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1 Vol. 32 Num. 12 Dec 09 To Promote Improved Patient Care, Research, and Education in Primary Care and General Internal Medicine Inspire Inform Connect CONTENTS 1. New Perspectives . . . . . . . . . . . . . 1 2. Curbside Consult .............. 2 3. President’s Column . . . . . . . . . . . . 3 4. Sign of the Times . . . . . . . . . . . . . . 4 5. Reflections . . . . . . . . . . . . . . . . . . . 5 6. Point ........................ 6 7. Counterpoint . . . . . . . . . . . . . . . . . 7 8. Morning Report ............... 8 9. Book Review . . . . . . . . . . . . . . . . 10 SGIM FORUM The Society of General Internal Medicine NEW PERSPECTIVES At the Starting Line Again: The Emotional Transition to Life as an Attending Shawn M. Cole, MD Dr. Cole is a clinical instructor, Department of Internal Medicine, at Yale School of Medicine and a primary care physician at the Veterans Affairs Connecticut Healthcare System in West Haven, CT. continued on page 11 O nce again, I have reached the huge VA parking lot reminiscent of a sports arena just beginning to fill with spectators. This time, how- ever, it is vastly different. A palpable absence of conscious breathing overcomes the long trek to my new office. Familiar faces pass by— some who remember me as a senior internal medicine resident rotating here a year ago and others who mistakenly believe I am still a resident. The environment is exactly as I recall; the only difference is my new per- ception of the facility. Excitement, intimidation, pride, and ambivalence all take turns surfacing through my mind. Is this the way it is supposed to be? Do I really possess the knowledge to be the primary care physi- cian for nearly 1,000 veterans, many of whom have a disproportionately extensive list of chronic conditions? Did my residency training ade- quately prepare me to become a competent attending for my patients and the residents and medical students I will suddenly now be supervis- ing? Did I digest the extensive orientation agenda in the days preceding? Do I call my former mentors, who are now my colleagues, by their first names? This is more awkward than I anticipated. As I return to the VA as a primary care physician, a position which was clearly my “calling” following a two-month rotation as a second-year resident, a healthy amount of fear and anxiety seems to predominate. I was told by my mentors that the transition from resident to attending physician would be my most nerve-wracking professional experience. How could this keep occurring? I recall the transition from medical stu- dent to intern as being the most difficult—until I made the transition from intern to resident. As a resident, I prided myself on staying relatively relaxed and calm during a rigorous three-year schedule. It was a unique time highlighted by intense medical education and camaraderie among the housestaff. We were afforded the luxury of constantly bouncing clinical questions and ideas off one another, sharing the excitement of a fascinating diagnosis, and of course commiserating about the lack of time to maintain any semblance of a non-medical life. As I approach the door of my new office, I cannot help but reflect on the lopsided residency curriculum that is largely skewed toward inpatient medi-

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Page 1: SGIM To Promote Improved FORUM Library/SGIM/Resource Library/Forum/2009/SGIM-December-2009...concept was proposed by Mihály Csíkszentmihályi in his book Flow, which describes a

1

Vol. 32

Num. 12

Dec 09

To Promote Improved

Patient Care, Research, and

Education in Primary Care and

General Internal Medicine

InspireInformConnect

CONTENTS

1. New Perspectives . . . . . . . . . . . . . 1

2. Curbside Consult . . . . . . . . . . . . . . 2

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

4. Sign of the Times . . . . . . . . . . . . . . 4

5. Reflections . . . . . . . . . . . . . . . . . . . 5

6. Point . . . . . . . . . . . . . . . . . . . . . . . . 6

7. Counterpoint . . . . . . . . . . . . . . . . . 7

8. Morning Report . . . . . . . . . . . . . . . 8

9. Book Review . . . . . . . . . . . . . . . . 10

SGIMFORUMThe Society of General Internal Medicine

NEW PERSPECTIVESAt the Starting Line Again: The EmotionalTransition to Life as an AttendingShawn M. Cole, MD

Dr. Cole is a clinical instructor, Department of Internal Medicine, at YaleSchool of Medicine and a primary care physician at the Veterans AffairsConnecticut Healthcare System in West Haven, CT.

continued on page 11

Once again, I have reached the huge VA parking lot reminiscent of asports arena just beginning to fill with spectators. This time, how-

ever, it is vastly different. A palpable absence of conscious breathingovercomes the long trek to my new office. Familiar faces pass by—some who remember me as a senior internal medicine resident rotatinghere a year ago and others who mistakenly believe I am still a resident.The environment is exactly as I recall; the only difference is my new per-ception of the facility. Excitement, intimidation, pride, and ambivalenceall take turns surfacing through my mind. Is this the way it is supposedto be? Do I really possess the knowledge to be the primary care physi-cian for nearly 1,000 veterans, many of whom have a disproportionatelyextensive list of chronic conditions? Did my residency training ade-quately prepare me to become a competent attending for my patientsand the residents and medical students I will suddenly now be supervis-ing? Did I digest the extensive orientation agenda in the days preceding?Do I call my former mentors, who are now my colleagues, by their firstnames? This is more awkward than I anticipated.

As I return to the VA as a primary care physician, a position whichwas clearly my “calling” following a two-month rotation as a second-yearresident, a healthy amount of fear and anxiety seems to predominate. I was told by my mentors that the transition from resident to attendingphysician would be my most nerve-wracking professional experience.How could this keep occurring? I recall the transition from medical stu-dent to intern as being the most difficult—until I made the transition fromintern to resident. As a resident, I prided myself on staying relatively relaxed and calm during a rigorous three-year schedule. It was a uniquetime highlighted by intense medical education and camaraderie amongthe housestaff. We were afforded the luxury of constantly bouncing clinical questions and ideas off one another, sharing the excitement of a fascinating diagnosis, and of course commiserating about the lack oftime to maintain any semblance of a non-medical life.

As I approach the door of my new office, I cannot help but reflect on thelopsided residency curriculum that is largely skewed toward inpatient medi-

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Plans change because opportuni-ties arise. How does one decide totake advantage of an opportunity?When someone is trying to convinceyou to take advantage of an opportu-nity, you can see that opportunity asbeing instrumental or fundamental.

To elaborate, instrumental deci-sions are those that you think willhelp you advance your career. If yourgoal is to become the dean of a med-ical school, you might accept commit-tee assignments because you believeyou will get to know the “right” peo-ple who will be making decisionsabout the medical school’s leadership.One makes fundamental decisions bymatching his/her skills and interestswith the potential benefits offered byan opportunity. Pink strongly arguesfor making decisions based on funda-mental reasons rather than instrumen-tal reasons. While instrumentalopportunities are often necessary tohelp you achieve your goals, funda-mental opportunities will help you toachieve “flow” in your career. Thisconcept was proposed by MihályCsíkszentmihályi in his book Flow,which describes a state when one’sskills are maximally matched to thelevel of challenge one encounters. Inthe state of flow, one’s mind is maxi-mally engaged and energized.

It certainly makes sense to haveplans and goals, but have enoughflexibility to seize great fundamentalopportunities when they arise. As im-portant as it is to be open to new op-portunities, one must recognize thatnot every “great” opportunity is agreat opportunity for you. A “great”opportunity to participate in some-thing that is neither fundamental norinstrumental is likely to result in frus-tration and a sense of tedium.

Lesson #2: Focus on strengths not weaknesses.The book First, Break All the Rules byMarcus Buckingham and Curt Coff-man puts forth management princi-

After serendipitously re-connectingthrough Twitter, Shalini and I dis-

covered that we had both recentlyread a book called The Adventures ofJohnny Bunko* by Dan Pink. This is adelightful short book written in mangaform that focuses on six principles ofdeveloping a satisfying and successfulcareer. This short graphic novel crystal-lized much of the advice that we havegiven to students, residents, and ju-nior faculty in the past. Many of theseideas come from other books that wehave read to which we will refer.

Lesson #1: There is no plan.Many advisors will tell you to de-velop a one-year plan, a five-yearplan, and often a life plan. These canbe worthwhile exercises that helpyou think about your priorities and in-terests. Be prepared, however, tobend and flex as opportunities arisethat will often redirect the trajectoryof your career. Most successful acad-emicians have changed their planmultiples times over the years.

For many of us, the path to acad-emic general internal medicine hasbeen a meandering one. Few of usentered medical school knowing wewanted to become academic generalinternists (few of us even knew thatthere was such a thing).

OFFICERS President

Nancy A. Rigotti, MD Boston, MA [email protected] (617) 724-4709

President ElectGary E. Rosenthal, MD Iowa City, [email protected] (319) 356-4241

Immediate Past-PresidentLisa V. Rubenstein, MD, MSPH North Hills, [email protected] (818) 891-7711

TreasurerJeffrey Jackson, MD, MPH Bethesda, [email protected] (202) 782-5603

Treasurer-ElectCarol K. Bates, MD Boston, [email protected] (617) 667-4877

SecretaryMonica L. Lypson, MD Ann Arbor, [email protected] (734) 764-3186

COUNCIL

Carlos A. Estrada, MD, MSBirmingham, [email protected] (205) 934-3007

Nancy L. Keating, MD, MPHBoston, [email protected](617) 432-3093

Arthur G. Gomez, MDLos Angeles, [email protected](818) 891--7711

Said A. Ibrahim, MD, MPHPittsburgh, [email protected](412) 688-6477

Laura Sessums, MD, JDWashington, [email protected](202) 782-5560

Donna L. Washington, MD, MPHLos Angeles, [email protected](310) 478-3711 ext. 49479

Health Policy ConsultantLyle DennisWashington, [email protected]

Executive DirectorDavid Karlson, PhD2501 M Street, NW, Suite 575Washington, DC [email protected](800) 822-3060; (202) 887-5150, 887-5405 Fax

Director of Communicationsand Publications

Francine JettonWashington, [email protected](202) 887-5150

EX OFFICIO COUNCIL MEMBERS

Regional CoordinatorHollis Day, MD, MS Atlanta, [email protected] (412) 692-4888

ACGIM PresidentKaren DeSalvo, MD, MPH, MSc New Orleans, [email protected] (504) 988-5473

Editors, Journal of General Internal MedicineMitchell Feldman, MD, MPhil San Francisco, [email protected] (415) 476-8587

Richard Kravitz, MD, MSPH Sacramento, [email protected] (916) 734-1248

Editor, SGIM ForumRobert Centor, MD Birmingham, [email protected] (205) 934-3007

Associate Member RepresentativeHannah E. Shacter St. Paul, [email protected] (612) 963-6813

CURBSIDE CONSULT

Career DecisionsRobert M. Centor, MD, and Shalini Reddy, MD

Dr. Reddy is an associate professor of medicine at the University of Chicago.

continued on page 12

SOCIETY OF GENERALINTERNAL MEDICINE

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The notion that to be competent, ageneral internist has to know

everything in internal medicine is acommon but mistaken belief. Med-ical students and residents some-times cite it to explain theirdisinterest in a general medicine ca-reer. The opposite idea, that a gener-alist forfeits the right to be an expertin anything, is less often mentioned,but I suspect that it is equally impor-tant in discouraging trainees fromembracing generalist careers.

Expertise in something—almostanything—is a highly prized attributein our academic environment, domi-nated as it is by specialists and sub-specialists who each know a lotabout a limited area. Generalists canfeel out of place in a culture wherethe depth of knowledge is morehighly valued than breadth of knowl-edge. Some generalists are at easein this environment, but for thosewho are not, this column offers threethoughts about how a physician canbe both an expert and a generalist.

First, as generalists, we already“specialize” in managing chronicdiseases. When one organ systemfails, it usually triggers problems inother systems or leads to treat-ments that cause complicationselsewhere. Generalists are expertsat managing conditions that crossorgan systems. We are experts atseeing problems in the broader con-text of the whole patient. Subspe-cialty colleagues often feel out oftheir comfort zone when their pa-tients develop symptoms in anorgan system outside their specialty.We generalists are used to manag-ing and coordinating care in thisway. Unfortunately, this cross-cut-ting expertise can be overlooked in

the traditional clinical environment. Second, I suspect that every one

of us generalists feels more skilled inhandling some problems than others.In training, we may have enjoyedlearning about one or two organ sys-tems more than others. We mighthave even considered going into oneof those specialties before choosinggeneral medicine.

I propose that each of us has aunique distribution of clinical expertisethat defines our skills and that repre-sents what I’ll call a generalist’s “clini-cal signature.” Operationally, thiswould be measured by assessing anindividual clinician’s likelihood of refer-ring a complex patient with an organ-based problem to the correspondingspecialist for diagnosis or manage-ment. Visually, for any one of us, thisclinical signature could be representedin a bar graph. (See figure on page13.) I propose that each generalist hasa unique signature of clinical expertisethat could be measured in this way.

The figure shows my own “clini-cal signature” as an example. I lovedendocrinology and infectious dis-eases and considered both as careertracks. In contrast, I never really un-derstood renal pathophysiology, and Ifound rheumatologic diseases con-fusing. Pulmonary, cardiology, and GIwere somewhere in between. Forme, problems like osteoporosis rep-resent comfortable islands of relativeexpertise in the maelstrom of gen-eral medicine practice. I follow the lit-erature more carefully in this area.When a patient’s problem is beyondmy knowledge, I enjoy consulting theliterature because it represents anopportunity to learn more about afield for which I already have an intel-lectual affinity and decent fund of

PRESIDENT’S COLUMN

Can a Generalist be an Expert, Too? Nancy Rigotti, MD

From this I developed my definitionof an “expert”—someone whoknows five more facts about aproblem than most of his or her peergroup.”

continued on page 13

EDITOR IN CHIEFRobert Centor, MD [email protected]

MANAGING EDITORChristina Slee, MPH [email protected]

EDITORIAL BOARDCaleb Alexander, MD, MS [email protected] Call, MD [email protected] Egan, MD, JD [email protected] Emott, MD [email protected] Federman, MD [email protected] Ferguson, MD [email protected] Deepthiman Gowda, MD, MPH [email protected] Gordon, MD, MPH [email protected] Haidet, MD, MPH [email protected] Harris, MD, MS [email protected] Henderson, MD [email protected] Jetton, MA [email protected] Keenan, MD [email protected] Kertesz, MD, MSc [email protected] Phillips, MD, MSc [email protected] Reddy, MD [email protected] Schutzbank, MD, MPH [email protected] Shacter, BA [email protected] Shah, MD [email protected]

The SGIM Forum is a monthly publication of the Society of General Internal Medicine. The mission of The SGIM Forum is to inspire, inform and connect—both SGIM members and those in-terested in general internal medicine (clinical care, medical education, 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 on topical 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 or potential articles. This news magazine is published by Springer. TheSGIM Forum template was created by Phuong Nguyen([email protected]).

SGIM Forum

knowledge. I don’t have the depth ofknowledge that my endocrinologist col-leagues do, but I am an “expert gener-alist” in this area.

Beyond this level of expertise, I pro-pose that a generalist can develop a formof clinical expertise that will be recog-nized by and yet distinct from that of oursubspecialty colleagues. Clinical medicinehas plenty of cross-cutting problems thatbeg to be addressed and don’t sort them-selves neatly into the organ-based silosthat we know as subspecialities. Think ofpalliative care, quality and safety of care,or preventive medicine. Each representsareas of clinical knowledge that wereonce neglected because they didn’t fitinto one subspecialty but came to be rec-ognized as critical. Generalists are leadersin many of these areas.

As an illustration, consider my own

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The Patient-centered MedicalHome (PCMH) is an approach to

care aimed at providing high-quality,cost-effective comprehensive carefor patients of all ages with chronicillness or preventive care needs.Geriatric medicine has extensive ex-perience in processes that empha-size comprehensive care for patientswith chronic illnesses and functionalimpairments. In the context of the“silver tsunami” and recent callsboth for expanding geriatric expertiseamong all health professionals anddeveloping new health delivery mod-els to care for older patients,1 it iscritical to understand the many waysin which the PCMH and geriatric prin-ciples are aligned in order to optimizethe care of our aging population.

In 2007, the American Academyof Pediatrics, American Academy ofFamily Physicians, American Collegeof Physicians, and American Osteo-pathic Association developed JointPrinciples describing the PCMH.2 Ateam approach centered on the pa-tient-physician relationship is key toachieving more effective and effi-cient health care delivery. Theseprinciples form the basis for ongoingdemonstration projects and propos-als to implement the PCMH.3

In this article, we highlight fourareas where the PCMH and geriatricprinciples are aligned and, throughtheir application, can achieve mutualgoals.

1. Physician-directed medicalpractice. The personal physicianleads a team of individuals at thepractice level who collectivelytake responsibility for theongoing care of patients.Interdisciplinary team care is ahallmark of geriatrics. A largebody of evidence oncomprehensive geriatricsassessment and managementsupports the principle of aphysician-directed medical homeand can be used to design

hospitalization baseline andhospital discharge), writingspecific orders for home healthand hospice agencies, andproviding nursing home care.PCMH can draw from models ofcoordinated or integratedgeriatric care that have beenshown to be effective.6,7

Care is facilitated by registries,information technology, healthinformation exchange and othermeans to assure that patients getthe indicated care when andwhere they need and want it.Current PCMH models focus ondisease-based registries.Information systems that can helppractice teams assess and monitortargeted patients at risk forproblems with function, frailty,care transitions, and caregiving willlikely have greater impact on thewell-being of these older adults.

4. Quality and safety. Quality andsafety are hallmarks of themedical home. Quality indicatorsbased on geriatric syndromes(e.g. falls, urinary incontinence,polypharmacy) have beendeveloped for the care of olderpatients8 and would powerfullycomplement the disease-orientedquality markers that currentlydominate PCMH models.

Evidence-based medicine andclinical decision-support toolsguide decision-making. A growingevidence base and set of practiceguidelines are directed at olderpatients but rarely incorporatedinto primary care practice. ThePCMH provides an opportunity tocreate the means and incentivesto do so. For example, the PCMHcould target older adults withscreening and managementprocesses for falls, incontinence,cognitive impairment, and pain.

innovations for primary carepractices. A key lesson fromthese trials is that improvedoutcomes are achieved whenpractices have control over thefollow-through onrecommendations and maintainlongitudinal follow-up.4,5

2. Whole-person orientation. Thepersonal physician is responsiblefor providing for all the patient’shealth care needs (acute andchronic care, preventive services,end-of-life care) or takingresponsibility for appropriatelyarranging care with other qualifiedprofessionals. Geriatricians haveplayed an important role inmanaging the care of adults withcomplex multi-dimensionalimpairments and frailty. Theimplications of simultaneousinteracting conditions (medical,cognitive, and affective); functionalimpairments; and dysfunctionalfinancial, caregiving, andenvironmental systems have notbeen addressed in current modelsof patient assessment in thePCMH. Geriatric principles ofintegrating medical and social carein ways that preserve function andpay attention to caregiving andenvironmental needs should beincorporated into PCMHprocesses as core components ofwhole-person care.

3. Coordinated and/or integratedcare. Care is coordinated and/orintegrated across all elements ofthe complex health care system(e.g. subspecialty care, hospitals,home health agencies, nursinghomes) and the patient’scommunity. Geriatric-trainedphysicians understand theimportant steps in integratingmedical and social care duringtransitions to subacute settings(e.g. documenting changes infunction between pre-

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SIGN OF THE TIMES

The Patient-centered Medical Home and Care of Older AdultsHelen Kao, MD; David C. Thomas, MD; Usha Subramanian, MD; Anna Chang, MD; and Brent C. Williams, MD

Drs. Kao, Thomas, Subramanian, Chang, and Williams are members of the SGIM Geriatrics Task Force.

continued on page 11

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In 1981, I was privileged to bepresident of SGIM—the Society for

Research and Education in PrimaryCare Internal Medicine as it wasknown then. Since that time, theSociety has grown from a smallgroup of 400 academic generaliststo an influential force of 3,000. Theagenda of the Society has becomemore eclectic as the organizationhas grown, and it has been gratify-ing to note the enthusiasm oftoday’s members for their roles inclinical care and education and thequality of their scholarly work.

Soon after my year as the Soci-ety’s president, I accepted a positionas general director and CEO ofStrong Memorial Hospital inRochester, NY, the principal teachinghospital of Rochester’s School ofMedicine & Dentistry. I held this po-sition for 11 years, and in that role, Ilearned a great deal about healthpolicy at the state and federal levels.

I have retired four times butseem not to understand what retire-ment has to offer. From 1995 to2000, I was with the Association ofAmerican Medical Colleges studyingthe impact of managed care on aca-demic medical centers (AMCs).AMCs did much better than mosthad predicted during this dismalphase of reimbursement for healthcare.

From 2002 to 2007, I workedwith colleagues at the Institute forHealth Care Improvement in Cam-bridge, MA, the pacesetting organi-zation that Don Berwick created. Iwas pleased to be among the devel-opers of a collaborative of 47schools of medicine, nursing, phar-macy, and health administration.This collaborative was established tohelp achieve student learning objec-tives for the improvement of care.

and, on a smaller scale, the redesignof individual practices.

The policy recommendations foreducation are devoted almost exclu-sively to funding for primary careand ambulatory education. There areimportant policy issues relating toeducation for roles in primary carethat SGIM might address. These in-clude support for educational tech-nology (e.g. simulation) andprograms in international medicine.

Finally, as regards policy, the So-ciety should be as inclusive as possi-ble, recognizing that general internalmedicine includes a host of careerpathways other than primary care.

The unique perspective and col-lective wisdom of the members ofSGIM are great. The Society’s mem-bers have an opportunity to influ-ence health policy throughparticipation in regional and nationalmeetings, work groups, task forces,and other venues such as personalcontact with their elected represen-tatives. More members should takeadvantage of this opportunity. Yourvoices need to be heard.

As with many of our colleagues, Ihave concerns about the future ofgeneral internal medicine in this coun-try, at least as we currently know it.Solving financial inequities in physi-cian incomes, providing debt relief,replacing paper with electronic med-ical records, and redesigning officesystems will welcomed—so also willbe the further development of inte-grated delivery systems withprospective reimbursement, reducingthe burden of administrative workand fostering coordinated care. Thesesystems need to be organized insuch a way that general internistsplay a lead role and have the opportu-nity for a professional counterpoint

My experience with this collabora-tive gave me both joy and reassur-ance knowing that undergraduatemedical education was a dynamicprocess at many schools of medi-cine, nursing, and pharmacy in thiscountry. It also convinced me of theimportance of inter-professionallearning in health care.

In my last professional journey, Ijoined Mike Barry and Al Mulley in2007 to develop a mentoring pro-gram for Harvard’s MassachusettsGeneral Hospital (MGH)-based pri-mary care faculty. Here I gained in-sight from and developed admirationfor women in primary care whohave succeeded in achieving bal-ance between career and home-based responsibilities.

We may be at a historic momentin the history of health care in thiscountry. SGIM is among the leadersin the further definition and fine tun-ing of rational health policy, but itspolicy positions related to HealthCare Reform (June 11, 2009) can bestrengthened. They combine healthcare reform with generalist work-force expansion. The result is thatthe statement of principles relatingto health care reform is weak, over-whelmed by those dealing with gen-eralist workforce expansion.Separate positions for reform andworkforce expansion would help.

The specific policy recommenda-tions for clinical practice focus exclu-sively on fee-based reimbursementand the patient-centered medicalhome. SGIM should consider sup-porting a broader set of options de-signed to improve quality, containcosts, increase patient and physiciansatisfaction, and promote general-ism. These include the developmentand testing of prospectively reim-bursed integrated delivery systems

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Looking Back with Paul GrinerPaul Griner, MD

We take great pleasure in introducing the new “Reflections” feature to the SGIM Forum. This issue continues thefirst in a series of essays written by SGIM past presidents. SGIM has a legacy of wonderful contributions. Our pastpresidents give us perspective on how our field has grown and where we might go in the future. We know you willenjoy revisiting the history of SGIM and reading the wisdom of our former leaders.

—Robert Centor, Editor

REFLECTIONS

continued on page 10

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We are all familiar with the re-peated and perpetuated practice

whereby a student is quizzed on a re-mote topic he/she is unlikely to be fa-miliar with; the probability of thestudent answering the question cor-rectly is quite remote. Many claim thismethod, called “pimping,” is a valu-able teaching tool. Having completeda year of internal medicine residency,and having curiously observed the atti-tudes, practices, and behaviors of fel-low residents and senior attendings, Ibelieve pimping serves yet anotherfunction and can be misused bysome: It is mostly a display of superi-ority and authority, a more civilizedform of bullying.

According to Sigmund Freud, twobasic drives govern most human be-haviors: sex and aggression. This ideais not too far fetched when one pon-ders the history of human kind, whichis laden with aggression and blood-shed. Then what is it that makes uscivilized beings? After all, some of us,erroneously or not, claim to fall withinthat category. Perhaps it is the abilityto keep in check the above-mentionedraw tendencies. Pimping, when mis-used, is a subtle form of aggressionagainst another. Being educated mem-bers of society, I simply think we cando better than that. There are manyreasons that might drive an attendingto act in such a manner; however, thepsychological aspect of such behavioris beyond the scope of this discus-sion. Here I would like to shed light onthis behavior and express my distasteto the article written in JAMA, on April1, 2009, titled, “The Art of Pimping.”

On one sundry afternoon, after arather long conversation revolvingaround the status quo of physiciansand their role as teachers, I was pro-vided with an article titled, “The Art ofPimping.” As the elephant-sized pho-tocopier spat out the copied pages ofthe paper, the article’s subheadingstrikingly popped right out at me. Thesubheading read “ADVICE FOR STU-DENTS.” It was this subheading that

This, in fact, is an inherent part of ourvocation—we teach our colleagues,patients, and even ourselves. It isthus not surprising that we are oftenjudged by our ability to teach. I betthat most of us were asked about ourideas and willingness to teach wheninterviewing for jobs in the past. Evenduring our training, we ourselvesoften make remarks regarding certainlecturers: “He was great,” “She wasboring,” “I wish he wouldn’t comeback anymore.” With the differentarray of approaches, is there a rightone? Unlikely. However, I strongly be-lieve that there are certain quintes-sential or fundamental facets of aneffective teaching method that willlikely augment and hopefully replacethis current approach, carelessly re-ferred to as pimping.

A teacher is essentially a sales-man—a salesman of knowledge. It isparamount that one entices his/her au-dience with the material in question. Ifin doubt, next time you buy a used caror watch television infomercials, scru-tinize them for their ingenuity. For in-stance, have you ever noticed thatcommercials geared toward womenare more colorful and impart more de-tailed information than those aimed atmen? The second ingredient is imagi-nation—a wonderful function of thehuman condition that most of ushaven’t used since childhood. Teach-ing has to be tailored towards each in-dividual person/audience based on hisor her background. A good imaginationwill aid the teacher in recognizing thisand capturing the intended audienceeffectively.

Lastly, I urge all of you to use thatgrossly underused expression ofhuman emotion—the smile. All in all, Iam convinced there are myriad otherlikely more effective, more human,and more respectful ways of teach-ing. We do not have to resort to sucha seemingly archaic and humiliatingmethod of teaching to impart theknowledge we possess to those weare trying to guide and educate. SGIM

invoked a feeling of shame and gaverise to this outburst of words in re-sponse to the article. Instead of ridi-culing a rather crude practice, thearticle facilitated a venting mechanismfor residents subject to it, hiding be-hind the alleged claim that pimping fa-cilitates teaching. The JAMA articleclearly legitimizes the practice ofpimping. Apparently, and I quote, “itis a small group interactive method ofclinical teaching aimed at impartingimportant knowledge in the right con-text and in a memorable fashion.”Whether it imparts knowledge isquestionable; memorable it definitelyis! The above definition convenientlyomits other often subconscious pur-poses of pimping: self-glorification,self-indulgence, and an overt displayof authority. Even if pimping doesserve a function inherent in its JAMAdefinition, its practice should befrowned upon because it also violatesthe most basic human right—dignity.

The easiest—but by no meansthe sole—argument against suchpractice is the etymology of the worditself. The first definition that comesto mind is the word’s connotation toprostitution. Why then, and how, didthe word find itself ingrained intomedicine—an institution that at itscore should represent respect andperpetuate compassion for a fellowhuman being? Perhaps the word wasadopted because it fittingly describeswhat actually takes place. The pimpis usually a physician with a goodfoundation of clinical knowledge,which often translates to more yearsof clinical practice. The resident is afledgling doctor, trying to establishhim/herself in a very structured,overtly hierarchical environment andis often forced into “submission” byhis/her superiors. Are there no otherways to impart knowledge?

The word doctor is derived from adescriptive Latin verb doceo, mean-ing “to teach.” There are likely asmany teaching approaches as thereare personality types, if not more.

6

POINT

An Archaic MethodDamian Frackowiak, MD

Dr. Frackowiak is an internal medicine resident at St. Vincent Charity Hospital/Case Western Reserve University inCleveland, OH.

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Dr. Frackowiak challenges us witha classic concern—the role of

pimping. He believes that it is an out-dated and ineffective teaching toolthat purposefully humiliates learnersand takes away their dignity. Pimpinghas a long tradition in medical educa-tion. Like many words and phrases,how one defines and reacts to pimp-ing differs greatly across medical stu-dents and residents.

Many students, residents, andfaculty use pimping as slang for anySocratic questioning about medicine.Some may use adjectives to modifypimping (i.e. benign or malignantpimping). Malignant pimping occurswhen the purpose of the pimping isto make the learner feel bad and thepimp artist feel power. The benignpimp artist respects learners’ feelingsand uses questions as a probing tech-nique to appropriately direct learning,while maintaining a positive learningenvironment that does not humiliatelearners. In our experience, mostpimpers fall into the benign category.

Thus, our challenge in consideringDr. Frackowiak’s essay is to be cer-tain that we react appropriately to hischallenge. We will note that his con-cerns are not unique. A brief Googlesearch finds many such discussionsthroughout the blogosphere.

A central issue to both Dr. Frack-owiak’s piece and this response is theimportance of the teacher student re-lationship. The context of the relation-ship and the expectations formedwithin that context determine whetherone’s questioning is malignant or not.One should consider not one set ofexpectations but two (teacher and stu-dent) and perhaps more. If the rela-tionship is not open and honest, these

readily divulge their fund of knowl-edge. We often encounter learnerswho are naturally quiet but are ableto write strong letters of recommen-dation or excellent evaluations afterwe discover their excellent fund ofknowledge through pimping.

Malignant pimping deserves ourscorn. Attendings have power overresidents and students. Residentshave power over interns and stu-dents. We should all remember thedifference between benign and ma-lignant pimping and avoid the nega-tive feelings that students andresidents can experience. But weshould never end the tradition ofquestioning. We all remember ourpimp sessions from medical schooland residency. They challenged us togrow. We have a responsibility tohelp our trainees grow. The SocraticMethod works much better than lec-turing. To end all pimping would de-crease the effectiveness of rounds.

So we offer this suggestion to at-tending physicians—use the modelof “question and rescue.” In ques-tion and rescue, one asks questions.One should label a question as basic,intermediate, or difficult. Make surethe complexity of your questions isappropriate to the learner. For exam-ple, do not ask medical studentscomplex questions first. Instead, askbasic questions and increase thecomplexity as they continue to getthem right. When one learner clearlyhas no idea, switch to anotherlearner, ideally at a higher level. If alearner knows the answer (or a par-tially correct answer), provide praise.When several learners do not knowthe answer, stop and exclaim, “Won-derful! We have a great learning op-portunity!” Celebrate the incorrectanswers as a teaching opportunity.

Also realize that attending physi-cians don’t know the answer toevery question. We suggest thatwhen attendings are stumped, theyshould ask learners the question,thereby empowering learners to

expectations may vastly differ, causingproblems. Across relationships, aquestion that is asked using exactlythe same words and in exactly thesame way could feel either benign ormalignant, depending on the expecta-tions of the learner, the teacher, theculture, or a combination of all ofthese. Ultimately, the relationships webuild with our students will frame ourquestion-asking activities and deter-mine whether learning occurs or not.

We believe that the SocraticMethod does help students and resi-dents learn. Attending physicianshave a responsibility to frame ques-tions that help learners put medicalconcepts into context. The key is todo that in the best learning environ-ment possible. Studies have shownthat a small amount of stress in edu-cational settings does facilitate learn-ing (whereas excessive stress doesnot). Benign pimping can add thatsmall amount of stress. When thingsare working well, our questions ide-ally create an atmosphere of inquisi-tive curiosity, where all are stimulatedto search out and learn informationthat is new for them. If we try onlylecturing, we get passive learning,which leads to less learning.

Pimping can be very positive.One can use pimp sessions to findexcuses to praise learners. One canframe issues in an interactive ses-sion to help learners grow. Further-more, whether we like to admit it ornot, as attending physicians, we areoften asked to evaluate the learner atthe end of the rotation. Sometimesthe best assessment of a learner’smedical knowledge is through pimp-ing, especially for those who are ei-ther shy or somewhat reticent to

7

COUNTERPOINT

Pimping: A Long and Important TraditionRobert Centor, MD; Craig Keenan, MD; Paul Haidet, MD, MPH; Daniel Federman, MD;and Deepthiman Gowda, MD, MPH

continued on page 10

We believe that the Socratic Method does help

students and residents learn. Attending physicians

have a responsibility to frame questions that help

learners put medical concepts into context.

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A22-year-old African-Americanmale presents with one month of

polyarticular arthralgias and threedays of a diffuse rash on the lowerextremities. He describes his jointpain as a dull ache of moderateseverity without radiation; it affectshis hands, wrists, and knees bilater-ally and is not improved by over-the-counter pain relievers. The rash firstappeared on the left lower extremitythree days ago and then spread tothe right lower extremity. It is neitherpainful nor pruritic. He denies fever,weight loss, or fatigue. He does,however, report having had a sorethroat four weeks ago, which re-solved without therapy. He is other-wise healthy with no significant pastmedical history. He lives in the south-eastern United States, works at asteel factory, and smokes a half packof cigarettes daily.

The differential for polyarticulararthralgias is extensive, but in ayoung person like this, two main cat-egories of disease immediately cometo mind: infections and rheumaticdisorders. Both of these categoriesare also frequently associated withrashes. The recent pharyngitis couldrepresent the initial symptoms of asystemic infection or a precursor toan inflammatory illness. One disorderthat follows this pattern but is lesscommonly seen in the United Statesnow is rheumatic fever. All threemanifestations seen here (rash,arthralgias, and recent sore throat)are consistent with rheumatic fever;however, the arthritis tends to be mi-gratory (i.e. moving from joint tojoint). As always, HIV is an importantconsideration in young persons withsystemic illness, and this will need tobe explored as well, particularly sinceacute HIV infection can be associ-ated with pharyngitis, rash, andarthralgias.

ripheral joint involvement, theseronegative spondyloarthropathiesshould be considered, particularly re-active arthritis given his recent infec-tion. Other conditions that cancause an inflammatory arthritis andrash that should be considered in-clude systemic lupus erythematosi(SLE); adult Still’s disease (juvenilerheumatoid arthritis); and infectionssuch as Lyme disease or other tic-borne illnesses, infective endocardi-tis, and a number of viral illnesses(HIV, parvovirus, hepatitis B, etc.). Acareful eye and genital exam are im-portant to evaluate for manifesta-tions of reactive arthritis or otherspondyloarthropathies.

Finally, we get to his rash. Inter-estingly, his rash does not blanchand predominantly involves thelower extremities, with sparing ofthe palms and soles. The differentialfor a maculopapular rash is quitebroad, but in context with the otherfindings it begins to narrow. Many ofthe disorders mentioned above ascauses for an inflammatory arthritiscan also cause rashes. Those notmentioned would include secondarysyphilis and rheumatic fever. If theconcentration of findings on the calfrepresents the initial target of Lymedisease, his rash could certainly becompatible with that disorder. Finally,the non-blanching aspect of the le-sions described raises the possibilitythat this is purpura. This again wouldpoint to an infectious or inflamma-tory cause. In children and youngadults, Henoch-Schonlein purpura, inwhich the purpura tends to preferen-tially be found on the lower extremi-ties, is also associated withglomerulonephritis.

At this point, urinalysis and care-ful evaluation of his kidney functionand blood counts (especially plateletsand peripheral smear) are in order, as

At this point, more informationabout the character of the rash isneeded, as well as additional infor-mation about the joint pain to testthe hypothesis that this is an inflam-matory arthritis. Specific informationabout morning stiffness, jointswelling, and/or redness would beparticularly important to discern.

On physical examination, bloodpressure is 148/96, heart rate 76, andrespiratory rate 18; he is afebrile.Joint examination reveals pain withmotion of the fingers, wrists, knees,and back without tenderness to pal-pation. The joints are mildly swollen.A non-blanching, erythematous, mac-ulo-papular rash covers his lower ex-tremities and is most prominent onthe left calf. The rash spares thepalms and soles. The remainder ofthe physical exam is normal.

Our patient’s physical exam is re-markable for several reasons. It istempting to quickly focus on therash, but the patient has a couple ofother interesting findings. First, hisblood pressure is markedly elevatedfor someone his age and who is pre-sumably otherwise healthy. Second,his joint swelling and pain with rangeof motion point to an inflammatorycondition in the joints, which appearsto involve both the axial (back) andperipheral joints (hands and knees).

Several considerations come tomind for these findings. The hyper-tension could be a sign of glomeru-lonephritis or other nephriticcondition, so evaluation of his urineand kidney function will be impor-tant. This would again fit with a sys-temic illness, either infectious orinflammatory (rheumatic in origin). Al-ternatively, the hypertension could in-dicate an endocrine or vascularcondition and, in a young person,definitely warrants further evaluation.

With regard to his axial and pe-

MORNING REPORT

A 22-year-old Male with ArthralgiasChris Hanlon and Parekha Yedla, MD (presenters); F. Stanford Massie Jr., MD (discussant, in italic)

Mr. Hanlon is a third-year medical student at the Univeristy of Alabama at Birmingham; Dr. Yedla is assistantprofessor of medicine at the University of Alabama Huntsville Rgional Medical Campus; and Dr. Massie is anassociate professor of general internal medicine at the University of Alabama at Birmingham.

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well as liver function tests to assessfor involvement of other organs. I amquite concerned about an evolvingsystemic illness of either an infec-tious or inflammatory etiology.

Laboratory studies return withthe following results: WBC 3,200;(normal: 4,000-10,000); Hgb 10.4;platelets 294; MCV 76; sodium 137;potassium 4.2; chloride 23; bicarb27; BUN 23; and creatinine 1.0; alka-line phosphatase, AST, and ALT arenormal; and serum albumin is 2.8.Urinalysis demonstrates large hema-turia and small proteinuria; micro-scopic examination shows 7 WBCsand 21 RBCs/hpf. ASO antibodyscreen is positive. ESR is 64, and C-reactive protein is 1.7.

He has a mild leukopenia andmild microcytic anemia, which wouldgo along with either an infection (es-pecially viral) or an inflammatoryprocess. His creatinine appears nor-mal. (However, this can be a mislead-ing estimate of GFR, and a baselinecreatinine would be helpful.) His LFTsare normal, but he has hematuria andproteinuria most likely suggestive ofglomerulonephritis (GN). RBC castswould be more definitive, but thesefindings in the context of his otherfindings strongly point to this diagno-sis. His ESR is elevated, which isnonspecific but again suggests in-flammation of some sort. His ASOtiter is positive, suggesting recent(i.e. last few weeks) infection withStreptococcus, but serial titers wouldbe more definitive about the timing.

All taken together, he likely has aglomerulonephritis associated withrecent Strep infection. Poststrepto-coccal GN (PSGN) typically presentstwo to four weeks after Streppharyngitis, and the timing with ourpatient fits this well. The finding oflow complement levels would solid-ify this diagnosis further, as there areonly a handful of disorders that causeGN with low complement levels:PSGN, lupus, infective endocarditis,and cryoglobulinemia.

He does not meet criteria forrheumatic fever at this point, butthere may be some overlap be-tween the findings in this disorderand a reactive arthritis that can fol-

most serious manifestations of SLE;as such, treatment with aggressiveimmunosuppression is appropriateto prevent further kidney damage.

I remain puzzled about his otherautoantibodies (SCL-70 and RNP) andwould ask one of my rheumatologycolleagues about this. I am also curi-ous about his rash. Although lupusskin manifestations can be varied,this does not sound like typical lupusskin involvement. A skin biopsy maystill be warranted.

Lastly, the ASO titer elevation re-mains difficult to explain. Did he havean unrelated Strep pharyngitis sev-eral weeks before? Repeating thetiter in two to four weeks from nowcould provide useful information, asit should begin to fall by this time ifhe really had an acute infection.

Summary1. The differential for polyarthritis is

broad, but information about thejoints involved, pattern ofinvolvement, and presence offeatures that suggest jointinflammation (stiffness, redness,swelling, etc.) are important todiscern and can help to focus theevaluation.

2. The finding of new hypertensioncoupled with proteinuria andhematuria should raise thepossibility of glomerulonephritis.

3. Systemic lupus erythematosus(SLE) is a disease with proteanmanifestations and shouldalways be considered in thedifferential for individuals withillness affecting multiple organsystems, especially skin, joints,and kidneys.

SGIM

low Strep infections. The only clini-cal finding that I still can’t totally rec-oncile is the rash. It is not typical forrheumatic fever, and I’m not sure ifPSGN is associated with a rash. Ialso can’t rule out Henoch-SchonleinPurpura, which can also followupper respiratory infections. I wouldpush for a skin biopsy and checkcomplement levels.

Based on the initial labs, furthertests are ordered and show HIV,monospot, and RPR negative. ANA,ds-DNA, anti-Sm, anti-SCL-70, anti-RNP, and anti-Sm RNP antibodiesare all positive.

A diagnosis of lupus depends onthe presence of certain clinical mani-festations and auto-antibodies. Basedon the combination of his polyarthri-tis, renal involvement (and perhapshis rash) with the positive ANA, anti-DS DNA, and anti-Smith antibodies, adiagnosis of SLE is highly likely as theexplanation of his symptoms. Anti-Smith antibody is the most specific ofthe serologic tests for SLE but is onlyseen in a minority of SLE patients.

That being said, I am unable toreconcile the presence of two ofthe autoantibodies that are specificfor other clinical conditions: anti-SCL-70 (systemic sclerosis) andanti-RNP (mixed connective tissuedisease). I don’t believe his presen-tation fits with either of these disor-ders, but he may have anundifferentiated connective tissuedisorder that could become moredefined over time.

I would consult rheumatology atthis point for input regarding the au-toantibodies. In addition, a renalbiopsy should be pursued sincecomplications of renal involvementin SLE are a major cause of morbid-ity. Depending on the pathologic le-sion identified on biopsy, aggressiveimmunosuppressive therapy may berequired.

The patient underwent a renalbiopsy that revealed class IV lupusglomerulonephritis with diffuseglomerular involvement and cres-cent formation. He was treated with high dose prednisone and cyclophosphamide.

Renal lesions are one of the

He does not meet criteria for

rheumatic fever at this point, but

there may be some overlap

between the findings in this

disorder and a reactive arthritis

that can follow Strep infections.

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Lisa Sanders, a dedicated SGIMmember, has written an important

new book—Every Patient Tells aStory. For those members who donot know Lisa, she works in the YalePrimary Care Program and writes aregular column called “Diagnosis”that appears in the New York TimesSunday Magazine. The Internet al-lowed Lisa and me to becomefriends. Most readers know that Ihave written a blog since 2002. Aspart on my blogging, I read opinionpieces and news reports to getideas. The New York Times healthsection is a great source for ideas. Ifound Lisa’s column in that sectionsix years ago.

I must declare my conflict here.Lisa asked me to write a blurb for herbook, which I did. I read the book sixmonths prior to publication, devouredit, and loved it. I am conflicted be-cause I am friends with Lisa, and wehave a mutual admiration society.

Lisa has written an internist’sview of diagnosis; she is a storyteller.Her columns and her book tell storiesabout people who have puzzling diag-noses. She writes beautifully, captur-ing patients’ personal stories as wellas the medical details and a thought-ful explication of the diagnostic

York Times Sunday Magazine. Aboutsix months later, she was surprisedwhen he asked her to write a samplecolumn. Apparently, the other writerhad not been a good fit for the maga-zine. The editor gave her three daysto write the column. That columnwas published in August 2002, andshe was offered “a regular gig.”

I love her columns. She tells sto-ries from both a left- and a right-brainperspective. I asked her what lessonsshe learned from writing her columns.She mentioned these things: Diagnos-tic errors are common, and most diag-nostic errors occur due to prematureclosure. Therefore, she teaches stu-dents and residents to “keep an openmind” with respect to diagnosis. Fi-nally, she noted that anyone canmake an interesting diagnosis andthat usually when you do not make aninteresting diagnosis you are not pay-ing attention.

The book is delightful because ofthe breath of the cases it containsand Lisa’s use of cognitive psychol-ogy in both doctoring and diagnosing.I highly recommend Lisa’s columnsand her book. You will find her a kin-dred spirit and will want to meet herin the future.

SGIM

process. Lisa captures the challengeof making difficult diagnoses andhighlights the reason we make diag-nostic errors.

I recently talked to Lisa about writ-ing and being an internist. Lisa ma-jored in English literature and thentook a job in TV journalism. Duringthat time, she worked with physicianBob Arnot. This experience helpedher think about the possibility of be-coming a physician. She decided totake a pre-medical course, did well,and then went to medical school.

During her time in medicalschool, she considered many possi-ble specialties, choosing internalmedicine because she loved solvingpatient problems. Sometime duringresidency, she met a gentleman at a party who eventually became an editor at the New York Times. Likemany internal residents, she recallstelling patient stories at parties. As she said, she really had nothingmuch else to talk about during that time.

Apparently, the editor recalledone of the stories and asked her tohelp design a new column. Sheworked with the editor, and they de-signed a column that someone elsewas scheduled to write for the New

10

BOOK REVIEW

Every Patient Tells a StoryRobert Centor, MD

REFLECTIONScontinued from page 5

(i.e. participation in teaching and re-search, an area of special expertise, a link with an international medicinesite) and time for reflection. Despitethese concerns, as I prepare to returnfor my 50th medical school reunion, Icannot imagine a more rewarding lifethan that of an internist. I have beenprivileged to know and help peoplethrough a breadth and depth ofknowledge that is not found in anyother field of medicine. I admire andenvy those of you who are in theearly stages of your own careers asgeneralists. The future of the field isin your hands.

SGIM

ginning of the rotation. Tell your teamthat you are going to pimp but thatyou are doing so to teach. Remindthe learners that the purpose of find-ing holes in their knowledge is to ap-propriately direct education for boththe attending and the learner.

So while we respect Dr. Frack-owiak’s concerns, we believestrongly that intelligent benign pimp-ing represents an integral part of clin-ical education. If we do not explorelearners’ knowledge, how can wehelp direct their growth? We shouldstrive to do this in a caring way, butwe should also continue the pimpingtradition. SGIM

either answer the question or spendtime researching the question andeducate the inquisitive attending (orthe attending can look it up and rolemodel active learning). This methoddemonstrates physicians’ perpetualquest for additional knowledge. Italso shows that the attending andlearner are not adversaries but ratherteammates enmeshed in the searchfor knowledge and excellence in pa-tient care. It lowers the power differ-ential between attending and learnerand creates opportunities for learnersto teach their mentors.

This strategy works best whenone explains the technique at the be-

COUNTERPOINTcontinued from page 7

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cine despite the fact that my genera-tion of soon-to-be general internistsand subspecialists will primarily carefor patients in outpatient settings.How is it that managing a septic pa-tient who requires mechanical ventila-tion seems like a routine task whencompared to the patient with a hairlinemetacarpal fracture who needs a basicsplint with care instructions?

I am suddenly grateful for my per-sonal approach to learning during resi-dency. Fortunately, I sought additionalknowledge about and became com-petent in the interventions used totreat common primary care com-plaints, including musculoskeletalpain, poorly healing wounds, and skinailments that are commonly referredto specialists. My goal was always tobe a complete primary care physicianwho was prepared to evaluate andtreat almost any chief complaint whilereferring to specialists only when ab-solutely necessary. This is a confi-dence that I feel is difficult to achievein three years of residency training,

but I also believe it is the foundationof being a great primary care provider.

Becoming a resident clinic pre-ceptor and medical student instructorare positions I always knew I wouldcherish. Much of residency involvedpeer teaching, which was of im-mense educational value. Am I reallyprepared to be an impactful educatorwithout completing a chief-residentyear or a fellowship to directly honethese important skills? Refining andmaximizing my precepting opportuni-ties with my past interns and medicalstudents hopefully have helped mebecome a better teacher. Taking thisto the next level may prove to be achallenge; after all, only a fewmonths ago I was socializing andhaving a beer with some of the resi-dents whom I will be precepting laterthis week. I can only hope to makean impact on my residents’ clinicaleducation, much like my mentorshave in my own training.

There is an inherent pride to hav-ing become a primary care provider. It

involves a special responsibility regard-less of its well-publicized challengesand demands in coordinating themany facets of a veteran’s health careneeds. I aim to become a solid diag-nostician of their physical and mentalcomplaints, to comprehensively man-age their chronic disease states, andto play an instrumental role in patienteducation and advocacy, thereby limit-ing the development of future chronicmedical conditions. At a time whenthe need for good primary care physi-cians couldn’t be greater, I hope toshow my residents and medical stu-dents the importance of being self-di-rected learners under residencywork-hour restrictions, which mayvery well be limiting opportunities todevelop sufficient outpatient experi-ences. As I undertake this ultimatenew role, I know my fears may neverfully subside, but my passion for mypatients and primary care will guideme through my new journey. I em-brace the challenges to come.

SGIM

NEW PERSPECTIVEScontinued from page 1

Looking AheadAs practices establish themselves asPCMH models, there are countlessopportunities to improve the care ofolder adults. PCMHs provide formalrecognition for many of the currentlyunder-recognized practices of geri-atric care (e.g. team-based care; carecoordination; and attention to progno-sis and quality of life, end of life, and palliation). They also open doors for developing infrastructure andprocesses targeting care of olderadults. By recognizing the multi-faceted ways in which the PCMHand geriatrics are aligned, practicescan optimize the care of all patientswith multiple chronic, interacting conditions, especially the growingpopulation of older adults.

References1. Institute of Medicine. Retooling

for an aging America: building thehealth care workforce.

Washington, DC: The NationalAcademies Press, 2008.

2. Joint Principles of the Patient-Centered Medical Home. AAFP,AAP, ACP, AOA. March 2007.Available at: http://pcpcc.net/content/joint-principles-patient-centered-medical-home,Accessed Oct 10, 2009.

3. Physician Practice Connections—Patient-Centered Medical Home(PPC-PCMH) Standards CMSversion. National Center forQuality Assurance 2008. Availableat: http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/MedHome_PPC.pdf.Accessed October 14, 2009.

4. Stuck AE, Siu AL, Wieland GD,Rubenstein LZ, Adams J.Comprehensive geriatricassessment: a meta-analysis ofcontrolled trials. Lancet1993;342:1032-6.

5. Counsell SR, Callahan CM, Clark

SIGN OF THE TIMEScontinued from page 4

DO, et al. Geriatric caremanagement for low-incomeseniors: a randomized controlledtrial. JAMA 2007;298(22):2623-33.

6. Beland F, Bergman H, Lebel P,Clarfield A, Tousignant P,Contandriopoulos A, et al. Asystem of integrated care for olderpersons with disabilities in Canada:results from a randomizedcontrolled trial. J Gerontol A BiolSci Med Sci. 2006;61(4):367-73.

7. Wolff JL, Rand-Giovanetti E,Palmer S, Wegener S, Reider L,Frey K, Boult C. Caregiving andchronic care: the guided careprogram for family and friends. JGerontol Med Sci 2009;64(7):785-91.

8. Wenger NS, Roth CP, Shekelle P,ACOVE Investigators.Introduction to the assessing careof vulnerable elders-3 qualityindicator measurement set. JAGS2007;55:S247-52. SGIM

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CURBSIDE CONSULTcontinued from page 2

ples that are just as relevant to thosewho are not in management posi-tions. It advises great managers toallow the people with whom they areworking to develop their strengthsand avoid their weaknesses. A coupleof examples help clarify this.

A new faculty member wants aresearch career. She was a greatresident and a good fellow in gen-eral internal medicine. While she isan excellent teacher who loves toteach, she tends to be a bit slowwith patients and dreads going toclinic. She starts on her research ca-reer, and it becomes clear that shehas difficulty writing and submittinggrants. She continues to function asa ward attending and gets rave re-views. She was hired originally to bea researcher, but it is clear that herskill set is better suited to being an educator.

How would you advise this juniorfaculty member? Because she washired as a researcher and wants a re-search career, should she persist andtry to improve her grant-writingskills? With work, she may become apassable researcher, perhaps evengarnering a small grant or two. Or,should she change directions andfocus on a career as a clinician-edu-cator? While she may ultimately be-come a good clinician scientist, byfocusing on her strengths as ateacher, she can become a great clin-ician-educator.

This faculty member was advisedto focus on clinical activity that hasan educational focus (e.g. attendingon the wards, precepting residents).She was ultimately steered towardintramural and extramural opportuni-ties to further hone her teaching andleadership skills.

Another faculty member is a bril-liant thinker and excellent writer. Un-fortunately, he has a very abrasivepersonality, and whenever he comesin contact with students and resi-dents, uproar and discontent follow.This faculty member was redirectedto a job description that allowed himto succeed at his strengths and mini-mize his weaknesses.

As the book First, Break All the

Rules suggests, it’s far more satisfy-ing and pleasant to spend your timeaugmenting your strengths ratherthan overcoming your weaknesses.

The first step in augmenting yourstrengths is to identify them. Self re-flection coupled with feedback fromothers will help you to do this. It isfrequently difficult for us to see ourown strengths and weaknesses.Mentors, colleagues, family, andfriends are sometimes in the best po-sition to point out the often-obviousstrengths and weaknesses that wecannot see in ourselves.

Lesson #3: It’s not about you!There are many reasons for successand failure in academic general medi-cine. One reason for failure is beingcompletely focused on one’s own ad-vancement rather than the advance-ment of the group as a whole. Asuccessful faculty member enhancesthe value of the group as a wholethrough his/her ability to foster ateam environment. This is best illus-trated by examining the impact thatelite athletes have on their teams:Larry Bird and Magic Johnson aretremendous individual basketball play-ers who elevated the performance oftheir teams as a whole. Some peoplecall this attribute citizenship. Many di-vision chiefs praise faculty who theyknow will chip in when things aretough, even when it is not convenientfor that faculty member. These “sacri-fices” are noted and necessary forthe group to excel.

Lesson #4: Persistence trumps talent.There are a few lucky individuals whoare naturally gifted and who excel nat-urally. Most of us have predilectionsor skills that, through consistent prac-tice, can result in excellence. In orderto continue to improve, you mustpractice. A recent bestseller—Outliersby Malcolm Gladwell—refers to theinteresting phenomenon that concen-trated practice with formative feed-back is necessary to achieveexcellence. Practice, feedback, andtime “in the trenches” are necessaryfor success. Practicing a skill incor-

rectly, no matter how diligent youare, will not lead you to mastery. Ad-ditionally, persistence in the theoreti-cal realm (i.e. book knowledge) isinadequate to develop mastery. Youmust spend time practicing your skillin real situations. Practice is essentialto becoming an expert. Becoming amaster clinician or outstanding educa-tor takes practice. If your goal is tobecome an excellent physician, thenyou need to practice medicine. Evalu-ate yourself and have others evaluateyour clinical abilities. If you want tobe an excellent educator, evaluateyour educational abilities and haveothers help you improve your skills.Becoming a writer takes practice.Spend a lot of time writing, and overtime you will write with clarity andmeaning. If you wish to perfect yourpresentation skills, you have to pre-sent. Your first talk likely will not beas good as your 10th talk, which willnot be as good as your 25th talk. Justas one cannot become a master clini-cian without deliberate practice, onecannot excel at teaching, writing, orpresenting without spending timewith your “skin in the game.”

Lesson #5: Make excellent mistakes.Tom Peters, co-author of the book In Search of Excellence, has oftenchampioned this concept. So what isan excellent mistake? An excellentmistake occurs when you learnsomething important by taking a riskon a new venture. One makes an ex-cellent mistake by taking a chance ona new project. If you don’t take risksby developing a new conference,writing a paper that is not exactlymainstream, or trying a new teachingtechnique, then you cannot improve.If you make no mistakes in your ca-reer, then you are not takingchances—and likely have a boringjob! Only by making mistakes willyou learn the important lessons thatallow you to grow and achieve whatyou want to achieve.

Lesson #6: Leave an imprint.At most institutions, the people whoare promoted and awarded tenure

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PRESIDENT’S COLUMNcontinued from page 3

are those who make an imprint onthe institution. It is not good enoughto be an excellent utility infielder; youactually have to be a star of somekind. Different types of stars get pro-moted—there are quiet stars, loudstars, research stars, clinical stars,and educational stars. Their underly-ing similarity is that they have allmade an impact. You need to figureout what your impact will be andmultiply that in every way you can.

By seizing the right opportunities(Lesson #1), focusing on yourstrengths (lesson #2), being a teamplayer (lesson #3), engaging in delib-erate practice (lesson #4), and takingrisks and learning from your mistakes(lesson #5), you will be well posi-tioned to make your imprint (lesson#6) on your institution.

*This short book with simple mes-sages should make everyone think

CURBSIDE CONSULT

about career development. Becausecareers are dynamic rather than sta-tic entities, engaging in lifelong self-reflection using these six principlesthroughout your career can help youachieve a state of flow. We haveused many of these principles inguiding our mentees and in guidingour own careers. We hope theseseemingly simple lessons will stimu-late much thought and discussion.

SGIM

experience. Long ago I developed ex-pertise in addressing tobacco use. I’dlike to say that this was a brilliantstrategic decision, but the truth is thatI just tried to answer a patient’s ques-tion. During my internship, a patientasked me how to quit smoking. I hadno idea. In medical school I hadlearned that smoking was hazardousand quitting was desirable, but I hadnever gotten the impression that itwas my job to do more than tell pa-tients to quit. A lifelong nonsmoker, Ihad no personal experience to drawon. Of course, as an intern, I didn’tknow a lot of things and usually gotthe answer by enquiring up the hierar-chy, starting with my resident, then aclinical fellow, and finally an attending.I tried this tactic, but even our mostsenior primary care faculty memberdidn’t have a clear answer.

When my turn came to present atintern conference, I decided to learnabout quitting smoking. I did somereading, learned maybe five facts,and taught everybody else these fewtidbits that they, like me, didn’tknow. In relatively short order, I be-came a local expert just because Iknew a little more than everyoneelse in my institution on a topic thatpeople realized was worth knowingabout. Over time, I taught many ofmy colleagues my few facts. I thenwent out and learned more facts andbrought them home to teach others.

From this I developed my defini-tion of an “expert”—someone whoknows five more facts about a prob-

lem than most of his or her peergroup and teaches what he or sheknows to others. In the academic en-vironment, this usually also meanswriting for publication. To maintainhis or her stature, the expert needsto stay five facts ahead of what he orshe has already taught others. This isnot difficult because new approachesto management are always appear-ing. If you have passion for the topic,it will be a pleasure to learn more.

To maintain expertise you can at-tend meetings or take courses inyour area of interest, read specialtyjournals, or do research. Meetings areespecially important because theyprovide you exposure to the latestideas in ways that reading journalscan’t do. Then, armed with somenew ideas, you can return home toteach colleagues. Over time, withluck, you can extend your reputationas an expert beyond your own institu-

tion and have the opportunity to en-lighten colleagues at other institutionsin other parts of the country or evenin other parts of the world.

For me, developing a special clini-cal expertise has been a rewardingjourney to accompany—not re-place—my clinical skills as a generalinternist. You can do it, too, if you areso inclined. The secret is simply todefine your field strategically. A com-mon but underappreciated topic isideal, something that your colleaguesrecognize that they should knowmore about to be better doctors. Thetopic must also be something that in-trigues your intellect or engages youemotionally. Once you find it, learn alittle, teach what you know to yourcolleagues, and stay five facts aheadof your them at all times.

Soon, you too will be an expert—and a generalist too. Good luck, andhave fun. SGIM

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MPH or MS in Clinical Research. There isalso ample support for conference traveland other training experiences.

A letter of interest and resume may besubmitted through the online applicationsystem at: employment.umn.edu, under requisition number163022.

For more information, please contact Andy Sturdevant at 612-626-3378 [email protected].

The University of Minnesota is anequal opportunity educator andemployer.

Staff Physician SpecialistsImmediate Openings are currentlyavailable for Staff Physician Specialistfor the Robert Wood Johnson MedicalGroup (RWJMG) Non-TeachingHospitalist Service (NTHS). Candidatemust be board certified in FamilyMedicine or Internal Medicine, able towork weekends as well as home nightcall, which will be rotated among thehospitalists in the NTHS group. Homenight call to take calls from in-housepractitioners regarding orders on newadmissions, will require that you work inthe Robert Wood Johnson UniversityHospital (RWJUH) for the RWJMG anaverage of 40 hours per week, whichwill be scheduled so as to cover thehours daily from 7:00am to 11:00pm.

Send letters of interest andaccompanying CVs to Martha Lansing,MD: Associate Professor and ViceChair, Department of Family Medicine,PO Box 19, MEB Room 288B, New Brunswick, NJ 08903-0019. EOE.

General Internal MedicineThe Department of General InternalMedicine is seeking board certified/boardeligible candidates interested in anacademic career focusing on teaching orresearch and patient care. Candidateswith research expertise in medicaleducation, outcomes, and qualityimprovement, particularly in diabetesmellitus and other chronic diseases, areespecially welcome.

The Medicine Institute is responsiblefor Cleveland Clinic medical student,resident, and fellow education in internalmedicine. Current GIM faculty holdsignificant leadership positions in themedical school, residency program, andinstitutional administration. The practiceuses an electronic medical record systemand is focused on quality improvementand innovation in care delivery. GeneralInternal Medicine candidates shouldqualify for faculty appointment at theassistant or associate professor level atthe Cleveland Clinic Lerner College ofMedicine. All candidates must be eligiblefor Ohio medical license.

Cleveland Clinic is an equalopportunity employer and is committedto increasing the diversity of its faculty. It

welcomes nominations of and appli-cations from women and members ofminority groups, as well as others whowould bring additional dimensions to itsresearch, teaching, and clinical missions.Cleveland Clinic is a smoke/drug freework environment.

Interested candidates should forwarda current copy of their CV in WORDformat to the attention of:Joe Vitale, Senior Director, PhysicianRecruitment, Office of ProfessionalStaff Affairs at [email protected] or applyonline on at www.clevelandclinic.org.

Academic Hospitalists/Clinician-Educator

Tulane University School of Medicine,Section of General Internal Medicine isseeking BE/BC general internists to joinour academic hospitalist program. Rankwill be commensurate with experience.

These faculty provide inpatient andmedical consultative care at Universityaffiliated hospitals in concert withhousestaff. Applicants will join a robustacademic hospitalist group active inscholarly activities including qualityimprovement and medical education.Those with experience and interest instudent and resident education desired.

Physicians enjoy competitive salariesand benefits package. Candidates fromunderrepresented minorities areencouraged to apply. No J-1, O-1 or H1-Bvisas please.

Interested applicants should submita CV and cover letter to:Alys Alper, MD, MPH, Associate Chief,Section of General Internal Medicineand Geriatrics, Tulane UniversityMedical School, 1430 Tulane Avenue,SL-16, New Orleans, LA 70112,[email protected] or 504-988-7518.Applications will be accepted untilqualified candidates are identified. AA/EOE.

Policy-Oriented InvestigatorBridging Decision Sciences And

Health Services ResearchThe Section of Value and ComparativeEffectiveness (SolvE), within the Divisionof General Internal Medicine of New YorkUniversity School of Medicine, seeks torecruit an investigator to conduct policy-relevant health services research with adecision-centered perspective. Ourresearch mission is to improve the valueof health care systems by applyingquantitative methods, building ongrowing investments in comparativeeffectiveness research and healthinformation technology. Candidate willjoin a collegial, mentorship-rich environ-ment, working alongside investigatorswith national and internationalrecognition. Candidate will also contri-bute to The Operations ResearchCollaboration for Health (T.O.R.C.H.), amulti-institutional, multi-disciplinary colla-boration uniting clinical and operationsresearch expertise.

Areas of interest include prioritizingand personalizing clinical guidelines

Positions Available and Announce-ments are $50 per 50 words forSGIM members and $100 per 50words for nonmembers. These feescover one month’s appearance inthe Forum and appearance on theSGIM Web-site at http://www.sgim.org. Send your ad, along with thename of the SGIM member spon-sor, to [email protected]. It isas-sumed that all ads are placed byequal opportunity employers.

Andrews Air Force Base, MDInternal Medicine Physicians—

HospitalistsFull Time Positions Providing CivilianServices at this Military MedicalTreatment Facility. Excellent Compen-sation and Benefits Package GreatWorking Environment

Qualifications:Completion of a residency or fellowshipin internal medicine. Current boardcertification by the American Board ofInternal Medicine or the AmericanOsteopathic Board of Internal Medicine.

Have been employed in the practiceof Internal Medicine or in training for 24of the last 36 months. Board CertifiedInternist will function primarily asHospitalist.

Physicians Please Send CVs by Emailto: [email protected] or Fax to: 305-576-5864 RLM Services, Inc. EOE

University of MinnesotaPostdoctoral Associate

The Department of Medicine is excitedto announce the availability of a post-doctoral associate position in: healthdisparities, nicotine dependence/smoking cessation, obesity/weight loss,cardiovascular disease, and cancerprevention and control. The post-doctoralmentor will be Jasjit S. Ahluwalia, MD,MPH, MS, who is the PI of a new NIHfunded P60 Comprehensive Center ofExcellence in Minority Health and HealthDisparities. He has a long track record ofsuccessfully mentoring trainees whohave gone on to secure NIH funding.

Eligible candidates should have adoctoral degree in behavioral science,health education, health servicesresearch, sociology, anthropology,psychology or a related discipline. Theprogram provides exceptional mentoredtraining with an opportunity to developresearch skills and collaborate withdynamic, federally funded, faculty. Theposition is annually renewable, for up totwo years, with a flexible start date,competitive salary, and excellentresources for career development. Thepost-doctoral training can be tailored tosuit the individual’s training requirementswith opportunities for authorship onrelevant manuscripts, collaborative grantwriting experience, independent grantsubmission, and funding to obtain an

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based on individual patient charac-teristics, aligning health systemincentives with measures of value, andallocating resources to combat highmorbidity and mortality conditions (e.g.HIV, cardiovascular disease),domestically and globally. Method-ological foci include mathe-maticalmodeling, decision analysis, cost-effectiveness, evidence synthesis,behavioral economics, and informatics.Successful candidates will becomfortable communicating with othersoutside of their discipline and/or in apolicy sphere.

Remarkable opportunities forresearch span NYU Langone MedicalCenter’s extensive delivery system aswell as principal teaching and researchaffiliates including Bellevue HospitalCenter and VA NY Harbor HealthcareSystem. Strong ties exist with NYCpublic health agencies as well as withcross-disciplinary initiatives at NYU’smany schools including the WagnerGraduate School of Public Service. Corequalifications include evidence of qualityscholarship; extramural funding; mento-ring skills; and a research agenda thataddresses population health, under-served populations, and/or issues ofcomparative effectiveness. Applicants ofany faculty rank will be considered, withpositions tailored accordingly. For MDapplicants, board certification or eligibilityin internal medicine, and NY Statelicensure or eligibility required.

Send cover letter and CV to: Dr. ScottBraithwaite, NYU School of Medicine,423 East 23rd Street 15-091S, New York, NY 10010 or [email protected] School of Medicine is anAffirmative Action Equal OpportunityEmployer

Healthcare DisparitiesInvestigator, University of

Pittsburgh School of MedicineThe Division of General InternalMedicine invites applications for full-time investigators (rank Assistant orAssociate Professor) in the Section ofHealth Care Disparities and InternationalHealth. Extensive collaborativeopportunities exist with faculty at theUniversity of Pittsburgh, RAND HealthPittsburgh, and the VA Pittsburgh Centerfor Health Equity Research andPromotion. Candidates should have MDand/or PhD with strong research trainingin healthcare disparities. Investigatorsfrom minority backgrounds areencouraged to apply.

Applicants should submit a statementof interest and a CV to: Said A. Ibrahim,MD, MPH, Chief, Section of Health CareDisparities and International Medicine,email: [email protected]. TheUniversity of Pittsburgh is an AffirmativeAction, Equal Opportunity Employer.

Academic General InternistsBrigham and Women’s Hospital’sDivision of General Internal Medicine

candidates will be notified by April 1,2010.

Duke UniversityDurham, N.C., Contact: Patsy Clifton, Program CoordinatorPhone: (919) 668-8744E-mail: [email protected]

Mid America Heart InstituteKansas City, MO, Contact:Mikhail Kosiborod, M.D. (Training Director)Phone: (816) 932-5475E-mail: [email protected].

Stanford University-KaiserPermanenteStanford and Oakland, CA, Contact:Elaine SteelPhone: (650) 723-6426E-mail: [email protected]

University of California, Los AngelesLos Angeles, CA, Contact:Eliza D. Aceves, M.B.A., CenterAdministratorPhone: (310) 206-7671 E-mail: [email protected] site for Application: http://sites.google.com/site/uclaahaprtorc/

Postdoctoral ResearchFellowships in Cardiovascular

Disease PreventionThe Stanford Prevention ResearchCenter, an interdisciplinary researchprogram on the prevention of chronicdisease, is seeking applicants forpostdoctoral research fellowships for2010-2011. Fellows gain direct researchexperience in cardiovascular diseaseprevention, community and health psy-chology, behavioral medicine, inter-vention methods, clinical epidemiology,research design, and biostatistics. Con-current enrollment in a masters degreeprogram in clinical research methods ispossible. We particularly encourageapplicants with interests in exercise,nutrition, the effects of the builtenvironment on health, technology andbehavior change, social and culturaldeterminants of health, child andadolescent health promotion, suc-cessful aging, and women’s health.Stanford University is committed toincreasing representation of womenand minorities in its fellowshipprograms and particularly encouragesapplications from such candidates. OnlyU.S. citizens and permanent residentsare eligible for this fellowship. Appoint-ments are from 2 to 3 years. Appli-cations are due by 01 December 2009.

Information and applicationprocedures are on our website:http://prevention.stanford.edu>, oremail: [email protected]

seeks academic general internists withinterest in clinical epidemiology/healthservices research especially inevaluation of healthcare informationtechnology. Positions will provide50–80% protected time to conductresearch. Academic rank and salary willbe commensurate with qualifications;seeking instructors to associateprofessor level. Review of applicationswill begin immediately.

Send letter of interest and CV to:David Bates, MD, Division of GeneralInternal Medicine, BC3-2M, Brighamand Women’s Hospital, 1620 TremontSt, Boston, MA, 02120-1613. Brighamand Women’s Hospital is an affirmativeaction, equal opportunity employer.

AHA-PRT Outcomes ResearchPostdoctoral Fellowships—

Round TwoThe American Heart Association-Pharmaceutical Roundtable OutcomesResearch Centers invite applications fortwo-year postdoctoral fellowshipsbeginning in July 2010. Applicants shouldbe exceptional and highly motivatedindividuals seeking advanced researchtraining and experience to becomeleaders in cardiovascular disease orstroke outcomes research. Thefellowships are intensive experiencesthat will prepare post-doctoral scholarsfor careers in outcomes research. Allcenters’ training programs includeprotected time for research andmentorship from experienced faculty.Fellows will design and complete one ormore independent research studies.Each training program also includesopportunities for didactic as well as cross-center training through a collaborativenetwork among the four centers.

Prerequisites can be found onhttp://www.americanheart.org/presenter.jhtml?identifier=3064953

General themes for each center:

Duke University• Improving transitional care for

patients with coronary disease,myocardial infarction and heartfailure

Mid America Heart Institute, KansasCity, Mo. • Developing novel strategies to

translate individualized, patient-centered, risk prediction models intothe process of routine clinical care

Stanford University-KaiserPermanente• Defining and delivering optimal

therapy for ischemic heart diseaseand heart failure in routine practice

University of California, Los Angeles• Reducing stroke occurrence and

improving stroke outcomes invulnerable populations

Applicants should contact theappropriate person below for additionalapplication procedures. Deadline for allcandidates is Jan. 30, 2010. Successful

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Society of General Internal Medicine2501 M Street, NWSuite 575 Washington, DC 20037www.sgim.org

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