COMLEX-USA® Level 1

Test Overview
The COMLEX-USA program is designed to assess the osteopathic medical knowledge considered essential for osteopathic generalist physicians to practice medicine without supervision. It is created by the National Board of Osteopathic Medical Examiners, Inc.
COMLEX Level 1 represents the basic science examination component of the licensing process of osteopathic medicine. COMLEX Levels 2 and 3 deal with the clinical aspects of diagnosis and management, respectively.
COMLEX Level 1 examination items are designed to test the application of basic science principles to clinical situations covering the following disciplines: Anatomy, Biochemistry, Microbiology, Osteopathic Principles, Pathology, Pharmacology, Physiology, and Behavioral Science.
COMLEX Level 1 will soon replace the paper-pencil version of the exam with a non-adaptive, computer-based test starting in May 2006. The last paper-and-pencil version of the exam will be administered on October 11-12, 2005. With the new computer-based test, examinees will have 8 hours to complete 8 blocks of 50 questions each, for a total of 400 questions. Breaks will be offered at various times during the day. Question formats will basically remain the same as seen on the paper-and-pencil exam: one-best-answer, matching type, and case clusters. For more information on the new computer test changes, visit the NBOME website at www.nbome.org.
Some osteopathic students take the USMLE Step 1 in addition to the COMLEX Level 1. The following summarizes the similarities and differences between these exams:
Similarities between COMLEX Level 1 and USMLE Step 1
Both examinations lean toward clinical applications of basic medical science concepts stressing the understanding of underlying functions and mechanisms.
Both exams use similarly styled clinical vignettes with short answer questions.
Both exams have no subject specific sections; the questions are distributed randomly.
Both exams are non-adaptive, computer-based tests.
Differences between COMLEX Level 1 and USMLE Step 1
COMLEX Level 1 includes questions based on the understanding of osteopathic principles and applications.
On COMLEX Level 1, some of the traditional clinical vignettes include osteopathic symptoms and answer choices.
COMLEX Level 1 includes case clusters. These are one-paragraph clinical scenarios followed by 2 to 3 independent questions. The questions will usually cover underlying disease mechanisms, diagnosis, and basic treatment.

Note to all our visitors

dear visitor
this blog is dedicated to publish all the available materials ( articles, books , experiences .. etc ) about medicine and health
we started this blog by posting the most important topic for most of international physicians , the USMLE
this will last during the next month as long as we get new materials available to be published
we will also publish other medical stuff as soon as we are ready to do so
we hope you to enjoy your stay here and please read our archive and try to tell your friends about it
regards
EGmedicine

a plan to do in the future

TOO ALL MED-STUDENTS OUT THERE: Don’t freak out! I’m a man with a plan
…Okay,

so here’s my backup plan…

1. Graduate from Med-School with a clean criminal record.
2. Go to the U.S.A or Canada and make friends with many of those rich dudes who desperately ned organ transplanting.
3. Go to Indonesia or Malaysia with a list, and get to know matching dudes who would do anything for money.
4. Go to Turkey to do all the dirty surgeries.
5. Go to Mexico to spend the rest of your life out reach of the Interpol.
   “TOTALLY WORTH IT!”

Friendly Hospitals for International Medical Graduates

Remember to include some of these hospitals in your program lists.

Alabama
Anniston, Alabama (GC)

California
Alameda County Hospital, Highland, CA
Kern Medical Center, CA
St Mary’s Hospital, San Francisco, CA
University of California, San Francisco, CA
USC, Los Angeles, CA

Conneticut
Bridgeport Hospital, Bridgeport, CT (H1,J1,GC)
Danbury Hospital, Danbury, CT (H1,J1,GC)
Hospital of St Raphael, CT (H1,J1,GC)
Norwalk Hospital, Norwalk, CT (H1,J1,GC)
St Vincent’s Medical Center, Bridgeport, CT (H1,J1,GC)
U of Connecticut, Farmington, CT (J1,GC)

District of Columbia (Washington, DC)
District of Columbia General Hospital, Washington, DC
Howard University Hospital, Washington, DC (H1,J1,GC)
Providence Hospital, Washington, DC (H1,J1,GC)

Illinois
Cook County Hospital, Chicago, IL (H1,J1,GC)
FUHS/Chicago Medical School, Chicago, IL
Illinois Masonic Med Ctr, Chicago, IL
Jackson Park Hospital, Chicago, IL(GC)
Mercy Hospital, Chicago, IL (J1,GC)
Ravenswood Hospital, Chicago, IL (J1,GC)
Rush Copley Medical Center, Aurora, IL (J1,GC)
Rush Presbyterian Hospital, Chicago, IL (J1,GC)
Rush Westlake, Melrose Park, IL (J1,GC)
St Francis hospital, Evanston, IL (H1,J1,GC)
Univ of Illinois at Urbana Champaign, IL (GC)
Univ of Illinois at Chicago, Chicago, IL (J1,GC)
Univ of Illinois/Michael Reese Hospital, Chicago, IL (J1,GC)
Univ of Illinois at Peoria, IL

Maryland
Franklin Square Hospital, Baltimore, MD
Good Samaritan Hospital, Baltimore, MD
Harbor Hospital,Baltimore, MD (H1,J1,GC)
Maryland General Hospital, Baltimore, MD (H1,J1,GC)
Prince George’s Hospital, Cheverly, MD (GC)
St Agnes Health Care, Baltimore, MD (J1,GC)

Michigan
Henry Ford Hospital, Detroit, MI (J1,GC)
Hurley Med Ctr/MSU , Flint, MI (J1,GC)
McLaren Regional Medical center, Flint, MI
Midmichigan Medical center, Midland, MI
Providence Hospital, MI (J1,GC)
Saginaw Cooperative Hospitals, Saginaw, MI
St Joseph’s Mercy Hospital, Pontiac, MI (H1,J1,GC)
St John Hospital, Detroit, MI (J1,GC)
Wayne State University, Detroit, MI (J1,GC)
William Beaumont Hospital, Royal Oak, MI (J1)

Missouri
St Mary’s Hospital, St. Louis, MO
St Lukes Hospital, St. Louis, MO

New Jersey
Atlantic City Med Center, Atlantic City, NJ (J1,GC)
Jersey Shore Med Ctr, Neptune, NJ (GC)
Monmouth Med Ctr., Long Branch, NJ (J1,GC)
Mountainside Hospital, Montclair, NJ
Mount Sinai, Englewood, NJ
Mount Sinai, Jersey city, NJ
Muhlenberg Regional Med Ctr. , Plainfield, NJ (J1,GC)
Overlook Hospital, Summit, NJ (GC)
Raritan Bay Med Ctr., Perth Amboy, NJ
St Barnabas Medical Center, Livingston, NJ (GC)
St Joseph’s Medical Center, Paterson, NJ (GC)
St Francis Med Ctr, Trenton, NJ
UMDNJ, Pistacaway, NJ
UMDNJ, Newark, NJ (GC)
UMDNJ, Camden, NJ (J1,GC)
UMDNJ, New Brunswick, NJ (J1,GC)

New York
Albert Einstein/ Jacobi Med Ctr., Bronx, NY (H1,J1,GC)
Bronx Lebanon Hospital, Bronx, NY
Brooklyn Hospital, Brooklyn, NY (GC)
Brookdale University Hospital,Brooklyn, NY
Catholic Med Ctr., Jamaica, NY (GC)
Lincoln Medical and Mental Health Center, Bronx, NY
Maimonides Hospital, Brooklyn, NY (H1,J1,GC)
New York Hospital and Med Ctr of Queens/Cornell U., Flushing, NY
New York Methodist Hospital/ Wyckoff Heights, Brooklyn, NY (H1,J1,GC)
NYMedical college (Metropolitan) Hospital, NY (J1,GC)
NYMedical College (Sound Shore) Hospital, New Rochelle, NY
NYU VA Med Ctr., NY
New York Flushing Hospital, Flushing, NY
St Barnabas Hospital, Bronx, NY
St Lukes Hospital, New York, NY (J1,GC)
St Joseph’s Hospital, NY
St John’s Episcopal South Shore Hospital, Fair Rockaway, NY (H1,J1,GC)
SUNY at Brooklyn, NY (H1,J1,GC)
SUNY at Buffalo, Buffalo, NY (H1,J1,GC)
SUNY at Syracuse, NY (J1,GC)
Winthrop University Hospital, Mineola, NY (J1,GC)
Woodhull Med Ctr., Brooklyn, NY (J1,GC)

Nevada
U of Nevada, Reno, NV
Univ of Nevada, Las Vegas, NV

Ohio
Fairview Hospital, Cleveland, OH (J1,GC)
Good Samaritan Hospital, Cincinnati, OH
Jewish Hospital of Cincinnati, Cincinnati, OH
Meridia Huron Hospital, East Cleveland, OH (H1,J1,GC)
Mount Sinai of Cleveland, OH

Pennsylvania
Abington Memorial Hospital, Abington, PA (H1,J1,GC)
Allegheny General Hospital, Pittsburgh, PA (J1,GC)
Easton Hospital, Easton, PA
Frankford Hospital,Philadelphia PA (H1,J1,GC)
Guthrie Healthcare, Sayre, PA
Lehigh Valley Hospital, Allentown, PA
Mercy Hospital, Pittsburgh, PA
MCP Hahnemann University Hospital, Philadelphia, PA
Pinnacle Health/ Polyclinic Hospital, Harrisburg, PA
UPMC Health System/ Shadyside Hospital, PA

Rhode Island
Miriam Hospital of Brown University, Providence, RI (J1,GC)
Roger Williams Hospital, Providence, RI

Texas
Texas Tech University, Amarillo,TX
Texas Tech University, Odessa, TX
Texas Tech University, El Paso, TX (J1,GC)

Virginia
U of Virginia, Roanoke Salem, VA (J1,GC)

West Virginia
West Virginia University Hospital, WV (J1,GC)

Wisconsin
Sinai Samaritan Medical Center, Milwaukee, WI

Credentialing and Ongoing CME

Paul Gitman, MD, FACPMedical Director and Vice President for Clinical Care and Resource ManagementLong Island Jewish Medical Center, New Hyde Park, NYNYACP Governor, Downstate II Region

As a physician about to enter practice, you will need to understand the myriad of agencies and regulations that impact or potentially impact upon the environment in which you must conduct your practice, in addition to the State and Federal regulations of which you must be cognizant. If you practice within a hospital environment there are other agencies or organizations that will impact upon your activities. The following will highlight some of the more important areas that you should familiarize yourself with.

1. Hospital appointment
If you intend to care for patients when admitted to a hospital, you will need to apply and receive a hospital staff appointment. Although the process is not difficult, it is time consuming and may require a number of documents and letters of reference. You should begin to apply to hospitals where you intend to see patients at least 6 months prior to the date you plan to admit patients. You should call the hospital to request an application and begin to collect any information that will need to be provided. Read the hospital by-laws as this is the contract between you and the institution and the rules by which you must provide care. Once on the staff, you care will be monitored as is all processes within the hospital. The process of continuous evaluation and looking for opportunities to improved is called performance improvement. Care is evaluated by peers and if problems identified may result in corrective action. Such corrective action is subject to due process, which is detailed in the by-laws previously mentioned. Of importance, you should know that in New York and I believe some other states, comments made to a peer review committee (orally or in written form) by a person involved in the care of a patient who then becomes party in a suit may be discoverable. Having a hospital appointment may also be critical because many managed care plans require such before they will allow you on their panel.

2. Office of Professional Medical Conduct. (OPMC)
Although this board may be named differently in different states, the function is quite similar. This board is responsible for reviewing complaints against physiciansÕ care and practices. The result of an adverse action may cause you to lose your license. Therefore, if you receive a letter from the Board, it is critical that you contact a lawyer and be represented.

3. Peer Review Organization
The Peer Review Organization has a contract with the federal government to review care provided within hospitals and some outpatient areas. Although their efforts are more educational than punitive, they do have the ability to report apparent behavior or practice patterns to the office of inspector general for prosecution

4. Stark anti self-referral laws.
You should read the regulations and fully understand what constitutes self-referral. Ignorance of the law is not an acceptable response if caught breaking the law.

5. Fraud and Abuse Regulation
There is a perception by some elements of government that the amount of fraud and abuse within the Medicare system is significant. Although the percentage of physicians who commit such crimes are small, it is critical that you are aware of the efforts of the OIG to look for and prosecute those at fault. The punishment is severe, so be do not take chances. Be aware of the rules. In an effort to help physicians understand the rules, the OIG has published a number of compliance guidelines. These are available on their web site and should be read.

6. Joint Commission on Accreditation of Health care Organizations (JCAHO).
JCAHO as an organization surveys (inspects) organizations to determine compliance with their published standards. The federal government contracts with JCAHO to survey organizations to assure the government that standards of care are met. If a hospital is not successful in attaining accreditation, it might lose the ability to care for patients covered under the Medicare Program. As you can understand, JCAHO surveys which occur every three years are critical to the survival of an organization. Also of note, whereas inspections in the past were limited to organizations, there is a strong drive to extend these surveys to the physicianÕs office.

Implications of the Internet for Medical Practice and Education

Edward H. Shortliffe, MD, PhDProfessor and ChairDepartment of Medical InformaticsColumbia UniversityNew York, NY 10032 USA

International Graduates Web SiteNew York ChapterAmerican College of Physicians
The Internet phenomenon has had a remarkable impact on our global society in just a few short years. Health-related sites are among the most frequently accessed information resources on the Web. But despite growing enthusiasm for the Internet, any Web user can attest to its severe limitations. What will the evolving international networking infrastructure mean to the practice of medicine, to personal health practices, and to the education and involvement of patients regarding health and disease?
For practicing physicians, the Internet offers both a challenge and an opportunity. It can be difficult to gain access in some parts of the world, and in turn to learn how to take advantage of the technologies and information resources that it offers. Integrating computer use into practice workflow is particularly challenging. On the other hand, rapid access to the most current biomedical information is facilitated by the Internet in ways that were never possible in the era of print publication, when we depended on worldwide distribution via postal services. Furthermore, more of our patients are becoming facile with the Internet and use its features both to learn about health and disease and to communicate with others. Thus the Internet is resulting in a more informed public and in new opportunities for physicians to implement effective patient education and monitoring of disease outside of the traditional office or hospital settings.
On the current Internet, physicians tend to be particularly attracted to resources that provide access to the most current scientific literature (journal articles or textbooks). The Medline service of the National Library of Medicine (NLM) is now available without cost to users who can access it from anywhere in the world. With the addition of a consumer site (Medline Plus), the NLM is now a major site for high quality information that can be useful both to practitioners and their patients. Professional societies and publishers are also increasingly providing online access to current information, often without charge to the public or, at least, to their members or subscribers.
The Internet can also be used to facilitate electronic communications between patients and care providers, typically in the form of electronic mail (email). Email has been used sporadically between patients and providers, but it could prove to be an effective mechanism for improving care and lowering costs, by allowing more frequent communications that might enable better tracking of a patient’s progress or eliminate the need for an office visit. The most pressing technical issue is security. Several options are available for improving the security of data exchanges between patients and providers, but the most challenging issues center around institutional policies for confidentiality and for integrating activities such as email into workflow. The Internet is also emerging as a medium for allowing consumers direct access to their personal health records, with similar security concerns.
The Internet also offers physicians the opportunity for improved monitoring of their patients and, potentially, provision of in-home care through video-based examinations or by controlling medical equipment (e.g., pacemakers, dosimeters) deployed in the home. The goals of such initiatives are to assist in early-detection of potential health problems ranging from heart attacks to congestive heart failure to diabetes and to reduce the need for clinical intervention and costly hospital stays. Continued advances in computing and communications technologies could enable more widespread deployment of affordable home-based health monitoring systems.
The Internet is becoming a significant enabler of consumer health initiatives in that it provides an increasingly accessible communications channel for reaching a growing segment of the population, and, in contrast to television, offers the possibility of greater interactivity and better tailoring of information to individual consumer needs. One recent survey in the US shows that consumer sites are being used to gather information on diseases, medications, and nutrition, as well as to find care providers or participate in support groups (Table 1). The most visible aspect of this phenomenon is the explosion of sites of the World Wide Web geared toward consumer health issues, although many sites are aimed primarily at practitioners or seek to attract both kinds of users (See Table 2). These sites are dedicated to the diagnosis and management of diseases, promotion of various healthy lifestyles, and interventions to prevent the onset of disease. Due to concerns about the validity of information that is offered via such Web sites, several initiatives are under way to evaluate the quality of health information on the Internet.

Searching Medline
The Internet offers a wide variety of tools that can be used to find information in support of clinical practice. Examples drawn from a variety of free Web-based information resources:
Tools for searching bibliographic citations and their abstracts. The National Library of Medicine’s PubMed resource (http://www.ncbi.nlm.nih.gov/entrez/query) is perhaps the most commonly used literature citation search engine. The use of PubMed will be demonstrated, including some of its more advanced features such as its ability to find articles that are “similar to” another article. An alternative search engine, WebMedline (http://www.medweaver.com/cgi-bin/webmedline), will be demonstrated so show how other search engines can take advantage of the Medline database while providing search environments with varying features.
Tools for searching the World Wide Web to find filtered clinical information. CliniWeb (http://www.ohsu.edu/cliniweb/) supports search for medical information in five different languages (English, German, French, Spanish, Portuguese). CliniWeb provides an index and table of contents to clinical information on the World Wide Web and has direct links to Medline searches via PubMed.
Tools that organize clinical information on the Internet into categories and thereby provide a “portal” for clinicians who wish to find specific information. Two excellent examples of this type of resource are MedWeb (http://www.medweb.emory.edu/MedWeb/) and Medical Matrix (http://www.medmatrix.org)/. The maintainers of these sites have taken on the custodial task of evaluating Web-based clinical information and organizing the sites by category after making efforts to assure their quality.
Tools for searching the full text of articles, providing entire journals or books online. The Web site of the American College of Physicians (http://www.acponline.org/) provides full-text access to all its major publications, including the Annals of Internal Medicine (http://www.annals.org/). Access to the ACP’s publications is provided without charge to members or to subscribers of the print versions.
Brief bio:
Edward H. Shortliffe is Professor and Chair of the Department of Medical Informatics at Columbia University’s College of Physicians and Surgeons in New York City. During the early-1970s, he was principal developer of the medical expert system known as MYCIN. After a pause for internal medicine house-staff training at Harvard and Stanford between 1976 and 1979, he joined the Stanford internal medicine faculty where he directed an active research program in clinical information systems development. At Columbia, he continues to be closely involved with medical informatics graduate training and his research interests include the broad range of issues related to integrated decision-support systems, their effective implementation, and the role of the Internet in health care. Dr. Shortliffe is a member of the Institute of Medicine and a fellow of the American College of Physicians. He is a member of the Board of Regents of the ACP, has served on the editorial board of the Annals of Internal Medicine and as chair of the College’s Publication Committee, and he is current chair of the Steering Committee for the Physician Information and Education Resource (PIER).

Hospitalism

Suhail A. Shah, MBBSAssociate Chief of the Hospitalist ProgramNorth Shore University HospitalManhasset, NY 11030

Hospitalism is a rapidly developing concept that has been widely accepted and used throughout the United States. Much of Europe has been using internists in a model more or less like the hospitalist in the US for years. In the US, the hospitalist is defined as an internist whose ‘major’ time commitment is towards inpatient care, with varying proportions cited in different states.
The hospitalist era in the US was brought about by a radical shift in thinking. The main reason may have been financial. In these days of managed care and ever decreasing reimbursements, the internists trip from his or her office to the hospital for one or two inpatients is not financially worthwhile. Also, the hospitalists’ constant presence in the hospital and their exposure to the relatively sicker inpatient is a powerful stimulus for improvement; and probably more efficient care of the hospitalized patient. Hospitalists have in the past been sub-specialists but now mainly comprise are doctors just out of residencies.
Some key points concerning hospitalists.
The degree of inpatient to practice-based work varies widely. Some larger internist group practices hire a hospitalist to do all their inpatient work exclusively; whereas some use each internist as a ‘rotating hospitalist’ for specific periods of time.
The remuneration varies widely, expectedly with geographical locations with pay scales inversely proportional to the proximity of the hospital to larger cities. Some hospitalists are reimbursed on the basis of an incentive plan.
It is not entirely clear if the hospitalists ever ‘pull their weight’ in creating enough revenue through their own billing to cover their salary. However, indirectly, they probably do, through their effect on decreased utilization of resources, lower length of stay. In addition, if they employ a hospitalist, a group of internists can save time and bill more patient visits in the office setting which mostly are reimbursed at higher rates.
Is it a sustainable career for residents, short term or long term? In my experience, I have seen several residents join large group practices and work as their hospitalists for a year before moving on to pure out-patient practice. It is probably too early to judge, since the concept is very new.
A frequent concern is of ‘burnout’. Being more or less constantly ‘on’ for admissions and in-patient work. However, I and at least three of my colleagues have been hospitalists for more than 3 years now with no significant sign of immediate mental decompensation!
What about satisfaction? In my experience, there is ample satisfaction involved with taking part in the treatment and care of relatively sick patients and getting them back on their feet and mending. There however are concerns with not having the opportunity to follow up with these patients again and sometimes a ‘hiatus’ in satisfaction.
What about transfer of care? A major contentious point has been whether primary care providers can effectively transmit information to the hospitalist and vice versa. These concerns can easily be addressed by effective communicating tools, e.g. the phone, fax, email, regular mail. Also invariably there is some transfer of care involved (e.g. on weekend coverage arrangements) even if hospitalists are not used.
What about follow up or liability issues? Certain patients who are non-compliant with follow up or do not have either insurance or doctors pose a challenge. For example, if there are studies or blood tests to be done on an outpatient basis, who will order them and then check the result? The case of prothrombin times monitoring on patients discharged on coumadin is a typical example. The hospitalist referring these cases to the appropriate out patient setting e.g. medical clinics, faculty practice out patient practices (if available) can solve some these concerns.
Overall, hospitalism is rapidly emerging as one of the fasting growing fields of internal medicine and I believe, provide a satisfying and enriching experience for any doctors who choose to immerse themselves in it.

Suggested further reading
1) Wachter RM, Goldman LM. “The Emerging role of ‘hospitalists’ in the American Health Care System.” New England Journal of Medicine. 1996; 335: 514-7.
2) Wachter RM. “An Introduction to the Hospitalist Model.” Annals of Internal Medicine. 1999;130:338-342.
3) Whitcomb W. “The Hand-off: Innovation and Solutions for the Continuity between Hospitalists and Referring Physicians.” ACP-ASIM Annual Session, April 1999.
4) Craig DE, et al. “Implementation of a Hospitalist System in a Large Health Maintenance Organization: the Kaiser Permanente Experience.” Annals of Internal Medicine. 1999; 130: 355-359.
5) Goldman LM. “The Impact of Hospitalists on Medical Education and the Academic Health System.” Annals of Internal Medicine. 1999; 130:364-367.
6) Wachter RM, “New Issues in the Hospitalist Movement.” ACP-ASIM Annual Session, April 1999.
7) Whitcomb W. “The Hand-off: Innovation and Solutions for the Continuity between Hospitalists and Referring Physicians.” ACP-ASIM Annual Session, April 1999.
8) Nolan JP. “Internal Medicine in the Current Health Care Environment: A Need for Reaffirmation.” Annals of Internal Medicine. 1998; 128: 857-862.
9) Sox H. “The Hospitalist Model: Perspectives of the Patient, the Internist, and Internal Medicine.” Annals of Internal Medicine. 1999;130:368-372.

Training Guidelines for Consultants in Cardiovascular Disease

Ernesto A. Jonas, MD, FACP, FACCFormer Chief, Div. of Cardiology, and Cardiovascular Program Training Director Nassau University Medical CenterAssociate Professor of Medicine, SUNY at Stony Brook

This outline is offered as an aid in selecting among the Cardiovascular Training Programs in the United States and asking pertinent questions during the interview.
A pre-requisite to training in cardiovascular disease is the successful completion of three years of training in Internal Medicine acceptable to the American Board of Internal Medicine (ABIM).
The continued advances in cardiovascular medicine have necessitated the increase in the years for basic (Level 1) training from one year in the late 1960صs to the current three years full-time requirement. This level of training is the minimum required for admission to the ABIM Subspecialty Board on Cardiovascular Disease.
Level 1: Basic training required of all trainees to be a competent, consulting cardiologist.
Specialized competence (Level 2) in performing or interpreting some procedures requires additional training beyond the core program with specific guidelines.
Level 2: Additional training in one or more specialized areas enabling a cardiologist to perform or interpret, or both, specific procedures at an intermediate skill level.
Advance training (Level 3) requires the acquisition of a high level of skills beyond those of the core program that enables the cardiologist to not only perform and interpret specific procedures, but also trains others in these skills.
Level 3: Advanced training in a specialized area enabling a cardiologist to perform, interpret and train others to perform and interpret specific procedures at a high skill level.
The core training should be undertaken in university or university-affiliated institutions with fully accredited residency-training program in internal medicine.
There should be adequate balance between academic endeavors and clinical service
24 months of the three year core program should include a minimum of:
8 months in nonlaboratory clinical practice:1) Cardiac consultation 2) In-patient cardiac care3) Coronary care (3 months)4) Cardiothoracic/cardiovascular surgery5) Congenital heart disease6) Heart failure/cardiac transplantation7) Preventive cardiology
4 months in the cardiac catheterization laboratory.
6 months in noninvasive imaging:1) Echocardiography and Doppler (minimum 3 months)2) Peripheral vascular studies3) Nuclear cardiology techniques (minimum 2 months)4) Nuclear magnetic resonance, computed tomography, and other techniques
2 months in electrocardiography, stress testing, ambulatory electrocardiographic monitoring
2 months in arrhythmias, permanent pacemaker management, and electrophysiology
The remaining 1 year should be dedicated to research (6 to 12 months) or research combined with focused areas of individual interest and future career goals.
Ambulatory care experience of at least _ day per week (or its equivalent) should be part of the total 3-year core exposure.
In all areas of training, there are minimal numbers of procedures or encounters recommended by guidelines. It is understood that the quality of these encounters more than the quantity is essential in molding good consultants therefore supervision, and critique by faculty are an important part of the overall training program.
Electrocardiography: 3,500
Ambulatory ECG Monitoring: 75
Exercise Testing: 50
Cardiac Catheterization and Interventional Cardiology: 100 patients exposures to include right heart catheterization (including balloon flow-directed catheters), temporary right ventricular pacemaker insertions, left heart catheterization with ventriculography and coronary angiography, pericardiocentesis.
Echocardiography: 150 studies
Nuclear Cardiology Procedures: 80 hours of active participation in daily study interpretations
Electrophysiology, Cardiac Pacing, and Arrhythmia Management: 2 months exposure in this area to include at least 10 temporary pacemaker insertions and 8 elective cardioversions
Cardiovascular research: 6 months
Congenital Heart Disease in Adults: minimum of 3 hours of formal lectures.
Preventive Cardiology: Equivalent of one month full-time cumulative training.
The program should have adequate training resources in place.
There must be inpatient and outpatient facilities with an adequate number of patients of a wide age range with a broad variety of cardiovascular disorders. Trainees must be supervised and evaluated on every rotation by qualified faculty members when seeing patients in both areas. Faculty members must carefully supervise outpatient care.
The facility must provide laboratories for cardiac catheterization, electrocardiography, exercise and pharmacologic stress testing, Doppler/echocardiography, ambulatory ECG monitoring and noninvasive peripheral vascular studies. There must be appropriate facilities for cardiac catheterization, angiography and hemodynamic assessment, with adequate numbers of patients undergoing interventional procedures, including coronary angioplasty, atherectomy, stent placement, myocardial biopsy, transvalvular balloon dilation and intraaortic balloon placement
Facilities for nuclear cardiology must be available, including ventricular function assessment, myocardial perfusion imaging and studies of myocardial viability
There must be appropriate facilities for the management of patients with arrhythmias, including electrophysiologic testing, arrhythmia ablation, signal-averaged electrocardiography and tilt-table testing as well as the previous evaluation, implantation and assessment of patients with cardiac pacemakers and implantable antiarrhythmic devices and their long-term management
Facilities and faculty for training in cardiovascular research, including various basic science modalities, are important.
There must be modem intensive cardiac care facilities.
There must be facilities for cardiac and peripheral vascular surgery and cardiovascular/cardiothoracic surgical intensive care. Close association with and participation in a cardiovascular/cardiothoracic surgical program is an essential component of the cardiovascular training program. This must include active participation in the preoperative and postoperative management of patients with cardiovascular disease. Exposure to cardiac transplantation is strongly recommended.
There must be facilities and faculty involved in the diagnosis, therapy and follow-up care of patients with congenital heart disease.
There must be appropriate facilities for the clinical and laboratory assessment of patients with systemic hypertension and peripheral vascular disease
There must be facilities for assessment of cardiopulmonary and pulmonary function, cardiovascular radiography and magnetic resonance imaging (MRI).
There must be appropriate expertise and instruction in preventive cardiology and risk factor modification, including management of lipid disorders
There must be facilities and faculty with knowledge of cardiovascular pathology.
There must be facilities, personnel and faculty with expertise in cardiac rehabilitation.
There must be other appropriate facilities and resources necessary to accomplish the training, including a comprehensive medical library, facilities for continuing medical education, experimental study design and statistics and quality assurance.
Opportunities to gain knowledge and experience in related fields of medicine should be available.
Magnetic resonance imagingFamiliarity with the cardiovascular applications and interpretations of magnetic resonance images is essential to the training of a cardiovascular fellow. This imaging modality has many existing uses and considerable potential in noninvasive diagnosis. It is recommended that, where available, the fellow devote 2 months of time to magnetic resonance imaging (MRI). To become conversant enough with this methodology to be proficient with interpretation, a 4-month experience is recommended, and to become experienced enough for development and management of an MRI laboratory, a I -year comprehensive experience is essential.

Radiology
The interpretation of cardiovascular X-ray films, with particular reference to vascular structures and special cardiovascular radiologic procedures.

Surgery
The risks and benefits of cardiothoracic and cardiovascular surgery and the rationale for the selection of candidates for surgical treatment, as well as the natural history and the preoperative and postoperative management of patients with cardiovascular disease and various comorbid conditions.

Anesthesia
Close collaboration with anesthesia colleagues in the preoperative and postoperative management of patients with cardiac disease for cardiac and noncardiac surgery, and cardiac procedures requiring anesthesia (e.g., cardioversion).

Pulmonary disease
A solid knowledge of basic pulmonary physiology in addition to the interpretation of pulmonary and cardiopulmonary function testing, blood gases, pulmonary angiography and radioactive lung scanning methods and experience with the management of patients with acute pulmonary disease.

Obstetrics
A solid knowledge of the interrelations between pregnancy and heart disease, together with experience in the clinical management of patients with heart disease who are pregnant.

Physiology
The physiology of the cardiovascular system, its response to exercise and stress and the alterations produced by disease.

Pharmacology
The pharmacology and interactions of cardiovascular drugs and drugs affecting cardiovascular function.
Pathology
Familiarity with the gross and microscopic pathology of all major forms of heart disease.

Geriatrics
Familiarity with the effects of aging on cardiovascular disease and therapeutics is important
Conferences, seminars, review of published reports and lectures with full participation of the trainee should occur at a minimum of three per week.
The trainee must be offered the opportunity to teach.
Useful Link – Guidelines for Training in Adult Cardiovascular Medicine: http://www.acc.org/clinical/training/adult.htm

Author Bio:
Ernesto A. Jonas is a Graduate of the University of Nuevo Leon, Monterrey, Mexico. He completed is residency training in Internal Medicine at the Nassau University Medical Center (NUMC), East Meadow, NY, and his cardiovascular training at St. Elizabethصs Medical Center, Boston. MA. He joined the full-time faculty of the NUMC in 1973, and served as Chief of the Division of Cardiology until 1997 when he retired. He was also the Cardiovascular Program training director.

Guide to Licensure

Mohammed K Rizvon MD FACPAttending Physician, Department of MedicineNassau University medical Center, East Meadow, NY 11554Assistant Professor of Medicine, SUNY at Stony Brook

The application for licensure begins with passing the Medical Licensing Examinations I, II, III, the proficiency in English test and Clinical Skills Assessment. Since steps I and II of the Unites States Medical Licensing Examinations and Clinical Skills Assessment are now required prior to joining the residency program, consider taking USMLE III soon after starting residency training. Many residents try to postpone taking this exam to avoid interfering with the hectic schedule of internship. This may not be a good idea as a good basic knowledge in multiple specialties is essential for passing this examination.
USMLE III can be taken in any US State. Consider taking the exam in states, which require the least paper work. One example in the Northeast is Connecticut whose USMLE application is relatively simple. Some of the other states require a completed application form for medical license including all the verifications as a requirement to sit for the exam.
It is essential to identify one state where you would like to practice Medicine after your residency training. Application fees are expensive for a resident physician and the application process is a considerably long one that requires a lot of time commitment.
Some of the factors that could help decide on applying to a particular state are the visa requirements of some medical boards or other requirements like fingerprinting or direct verification of credentials which usually take a lot of time. New York State Medical Board issues unrestricted license to practice Medicine only to US citizens and permanent residents. Applicants on non-immigrant visas can only apply for limited license to practice Medicine only in qualified medically under-served areas/ Health professional shortage areas. The NY State department of health and the US federal register are the sources of information for the updated list of available medically under-served areas.
Direct verification of applicant’s credentials is a requirement of many state medical boards. This takes a lot of time especially for international medical graduates, whose medical schools usually do not have a procedure to deal with these requests. To facilitate this, establish contact in advance with the academic offices of the high school, medical school and your country’s licensing board who will be contacted by the State Medical Boards for direct verification. Verifying agencies in the US charge a fee for the processing time and postal expenses. However the international verifying centers do not charge a fee and sometimes hold up the verification process due to lack of payment to cover postal expenses. It is a good idea to appoint a liaison to expedite this process.
Verifications of USMLE scores, ECFMG certification and residency training are also required. Eventhough the mechanism of verification of these credentials is simpler, do not assume they will be automatic. It is a good idea to check with these agencies if the verification has been done and the information forwarded to the State Medical Board.
Once the direct verifications are complete, the completed application package is then forwarded to the next board meeting when a decision is made on awarding or denying the license. On an average the entire processing time is about four months.
It is essential to keep the registration of the license current. This involves paying the requisite fee at the prescribed time, completing the required continuing medical education credit hours and complying with the rapidly changing health care management laws. Many state medical boards have web sites where you can check the validity of your license and registration.
Useful Links:
ECFMG: http://www.ecfmg.org/
FSMB: http://www.fsmb.org/
NY State Department of Health: http://www.health.state.ny.us/
US Federal Register: http://fr.cos.com/
Author Bio:
Mohammed K Rizvon is a graduate of the Madras Medical College, Madras, India. He completed his residency training in Nassau University Medical Center (NUMC), East Meadow, NY and joined the faculty after a year as Chief Resident. He serves as Director of Medical Consultation Service at NUMC and is a fellow of ACP.

Applying to The U.S. for Training

Ramon F. Soto, MDACP Governor, Venezuela

I’ll try to summarize what an ordinary young graduate from Venezuela, and possible from any other Latin American country, will have to endure if he (she) wishes to go to the U.S. for postgraduate training, fellowship, visitor observership, or to participate in refreshing courses in any medical branch.
The first thing to do is to obtain an American Visa, which will be different depending on the graduate’s purpose. A type J-1 visa will allow the candidate to work as resident earning a salary for up to 7 years, if all other requirements are met. A type F-1 visa will permit the candidate only to study or do a fellowship for a shorter lapse, without getting any payment, and as an observer without any intervention nor responsibility in the patient care. Finally, with a B-1/B-2 tourist visa the candidate could remain in US for up to six months to study or do a short fellowship, again without payment and patient responsibilities. The chances of getting any kind of visa will depend on the US immigration policies in force at the time the petition is formulated; and not infrequently it is rather tough to obtain one.
If the graduate plans to do a residency in any American hospital it is mandatory for him (her) to pass: 1) The TOEFL examination of English language proficiency with an score above 550. This examination usually is not a problem and most applicants find it rather easy to pass. 2) Step 1 and Step 2 medical knowledge tests. 3) The Clinical Skills Assessment. Once the candidate has approved these examinations he (she) can obtain the certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) Subsequently, he (she) can register on the Electronic Residency Application Service (ERAS), in order to be able to publicize his (her) credentials and aspirations, make them known to the employers (hospitals, universities, etc) and to respond to any call, like coming for an interview. Finally, through the computerized Residency Matching Program his (her) priorities are matched with those of the employers interested in his (her) services. The candidate’s eligibility for any given post will depend on the compatibility of both priorities.
Once all this complicated process is successfully completed and the candidate is accepted for a residency, he (she) is in a good position to apply for a visa. Usually the problems graduates come across after they start working are the same faced by their American peers, and have little to do with their condition of foreigners. An important regulation, which is frequently by-passed, is that the graduate must return to his country of origin at the end of his training in the US.
On returning home after his training the professional and academic future of graduates will depend in large measure on what condition he went to US. In Venezuela most graduates go on their own initiative and have no pre-established connection, like hospital, public health service, or university, to come back to after they finish training. So, as soon as they are back they have to start looking for a job or settle down as private physicians. This uncertainty of what to do after getting home has been a strong deterrent for our young physicians trained in the US to come back, and an incitement for them to remain there. Of course, the minority who were sent abroad by the medical or academic institutions where they worked rejoin their original positions as soon as they return. However, it does happen that some of these graduates desert their Venezuelan position and prefer to stay in the US. The number of IMGs from LA nations living and working in the US is very large and is on the rise. It is a professionally notorious and prosperous community and includes many distinguished professors, clinical investigators and practitioners. In Florida, for instance, there is an Association of Venezuelan Doctors of Florida.
For those foreign graduates coming to the US with other purposes than doing residency training the panorama is different in many ways. Visa and other requirements are less stringent, and as they cannot earn a salary to cover their living expenses the big problem is funding. Many support themselves, but the majority have to depend on a stipend or grant awarded by a variety of institutions and foundations from the US or other countries. The American College of Surgeons has a well structured program of short fellowships. In LA arrangements have been established between regional medical institutions and American universities, to enable young physicians to come to the US for intense activities in educational and refreshing courses. At the American College of Physicians efforts are being made to reinstall their former program of mini-fellowships for graduates from foreign countries.
Brief bio:
Ramon F. Soto was born in Venezuela. He graduated from the Complutense University, Madrid, Spain and his postgraduate training in internal medicine was in London, Great Britain. Back in Venezuela he joined the Faculty of Medicine at the Central University of Venezuela, in Caracas, where he served for 30 years until retirement in 1986. Since then he has been very active as a full time general internist in private practice in Caracas. Dr. Soto became a Fellow of the American College of Physicians in 1982, and has been serving as Governor for its Venezuela Region since 1997, and as a member of the International Subcommittee since 1999.”