LLU&MC Scope, Autumn 1997, high exam scores

INTERNAL MEDICINE RESIDENTS AND MEDICAL STUDENTS INCREASE THEIR TEST SCORES ON NATIONAL EXAMS

Larry Loo, MD, director of the internal medicine residency program (right), consults with one of his residents about a patient during an afternoon clinic at the Jerry L. Pettis Memorial Veterans Medical Center.

It's not the nature of department of internal medicine administrators and faculty to make a big deal out of what they're doing. As the backbone of medical education and one of a handful of specialties classified as "primary care," they are accustomed to providing medical students and residents with the fundamentals of medicine.

"This is significant," explains James Couperus, MD, chair of the Loma Linda University and Medical Center departments of internal medicine. "Over the past three years, we have seen a steady increase in national exam scores--both among the medical students and among our residents."

School of Medicine students have been scoring higher on their mock board exams in areas under the umbrella of internal medicine. The residency program has also seen a steady increase in the scores of its residents in comparison with the national average.

What are the mechanisms--the pathways--that have caused both students and residents to score higher?

Dr. Couperus points to two areas in particular where the department has made significant strides: the quality of educational leadership and the level of teaching.

"The general climate of student education in our department has improved," Dr. Couperus explains, "and guess what--student scores have improved as well."

"We have excellent leadership, both in our student education and in our residency program," Dr. Couperus continues, speaking of Raymond Wong, MD, who oversees the department's involvement with medical students in the School of Medicine, and Larry Loo, MD, who heads the residency program. "Both make it a point to stay in touch with what other programs are doing throughout the nation," Dr. Couperus aDDS, "attending a variety of professional conferences where they interface with directors of other student education and residency programs."

Drs. Wong and Loo are backed by more than 100 full-time faculty who represent the areas of general medicine, adolescent medicine, allergy, cardiology, clinical pharmacology, critical care medicine, endocrinology, gastroenterology, infectious diseases, nephrology, oncology, pulmonary medicine, and rheumatology.

Early on, the internal medicine department faculty play a pivotal role in the education of medical students at Loma Linda.

During the first two years of didactic training, internal medicine faculty cover the subspecialty areas of their field, as well as teach many of the basic skills of physical diagnosis and patient care.

"Right now we have six to eight faculty who are involved with freshman medical students," Dr. Couperus notes, "working with them in small groups for two hours at a time, helping them put the facts they are learning into a proper context."

At the end of the second year, the medical students sit for their first written board examination, which has become more case-oriented in recent years.

"Our students' scores in the national board exams have gone up, in part," says Dr. Wong, "because we have tended to teach the students from real-life cases rather than just filling them with facts." He continues, "In recent years, changes in the styles of questions asked have increasingly favored our style of preparing our medical students."

James Couperus, MD, chairs the LLU&MC departments of internal medicine.

During the third and fourth years of medical school, students are assigned to rotations in the various subspecialties of medicine. Because internal medicine encompasses so many subspecialties, the department again oversees a number of the student rotations.

During each of these rotations, the students begin working with real patients, either in an inpatient or outpatient clinic setting. They also continue to attend periodic lectures, and take quizzes and mock boards (national exams given to medical students across the nation) as part of each rotation. Mock board scores for students taking various internal medicine and subspecialty rotations have also shown improvement over the past three years. At the end of medical school, the students sit for their part two board examination; again, scores in the subject areas that are part of internal medicine have improved.

"Our faculty--particularly the younger members--provide enthusiastic role models for students," observes Dr. Couperus. "This enthusiasm is caught by students, helping them to learn more effectively."

The LLUMC internal medicine residency program accepts about 35 residents each year. While some are graduates of LLU's School of Medicine, many come from other schools around the country.

"Because of our affiliation with the Seventh-day Adventist Church, we seem to attract residents with certain qualities," says Larry Loo, MD, residency program director. "The residents who are interested in our program tend to see medicine more as a mission than simply as a career."

Dr. Loo continues, "Attending physicians and faculty approach medicine from a wholistic viewpoint, treating the patient as a whole person, rather than just a particular diagnosis." He adds, "We try to share that philosophy with our residents."

Of the 35 entering residents, an average of 12 are part of the preliminary program, taking a full year of internal medicine as part of the requirements for other specialties, including anesthesiology, dermatology, emergency medicine, neurology, ophthalmology, physical medicine and rehabilitation, and radiology.

For the remaining two years, each class has between 20 and 25 residents, with a total of approximately 94 residents in the program at any given time.

With all of the other residency programs at Loma Linda, however, well over 100 residents are being trained by internal medicine faculty.

Dr. Loo believes in keeping the lines of communication open. Four chief residents--one each at LLUMC and Jerry L. Pettis Memorial Veterans Medical Center, and two at Riverside General Hospital--provide an important link with the residents. A special forum convenes regularly where residents can ask the residency faculty and attending physicians candid questions about various aspects of the program.

"I have only one rule," laughs Dr. Loo. "If the residents are going to say something negative about the program, they must also find something positive to say."

"Our chief residents stay on an extra year at Loma Linda," points out Dr. Loo. "They fill the role of a junior faculty member, teaching and supervising other residents and fulfilling various administrative responsibilities."

Residents can choose to go a number of directions with their training experience. Some may follow the traditional internal medicine track. At the end of their residency experience, they may opt to enter directly into private practice or apply to a fellowship program in one of the subspecialties. Loma Linda's internal medicine residency program offers fellowships in cardiology, gastroenterology, pulmonary and critical care medicine, and rheumatology.

Others might choose the primary care track, which provides a comprehensive training program for those who plan to stay in primary care general internal medicine.

While maintaining the traditional core training in internal medicine, this track emphasizes the role of the internist as a member of the interdisciplinary health-care team, working not only with other physicians, but also with allied health professionals such as psychologists, nurses, social workers, dietitians, physical therapists, and occupational therapists.

Another track combines internal medicine and pediatrics, taking a fourth year to complete. At the end of this training, residents are eligible to sit for both the internal medicine and the pediatrics board examinations.

The purpose of the "med-peds" program, as it is called, is to provide broad, in-depth training for individuals interested in primary care of both children and adults.

The LLUMC internal medicine residency program works closely with all of its residents to ensure that they successfully complete their training.

"Each resident meets with me or one of the associate program directors twice a year to review strengths and weaknesses," explains Dr. Loo. "This one-on-one attention helps our residents identify areas they need to work harder in."

Residents are also required to complete some scholarly research while at Loma Linda. Some choose to work on a case study. Others choose to become involved with some of the department's research faculty on actual projects, co-authoring papers about their findings.

"I want our residents to understand how research is actually done," says Dr. Loo, "so they can keep up with their field once they get out and be able to recognize good research when they see it."

With the trend in medicine towards outpatient, ambulatory care, the LLUMC internal medicine department provides its residents with opportunities to experience both inpatient and outpatient care. During their intern year, residents rotate through various subspecialty clinics including adolescent medicine, allergy medicine, dermatology, diabetes, ear/nose/throat, endocrinology, geriatrics, podiatry, and preoperative clinic. Residents also experience continuing care through visits to outpatient nursing homes and actual house calls.

During their second year, residents continue to receive ambulatory care experiences, rotating through clinics such as ophthalmology, orthopaedics, dermatology, psychiatry, preventive medicine, women's clinic, adolescent medicine, and pediatrics.

Another important part of the resident experience includes attending the department's conference series. Didactic conferences are scheduled daily, conducted by members of the internal medicine subspecialty faculty.

"The conference series," Dr. Loo asserts, "is an important reason why our residents have been scoring higher on the national exams."

Topics are coordinated through his office; the major topics of internal medicine are presented in 12 one-month blocks, repeated each year and designed to help facilitate learning and guide residents in independent study.

All residents who are involved with inpatient care are required to attend resident report meetings. During these sessions, one or more cases from the inpatient wards are presented to the attending physicians, chief medical residents, and house officers.

A diagnosis is developed, emphasizing the pathophysiological mechanisms, and principles of medical decision making and evidence-based medicine.

Continuity care clinic conferences are held each week which compliment the core curriculum, and emphasize primary care and ambulatory care principles of the practice of medicine.

Weekly grand rounds, presented by School of Medicine faculty and invited speakers from across the country, feature topics dealing with leading developments in the basic sciences and clinical medicine, as well as the practice of medicine.

The Journal Club conference teaches residents to critically appraise the medi-
cal literature, a skill they will rely on throughout their professional careers. Residents learn about research methodology and design, clinical epidemiology, and how to screen journal articles, as well as studying the latest medical advances.

Residents are required to take national in-service exams each year prior to their final year. These exams are used internally to help rank them against their peers throughout the country and provide them with a tool for discovering strengths and weaknesses. The department of internal medicine provides residents with an intensive, didactic review which is designed to supplement a resident's personal review for the American Board of Internal Medicine certification examination. Review conferences are held weekly from October through May of each year.

William Wechter, PhD (right), research professor of medicine, and John McCracken, MD, assistant professor of medicine, made the news recently when they discovered that
R-flurbiprofen both reduced and prevented colon cancer in the laboratory setting.

Internal medicine faculty, like many of the other disciplines at Loma Linda, are involved in their share of research.

Two faculty, William Wechter, PhD, research professor of medicine and director of the laboratory of chemical endocrinology, School of Medicine; and John McCracken, MD, assistant professor of medicine in the gastroenterology section, School of Medicine, recently made the news with an important discovery. The story was covered by the Redlands Daily Facts; the San Bernardino Sun; and the Riverside Press-Enterprise, San Bernardino County Edition.

Drs. Wechter and McCracken had been conducting research on the effects of the drug, R-flurbiprofen (R-FB), on laboratory animals and found that the drug successfully treated and prevented the formation of colon polyps, a precursor to colon cancer. Their findings were reported in Cancer Research (volume 57, pages 4316-4324).

"I've been wanting to do research with this drug for many years," says Dr. Wechter. "However, I never had the opportunity until I came to Loma Linda."

R-FB is a pure, single-isomer form of the currently marketed non-steroidal anti-inflammatory drug, ANSAID^®, marketed as a 50/50 mixture of R- and S-flurbiprofen isomers.

Retrospective epidemiological studies have shown that long-term use of non-steroidal anti-inflammatory drugs such as Advil^®, Naprosyn^®, and ANSAID^®, as well as aspirin, reduce the incidence of cancer. However, long-term use of such drugs has also been found to have a tendency to cause stomach upset and possibly lead to bleeding stomach ulcers.

Research has linked the unwelcomed gastrointestinal side effects to the S-isomer form of the drug; however, none of the side effects are associated with the R-isomer, which still provides the benefits.

"We were pleasantly surprised," adds Dr. McCracken, "to find that R-FB not only prevents formation of polyps but, when administered to animals with preformed polyps, causes the polyps to disappear."

This suggests the R-FB might also prove useful in the acute treatment of human colon cancer, according to Dr. McCracken, either as an adjuvant to surgical intervention and/or as a postoperative therapy to prevent colon cancer from recurring.

"The fact that the drug has no known toxicity and more than 30 years of safe human use," enthuses Dr. McCracken, "bodes well for the drug's rapid clinical development."

An estimated 130,000 new cases of colorectal cancer were diagnosed in the United States in 1997, fourth highest in the number of cases after lung, breast, and prostate cancers. It is estimated that colorectal cancers will account for approximately 55,000 deaths in 1997, second only to lung cancer. There is no cure for colon cancer other than early detection and surgical resection of the cancerous tissues.

Clinical trials on humans are set to begin shortly. "We expect to begin human clinical trials in the first half of 1998," projects Dr. McCracken.

Grant money has already been secured by Dr. Wechter, and the process of looking for various sites for the clinical trials has begun. Because of the long track record of racemic-FB, Drs. Wechter and McCracken expect the process to be much quicker than most drug trials. And the prospects of having a safe, non-toxic alternative to chemotherapy for some individuals should further expedite the process.

Dr. Wechter is grateful to Loma Linda--and to one man in particular--for giving him the opportunity to become involved in research at the University.

"I want to personally thank Dr. Hinshaw for his insight and foresight," says Dr. Wechter. "He was able to see the potential of my research efforts."

David B. Hinshaw, Sr., MD, retired at the end of 1994 as president of Loma Linda University Medical Center.

Drs. Wechter and McCracken are part of a growing number of faculty at Loma Linda University who are becoming involved in some very exciting and promising research. In the department of internal medicine alone, numerous individuals are working on life-saving and life-improving research in an effort to help people everywhere to live happier and healthier lives.