a one-hour-long didactic. Ten minutes at the bedside, while looking at an example (your nice patient), will be at least as valuable, if not more so.

It is your duty to teach. Students are hungry for knowledge and will listen to your every word (or they should, as they are paying to be there). The Interns and Residents owe it to them to make time in the day to provide basic, clinical knowledge. Upper level residents should function as “junior staff.” They should play a large role in patient care, but also a very large role in teaching the Interns and students on the team. This is a big responsibility, not to be taken lightly. As the resident, you are playing a significant role in the education of your team. New staff doctors will probably find it hardest to allow the resident to learn by doing. It is hard to trust your team and allow them make their own decisions in the treatment of “your patients.” You have to be calm, supervise carefully, but let the residents treat and care for people on your service.

I did not understand when I started out how much teaching is involved with being a doctor, but it can be a lot of fun, while being a big responsibility.

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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2011 ANNUAL CONVENTION: ACOI, SAN ANTONIO AND YOU...

As an internal medicine resident, you hopefully now are aware that recent changes in curriculum requirements state you must attend at least one ACOI educational program during your three years in training. The annual ACOI convention not only fulfills the above requirement, but also is an excellent opportunity for personal and professional growth.

When attending any professional convention, especially a national conference, it can be difficult to navigate a busy program while making sure to absorb as much as possible. One can end up overwhelmed and exhausted if not prepared. In order to get the most out of your time at the ACOI convention, some simple planning will ensure your hours are well spent.

Resident/Student Seminars:
After reviewing last year’s feedback, the ACOI has moved the resident/student lectures from the afternoon to the morning. This will enable you to partake in more of the convention’s general sessions without sacrificing those geared specifically for young physicians. The resident/student seminars promise to provide pertinent information while affording an opportunity to meet others from around the country. Also this year, one resident/student who attends these sessions will win an iPad that has been generously donated.

Making the Most of Sessions:
Review the conference schedule (preliminary program available at http://www.acoi.org/2011Convention/PreliminaryProgram.pdf) before you arrive. Determine which lectures and topics are of particular interest and create your own agenda of events. Ensure you allow time to travel between lectures and do not stay for a session if you are not finding it helpful - there are plenty of simultaneous seminars. While note taking is a great idea, do not write down every single point made. There is no test and you will most likely never review lengthy notes. Jot down only a few ideas that are clinically relevant for you. Also, be sure to ask questions if you have them.

Socializing and Networking:
National conventions are an excellent way to meet new colleagues and hone networking skills. Resist the temptation to interact with and only talk to other residents and students from your training program. When entering a session, sit with a new group and introduce yourself. Limit the time you spend in your hotel room and attend social events in the evenings. As a student, introduce yourself to program directors and residents where you may apply for internship. As a resident, keep an updated copy of your CV available and seek out young attendings for advice.

A New Adventure:
The ACOI yearly conference is an excellent way to visit a new city. Reserve time for exploration and relaxation with friends and family.

I look forward to seeing you in San Antonio! As always, please feel free to send comments, questions and ideas to acoiresidentrep@gmail.com.

Kelly Schiers, DO

ACOI Board of Directors Resident Representative Kelly Schiers, DO, is a first year pulmonary fellow at the University of Medicine and Dentistry of New Jersey. She may be reached via email at acoiresidentrep@gmail.com.

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THE PHYSICIAN BURNOUT SYNDROME, PART III: THE CURE

The Physician Burnout Syndrome is a multidimensional problem that can have dire consequences if left untreated. The following acronym “BREAK” represents 5 different aspects of handling burnout, which can ultimately help to break the cycle of burnout.

B= Balance
It is important to find balance between your career and your personal life. Maintaining and pursuing relationships outside of professional relationships are essential. Pursuing activities (hobbies, exercise, religious/spiritual activities, etc) and personal relationships can diversify your life experiences and help define your personal successes.

R= Rest
Physicians are human beings as well, and though we are held to a higher standard, we need to be aware of our physical limitations. We have the responsibility to ourselves, and to our patients to take time to rest physically. Some examples include establishing work hour policies, patient census caps, and enforcing mandatory time off.

E=Evaluation
Evaluations are critical to being successful in any job. Revisit the reasons why you entered this profession, and determine if you reached the goals you initially set out to achieve. Take an inventory of your current roles and accomplishments in your career. A large part of burnout is a discrepancy between your initial career goals and your current status. If discrepancies exist, it may be time to reassess, redefine, and rectify your approach to achieving those goals.

A=Accountability
No man is an island unto himself. It is essential to have a strong accountability network made of other physicians, family members and friends. Accountability partners will help establish a mutual responsibility of identifying the signs of burnout and also helping to overcome the obstacles associated with burnout.

K=Knowledge
Knowledge of the syndrome is the key to successfully handling and preventing burnout. You cannot change what you are unable identify. It is essential to be aware of the signs, symptoms, consequences, and solutions to burnout.

Maryanne Samuel, DO

ACOI Council on Education and Evaluation Representative Maryanne Samuel, DO, is a first-year internal medicine resident at Palmetto (FL) General Hospital. She may be reached via email at maryanne@nova.edu.

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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 certifying board members to write this feature. This month's question is by Joanna R. Pease, DO, FACOI, who was a member of the American Osteopathic Board of Internal Medicine for 10 years. She helps demonstrate how the questions are constructed, and some of the concepts that will enhance test taking.


A 65-year-old man presents to your office for follow up evaluation of his hypertension. He is currently taking lisinopril and aspirin. He has no complaints. On exam, his BP is 120/76 and his BMI is 28. Otherwise his exam is normal. he has never had any abnormal lab results in the past but he had routine fasting lab done during the previous week as part of the monitoring of his kidney function while on lisinopril. he results are: Glucose 130Na 140, K 4.2, Cl95, HCO3 26, BUN 20, creatine 1.0. What is your recommendation based on these results?

  1. Lab satisfactory; routine recheck in one year
  2. Repeat fasting glucose within a month
  3. Obtain hemoglobin A1C during this visit
  4. Obtain a 2 hour postprandial blood glucose
  5. Order a 2 hour glucose tolerance test
The answer is 2. this question is in a classic format where you must know nationally accepted guidelines to make a diagnosis and a recommendation based on a case history. In this case, the guidelines are those established by the American Diabetes Association to make a diagnosis of diabetes. The guidelines say that the fasting glucose must be greater than or equal to 126 on more than one occasion. In this case, as this is his first time with an abnormal lab result, the glucose must be repeated to meet the guidelines. Answer 1 is obviously wrong as his glucose is high. Answer 3 and 4 are wrong because HgA1C's and 2 hour postprandial glucoses are not sued to make the diagnosis of diabetes. Answer 5, the 2 hour glucose tolerance test (GTT), could also make the diagnosis of diabetes, but is currently not recommended as the preferred way by the ADA. Of course, all board questions are subject to statistical analysis. If a question does not meet a certain "r value," which is a value that shows if a question can discriminate between those who will do well on the test and those who will do poorly, then the question is revised or rejected for the next exam. In this question, it is possible that it will not meet the "r value" as it could be too easy, or perhaps to ambiguous since diabetes can be diagnosed by either FBS or GTT even though the GTT is not preferred. I always found that I never could determine very well what questions would perform well statistically and which ones would not, so I spent a lot of time rewriting questions.



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DEBT CEILING AGREEMENT IMPACTS STUDENT LOANS
The President signed into law the “Budget Control Act of 2011” (S. 365, Pub. L. 112-25) on August 2, just hours before the government began to default on some of its financial obligations. The House approved the legislation on August 1 by a vote of 269 to 161. The Senate approved S. 365 on August 2 by a vote of 74 to 26. While the compromised legislation provided a temporary solution, it left many other problems on the table.

S. 365 impacts student loan affordability. Specifically, the Act eliminates the interest subsidy on subsidized student loans for almost all graduate students while a barrower is in school, in the post-school grace period, and during any authorized deferment period beginning July 1, 2012. In addition, beginning July 1, 2012, the Act terminates the Secretary of Education’s authority to make incentive payments to borrowers to encourage the on-time repayment of their federal loans. The current interest rate reduction will still be allowed for those who agree to repay their loans through electronic debiting.

The legislation increased the debt limit by $900 billion, $400 billion of which is available immediately. Once the federal debt comes to within $100 billion of the debt ceiling the President may ask for an additional $1.2 trillion, which could rise to $1.5 trillion under certain circumstances. Central to the legislation is a Joint Select Committee on Deficit Reduction that is to propose at least $1.5 trillion in budgetary savings over 10 years. If the Committee fails to produce a recommendation that is approved by the House and Senate by December 23, a “trigger” will create automatic across-the-board reductions.

The legislation does not include a mechanism to replace Medicare’s Sustainable Growth Rate (SGR) formula which controls physician reimbursement under the Medicare program. In fact, if the Joint Commission fails to produce a package that is agreed to by both the House and Senate, physicians may face an additional two percent reduction on top of the 29.5 percent reduction projected for January 1, 2012. The ACOI will continue to closely monitor these negotiations.

SUPREME COURT LIKELY TO REVIEW CONSTITUTIONALITY OF ACA
The U.S. Court of Appeals for the Eleventh Circuit in a 2-1 decision found the “individual mandate” of the “Patient Protection and Affordable Care Act” (ACA, Pub. L. 111-148) to be unconstitutional on August 12. The court stopped short of declaring the entire law unconstitutional. The majority found that the commerce clause of the Constitution does not allow the Federal government to “mandate that individuals enter into contracts with private insurance companies for the purchase of an expensive product from the time that they are born until the time that they die.”

The case, Florida v. Department of Health and Human Services, was brought by 26 states and has been viewed as a likely candidate for the U.S. Supreme Court to consider the constitutionality of the ACA. As a result of the ruling, there is now a divide within the U.S. Court of Appeals. The U.S. Court of Appeals for the Sixth Circuit in a 2-1 decision upheld the constitutionality of the individual mandate in Thomas More Law Center v. Obama on June 29. As such, it is nearly certain that the U.S. Supreme Court will step in to resolve the split between the circuits. The U.S. Supreme Court is currently in recess and will begin its next term in October.

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

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.



2011 CERTIFICATION EXAMINATION DATES/APPLICATION DEADLINES
Internal Medicine Certifying Examination
Computerized Examination 200 Sites Nationwide
September 15, 2011
Application Deadline: Expired
Late Registration Deadline: Expired

Subspecialty & Certification of Added Qualifications Examinations
August 27, 2011
Lombard, IL
Application Deadline: Expired
Late Registration Deadline: Expired

  • Allergy/Immunology
  • Cardiology
  • Critical Care Medicine
  • Endocrinology
  • Gastroenterology
  • Hematology
  • Infectious Disease
  • Interventional Cardiology
  • Nephrology
  • Oncology
  • Pulmonary Diseases
  • Rheumatology
  • Sleep Medicine

Hospice & Palliative Medicine
Certification of Added Qualifications Examination
October 30, 2011 in Orlando FL
Application deadline: July 1, 2011
Application packet available here



2012 CERTIFICATION EXAMINATION DATES/APPLICATION DEADLINES
Internal Medicine Certifying Examination Computerized Examination 200 Sites Nationwide
September 13, 2012
Application Deadline: February 1, 2012
Late Registration Deadline: April 1, 2012

Sports Medicine Conjoint Examination For Certification of Added Qualifications
Tuesday, April 17, 2012
During AOASM 27th Annual Clinical Conference, April 18-22, 2012
Held at the Marriott Louisville Downtown Hotel, Louisville, Kentucky
Application Deadline: Tuesday, January 17, 2012 (no penalty)
Final Application Deadline: February 17, 2012 ($100.00 penalty)
Application packet available here

Contact Information:
AOA – Certifying Board Services
Phone: (312) 202-8195
ekraynak@osteopathic.org

Visit www.acoi.org/CertGen.html for additional information.




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ACOI Contacts
Thomas F. Morley, DO, FACOI
President
tmorley@comcast.net
Jack D. Bragg, DO, FACOI
President-Elect
braggj@health.missouri.edu
Kelly Schiers, DO
Board of Directors Resident Representative
schierka@umdnj.edu
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
Robert A. Cain, DO, Vice Chair
racain@sbcglobal.net
Gary L. Slick, DO (AOBIM)
aobim@mail.com
Susan M. Enright, DO
senright@genesys.org
Joanne Kaiser-Smith, DO
jksdoc@aol.com
Robert T. Hasty, DO
hasty@nova.edu
Frederick A. Schaller, DO
frederick.schaller@touro.edu
John M. Kauffman, Jr., DO
Contact by Email
Jo Ann Mitchell, DO
Contact by Email
Maryanne Samuel, DO
Council Resident Representative
maryanne@nova.edu