• IM Certification Exam Application Deadline Approaches
• How to Get Involved With Research as a Student and Resident
• Reflecting on the End of the Calendar Year
• Resident Restrictions
• Board Question of the Month
• Health Care Reform Package Approved by the Senate
• News of Note
• ACOI Staff Resources for Residents and Fellows
• Resident/Fellow Check List of Responsibilities
• ACOI Contacts
• Council on Education and Evaluation

IM CERTIFICATION EXAM APPLICATION DEADLINE APPROACHES

The ACOI staff and leadership hope that each of you has a healthy and successful 2010. For those of you planning to sit for the internal medicine or subspecialty certifying examinations this year, please pay close attention to the application deadlines. Applications must be submitted to the American Osteopathic Board of Internal Medicine (AOBIM) by February 1 for the internal medicine exams and April 1 for the subspecialty exams. If you are completing training this year, it is a very good idea to sit for certification immediately. It consistently has been shown that the pass rate declines precipitously for those who delay taking the certifying exam by as little as one year after training completion.

Brian J. Donadio, FACOI

HOW TO GET INVOLVED WITH RESEARCH AS A STUDENT AND RESIDENT

A case study is a good place to start. Find a patient that is a “good case,” get all of the patient’s information and do a literature review. Presenting these cases at various medical meetings is educational and can be a lot of fun.

If you are in a smaller hospital, it may be a little harder, but there is research to be found. Talk to people in the hospital IRB (Internal Review Board) and ask what kind of research is taking place. Ask staff of the various departments to see if there is anything interesting ongoing.

Another avenue is to do it your-self. Not all-worthwhile research is national, multi-centered trials. Is there a clinical question that has been bothering or interesting you? Things like: How can we lower length of stay and readmission rates for our elderly patients with CHF? Who can we increase compliance with inpatient vaccinations? Once you have a question, think about a solution and/or possible intervention. Finding someone to help you through the process will be helpful.

A good place to start would be a current literature search to find out what has already been found on a topic. Then ask yourself what your clinical question is. Then figure out how you would like to obtain this information (chart review, prospective patient analysis, patient survey, etc).

Data analysis can be difficult and most Hospitals have a statistician to help you out, or can point you in the direction of a solid company.

Once the analysis is done, you need to send your research paper to various meetings or journals. This can be a time consuming and frustrating process as well, but stick with it. There is a real sense of pride seeing your name in print in a national journal, or up on a poster at a national convention.

This can be a lot of work, but it is also a great accomplishment to have started completed and hopefully published your own research project.

Please contact me if you have any questions, or would like to discuss anything further.

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Reflecting on the End of the Calendar Year

As the new year gets underway, it is interesting to reflect on the closing of the old year. As the last month of the calendar year, December has an attraction for activity. Holiday spirits and festivities abound. Colorful lights adorn trees, store windows are decorated with bargain prices beckoning patronage, and schools across the country are encouraging thoughts of New Years resolutions. Yet amidst the excitement, December, for the resident is the midpoint of the academic year. By this time, the first year resident has acclimated to the clinic and hospital system, the second year resident has decided if future training through fellowship is warranted and the third year resident is feeling comfortable in the hierarchy of Internal Medicine training. Despite the flurry of activity, December is at a junction where a thorough self-examination permits the time and opportunity for self-correction.

While on trial for encouraging students to question convention, Socrates chooses to defend his commitment to truth and knowledge. The Athenian jury offers him exile, permanent silence on the subject, or death. He responds by immortalizing the phrase, “the unexamined life is not worth living,” and chooses death. He shows us that in order to fully understand the truth behind a belief or action, we must challenge. If we do not look back on our actions we will never find our errors or be able to correct our mistakes.

As physicians, our profession in comparison to others is held to a higher standard. On a daily basis we make clinical judgments that impact the lives of many. Our experience, the art of medicine, is a result of those judgments. If we take time to examine our actions and thought processes, our clinical judgment sharpens. Honing skill becomes the result of practiced self-examination.

Making an honest inventory of our misdeeds is humbling. Yet comfort can be found in the knowledge that now that mistakes have been identified the chance of repeating them has lessened. There are six more months left in the year before our responsibilities and expectations change. Plenty of time to make adjustments in preparation for the challenges of the upcoming year. I encourage you all to take some time for reflection and hope you have a successful new year!

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RESIDENT RESTRICTIONS

Have we seen any improvement in patient care since the establishment of the 80 hour rule? An article published in the New England Journal of Medicine in October of 2004 found that Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. It concluded that eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit. This was supported by a study published in the September 5, 2007 issue of the Journal of the American Medical Association (JAMA). In this VA study, over 300,000 patients admitted to acute care hospitals from 2000-2005 were checked for all cause mortality. It concluded that the ACGME duty hour reform was associated with significant relative improvement in mortality for patients with four common medical conditions in more teaching-intensive VA hospitals in post-reform year two. These conclusions were challenged by a parallel article in the same issue of JAMA that analyzed over eight million Medicare cases from 2001 to 2005. This study looked at all location mortality within 30 days of admission to the hospital system. It concluded that duty hour reform was not associated with either significant worsening or improvement in mortality for Medicare patients in the first two years after implementation. In truth, there is no good way to assess the impact of the 80 hour rule on patient care. There are simply too many variables that must be taken into consideration, and finding the line between correlation and cause/effect can be difficult.

As I am sure many of you are aware, internal medicine residents seem to be particularly vulnerable to burnout. Our programs are driven by long hours, frequent call nights, high acuity patients and, frequently, little oversight. Many struggle with the increased work load and responsibility that comes with being in this field, and many more are still trying to learn about the tests that they are ordering. Interestingly, one of the primary groups to be against the work hour rules has been internal medicine residents as a whole. There is a sense of being better rested and having an increased ability to make quick decisions, but there is also a sense of dissatisfaction toward the learning environment. A study in the Archives of Internal Medicine looked at the concept of burnout in Internal Medicine residents. The authors felt that the hallmark features were emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. Utilizing a Likert scale survey, the study found that there was a significant drop in the amount of emotional exhaustion felt among internal medicine residents and that there was a trend toward decreased depersonalization. However, there was also a significant decrease in overall residency satisfaction during the same time period. Most recently, a study published in the Journal of Hospitalist Medicine found that duty hour restrictions have decreased the teaching time for as many as 25 percent of internal medicine residents, while the restrictions have not significantly decreased the amount of time spent in patient care. This study also encourages hospitalists to take the lead in teaching that has been dropped by the residents, which leads to one of many unintended consequences.

The law of unintended consequences is that actions of people always have effects that are unanticipated or unintended. It is the challenge of any physician to be aware of and attempt to minimize these effects by making every effort to educate ourselves and think from a higher ground. In regard to work hours: continuity has been lost, hazing of new physicians is a constant presence, there is loss of patient ownership, attendings are not picking up the educational slack, there are few over all patient encounters, fewer procedures to log for credentialing, and more young physicians who do not feel comfortable in practice after their residency. So why is this important? Effective July 1, 2010, the Accreditation Council for Graduate Medical Education is adopting rules changes that will further restrict the number of patients internal medicine residents may follow. At this time, osteopathic education leaders have adopted similar restrictions, but further change is likely. I feel that it is important that residents consider what they want in their residency programs, consider the unintentional consequences, and make sure that we are building a medical education system that is patient-centered.

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 54 year old patient returns to your office for a blood pressure recheck. One month ago you had increased his hydrochlorothiazide from 12.5 mg a day to 25 mg a day as his blood pressure was still not controlled. Today his blood pressure is 138/88. He states he has been adhering to a low sodium, high potassium diet. He has no other medical problems except obesity: his BMI is 31. Lab evaluation done on the previous day showed the following results: Na- 140, K-3.0, Cl-95, CO2-25, Mg-1.8, Ca-9.9, Bun-25, creat-1.0. What would be your next recommendation?

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HEALTH CARE REFORM PACKAGE APPROVED BY THE SENATE

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