• Record Convention Reflects Growth of Internal Medicine
• Approaching the Elderly Patient
• Through the Eyes of a Generation X Physician
• Board Question of the Month
• Interesting Case of the Month
• Advocacy
• Federal Courts Divided on Constitutionality of Health Care Reform Act
• News of Note
• New Resident Representative to Education Council Announced
• ACOI Staff Resources for Residents and Fellows
• Resident/Fellow Check List of Responsibilities
• ACOI Contacts
• Council on Education and Evaluation

RECORD CONVENTION REFLECTS GROWTH OF INTERNAL MEDICINE

The 2010 ACOI Annual Convention and Scientific Sessions took place at the end of October in San Francisco. It was the largest and most successful ACOI Convention ever held. Internal medicine is the fastest growing specialty in the profession. That trend was reflected in our convention attendance, with nearly 1200 practicing physicians, residents, fellows and students registered.

• First Place: "Optimal Timing of Tracheotomy Utilizing APACHE III Scores as a Clinical Predictor: A Retrospective Study"
  Heather Scheper, DO (Third-year, Mount Clemens)
• Second Place: "DKA Etiology"
  Nick Sansone, DO (Third-year, Midwestern/CCOM)
• Third Place: "Urinalysis: An Underutilized Resource: Indications and Interpretations"
  Nicole Longo, DO (Third-year, PCOM)

• First Place: "Hyperammonemic Encephalopathy in Multiple Myeloma"
  Thomas Nasheir, DO (Third-year, Richmond Heights)
  Kris Palmer, DO (Third-year Richmond Heights)
  Amanda Zarowitz, DO (Third-year Richmond Heights)
• Second Place: "Treatment of Severe P. Falciparum Malaria with Artesunate"
  Kristine Angelo, DO (Third-year Arrowhead Regional Medical Center)
• Third Place: "Babesiosis (WA-1) Transmitted by Plasma Transfusion in an Asplenic Patient"
  John H. Grider, DO (Third-year Northeast Regional Medical Center)

THE APPROACH TO THE ELDERLY PATIENT

I hope that everyone had some time to be with your families over the holidays and I invite you use the New Year to reflect on the coming year.

As the population of the country ages, the practice of Internal Medicine increasingly involves the care of the geriatric patient. I would guess that your current rotation or assignment has you caring mostly for people over the age of 60. There are some things to remember when seeing people of this age.

Time: be prepared to take some extra time with the elderly. It may take them a little longer to understand your questions and to give you the right information. If you ask a question a couple of different ways and allow time for response, you will likely get the information you are looking for. We are all busy, try not to get frustrated.

Hearing: an elderly patient may have trouble hearing you. Hearing impairment may be mistaken for cognitive impairment. Yelling is often not needed, but good enunciation and speaking slowly work best. Ask family members which ear is better for hearing and if the patient wears hearing aids. Many clinics and hospitals have devices that can be worn like headphones by the patient, which amplify your voice so that you can be heard without shouting.

Respect: both theirs and yours. An elderly patient may defer all clinical decisions to you because you "are the doctor." This is a big responsibility. Always be respectful and help the patient and their family get to the right decision. In addition, the very elderly patient is often very thankful for your time and care. This generation does not feel "entitled" or demanding, for the most part. It feels good to care for someone who understands that you are doing your best to help them and is thankful for your efforts.

Complex medical care: The elderly patient almost certainly has more than one medical issue or chronic disease process. These issues interplay within your patient and certainly influence your plan of care (one of the most frequently seen is the patient with both renal failure and congestive heart failure). The literature can help guide you in your medical plan, but there are few randomized studies in patients where the studied group was all over the age of 75 or 80, and even fewer where the patients resided in a nursing home and was taking 20 medications (a typical patient on the Internal Medicine service). So let the studies guide you, but know that these people have complex medical issues and may not follow the expected course. The intellectual puzzle that this provides an Internist is one of the great benefits of the profession.

End of Life care: This is something that is learned through mentors and also time and practice. After providing all the best care, including taking time to talk to a patient and their family, there will be a time to make sure that the patient is comfortable and allowed to pass away with respect. Keep the patient and family updated on their condition, provide informed medical insight, and allow for discussion on how the person would like to be treated in the face of their current illness. These are hard conversations. Allow for lots of time and take time to listen to everyone.

The elderly patient is going to be the majority of your patient population on a Medicine clerkship, while you are a resident and once you start an Internal Medicine practice of any sort. Learning how to communicate with these nice people and enjoy their company will be important for your happiness as an Internist.

Please feel free to comment or send any questions to me about this article or anything else having to do with Internal Medicine, The ACOI, or student/resident issues.

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THROUGH THE EYES OF A GENERATION X PHYSICIAN

A few months ago, I came across an article in Physicians Practice while sitting in a waiting room as a patient. Titled "Hiring a Young Gun" (Vol 19, No 3), editor Kellie Rowden-Racette explored a description of young physicians that seemed intriguing but was not one that I had stopped to think about previously... Does the current generation of residents and young doctors prioritize quality-of-life more than previous generations, and if so, what does that mean for the future of medicine?

Labeled Generation X and Y (typically regarded as being born from 1968-1982 and 1983-1995, respectively), this may be the first group of doctors to consistently place their personal time, well-being and quality of life as "first" when making decisions, including choices about what type of medical practice they desire. Rowden-Racette comments, "Unlike past generations, today's new physician work force... aren't motivated by traditional carrots, like promotions or money, and instead, are seeking balance between their work and personal lives." While Rowden-Racette is not herself a young physician (or a physician at all), she seems to have tapped into an idea that may hold true.

In fellowship at a fairly large training program, I started asking everyone from students to young attendings about the possibility of a generational divide in priorities. Again and again, people told me that they would choose a position that allowed the best balance between work and personal life, with an emphasis on enough time to spend with family. Consistently, people were willing to have less income if it meant a better lifestyle. Interestingly, males and females equally commented that part-time employment was something they would consider. I admit this is not a scientific survey, but I was surprised with the consistency in answers. Many also stated their work ethic is no different from their predecessors; it is just a matter of the balance that they want to strike between their careers and personal lives.

If Rowden-Racette is correct, what does this mean for the future of physician employment? According to the AAMC 2009 State Physician Workforce Data Book, 82% of physicians are age 40 or older, with one-third of physicians reaching retirement age during the next decade. The most recent American Medical Group Associate/Cejka Group Survey found part-time physician numbers growing steadily each year (19% in 2007, to 21% in 2009). If the vast majority of physicians are over 40 years old, more each year only working part-time, and the newest doctors are interested in restructuring their jobs to better suit personal needs, could the projected physician shortage be worse than feared?

The AAMC anticipates a dearth of 91,500 medical providers by 2020 - given the notion of generational changes, could this be a gross underestimation? Please let me know what you think. I'll share your feedback with our colleagues in a future article. Kelly A. Schiers, DO

BOARD QUESTION OF THE MONTH

Bell Palsy is most often considered to be due to herpes simplex viral activation. Other etiologies can be identified in some cases. Of the following, which is most likely to cause acute facial nerve palsy?

1. Lyme disease
2. Rickettsial infection
3. HIV infection
4. Extrapulmonary tuberculosis infection
5. Melkersson-Rosenthal Syndrome

INTERESTING CASE OF THE MONTH

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FEDERAL COURTS DIVIDED ON CONSTITUTIONALITY OF HEALTH CARE REFORM ACT

Specifically, the court struck down the provision that requires individuals to carry a minimum amount of health care insurance unless they qualify for one or more of the exceptions established in the ACA (the individual mandate). At issue is whether or not the Commerce Clause of the Constitution can be used to require an individual to purchase a minimum level of health insurance. Prior to the ruling issued by Hudson, other federal courts found the provision in question to be constitutionally sound. This ruling establishes an emerging division within the federal courts and increases the probability that the Supreme Court will address the issue. It appears likely that this particular case will be the case considered by the Supreme Court to determine the constitutionality of the individual mandate. The Fourth Circuit Court of Appeals is expected to hear the appeal in this case in early 2011. The Supreme Court will hear this or a similar case prior to the 2012 elections. Additional information will be provided as it becomes available.

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