Preparing Our Future Physicians: "We Will Reap What We Sow".

As Designated Institutional Officer (LMB) and Program Director (EM) in a community teaching hospital, we are intimately involved with all aspects of Graduate Medical Education (GME) and find the rewarding part to consist of contributing towards the teaching of our future physicians, as well as the challenges imposed by the continuously evolving training requirements as set forth by the Accreditation Council for Graduate Medical Education (ACGME). While we are very aware of the standard training requisites that are put in place without exception for all accredited GME residency programs, whether they are part of a major (University) or minor (Community) teaching medical center, in this manuscript we are hoping to perhaps initiate a dialogue among clinical educators as to the future of graduate medical training, and how we as a medical community can commit to providing the best education experience for our residents, while preparing them to be the physicians our patients expect and deserve.

Recurrent diabetic myonecrosis in an African American woman with long-standing uncontrolled type 2 diabetes: a case report.

BACKGROUND: Diabetic myonecrosis, also called diabetic muscle infarction, is an uncommon complication of uncontrolled diabetes mellitus and is frequently underdiagnosed. The objective of this case report is to highlight the challenges in the early diagnosis and treatment of this disease. CASE PRESENTATION: A 51-year-old African American woman with a long history of uncontrolled diabetes mellitus presented to her primary care physician with right thigh pain. A diagnosis of diabetes myonecrosis was made on the basis of magnetic resonance imaging, biopsy, and negative autoimmune panel. After failing conservative treatment, the patient was treated with prednisone with gradual improvement of her symptoms. However, she had a recurrence of myonecrosis almost one year after her original presentation, which was also treated with prednisone. The recurrence had a shorter course and the patient recovered well. Challenges to the treatment in this patient were her debilitating pain and her underlying chronic kidney disease. CONCLUSIONS: A high index of suspicion for diabetic myonecrosis is necessary when a patient with diabetes presents with unilateral focal leg pain and swelling. Magnetic resonance imaging and biopsy can help confirm the diagnosis. Prednisone may be considered in patients who lack spontaneous regression with just rest. Educating healthcare professionals about this uncommon condition is of utmost importance in avoiding unnecessary testing and inappropriate treatment.

Graves' Disease Presenting as a Unilateral Breast Mass.

Introduction: Graves' disease is an autoimmune thyroid disorder that is the most common cause of hyperthyroidism. Common manifestations of Graves' disease include weight loss, palpitations, heat intolerance, fatigue, tremors, and exophthalmos, occurring in more than 50% of patients. In rare cases, findings may predominate in one organ system; isolated findings of diarrhea, anxiety, or gynecomastia (as in our case) may occur, distracting from the correct diagnosis. Case Report. We report on a 37-year-old male who presented to the primary care clinic with the chief complaint of a tender right-sided breast mass and with an associated loss of appetite and forty-pound weight loss. Laboratory evaluation revealed suppressed TSH and elevated free T4. A bilateral diagnostic mammogram revealed bilateral gynecomastia. A nuclear medicine thyroid uptake scan was subsequently ordered, which showed the diffusely enlarged thyroid gland with homogenous increased uptake throughout, consistent with Graves' disease. Conclusion: It is important to keep a high index of suspicion for thyroid disease as hyperthyroid states may be deceiving in presenting with single organ system involvement. Although it is rare, gynecomastia is a known finding in Graves' disease and can be the presenting sign. Patients with unexplained gynecomastia or breast masses should be screened for thyrotoxicosis.

Self-care perspective taking and empathy in a studentfaculty book club in the United States

PURPOSE: We aimed to study the impact of a combined faculty-student book club on education and medical practice as a part of the informal curriculum at the University of Florida College of Medicine in the United States. METHODS: Sixteen medical students and 7 faculties who participated in the book club were interviewed through phone and recorded. The interview was then transcribed and entered into the qualitative data analysis program QSR NVivo (QSR International, Burlington, MA, USA). The transcripts were reviewed, and thematic codes were developed inductively through collaborative iteration. Based on these preliminary codes, a coding dictionary was developed and applied to all interviews within QSR Nvivo to identify themes. RESULTS: Four main themes were identified from interviews: The first theme, the importance of literature to the development and maintenance of empathy and perspective-taking, and the second theme, the importance of the book club in promoting mentorship, personal relationships and professional development, were important to both student and faculty participants. The third and fourth themes, the need for the book club as a tool for self-care and the book club serving as a reminder about the world outside of school were discussed by student book club members. CONCLUSION: Our study demonstrated that an informal book club has a significant positive impact on self-care, perspective-taking, empathy, and developing a "world outside of school" for medical school students and faculty in the United States. It also helps to foster meaningful relationships between students and faculty.

Design and Early Implementation Successes and Challenges of a Pharmacogenetics Consult Clinic.

Pharmacogenetic testing (PGT) is increasingly being used as a tool to guide clinical decisions. This article describes the development of an outpatient, pharmacist-led, pharmacogenetics consult clinic within internal medicine, its workflow, and early results, along with successes and challenges. A pharmacogenetics-trained pharmacist encouraged primary care physicians (PCPs) to refer patients who were experiencing side effects/ineffectiveness from certain antidepressants, opioids, and/or proton pump inhibitors. In clinic, the pharmacist confirmed the need for and ordered CYP2C19 and/or CYP2D6 testing, provided evidence-based pharmacogenetic recommendations to PCPs, and educated PCPs and patients on the results. Operational and clinical metrics were analyzed. In two years, 91 referred patients were seen in clinic (mean age 57, 67% women, 91% European-American). Of patients who received PGT, 77% had at least one CYP2C19 and/or CYP2D6 phenotype that would make conventional prescribing unfavorable. Recommendations suggested that physicians change a medication/dose for 59% of patients; excluding two patients lost to follow-up, 87% of recommendations were accepted. Challenges included PGT reimbursement and referral maintenance. High frequency of actionable results suggests physician education on who to refer was successful and illustrates the potential to reduce trial-and-error prescribing. High recommendation acceptance rate demonstrates the pharmacist's effectiveness in providing genotype-guided recommendations, emphasizing a successful pharmacist-physician collaboration.

Lung Adenocarcinoma Presenting as Worsening of Chronic Neck Pain-A Cautionary Tale.

INTRODUCTION: Neck pain is a common musculoskeletal problem that up to 70% of the world population will experience at some point in their lives. Intramedullary spinal cord metastasis is an exceedingly rare complication of malignancy that affects less than 1% of all patients with cancer. CASE REPORT: We report a case of a 61-year-old man who presented to primary care clinic with 1-month history of worsening neck pain with associated neurologic deficits. Despite initial conservative management, the patient continued to have progressive worsening of sensory and motor deficits. Magnetic resonance imaging of the cervical spine showed vasogenic edema of the brain and spinal cord and nodularity at the C4-C5 level. A computed tomography of the chest showed a dense lesion in the left lower lobe of the lung; histopathology of the biopsied specimen was consistent with moderately differentiated lung adenocarcinoma. CONCLUSIONS: A high index of suspicion is necessary when chronic neck pain acutely worsens, changes in character, or is accompanied by neurologic deficits. These clinical signs warrant further investigation into a secondary cause of neck pain. Intramedullary spinal cord metastases are rare complications of systemic cancer that commonly present with neck pain and upper extremity paraesthesias; early diagnosis and management are necessary to prevent complications such as spinal cord hemisection syndrome or spinal cord transection.

Risk for contrast nephropathy in patients undergoing coronarography.

Among the causes of in-hospital acute renal failure, contrast-induced nephropathy ranks third in prevalence. Although it represents a condition of renal impairment with spontaneous recovery, contrast nephropathy should always be considered, because it prolongs hospitalization and it may become a severe complication requiring dialysis. The purposes of this study are: (i) to determine if the application of the most effective contrast-induced nephropathy prevention strategies in the Cardiology Intensive Care Unit can prove to be successful in reducing nephropathy risk; and (ii) to identify which of the involved risk factors persist after the preventive treatment. We examined the patients who had a coronarography at the Bentivoglio hospital from April 2007 to April 2008 who required at least 3 days of permanence in hospital due to the presence of potential risk factors; 136 out of 784 patients were included. Among the selected patients, 21 (15.44%) developed a renal impairment compatible with contrast-induced nephropathy. The risk factors that seemed to display the best correlation with risk of contrast nephropathy were advanced age and an ventricular failure (ejection fraction <40%); however, the critical condition did not appear to be due to a single risk factor, but it resulted from the association of more contextual risk factors. Particularly, the concomitant presence of ventricular failure, anemia, diabetes, previous myocardial infarction and advanced age (>70 years) determined a threefold increased risk of contrast nephropathy. Our data suggest that the development of contrast nephropathy following coronarography is associated with worse renal function during hospitalization and at discharge.