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ResidencyChoosing a Medical Specialty, a location...etc

Many students enter medical school thinking they know exactly what kind of medicine they want to practice. A few of those people actually stay true to those original plans, while the rest of us are thrown into a world of possibilities.

I was one of those students. I entered medical school set on surgery, but I can truthfully say that every class opens up my eyes to the possibility of something new. At this point in my education, I’m completely unsure of what my future holds, and apparently that’s normal. But the idea that I’m hurtling through medical school without any idea of my future is terrifying. I have found that narrowing down a specialty is very difficult and a very lonely-individual process. But over the many hours of unwarranted stress and unease I have realized that guidance is out there, we just have to look/ask for it.

SOSA chose to create this special issue of CUT-THROAT to provide a starting point for our readers when considering residency. There is no reason that

we should all go through this anxiety alone; instead we should collaborate and share the information we find. SOSA hopes that you find the information we have gathered useful on your journey through your medical education. We believe that no matter where you lie in the decision process this issue can be extremely helpful.

A little advice is always appreciated and we gathered a lot of it! We gathered information from: current residents, current physicians, and a few nurses on their opinions regarding residency.

I want to personally thank everyone who contributed to this issue. We had over seventeen individuals provide us with feedback. Each individual provided a unique interpretation of an experience that we all have to undergo. Their insights into residency are extraordinary and I believe it will be beneficial to all.

Kelsy Avalos-Feehan

ContentsEditorial ...........1

Advice from Current Residents.......2-5

Article Review: How Should Unmatched Orthopedic

Applicants Proceed...5

Residency: Insights from the Other Side ......6-10

Article Review: Recipe for Becoming a Plastic

Surgeon .....11

From Internal Medicine to Radiation Oncology: Going back to Residency......12-14

Tips from The Nursing Staff.............15

Case Study Challenge.......15

FAQ: GME Merger......16-19

Useful Resources.....20

Editorial:

Presented by the Western University of Health Sciences COMPStudent Osteopathic Surgery Club

CUT-THROATA GUIDE TO EVERYTHING SURGERY

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RESIDENCY

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Describe your typical day

A.M.As Chief Resident, I arrive at 630am for sign out.  We go over what happened overnight and talk about the new admissions, go over the latest updates with the patients on each of our teams, and then we will make rounds.  We see each patient and make updates on the daily plans. At 7:45am the first case in the OR begins.  I usually pre-op the patient earlier in the morning.  We meet the patient in the OR and perform the scheduled surgery.  Once all of the surgeries are completed for that day we make post-op rounds and check in on everyone we operated on.  I will also round again on the floor patients to get updated on anything that happened during the day.Our sign out is 6pm in the evening, where we again go over any updates from the day. Surgery training is about learning to become efficient but still very detailed. You are constantly juggling multiple tasks throughout the day - including rounding on your patients, going to the OR, and helping with consults and traumas. Everyday is busy and exciting

A.Z.As a first year general surgery resident I still get to focus mostly on surgery, but I do have other rotations like ER, OB/Gyn, Radiology, etc. As a first year at McLaren Macomb on the gen surg service we work 3 weeks of days which are 5am to 6pm.  The other week is nights, 6pm to 7am.  We get 4 full weekend days off.  

Every day starts with rounding/writing progress notes.  After that we spend an hour for sign-out discussing patients and what needs to be done for the day, and education.  Then we all go our separate ways, whether it's to the OR, library or seeing more patients.  As a first year our main focus is the floor work and learning how to manage surgical patients.  As we progress through the years we focus more on surgery and technique.

S.K.Surgery training is about learning to become efficient but still very detailed. You are constantly juggling multiple tasks throughout the day - including rounding on your patients, going to the or, and helping with consults and traumas. Everyday is busy and exciting.

Were you prepared for the rigors of residency? What sacrifices have to be made?

A.M.Surgery residency is a little different for everyone.  Some people are married and have families.  For myself, my training takes up pretty much all of my time.  Besides working at the hospital all day and taking call on the weekend we also have to study to keep up our knowledge, work on research projects, and as Chief coordinate administrative activities.Its completely reasonable not to see daylight for a couple weeks.  I joke that I end up mowing my yard at

night and as a result have run over the sprinklers countless times.There is still time to get away however.  Luckily my friends and family are only about an hour away in San Diego.  We in general have every other weekend off.  I tend to go to San Diego on the weekends or have people come up to the IE and go to the mountains for fun.

A.Z.I feel like medical school definitely helped prepare me with the knowledge that I needed.  What surprised me, was what I could do now that I had that "D.O." behind my name.  Now all of my progress notes mean something and I can make decisions for patients without consulting others and writing that order.  After 4 1/2 months of residency it still feels weird calling myself doctor and knowing that I have the power to write orders and prescriptions and signing my name to them.I think that the biggest sacrifices made were by my husband.  He was forced to move again so that I could pursue my dreams.  He had to quit his job and find a new one.  And he had to leave all the friends that he made while I was in medical school. Now that that's over with, I'm working long hours and we don't get to see each other as much as we used to. 

“As one of my Attendings once said... There are no females or

males in surgery.... only surgeons.”

-Dr. Shulz, PYM-1

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2 Advice From Current ResidentsAndrew McCague, D.O. Chief Resident General Surgery Arrowhead (A.M.)Kat Schulz, D.O. First Year General Surgery Resident. Arrowhead (K.S.)

Sadia Khan, D.O. Fourth Year General Surgery Resident. Arrowhead Medical Center (S.K.)Ashley Zilles, D.O. First Year General Surgery Resident, McLaren Macomb (A.Z.)

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S.K.Residency is very time consuming no matter what specialty you choose. You often sacrifice sleep and having traditional holidays! 

Do you have any advice for medical students like myself, in terms of making myself a more competitive applicant

A.M.General surgery residency is competitive and will likely get more competitive as the new ACGME changes take effect. Some tips to get ahead of the ball as a student:- Join SOSA- Come to the national SOSA meetings- Run for a leadership position - ideally in SOSA or National SOSA but student government or other organizations will help show your leadership skills- Do research - try to get involved with a research project.  Communicate with your local residency program and get involved with a project.  Even a case report will set you apart.  Ideally try to get something published and presented at a scientific meeting.  My advice though is to feel out the project first - is it likely to get published?  are you going to have support and help from others involved?  You don’t want to spend a lot of time if its not likely to go anywhere.- Shadow a surgeon.  Most hospitals or residency programs will have a system where you can shadow and even come into the OR.  The earlier you start coming the more you will know on your third year rotation.- Work hard on your 3rd year clerkship.  You need honors.  Don’t be discouraged if you don’t get it though but try your hardest, come early, stay late, know your patients.

-Get good letters of recommendations from surgeons.  Try to ask for a letter from someone you know a connection with either through your research project or SOSA.  The letter will be better if they know you personally.

A.Z.I tried to be involved in a variety of activities, but without over-doing it.  I wasn't president of any club, but I did stay active in a select few.  I think the most important club to be involved in is Sigma Sigma Phi.  So that means you have to get in.   Another thing I noticed during residency interviews was that a lot of them were interested in my teaching experience.  I was a teaching assistant for our surgical skills lab and I'm pretty sure that helped give me an edge over others.  When it comes to setting up "audition rotations" for 4th year, a couple of them had applications that asked for class rank and board scores.  So having a good standing there definitely helps.

K.S.To be the most competitive applicant, you want to have a solid GPA, above average board scores for your speciality, and ideally be involved in some type of research.  But in my opinion, the best thing you can do is to do an excellent audition rotation.  Rotating at a program you are interested not only gives the program a chance to get to know you, but it gives you a chance to get to know them.  

What do you feel the bias is against DO’s? specifically in surgery?

S.K.Yes there is a bias, but as you have heard things are changing. An often if

you rotate at a program and make a good impression they tend to look past the letters behind your name. 

Are there challenges specific to women as a surgeon?

A.Z.I could see starting a family during residency a challenge.  S.K.No, not in my opinion. There are many options in surgery. 

K.S.As one of my attendings once said... There are no females or males in surgery.... only surgeons.

Is It anything like Grey’s Anatomy?

A.Z.Yes, except we're smarter and our drama is not quite so crazy.

(Continued on Page 5: Residents)What does your personal life look like for the next 5 years? How much time is spent at the hospital?  

A.Z.It has definitely gotten more difficult.  I'm working longer hours and more days of the week/

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weekend.  You really need to keep yourself organized and plan out your free time and utilize it the best you can.  It is even harder now to plan activities with friends because we all work such odd hours and hardly ever have the same days off.

S.K.Residents can still have lives or raise families. It comes down to time management and prioritizing. Life as a surgery resident is busy but I still find time to travel, see my family and friends, and enjoy life. Work week regulations limit how much you are at the hospital. Its not a walk in the park but feels fulfilling and worth it if you really love it. How many programs did you apply to? A.M.I applied to about 20 programs.  Its not as expensive as applying to medical school so I applied broadly.  I was influenced mostly by geography.  I was going to school at UMDNJ and am from

San Diego.  So I applied to programs across the country.    You have to keep in mind each interview will cost about $500 or more including flight and hotels so it ads up quickly.  You have to gauge how competitive you feel you are.  There is not an official ranking of DO General Surgery residency programs.  Most offer about the same thing.  I even tried to make my own scoring system to compare based on location, call schedules, salary etc.  I found it very hard to compare one program to the next.  I ended up going with my gut and was between Doctor's Hospital in Columbus, Ohio and Arrowhead Regional Medical Center in Colton, California.  Things I would say to look for in hindsight are: age of the program, how organized the program feels to you, do the residents have time to make it to educational programs, the personalities of the attendings/residents, and pass rates on boards.  Of course also location, weather, city lifestyle are also huge factors.

Any other advice on the interviewing process? Choosing a program? etc.

A.M.Interviewing is a difficult process.  I've heard it described as "speed dating."  Often you are scheduled to interview with several people in a row.  They all tend to have the same basic questions so you feel as though you are repeating yourself or asking the same questions over and over.Some general tips I can recommend are:- Be on time- Read as much as possible about the program ahead of time, most have websites- Have lots of questions.  The more questions you have the more interested you come across.  If you ask more questions it will use up time so they don’t start pimping you.-Do not ask about salaries or call schedules, you are there to learn.  Also don’t ask about simple things that are already available on their website.    - Find out who you are

interviewing with before you arrive.  Try to come up with some specific questions for each interviewer.  Have a different set of questions for residents.

- Always send thank you cards.  -Make sure to send a follow-up letter to the program director.  As the interview season comes to and end send a formal letter to the program director thanking them again for the interview and confirming your interest.  I always like to put a question to try to prompt a response.  -If a program is your first choice make sure to let the program

Residents Continued:CU

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ARTICLE REVIEW: By Jason Kafbaj

ARTICLE REVIEW:JASON KAJBAF

Do you love orthopedic surgery and everything related to the field?Last year, 762 spots were offered between the AOA/ACGME for orthopedic surgery. For

the 682 ACGME spots there were 1,046 applicants (AOA/ACGME/Canadian/Non-US students, etc). All 682 spots were filled, 2 of which were Osteopathic Students. The

statistics and figures alone may very well make matching into orthopedic surgery one of the most daunting challenges a medical student can face.

Ergo, lets talk about the backup plan: what to do if you do not match into an orthopedic residency…

A recent study was published in the journal of “Clinical Orthopedics and Related Research” regarding this predicament. Dr. Nirav Amin and his team performed an extensive study involving 91 of the 151 orthopedic residency programs, gathering data on what factors would contribute to the future success of an unmatched candidate. First, it is necessary to look at the history of the program you are applying to, do they have a record of granting interviews to re-applicants? Second, what would be the most efficient way to keep yourself busy during this year of purgatory? And third, how important are the stats, eg: USMLE, letters of recommendation, etc.? Out of the 91 programs, only 11% of the programs admitted to accepting re-applicants. However, do not let this number discourage you, for your chances improve significantly if you take the following steps. If you find yourself unmatched, your first alternative should be a year of a general surgery internship. Of the responding residency programs, 65% agreed that they would be extremely likely to grant an interview to a previously unmatched applicant, had they completed a year of a general surgery. Furthermore, all programs stated that they would be even more likely to accept a reapplying applicant, had they performed their year of preliminary surgery through their institution.

However, if you don’t land a surgery internship, your next option is to participate in an academic research project. Why academic specifically? Re-applicants who are a part of an academic research projects are 90% more likely to get an interview than an applicant who performed a nonacademic research project. Again, if the research project is carried out through the program of your choice your chances further increase.

During your internship or research project, focus on making new relationships with faculty members, advisors, etc. for 78% of the responding residency programs indicated an emphasis on new letters of recommendation. It should be no surprise that professional relationships are extremely valuable; it will be those connections that will help patch up a flat tire and make the path a tad less bumpy.

In conclusion, if you find yourself stuck at a crossroads because you did not match into an orthopedic residency position, do not give up; there is always a back road. Many students opt out after being rejected because they feel that it poses too many challenges. Don’t take the easy way out! Don’t settle for a different residency position! Accept the challenge, achieve your goals, and exceed your expectations.

How Should Unmatched Orthopedic Surgery Applicants Proceed?Amin NH, Jakoi AM, Cerynik DL, Kumar NS, Johanson N.

Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA, 19102, USA(Full Article @ http://www.ncbi.nlm.nih.gov/pubmed/22826011)

know.  If they know you are serious that in itself can help move you up the rank list.- You can do a "second look" at your top program. 

This will show you are interested and also help

confirm in your mind that this is where you want to go. 

(Interviews completed November 2012)

Residents Continued:

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With the knowledge you have gained what would you say is the most important things to consider while choosing residency? How has that changed from when you started residency to when you completed it to even now? 

C.A.It's always easier to go to work in the morning if you're doing something you love.  The need to find an area of medicine that fulfills your needs for interacting and serving patients in populations your committed to is paramount.  Truly, money and location are secondary.If you tinker and like to use your hands certainly finding a residency that allows you to do procedures may fulfill your natural tendencies.  Don't forget, family medicine docs can do procedures, they may be doing more in the future.After my internship, I had two years to consider my first residency, which was family medicine.  I thoroughly enjoyed the time I spent as a family physician.  I got involved with administrative responsibilities and wanted to return to the practice of medicine and the opportunity to do anesthesia presented itself.  I enjoyed anesthesia more because of the pharmacology and physiology and less so because of the procedural aspects.

E.B.When considering a residency you should be true to yourself. Knowing what I know now, I believe it is essential for students to distinguish between if they excel at understanding processes or if they have a talent for visualizing the anatomic structures of the body. Identifying this early might help you determine if you are more of a medical person or a surgical person. Once you identify that, you should keep an open mind on rotations to see where you

feel at home during your clinical experiences.

M.F.There are three things all students should consider before choosing a residency. First, consider the quality of the institution and training program. Residency is the point in your life where you should see and do the most as possible. Go for the program with the highest caliber and most opportunities. Secondly, consider location. Will you be happy here? Will your family be happy here? Third, you have to like the people/environment of the residency. This is a feeling you just get. You will work with these people everyday and see them more than most other people in your life. If they don’t make you happy it could be many years of misery, which will impact your performance and experience.

S.L.I would say knowing the residency before you decide upon it is the most important thing when choosing residency. Know the ins and outs, how the hospital is run, how the teaching staff teaches students, how the nurses treat the students. All those things play into the happiness factor. Choose one that can realistically enhance your ability. In the past, there have been students that have gone on to residency with the idea to go into the toughest residency without rotating there prior and as a result dropped out because realized though it was the best residency they had matched at, it wasn’t a place that made them happy.

“Knowing what I know now, I believe it is essential for students to distinguish between if they excel at understanding processes or if they

have a talent for visualizing the anatomic structures of the body. Identifying this early

might help you determine if you are more of a medical person or a surgical person.”

~Dr. Edward Barnes

Residency: Insights from the Other Side

Dr. Clinton Adams (C.A.), Dr. Edward Barnes (E.D.), Dr. Marcel Fraix (M.F.), Dr. Steven Lam (S.L), Dr. Andrew Pumerantz (A.P.), Dr. David Redding (D.R.), Dr. Anna Yeung (A.Y.)

Participating Physicians:

Dr. Clinton Adams, DO, MPA, FACHEDiean-Western University of Health Sciences COMPMedical School:Midwestern University, Chicago College of Osteopathic Medicine Residency:Family Medicine- Charleston Naval HospitalAnesthesiology- George Washington University

Dr. Edward Barnes, II, MD, FACPAssistant Professor of Internal Medicine/Division of Nephrology and Hypertension-Western Uniiversity of Health SciencesDirector of Renal Services- Western Diabetes Institute Medical School:University of Kansas School of MedicineResidency:Brooke Army Medical CenterNephrology and Hypertension Fellowship-Walter Reed Army Medical Center

Dr. Marcel Fraix, DO FAAPMRDirector of Renal Services- Western Diabetes InstituteCourse Director for Renal System-Western University of Health SciencesMedical School:Western University of Health Sciences-COMPResidency:Internship-Pacific Long BeachPhysical Medicine and Rehabilitation-UC Davis School of Medicine OMM/NMM Fellowship-Downy Regional Medical Center

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A.P.I can honestly say my thoughts about choosing residency haven't changed over the past 25 years. What remains most important to me is the variety and mix of populations and pathology to which one could be exposed. In addition, training programs with multiple hospitals (private, public, and government) remain my ideal for residency training. Also, in an era of increasing need for expert hyper-specialization and integrated, team-based care, choosing a program with myriad fellowships opens up unlimited opportunities for furthering one's career and marketability

A.Y.The most important thing to consider while choosing residency is simply whether or not you actually like the field and the patient population and can envision yourself in it for the rest of your career. Of course, economics and lifestyle considerations are important but if you don't like what you are doing, no amount of money or time off is going to makeup for the loss of satisfaction in your daily working life. As for which program to choose after you decide on a particular specialty, I myself chose the hardest one and never regretted it. It's better to overexpose and learn more than you need while training than trying to play catch-up later at the attending level.

If you could do residency again how would you do it?

E.B.If I could do residency again I would really focus on enjoying the experience more. The lives that I touched, the knowledge that I

gained, and the relationships I had are irreplaceable. I wish that I would have taken the time to value the experience more.

S.L.No, because of the way I chose residency it was one of the best decisions of my life. I owe that to the fact that I knew the program well, I knew that the staff, students, and faculty were happy there. I believe the goals throughout residency are slightly different. When you just begin you are just trying to survive “how am I going to survive this? Do I know enough medicine to do this? Can I function independently?” Second year it is a time to buckle down. It is a realization that you have very little time before you are on your own. After residency there will no one there to turn to for help. Time goes by quickly and its time to learn now. The final year is about leadership, it is about being chief resident, it is about teaching and giving back the knowledge and skills you have to your junior residents and interns. It is about preparing for your future jobs.

A.P.I would choose a program whose health care delivery system was focused on value-based competition and patient-centric outcomes. In my opinion, Cleveland Clinic and Dartmouth-Hitchcock lead the list of visionary institutions in this area. Getting involved with such programs would offer unique experience and an extremely competitive edge to any new graduate in the 21st century.

(Continued page 8: Physician’s Advice)

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Dr. Steven Lam, DOAssistant professor of Family MedicineMedical School:Western University of Health Sciences COMPResidency: Family Medicine-West Chester General Hospital

Dr. Andrew Pumerantz, DO, FACPAssociate Professor of Internal Medicine/ Chief, Division of Infectious Disease - Western University of Health SciencesExecutive Director/Assistant Provost for Strategic Initiatives- Western Diabetes Institute Medical School:Philadelphia College of Osteopathic Medicine Residency:Internal Medicine-Beth Israel Medical CenterInfectious Disease Fellowship- Yale University School of Medine

Dr. David Redding, DOAssociate Professor of NMM/OMM and Family MedicineD.O., 1993Medical Education:Osteopathic Manipulative Medicine/Neuromuscular Medicine, 2007M.S. Health Professions Education, C.O.M.P., 1996American Osteopathic Board of Family Physicians, 1996

“If I could do residency again I would really focus on enjoying the experience more. The

lives that I touched, the knowledge that I gained, and the relationships I had are

irreplaceable.”~Dr. Edward Barnes

“Medical school only prepares you to become a resident.  It is the residency that is

your last opportunity to truly create the foundation that will carry you for the rest of

your career”

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D.R.There would be no changes in the areas that I had control over, meaning location, call schedule and quality of education and opportunity for procedures. If I had the power, I would delete three obnoxious individuals that made internship and residency more difficult than it needed to be. Lesson is, work together and don’t let your ego get in the way of being nice, thoughtful or courteous.

A.Y.If I could do residency again, I wouldn't change my choices. If it wasn't for my exposure to the formal geriatric training integrated into my residency training, I would never have realized how interesting geriatric medicine is. If it wasn't for my family medicine residency (then later geriatric fellowship) at a high-volume acute county facility, I wouldn't be so confident of my clinical skills and judgement today. Had I not gone through a program that had attendings who were actually interested in teaching and being

role models, I may not be in academia today.

Your best advice on staying sane during residency? 

C.A.One should enter residency with the mindset that you're going to work very hard and very long hours in order to best prepare yourself for the lifelong practice.  Medical school only prepares you to become a resident.

(Continued page 8: Physicians Advice)  It is the residency that is your last opportunity to truly create the foundation that will carry you for the rest of your career.  You should avoid as much conflict, distractions, and alternative/competitive distractions during your residency.  After your residency, you may be able to choose to work as much or as little as your budget allows but until then the best advice is to injure residency with the understanding that you wish to become the best position possible and that requires time, talent and tenacity.

E.B.Find an outlet! I spent a lot of time with my family and friends. I traveled when I had time and enjoyed exercising and staying fit.

M.F.Balance. Try to have a well rounded life, don’t give up the things you love to do. Exercise, eat well, get outside and see friends. If you have a family make sure to give them time. The key to residency is work hard, and though it is hard work hopefully you enjoy it. Even if you are up for 24-36 hours you should still want to do it because you realize how great it is to be a doctor.

Dr. Anna Yeung, DOAssistant Professor of Family Medicine and Director of Division of Geriatrics-Western University of Health SciencesEducationMedical School:Western University of Health Sciences-COMPResidency:Family Practice-Arrowhead Regional Medical Center Geriatric Fellowship-Arrowhead Regional Medical Center.

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“Stay hungry, stay foolish, stay flexible, stay humble, stay curious, stay focused...keep your

sense of humor...don't take yourself too seriously... “

~Dr. Andrew Pumerantz advice on staying sane during residency

Physician’s Advice continued:

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S.L.Choosing the right residency! Do not choose something that is too easy but don’t choose something that is way beyond your comfort level. In order to stay sane, you need time to grow, explore your hobbies, and remember to enjoy life. You are still at the prime of your life so you should be able to enjoy it. Keep in touch with your family, make sure to visit them. Get to know the area! I believe one should be involved in the

community where residency is, it doesn’t matter what it is, join a team, volunteer just become involved so you feel a bond to the community. There are 24hrs in a day there is plenty of time to do things you want to do during residency. A.P.Stay hungry, stay foolish, stay flexible, stay humble, stay curious, stay focused...keep your sense of humor...don't take yourself too seriously...remember existential experience trumps knowledge... experience is a function of time and intellectual curiosity.

Eat first (when on-call)...go to art museums and ride your bike (on post-call days and days off). Hug and kiss your

(Continued Page 10: Physicians’s Advice)

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“Stay on top of your work, if possible complete all the work you can before leaving your shift even if you have

to stay a little longer. Undone stuff will rob you of sleep, make you worry and it will still be there on top

of the next shifts work, making that shift even harder.”Dr. David Redding

advice on staying sane during residency

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kids (if you don't have any, borrow someone else's). If your married or have a 'significant other' make sure you always have the last word: "Yes, dear"

D.R.Recognize that there is an end to the residency and every day brings you closer to it. Recognize that there have been many residents before you that made it through with the same degree of sleep deprivation, over worked conditions and the lack of enough time outside of residency for family and friends. Be nice to all, if not it will come back to bite you. Recognize that patient’s come first, don’t neglect them.

Stay on top of your work, if possible complete all the work you can before leaving your shift even if you have to stay a little longer. Undone stuff will rob you of sleep, make you worry and it will still be there on top of the next shifts work, making that shift even harder. Last note, if you think it is bad, remember that it might get worse still so be thankful it is what it is. For the religious among you, my prayer every day before arriving at the hospital was; “Lord, help me not to kill anyone today” and I didn’t.

A.Y.Honestly, it's the other residents that keep you sane during residency. It's analogous to soldiers on the battlefield, you always have a special relationship with the other residents in your class. There's also the knowledge that residency is a defined period of time; the only priority is to learn as much as possible before the training wheels (and the safety net) come off when you graduate.

Were you married/dating/single/kids before/after residency?and how did that contribute to your decision process? 

E.B. I got married during my second year of residency. I believe having a wife and a growing family allowed me to focus and learn how to multi-task. It was good training for what my everyday life today. Nurturing your home relationships is an essential part of being successful in life.

M.F.Yes, I went through training with a family. It all comes down to a balance. Find the best program possible that

meets the needs of training and education but also a place where your family can be happy living. Residency is the point in your life where you should see and do the most as possible. Go for the program with the

highest caliber and most opportunities.Is it possible to go through training with a partner, yes totally.

S.L. I was in a long distance relationship and was warned that that would be harder, but I beg to differ. If the relationship is strong enough you should prevail. You don’t let go of the person who is right for you. You see residency as a test, you both do your best and then you go from there.

A.P.Life is full of guarantee-less choices. I was married with a newborn son during my internship....not for the faint of heart! Ultimately, my sanity survived; my marriage didn't...likely wouldn't have anyway. The divorce definitely limited my geographical search for fellowship in order to stay close to my son as he grew up. I don't regret anything. I'm blessed: my son (who's 23) is a terrific man and we're closer than ever...life's a journey and as a human, experiencing the spectrum of emotions reminds us we're alive. I've lived every bit of 50 years...and I'm just getting started.

D.R.I was married and my wife was a great support all the way thru residency, except for the calls coming in where I had to leave the family on Christmas eve as dinner was starting to place a central line or admit a patient, but it all worked out.

A.Y.I was seeing someone during residency but that didn't contribute to the decision process as the relationship started after internship started. I must say, though, it's difficult to maintain a relationship while in residency, especially if the significant other is not understanding of the unique pressures that residents have to live under. Then again, I doubt I was my usual sweet loving patient self during training.

(Interviews completed November 2012)

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ARTICLE REVIEW:By: Peyman Tashkandi

Recipe For Becoming A Plastic Surgeon When one looks at the TV shows such as Nip-Tuck and Dr. 90210, he/she wonders about the lifestyle of fancy cars, beautiful people and ultra luxurious living that is associated with these depicted hotshot plastic surgeons. Then, one might ask himself/herself, if I want to become a surgeon, why not become a plastic surgeon? Well, I have not come across any article that would discuss the primary motives of students who apply to plastic surgery residencies; however, I have come across a research paper that tells you what you need to have to be competitive for a plastic surgery residency spot. Over the years plastic surgery residencies have become more and more competitive and according to Jeffery LaGrasso, MD, it is due to the scarce number of plastic residency spots offered and an increase in the number of applicants. In 2004, a team of researchers began a study to find

out what program directors believed demonstrates that an applicant can be a successful plastic surgery resident. La Grasso, MD and his team of researches designed a questionnaire that was sent to 20 different plastic surgery program directors across the country. The questionnaire was divided into three parts. The first part asked about the objective characteristics that program directors look for in an application, such as honor society membership, board scores, or publications. Secondly, the subjective characteristics were considered through recommendation letters and leadership roles. Finally, the reasons behind why residents fail to finish their residency programs were explored. Out of the fifteen program directors who completed the questionnaires, the results showed that the most important objective criterions in order of significance were: membership in an academic honors society, publications in peer

reviewed journals, recommendation letters from a plastic surgeon known to the directors, and finally board scores. The top four subjective factors in determining a competitive applicant were: leadership capabilities, perceived maturity of the applicant, the answers given at the interview, and finally the applicant’s interest in teaching/academics. Among the reasons that residents failed to complete their residencies were, personal issues such as family obligations, death in the family or academic inadequacies. In conclusion, whether it is the lifestyle or the passion for beauty and symmetry that motivates you to become a plastic surgeon, get honors, publish in a plastic surgery peer reviewed journal, rub shoulders with an influential plastic surgeon (preferably a program director), and hit the boards hard. Then combine that with leadership positions, maturity, and interest in teaching. Or in other words, be on top of your game.

Selection criteria for the integrated model of plastic surgery residency.LaGrasso JR, Kennedy DA, Hoehn JG, Ashruf S, Przybyla AM.

Division of Plastic Surgery, Albany Medical Center, NY, USA(Full article: http://www.ncbi.nlm.nih.gov/pubmed/18317094)

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Internal Medicine To Radiation Oncology Dr. Patrick Feehan, D.O.Interviewed by Kelsy Avalos-Feehan

Dr. Feehan graduated from University of Health Sciences of Osteopathic Medicine-Kansas City. After completing his internship year he entered an Internal Medicine residency at Grant Medical Center,Travis Air Force Base. After practicing Internal Medicine for four years, Dr. Feehan returned to residency in the field of Radiation Oncology at UC San Francisco. Dr. Feehan continues to practice radiation oncology at the Community Hospital of Monterey Peninsula.

He is currently head of his practice.

After going through such a drastic change in your medical specialty, if you could would you do anything differently? The simple answer is no. The better answer is I don’t believe we have many chances to change once we propel ourselves down a road.

Why did you originally choose Internal Medicine? After completing a year of internship, as DOs, we were expected to be prepared to immediately enter family medicine without further graduate medical education. It was the AOAs original plan to produce family doctors quickly for areas that needed physicians. Many of my peers were able to continue on this path without any problems after their internship year was complete. But when I told the interview committee, that I wanted to go on to an internal medicine residency after my internship, a Pathologist asked me if I felt insecure and not ready to practice medicine. The

truth was that I was not ready to practice and I was very afraid. 

Are you still licensed as an IM or did you have to give up that license?After completing my internship year at Tucson General hospital, which at that time was a DO hospital,  I entered a three-year internal medicine residency at David Grant Medical Center, Travis AFB. At the time it was not accredited with the AOA. The AOA informed me that I would have to pay for a team to fly out and accredit the institution if I wanted my IM residency to be recognized by the AOA.  It would have cost me thousands of dollars to fly the team out and house them, just to guarantee the quality of my education.  I was embarrassed by the notion that I needed to pay some old duff to come out and review my accredited residency, which was affiliated with UC Davis. It really didn’t matter to me and furthermore I didn’t have any money.  Today I possess only the ABIM Certification and have never bothered with the AOA. I am not sure there is an advantage of one over the other. They are simply markers that you did all the work and should have a level of competency.  

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Dr. Patrick Feehan, DO Specialties:Hyperbaric MedicineRadiation OncologyWound CareMedical School:University of Health Sciences of Osteopathic Medicine Residency:Internship- Tucson General HospitalInternal Medicine- David Grant Medical Center -Travis Air Force BaseRadiation Oncology -University of California San Francisco

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What was your internal medicine residency like? What advice would you give students as they embark on this path?

The residency at David Grant Medical Center was miserable.  We pulled every third or fourth night call and would work the day after call.  I was working 100+ hour weeks and didn’t have time for anything. Thank God they won’t do that to you.  I could put in a pace maker, manage a patient on dialysis, evaluate and care for any patient in the ED or ICU, (but I would have been better served with more time to read). At a later date, I had the opportunity to become a staff member at David Grant and work with the internal medicine residents. They had stopped the 30-hour shifts and had added mandatory reading times. At that time they had achieved a top 10 rating for the residency on board scores.  It was amazing how much better life was for internal medicine residents and how much more they learned.  Look carefully at your life style.  Hard work and long hours do not equate with how much you will learn.

What made you decide to reapply? Were there any specific experiences that made you have a change of heart? I practiced Internal Medicine in a small town in Idaho for 4 years; I was a minor celebrity.  I couldn’t go to the post office to get my mail or the hardware store without being stopped by someone.  It would start out as a chat but end up with free medical advice.  I also found myself in the emergency room 3 or 4 nights a week and the hospital 4 or 5 times on any given weekend. With the birth of my oldest daughter I realized I would never be home with my family if I remained an internist. I had known two Radiation Oncologists and spent a good deal of time with them, so although I knew nothing of it as a medical student, I chose to do a second residency.  It was extremely hard to psych myself to go back for another

residency because of the grueling experience I had already encountered before.

How difficult was it to go back and do residency over again? Did you feel that it was easier since you had already experienced it?

Because I was boarded and a practicing internist, I had far more programs interested in me for Radiation Oncology than I would have if I were a DO student right out of medical school.  I wanted to be in California and was accepted at the two schools I applied, USC and UCSF. I attended UCSF and being my second residency, it was far better than my first.  I had lots of time to read, was always home at 5pm, and had my weekends off. I had brilliant colleagues and attendants that made the whole process fun.  I was married with children, and we made it a point to take the kids and the dog for a walk in a different districts of San Francisco every evening after work. I really enjoyed my life and my time with my family. In contrast, I had spent the last two years of my internal medicine residency with my wife and never saw her. I didn’t spend much time with her in the internal medicine practice.  

Do you find yourself using the skills you learned through IM when dealing with patients now?When I was a medical student I thought the best doctors were internists.  I have learned that internists are vital to the health care system. I have learned that being a small town doctor is really hard.  I can truthfully say that there are far better options.  I do use my skills from my internal medicine residency all the time.  I can use my skills

“Look carefully at your life style.  Hard work and long hours do not equate with how much

you will learn.”Dr. Patrick Feehan

advice on residency

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for other medical projects like free clinics, and medical missions abroad, but also basic medicine is involved every day in my practice. I loved internal medicine but couldn’t have done it for many years.  I plan on practicing Radiation Oncology well past 70 years old. 

Any last bits of advice for advancing medical students?My one piece of advice for psyching yourself up for anything you do in medicine, is find what is interesting in every single patient you see. To this day I try to find something medically fascinating about every patient I see, and I usually do find something amazing.  The other piece of advice is take an interest in every patient you meet on a personal basis. Try to weave what you learn in the introductory chat with something about them later on. This reinforces to the patient you are listening. Finally, a wise old internist once told me to always touch a patient before they leave, which will seal the memory of the appointment.  I have found this also helps me remember them. Don’t hold back the hugs, the tears, and the quiet listening, both with your patients and at home. Buy a dog if you need a friend.  Best of luck to all of you.

(Interview with Dr. Patrick Feehan conducted November 2012)

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Talk to the nurses and make sure to listen to them because they know what is going on, they hear everything! They listen to the attendings, they listen to the patients, they hear the staff.

Don’t Be afraid to ask for help. It wont be a sign of ignorance, or inability but a sign of responsibility, a responsibility to your patient who is the number one priority.

Listen to the patients. For example “Don’t stick me here, people can never get the IV there, try over here”

The nurses are your advocates they are there trying to help you. They know you are just getting your footing, let them help you learn.

Nurses are a great tool! They are there to expand upon the gaps. For example, it you have to run off (which

you will) they can provide you with the rest of the patients story.

We know you are short on time. If you begin a sentence with I only have 2-3 mins but could you explain/help me with this. We will be more understanding and less likely to interpret it is as rude.

The easiest way to get on the bad side of the nursing staff is when you come in with the attitude “I am Doctor, you are Nurse.” Don’t disrespect the nurses.

If you gain a reputation, as a rude individual, the nurses will be less willing to make your life easier. They will start avoiding you, if you are stressed and rushed, they wont do that extra little favor that you ask for.

With a bad reputation, the nurses’ willingness to drop everything to help you immediately will dwindle.

Tips From the Nurse Station

Case Study Challenge:Ben-Chetrit E, Munter G. Purple Urine. JAMA. 2012;307(2):193-194. doi:10.1001/jama.2011.1997

An elderly frail woman with dementia was admitted to the internal medicine service because of malfunction of her percutaneous gastrostomy tube. The patient had a history of recurrent hospitalizations for pneumonia and urinary tract infections. She had a permanent indwelling urinary catheter because of repeated episodes of urinary retention. The gastrostomy tube was replaced.

During admission a nurse noticed that the color of the urine was purple (Figure 1). A urine dipstick analysis revealed +2 leukocytes, +1 red blood cells, positive nitrites, and a urinary pH of 8.2.

What Is the Diagnosis?

What Would You Do Next?

A Order a urinalysis for porphyrins

B Order a urine culture and replace the catheter

C Review the patient’s medications

Case Study:http://jama.jamanetwork.com/article.aspx?articleid=1104832#Diagnosis

Figure 1

Answers: page 15

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Why is the AOA pursuing a unified accreditation system with ACGME?

About a year ago, the ACGME proposed two policies (Common Program Requirements). One policy would limit the ability for AOA-trained DOs to enter a second year of training in an ACGME program. The other policy would not recognize completion of an AOA-accredited residency program for entry into an ACGME fellowship.

The AOA is interested in ensuring that physicians who complete osteopathic graduate medical education have access to ACGME residencies and fellowships.

Did the AOA try to get the ACGME to rescind or amend these proposed Common Program Requirements?

The AOA met multiple times with ACGME leadership to share our concerns. We also testified before the ACGME Committee on Requirements. As a result, the ACGME Board did delay the effective date for the new Common Program Requirements to allow for more discussion.

Will the ACGME organizational structure include osteopathic representation?

If negotiations are successful in moving forward with the unified accreditation system, AOA and AACOM will become member organizations of the ACGME – along with the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies – and will nominate DOs to serve on the ACGME Board and to the individual Residency Review Committees.

How does a unified accreditation system benefit the osteopathic medical profession?

The unified accreditation system will preserve access to all training programs for DOs. Currently, there are 11,025 AOA training positions and more than 4,000 DO graduates each year. Osteopathic programs alone could not support the demand to train

more DOs and help fill the upcoming physician shortage.

This move also preserves access to ACGME residency and fellowship programs for our DOs as well as eliminates any issues with DO eligibility for ACGME programs.

In addition, those DOs who want to be program directors/faculty for ACGME programs can do so with AOA certification beginning in 2015.

For physicians who completed AOA GME in the past, the ACGME’s agreement to deem the AOA programs ACGME accredited represents an historic acceptance of AOA graduate medical education.

What will happen to the osteopathic training programs?

If negotiations are successful, as of July 2015, all osteopathic training programs will automatically be deemed accredited by ACGME. And, as occurred in the osteopathic accreditation process, when inspection time rolls around, all training programs will have to meet the same ACGME requirements.

Will the osteopathic training programs become allopathic programs?

No. If discussions are successful, current AOA GME programs will be accredited by ACGME, but will not abandon OPP and OMM as expected competencies. We will be having ongoing discussions with ACGME regarding preserving OPP and OMM within osteopathic training programs. In addition, these discussions will include how OPP and OMM can remain central to these osteopathic-focused training programs.

FAQs-ACGME Unified Accreditation SystemPosted Oct. 24, 2012

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The single system presents a unified commitment to advocating for continued

public support for funding the best-trained future physician workforce... As efforts are made to potentially cut GME funding, the

unified accreditation process is a clear reflection of the collaborative work being done by the AOA and ACGME to improve

graduate medical education with a focus on achieving demonstrated quality

improvement.

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Will the osteopathic rotating internship required in some states become a transitional year for ACGME purposes?

This will be determined in discussions with ACGME, but it is certainly possible that the Residency Review Committee that oversees transitional year programs will also be responsible for current AOA accredited internships. However, some state licensing boards may choose to do away with the internship requirement if discussions are successful on the unified accreditation system.

Will there be a single Match?We will be discussing implementation of the

unified accreditation system with AACOM over the next several months, including the best approach to a Match system. However, starting in March 2015, if all programs are considered ACGME approved, it is likely there will be one Match.

Will MDs and IMGs be allowed to train in osteopathic training programs?

Allowing MDs to enter into osteopathic-focused training programs will also be part of our transition discussions with ACGME. However, if they are allowed into osteopathic-focused programs, we would work with ACGME to identify educational prerequisites or other accomplishments or “check points” expected for MDs to meet in regard to OPP and OMM. The same would apply for IMGs.

What will happen to the PTRC, COPT and other AOA education committees associated with postgraduate training?

All AOA education committees will still be active at least until 2015. At that time, there will likely be DOs from these committees who will be appointed to the ACGME Residency Review Committees as well as the ACGME Board and various ACGME Board committees.

The COPTI, however, may stand as ACGME does not have an OPTI structure and is interested in pursuing discussions on this model.

How will this affect DOs in residency training now?

There will be no changes for those in postgraduate training programs (either AOA or ACGME) until 2015.

If discussions are successful, as of July 1, 2015, all programs become ACGME-accredited and DOs will have access to all training programs and fellowships when the Common Program Requirements are implemented.

How will this affect DOs entering into residency programs in 2015 or after?

For those entering residency programs in 2015 or later, they will have the option to choose osteopathic-focused training programs or allopathic-focused training programs.

While details will be worked out in negotiations with ACGME, AOA board certification will be stressed for all DOs at the end of training as a demonstration of continued competence in osteopathic medicine..

How does the single, unified accreditation system affect Resolution 42?

Resolution 42 is the current mechanism used by four states who require a first year of AOA residency training for licensure in their state. The AOA has a process to provide recognition of DOs who have completed a first year of training in an ACGME program for acceptance of their PGY1 year as AOA approved to satisfy the requirements of an OGME1 year. Resolution 42 will remain available for the foreseeable future for DOs who are currently completing or have already completed ACGME training. Unless the four states change their requirements for licensure, the AOA will reevaluate the situation after the unified system is implemented and determine if Resolution 42 will still be needed. It is likely that Florida, Michigan, Oklahoma and Pennsylvania will continue to require a first year of

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COMLEX-USA will continue to be the required examination series and the pathway to licensure for osteopathic

physicians.

Starting in March 2015, if all programs are considered ACGME approved, it is

likely there will be one Match.

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AOA training for licensure in their state for any DO who completed an ACGME program prior to the start of the unified accreditation system which will start in July 2015.

What does the new single, unified GME accreditation system mean for osteopathically distinctive competency assessment, licensure, and COMLEX-USA?

COMLEX-USA will continue to be the required examination series and the pathway to licensure for osteopathic physicians. It is widely recognized and universally accepted as the valid examination for osteopathic physician competency assessment for licensure. It is also required by accreditation standards established by the Commission on Osteopathic College Accreditation (COCA), and is a requirement for graduation from all colleges of osteopathic medicine. COMLEX-USA is regarded by the majority of residency program directors of AOA and ACGME accredited residency programs as an important and useful assessment tool as part of evaluation of DO residency applicants for their programs.

How will this affect ACGME programs taking or interpreting COMLEX-USA scores and what will the AOA/AACOM/NBOME be doing to help those Program Directors understand those scores?

While COMLEX-USA is first and foremost a licensure examination, a widely recognized secondary use is as a means for Residency Program Directors to assess applicants to their programs. In addition, the National Board of Osteopathic Medical Examiners (NBOME) has for the past several years escalated its efforts to educate ACGME Residency Program Directors about COMLEX-USA scores, score interpretation, the predictive validity of COMLEX-USA scores in relation to

performance in residency, etc. The planned unified GME negotiations should afford even more opportunities for helping ACGME Residency Program Directors understand and interpret COMLEX-USA scores. The AOA, AACOM, and the NBOME, will work with the ACGME to develop and implement an

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The AOA believes the unified accreditation system will be helpful to

our work in gaining practice rights around the world because

ACGME accreditation is better known internationally than the AOA’s.

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appropriate informational and educational program for ACGME Residency Program Directors.

How will we be able to distinguish osteopathic programs from ACGME programs after July 2015?

The details of how we will be able to distinguish between osteopathic-focused training programs and allopathic residencies are still under discussion. Of course, the osteopathic-focused programs will have expected core competencies in OPP and OMM, but for purposes of programs recruiting residents and providing comprehensive information for students selecting residencies, we will want osteopathic medical students to be able to distinguish which programs have an osteopathic-focus.

How will a single, unified accreditation system impact AOA's efforts in Washington, D.C.?

The single system presents a unified commitment to advocating for continued public support for funding the best-trained future physician workforce, especially to Members of Congress and the Institute of

Medicine. As efforts are made to potentially cut GME funding, the unified accreditation process is a clear reflection of the collaborative work being done by the AOA and ACGME to improve graduate medical education with a focus on achieving demonstrated quality improvement.

How will a single, unified accreditation system impact AOA's efforts internationally for practice rights of U.S.- trained DOs?

There are currently some countries that will accept AOA or ACGME training while others accept ACGME only or require additional training completed within that country. Therefore, the AOA believes the unified accreditation system will be helpful to our work in gaining practice rights around the world because ACGME accreditation is better known internationally than the AOA’s. However, it will not provide carte blanche recognition of postgraduate training internationally, as every country’s licensure system is different.

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What is The Diagnosis?

Purple Urine Bag Syndrome (PUBS)

What to Do Next

B. Order a urine culture and replace the catheter.

The key finding that suggests the diagnosis of PUBS is the purple color of the urine in the bag and tubing. In most cases, the color of the urine entering the catheter is normal and later becomes purple. Many pathogens have been associated with purple urine, including Pseudomonas aeruginosa, Escherichia coli, Proteus mirabilis, Proteus vulgaris, Providencia rettgeri, Providencia stuartii, Morganella morganii, Klebsiella pneumoniae, and Enterococcus species.

Comment

Abnormal urine color may imply a variety of pathologic or normal clinical states. 1)White or cloudy urine may be due to pyuria, whereas pink or red urine is usually due to hematuria, hemoglobinuria, or myoglobinuria. Dark yellow urine may suggest dehydration, and dark brown urine can be seen with bilirubinuria. Some medications such as rifampicin or phenazopyridine can yield an orange-colored urine. In porphyria cutanea tarda, the urine is red to brown in natural light and pink to red in fluorescent light. 2)PUBS was first reported more than 30 years ago. 3)Although rarely encountered, this medical condition typically occurs in elderly female patients with permanent indwelling urinary catheters. Alkaline urine, constipation (which allows increased absorption of tryptophan), dehydration, and renal failure are risk factors.

The purple discoloration of the urine results from a series of chemical reactions. Tryptophan in the diet is metabolized by bacteria in the gastrointestinal tract to

produce indole, which is absorbed into the portal circulation and converted in the liver to indoxyl sulfate, which is excreted in the urine. In PUBS, gram-negative bacteria that colonize the catheter produce indoxyl sulfatase and phosphatase, which further convert the indoxyl sulfate to indirubin (red color) and indigo (blue color).

The clinical course is usually benign. In asymptomatic patients, antibiotic treatment is not required. Alleviation of constipation along with catheter replacement usually leads to resolution. Some argue in favor of antibiotic treatment directed at the specific organisms detected in the urine culture.

In this patient, both P mirabilis and K pneumoniae were detected in the urine. The patient’s urine color became clear after replacement of the indwelling urinary catheter.

DiagnosisPurple urine bag syndrome (PUBS)

What to Do NextB. Order a urine culture and replace thecatheter

The key finding that suggests the di-agnosis of PUBS is the purple color of theurine in the bag and tubing. In mostcases, the color of the urine entering thecatheter is normal and later becomespurple. Many pathogens have been as-sociated with purple urine, includingPseudomonas aeruginosa, Escherichia coli,Proteus mirabilis, Proteus vulgaris, Provi-dencia rettgeri, Providencia stuartii, Mor-ganella morganii, Klebsiella pneumo-niae, and Enterococcus species.

CommentAbnormal urine color may imply a va-riety of pathologic or normal clinicalstates.1 White or cloudy urine may bedue to pyuria, whereas pink or red urineis usually due to hematuria, hemoglo-binuria, or myoglobinuria. Dark yel-low urine may suggest dehydration, anddark brown urine can be seen with bili-rubinuria. Some medications such asrifampicin or phenazopyridine can yieldan orange-colored urine. In porphyriacutanea tarda, the urine is red to brownin natural light and pink to red in fluo-rescent light.2

PUBS was first reported more than30 years ago.3 Although rarely encoun-

tered, this medical condition typicallyoccurs in elderly female patients withpermanent indwelling urinary cath-eters. Alkaline urine, constipation(which allows increased absorption oftryptophan), dehydration, and renalfailure are risk factors.

The purple discoloration of the urineresults from a series of chemical reac-tions. Tryptophan in the diet is me-tabolized by bacteria in the gastroin-testinal tract to produce indole, whichis absorbed into the portal circulationand converted in the liver to indoxylsulfate, which is excreted in the urine.In PUBS, gram-negative bacteria thatcolonize the catheter produce indoxylsulfatase and phosphatase, which fur-ther convert the indoxyl sulfate to in-dirubin (red color) and indigo (bluecolor).4,5

The clinical course is usuallybenign. In asymptomatic patients,antibiotic treatment is not required.Alleviation of constipation along withcatheter replacement usually leads toresolution. Some argue in favor ofantibiotic treatment directed at thespecific organisms detected in theurine culture.6,7 In this patient, bothP mirabilis and K pneumoniae weredetected in the urine. The patient’surine color became clear after replace-ment of the indwelling urinary cath-eter (FIGURE 2).

Conflict of Interest Disclosures: All authors have com-pleted and submitted the ICMJE Form for Disclosureof Potential Conflicts of Interest and none were re-ported.

REFERENCES

1. Raymond JR, Yarger WE. Abnormal urine color: dif-ferential diagnosis. South Med J. 1988;81(7):837-841.2. Rich MW. Porphyria cutanea tarda: don’t forgetto look at the urine. Postgrad Med. 1999;105(4):208-210, 213-214.3. Buist NR. Purple urine bags. Lancet. 1978;1(8069):883-884.4. Dealler SF, Hawkey PM, Millar MR. Enzymatic deg-radation of urinary indoxyl sulfate by Providencia stu-artii and Klebsiella pneumoniae causes the purple urinebag syndrome. J Clin Microbiol. 1988;26(10):2152-2156.5. Lin HH, Li SJ, Su KB, Wu LS. Purple urine bag syn-drome: a case report and review of the literature.J Intern Med Taiwan. 2002;13:209-212.6. Wang IK, Ho DR, Chang HY, Lin CL, Chuang FR.Purple urine bag syndrome in a hemodialysis patient.Intern Med. 2005;44(8):859-861.7. Su FH, Chung SY, Chen MH, et al. Case analysisof purple urine-bag syndrome at a long-term care ser-vice in a community hospital. Chang Gung Med J. 2005;28(9):636-642.

Figure 2. Patient urine after treatment.

JAMA CLINICAL CHALLENGE

194 JAMA, January 11, 2012—Vol 307, No. 2 ©2012 American Medical Association. All rights reserved.

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Useful Websites:ACGME Statistics with the Match: http://www.nrmp.org/http://www.nrmp.org/data/resultsanddatasms2012.pdfThe American Osteopathic Board of Surgery: http://www.aobs.org/AOA Residency Training in Surgery and the Surgical Subspecialties:http://www.osteopathic.org/inside-aoa/accreditation/postdoctoral-training-approval/postdoctoral-training-standards/Documents/basic-standards-for-residency-training-in-surgery-and-surgical-specialties.pdf

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