1

Vol. 36

Num. 9

Sep 13

To Promote Improved

Patient Care, Research, and

Education in Primary Care and

General Internal Medicine

InspireInformConnect

CONTENTS

1. Commentary . . . . . . . . . . . . . . . . . 1

2. Sign of the Times Part I . . . . . . . . . 2

3. President’s Column . . . . . . . . . . . . 3

4. Morning Report . . . . . . . . . . . . . . . 4

5. New Perspectives: Part I . . . . . . . . 5

6. Sign of the Times Part II . . . . . . . . 6

7. From the Society: Part I . . . . . . . . . 7

8. From the Editor . . . . . . . . . . . . . . . 8

9. New Perspectives: Part II . . . . . . . 9

10. From the Society: Part II . . . . . . . 10

SGIMFORUMThe Society of General Internal Medicine

COMMENTARY Changing Jobs: Four Lessons LearnedDenise Millstine, MD

Dr. Millstine is a member of the Forum editorial board and can be reachedat Millstine.Denise@mayo.edu.

continued on page 13

We can barely open a journal or newsletter without being remindedthat these are changing times in health care. Never in the history

of providing healing to patients have physicians found a more shiftinglandscape. With uncertainty comes dissatisfaction and with dissatisfac-tion, change.

Estimates for the number of physicians planning to change jobs inthe next year vary. Jackson Healthcare, a large physician staffing service,surveyed thousands of doctors in 2013 and found nearly a quarter wereplanning to change jobs in the next year.1 Job changes may be occurringmore frequently, but they are hardly a new phenomenon. Still, very littleis published regarding these transitions in the workforce.

In the last six months, I chose to leave a community academic med-ical center for another academic position. My reasons were varied. Thenew position offered a scope of practice more aligned with my clinical in-terests and training. I deemed the potential for professional developmentto be greater with new mentors and collaborators. My commute timewould be reduced dramatically, and I would be able to spend more timewith my young family. Still, the decision for the change was a difficultone. My old position had offered many opportunities, and I was part ofan established and familiar team. I opted to take the leap. In the process,I learned the following lessons.

Where Nobody Knows Your Name: Re-establishing Your ReputationIn a new position, your reputation is not established. This affects minorand major details alike. Whether you wear a suit or khakis is suddenlyinterpreted as part of your professionalism. Whether you practice medi-cine by applying the US Preventive Services Task Force, American Con-gress of Obstetrics and Gynecology, American College of Radiology, orAmerican Cancer Society guidelines matters as well, particularly if yourguideline organization of choice differs from that of your new colleagues.

OFFICERSPresidentEric B. Bass, MD, MPH Baltimore, MDebass@jhmi.edu (410) 955-9871

President-ElectWilliam P. Moran, MD Charleston, SCmoranw@musc.edu (843) 792-5386

Immediate Past-PresidentAnn B. Nattinger, MD, MPH Milwaukee, WIanatting@mcw.edu (414) 805-0840

TreasureKatrina Armstrong, MD, MSCE Boston, MAkarmstrong6@partners.org (617) 726-8447

Treasurer-ElectMartha Gerrity, MD, MPH, PhD Portland, ORgerritym@ohsu.edu (503) 220-8262

SecretaryGiselle Corbie-Smith, MD, MSc Chapel Hill, NCgcorbie@med.unc.edu (919) 962-1136

COUNCILDavid W. Baker, MD, MPHChicago, ILdbaker1@nmff.org(312) 503-6407

Clarence H. Braddock III, MD, MPHStanford, CAcbrad@stanford.edu(650) 498-5923

Shobhina G. Chheda, MD, MPHMadison, WIsgc@medicine.wisc.edu(608) 263-2780

Hollis Day, MD, MSPittsburgh, PAdayh@upmc.edu(412) 692-4888

LeRoi S. Hicks, MD, MPHWorcester, MAleroi.hicks@umassmemorial.org(508) 334-6440

Michael D. Landry, MD, MSNew Orleans, LAmlandry@tulane.edu(504) 988-5473

Health Policy ConsultantLyle DennisWashington, DCldennis@dc-crd.com

Executive DirectorDavid Karlson, PhD1500 King St., Suite 303Alexandria, VA 22314karlsond@sgim.org(800) 822-3060;(202) 887-5150, 887-5405 Fax

Director of Communicationsand PublicationsFrancine Jetton, MAAlexandria, VAjettonf@sgim.org(202) 887-5150

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mix? The second reason is moresubtle—geriatricians are often pri-mary care providers and not per-ceived as referral specialists. If thegeneralist refers, he/she may be giv-ing up the care of the patient.

First, why add to the mix? Geria-tricians are trained to simplify. Theymay look at the patient’s medicationregimen, both prescription and non-prescription; modify the regimen ifadverse interactions are present;eliminate duplication; and make sureall participating health care profes-sionals are aware of each other’s ac-tivities with regard to the patient. Itmay be, for example, that our pa-tient with Parkinson’s developed atremor after starting an SSRI, beingseen by the neurologist, receivingthe diagnosis of Parkinson’s, andstarting carbidopa/levodopa, perhapswithout direct involvement of the in-ternist. The outside observer—thegeriatrics professional—may be ableto see the time pattern of symp-toms, change the antidepressant,and eliminate the need for the car-bidopa/levodopa.

Second, although most geriatri-cians do have a panel of primary carepatients, they also work as referralspecialists, and if you the internistwant to continue to manage your pa-tient, you simply need to make itclear that you consider the referral arequest for expert advice, not trans-fer of care. The patient and familyshould also be aware that you wantto continue to be involved so thatthey know to whom to return.

What about when to refer? Ioften hear, jokingly, that an internistdecides to refer an older patientwhen the visit takes longer than 15minutes. In truth, however, com-plexity is a major factor in decidingto refer. An internist’s schedule isnot designed to deal with five

Irecently asked a group of internalmedicine residents the differencebetween internal medicine and geri-atrics, and the overwhelming answerwas that there was none. Good, Ithought. I can write a different article.

But, of course, I am a geriatrician.I think there are enormous differ-ences between what I see and whata general internist regularly handles.Just as I shudder when (rarely) facedwith a woman with menometorrha-gia, I imagine that the generalistdreads an appointment with an agi-tated, aggressive, and paranoid 85-year-old man with Parkinson’s diseaseand two exhausted offspring.

However, if you have been treat-ing that 85-year-old patient withParkinson’s for the last 15 years, youmay not notice right away when thegeriatrics referral can help. Funny,you referred directly to the neurolo-gist when he developed a tremor,but why make a geriatrics referral?

So, should you refer? If so,when? And why are you reluctant?

Let’s look at the last questionfirst—reluctance to refer. Many prac-titioners do not refer because theyfeel that patients already see toomany physicians. Why add to the

SIGN OF THE TIMES: PART I

Outpatient Geriatrics Referrals:A Balancing ActPatricia Harris, MD

Dr. Harris is a member of the Forum editorial board and can be reached atpatricia.harris.md@gmail.com.

SOCIETY OF GENERALINTERNAL MEDICINE

continued on page 12

EX OFFICIO COUNCIL MEMBERS

Chair of the Board of Regional LeadersChristopher Masi, MD, PhD Evanston, ILcmasi@northshore.org (847) 250-1277

ACLGIM PresidentStewart F. Babbott, MD, FACP Kansas City, KSsbabbott@kumc.edu (913) 588-5165

Co-Editors, Journal of General Internal MedicineMitchell D. Feldman, MD, MPhil San Francisco, CAmfeldman@medicine.ucsf.edu (415) 476-8587

Richard Kravitz, MD, MSPH Sacramento, CArlkravitz@ucdavis.edu (916) 734-1248

Editor, SGIM ForumPriya Radhakrishnan, MD Phoenix, AZpradhakri@chw.edu (602) 406-7298

Associate Member RepresentativeBrita Roy, MD, MPH Birmingham, ALbritaroy@uab.edu (248) 506-1511

In my last column, I introducedSGIM’s new tag line—“CreatingValue for Patients.” While waiting tohear the reaction to the tag line, Ispent the last month thinking aboutthe opportunities that SGIM mem-bers have to create value for patientsthrough their work in research, edu-cation, and clinical practice. There isno question in my mind that we havemany such opportunities! The prob-lem is that the academic approach toour scholarly work often falls short ofthe mark when measured in terms ofthe impact on our patients. To ad-dress this problem, we need to giveserious attention to changing acade-mic promotion priorities.

As a member of the ProfessorialPromotion Committee at the JohnsHopkins University School of Medi-cine, I see what is valued in promo-tion decisions. The h-index provides aconvenient measure of a facultymember’s scholarly productivity,measuring the number of publica-tions that have been cited in otherpublications at least h times. If an in-vestigator has published 40 peer-re-viewed journal articles that havebeen cited 40 or more times, thecandidate almost always will be pro-moted. Usually, candidates with astellar h-index have other convincingevidence of the national and interna-tional impact of their work. However,we frequently have only limited evi-dence of how the work has bene-fited patients. For candidates lackinga high h-index, we struggle to findevidence of impact even when itseems relatively obvious that pa-tients have benefited tremendously.

What can promotion committees

do to support efforts to create valuefor patients? At many schools, pro-motion committees have createdmultiple tracks to recognize differentforms of scholarship. Indeed, clini-cian-educators in SGIM helped leadthe way in advocating for changes inthe criteria for promotion thatbrought greater recognition to educa-tors.1-4 Similar efforts are needed torecognize the scholarly work of thosefaculty members who are workinghard to bring value to patientsthrough activities beyond traditionalresearch and education.

One of the best examples ofscholarly work that directly benefitspatients is in the area of quality im-provement and patient safety. Unfor-tunately, only a few medical schoolsexplicitly recognize quality improve-ment and safety activities as a pathto promotion. In my institution, whichhas a “one-track” promotion system,faculty can get promoted based onthe quality and impact of scholarshipin quality improvement and patientsafety. The difficulty lies in how wemeasure the impact of such work,since standard publication metricsare inadequate.

Recently, the SGIM AcademicHospitalist Task Force published astatement advocating for use of aquality portfolio to document qualityimprovement and patient safety ef-forts.5 The Task Force recommendedincluding six categories in the qualityportfolio: 1) leadership and adminis-trative activities; 2) project activities;3) education and curricula; 4) re-search and scholarship; 5) honors,awards, and recognition; and 6) train-ing and certification. The Task Force

PRESIDENT’S COLUMN

Creating Value for Patients: Implications forAcademic Promotion PrioritiesEric B. Bass, MD, MPH

One complaint I’ve heard frompromotion committee members whoare not fans of portfolios is that theybecome lengthy tomes that merely listnumerous activities without providingsubstantive measures of impact.

continued on page 11

emphasized that outcomes and re-sults were the most important com-ponents of the section on projectactivities. In my opinion, the TaskForce’s statement did not go farenough in emphasizing the impor-tance of highlighting measures of im-pact, such as the number of patientsbenefiting from each project. Onecomplaint I’ve heard from promotioncommittee members who are notfans of portfolios is that they becomelengthy tomes that merely list nu-merous activities without providingsubstantive measures of impact. If aportfolio succinctly summarizes evi-dence of impact on patients, it willbe much more valuable.

I believe we should be advocat-ing for widespread adoption of theTask Force’s recommendations, not-ing that the quality portfolio hasbeen endorsed by SGIM, the Asso-ciation of Chiefs and Leaders inGeneral Internal Medicine(ACLGIM), and the Association ofProfessors of Medicine. We should

3

EDITOR IN CHIEF

Priya Radhakrishnan, MD Priya.Radhakrishnan@DignityHealth.org

MANAGING EDITOR

Christina Slee, MPH tinaslee@me.com

EDITORIAL BOARD

Chayan Chakraborti, MD cchakra@gmail.comDeepa Bhatnagar, MD dbhatnag@tulane.eduMichele Fang, MD michele-fang@uiowa.eduPatty Harris, MD, MS patricia.harris.md@gmail.comFrancine Jetton, MA jettonf@sgim.orgMike Landry, MD, MS mlandry@tulane.eduDenise Millstine, MD Denise.Millstine@DignityHealth.orgDouglas Olson, MD olson.douglas@gmail.comLeigh Simmons, MD lhsimmons@partners.orgNeeraj Tayal, MD Neeraj.Tayal@osumc.eduCharmaine Wright, MD smich@mail.med.upenn.edu

The SGIM Forum is a monthly publication of the Society ofGeneral Internal Medicine. The mission of The SGIM Forum isto inspire, inform and connect—both SGIM members and those in-terested in general internal medicine (clinical care, medicaleducation, research and health policy). Unless specifically noted,the views expressed in the Forum do not represent the official po-sition of SGIM. Articles are selected or solicited based ontopical interest, clarity of writing, and potential to engage the read-ership. The Editorial staff welcomes suggestions from the reader-ship. Readers may contact the Managing Editor, Editor, or EditorialBoard with comments, ideas, controversies orpotential articles. This news magazine is published by Springer. TheSGIM Forum template was created by Phuong Nguyen(ptnnguyen@gmail.com).

SGIM Forum

4

A38-year-old Caucasian womanwith no prior medical history pre-

sents to the emergency departmentwith a rash on her lower back thathas spread over the course of threedays to cover her anterior trunk,face, upper back, and extremities.The spreading rash is associatedwith fevers of 103° F with rigors,nausea, vomiting, and progressiveepigastric pain.

Given the acuity of the rash, theinitial differential in this case includesinfection, autoimmunity, and a hyper-sensitivity reaction. In a febrile pa-tient, it is important to rule outsources of infection that could gener-ate a fever, such as pneumonia, uri-nary tract infection, skin infection, oracute abdomen. An acute rash canprovide clues as to possible autoim-munity or drug reaction, and the his-tory of any antecedent events ornew medications can suggest causal-ity. A thorough history and physicalexam can help to narrow the differ-ential diagnosis. Judicious use oflabs guided by clinical suspicion willhelp us to rule in or out variouspathophysiologic entities.

On further history, it is discoveredthat the patient had taken a two-week course of amoxicillin for a den-tal extraction that was completed sixweeks prior to presentation.

The rash is initially maculopapularbut progressively coalesces and be-comes confluent, particularly on theback, chest, and face. The facial rashis associated with edema (sparingthe eyes) and erythroderma. Concernfor progressive desquamation isnoted. Cervical lymphadenopathy andhepatomegaly are also noted.

Initial laboratory testing reveals anaspartate aminotransferase of 1,074U/L; an alanine aminotransferase of1,493 U/L, concerning for acute he-patitis; and a total bilirubin of 1.4mg/dL, alkaline phosphatase of 235U/L, WBC of 6.67 x 1,000/mcL, he-

et al. yielded a point total of 5, desig-nating this as a probable case ofDRESS.3 Despite the fact that this pa-tient did not have eosinophilia, the lit-erature shows variable occurrence ofeosinophilia in confirmed cases; it isnot required to make the diagnosis.4

Amoxicillin is a widely used antibi-otic and is often a first-line agent,largely due to its safe administration.Due to its heavy use in outpatientsettings, an accurate gauge on pre-scription rates is challenging. Studieshave shown that 52% of dentists useit as first-line therapy for infection5

and that it is the most frequently dis-pensed prescription among infantsand children.6 Another study suggestsa high rate of amoxicillin prescribingdue to its placebo effect.7

Despite its common uses, amoxi-cillin has only been implicated as acause of relapse of DRESS syn-drome. While there are many docu-mented cases of amoxicillinprovoking a penicillin-like hypersensi-tivity allergy, this is a distinct andseparate clinical entity from DRESS.DRESS syndrome has been reportedwith other antibiotics (e.g. minocy-cline, streptomycin, sulfamethoxa-zole, vancomycin)—and notablyamoxicillin plus clavulanic acid—butamoxicillin as the primary instigatorhas not been demonstrated.

DRESS syndrome often presentsvery similarly to an acute viral hepati-tis, and should be worked up assuch. But given the 10% mortalityrate and the length of time it takesfor autoimmune serologies to be re-sulted, it is crucial to considerDRESS when presented with thisconstellation of symptoms. Oncerecognized, the primary treatmentfor DRESS syndrome involves stop-ping the offending agent. Case se-ries have shown DRESS syndromeas usually beginning with fever ac-companied almost uniformly with a

moglobin of 13.3 g/dL, hematocrit of39.3%, and platelets of 164x1,000/mcL. Hepatitis serologies areall negative, and EBV serologies areconsistent with past infection. CMVIgM is negative, with IgG positive.HSV 1/2 is negative, as is anti-smooth muscle antibody, anti-mito-chondrial antibody, and theantinuclear antibody. Blood culturesand urinalysis are also negative.

Given the findings on history andphysical exam, the diagnosis ofDRESS syndrome is considered.DRESS syndrome (drug reaction witheosinophilia and systemic symp-toms), also known as drug-inducedhypersensitivity syndrome (DIHS), isa relatively common disorder occur-ring in one out of every 1,000 to10,000 new drug exposures.1 Its clin-ical presentation consists of fever,mucocutaneous rash, lymphadenopa-thy, hematologic abnormalities andatypical lymphocytes (most ofteneosinophilia), and hepatitis. It occa-sionally involves other organs pre-sumably due to eosinophilicinfiltration.2 It commonly has onset ofthree weeks to three months afterexposure to drug therapy.2 DRESS isassociated with a 10% mortality rate,usually due to organ failure thoughtto be from eosinophil infiltration,making early recognition and treat-ment especially important.

The diagnosis of DRESS is madebased on the characteristic presenta-tion (e.g. rash, fever, adenopathy, andhepatitis) with a known drug expo-sure and a negative infectiousworkup. The patient had already com-pleted the prescribed amoxicillincourse six weeks prior and wasstarted on systemic steroid therapywith a planned prolonged taper.Transaminases continued a down-ward trend in the hospital, and therash began to resolve at time of dis-charge. Application of the RegiSCARscoring criteria described by Karduan

MORNING REPORT

Amoxicillin-induced DRESS SyndromeJoseph R. Roberts, MD (presenter), and Julia J. Rhiannon, MD, MSW (discussant, in italic)

Dr. Roberts is a PGY-1 and Dr. Rhiannon is assistant professor in the Department of Medicine at theUniversity of Colorado.

continued on page 12

Change and adaptability were defi-nitely the themes at the recent

Colorado Residency Patient-centeredMedical Home (PCMH) ProjectLearning Collaborative in Denver, CO.I had the opportunity to representHigh Street Primary Care Center, aUniversity of Colorado practice that isthe newest addition to the Collabora-tive as well as the only general inter-nal medicine residency program ofthe group. There was a palpablesense of creative energy throughoutthe two-day event as individuals andprograms came together to discusstheir progress in the past year andreview the successes and obstaclesthat other programs had experi-enced. I attended a number of break-out sessions and group discussionson topics such as disruptive innova-tion, managing complex patients, andprofessionalism, as well as the roleof the personal physician within thePCMH model.

I heard quite a bit about PCMHsduring my medical education, but Ido not think I ever really had a goodunderstanding of what makes themso unique. None of the ideas I hadpreviously heard seemed very radi-cal to me. Group visits, patient reg-

health records for standard report-ing. Many of the problems encoun-tered were similar across differentprograms, and it was interesting tonote the variety of different ap-proaches to solving them. Creatinga culture of change when financialsupport is lacking and overcomingthe inertia to change are difficult.The process is not always smoothin the evolution of a PCMH andoften progresses in fits and startsas unique obstacles are faced andvarious solutions are implemented.

This is without a doubt a veryexciting time for primary care. Asresidents, we are uniquely posi-tioned to take a prominent role indelivery system redesign. Whetheror not the PCMH model remains adominant model of change ormerely a chapter in the history ofprimary care will depend on whethercollaboratives, such as the one I at-tended, continue to exist and helppractices push the envelope forchange. I do believe that the focuson patient care and many of the dri-ving forces behind the PCMH initia-tion will continue to transformprimary care for the better.

SGIM

istries, quality improvementprocesses, electronic healthrecords, transitioning toward team-based care, and increasing accessthrough open-access schedulingjust seem like common-sense prac-tices that should be standard ofcare rather than some revolutionarynew concept. Unfortunately, thesepractices are a lot less commonthan they should be, are often diffi-cult and costly to implement, andrarely have demonstrable benefitsin the short term. During this collab-orative I gained a deeper apprecia-tion for the goals of the PCMHs andthe difficulties faced in makingthem a reality.

The transition from a physician-centered “doctor’s office” to a “pa-tient-centered” medical home is aprofound one and not to be over-looked. The terminology itself iseven important, as it signifies thetrend in medical care toward patientautonomy and away from physicianpaternalism. The core of the PCMHseems to be a commitment to pa-tient care supported by quality im-provement systems, with an abilityto evaluate reliable outcomes databy using and configuring electronic

5

NEW PERSPECTIVES: PART I

A General Internal Medicine Resident’s Appraisal of the MedicalHome: Innovation or Evolution?Steve Mack, MD

Dr. Mack is a PGY-2 in the University of Colorado Internal Medicine Residency Training Program, Primary Care Track.

Student health centers (SHCs)have highly variable characteris-

tics generally reflecting the differingnatures of educational institutions. Ofthe more than 4,000 institutions ofhigher learning in the United States,the 2010 Carnegie Foundation surveyidentified 295 research universities,728 master’s institutions, and 808baccalaureate institutions. In 2012,the Chronicle of Higher EducationAlmanac reported 19 not-for-profitfour-year universities with more than40,000 students each and listed Ari-zona State University as the largestwith 70,440 students. Although atone time facilities for overnightinfirmary care were common atSHCs, this is now rare. For practicalpurposes, SHCs are outpatientcenters—but they can be very busywith hundreds of visits per day.Many SHCs experience dramatic de-mand surges such as when mostmembers of a living unit present forthings like scabies or other actual orsuspected communicable diseaseoutbreaks. The H1N1 influenza out-break in 2009 highlighted the de-mand surges and other uniquedelivery system factors that canoccur in the student health setting.The SHC director is often an informalpublic health officer for the campus.

Most SHCs are administeredthrough departments of student lifeor student affairs. These administra-tive units typically have responsibilityfor housing, food services, registra-tion, admissions, student counseling,and other aspects of campus life.Most often, the clinical services ofthe student counseling center andthe SHC are managed by appropriateprofessionals (i.e. psychologist andmedical practitioner, respectively),but their services are qualitatively dif-ferent from the remainder of activi-ties administered through thestudent life/affairs department.

portal. Our EHR (EpicCare) supportsrapid sequential care by multipleproviders. We reserve approximately50 medical provider and 80 consult-ing nurse “appointment slots” perday. Of patients who request medicalcare, 100% who desire a meetingwith a consulting nurse can have onethat same day, and 80% to 90%who desire or need a provider visitare able to receive a same-day ap-pointment.

Most SHCs use an EHR; mostoften, they are not record systemsthat SGIM members would typicallyuse because they are designed forsmaller practices that are not hospi-tal affiliated. The EHRs contribute toclinical service integration across se-quential providers and patient safetygoals, such as electronic prescrib-ing, but are not directly used foractivities such as attestation for“meaningful use” that are so wellknown to most SGIM members.

Concerns about student mentalhealth have been rising for more thanfive years. Highly publicized acts ofviolence resulting from mental illnessin a student (such as the VirginiaTech shootings) are very unusual butat least partly attributable to subopti-mal mental health care. The preva-lence of mental health disorders hasgrown. (See citation for National Col-lege Health Assessment-II in Sug-gested Reading.) For example, in2012, 5.7% of students reportedbeing diagnosed with a psychiatricdisorder, compared with 4.2% in2008. Comparable rates of attentiondeficit disorder were 7.4% and5.1%, respectively. Mental healthconditions account for a large frac-tion of the chronic illness burden ofadolescents and young adults.

Much more common are less se-vere conditions contributing to diffi-culties with academics or poor

In Part I of this series, I describedthe clinical content of college health.Because the great majority of visitsto a SHC are for acute concerns, thefocus of care tends to be on efficientand cost-effective care pathways forcommon problems, with an oppor-tunistic approach to preventive ser-vices. An “all-physician” clinicalworkforce is unusual, and theprovider group is more often a com-bination of nurse practitioners (NPs)and/or physician assistants practicingside by side with family or internalmedicine physicians. Registerednurses often play a large role in lever-aging the capacity of this workforce.At the University of WashingtonSHC, the medical provider group has16 clinical FTEs. Over the past fiveyears, 40% to 45% of provider timehas been composed of family NPs,with the remainder being composedof physicians. Of the physician time,approximately 75% is family medi-cine, 20% general internal medicine,and 5% gynecology.

Students generally prioritize con-venience of access over continuity ofprovider. Competing schedule de-mands of students create a high de-mand for same-day services. ManySHCs use a consulting nurse serviceas the initial point of assessment,with subsequent care by an NP orphysician. Others, including the Uni-versity of Washington, have a com-bined approach to scheduling: Astudent can call our consulting nurseservice for advice or come for a face-to-face visit. The consulting nursevisit can result in a plan for self-careor a referral to an NP or physician. Inaddition, a student can schedule avisit with a medical provider byphone or via a patient portal inte-grated with our electronic healthrecord (EHR). A student who has anestablished care relationship can alsoseek medical advice via the patient

6

SIGN OF THE TIMES: PART II

College Health: Part IIDavid C. Dugdale, MD

Dr. Dugdale is director of Hall Health Center, Division of General Internal Medicine, Department of Medicine, at theUniversity of Washington in Seattle, WA.

continued on page 14

This fall, the Journal of GeneralInternal Medicine will launch its

premiere site, JGIMWeb, under theleadership of JGIMWeb Editor NeilMehta, MD. The website can be ac-cessed through both “JGIM.org” and“www.sgim.org/JGIM.”

JGIM Web will bring together ex-isting JGIM Web resources, provid-ing streamlined user experience forreaders, authors, reviewers, JGIMeditors, and the press. The websitewill link to the publisher’s site(Springerlink.com), providing full arti-cle access for SGIM members whologin via the “members only” sec-tion of the SGIM website. Authorswill be brought directly to the manu-script management page, which willsmoothly interface with the Regen-strief Institute manuscript submis-sion system. Reviewers will haveaccess to documents on best prac-tices in manuscript peer review,while the Journal’s deputy editorswill be able to find key referencematerial regarding manuscript adju-dication. The press will have accessto updated JGIM press releases, ci-tations in the national/internationalpress, and Journal statistics. Callsfor articles for special issues, sup-plements, and symposia will be reg-ularly posted, as will key articlestatistics for most cited and down-loaded JGIM manuscripts.

Under Dr. Mehta’s leadership,JGIMWeb and social media initiativeswill feature:

(JGIM co-editor in chief), com-mented, “We are excited about thelaunch of the new JGIMWeb, whichwill bring JGIM more firmly into thedigital age. These added-value fea-tures will extend the reach of currentJGIM content and provide the JGIMreadership with a host of new pub-lishing opportunities.” Mitch Feld-man, MD (JGIM co-editor in chief),added, “Under Dr. Mehta’s leader-ship, JGIMWeb will provide cross-platform opportunities to disseminateour current work and create a newtype of dialogue with our readership.”

Dr. Mehta has begun recruitingJGIMWeb associate and deputyeditors. We look forward to yourthoughts on providing value-addedfeatures for our readership. Pleasejoin in our expanded JGIM conversa-tion, and follow JGIM at @JournalGIMand via Google+. SGIM

• Clinical Images and Cases. High-quality, peer-reviewed clinicalimages and short cases,published at regular intervals, willprovide an additional publicationopportunity for SGIM members.(Images/cases may be “Webonly” or Web-formatted materialfrom the print journal.)

• Medicine and Arts (TheLiving Hand). These personalexperiences and reflectionsabout health and health carewill be edited by JGIM WebAssociate Editor Bryan Sisk, MD.

• The Bottom Line. Summaries ofkey original articles, created bythe SGIM Evidence-BasedMedicine (EBM) Task Force, willbe featured here.

• Value added material for medicaleducators. Slide sets andteaching materials from theExercises in Clinical Reasoningseries (led by Carlos Estrada,MD, and Jeffrey Kohlwes, MD)will be available.

• JGIM Twitter. The Twitter feedwill include updates on new JGIMissues, calls for manuscripts,discussions about JGIM articles,and more (@JournalGIM).

• Google+. JGIM will stimulateconversation around currentarticles and features, includingsharing relevant content links.

In response to the developmentof JGIMWeb, Richard Kravitz, MD

7

FROM THE SOCIETY: PART I

JGIM Web Launches in Fall 2013Malathi Srinivasan, MD

Dr. Srinivasan is associate editor for the Journal of General Internal Medicine and can be reached atmalathi@ucdavis.edu.

7JGIM Web Launches in Fall 2013• Check out: "www.jgim.org" or

"www.sgim.org/JGIM"• Find information for authors,

reviewers, readers• Meet Neil Mehta, MD, JGIM

Web editor• Explore new clinical cases and

medical humanities features• Review evidence-based article

summaries• Follow JGIM on Twitter

@JournalGIM• Stay tuned for call for new

JGIMWeb associate editors

Istarted to read this book with trep-idation: Was it a tell-all memoir byone of our own on the practice ofmedicine? Would it bring back un-wanted memories from my intern-ship in a county hospital? Or wouldshe show the public the intricatemechanics of hospital and cliniclife—the good, the bad, and theugly?

Danielle Ofri accomplished all ofthis with great alacrity. I was rivetedfrom the first chapter, which beganwith the journey of Ofri as a newclerk exposed to her first patient, ahomeless woman who presents tothe rape crisis center. Those of uswho have trained and worked insafety net hospitals know this pa-tient well. Although the awfulnessof the situation demands our med-ical expertise, our olfactory andchemoreceptor trigger zones colludeagainst us, inducing a physicalsense of revulsion that is at firstvery hard to overcome in order toexamine the patient. The physicianmust summon from deep within theprofessionalism that this patient de-

rience was almost cathartic. I felt anoverwhelming sense of relief that aphysician-author had addressed thewhite elephant in room—the roller-coaster of emotions that makes uswho we are. Whether we like it ornot, our practice of medicine is in-deed colored by our feelings. As aprofession, we tend to avoid allemotions unless we are celebratingour medical successes. Ofri warnsof severe fatigue leading to com-plete supra-tentorial shut down—aphenomenon most of us have expe-rienced. Ofri reminds us that weshould indeed be looking out for ourtrainees and colleagues.

I finished the book with a senseof fulfillment. While the book didforce me to recall some “unwantedmemories,” I felt a sense of valida-tion. Here was someone of my ilkreminding me that it is okay to feelanger, joy, shame, relief, and peace.Accepting the emotional side ofmedicine makes me a better doctor,ready to undertake population-basedhealth, HCAPHS, and other qualitymeasures. SGIM

mands. The simple act of the med-ical aide demonstrating both human-ity and empathy will strike aresounding chord among many of uswho had to learn to overcome ourrevulsion the first time we werefaced with a patient with a horrificphysical appearance.

Physicians, particularly internists,will identify with the adeptnesswith which she has woven thestory of her young heart failure pa-tient, Julia. We experience the trialsand tribulations of taking care of theundocumented sweet patient, whois similar in age to the author; thehours of patient advocacy; and thefine tuning of medications untilthere is no more that can be done.Ofri tells the all-too-familiar storywell.

Perhaps the best part of thebook for physicians is the honestywith which Ofri recounts the storiesof her patients, the medical errors,and the toll that a career in medicinecan take on an individual. I wasforced to relive several similar sto-ries and ethical dilemmas. The expe-

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FROM THE EDITOR

Book Review: What Doctors Feel: How Emotions Affect the Practiceof Medicine by Danielle OfriPriya Radhakrishnan, MD

Summer marks transitions for aca-demic medical centers. Morning

report, a revered tradition in mostprograms, is a time for learning andgrowing. Most of us can identifygreat faculty who seemed to effort-lessly conduct a session withoutknowing the case ahead of time.These revered faculty membersseem to be born with the morningreport gene. In contrast, new faculty,chief residents, and senior residents(in some programs) may feel somefear and trepidation when preparingfor their first morning report.

For junior faculty and beginners,there may be comfort initially inknowing the case. My own prefer-ence is not to know the case aheadof time. I find that knowing the caseoften leads the discussion towardthe diagnosis, and the due diligenceof discovery is lost. I do howeverlike to ask the resident or intern pre-senting the case what he/she wouldlike to focus on: arriving at the diag-nosis or understanding the work upor treatment. This ensures that thepresenter is in the loop and alsoengaged.

Like the creative writing class inhigh school, morning report thrivesin a safe learning environment witha structured format. All morning re-ports should have a beginning, dis-cussion, and summary. You willsoon find out that there are greatpresenters and tongue-tied resi-dents. It is important to diagnosethe presenter at the outset. In theformer case, the facilitator can letthe presenter build up the story; inthe latter, it is better to have thepresenter deliver information inshort bursts, often prompting theaudience to ask questions based onthe presenting complaint. (Don’t for-get to give private but directed feed-back to the presenter at the end.) Ifthe flow is not going well, take over,

If your learners are a mixed audi-ence of students and faculty, havingsmall group discussions ensuresthat your seniors are engaged andhave an opportunity to teach. Stu-dents will also have a safe environ-ment to ask questions if thediscussion is above their heads. Be-fore you start group exercises, it ishelpful to have another facultymember or the chief help you out.Define clear expectations of thegroup, such as developing a differ-ential diagnosis and treatment plan.Put the senior resident of the groupin charge of facilitating and teaching;have him/her pull out a handheld de-vice and ensure that each group hasa scribe. Time management is im-portant, so make sure you teachsmall groups in a rotation and guidethe discussions if learners are noton track.

Some useful techniques to thinkabout:

1. Use the traditional classificationof diseases. This helps learners(particularly at the beginning ofthe year) develop a differentialbased on system (e.g. cardiac,metabolic, infections, malignancy,etc.)

2. Brush up on your physical exam.This is a great time to relearnphysical exam and teachtechniques. If you are theteaching attending and thepatient has an interesting physicalexam finding and agrees toparticipate, bring the patient intothe room.

3. Embrace technology. For the“boring or oft-repeatedcomplaint,” pull up videos fromYouTube, New England Journal ofMedicine (procedure videos),American College of Cardiology,and American Thoracic Society.

ask specific questions, and help thepresenter develop the story. Theworst morning report session is onewhere the presenter is humiliated,the audience embarrassed, and thefacilitator angry. Remember publicflogging is outlawed, and railing atresidents rarely benefits anyone.

Change it up and be aware ofyour learners: Morning report in July(the beginning of the academic year)should be very different from June(the end of the year). This ensuresthat there is no “boring case,” suchas a patient with chest pain, whichmay be presented several times dur-ing the year.

For programs that have similarlevels of learners, such as separateintern and resident morning reports,it is easier to focus on shared learn-ing. During the beginning of the yearfor interns, it’s a good idea to focuson developing the differential, thenthe work up, and finally the plan.One important tip is not to try toteach too many things. If chest painhas been discussed several times, asis often the case, use strategies suchas having the group classify the caseon identifying risk. I like to ask ques-tions, including “Does this patienthave red flags?”, “What may kill thispatient now?”, and “Is this patientstable enough to discharge?” Statelearning points and clinical rulesclearly, such as “The pain from peri-carditis is classically relieved by lean-ing forward” or “TIMI scores andcoronary risk stratification must bedone in all cases.” I have the resi-dents pull out Epocrates on theirsmart phones and ask themto calculate risk. Give learners ques-tions to look up and report back.(I have a folder of landmark articlesthat I can easily access; ACP journalclub, PIER, and old faithful Uptodateare all great resources to access atthe point of learning.)

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NEW PERSPECTIVES: PART II

Demystifying Morning Report: How to Conduct a StimulatingMorning Report: Part IPriya Radhakrishnan, MD

Dr. Radhakrishnan is Forum editor and can be reached at PRadhakri@dignityhealth.org.

continued on page 15

The Society of General InternalMedicine presented the follow-

ing awards for presentations givenduring the 36th Annual Meetingin Denver, CO, held April 24-27,2013. SGIM is pleased and proudto announce the recipients byaward.

Recognition AwardsThe Exemplary Clinical WorkshopAward recognizes those who pre-sent an outstanding clinically fo-cused workshop at the SGIMannual meeting. All workshopspresented at the annual meetingare considered for this award.This year’s recipient is JenniferCorbelli, MD, from the Universityof Pittsburgh Medical Center forher workshop, titled “Is Pregnancya Stress Test? The AHA Guidelinesfor Prevention of CVD in Women:A Woman’s Heart from Pregnancyto Menopause.”

Three David E. Rogers JuniorFaculty awards were given to ju-nior faculty for workshops judgedthe most outstanding among those

The Women in Medicine TaskForce has an annual awards programto acknowledge the best women’shealth oral abstract presentation andthe outstanding women’s healthposter. Trainees and junior facultymembers who submit abstracts inthe women’s health category at theSGIM annual meeting are eligible.This year the recipients are:

• Women’s Health Oral AbstractAward: Sonya Borrero, MD,of the University of Pittsburghfor her abstract, titled“Contraceptive AdherenceAmong Women Veterans:Differences by Race/Ethnicityand Contraceptive Supply”

• Women’s Health Poster Award:Wendy Bennett, MD, MPH, ofJohns Hopkins UniversitySchool of Medicine for herposter, titled “Predictors ofPostpartum Primary CareUtilization for Womenwith Medically ComplicatedPregnancies: An Analysis ofMedical Claims” SGIM

presented at the SGIM annualmeeting. To be eligible, the work-shop coordinator must be an SGIMmember and faculty at the instruc-tor or assistant professor level atthe time of presentation. TheZlinkoff Fund for Medical Educationendows these awards. The threerecipients in 2013 are:

• Carlin Senter, MD, University ofCalifornia San Francisco, “TheDiagnosis-Driven Physical Examof the Knee and Shoulder:A Hands-On Workshop”

• Gwen Crevensten, MD,Massachusetts GeneralHospital, “ManagingAdmissions and Readmissions:A Multi-Institutional Review ofCurrent Practices andInnovations”

• Patrick T. Lee, MD,Massachusetts GeneralHospital, “‘RePlay Health’:A Serious Game forUnderstanding US HealthSystem Dynamics and PolicyInterventions”

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FROM THE SOCIETY: PART II

Announcement of Additional Award Winners fromthe 36th Annual MeetingFrancine Jetton, MA

Ms. Jetton is Director of Communications at SGIM and can be reached at jettonf@sgim.org.

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also explore whether similar effortsare needed to support other typesof activities that are essential totranslating innovations into mean-ingful sustainable benefits for ourpatients. I’m thinking about thosefaculty who are engaged in imple-mentation science and dissemina-tion work that may not produce thekinds of publications that jack up anh-index. Although traditional acade-mic promotion criteria will remainvaluable for rewarding investigatorsengaged in discovery-oriented re-search, we should continue to advo-cate for promotion criteria thatreward the full spectrum of schol-arly work that is needed to createvalue for our patients.

References1. Beasley BW, Wright SM,

Cofrancesco J, Babbott SF,Thomas PA, Bass EB. Promotioncriteria for clinician-educators inthe United States and Canada. Asurvey of promotion committeechairpersons. JAMA 1997;278:723-8.

2. Atasoylu AA, Wright SM, BeasleyBW, Cofrancesco J, MacphersonDS, Partridge T, Thomas PA, BassEB. Promotion criteria forclinician-educators. J Gen InternMed 2003; 18:711-6.

3. Beasley BW, Wright SM. Lookingforward to promotion:characteristics of participants inthe Prospective Study ofPromotion in Academia. J GenIntern Med 2003; 18:705-10.

4. Simpson D, Hafler J, Brown D,Wilkerson L. Documentationsystems for educators seekingacademic promotion in USmedical schools. Acad Med 2004;79:783-90.

5. Taylor BB, Parekh V, Estrada CA,Schleyer A, Sharpe B.Documenting qualityimprovement and patient safetyefforts: The quality portfolio. Astatement from the AcademicHospitalist Task Force. J GenIntern Med 2013 Jun 27. [Epubahead of print]

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PRESIDENT’S COLUMNcontinued from page 3

The Harvard Medical SchoolResearch Fellowship inIntegrative Medicine invitescandidates to apply for our NIHfunded training program tobegin July 1, 2013 for a threeyear fellowship. This jointprogram of Harvard MedicalSchool-affiliated teachinghospitals is searching forpostdoctoral candidatesincluding physicians (primarycare specialties such as internalmedicine preferred),anthropologists, healthbehavioralists, sociologists andpsychologists with MDs and/orPhDs who are interested intraining in one or more of threegeneral tracks: 1. healthbehavior research, 2. mind-bodytherapies, and 3. placebostudies. The program is led byresearchers in the Division of

General Medicine and PrimaryCare at Beth Israel DeaconessMedical Center. Research areasof special interest within theDivision include the chronicdisease management,innovations in primary care,obesity and cardiovascularhealth, patient-providerrelationship, end of life andpalliative care, and aging.http://www.bidmc.org/Research/Departments/Medicine/Divisions/GeneralMedicineandPrimaryCare.aspx.

The program offers candidatesthe opportunity to obtain anM.P.H. degree at the HarvardSchool of Public Health.

The deadline for applications forthe year beginning July 1, 2014 isOctober 1, 2013.

Harvard Medical School Research FellowshipINTEGRATIVE MEDICINE

For information and application forms, please contact:Ms. Rachel QuadenHMS Fellowship in Integrative MedicineDivision of General Medicine and Primary CareBeth Israel Deaconess Medical CenterHarvard Medical SchoolEmail: rquaden@bidmc.harvard.edu

The participating institutions are equal opportunity employers.Underrepresented minority candidates are encouraged to apply.

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continued on page 13

chronic medical conditions, plusmemory loss, plus a recent fall. Ageriatrician’s practice is often set upto screen for functional issues, per-form a cognitive evaluation, do amedication reconciliation check, andrefer for further gait evaluation—allin the first visit. In short, referral toa geriatrician should be consideredwhen:

• Functional issues that may hinderevaluation and treatment of othermedical conditions. Geriatriciansare well versed in helpingpatients decide when to pursuefurther testing and treatment andwhen to consider quality of lifeand functional capacity whenmaking diagnostic and treatmentdecisions.

• Cognitive decline is apparent,either with or without functionalimpairment. Geriatricians canhelp with diagnosis, treatmentdecisions, and behaviormodification.

interactions, over-the-counterappropriateness, and treatment ofthe side effects of one medicationwith another. (Is it appropriate toeliminate both drugs?)

• Frailty or failure to thrive is aconcern. Geriatrics professionalscan help a patient and caregiversmanage difficult evaluation andtreatment decisions and work toachieve the highest level offunction possible.

In short, referral to a geriatricsspecialist can help the internistin assessing the overall picture.Geriatricians are skilled in workingclosely with other specialists toassure that older patients get themost comprehensive care possible.General internists may serve theirolder more frail patients best ifthey refer early, establish a workingrelationship with the geriatricsgroup, and maintain the team-basedapproach to patient care.

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• Depression has made a majorimpact on function. Many olderpatients have significantdepression, and the medicationsoften used without side effects inyounger adults affect older adultsadversely. The geriatrician canhelp with a geropsychiatricreferral when appropriate, modifythe treatment regimen, adjustmedications, and assure that thedepression is having as littleimpact on other medicalconditions as possible.

• Gait and balance issues areprominent. Geriatricians oftenwork in interdisciplinary teamsand have ready access to well-trained therapists. A medicationevaluation is also part of gait andbalance assessment to look forpotential contributors to falls.

• There is significant polypharmacy.A pharmacist may be part of theinterdisciplinary team often foundin the geriatrics office and canassist with discussions of drug

SIGN OF THE TIMES: PART Icontinued from page 2

rash. In one recent series of 29cases, a fever of more than 38° Cwas present in 89% of patients,with lymphadenopathy present in55%. The most common organs af-fected in DRESS include the liver,kidney, and lung; 69% of patientshad a single organ involved,while17% had two organs involved.More recent studies suggest 89% ofpatients had eosinophilia, contrastingwith earlier reports estimatingeosinophilia at 30%.4,8

The need for systemic corticos-teroid therapy is not well establishedin the literature. The proposed mech-anism of action is the inhibition ofeosinophil accumulation, which isthought to be the main cause oforgan dysfunction. Such attenuationis likely supported by the general anti-inflammatory effect of corticosteroid-mediated inhibition of the NF-kBpathway, thus potentiating clinical im-

rash, fever, adenopathy, andhepatitis) in the setting of knowndrug exposure, while ruling outinfection.

4. Therapy includes removal of theoffending agent, with provisionof corticosteroids and supportivecare.

References1. Fiszenson-Albala F, Auzerie V,Mahe E, Farinotti R, Durand-StoccoC, Crickx B, et al. A 6-monthprospective survey of cutaneousdrug reactions in a hospital setting.Br J Dermatol 2003; 149:1018-22.

2. Roujeau JC, Stern RS. Severeadverse cutaneous reactions todrugs. N Engl J Med 1994;331:1272-85.

3. Kardaun SH, Sidoroff A, Valeyrie-Allanore L, et al. Variability in theclinical pattern of cutaneous

provement as well. Moreover, manydocumented cases show a dramaticimprovement with corticosteroids, aswell as relapse after tapering or with-drawing steroid therapy.9-11

Further research is needed to de-termine exactly what the risk of re-currence of DRESS syndrome iswhen exposed to novel drugs of ei-ther the same or different class. Addi-tionally, no clear predisposing factors,aside from a prior episode of DRESS,have been implicated in the disease,and this also warrants investigation.

“Take-home” Points for Learning1. DRESS often includes an acute

hepatitis and should be in thedifferential of an acute febrile rash.

2. The patient should be queriedregarding any new recentmedications.

3. Diagnosis is made by noting acharacteristic presentation (e.g.

MORNING REPORTcontinued from page 4

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but the concept of documentingnon-clinical activities is often over-looked. Departmental and clinicalsystem projects can be huge invest-ments of time and energy, but theseefforts are prone to disappear. Yourteam members might recognize theeffort and effect of these projects,but the length of that memory andappreciation is certainly finite.

In a transition, remember torecord professionally meaningfulprojects and activities. The most ro-bust track record is publication orpresentation, which should be en-couraged and prioritized. Whenchanging jobs, avoid letting theseactivities slip into the void.

Changing jobs is both challengingand exhilarating. As a fresh start, thepossibilities are endless. The poten-tial for growth is limitless. Overall,try to take a fresh look at the pastand an open look at the present.

Reference1. http://www.jacksonhealth

care.com/media/191888/2013physiciantrends-void_ebk0513.pdfaccessed 7/28/13).

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COMMENTARYcontinued from page 1

In turn, your thoughtful commu-nication cannot be overemphasized.E-mails should be carefully wordedand conversations given your full at-tention. Repeat your name so oth-ers learn it, and try to memorizetheirs as well. Remember, initially atleast, that every impression is a firstimpression.

You’re Not in Kansas Anymore:Learning the New CultureEvery hospital, every clinic, and everydepartment is a little bit different.What worked in your old positionmight be a glaring diversion from thenorm in the new one. You might havestuck your head into your old chair’soffice for impromptu meetings, forexample, while your new bossprefers scheduled appointments.

Observe the culture as much aspossible upon arrival. Try to under-stand it and embrace it. Unless youare certain that a suggestion to “dothings the way they were done inmy old office” is a world-class idea,keep it to yourself. There will betime to gently affect the culturewith tenure in your position, but theinitial few months are not the idealtime to “buck the system.”

Second Chances: Don’t RepeatYour MistakesOnce we practice for several years,we develop a pattern. Many times,the pattern is imperfect. We stickwith it because of its comfort andfamiliarity, but a new position is theoptimal time for recognizing pastmistakes and intentionally not re-peating them.

One of my partners called herpatients personally with results aftereach visit. She built a patient panelwith this expectation. While it wassmall, she was able to keep up withthe workload. Once she had morepatients and additional responsibili-ties, it became harder to makethese phone calls herself. A new jobis an ideal time to alter those com-ponents of your style that youwould have done differently withhindsight. Change these habits withyour move. Even if old patients fol-low you to the new practice, theywill be understanding that things aredifferent.

If You Didn’t Write it, You Didn’tDo It: The Power of TransparencyThe importance of documentation inthe medical record is never in doubt,

side-effects of drugs withsystemic symptoms: does aDRESS syndrome really exist? BrJ Dermatol 2007; 156:609-11.

4. Gentile I, Talamo M, Borgia G. Isthe drug-induced hypersensitivitysyndrome (DIHS) due toherpesvirus 6 infection or toallergy-mediated viralreactivation? Report of a caseand literature review. BMCInfectious Dis 2010; 10:49.

5. Kudiyirickal MG, Hollinshead F.Antimicrobial prescribing practiceby dentists: a study from twoprimary care centres in UK.Minerva Stomatol 2011;60(10):495-500.

9. Hellman C, Lonnkvist K, HedlinG, Hallden G, Lundahl J. Down-regulated IL-5 recepatientorexpression on peripheral bloodeosinophils from butesonide-treated children with asthma.Allergy 2002; 54:323-8.

10. Chopra S, Levell NJ, Cowley G,Gilkes JJH. Systemiccorticosteroids in the phenytoinhypersensitivity syndrome. Br JDermatol 1996; 134:1109-12.

11. Yamamoto Y, et al. Therapeuticpotential of inhibition of the NF-kappaB pathway in thetreatment of inflammation andcancer. J Clin Invest 2001;107(2):135-42. SGIM

6. Chai G, Governale L, McMahonAW, Trinidad JP, Staffa J, MurphyD. Trends of outpatientprescription drug utilization in USchildren, 2002-2010. Pediatrics2012; 130(1):23-31.

7. Murphy M, Bradley CP, Byrne S.Antibiotic prescribing in primarycare, adherence to guidelinesand unnecessary prescribing—anIrish perspective. BMC FamPract 2012; 13(1):43.

8. Tanno LK, et al. Drug reactionwith eosinophilia and systemicsymptoms (Dress): What we stillhave to learn? World AllergyOrganization Journal 2012;5(Suppl 2):S39.

MORNING REPORTcontinued from page 12

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quality of life. When asked what fac-tors affected their academic perfor-mance, 28% of students reportedstress, 20% sleep disturbances,19% anxiety, 11% depression, 10%concern for a troubled friend or fam-ily member, and 9% relationship dif-ficulties. Therefore, SHCs servemany students who have diagnos-able psychiatric conditions or stres-sors with other behavioral healthsymptoms. This service is dividedamong all care providers at an SHC.If the SHC has a mental health unit,a distressed student may be prefer-entially directed to mental healthspecialists or to the counseling cen-ter. At the University of Washington,approximately 12,000 visits per yearoccur in our specialty mental healthdepartment. Another 5,000 to10,000 visits for a mental health di-agnosis occur in our medical units.In addition, about 9,000 visits peryear occur in the counseling center,which is physically and organization-ally separate from the SHC.

Although critically important to di-agnose and manage well, relativelyfew visits for mental health concernsare by students who have or developa serious chronic mental illness. Inaddition to the medical model, we

SIGN OF THE TIMES: PART IIcontinued from page 6

train our medical providers to under-stand the developmental approach tobehavioral health concerns of stu-dents—one that recognizes thatstress is a part of normal develop-ment for adolescents and youngadults and that learning how to copewith this is also part of normal devel-opment. Student health programsput substantial efforts into this whilemaintaining a safety net for studentswhose concerns either greatly inter-fere with function or who have morelasting problems. Student counselingcenters tend to use the developmen-tal model for designing care and pre-vention programs, with recognition ofmore serious mental health concernsand referral of this relatively smallgroup of student clients to centerswith more resources—either at theSHC or in the surrounding commu-nity. More information about counsel-ing centers can be obtained throughthe Association of University and Col-lege Counseling Center Directors an-nual survey.

In summary, although SHCs havediverse organizational models, theyshare common features that prioritizeconvenient access and care for acuteillnesses. Given the demographics ofthe population served, mental health

concerns are much more commonthan chronic medical diseases as im-pediments to academic work andquality of life. SHCs, which functionin a medical model, and counselingcenters, which take a developmentalperspective, provide complementaryapproaches to caring for students.

Suggested Reading2010 Carnegie Classification of

Institutions of Higher Education.Available athttp://chronicle.com/article/2010-Carnegie-Classification/128571/(accessed July 8, 2013).

Almanac of Higher Education 2012.Available at http://chronicle.com/article/Campuses-With-the-Largest-Enrollments/133411/(accessed July 8, 2013).

American College Health Association.National College HealthAssessment-II. Spring 2012.Available at http://www.acha-ncha.org/reports_ACHA-NCHAII.html (accessed July 8, 2013).

Association of University and CollegeCounseling Center Directors.http://www.aucccd.org/support/aucccd_directors_survey_monograph_2011.pdf (accessed July 20,2013). SGIM

Rhode Island Hospital, Division of General InternalMedicine, Department of Medicine, Providence, RIseeks a clinician-investigator. The selected individualwill have 80% protected time to develop independentresearch projects and collaborate on projects withother investigators at the Alpert Medical School.He/she will also participate in inpatient clinical rounds,and/or in the primary care practice at Rhode IslandHospital or Providence VA Medical Center, as well asthe training of medical students and internal medicineresidents. The successful candidate must qualify for afull-time medical faculty position at the rank ofAssistant or Associate Professor of Medicine at theWarren Alpert School of Medicine at Brown University.Associate Professor level candidate should have anational reputation and scholarly achievements.Minimum requirements include: board eligibility or

certification in internal medicine, strong clinicalbackground in internal medicine, excellence in patientcare and teaching, and a commitment to develop anindependent research career. Fellowship training ingeneral internal medicine or the equivalent is highlydesirable. It is preferred that the candidate’s researchinterests focus on health care quality, comparativeeffectiveness, women’s health, cancer prevention,behavioral medicine, pain medicine, correctionalhealth, substance abuse, or a closely related field.Rhode Island Hospital is an EEO/AA employer andencourages applications from minorities, and women.Review of applications will begin immediately and willcontinue until the position is filled or the search isclosed. Applicants may apply by uploading a CV andletter of interest through Interfolio at https://secure.interfolio.com/apply/20647.

CLINICIAN-INVESTIGATOR

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Familiarize yourself with thecontent.

4. Use evidence-based medicine.Use the PICO (population,intervention, control, outcome)to develop a clinical question,and make sure that the residentassigned the question follows up.If you are unable to attend,assign the next day’s facilitatorto ask for the resident’s answer.

5. Integrate the ITE exam and classicquestions. These provide helpfullearning points (e.g. hypotensionresponsive to fluids is classic inright ventricular infarction).

6. Use radiology, EKGs, and labs forteaching. Divide the residents insmall groups and have them lookup manifestations of disease andtheir labs.

7. Use morning report to teachsystems-based practice. I oftenpull up the electronic healthrecord and demonstrate tips,calculators, and even theimportance of having the correctdocumentation.

8. Use the American Board ofInternal Medicine’s ChoosingWisely to discuss theappropriateness of tests.American College of Radiologyhas imaging appropriatenesscriteria for imaging. Use the datato teach.

9. Integrate basic sciences:pathophysiology, biochemistryand pharmacology. Invite thelibrarian, pharmacist, or the nurseif relevant.

(http://www.acr.org/Quality-Safety/Appropriateness-Criteria)

4. ACP Journal Club(http://acpjc.acponline.org/)

5. Center for Health Evidence(http://www.cche.net/projects/main.asp)

6. Rational Physical Exam (http://jamaevidence.com/resource/523)

7. ECG wave maven (http://ecg.bidmc.harvard.edu/maven/mavenmain.asp)

8. Medportal (https://www.mededportal.org): You need to register;it’s free and has lots of teachingideas.

9. Journal of General InternalMedicine: The new website haslots of teaching resources.

10. Annals of Internal Medicine(particularly the Annals forEducators section): It walks youthrough great teaching tips fortopics.

11. YouTube: Another great resourcefor videos. Remember to checkthe video in its entirety beforehand, especially if it is long, andrequest the resident or the chiefto download it beforehand. Keepa couple of questions handy forstimulating discussion.

12. TALENT (Teaching and LearningEducation for New Teachers):A short helpful module (http://somis.umh.edu/talent/index.asp)

13. SGIM: Great handouts areavailable from meeting workshops.(http://www.sgim.org/resource-library?k=ResourceLibrary)

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10. For patients with multipleadmissions, consider using themorning report to develop a plan.As a follow up, invite the casemanager, nurse, and perhaps thepalliative care team.

Remember at the end of thesession, ask your learners to stateone thing that they learned fromthe session. This ensures that theywill retain the information. Restatethe learning points that you taughtthem, and point them to the rightresources. Above all, make it a safelearning environment, and don’t beafraid to say “I am not sure” or “Idon’t know” and look it up together.Make sure that you analyze whatwent well and what did not—thisensures your growth as a teacher. Ifyou have an education specialist,mentor, or colleague, invite him/herto observe you, and write downshared observations.

In the words of Colin Powell,there are no secrets to success. It isthe result of preparation, hard work,and learning from failure.

Resources1. Videos in Clinical Medicine(http://www.nejm.org/multimedia/medical-videos)

2. Cardiosource: ACC guidelines(http://www.cardiosource.org/science-and-quality/practice-guidelines-and-quality-standards.aspx)

3. American College of CardiologyAppropriateness Criteria

NEW PERSPECTIVES; PART IIcontinued from page 9

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Society of General Internal Medicine1500 King Street Suite 303Alexandria, VA 22314202-887-5150 (tel)202-887-5405 (fax)www.sgim.org

SGIMFORUM

The ISSN for SGIM Forum is: Print-ISSN 1940-2899 and eISSN 1940-2902.