Alejandro Moreno

Forensic investigations of torture and ill-treatment in Mexico. A follow-up study after the implementation of the Istanbul Protocol.

* Dr. Moreno is a member of Physicians for Human Rights (PHR), a non-governmental organization that uses medical and scientific knowledge to document violations of international human rights and humanitarian law. He is also an Assistant Professor of Internal Medicine and an Associate Director of the Internal Medicine Residency Program at the University of Texas Medical Branch Austin Program. Address correspondence to alemoren@vmth.edu. Dr. Moreno thanks Dean Jose Roberto Juarez, University of Denver Sturm College of Law, for his insightful comments on an earlier draft of this manuscript. ∗∗Dr. Iacopino is the Senior Medical Consultant of PHR and an Adjunct Professor of Internal Medicine at the University of Minnesota School of Medicine. Address correspondence to Physicians for Human Rights, 100 Boyleston Street, Suite 702, Boston, MA 02116 or via e-mail at viacopino@aol.com. 1 See LAWYERS COMM. FOR HUM. RIGHTS AND MIGUEL AGUSTı́N PRO HUM. RIGHTS CTR., LEGALIZED INJUSTICE: MEXICAN CRIMINAL PROCEDURE AND HUMAN RIGHTS (2001); Nigel S. Rodley, U.N. HIGH COMM’R FOR HUM. RIGHTS, On the Question of the Human Rights of All Persons Subjected to Any Form of Detention or Imprisonment, in Particular: Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, Visit to Mexico, U.N. Doc. E/CN.4/1998/38/Add.2 (1998); AMNESTY INT’L, MEXICO: JUSTICE BETRAYED—TORTURE IN THE JUDICIAL SYSTEM, AI Index AMR 41/021/2002, (July 10, 2001), available at http://www.amnesty.org/en/library/asset/AMR41/021/2001/en/dom-AMR410212001en.pdf (last visited July 28, 2008); HUM. RTS. WATCH, WORLD REPORT 2002: AMERICAS: MEXICO (2002), available at http://www.hrw.org/wr2k2/americas8.html (last visited July 28, 2008); BUREAU OF DEMOCRACY, HUM. RTS., AND LABOR, U.S. DEP’T OF STATE, 2001 COUNTRY REPORTS ON HUMAN RIGHTS PRACTICES (2002), available at www.state.gov/g/drl/rls/hrrpt/2001 (last visited July 28, 2008). 2 OFF. OF THE HIGH COMM’R FOR HUM. RTS., U.N. CONVENTION AGAINST TORTURE AND OTHER CRUEL, INHUMAN OR DEGRADING TREATMENT OR PUNISHMENT, 1465 U.N.T.S. 85 (1987), available at http://web.archive.org/web/20070826204607/www.unhchr.ch/html/menu3/b/h cat39.htm (last visited July 28, 2008); Organization of American States, American Convention on Human Rights “Pact of San José, Costa Rica,” Mar. 02, 1981, O.A.S.T.S. No. 36, available at http://web.archive.org/ web/20050129084609/http://www.oas.org/juridico/english/Treaties/b-32.htm (last visited July 28, 2008); Organization of American States, Inter-American Convention to Prevent and Punish Torture,

Group A streptococcal toxic shock syndrome secondary to necrotizing pelvic inflammatory disease in a postmenopausal woman

Group A β-hemolytic streptococcus (GAS) is well known to cause upper respiratory tract or cutaneous infections, but some more virulent species of GAS can lead to a rapidly progressive life threatening soft tissue necrotizing infection and streptococcal toxic shock syndrome (STSS). In the modern era, GAS infections within the female reproductive tract leading to STSS are unusual and are often the result of retained products of conception or intrauterine devices. This report describes a case of GAS necrotizing pelvic infection in a previously healthy menopausal woman with no obvious portal of entry. Her clinical course rapidly progressed to septic shock and multiorgan failure. She required multiple surgeries in addition to targeted antimicrobials and aggressive management of shock and organ failures. After a prolonged hospital stay, she had a full recovery.

Good-Bye and Good Luck: Teaching Residents the Business of Medicine After Residency

A physician’s first job after residency is the culmination of hard work, long hours of poring over books, and years of rigorous clinical training. Yet, few residents seem to receive training on what to expect after graduation, and how to negotiate the sometimes treacherous waters of postresidency employment. Few programs train their residents on risk management, job hunting, negotiation skills, employment contracts, and other key issues of the business practice of medicine after graduation. Of particular importance are ‘‘noncompetes’’ (or ‘‘restrictive covenants’’) and ‘‘tail’’ liability insurance, which can significantly hinder a physician’s career options and flexibility if not properly understood. As a matter of fact, the American College of Physicians Center for Practice Improvement and Innovation calls restrictive covenants ‘‘one of the most important yet least understood and potentially most contentious aspects of an employment agreement,’’ because ‘‘these clauses seek to prohibit the physician from practicing medicine for a specified period of time in a specific geographical area.’’ Similarly, tail liability insurance can discourage a physician from considering a new practice because of the cost associated with it. Even for physicians who hire attorneys, knowing what items in a contract are the most important to them personally can help them ‘‘pick their battles’’ and negotiate more effectively, or guide their attorney on what matters most to them. There is little published information about efforts to educate residents on these subjects; the few programs that have done this are in psychiatry, anesthesia, pediatrics, radiology, and surgery. One initiative offers psychiatry residents a hands-on experience at its ‘‘independent practice’’ clinic. Residents spend a halfday per week running the business aspects of the clinic concurrent with their clinical work. Another effort to teach residents these critical skills consists of an interactive curriculum, delivered during a weekend retreat, that educates anesthesia residents about how to find a job, including drafting a curriculum vitae, as well as coding and compliance, medical malpractice insurance, life and disability insurance, wealth management, and other topics. The program satisfies several Accreditation Council for Graduate Medical Education competencies. Other than this small number of focused interventions, very few programs specifically address employment contracts and negotiation tactics. As a result, the majority of newly graduated physicians are unlikely to have prior exposure to contract terms and negotiation. One of the barriers to educating residents about these matters is the time constraints in most residency programs, along with competing educational priorities. Over the last few years, we have conducted a ‘‘Life After Residency’’ session for the residents in our internal medicine program. During this conference, we introduce residents to the basic concepts of the business side of medicine after graduation. The curriculum covers physician employment agreements, restrictive (noncompete) covenants, and malpractice insurance. It also teaches the basics of job hunting, interview skills, important negotiation tips, and pearls of wisdom. The conference does not provide formal legal training, but instead offers practical points learned primarily from personal experience, focusing on issues that all residency graduates will encounter sooner or later. The conference starts with a traditional lecture format that covers key concepts (see the TABLE summarizing the topics covered). This is followed by several faculty members sharing their experiences, then facilitating subsequent small group discussions, with a question-and-answer session at the end. The Life After Residency session is conducted annually during 1 of our scheduled afternoon conferences, and all residents are expected to attend. A follow-up session that will address the peer-review process, hospital credentialing, and medical board investigations is being developed. There are also DOI: http://dx.doi.org/10.4300/JGME-D-14-00720.1

Chronic lymphocytic leukemia and apparent hyperkalemia.

The day after chemotherapy, the patient’s plasma potassium level was 7.7 mmol/L and the next day it rose to 10.9, but he had no signs or symptoms of hyperkalemia. What was the cause?

The clinical picture: Black esophagus

A 60-year-old man with gastrointestinal bleeding due to alcoholic cirrhosis has necrosis of the distal esophagus.

Call for the Turkish government to respect medical workers' duty to provide medical care to those in need.

The Turkish government has intensified its assault on medical neutrality.1 2 On 2 January 2014, a new health law was passed that criminalises the delivery of unauthorised emergency medical care and requires reporting of confidential patient information to state authorities for all clinical encounters. On 27 January 2014, the Ministry of Health brought a court suit against the governing and …