March 2014

Internal Medicine: Global Perspectives

Shashi B. Gupta, MD, FACP (Hon)
Department Head of Medicine and Cardiology
Central Railway Headquarters Hospital, Mumbai, India
Dean, Indian College of Physicians

 

India, officially the Republic of India, is a country in South Asia that is the seventh-largest country by area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world. Bounded by the Indian Ocean on the south, the Arabian Sea on the south-west, and the Bay of Bengal on the south-east, it shares land borders with Pakistan to the west; China, Nepal, and Bhutan to the north-east; and Burma and Bangladesh to the east.

India is a federal constitutional republic governed under a parliamentary system consisting of 28 states and 7 union territories. It became an independent nation in 1947 after a struggle for independence that was marked by non-violent resistance led by Mahatma Gandhi. India is a pluralistic, multilingual, and a multi-ethnic society that is the birthplace of four world religions-Hinduism, Buddhism, Jainism, and Sikhism. It is also home to a diversity of wildlife in a variety of protected habitats.

*source: Wikipedia

 

On Being a Doctor

Dr. Gupta, what made you pursue a career in medicine?

Medicine has always been a fascinating field for me. My elder sister is a doctor and visiting her at medical college and seeing medical students in white aprons was so inspiring. Also, I have always been a care-giver and I wanted to serve patients, especially those from the lower strata. There is no profession like medicine in which you can take care of humanity. I am happy that I became a doctor.

In what area of medicine-clinical practice, education, or administration-do you spend most of your time? What do you enjoy most about the work that you do?

I am currently Department Head of Medicine and Cardiology at Central Railway Headquarters Hospital, Mumbai, India. Initially, I devoted most of my time to my clinical practice. Administrative responsibilities gradually increased as I developed more seniority in my position, but it did not affect my clinical practice. In 1995, our hospital began offering post-graduate education and I got involved in medical education. I love teaching, and I have enjoyed all 3 aspects of my career - clinical practice, education and administration; but, clinical practice has always been my passion.

Internal Medicine in India

What is the role of the internist in India (e.g. primary care, specialist, consultant)? What are the education and training requirements needed to practice internal medicine?

The Internist in India fulfills all 3 roles- providing primary care, working as a specialist and as a consultant-depending upon the area where one is practicing. Before one can practice internal medicine in India, one must first complete the MBBS (5 ½ years undergraduate course), and then the 3-year postgraduate program in Internal Medicine to receive a Doctorate of Medicine (MD in Internal Medicine).

What illnesses and problems do internists in your country treat most often? Are there any trends in chronic illness or disease that you are particularly concerned about?

In India, we have a double burden. We treat a lot of infectious diseases, both acute and chronic, as well as non-communicable diseases, like hypertension, diabetes and coronary artery disease. The acute infectious diseases include viral fevers, malaria, pneumonias, diarrheas, enteric fever, hepatitis, and meningitis, and the chronic ones include tuberculosis and HIV-related illnesses. We have also seen cases of Kala-Azar. Tuberculosis and the rise in non-communicable diseases are always a matter of concern.

Do internists work most often in private offices or in hospital settings? To what extent do physicians and hospitals use electronic health records?

Internists work in private clinics and hospitals. In bigger cities, some of them practice in both settings. Many physicians are internet savvy and are using electronic health records. Most of the major hospitals in India are using electronic health record systems.

Does everyone in India have access to health care? Who pays for health care services-patients, employers, or the government?

Yes, everyone has access to heath care. There are primary care centers in villages and larger centers and hospitals are located in semi-urban and urban cities. There are many government-run centers where patients get free or subsidized services, and there are many corporations who take care of their employees (up to a limit of medical expenses). Railways and the Army provide free medical service to their employees and their families, even after superannuation. But, there are still many patients who have to pay for their own medical treatment.

Are enough young physicians choosing to be internists? What makes them choose (or not choose) to practice internal medicine?

Physicians are choosing MD in Internal Medicine as part of their educational path to the super-specializations like Cardiology, Gastroenterology, Neurology, Nephrology, etc. Practicing Internal Medicine alone is becoming difficult with so many super-specialists around; however, there is always a need for a good internist who can treat the whole patient.

Is access to the internet or social media influencing the patient-physician relationship?

The internet and social media have a lot of influence on patients and clinicians. As lots of patients view their problems via the internet or social media, they want more treatment. Clinicians are also becoming more conscious of medical-legal issues.

What are some of the most significant challenges that physicians in your country face? What are your thoughts on the best way to meet those challenges?

Over-population, over-crowding, the increasing cost of health delivery and adequate medical facilities at the periphery are cause for concern. Government, corporations, Non-Governmental Organizations and the medical community have to join hands to solve these issues.

What can other countries learn from your health system?

Basic clinical skills are still being practiced by Internists to diagnose many problems in busy outpatient departments, which is the biggest strength of Internists in India. The cost of medicine in India is much cheaper compared to the international market and a lot of generic medicines are being used to make health delivery cheaper in other parts of world.

ACP

As Co-Chair of the Scientific Program Committee for ACP's First National Conference in India (September 2014), how important do you feel this conference will be to attendees?

I am excited about ACP's first National Conference in India. The format of the Scientific Program is different from our conferences. For most of the sessions, we will have one Indian and one US speaker and the delegates will receive input from both worlds. It is my hope that we will learn a lot from this meeting and will have even better meetings in the future as a result of this experience. Attendees will definitely benefit from the different concepts presented at this meeting.

Please describe the plans for the ACP India National Conference.

Plans for the ACP-India National Conference are being discussed with Dr. Tanveer Mir, Chair, Scientific Program Committee (USA), and other members on the Scientific Committee to make the program as educational and successful as possible. An excellent faculty has already been chosen to deliver the goods.

Why is it important for physicians in India to belong to professional organizations like ACP?

Joining international organizations like ACP provides a wider range of experience and broadens one's vision.

How can ACP and Indian medical societies, as well as hospitals, work together to improve patient care in India?

ACP's India conference is a good start. We would like ACP to collaborate with the Association of Physicians of India - Indian College of Physicians and Major Hospitals from Metro Cities to improve the medical education and patient care in India.

For more information on ACP India, visit acponline.in.

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Register Now for Internal Medicine 2014

There is still time to join ACP and thousands of your colleagues in Orlando, Florida, and transform the way you practice medicine. Internal Medicine 2014 is the only meeting of its kind-combining clinical skills workshops with over 200 scientific sessions to update your knowledge in all facets of internal medicine and the subspecialties.

Refresh your internal medicine knowledge, sharpen your practice management skills, and network with the best and brightest physicians from around the globe. All of this plus a variety of special events including a reception for International attendees make this a meeting not to be missed.

Special offerings for international internists include:

International Reception
Thursday, April 10, 2014
8:00 - 9:30 PM
Hyatt Regency Orlando, Orlando
Ballroom M-N

International attendees and their guests are invited to socialize and network with leaders from ACP and internal medicine societies from around the world.

Complementary and Alternative Medicine: Global Approaches to Wellness
April 11, 2014
4:30-5:30 pm
Room 311 AD

Cancer Screening in 2014: An International Perspective
April 12, 2014
7:00 - 8:00 am
Room 311 AD

Hands-on Training at the Herbert S. Waxman Clinical Skills Center
A dynamic collection of educational activities has been assembled to provide hands-on learning and interactive self-study.

Advancement to Fellowship Consultation Sessions will be offered during Internal Medicine 2014

Led by members of ACP's Credentials Committee, the sessions will be held on Thursday, April 10, and Friday, April 11, at 1 p.m. in the ACP Resource Center. Spanish-speaking staff will be present to translate information and questions. Fellowship application materials will be available for all eligible members.

Visit im2014.acponline.org/for-meeting-attendees/international-attendees for more information. Hope to see you in Orlando!

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Update Your Knowledge with MKSAP 16 Q & A

The new Medical Knowledge Self-Assessment Program® (MKSAP® 16) provides you with the most current and critical information in the core of internal medicine and its subspecialties so you can stay aware of what you need to know as a practicing physician in internal medicine today.

For more information on MKSAP 16, or to order your copy, visit http://www.acponline.org/products_services/mksap/16/

MKSAP 16 Q & A

A 78-year-old man is evaluated in the emergency department after a witnessed episode of syncope. The patient reports that, while eating dinner, he experienced a pounding in his chest and then fell to the floor. His wife estimates he was unconscious for approximately 30 seconds, had no head trauma, and was oriented and alert upon regaining consciousness. He has not experienced any similar episodes in the past, although he has felt the pounding previously. Medical history is significant for hypertension, COPD, osteoarthritis, and benign prostatic hyperplasia. Medications are chlorthalidone, lisinopril, celecoxib, ipratropium-albuterol inhaler, and tamsulosin. He currently feels well except for pain in his right thigh where he fell.

On physical examination, temperature is normal. Blood pressure is 138/88 mm Hg and pulse rate is 82/min, without orthostatic changes. Respiration rate is 16/min. Oxygen saturation on ambient air is normal. Carotid upstrokes are +2 without bruits, and there is no jugular venous distention. Cardiac examination is normal, with the exception of occasional extra beats. The remainder of the examination, including neurologic examination, is normal. 12-Lead electrocardiogram shows a few premature ventricular contractions without evidence of ischemia.

Which of the following is the most appropriate next step in this patient's management?

A. Carotid Doppler ultrasonography
B. Echocardiography
C. Inpatient cardiac monitoring
D. Noncontrast CT of head

Click here for the answer and critique.

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International Meetings Update

ACP Central America Chapter Meeting
February 7-8, 2014

The annual meeting of the ACP Central America Chapter was held Februry 7-8, 2014 in Panama City, Panama. There were over 400 attendees from Panama and other parts of Central America in attendance at the meeting, including a mix of medical residents, students, and practicing physicians.

Molly Cooke, MD, FACP, ACP President, served as the ACP Leadership Liaison to this meeting. Dr. Cooke spoke on several topics, including "Internists and Revolution in Health Care" and "Evidence Based Advances in Internal Medicine," in addition she gave an ACP presentation.

Dr. Benzadon and Dr. Cooke

Dr. Aron Benzadon-Cohen, ACP Central America Chapter Governor, is presented with the Chapter Excellence Award by ACP President, Dr. Molly Cooke.

The Central America Chapter was presented with the 2013 Chapter Excellence Award during this meeting. The Chapter bestowed Laureate Awards to Abraham Garcia Kutzbach, MD, MACP, and Franklin Espino Herrera, MD, FACP.

An ACP exhibit booth was present at this meeting. There was strong interest in MKSAP 16 and membership in the College from attendees.

Dr. Cooke, Dr. Benzadon, and Dr. Ulloa

Dr. Molly Cooke presents a lecture while Dr. Aron Benzadon-Cohen and Dr. Eric Ulloa, President of the Panamanian Society of Internal Medicine, look on at right.



 

XXIV Central American and Carribean Congress of Internal Medicine
February 26-28, 2014

Dr. Bado

The XXIV Central American and Carribean Congress of Internal Medicine was held February 26-28, 2014 in Antigua Guatemala, Guatemala. There were approximately 1,000 attendees from the region. The theme of this meeting was "State of the Art Internal Medicine Diagnosis and Treatment." Dr. Rodolfo Bado, FACP (Hon.), President of the International Society of Internal Medicine, provided the key note lecture at the opening ceremony (pictured, left).

Dr. Aron Benzadon-Cohen, FACP, Governor, ACP Central America Chapter, was invited to serve as the ACP International Ambassador to this meeting by Carlos Guillermo Nitsch Montiel, MD, FACP, President of the Central American and Carribean Internal Medicine Association. Other notable ACP leaders who served as faculty at this meeting included Nuria Tortosa, MD, MACP, Governor Emeritus, ACP Central America Chapter.

Opening Ceremony

The opening ceremony of the XXIV Central American and Carribean Congress of Internal Medicine






 

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New International Fellows

ACP is pleased to announce the following newly elected International Fellows, who were recommended by the Credentials Committee and approved for election by the Board of Regents as of March 1, 2014. They are listed by current location and may have been credentialed through a different Chapter.

Bangladesh

  • Prof. Sheikh Nesaruddin Ahmed, MBBS, FACP - Dhaka

  • Hossain Shahid Ferdous, MBBS, FACP - Dhaka

  • Mohammed Ismail Patwary, MD, FACP - Sylhet

Brazil

  • Renata RT Castro, MD, PhD, FACP - Rio de Janeiro

Canada

  • Padmaja R. Naidu, MBBS, FACP - Windsor, Ontario

Chile

  • Sylvia Echavarri Vesperinas, MD, FACP - Santiago

  • Alberto Rossle Schott, MD, FACP - Conception

  • Jorge Sapunar, MD, FACP - Temuco

Grenada

  • Kecia M. Brooks-Smith-Lowe, MD, FACP - St. George's

India

  • Suresh Babu, MD, FACP - Karnataka

Ireland

  • Martin J. Buckley, MBBCh, FACP - Cork Munster

Jamaica

  • David T. Gilbert, MD, FACP - Kingston

Japan

  • Masashi Izumiya, MD, FACP - Tokyo

Mexico

  • Jesus Ruiz Macossay, MD, FACP - Villahermosa

Nigeria

  • Okechukwu Samuel Ogah, MBBS, FACP - Ibadan

Pakistan

  • Sultan Ahmad Mubashir, MBBS, FACP - Chenab Nagar Punjab

Paraguay

  • Angel Jose Ortellado Maidana, MD, FACP - Asuncion

Philippines

  • Geselita N. Maambong, MD, FACP - Consolacion

  • Leilani B. Mercado-Asis, MD, FACP - Manila

Saudi Arabia

  • Khalid H. Al-Musailhi, MD, FACP - Riyadh

  • Walid A. Fitaihi, MD, FACP - Jeddah

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32nd World Congress of Internal Medicine 2014

32nd World Congress of Internal Medicine (WCIM 2014)

 

Friday, October 24 - Tuesday, October 28, 2014

Theme: Internal Medicine & Beyond: Toward a Healthier World

Venue: COEX (Convention and Exhibition Center), Seoul, Korea
Hosted by: International Society of Internal Medicine

 

Organized by:

  • The Korean Association of Internal Medicine
  •  
  • Korea Research Foundation of Internal Medicine
  •  
  • Organizing Committee for the 32nd WCIM 2014

Endorsed by: American College of Physicians

Official Website: www.wcim2014.org
Contact Secretariat wcim2014@intercom.co.kr

Important Dates

  • Abstract Submission Deadline: Saturday, May 31
  • Early Bird Registration: Monday, June 30
  • Regular Registration: Tuesday, September 30

Topics:

  • Asthma, Allergy and Clinical Immunology
  • Cardiology
  • Clinical Oncology
  • Clinical Ultrasound
  • Digestive Endoscopy
  • Endocrinology and Metabolism
  • Gastroenterology
  • Hematology
  • Infectious Diseases
  • Nephrology
  • Rheumatology
  • Tuberculosis and Respiratory Diseases

For more information, click here to view the WCIM 2014 program leaflet.

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Future Worldwide Internal Medicine Meetings

Upcoming meetings will be held in Greece, and Chile.

A complete list of other Future Worldwide Internal Medicine Meetings is available here.

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Highlights from ACP Internist and
ACP Hospitalist

ACP Internist January/February 2014

  • Long-term view for chronic pancreatitis
    Unlike acute cases of pancreatitis, chronic cases present with varying degrees and types of pain, and without other clinical indicators such as calcification or damage to pancreatic ducts. It's best to refer to a gastroenterologist early to clarify the diagnosis, so the internist can better manage the patient.
     
  • Transparent charts and opening the problem list to patients
    Doctors use the patient's medical chart as a notepad of sorts, to record clinical impressions and thinking. But the record's increasingly open nature requires physicians to reconsider how they document the patient's history and what they might be willing to share with the patient.
     
  • Look for reasons if patients refuse advice
    Refusal can be frustrating for physicians, who likely see their medical advice as contributing toward healing and improving quality of life. But patients reserve the right to make informed decisions about their care, even if these decisions run counter to what's been recommended.
     
  • Psoriasis symptoms can be tough to address
    A recent survey showed that many psoriasis patients are not satisfied with their care, reporting inadequate relief from such symptoms as itching and scaling. Learn more about clues to diagnosis and suggestions on treating and managing symptoms of both mild and more severe disease.
     

ACP Hospitalist February 2014

 

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Annals for Educators - Response Requested

ACP is interested in engaging its international academic physician members by offering them resources from the College specific to their role as teachers. One of these resources is Annals for Educators. This twice monthly e-mail alert highlights articles and features from the Annals of Internal Medicine. The Annals for Educators alerts provide busy educators like you with ideas and content that may be useful in your teaching activities.

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MKSAP 16 Answer & Critique

Answer: C, Inpatient cardiac monitoring

Educational Objective: Manage syncope in an elderly patient.

Critique: Cardiac arrhythmia is the most likely cause of syncope in this patient, given his prodrome, time course, and complete recovery immediately following the event. Cardiac causes of syncope carry a high mortality, and patients with suspected cardiac causes warrant further evaluation in the hospital regardless of age. High-risk patients requiring immediate in-hospital telemetry are those with exertional or supine syncope, palpitations prior to the event, a family history of sudden death, nonsustained ventricular tachycardia, and abnormal electrocardiographic findings. Thus, monitoring by telemetry in the hospital is appropriate for this high-risk patient.

Neurologic abnormalities are uncommon causes of syncope. Therefore, studies to assess for an intracranial or carotid process are very low yield in patients without new neurologic findings; thus, neither carotid Doppler ultrasonography nor head CT scan is indicated. Brain imaging may be appropriate to assess head trauma associated with his syncopal event, but not as a routine component of syncope evaluation.

Echocardiography for evaluation of syncope is also low yield except in patients suspected of having structural heart disease or with significant findings on cardiovascular examination, neither of which is the case in this patient.

Key Point: Cardiac causes of syncope carry a high mortality, and patients with suspected cardiac causes warrant further evaluation in the hospital.

Bibliography:

Mendu ML, McAvay G, Lampert R, Stoehr J, Tinetti ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169(14):1299-1305. [PMID: 19636031]

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