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Internal Medicine Residency News, December 15, 2014

Mon, 12/15/2014 - 10:48
From the Director

#Bestpartyever! Thank you to Dr. Klotman and the DOM for a fantastic holiday party.  Reported to have over 500 people in attendance, this year’s holiday party was outstanding.  It was great to see everyone all dressed up, and, of course, the highlight was the amazing chiefs video lip synch masterpiece…outstanding work Nilesh, Coral, Bonike and Aaron.  #setthebar.  If you haven’t seen the video and the bootleg videos of the lip synch, take a few minutes to be entertained.  Jenn, Armando, Chris and Lindsay … start planning.

Thanks to all who brought toys for our Toys for Tots collection.  If you forgot, details on how to donate follow.

It’s countdown to holiday schedule with just a couple more interview days until next year.  Thank you to Azalea Kim, Maggie Infeld, Rajiv Agarwal, John Yeatts as well as Juan Sanchez, Brittany Dixon, Joy Bhosai and Aparna Swaminathan for “resident share” with the applicants (or, perhaps, it’s new name of “My Take”?).  Also kudos to Jim Lefler for an amazing chair’s conference, complete with YouTube education. Amazing job.  Also kudos to Brian Sullivan from Jon Bae for outstanding night JAR work, and also to from Jon Bae to Pavle for an epic H&P and discharge summary, for Anubha Agarwal for being our constant cheerleader, and for Deng as our team leader powering us to a personal 2 week record of 51 discharges and 65 patients cared for.

 

Rumor has it that the 2nd annual latke cook off is to take place on Thursday.  Will Dr. Kussin beat Dr. Klotman? Will my sweet potato latkes stick together? Do you not know what a latke is?  Stop by the med res library Thursday afternoon to find out (details to follow).

We also celebrated a wonderful retirement party for Randy Heffelfinger on Tuesday.  Much thanks to Lauren Dincher for organizing!

We will have one more MED RES NEWS of 2014, so send in your kudos, and get ready for 2015!

Pubmed from the program goes to Carli Lehr for her article in Chest written with Ira Chiefetz, David Turner and David Zaas..””Ambulatory Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation: Walking While Waiting”

Have a great week

Aimee

Also congrats to the Atkins family on the birth of Abigail!

What Did I Read This Week?

Submitted by: Aimee Zaas, MD

Chronic Lymphocytic Leukemia: A Review” by Nabhan and Rosen in the Dec 3 issue of JAMA.

Why did I read this? We were talking about a patient with small B lymphocytic lymphoma in resident report and I wanted to review CLL and better understand the classification and therapies available. Fortunately, this article came out several days after report and fit what I was looking for.

What did the authors do? This is a structured review, looking at biology and therapy of CLL. They did a comprehensive search of appropriate databases (Pubmed, Google scholar, Cochrane and Scopus) and found 277 articles. Ultimately 24 articles met their preset criteria for inclusion.

What information did they learn from the literature?

Demographics: CLL is the most common blood malignancy in the Western World, with 15000 new cases a year and 5000 deaths. It is defined as a malignant proliferation of mature B cells. Molecular diagnostics is revolutionizing phenotyping and therapies.

Clinical presentation: Most diagnoses are made on routine CBC’s of asymptomatic adults. Lymphadenopathy is common but B symptoms are present in only 10%. Hepatosplenomegaly can be found 20-50% of time.

Lab findings include absolute lymphocyte count > 5000, with 10% of people having Autoimmune hemolytic anemia, ITP or hypogammaglobulinemia. On peripheral smear, you see lots of small cells with large dense nuclei. Smudge cells on a smear are characteristic.

Diagnosis is made by flow cytometry showing B cells with CD19, CD5 and CD23. CD 20 may weakly expressed and the cells should be kappa or lambda restricted (another sign of clonality). Imaging is not needed and BmBx or lymph node biopsy are sometimes done, but not a necessary part of the diagnostic algorithm.

What is small lymphocytic lymphoma: When CLL is restricted to nodes and marrow. A premalignant condition to CLL (kind of like MGUS is to MM) is monoclonal B lymphocytosis where there are monoclonal B cells but an ALC of < 5000. 1-2% of these patients progress to CLL per year.

How do we prognosticate for a patient with CLL? Historically, the Rai and Binet classifications are used.

To refresh, Rai prognosticates on the basis of lymphocytosis alone (survival > 10 years), LAD or HSM (7 years) or anemia/thrombocytopenia (< 4 years) and Binet prognosticates on how much LAD is present and if cytopenias are present.

More sophisticated prognostic indicators are shown here: Adverse Clinical/Laboratory Prognostic Factors

  1. Advanced agea
  2. Advanced stage (Rai III/IV or Binet C)
  3. Poor performance status
  4. Short lymphocyte doubling time (<12 mo)
  5. Diffuse bone marrow infiltration pattern
  6. Increased percentage of prolymphocytes
  7. Male sex
  8. High lactate dehydrogenase levelb
  9. High β2-microglobulin levelc
  10. Increased levels of soluble CD23
  11. Advanced stage (Rai III/IV or Binet C)

Novel/Molecular Adverse Prognostic Factors

  1. 17p and 11q deletions by fluorescence in situ hybridization
  2. CD38 overexpression (>30%)
  3. Zap-70 greater than 20%
  4. Unmutated IgVH
  5. NOTCH-1 mutations
  6. High lipoprotein lipase expression
  7. Variance expressions of specific micro-RNAs (ie, down-regulation of miR-15a and miR-16-1 is associated with good prognosis, whereas down-regulation of miR-29 family is associated with poor prognosis)

What about therapy?

First principle is not to treat until the patient is symptomatic, including anemia/thrombocytopenia, massive splenomegaly or adenopathy, rapid doubling time of lymphocyte count, debilitating constitutional symptoms.

The major agents classically are either alkylating agents (chlorambucil, bendamustine or cyclophosphamide) or purine analogs (fludarabine). Fludarabine is less toxic and has better response and is first line over chlorambucil.   Additional trials showed the combination of fludarabine and cyclophosphamide provide the best response rates and progression free survival so this is considered the gold standard for new therapies to compare to. Alkylating agents damage DNA and purine analogs interfere with DNA repair, so one can see why they might be synergistic.

Currently, chemoimmunotherapy is the new gold standard. Why is that the case?

Chemoimmunotherapy involves using ‘traditional’ chemotherapy agents plus a biologic agent (e.g. monoclonal antibody).

A landmark study compared rituximab (anti CD 20) plus cyclo plus fludarabine to the gold standard cyclo + fludarabine and showed significantly better overall and progression free survival at 86 months for the 3 drug arm (70% vs 62%). This study brought biologics to the forefront of CLL treatment.

Ongoing studies have shown that perhaps bendamustine + rituximab is better than the 3 drug combination but have not been fully published.

Overall, a retrospective surveillance study showed that survival in CLL is improved in the cohort of patients treated from 2001-09 than 1992-2000 (66% vs 60%).

Emerging possible therapies are the TKI ibrutinib and the PI3K inhibitor idelalisib.

Guidelines now recommend chemoimmunotherapy with stratification of choices based on performance status and renal function, as the 3 drug regimen listed above is not advised in individuals with GFR less than 70.

What is on the horizon? What remains controversial or needs further study?

Physicians and investigators are still debating the optimal treatment for Richter’s transformation (CLL progressing to an aggressive B cell lymphoma). It also remains unclear the best way to treat CLL associated AIHA or ITP.

Finally, in older patients or those with poor renal function or comorbidities may do best with chlorambucil plus  obinutuzumab.

 

Clinic Corner

Hello from Pickett! We had a great November and Thanksgiving gathering. Allan, Pascale and Jason were lucky to be in clinic during our Thanksgiving Feast. We will be having a clinic Christmas party as well on this week Thursday at the clinic at lunch and all Pickett Road Residents are welcome to come. Enjoy good food and a celebration for the holidays.

Welcome to Kelly Sullivan our new Nurse Manager! Her office is closest to the residency work room, across from the water fountain. Any nursing concerns or SRS can be now directed to Kelly.

Congratulations to our SARS who matched for fellowship! We are very proud of you!

Dr. Wolf is leaving at the end of the month. Make sure to say good bye and thank him for all his teaching. He will be starting at Signature Care in January and then precepting at the DOC. We will miss Dr. Wolf!

Lunch time topics start 12:45-12:50 pm if you are there all day. Please come back so we can go over the topics. We can try to go over the material if there is a break during the session but we are always so busy.

Remember mini cex’s: the new schedule is in the work room. Sharee sends out the email, I send Maestro Epic message. Remind your attending to perform one that day. Interns you need 3 mini cex’s to start seeing patients on your own in January. JAR and SAR you need 3 to sign out 2 patients (if one of them is a simple Aunt Minie).  Make sure you mark down when you had done a cex and remind your attending to put this into med hub (get credit!).

Make sure if you are on call, you are reviewing Sharee’s email, and that your pager is correct.

We take care of a lot of Duke Employees. There is not much of preferred medications for Express Scripts but I will be posting the lists in all the patients rooms and the resident areas. We are enrolling the whole clinic to help with prior authorization for Express Scripts. if you get an email asking if Sharee Southern can be proxy to the account, log in and allow her to help expedite the Prior authorization process for Express Scripts.

Let me know ASAP if there are PECOS issues: prescribing for medications, test strips, durable medical equiptment.

Have a safe and happy holiday and new year!

Sincerely,

Sharon Rubin, MD, FACP

 

 

What? The Ambulatory Care Leadership Track:

An elective clinical track for people interested in ambulatory medicine – either general medicine OR subspecialties with an outpatient focus.

  • Eligible to start as a JAR, for a two year track
  • 8 total residents, generally 4 JARs and 4 SARs
  • 3 blocks of ambulatory together, each year
  • Expanded offerings in clinics outside of medicine, per your preference: sports medicine, gynecology, dermatology, ENT, ophthalmology, and more
  • Focused curriculum in teaching skills, advanced evidence synthesisand presenting scholarship, and leadership/health policy.
  • Advocacy trips to Washington, DC and Raleigh, NC – alternating every other year

Interns are encouraged to apply now! Deadline for applications extended to January 15

ACLT application form – 2014-15

 

QI Corner

 

Hey everyone! This week I have an update on the GME incentive program (that’s where you guys can earn extra $$$ in your paycheck for meeting certain quality measures at the end of the year), and I have news that is even more epic than Nilesh lip-synching to Iggy Azalea. Ok, not quite. But pretty close. For the first time ever, medicine has passed pediatrics to become the fastest-responding program in the hospital to ED consults. Way to go guys! All of you on the 1010 pager are totally killing our target time, and are putting everyone well on their way to getting an extra $200 in June.

 

 

In terms of SRS reporting – November was the highest month yet, with 92 reports filed by trainees, but we will still need to pick up the pace quite a bit in order to get 1698 more by the end of the year.

 

 

From the Chief Residents Grand Rounds

Fri., Dec. 19: Rheumatology, Dr. Irene Whitt

Noon Conference Date Topic Lecturer Time Vendor 12/15/14 Interview Day  Lunch with applicants 12:00/MedRes  Nosh 12/16/14  MED PEDS INTERVIEW/ G Briefing Session  Lunch w/applicants 12:00/MedRes  Saladelia 12/17/14 Resident Jeopardy QI Team 12:00/Room 2002  China King 12/18/14 QI Patient Safety Noon Conference 12:15/2001  Chick Fil A  12/19/14  Interview Day  Lunch w/ applicants  12:00/MedRes  Pipers in the Park                     From the Residency Office

2014 Internal Medicine Residency Council Holiday Toy Drive

All toys will be donated to the 2014 Marine Corps Reserve Toys for Tots  Campaign! A donation to Toys for Tots would give toys to needy families in the local area just in time for Christmas!   If you were unable to attend the holiday party, we will also be collecting toys in the Medical Resident’s office through the end of the day on Wednesday, December 17th.

Details:

– Unwrapped

– New/Unused

– No guns

– Accepting toys for all ages including stuffed animals (really need toys for ages 0-2 and 11-13)

ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!     Stead Research Grant RFA

On behalf of the Stead Scholarship Committee, we would like to announce a Request for Applications for a clinical or translational research project involving a team of Internal Medicine, Med-Peds, and/or Med-Psych residents under the leadership of a faculty mentor in the Department of Medicine. The RFA is attached.

We are grateful to the leadership of the Stead Scholarship Committee (Chris Woods, Karen Alexander and Ravi Karra) for this generous initiative to promote and support team-research by our residents.

Best regards to all,

Murat and Aimee

 

Annual GME Holiday Celebration

Please join the Office of Graduate Medical Education and the Medical Alumni Office for the Annual GME Holiday Celebration.

Wednesday, December 17
7:30-9:30 am
T-401 Duke North (Bunker)

Thursday, December 18
4:30-6:30 pm
DMP 2W91 (conference room over the DMP gift shop)

Please make plans to join us for good food and giveaways!

 

Uniforms Ordering Closes December 31

All continuing trainees will be able to order uniforms one time,online through the Medical Center Bookstore. Orders must be placed by December 31, 2013.

Each individual department and/or program selects the style and quantities available to you and is provided to you at no cost by the GME Office.

Go to https://shopgmeuniforms.dukestores.duke.edu to place your order.

You will need to use the email address that is in MedHub to be able to log into the dukestores web site.

Do No Harm Project

The Lown Institute, in collaboration with the Do No Harm Project, is calling for applications to the first Do No Harm Project Vignette Competition.

The top two vignettes will be eligible for up to two scholarships ($1200/person in reimbursements in accordance with the Scholarship Policy). They will participate in the third annual Lown Institute Conference, March 8-11, 2015 in San Diego, CA AND will give an oral presentation during the Do No Harm Project workshop session on March 10, 2015 at the conference. To learn more about the eligibility and selection criteria, click here.

We are seeking clinical vignettes written by trainees describing harm or near harm caused by medical overuse. We want to hear about tests and treatments that are commonly performed and seen acceptable rather than errors or obvious malpractice.

We hope you will apply, or encourage your colleagues to apply, for this award to help improve clinicians’ awareness of the harms patients may experience because of overuse and to share ideas about how the delivery of care may be improved in the future.

Applications are due by January 7, 2015, and grant recipients will be announced in late January. Apply here today. This program is made possible through the generous support of the Robert Wood Johnson Foundation.

We look forward to receiving the many applications and we expect launching the creative projects will take us a step closer to restoring effective, compassionate and thoughtful medical care. Should you have questions, please do not hesitate to let us know at DoNoHarm@lowninstitute.org.

Thank you,

Vikas Saini, MD                        Shannon Brownlee, MSc
President                                  Senior Vice President
Lown Institute                            Lown Institute

 

Evidence-Based Medicine: A Cross-GME Course

Open to all Duke residents and fellows

January 7 – February 11

Wednesdays 5:30 – 7:00 PM

(Duke Medicine Pavilion Conference Rooms)

Dinner Served

Evidence-based medicine provides the necessary foundation for clinical practice in this new era of accountable care and is recognized by the ACGME as an important educational outcome. However, many programs lack the time and resources to provide a solid EBM curriculum to their trainees. EBM training remains an unmet need at this institution: in a 2012 survey of trainees, we found that 78% highly value EBM, but only 28% are extremely confident in the ability to find the evidence and only 16% are extremely confident in appraising the evidence they find.  We have a way for you to fill this gap!

This interactive six session course will be presented by expert EBM faculty from across Duke Medicine and will provide the opportunity for residents to interact with others outside their programs.

We invite you to identify and send residents from your program or forward this notice to individual residents who may wish to participate.

Registration available at the following link: http://tinyurl.com/ebmgme

For questions, please contact Megan von Isenburg (megan.vonisenburg@duke.edu

 

Information/Opportunities

Sign up to receive a complimentary e-subscription to The American Journal of Medicine in 2015! All you have to do is to complete the online form by December 8, 2014.  The subscription starts in January.

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

February 18, 2015 – Duke vs UNC @ Tyler’s Tap Room

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, December 8, 2014

Mon, 12/08/2014 - 10:49
From the Director

Hi Everyone!

What a fantastic week we had. We are so proud of our SARs for their fellowship match and job opportunities. Great party on Wednesday to celebrate, starting with the sparkling apple cider in the Med Res library and continuing on! See the amazing list here.

Other kudos this week to Ashley Bock and Ryan Jessee for covering so our SARs could celebrate. Also kudos to Kahli Zeitlow and Brian Wasserman from Adrienne Belasco for great teamwork on gen med and to Dinushika Mohottige and Gena Foster from Tim Collins for great work helping out in headache clinic. Also compliments to Sneha Vakamudi from a patient for great work and to Jon Hansen from the DOC team for humanistic care.  Thanks much to Ben Lloyd for a fantastic chairs conference and to Venu Reddy for a spectacular SAR talk. Thanks also to Lauren Collins, Titus N’geno and Chris Merrick for resident share on Friday as well – great job.

SARs – sign up for you boards before the price goes up!

Schedule requests will be sent out before the holiday break. So, find out when all those family and friend weddings are while you are on break – requests due right after we return.

This week’s pubmed from the program goes to Carli Lehr for her article published in Thoracic Surgery Clinics…

Lehr C and Zaas  DW.  Candidacy for Lung Transplant and Lung Allocation.  Thoracic Surgery Clinics; February 2015, Vol 25, Issue 1;p1-15 (epub ahead of print)

Have a great week

Aimee

MATCH DAY!

Congrats to our current and former residents who were presenting at ASH in San Francisco – Allyson Pishko, Mallika Dhawan and Callie Coombs.

 

What Did I Read This Week?

Submitted by: Sue Woods, MD

Clinic-Community Linkages for High-Value Care

New England Journal of Medicine 2014; 371: 2148-2150

Authors:  Thomas D. Sequist, MD, MPH and Elise M. Taversas MD, MPH

Why did I read this article: I am interested in the study and delivery of high value care. Carolyn Avery and I have a three year Duke GME Innovations grant to educate house staff on this topic. We have been working for the past one and a half years with Medicine, Pediatrics, Radiology and Emergency Medicine to create curricula. This perspective piece caught my attention as it addresses the need to link the delivery of health care with the community and patient in an integrated manner.

Summary: As healthcare waste is making more headlines and improving health outcomes are being talked about more each day, there is a growing pressure to pair the delivery of quality health care with controlling the costs of that care. The authors note that “one essential strategy for improving population health is linking the delivery system, the community and the patient in an integrated effort.”   One needs to investigate and understand the characteristics of individual patients and the community in which they reside as this impacts the quality of the health care each receives as well as their health outcomes. The authors describe an approach which looks at reporting and acting on clinical performance measures at the community level instead of at the health system (hospital, physician) level as is commonly the case. Such an approach will give a more accurate picture of how one’s environment affects an individual’s health outcomes.

The strategy that the authors outline has the following components:

  1. Define community and establish a sound infrastructure for data analysis.
    1. They look at outcomes in a community instead of by a specific provider or clinic. This helps to identify “hot spots” communities where the clinical performance is low or disease burden is significantly high.
  2. “Target positive outliers” in these specific communities.
    1. They look for patients who have attained favorable outcomes, especially those with historically poor outcomes who have had recent improvements in health care issues.
    2. Obesity, hypertension, diabetes, readmission to hospital are examples
    3. Once the outliers are identified, the goal is to identify strategies for achieving success
    4. The goal is to “create an operational toolkit specific to a given community.”
  3. Integrate the approaches and strategies for success into patients’ care plans.

A potential uses for this strategy that was described is to create community group visits for successful patients to share with those who are struggling with a disease or condition.

For success with this strategy, here are some recommended components:

  • Large integrated system with large enough patient populations to study
  • Careful consideration of how to define community
  • Well-defined operational infrastructure – align financing with this strategy
  • Patient-centered medical home
  • Payment structures to reward value-driven care models) look at value, outcomes and limitation of waste vs office visit volume

Challenges identified by the authors include:

  • Sustainability
  • Short and long-term buy in by health system
  • Gaining support of the clinicians
  • Constant monitoring of community resources, assessment of the positive outliers and maintaining focus groups

I agree with the authors that if we do not recognize and appreciate the challenges many of our patients face with respect to achieving favorable health outcomes and target our interventions appropriately we will not be successful in obtaining and maintaining desired health outcomes. Value must be considered as well as a cost conscious approach to health care.

Clinic Corner

DOC Clinic Corner 12/8/14

  1. Check out this month’s DOC Newsletter for new info!
  1. Another quick plug for the ACLT – Ambulatory Care Leadership Track. Rising JARs with an interest in ambulatory medicine (general medicine and subspecialties) as well as teaching, scholarship, and advocacy/health policy, should please contact Dani Zipkin, Alex Cho, or Bonike Oloruntoba.
  1. Maestro Survival Tips:

We are doing lunch time Maestro teaching sessions twice per month at the DOC, and we’ve had two so far. We know it’s a lot to absorb and repetition is key. Here are some pearls from those sessions (as well as other stuff):

  • Sending LETTERS to patients or third parties has changed.
    • FIRST SELECT THE RECIPIENT ABOVE THE TOP EDGE. This is necessary for the letter to be “closed out” later. Usually, you can select “patient”.
    • SECOND, RIGHT CLICK OVER THE BLUE PORTION OF THE LETTER AND CLICK “MAKE SELECTED TEXT EDITABLE”. Then, edit as you see fit, delete rows of confusing or unnecessary text.
    • FINALLY, DO NOT JUST “PREVIEW” THE LETTER AND PRINT!! This results in your attendings not being able to close the encounter later. PLEASE EITHER “SEND”, WHICH PRINTS IT OUT AND COMPLETES IT, OR “ROUTE” TO CAROLYN LAWRENCE IN MEDICAL RECORDS, AND THE MEDICAL RECORDS POOL (TYPE IN “P DUKE OUT… TO SEE THE POOLS, AND SELECT MEDICAL RECORDS. OTHER POOLS MAY NOT BE ACTIVE).
  • Frequently used Smartphrases to use for social services (thanks Adam Banks for the idea to consolidate this!):
    • Mental Health for Medicaid and uninsured: .SWALLIANCEREFERRAL (Synonyms: .DOCALLIANCEREFERRAL, .ALLIANCEREFERRAL, .DOCSWALLIANCEREFERRAL). A description and instructions are included in the smartphrase. The patient must make a phone call to get started. Remember that if patients have insurance, they should start with the mental health number on their insurance card.
    • For Home Health services – skilled need for RN nursing (wounds or catheters, etc.), or PT, OT, Speech. For Medicare and most private insurance, patient must require CONSIDERABLE AND TAXING EFFORT TO LEAVE THEIR HOME. For Medicaid, YOU must determine that the home is the optimal location for care.
      • Here’s the deal: (1) Talk to the patient about what provider they want. If they know, indicate that on the form. (2) DROP IN .HOMEHEALTHFACETOFACE – Create the form in the patient instructions field or a letter field. (3) Print the form, HAVE ATTENDING SIGN. (4) Give form to Carolyn in Medical Records or place in med records bin.
    • Personal Care Services for patients with Medicaid: While we’re at it, might as well throw this in too. This is a home attendant for help with ADLs. Patient must NOT BE ABLE TO ACCOMPLISH AT LEAST 3 OF 5 ADLs ON THEIR OWN. If you are not sure about their function at home, you can order a pre-assessment by the Medicaid OT, Carol Siebert (email her). To order Personal Care Services, download the form at http://info.dhhs.state.nc.us/olm/forms/dma/dma-3051-ia.pdf.

 

What? The Ambulatory Care Leadership Track:

An elective clinical track for people interested in ambulatory medicine – either general medicine OR subspecialties with an outpatient focus.

  • Eligible to start as a JAR, for a two year track
  • 8 total residents, generally 4 JARs and 4 SARs
  • 3 blocks of ambulatory together, each year
  • Expanded offerings in clinics outside of medicine, per your preference: sports medicine, gynecology, dermatology, ENT, ophthalmology, and more
  • Focused curriculum in teaching skills, advanced evidence synthesisand presenting scholarship, and leadership/health policy.
  • Advocacy trips to Washington, DC and Raleigh, NC – alternating every other year

Interns are encouraged to apply now! Deadline for applications extended to January 15

ACLT application form – 2014-15

 

Last week’s Clinic Corner started to explain the requirements for coding a Level 4 E/M visit, but was inadvertently cut off.  Here it is – enjoy!

*In case you were curious, billing a Level 4 Return Visit (99214) requires documentation reflecting 2 of 3 of following:

-detailed history (HPI-4+ elements for acute/3+ for chronic diseases, plus 2-9 point ROS, AND review of either PMH, SH, or FH);

-detailed physical exam (5-7 systems, or 12 elements from any single organ system); and/or

-a medical decision making level of at least moderate complexity (itself requiring 2 of 3 of: multiple management options for diagnosis/treatment, a moderate amount of data to be reviewed, moderate risk of complications and/or morbidity or mortality (which can be satisfied by the act of prescribing a new medication)).

And if that wasn’t enough, see http://www.cgsmedicare.com/partb/mr/pdf/99214.pdf for even more detail.

 

QI Corner

 

I wanted to let you know about the abstract submission deadline for the Duke Patient Safety Conference, which will be happening in March. For whatever reason, they have not been advertising the abstract submission process this year (there is not much about it on the website: http://dukepatientsafetycenter.com/index.asp ), so I asked Cynthia Gordon ,who is one of the coordinators. Turns out the deadline is coming up on December 12 to submit an abstract.

That is not a ton of time, but it is certainly enough. This is just the abstract – only about 300 words, and you would have months to put together the poster if accepted. So, if you have been working on a relevant project (patient safety, quality improvement) and would like to present, let me know ASAP and I will get you the submission form.

 

From the Chief Residents Grand Rounds

Fri., Dec. 12: Pulmonary, Dr. Claude Piantadosi

Noon Conference Date Topic Lecturer Time Vendor 12/1/14 Interview Day  Lunch with applicants 12:00/MedRes  Panera 12/2/14  MED PEDS INTERVIEW/ G Briefing Session  Lunch w/applicants 12:00/MedRes  Saladelia 12/3/14 Antibiotic Stewardship Deverick Anderson 12:00/Room 2002  Cosmic Cantina 12/4/14 Infection Control Luke Chen 12:15/2001  Domino’s  12/5/14  Interview Day  Lunch w/ applicants  12:00/MedRes  TBD                   From the Residency Office Many Thanks!

Below is a note we received from the VA in appreciation of the donation of gift cards we made as part of our Thanksgiving Food Drive.

“We have a veteran employee who is very sick with cancer, Vietnam Veteran with a young son.  (the mother is a drug addict and nowhere to be found) he is awaiting his medical disability although not sure how long this poor man will be able to even have the time to rest.  He received a gift card “”Yesterday I had a 79 year old veteran and his wife who lost their home to a fire that burned it to the grounds. No insurance.  We provided that couple with a card to purchase food etc. and we supplemented with items from the Food Pantry I maintain.”  ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!     Stead Research Grant RFA

On behalf of the Stead Scholarship Committee, we would like to announce a Request for Applications for a clinical or translational research project involving a team of Internal Medicine, Med-Peds, and/or Med-Psych residents under the leadership of a faculty mentor in the Department of Medicine. The RFA is attached.

We are grateful to the leadership of the Stead Scholarship Committee (Chris Woods, Karen Alexander and Ravi Karra) for this generous initiative to promote and support team-research by our residents.

Best regards to all,

Murat and Aimee

ACP Abstracts Due!

Please find attached the information to submit abstracts by December 12, 2014 of your scholarly activities (case reports, research, QI projects)

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

http://www.acponline.org/about_acp/chapters/nc/abstract_comp.htm
Wishing you all success with your projects !

Murat and Aimee

 

Annual GME Holiday Celebration

Please join the Office of Graduate Medical Education and the Medical Alumni Office for the Annual GME Holiday Celebration.

Wednesday, December 17
7:30-9:30 am
T-401 Duke North (Bunker)

Thursday, December 18
4:30-6:30 pm
DMP 2W91 (conference room over the DMP gift shop)

Please make plans to join us for good food and giveaways!

 

Uniforms Ordering Closes December 31

All continuing trainees will be able to order uniforms one time,online through the Medical Center Bookstore. Orders must be placed by December 31, 2013.

Each individual department and/or program selects the style and quantities available to you and is provided to you at no cost by the GME Office.

Go to https://shopgmeuniforms.dukestores.duke.edu to place your order.

You will need to use the email address that is in MedHub to be able to log into the dukestores web site.

Do No Harm Project

The Lown Institute, in collaboration with the Do No Harm Project, is calling for applications to the first Do No Harm Project Vignette Competition.

The top two vignettes will be eligible for up to two scholarships ($1200/person in reimbursements in accordance with the Scholarship Policy). They will participate in the third annual Lown Institute Conference, March 8-11, 2015 in San Diego, CA AND will give an oral presentation during the Do No Harm Project workshop session on March 10, 2015 at the conference. To learn more about the eligibility and selection criteria, click here.

We are seeking clinical vignettes written by trainees describing harm or near harm caused by medical overuse. We want to hear about tests and treatments that are commonly performed and seen acceptable rather than errors or obvious malpractice.

We hope you will apply, or encourage your colleagues to apply, for this award to help improve clinicians’ awareness of the harms patients may experience because of overuse and to share ideas about how the delivery of care may be improved in the future.

Applications are due by January 7, 2015, and grant recipients will be announced in late January. Apply here today. This program is made possible through the generous support of the Robert Wood Johnson Foundation.

We look forward to receiving the many applications and we expect launching the creative projects will take us a step closer to restoring effective, compassionate and thoughtful medical care. Should you have questions, please do not hesitate to let us know at DoNoHarm@lowninstitute.org.

Thank you,

Vikas Saini, MD                        Shannon Brownlee, MSc
President                                  Senior Vice President
Lown Institute                            Lown Institute

 

AAMC-CDC Public Health Policy Fellowship

Public health policy experiential learning opportunities for early-career physicians

 

Information/Opportunities

Sign up to receive a complimentary e-subscription to The American Journal of Medicine in 2015! All you have to do is to complete the online form by December 8, 2014.  The subscription starts in January.

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

December 13, 2014 – DoM Holiday Party

February 18, 2015 – Duke vs UNC @ Tyler’s Tap Room

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Duke Heart Center launches new mobile app for cardiovascular education

Fri, 12/05/2014 - 11:19

The fellows and faculty of the Duke Heart Center have developed a free iOS mobile application, Duke Cardiology Fellows Cardiovascular Education App, that serves as a cardiovascular educational reference.

The app is meant for medical students, residents, fellows, practicing cardiologists, internists or anyone else interested in heart disease.

The project was orchestrated by Sudarshan Rajagopal, MD, PhD, assistant professor of medicine (Cardiology), and Sreekanth Vemulapalli, MD, medical instructor (Cardiology).

 

Results posted for 2014-2015 fellowship match

Wed, 12/03/2014 - 16:15

The 2014-15 national fellowship match was announced today.

“We are incredibly proud of our senior residents who have matched at phenomenal programs around the country,” saidAimee Zaas, MD, MHS, associate professor of medicine (Infectious Diseases) and director of the Internal Medicine Residency Program.

See list below for where Duke Internal Medicine Residents have matched for their fellowship training.

Residents who are not matching in fellowships are also taking faculty positions at outstanding medical centers, both in hospital medicine and outpatient general medicine, said Dr. Zaas.

“We greatly appreciate the mentorship provided by the faculty in the Department of Medicine to all of our residents,” said Mary Klotman, MD, professor of medicine and chair of the Department of Medicine.

Name Specialty Location Adefolakemi Babatunde Cardiology Washington University St. Louis Adam Banks Cardiology Duke Adrienne Belasco Palliative Care Duke Nina Beri Hematology Oncology University of Pennsylvania Christine Bestvina Hematology Oncology University of Chicago Amit Bhaskar Gastroenterology University of North Carolina Erin Boehm Cardiology Oregon Health Sciences University Lindsay Boole Chief Resident Quality/Safety DVAMC Harold Boutte Gastroenterology Washington University St. Louis Kathleen Broderick-Forsgren Hospital Medicine University of Cincinnati Joseph Brogan Hospital Medicine - Amanda Elliott Endocrinology Joslin Diabetes Center Boston Hany Elmariah Hematology Oncology Johns Hopkins Ben Heyman Hematology Oncology Duke Matthew Hitchcock Infectious Diseases Stanford University Ryan Huey Hospital Medicine - Veronica Jarido Hospital Medicine - Claire Kappa Primary Care Duke Pickett Road Kedar Kirtane Hematology Oncology University of Washington in Seattle Brice Lefler General Medicine - Carli Lehr Pulmonary Critical Care Cleveland Clinic Benjamin Lloyd Gastroenterology Duke Angela Lowenstern Cardiology Duke Tony Lozano Hospital Medicine - Deng Madut Infectious Diseases Duke Jay Mast Hospital Medicine - Alyson McGhan Gastroenterology Duke Christopher Merrick Pulmonary Critical Care Vanderbilt University Aaron Mitchell Hematology Oncology University of North Carolina Ragnar Palsson Nephrology Harvard Allyson Pishko Hematology Oncology University of Pennsylvania Amera Rahmatullah Pulmonary Critical Care Duke Sathavaram Reddy Hospital Medicine - Nicholas Rohrhoff Lieutenant US Navy Kevin Shah Primary Care Duke Sutton Station Aparna Swaminathan Pulmonary Critical Care Duke Sajal Tanna Infectious Diseases University of Pennsylvania Rachel Titerence Hospital Medicine - Kevin Trulock Cardiology Cleveland Clinic Sneha Vakamudi Cardiology Cleveland Clinic Iris Vance Gastroenterology Duke John Wagener Cardiology Cleveland Clinic Michael Woodworth Infectious Diseases University of California San Francisco

Internal Medicine Residency News, December 1, 2014

Mon, 12/01/2014 - 12:44
From the Director

Happy December everyone! It was a cold and rainy Thanksgiving, but an amazing showing at Turkey Bowl (and no one got hurt!).  This will go down in Duke IM Residency history as a 14-7 victory for the Marines (with an extra touchdown by Jake and two sacks of intern sensation QB Peter Hu by Jonah – thanks for letting them play!).  Special thanks to Coaches Krish Patel, Tony Galanos and Ryan Schulties, as well as referees Harvey Cohen, Don Heglund and David Butterly.  We loved seeing the faculty support from Lynn Bowlby, Jeremy Halbe, Matt Crowley, and Rob Harrison, as well as appearances by former chiefs (hi Vaishali!).  More special thanks to those who covered in the hospital so that the residents could come out and play football — Joel Boggan, David Karol, Lalit Verma, Adam Wachter and many others who I don’t know about!  The trophy will reside in Nilesh’s office for another year….

This should be a very busy month – we are starting up with recruits again for categorical medicine on Friday, and are very much looking forward to our fellowship match celebration on Wednesday.  Kudos to Iris Vance and Joseph Brogan for fantastic SAR talks last week and to Adam Banks for a great resident report on Monday for the applicants.

This is the week to get your NC ACP posters submitted – the meeting is local this year (no traveling to Greensboro!) so please go ahead and submit your interesting cases for the case report session and your resident research for the research poster session.  Details at the bottom of the Med Res News.

Jen and I will be meeting with the residency council in two weeks to talk about the upcoming ACGME survey and the results of the Duke GME survey from June 2014.  We will post the results of the survey in Medhub and also talk about them before noon conferences this week.  Please make sure to talk to your residency council reps if you have any questions or comments so that they can relay these to Jen and I.  Also, if you haven’t met with your advisor this year (i.e since July 1), please make an appointment with them before the holiday break.  I am also happy to meet with anyone to discuss careers, mentors, ITE results, milestones, etc.

Schedule request forms for 2015-16 will be coming out right before the holiday break and will be due on January 5th.  We hope to simplify the process this year so be on the lookout for the link to the schedule request form as the holiday break approaches.

This week’s pubmed from the program goes to our former chief Juliessa Pavon…. (and note our Clin Epi Director Nikki Hastings as first author!)

Assisted Early Mobility for Hospitalized Older Veterans: Preliminary Data from the STRIDE Program.

Hastings SN, Sloane R, Morey MC, Pavon JM, Hoenig H. J Am Geriatr Soc. 2014 Nov;62(11):2180-4. doi: 10.1111/jgs.13095. Epub 2014 Oct 30.

Have a great week

Aimee

What Did I Read This Week?

Submitted by: David Butterly, MD

ANCA-RituxNEJMNov2014

Rituximab versus Azathioprine for Maintenance in ANCA-Associated Vasculitis

L Guillevin et al New England Journal of Medicine 2014; 371: 1771-1780

This article appeared in the NEJM 3 weeks ago. It caught my eye, as I follow several patients in clinic with ANCA-Associated Vasculitis (AAV) and a patient I saw most recently has experienced a second relapse requiring further adjustments in the immunosuppressant regimen.

Background:

Granulomatous polyangiitis (GPA, formerly known as Wegener’s), microscopic polyangiitis, and renal limited ANCA-associated vasculitis are the 3 ANCA associated vasculitis variants. Although they differ in their genetics, pathogenesis, and clinical presentation, they share many clinical features and are currently treated similarly. The outcomes of AAV are frequently poor. The mortality is approximately 25% at 5 years and 20% of those who survive develop ESRD. A staged therapy employing induction regimens with Cytoxan and Glucocorticoids, followed by maintenance regimens have been shown to dramatically improve renal and patient survival and therefore have become standard of care.

The more recent emergence of Rituximab over the last years as a new therapy for AAV has been the single most important advance in the treatment of AAVs since Cyclophosphamide nearly 40 years ago. Rituximab was first introduced on the rationale that ANCA contributed to pathogenesis and B-cell targeted therapies would reduce ANCA levels and thus ameliorate disease. Two large randomized controlled trials using Rituximab for induction reported in the NEJM (RAVE NEJM; 363:221-232, 2010 and RITUXIVAS NEJM 363:211-220, 2010) showed that Rituximab was equal to Cytoxan for induction therapy. In the majority of patients, disease control was achieved with induction regimens within 3-6 months.

However, despite effective induction therapy, a significant proportion of patients go on to relapse resulting in progressive disease and treatment related side effects. Current therapies tend to suppress but not cure disease in most and relapse has been a constant problem in treatment trials. Current evidence supports the use of Azathioprine or Methotrexate with or without glucocorticoids to prevent relapse (NEJM 359; 26: 2790-2803, 2008). However, these agents have limited efficacy and carry risk of treatment related complications. This current article compares Rituximab to Azathioprine as maintenance therapy in relapse prevention.

Current Study:

This study enrolled 115 patients (87 with GPA, 23 with MPA, and 5 with renal limited AAV). Patients achieved remission using a Cytoxan-Glucocorticoid prior to randomization.

Randomization and protocol for the study are shown in Figure 1 page 1775. 58 patients were treated with Azathioprine (AZA) and 57 were treated with Rituximab. Patients in the AZA group received 2 mg/kg/day thru month 12, 1.5 mg/kg thru month 18, and then 1 mg/kg/day thru the end of 22 months. Those randomized to Rituximab received 500 mg on day 0 and 14, then at 6 12, and 18 months.

Demographics and clinical characteristics of the groups are shown in Table 1 page 1776. Mean ages were similar at 56 and 54 years. 40/58 (69%) patients in the AZA group and 47/57 (82%) in the Rituximab group had GPA. 26% of those in the AZA group and 14% of those in the Rituximab group had MPA, and the remainder in each treatment group had Renal-limited AAV. Roughly 80% in each group had newly diagnosed disease with approximately 20% in each group with relapsing disease. Organ involvement was similar between the groups. The GFR tended to be better in the Rituximab treated patients but did not reach statistical significance (p 0.06). Approximately 95% in each group were ANCA positive. Both the cumulative CTX given for induction (6.9 versus 7.2 grams) and Prednisone dosing were similar between the groups. Remission was obtained at a mean of 4.6 months in each treatment arm.

Findings:

The primary endpoint followed was the percentage of patients with major relapse defined as reappearance or worsening of disease with a Birmingham Vasculitis Activity Score (BVAS) > 0 and involvement of at least 1 major organ. Kaplan-Meier Curves for Probability of remaining free of relapse are shown in Figure 2 page 1777. The effect on the primary outcome was striking and at month 28, major relapse had occurred in 17 patients in the AZA group (29%) and in 3 patients (5%) in the rituximab group. The Hazard ratio for relapse was 6.61 in the AZA group compared to patients treated with Rituximab. The frequency of severe adverse events was similar between the groups (25 in each group). Eight in the AZA group versus 11 in the Rituximab group had severe infections.

Conclusions:

Although prior studies have demonstrated effective remission-induction agents, the best strategy for maintaining remission remains unclear. Rituximab maintenance therapy, at least in patients with PR-3 ANCA, led to clear benefit in this study. Patients receiving Rituximab had a reduction in relapses of nearly 6 fold. As the study includes patients only with CTX induction, it does not directly inform us on patients with Rituximab induction. Additionally, no cost effectiveness data is included, and a better understanding of the benefits of relapse prevention (ie hospitalizations, cost of further induction, worsening CKD or development of ESRD) would all be important and may offset some of the additional cost of therapy in the Rituximab group. However, this study is an important advance and provides further evidence of effectiveness of Rituximab when used for induction or for maintaining remission. However, the unmet need for curative therapy remains.

Clinic Corner

 

Ambulatory Clinic Corner

Want more autonomy in the clinic?

Did you ever wonder at what point clinic attendings can stop following residents into the room? Like most things, it depends. Medicare has created something known as the Primary Care (PC) Exception, permitting 4:1 resident:clinic attending ratios and not requiring attendings to see patients with their own eyes for more routine visits – i.e., no higher than a Level 3 visit.

But to bill a Level 4 Return Visit,* which pays 15-20% higher and more often accurately reflects the complexity of the patients you see, the PC Exception does NOT apply.   So don’t take being followed as an affront, but as an acknowledgement of just how difficult caring for your patients can be (balanced against a desire to keep things moving and avoid having to make you wait to be precepted).

The PC Exception also does not apply for supervision of trainees who have “completed less than six months in an approved GME Residency Program” (e.g., interns). So in past years, the point when an intern could stop being followed could be arbitrarily determined by the calendar, regardless of how much or little time one actually spent in clinic. However, beginning a few years ago with Duke’s participation in a multi-institutional pilot of milestone-based graduation of interns to more autonomous practice in the clinic, there has been a desire to make this process more rational – and use the requested three mini-CEXs a year in the clinic to help do that. Over this month and into early 2016, the clinic sites will be working to get the interns their magic three observations.

But we also wanted to make it worth the while of JARs and SARs, too. To reward those residents who continue to volunteer themselves for the requested three (3) Ambulatory Mini CEX observations — and who were rated to be at or above their expected level for their stage of training — with continued advancement in the level of their autonomy in clinic, as well. This one-pager summarizes the different levels, which includes being able to batch two signouts together if there is a queue and the first patient is routine.

So thank you to all the residents and attendings who have participated in the Ambulatory Mini CEXs completed to date this year – residents, for inviting preceptors into your clinic rooms to observe what you do well, and offer pointers on how you can become even better; and attendings, for taking the time to provide feedback (and enter it into MedHub).

 

*In case you were curious, billing a Level 4 Return Visit (99214) requires documentation reflecting 2 of 3 of following:

-detailed history (HPI-4+ elements for acute/3+ for chronic diseases, plus 2-9 point ROS, AND review of either PMH, SH, or FH);

 

Wanted: Future leaders in Ambulatory Care

Have you thought about how your training provides the kinds of knowledge and skills you’ll need in your career? For those interested in primary care or whose future practice will be predominantly in ambulatory settings, the two-year Ambulatory Care Leadership Track (ACLT) can help you prepare by providing you with broader ambulatory clinical exposure, plus additional experiences in clinical teaching, advanced EBM, communication, and leadership and advocacy. Created by Larry Greenblatt and now led by Dani Zipkin, who works closely with the Ambulatory Chief Resident, our beloved Bonike, the ACLT is now accepting applications for 2014-15.

We encourage you to consider applying, and to talk to any of the residents currently in the program (Claire Kappa, Brice Lefler, Adrienne Belasco, Matt Atkins, Ryan Jessee, Amy Little Jones, and Dinushika Mohottige) to see if the ACLT is the right choice for you. Four spots will be opening in the 2015-16 academic year for rising JARs (interested SARs should reach out to Dani and Alex Cho). And we should emphasize again that the track was designed not only for residents interested in primary care, but also for those of you who are interested in ambulatory subspecialty careers. We can also promise you social events and camaraderie with like-minded residents and faculty, organized by Sharon Rubin and others.

If interested or if you have questions please contact Dani, Alex, Bonike, or Larry.

A brief, one-page application will be due Wednesday, December 31.

ACLT application form – 2014-15

QI Corner

 

Hope everyone had a good Thanksgiving! This week on Friday will be a Morbidity and Mortality conference in the Grand Rounds time slot. I will be presenting a case that should be both interesting and instructive – hope to see you there!

Aaron Mitchell

 

I want to give a shout out to the resident safety and quality council for an awesome start to this year’s projects about choosing wisely.    We will share our preliminary findings in January at the quality noon conference.   Please email Aaron Mitchell or Alicia Clark if you are interested in joining (not too late) and we will get you onto one of the project teams. 

For those of you who are thinking that New Years/Holiday Break is really far away or you are starting to feel the “burn” on your current rotation.  Please consider listening to this 10min video link by Brian Sexton in the Duke Patient Safety Office.   It teaches about the concept of recalling 3 good things at the end of the day.   It has been proven to decrease burnout even after 1 week of participating.   If anyone is interested in tracking our use, we would be happy to set up an easy reminder and logging system.  For the record, I am starting it tonight….who wants to join me?

https://www.youtube.com/watch?v=57ru-P7EuMw​

Thanks so much !

Lish Clark

 

From the Chief Residents Grand Rounds

Fri., Dec. 5: M&M, Dr. Aaron Mitchell

Noon Conference Date Topic Lecturer Time Vendor 12/1/14 SAR Series: Good, Bad, Ugly, and Hilarious of Contemporary Healthcare Politics  Nick Rohrhoff 12:15/2002  Mediterra 12/2/14  MED PEDS INTERVIEW/ G Briefing Session  Lunch w/applicants 12:00/MedRes 12/3/14 MATCH DAY Fun Lunch 12:00/Room 2002  China King 12/4/14 SAR Emergency Series- Transfusion Overview Venu Reddy 12:15/2001  Chick-Fil-A  12/5/14  Interview Day  Lunch w/ applicants  12:00/MedRes                   From the Residency Office Congratulations to Lynsey Michnowicz!

Please join the MedRes office team in congratulating Lynsey Michnowicz on her recent promotion!  As of December 1, Lynsey is now Program Coordinator for the Internal Medicine, Med-Psych and Infectious Disease training programs!  Lynsey has been an amazing addition to our team and we are very fortunate to have her in this new position!

  ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!     Stead Research Grant RFA

On behalf of the Stead Scholarship Committee, we would like to announce a Request for Applications for a clinical or translational research project involving a team of Internal Medicine, Med-Peds, and/or Med-Psych residents under the leadership of a faculty mentor in the Department of Medicine. The RFA is attached.

We are grateful to the leadership of the Stead Scholarship Committee (Chris Woods, Karen Alexander and Ravi Karra) for this generous initiative to promote and support team-research by our residents.

Best regards to all,

Murat and Aimee

ACP Abstracts Due!

Please find attached the information to submit abstracts by December 12, 2014 of your scholarly activities (case reports, research, QI projects)

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

http://www.acponline.org/about_acp/chapters/nc/abstract_comp.htm
Wishing you all success with your projects !

Murat and Aimee

Information/Opportunities

Sign up to receive a complimentary e-subscription to The American Journal of Medicine in 2015! All you have to do is to complete the online form by December 8, 2014.  The subscription starts in January.

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

December 3, 2014 – SAR Match Party

December 13, 2014 – DoM Holiday Party

February 18, 2015 – Duke vs UNC @ Tyler’s Tap Room

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, November 24, 2014

Mon, 11/24/2014 - 12:25
From the Director

Hello Everyone,

Looking forward to Thanksgiving week….I hear there is a football game happening sometime? I have blocked out the Duke-UNC game, but the best game of the year is on Thursday.  VA is currently winning the publicity competition with a hilarious and fantastic video featuring some Hall of Fame Jets.  Waiting to see a video with Ricky Bobby Aertker cropping up to inspire the Marines.

Kudos to our program and the Dept of Medicine faculty who donated to our Thanksgiving Food Drive…we raised $925 to feed families in need from the DOC and the VA PRIME clinic.  Other kudos this week go to Emily Ray from hospital medicine faculty Liz Hankollari for outstanding work overnight on Duke NF and to our gen med SARs at Duke for hosting applicants 3 days a week for four straight weeks…Sajal Tanna, Claire Kappa, Nina Beri, Ben Lloyd and Amera Ramatullah.  Also to Ben Peterson for an awesome chair’s case, and  to Bhavana Singh from Rachel Hu for her work as a VA Jar! Other thank you’s to our “Resident Share” group of Lakshmi Krishnan, Brittany Dixon, Ragnar Palsson, Cece Zhang, Jenny Van Kirk and Mike Woodworth.

SARs, please don’t forget to register for your ABIM exam! Registration opens Dec 1…after MATCH DAY if you are matching on DEC 3, go ahead and register so you get the site you want!  Also, for all residents..if you haven’t met with your advisor since the year started, please schedule a meeting with them to discuss evaluations, ITEs, careers, etc.

Please see the announcement at the end regarding NC-ACP posters.  It’s in Durham this year and we want to represent well! If you have a chair’s case, submit it as a case report.  If you have any research projects, MAKE A POSTER! Looking forward to seeing many of you there.

This week’s pubmed from the program goes to our CLIN EPI group who presented their projects on Friday to close out a great month of CLIN EPI! I am also looking forward to seeing many of those projects as resident research grants this year.

Have a great week, and an EARLY HAPPY THANKSGIVING to you all and your loved ones.

Aimee

What Did I Read This Week?

Submitted by: Omobonike Oloruntoba, MD

Early versus On-Demand Nasoenteric Tube Feeding in Acute Pancreatitis

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1404393

Often times we underestimate the importance of nutrition in the care of our severely ill patient. In the case of patients with acute pancreatitis, the decision of when to advance the diet and more importantly the nutritional value of what we order for those patients (thumbs down for clear liquid diet!) is challenging. Furthermore, patient and physician discomfort with NG tube insertion may drive the physician to wait it out, and give that patient one more chance to tolerate an oral diet.

BACKGROUND:

20% of patients with acute pancreatitis disease course is complicated by major infection. Disturbed intestinal motility, bacterial overgrowth and increased mucosal permeability together provokes bacterial translocation from the gut leading to infection. Meta-analysis of several RCT demonstrated that nasoenteric tube feeding compared to total parental nutrition (TPN) reduces the rate of infections and mortality among patients with severe pancreatitis. Unlike TPN, enteric tube feeds is believed to stimulate intestinal motility, which decreases bacterial overgrowth and preserves the integrity of the gut mucosa by increasing splanchnic blood flow. In addition, several studies have demonstrated that early enteric tube feeding (36 to 48 hours after admission) significantly reduced the rate of major infection. Nonetheless despite many nutritional societies recommendation on early nasoenteric tube feeding for patients with severe pancreatitis, guidelines from gastroenterologic and pancreatic societies recommend initiation of tube feeding after a patient is not able tolerate an oral diet for up to 7 days at which time the potential benefits of enteric feeding may have passed. This study compared the effects of early nasoenteric tube feeding with those of an oral diet starting 72 hours after admission with an option to switch to nasoenteric tube feeding based on insufficient oral intake.

METHODS:

Study Participants:

  • Adults with a first episode of acute pancreatitis at high risk for complications as defined by:
    • APACHE Score (within 24 hours) ≥8
    • Imrie/Glasgow score ≥3
    • CRP ≥150 mg per liter
  • Pancreatitis was diagnosed as having 2 of the 3 features:
    • Typical abdominal pain
    • Amylase/Lipase 3 times the upper limit of normal
    • Characteristic findings on cross-sectional imaging
  • Exclusion Criteria
    • Recurrent pancreatitis
    • Chronic pancreatitis
    • Post-ERCP pancreatitis
    • Patients with enteral or parental nutrition at home
    • Pregnant patients
    • Patients presenting to the ED >96 hours after symptom onset
    • Patients transferred from OSH

Study Design:

  • Multi-centered, randomized controlled superiority trial.
  • Patients were assigned to either nasojejunal tube feeding within 24 hours of randomization (early group; n=102) or to an oral diet starting at 72 hours (on demand group; n=106)
    • Nutrition target: 25kcal/kg per day (ICU) and 30kcl/kg/day (Wards)
    • TF started at 20ml/hour during the first 24 hours. After 24 hours, the volume of nutrition was increased to 45 ml per hour, after 48 hours to 65 ml per hour and after 72 hours to full nutrition depending on patient’s actual body weight.
    • Oral diet was started on patients at 72 hours
      • Exceptions were made for patients that requested oral food during the 72 hour period
      • If an oral diet was not tolerated after 96 hours, nasoenteric tube feeding was started

Primary Endpoint: Composite of major infection (infected pancreatic necrosis, bacteremia, pneumonia) or death within 6 months after randomization.

RESULTS:

The primary end point occurred in 30 of 101 patients (30%) in the early group and in 28 of 104 (27%) in the on-demand group (risk ratio, 1.07; 95% confidence interval, 0.79 to 1.44; P=0.76). There were no significant differences between the early group and the on- demand group in the rate of major infection (25% and 26%, respectively; P=0.87) or death (11% and 7%, respectively; P=0.33). In the on-demand group, 72 patients (69%) tolerated an oral diet and did not require tube feeding.

CONCLUSION:

This study did not show the superiority of early nasoenteric tube feeding in reducing the rate of major infection or death in patients with severe acute pancreatitis. This study challenges the concept of the gut mucosa-preserving effect of early enteral feeding during acute pancreatitis. However, the study may have been too small to detect a difference between the two groups.

 

Clinic Corner

 

Hi everyone

Have a Happy Thanksgiving. I wanted to take a moment and congratulate Chris Merrick for winning our WOW award for last month. Please stop by and look at all of the positive comments that all of you have been receiving. Great job.

Dr. Zhang- Sr. Z is very caring and knowledgeable about her job. She is very thorough and I do appreciate her very much.

Dr. Wasserman- Dr W is a very profession al and thorough physician who also cares for his patients’ well-being.

Dr. Bhaskar- PRIME D great.

Dr. Merrick- Inspection of ear problem. Doctor fit me in to schedule ear exam. Excellent service. WOW!

Dr. Merrick- annual check-up, everyone is so nice.

Dr. Giattino- follow- up visit with new questions. Everything was great!

Dr. Palsson- follow-up of emergency room visit

 

Just a quick reminder for the upcoming December Holidays. Please discuss with your team and have your CPRS alerts forwarded to a co-team member.

Best,

Sonal Patel

VA PRIME

From the Chief Residents Grand Rounds

Fri., Nov. 28: Thanksgiving Holiday – No Grand Rounds

Noon Conference Date Topic Lecturer Time Vendor 11/24/14  Interview Day  Lunch w/ applicants 12:00/MedRes  Pipers in the Park 11/25/14  SAR Lecture Series – Topic TBA  Iris Vance 12:00/2002  Chick-Fil-A 11/26/14 SAR Emergency Series – Acute Stroke Joe Brogan 12:00/Room 2002 China King 11/27/14 THANKSGIVING! Turkey Dinner 1:00 MedRes Library  Bullocks  11/28/14  NO CONFERENCE-HOLIDAY                   From the Residency Office Thank You!! On behalf of the Warren Society and the Residency Council, we would like to thank our residents and faculty for your generous donations.  This year, we raised $925 for the Annual Thanksgiving Food Drive and delivered 30 Walmart and Food Lion gift cards to the DOC and VA Prime.  Thanks to your support, dozens of families will be able to enjoy a wonderful Thanksgiving meal this year!   We were also able to deliver our final “We Care Wednesdays” donation, in the amount of $1500, to the Lincoln Community Health Center.  Your continued support for your community here is Durham is tremendous!     ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!     Stead Research Grant RFA

On behalf of the Stead Scholarship Committee, we would like to announce a Request for Applications for a clinical or translational research project involving a team of Internal Medicine, Med-Peds, and/or Med-Psych residents under the leadership of a faculty mentor in the Department of Medicine. The RFA is attached.

We are grateful to the leadership of the Stead Scholarship Committee (Chris Woods, Karen Alexander and Ravi Karra) for this generous initiative to promote and support team-research by our residents.

Best regards to all,

Murat and Aimee

ACP Abstracts Due!

Please find attached the information to submit abstracts by December 12, 2014 of your scholarly activities (case reports, research, QI projects)

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

http://www.acponline.org/about_acp/chapters/nc/abstract_comp.htm
Wishing you all success with your projects !

Murat and Aimee

 

Partners In Health and BWH Hospitalist Program

PIH is currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) to join our teams in Rwanda, Haiti, and Malawi for the 2015-2016 academic year .  This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston.  Candidates interested in this exciting opportunity should submit an application at http://www.pih.org/pages/employment

before December 1, 2014, or can contact Dr. Neil Gupta at ngupta@pih.org.

Partners In Health and BWH Hospitalist Program

Background: Partners In Health (PIH) is a health and social justice organization with a mission to build high quality, comprehensive public health systems around the world.  PIH has partnered with local communities and governments over the past 25 years to provide high-quality health care to the poorest of the poor and train the next generation of physicians, nurses and public health professionals in countries around the world.

General Description: We are currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) with strong interest in global health and medical education to join our teams in Rwanda, Haiti, and Malawi.  This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston.

Specific Responsibilities: Internists at PIH field sites serve as clinician educators, working with local medical staff and trainees on inpatient medical wards and outpatient clinics in rural districts hospitals and health centers as well as academic teaching centers.  These clinician educators are faced with a vast diversity of diseases, including but not limited to, HIV, tuberculosis, malaria, non-communicable diseases, oncology, and other tropical infectious diseases. They also supervise international trainees and students rotating from Brigham & Women’s Hospital and other international institutions, engage in quality improvement and research activities, and help to develop and implement innovative programs to strengthen health delivery.

Financial Support: The Brigham and Women’s/Faulkner hospitalist program provides hospitalist salary support and full benefits package, including malpractice insurance and health insurance. PIH provides international airfare as well as full accommodations while at PIH sites. Successful candidates will also have the opportunity for academic appointment at Brigham and Women’s Hospital and a diversity of professional development opportunities.

Qualifications:

  • ABIM board-certification or board-eligibility in internal medicine or internal medicine / pediatrics; candidates with sub-specialty interests are welcome to apply
  • Board-eligible graduating senior medical residents are eligible to apply
  • A desire to gain experience with health care delivery in sub-Saharan Africa
  • A talent for teaching and an interest in medical education and quality improvement
  • Flexibility, humility, creativity and enthusiasm
  • A two-year commitment is encouraged but not required

Application and Contact Information: If you are interested in pursuing this opportunity, please submit your application at http://www.pih.org/pages/employment.  If questions, please contact Dr. Neil Gupta at ngupta@pih.org.

Information/Opportunities

Sign up to receive a complimentary e-subscription to The American Journal of Medicine in 2015! All you have to do is to complete the online form by December 8, 2014.  The subscription starts in January.

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

 

 

Upcoming Dates and Events

November 27, 2014 – Turkey Bowl

December 3, 2014 – SAR Match Party

December 13, 2014 – DoM Holiday Party

February 18, 2015 – Duke vs UNC @ Tyler’s Tap Room

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, November 17, 2014

Mon, 11/17/2014 - 10:58
From the Director

Hello everyone! Thanks again to Dr. Cohen for the basketball tickets! Hope you all had a good week and weekend, enjoying the Duke football tailgate despite the loss and some amazing early season Duke basketball.  New block for the interns…hard to believe we are almost halfway through the year.  Your excitement at recruitment continues to be appreciated … many thanks to our resident share team last week of Anubha Agarwal, Adrienne Belasco, Rajiv Agarwal, Aparna Swaminathan, Rachel Hu, Peter Hu, Adva Eisenberg and Jason Zhu.  Kudos this week also to Josh Briscoe for a fantastic chairs conference and Mike Woodworth and Doran Bostwick in “SAR row” for getting the case.  We also have kudos to Melanie Goebel from Chan Park at the VA ED for excellent work and to Stephanie Li from her JAR at the VA Myles Nickolich for general awesomeness on a busy VA team.

Keep the donations going for our annual Warren Society and Residency Council Thanksgiving Food Drive — see the email link for paypal or bring your cans to the med res office.  Proceeds will benefit families who get care at the DOC and PRIME.

For SARS, ABIM signup for boards is coming soon…registration at abim.org starts on December 1st.  We hear about the fellowship match on Dec 3 (see you at Surf Club that evening!) so you will know the place to choose for registration.   I had the opportunity to speak with many of our colleagues around the country in the past few weeks, and kudos abounded for our graduates who are in jobs and fellowships around the country (and around the world)..so long distance kudos to Carling Ursem, Brian Miller, Mallika Dhawan, Mandar Aras, Nancy Lentz, Lauren Porras Trevor Posenau and Matt Chung from your current fellowship directors/bosses!  It was so rewarding to hear what a fantastic job our graduates are doing and how well received the current SARs were in the fellowship process.

This week’s Pubmed from the Program goes to Duke Med 2014 grad and current ID fellow Meredith Edwards Clement for her JAMA article (along with another Duke grad and current ID fellow Lance Okeke and mentor Chuck Hicks) “Treatment of Syphillis: A Systematic Review”, JAMA 2014;312(18):1905-17.

 

Have a great week

Aimee

What Did I Read This Week?

Submitted by: Coral Giovacchini, MD

Soyka, MB, et al. Scientific foundations of allergen-specific immunotherapy for allergic disease. Chest. 2014 Nov 1;146(5):1347-57

Why Did I Read This:

Allergy and Immunology is a very interesting field within internal medicine to which we often get very little exposure. This review article provides an excellent summary into the background and application of immunotherapy for allergic disease.

Background:

Allergic disease is among the most common diseases worldwide, with an exponentially rising prevalence. Symptoms can involve a wide array of organ systems (ENT, skin, upper/lower airways, GI tract, etc.), and patients may present not only to their primary physician, but also to a number of subspecialists with allergic symptoms.

Broken down into the basics, allergens comprised of proteins are inhaled, ingested, or otherwise taken up leading to an IgE-mediated local or systemic inflammatory response. In thinking of immune tolerance, this is basically an adaptation of the immune system to external antigens/allergens. Somewhat paradoxically, it is an active immune response to a specific epitope/antigen that leads to clinical allergen tolerance; thus the ultimate goal for allergy therapy is to promote a change in the immune response for tolerance to a specific antigen.

Generally physicians prescribe medications for symptom management including antihistamines, topical/systemic corticosteroids, leukotriene antagonists, and many others; however the only therapy for disease modification remains allergen-specific immunotherapy (AIT). Despite the fact that we have been using AIT for the last century, the exact mechanisms in the efficacy of AIT remain somewhat unclear.

What We Know – Mechanisms of Allergic Inflammation:

During sensitization, allergens are presented by dendritic cells to naïve T cells, resulting in a Th2 switch and derivation of a clonal allergen-specific T-cell population. Depending on the nature of the allergen and the host microenvironment, either immune tolerance develops, OR IgE sensitization cascades. In the setting of allergic sensitization, once a dendritic cell sees an allergic antigen, it will migrate to lymphoid tissues to activate T-cell maturation and mediate cytokine release. These activated Th2 cells will then drive naïve B cells to class switch to IgE. Specific IgE antibodies will engage their receptors on mast cells and basophils, prompting these cells to degranulate once exposed to the same allergen again. In this setting, degranulation releases the vasoactive amines and cytokines responsible for the ensuing type 1 hypersensitivity reaction, furthered by an attraction of eosinophils to the area driving a late-phase reaction in the affected tissues.

What We’re Figuring Out – Immune Tolerance:

Immune tolerance can be thought of as an adaptation to allergen exposure that down-regulates the allergic inflammation response and thus promotes a “tolerance” to exposure. There are two broad populations of T-regulator cells (native and inducible) and B-regulator cells that produce suppressive factors, such as IL-10 (acts as a immune response suppressor) and up-regulation of IgG4 (which competes with allergen-specific IgE binding sites to prevent the vasoactive degranulation of mast cells and basophils). Interestingly, IgG4 has evolved only in primates as likely an adaptive tolerogenic antibody. A normal human immune response to high dose allergen exposure is induction of immune tolerance. For example a beekeeper with a bee venom tolerance who experiences numerous beestings during a season will still mount an elevated IgE level, but will also have an elevated IgG4:IgE ratio (on the order of thousands!) than an individual with a bee venom allergy. The loss of an immune tolerance (i.e. development of an allergic response to an allergen to which one was previously tolerant), involves several mediators and is an active area of research currently given that there are likely numerous targets for AIT.

Clinical Use of AIT:

Currently AIT is utilized to ameliorate all symptoms of allergic disorders (including rhinitis, asthma, atopic dermatitis), and has been shown to restore immune tolerance, as well as inhibit development of new sensitizations in the future. Patients are selected via molecular diagnostics demonstrating sensitization to specific allergens. Immunotherapy vaccines are targeted with a mixture of allergen components with the goal of driving an elevated immune response. Current delivery options include the subcutaneous and sublingual routes, and both have favorable efficacy and safety profiles across broad patient populations including children and the elderly. Though there have not been any large head-to-head trials, SLIT may have a lower side-effect profile, and SCIT may be more beneficial for grass pollen AIT, per meta-analysis review. Conventional dosing regimens include treatments every 1-2 weeks with final therapies concluding after a period of several months. There are shorter course regimens and “rush”/”ultra rush” protocols which have been shown to provide safe and efficient results in the appropriate patient populations. Severe and/or uncontrolled asthma is an absolute contraindication to AIT and an FEV1 >70% should be demonstrated in any patient prior to starting therapy. If appropriate asthma control cannot be achieved with standard medication regimens, systemic anti-IgE immunomodulators (i.e. omalizumab) may be initiated as an adjunct to AIT in a carefully selected asthma population. In children with allergic asthma, concurrent AIT has demonstrated improvement in objective parameters in some small trials (i.e. decreased exhaled NOS, improved peak expiratory flow measures, and decreased frequency of asthma exacerbations); however more research is needed in these areas to show definitive results. Interestingly performing AIT in children with allergic rhinosinusitis, despite the high upfront cost, has been proven cost-effective by reducing and eliminating additional allergy and asthma drug cost long term.

The Future Of AIT:

Currently safety and appropriate patient selection for AIT remains a challenge. Some of the more significant side effects of AIT remain to be local inflammation and wheal formation in up to 50% of patients, which while perhaps not so much of a problem for SCIT, can be a larger issue for SLIT where oral pruritis and swelling can occur in up to 80% of patients. There are current approaches looking into novel route administration (such as intra-lymph node approaches) as well as physical coupling of allergens to immunomodulators, as an attempt to decrease the initial local and systemic inflammatory responses during AIT, respectively. Additionally, there is an active need for identification and validation of specific biomarkers that would predict a clinical response to AIT in patients with an allergic phenotype.

In conclusion there are many opportunities for exciting research in the field of allergy and immunology with novel approaches evolving for AIT as a cure for a very widespread disease with global impact.

Clinic Corner

We welcome Christine Locklay our new Coumadin nurse and Laura Ferrell as our new LPN/triage.

We too are collecting food for Thanksgiving. See the Turkey in the front lobby. Food donated will go to one of the Pickett Road Family and the rest to the food bank.

Notes from the Ambulatory town hall last week: Thank you to Nina Beri, Jason Zhu, Pascal Khallariah and Alan Erdman for attending.
Issues brought up

  1. Forms: as courtesy to each other, please fill out the forms to the best of your knowledge (when reviewing chart).  The worst case is to find a form in the resident mailbox that needed to be filled out 3 months earlier.

– A request is also to print your name under your signature

  1. Rooming patients on time: we are getting more staff but if there are times when it is busy, Its OK to room your own patients. remember to place a green dot next to pt name (that way we know the patient has been brought back).
  2. Switching patients: please let your attending know first. If your rooming nurse can switch the patients in epic, that would be great. Please do not go to the front desk to have this changed. Go to Nicole or Sharee first. Remember the allotted slots are different intern, jar and sar. if we switch a 1pm SAR pt to a 1:00pm intern, this creates 2 slots one at 1pm and does not fill the 1:20pm slot so the intern could have 6 patients scheduled.
  3. Mini Cex: we are doing great! Please make sure you pick one or two patients as one could no show. We are not limited to 3, we can do more. Observation helps with our professionalism and looks for areas of improvement. You need 3 for intern to see patients alone, 3 for JAR and SAR for multiple sign out.
  4. Its OK to ask for help! I know its against the Duke Culture to be quite and take the work.  If you are overwhelmed, talk to your attending who can help redistribute patients or block slots.
  5. Due to printer problems in the room, all AVS are printing in the resident room.

For faster sign out – ask your preceptor for

SNAPPS Model of Learning Center Precepting

Summarize briefly the history and findings

Narrow the differential to 2 or 3 possibilities

Analyze the differential by comparing and contrasting the possibilities

Probe the preceptor by asking questions about uncertainties/difficulties/alternate approach

Plan management for patient medical issues

Select a case related issue for self-directed learning

Modified Aunt Minnie Model (good for the JAR and SAR sign out if 2 patients) Simple, straight forward UTI, URI

Have learner collect data from the patient (identify simple/straightforward case)

Have learner present chief complaint and probably diagnosis (30 seconds)

Learner and preceptor focus on patient management issues

Patient OK to go (not seen by attending) but make sure you have their phone number and pharmacy.

Sincerely,

Sharon Rubin, MD, FACP

 

QI Corner

Aaron Mitchell, MD

A lot of news this week!

1) Updates from the Duke Choosing Wisely task force on telemetry utilization. They have been collecting data on tele usage on the gen med teaching services and have found the following:

– A total of 66 gen med patients on tele were sampled

– These 66 represented about 17% of gen med patients

– 20% of patients had an ACC Class I indication for tele (definitely need it)

– 41% had an ACC Class II indication (maybe need it)

– 38% had an ACC Class III indication (probably don’t need it)

This 38% of patients on tele who don’t need it translates to about 2-4 gen med patients at any given time, which is a much smaller number than we had anticipated. Overall, we are doing a pretty good job regarding who we put on telemetry. Thanks to Adam, Jenny, Olinda, Lauren, Gena, and Peter for all your great work on this project so far!

2) There is a GME-wide Patient Safety and Quality Council meeting on Tuesday, at 6:30am. Breakfast is served. Let me know if you want to get involved in hospital-wide QI and patient safety issues.

3) Not quite QI but more health policy (my other hat), there is going to be a health care policy panel discussion at the medical school on Wednesday night at 6pm. Learn more and register here:

http://news.medicine.duke.edu/2014/11/health-policy-lecture-series-healthcare-reform/

4) We have an upcoming Morbidity and Mortality case at noon conference on Wednesday.

5) Go Jets!

 

From the Chief Residents Grand Rounds

Fri., Nov. 21: Rheumatology, Dr. Nancy Allen

Noon Conference Date Topic Lecturer Time Vendor 11/17/14  Interview Day  Lunch w/ applicants 12:00/MedRes  Picnic Basket 11/18/14  MED PEDS INTERVIEW  Lunch w/ applicants 12:00/MedRes 11/19/14  Resident M&M Qi Team 12:00/Room 2002 Dominos 11/20/14 HVCC High Value Screening Joel Boggan and Aaron Mitchell  12:00/Room 2001  Cosmic Cantina  11/21/14  Interview Day  Lunch w/ applicants  12:00/MedRes                   From the Residency Office Annual Thanksgiving Food Drive On behalf of the Warren Society and the Residency Council, we are pleased to announce the start of the Annual Internal Medicine Residency Thanksgiving Food Drive!  We will be collecting monetary donations via the PayPal link below, in cash (which we can collect in the MedRes office during normal office ours) or in check form, made payable to Duke University.  In addition, we are happy to collect any canned or non-perishable food donations which can be delivered to the MedRes office or the ACR offices at Duke, the VA or DRH.All monetary donations will be used to purchased gift cards to local grocery stores and those, along with the food donations, will be delivered to the social workers at the DOC and VA clinics on November 21, 2014.Your generosity in the past has been inspiring and as we remain committed to supporting our local community, please help us provide for those families who may otherwise go without this holiday season.Many, many thanks!https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=YN4YAUPCVJRYQ   ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!     Stead Research Grant RFA

On behalf of the Stead Scholarship Committee, we would like to announce a Request for Applications for a clinical or translational research project involving a team of Internal Medicine, Med-Peds, and/or Med-Psych residents under the leadership of a faculty mentor in the Department of Medicine. The RFA is attached.

We are grateful to the leadership of the Stead Scholarship Committee (Chris Woods, Karen Alexander and Ravi Karra) for this generous initiative to promote and support team-research by our residents.

Best regards to all,

Murat and Aimee

 

Chronic Hepatitis C Infection: Making the Decision to Treat

Join Andrew Muir, MD and Susanna Naggie, MD, MHS for a free live workshop for clinicians and patients

ACP Abstracts Due!

Please find attached the information to submit abstracts by December 12, 2014 of your scholarly activities (case reports, research, QI projects)

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

http://www.acponline.org/about_acp/chapters/nc/abstract_comp.htm
Wishing you all success with your projects !

Murat and Aimee

 

Partners In Health and BWH Hospitalist Program

PIH is currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) to join our teams in Rwanda, Haiti, and Malawi for the 2015-2016 academic year .  This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston.  Candidates interested in this exciting opportunity should submit an application at http://www.pih.org/pages/employment

before December 1, 2014, or can contact Dr. Neil Gupta at ngupta@pih.org.

Partners In Health and BWH Hospitalist Program

Background: Partners In Health (PIH) is a health and social justice organization with a mission to build high quality, comprehensive public health systems around the world.  PIH has partnered with local communities and governments over the past 25 years to provide high-quality health care to the poorest of the poor and train the next generation of physicians, nurses and public health professionals in countries around the world.

General Description: We are currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) with strong interest in global health and medical education to join our teams in Rwanda, Haiti, and Malawi.  This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston.

Specific Responsibilities: Internists at PIH field sites serve as clinician educators, working with local medical staff and trainees on inpatient medical wards and outpatient clinics in rural districts hospitals and health centers as well as academic teaching centers.  These clinician educators are faced with a vast diversity of diseases, including but not limited to, HIV, tuberculosis, malaria, non-communicable diseases, oncology, and other tropical infectious diseases. They also supervise international trainees and students rotating from Brigham & Women’s Hospital and other international institutions, engage in quality improvement and research activities, and help to develop and implement innovative programs to strengthen health delivery.

Financial Support: The Brigham and Women’s/Faulkner hospitalist program provides hospitalist salary support and full benefits package, including malpractice insurance and health insurance. PIH provides international airfare as well as full accommodations while at PIH sites. Successful candidates will also have the opportunity for academic appointment at Brigham and Women’s Hospital and a diversity of professional development opportunities.

Qualifications:

  • ABIM board-certification or board-eligibility in internal medicine or internal medicine / pediatrics; candidates with sub-specialty interests are welcome to apply
  • Board-eligible graduating senior medical residents are eligible to apply
  • A desire to gain experience with health care delivery in sub-Saharan Africa
  • A talent for teaching and an interest in medical education and quality improvement
  • Flexibility, humility, creativity and enthusiasm
  • A two-year commitment is encouraged but not required

Application and Contact Information: If you are interested in pursuing this opportunity, please submit your application at http://www.pih.org/pages/employment.  If questions, please contact Dr. Neil Gupta at ngupta@pih.org.

Information/Opportunities

Sign up to receive a complimentary e-subscription to The American Journal of Medicine in 2015! All you have to do is to complete the online form by December 8, 2014.  The subscription starts in January.

Internal Medicine Opportunities

MD Fellowship Flyer V5

Financial Planning Webinar for New Physicians – CST

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

 

Upcoming Dates and Events

November 27, 2014 – Turkey Bowl

December 3, 2014 – SAR Match Party

December 13, 2014 – DoM Holiday Party

February 18, 2015 – Duke vs UNC @ Tyler’s Tap Room

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, November 10, 2014

Mon, 11/10/2014 - 12:09
From the Director

Interview season is in full swing..thank you to everyone for your enthusiasm and ongoing efforts to meet and talk with applicants.  Thanks this week to our resident share participants Andrea Sitlinger, Ben Lloyd, Sneha Vakamudi, Angela Lowenstern, Joy Bhosai, Zach Wegermann, Kara Johnson, Jenny Van Kirk, and Brian Sullivan.   Kudos also to Nina Beri for doing our first applicant afternoon report and to Rajiv Agarwal for an amazing chair’s conference!  And a big thank you to Manesh Patel, Mary Klotman, Tony Galanos, Dave Zaas and Harvey Cohen for donating Duke Basketball tickets to the residents this week.  Hope all that went had a great time!

Thank you to Lauren Dincher for delivering our “BIG CHECKS” to the Durham Rescue Mission and the Lincoln Clinic, based on our donations from DOCTOBERFEST WE CARE WEDNESDAYS!

Other kudos go to Titus Ng’eno from Svati Shah for great work in clinic, to Adam Banks for doing leadership rounds in the CCU, to Katie Broderick-Forsgren from the CCU nursing staff for being organized and a great problem solver and to Matt Hitchcock for an excellent SAR talk on antibiotic management.

Important things to know….Agile MD is offering a free download of the UCSF Hospitalist Manual.  It’s usually $19.99, so take advantage and keep using your Duke Survival Guide APP as well.

We are kicking off our ANNUAL THANKSGIVING FOOD DRIVE! Steve Crowley and the Warren Society are our official “Stead Backers”.  We are making it REALLY easy for you to contribute, via a paypal account.  See upcoming email and other announcements for details.   We have a few short weeks to provide food for patients in need from the DOC and PRIME clinics!  As we enjoy our thanksgiving meal after Turkey bowl and another meal with our friends and families, let’s do our best to make thanksgiving for others who are less fortunate.

SARs…..if you are applying for fellowship, NOV 12 is the last day to enter your match list and certify it.  Right after you do that, get ready to sign up for the ABIM exam.  Details are posted in this week’s med res news and also on the ABIM website.

Pubmed from the program goes to our awesome chief resident Bonike Oloruntoba for her presentation at the AASLD meeting!

Have a great week

Aimee

 

What Did I Read This Week?

Submitted by: Lynn Bowlby, MD

New Eng Journal of Medicine 2014, 371:1324-1331 October 2, 2014

Review Article : Microcytic Anemia

One of the first and most basic issues in medicine I remember learning about as a medical student was the evaluation and treatment of anemia. At the DOC so many of our patients have so many other chronic diseases that capture our attention that anemia can be lost.

I was very happy therefore to find this comprehensive review article on one aspect of anemia. I was glad to see that some things have stayed the same since I was a student—RBCs in microcytic anemia is the size of a lymphoctyic nucleus–as well as new information to learn.

Causes: Microcytic due to lack of hemoglobin Lack of globin-thalassemia Restricted Iron delivery-Inflammation Lack of Iron delivery-iron-def anemia Defects in synthesis of heme–sideroblastic

  1. Thalassemia-

alpha thal-African, SE Asian and Mediterranean Heritage Hgb H/ Bart–more severe, SE Asian and Medicterranean B thal-major, minor and intermediate Hgb E– lysine substituted for glutammine

  1. Inflammation-

renal production of erythropoetin supressed by cytokines and lack of iron availability due to hepcidan

  1. Iron Def-most common anemia,   iron found in many key proteins of the cell, hence leading to the new concept of nonanemic iron deficiency leading to fatigue.

Women, athletes and post bariatric surgery at risk of iron def anemia.

Diagnosis:

MCV < 70 rare in inflammation

Anemia of inflammation is one of exclusion.

Iron deficiency–ferritin is the most efficient and cost effective test (as my Heme/Onc husband Neal Ready taught me years ago!) Determining the cause of iron def anemia is key, blood loss must be assumed.

Treatment:

In medicine Iron def anemia is the most easily treated–on a practical level (and what I have done) Ferrous sulfate 325 mg qd with meat/Vit C, AVOID tea, and likely coffee (interferes with absorption) change to Ferrous gluconate if can’t tolerate sulfate.

Retic count should go up in one week, HgB up at the end of 2 weeks.

IV iron if po not successful- infusion reaction is the issue.

Thallassemia- since a genetic disease, gene therapy will likely be an option in the future. So read, and learn about anemia!

Clinic Corner

Hello Team DOC!

Thanks for reading the Clinic Corner! I’m keeping it short and sweet this month:

  • See Dr. Bowlby’s slides attached from the recent Town Hall meeting last week. And keep your eyes peeled for the next one in the spring – the more of you that can make it, the happier we are!
  • See the DOC Newsletter 2014 November, with some resources that may be new to you, updates on what the Steads are doing, and our October and November Employees of the Month, Robin Claud-Everett and Gina Green!!!

Take care,

Dani

p.s. a big prize will go to the person who emails me remembering (or looking up) how I referred to the DOC last month

 

QI Corner

Aaron Mitchell, MD

Just as a reminder – this week on Wednesday afternoon we are having a meeting of the patient safety and quality group. This will be a chance to work on (or join!) one of the ongoing Choosing Wisely projects. We will spend at least some time talking about Maestro Care workbench reports, which is a great tool to generate data for chart reviews and QI projects. As always, if you have any project ideas or safety concerns, come and share!

We just got fresh data on how we are progressing towards our GME incentive program targets. We crushed ED consult time last month – go 1010! Great job to the night float residents! We hit our target of <30min for the first time, so let’s keep it up.

And, just in case you wanted to compare, to see how much we are dominating all the other departments:

 

Our SRS reporting has also picked up. We submitted 72 safety reports in October, from only in the 40s the last few month.

 

From the Chief Residents Grand Rounds

Fri., Nov. 14: Geriatrics, Dr. Mitchell Heflin

Noon Conference Date Topic Lecturer Time Vendor 11/10/14  Interview Day  Lunch w/ applicants 12:00/MedRes  Panera 11/11/14  SAR Emergency Series – Acute Stroke  Joe Brogan 12:00/2002  Chick-Fil-A 11/12/14  MED PEDS INTERVIEW  Lunch w/ applicants 12:00/MedRes  Saladelia 11/13/14  SAR Emergency Series – Topic TBA  Veronica Jarido  12:00/Room 2001  Mediterra  11/14/14  Interview Day  Lunch w/ applicants  12:00/MedRes  Jason’s Deli                   From the Residency Office Recruitment 2014! Reminder to All Residents: Please email your recruitment buddies! This has such a large impact on their visit and is greatly appreciated!   ABIM Summer 2015 Examination Dates

Please see the attached flyer for information on dates and registration!


Pin Station Re-located

The pin station is the MedRes library has been re-configured so that images can be projected on the large screen for report.  If you need an individual pin station for work, please feel free to use the one in the front cubicle of the MedRes office, suite 8254.

 

Duke AHEAD Announcement

Registration for “Celebrating the Education of Health Care Professionals” is now open at dukeahead.duke.edu.   The event begins on 11/13/14 in collaboration with the Duke Office of Graduate Medical Education and Duke University School of Nursing Institute for Educational Excellence.  Keynote Speaker, Dr. Lee Shulman, immediate past-president of the Carnegie Foundation will present “Interprofessional Collaboration: Value and Vision.”  Attached is the full itinerary.

While you’re at the website, please take a moment to check out the Duke AHEAD video, recently completed.

Thank you for your continued support of Duke AHEAD!

Kristin Dickerson

Duke AHEAD

Chronic Hepatitis C Infection: Making the Decision to Treat

Join Andrew Muir, MD and Susanna Naggie, MD, MHS for a free live workshop for clinicians and patients

ACP Abstracts Due!

Please find attached the information to submit abstracts by December 12, 2014 of your scholarly activites (case reports, research, QI projects)

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

http://www.acponline.org/about_acp/chapters/nc/abstract_comp.htm
Wishing you all success with your projects !

Murat and Aimee

 

Partners In Health and BWH Hospitalist Program

PIH is currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) to join our teams in Rwanda, Haiti, and Malawi for the 2015-2016 academic year .  This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston.  Candidates interested in this exciting opportunity should submit an application at http://www.pih.org/pages/employment

before December 1, 2014, or can contact Dr. Neil Gupta at ngupta@pih.org.

Partners In Health and BWH Hospitalist Program

Background: Partners In Health (PIH) is a health and social justice organization with a mission to build high quality, comprehensive public health systems around the world.  PIH has partnered with local communities and governments over the past 25 years to provide high-quality health care to the poorest of the poor and train the next generation of physicians, nurses and public health professionals in countries around the world.

General Description: We are currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) with strong interest in global health and medical education to join our teams in Rwanda, Haiti, and Malawi.  This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston.

Specific Responsibilities: Internists at PIH field sites serve as clinician educators, working with local medical staff and trainees on inpatient medical wards and outpatient clinics in rural districts hospitals and health centers as well as academic teaching centers.  These clinician educators are faced with a vast diversity of diseases, including but not limited to, HIV, tuberculosis, malaria, non-communicable diseases, oncology, and other tropical infectious diseases. They also supervise international trainees and students rotating from Brigham & Women’s Hospital and other international institutions, engage in quality improvement and research activities, and help to develop and implement innovative programs to strengthen health delivery.

Financial Support: The Brigham and Women’s/Faulkner hospitalist program provides hospitalist salary support and full benefits package, including malpractice insurance and health insurance. PIH provides international airfare as well as full accommodations while at PIH sites. Successful candidates will also have the opportunity for academic appointment at Brigham and Women’s Hospital and a diversity of professional development opportunities.

Qualifications:

  • ABIM board-certification or board-eligibility in internal medicine or internal medicine / pediatrics; candidates with sub-specialty interests are welcome to apply
  • Board-eligible graduating senior medical residents are eligible to apply
  • A desire to gain experience with health care delivery in sub-Saharan Africa
  • A talent for teaching and an interest in medical education and quality improvement
  • Flexibility, humility, creativity and enthusiasm
  • A two-year commitment is encouraged but not required

Application and Contact Information: If you are interested in pursuing this opportunity, please submit your application at http://www.pih.org/pages/employment.  If questions, please contact Dr. Neil Gupta at ngupta@pih.org.

Information/Opportunities

Sign up to receive a complimentary e-subscription to The American Journal of Medicine in 2015! All you have to do is to complete the online form by December 8, 2014.  The subscription starts in January.

MD Fellowship Flyer V5

Financial Planning Webinar for New Physicians – CST

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

 

 

Upcoming Dates and Events

November 27, 2014 – Turkey Bowl

December 13, 2014 – DoM Holiday Party

Useful links

Internal Medicine Residency News, November 3, 2014

Mon, 11/03/2014 - 10:42
From the Director

We had a great Doctoberfest! Thanks again to everyone for their Go Green efforts, their participation in our WE CARE WEDNESDAYS, answering the trivia questions and enjoying some food and fun with our residency family.  Special thanks to all those who were on overnight on the “extra hour” longest night of the year.  We started our recruitment on Friday with “Prelim Day”, and got a chance to meet some fantastic students.  Categorical recruitment starts TODAY, and I hope that dinner was fun last night and look forward to an outstanding recruitment season.  An early thank you to our stellar recruitment team of the chiefs, Erin Payne, Lynsey Michnowicz, Lauren Dincher, and Jen Averitt, as well as the APDs, advisors, attendings who interview, Dr. Klotman and, of course, our fabulous residency team who are the real reason that applicants want to become DUKE RESIDENTS!

Turkey bowl practice gets serious now, with the last of the combined practices happening on Sunday.  Look out for memes pitting Ryan Schulties against Coach G and Krish Patel as the game day approaches.

Kudos this week go to Sam Lindner from the gen med nursing staff for outstanding communication on the floors, to Sarah Nelson from her VA Gen Med team for excellent professionalism, to Zach Wegermann for helping with paging on gen med, and to our residency council (especially Azalea Kim and Jenny Van Kirk) for planning a fantastic residency halloween party.

This week’s pubmed from the program goes to Jim Lefler for his 1st place presentation at the national Medicine Psychiatry meeting entitled “Shift Work”.  Congratulations Jim!

Have a great week!

Aimee

What Did I Read This Week?

Submitted by: Aaron Mitchell, MD

Aaron Mitchell, MD

James C. Robinson, PhD, MPH; Kelly Miller. Total Expenditures per Patient in Hospital-Owned and Physician-Owned Physician Organizations in California. JAMA 2014;312(16):1663-1669.

http://jama.jamanetwork.com/article.aspx?articleid=1917439

Why did I read this:

One of my biggest interests in health care policy is the high cost of care, and the factors that cause it to be so high. The role of hospital consolidation in contributing to this problem is something I have been following closely.

I encountered this particular article in assembling my weekly email summary of health care policy articles. Let me know if you want to subscribe!

Background:

The United States has a serious problem with health care costs. We spend about 18% of our GDP on health care, compared to 9-12% for most other developed countries. As the Baby Boom generation ages and we docs continue to discover new and expensive treatments, the public financing of medical care is putting an increasing strain on federal coffers.

One trend that seems to be contributing to the rise in costs is that of provider consolidation. Unlike most industries, where greater consolidation/integration leads to lower prices by producing economies of scale, the opposite seems to be true for health care. When one health system (typically a large, academic center) starts to buy up local hospitals and physician groups, prices tend to go up rather than down. This is likely because having a dominant market share puts the health system in a better bargaining position against insurers, allowing it to demand higher reimbursements.

More research on this trend can be found in these sources:

http://www.rwjf.org/en/research-publications/find-rwjf-research/2012/06/the-impact-of-hospital-consolidation.html

http://jama.jamanetwork.com/article.aspx?articleid=1769891

Results:

The primary outcome measure was the annual per-capita health care spending in California, according to the type of health care system. The three models of care were physician-owned, local hospital-owned, and multihospital systems. After adjusting for severity of illness and other factors, the authors found that costs were significantly higher in multihospital systems – nearly 20% more than in physician-owned organizations.

 

Conclusions:

While it may be that larger systems are better able to coordinate care (more timely communication between providers, fewer repeated tests, etc.), the authors conclude that whatever cost benefits there may be from large health care organizations appear to be outweighed by other factors.

For the hospital-owned organizations represented in this study, however, any resulting improvements in coordination were not associated with lower expenditures per patient…These findings are in contrast to the hope and expectation that organizational consolidation of physicians with hospitals would result in greater coordination, and hence lower expenditures.

In other words, big hospital systems = big costs. But what can be done to stop this trend and hold costs down? Other studies have shown that health outcomes are not noticeably better in large health systems. Would it help to link reimbursement more closely to care quality and outcomes? Maybe we will get a chance to see, as the ACA starts to head in that direction.

 

From the Chief Residents Grand Rounds

Fri., Nov. 7: Endocrine, Dr. Brittany Bohinc

Noon Conference Date Topic Lecturer Time Vendor 11/3/14  Interview Day  Lunch w/ applicants 12:00/Room 2002  Saladelia 11/4/14 MPeds Interview DayG Briefing Session  Lunch w/ applicantsDN 8277 12:00  Saladelia 11/5/14  Ambulatory Town Hall  Ambulatory leadership 12:15/Room 2002  China King 11/6/14  SAR Emergency Series: Antibiotic Choices and Management  Matt Hitchcock  12:00/Room 2001  Dominos  11/7/14  Interview Day  Lunch w/ applicants  12:00/MedRes Library                   From the Residency Office Recruitment 2014! Reminder to All Residents: Please email your recruitment buddies! This has such a large impact on their visit and is greatly appreciated!”

 

Pin Station Re-located

The pin station is the MedRes library has been re-configured so that images can be projected on the large screen for report.  If you need an individual pin station for work, please feel free to use the one in the front cubicle of the MedRes office, suite 8254.

 

Open Enrollment for Benefits Begins 10/27/14!

Enrollment Period is from October 27th – November 7th 2014.

Open Enrollment is the only time of year when all Duke employees can enroll in or change their medical, dental, vision and reimbursement account benefit selections. If you have questions about Open Enrollment, please contact Jill Watkins at 684-2897.

Housestaff Healthcare, Dental and Vision Premiums 2015

Open Enrollment Information

If you take no action during Open Enrollment, the selections you made for 2014 for your medical, dental, and vision coverage will continue for 2015. However, to continue to use a reimbursement account, you must re-enroll for 2015.

Reminder: Your coverage term for benefits through Duke HR is one year. Changes in plan coverage can only be made outside of the Open Enrollment period for life changing events.

Qualifying events include, but are not limited to:

  • Marriage, divorce, or legal separation,
  • Birth or adoption (or placement of adoption) of a child,
  • Death of a covered dependent,
  • Loss or gain of eligibility for insurance coverage for you or a covered dependent (coverage must not be a student or individual policy),
  • Change in spouse’s employment status, and
  • Change in health insurance eligibility due to a relocation of residence or work place.
  • Change in your child’s full-time student status(marriage, death, baby, job, etc).

Job changes within Duke (e.g. GME to Duke Faculty) are not considered a life changing event. Please keep this in mind when you finalize your enrollment.

Thanks for Another Amazing Doctoberfest!

Thank you for another amazing month of community building.  Thanks to “We Care Wednesdays”, donations will be made to the Lincoln Health Center and Durham Rescue Mission this week!  We loved hearing about everyone “goes green” and enjoying some special treats and festivities.  Many thanks to the residency council for a fabulous Halloween party!  Now, on to Movember!

  Register Now for BLS Blitz – November 10-14, 2014

Use the Swank system to register for BLS classes.  If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account.  You may register for one session.  Detailed Registration Instructions and Informational Flyer
When you attend class, arrive 15 minutes before session begins and you must have your:

  • Class Registration Confirmation
  • Duke ID Badge
  • AHA BLS Healthcare Provider Manual 2010

All sessions are held at Hock Plaza – G07 Auditorium.
Parking is not available at Hock Plaza.
No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.

Trent Center Colloquium Series

Please join us at the Trent Semans Center for Health Education, Room 4030 for this upcoming colloquium and forward to interested faculty, students, residents and fellows. Space is limited. RSVP by Wednesday, November 5: trent-center@duke.edu.

The slow food movement has transformed the ways we think about eating. Could a ”slow medicine” movement transform the ways we think about illness and health?  In this discussion of the work of the physician, historian, and writer, Victoria Sweet, we will consider what it means to renew the practice of medicine.

Abraham Nussbaum, MD, MA directs the adult inpatient psychiatric service at Denver Health. His research interests include the history of psychiatry, medical professionalism, psychiatric diagnosis, and the treatment of people with schizophrenia.

The Trent Center Colloquium Series explores interdisciplinary topics in ethics and the social and cultural aspects of medicine. It is an opportunity for interested faculty, students, residents and fellows to both engage with current scholarship and, through informal, lively conversation, find avenues for collaborative exchange. This talk is also part of the Theology, Culture and Medicine Seminar Series co-sponsored by the Duke Divinity School and the Trent Center.

 

Ebola Virus Updates in MedHub

Given the rapidly changing national and international response to Ebola, Duke University and Duke Medicine have established a centralized information resource to provide ongoing updates to employees, students, patients and other members of the Duke community.  The Ebola Resources website will be updated regularly with new information regarding Duke’s Ebola preparations, plans and policies.  The site features updates from Duke Medicine leadership, information session announcements, videos with Duke Medicine infectious disease experts sharing the latest information regarding the virus, and an overview of DUHS’ infection control preparations.

The link to Duke’s Ebola Resources website as well as CDC Ebola information, NC Medical Society Ebola update and ACGME Ebola guidance statement will be listed in MedHub with the GME News stories for the duration of the active Ebola virus period.

Partners In Health and BWH Hospitalist Program

PIH is currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) to join our teams in Rwanda, Haiti, and Malawi for the 2015-2016 academic year .  This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston.  Candidates interested in this exciting opportunity should submit an application at http://www.pih.org/pages/employment

before December 1, 2014, or can contact Dr. Neil Gupta at ngupta@pih.org.

Partners In Health and BWH Hospitalist Program

Background: Partners In Health (PIH) is a health and social justice organization with a mission to build high quality, comprehensive public health systems around the world.  PIH has partnered with local communities and governments over the past 25 years to provide high-quality health care to the poorest of the poor and train the next generation of physicians, nurses and public health professionals in countries around the world.

General Description: We are currently seeking excellent physicians in Internal Medicine (or Internal Medicine/Pediatrics) with strong interest in global health and medical education to join our teams in Rwanda, Haiti, and Malawi.  This full-time position provides an opportunity to serve as both a clinician educator at a PIH field site and as an academic hospitalist at Brigham & Women’s Hospital in Boston.

Specific Responsibilities: Internists at PIH field sites serve as clinician educators, working with local medical staff and trainees on inpatient medical wards and outpatient clinics in rural districts hospitals and health centers as well as academic teaching centers.  These clinician educators are faced with a vast diversity of diseases, including but not limited to, HIV, tuberculosis, malaria, non-communicable diseases, oncology, and other tropical infectious diseases. They also supervise international trainees and students rotating from Brigham & Women’s Hospital and other international institutions, engage in quality improvement and research activities, and help to develop and implement innovative programs to strengthen health delivery.

Financial Support: The Brigham and Women’s/Faulkner hospitalist program provides hospitalist salary support and full benefits package, including malpractice insurance and health insurance. PIH provides international airfare as well as full accommodations while at PIH sites. Successful candidates will also have the opportunity for academic appointment at Brigham and Women’s Hospital and a diversity of professional development opportunities.

Qualifications:

  • ABIM board-certification or board-eligibility in internal medicine or internal medicine / pediatrics; candidates with sub-specialty interests are welcome to apply
  • Board-eligible graduating senior medical residents are eligible to apply
  • A desire to gain experience with health care delivery in sub-Saharan Africa
  • A talent for teaching and an interest in medical education and quality improvement
  • Flexibility, humility, creativity and enthusiasm
  • A two-year commitment is encouraged but not required

Application and Contact Information: If you are interested in pursuing this opportunity, please submit your application at http://www.pih.org/pages/employment.  If questions, please contact Dr. Neil Gupta at ngupta@pih.org.

Information/Opportunities

Sign up to receive a complimentary e-subscription to The American Journal of Medicine in 2015! All you have to do is to complete the online form by December 8, 2014.  The subscription starts in January.

Career Fair-Chapel Hill

Financial Planning Webinar for New Physicians – CST

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

 

Upcoming Dates and Events

November 27, 2014 – Turkey Bowl

December 13, 2014 – DoM Holiday Party

Useful links

Internal Medicine Residency News, October 27, 2014

Mon, 10/27/2014 - 10:32

 

From the Director

Hi everyone!

Thank you all for the great birthday celebration, and especially for the photo book.  I love it, and am glad to have a chance to celebrate with you all.  Happy birthday also to Lynsey Michnowicz! We had a lot happening this week, with a great SAR talk by Deng Madut, an awesome chair’s by Sneha Vakamudi, the CIMIGRO med student event at Tyler’s (Chris Hostler gets to go to Tyler’s twice in ONE week!), a really fun lunch in the courtyard on Tuesday (thanks, chiefs, for planning it!), teaching by Joe Brogan captured on film, a farewell to our fantastic ACRs Claire Kappa, Adam Banks and Kevin Trulock, and ongoing Doctoberfest trivia.   Other kudos to Jay Mast from Jan Dillard, LCSW at the DOC for great patient-centered care.

In other big news this week…Marc Samsky and Sarah Goldstein got engaged! Erin and I were pretty psyched to have the first ever ring sent to the program office for pre-proposal safekeeping.  Also belated engagement congratulations to Bassem Matta, and also to Adam Banks.  And a belated wedding congratulations to Rachel Titerance Hughes and Daniel Hughes.

Recruitment officially kicks off this week! We have our Monday night party, and then prelim interview day on Friday, with the first categorical day on Monday Nov 3.  Thanks to all who have signed up for dinners, tours, resident share, etc.  It’s going to be a great season, and you all are the most important part!  The end of the week is the Residency Council’s annual Halloween Party, so get your costumes ready.

Welcome to our new ACRs John Wagener, Iris Vance and Christine Bestvina.  We need some Turkey Bowl trash talk to get started before the big game.

In other program news, the ITE scores will be sent to your advisors this week and also to each of you individually.  As a program, we did really well this year (great work!), and we will be doing some more analysis to see what areas we can improve on as a group.  With thanks to Katie Broderick-Forsgren and GME Concentration mentor Dr. Sue Woods, as well as the ambulatory team, we are looking to improve our ambulatory curriculum.  Please pay attention to the upcoming ambulatory evaluations and surveys, and get ready for the introduction of the Ambulatory Online PACE curriculum!

There are two opportunities this week to meet the editor of JAMA! Dr. Howard Bauchner will be speaking Monday at 11:45 in the Trent Siemans Center (med school) on cardiovascular guidelines and then at noon conference on Tuesday about careers in medicine.  Please take advantage of these great talks!

This week’s Pubmed from the Program goes to Mike Woodworth for his presentation at ID Week detailing the history and epidemiology of nocardia infections at Duke, as well as his outstanding ID grand rounds “Lung in the time of Nocardia”.  Great job, Mike.

 

Have a great week!

Aimee

What Did I Read This Week?

Submitted by: Saumil Chudgar, MD

Haubitz S, Hitz F, Graedael L, Batschwaroff M, et al. “Ruling Out Legionella in Community-Acquired Pneumonia.” Am J Med 2014; 127: 1010e11-1010e19.

Legionella Score in CAP

WHAT I READ THIS WEEK

 

What I read:

Haubitz S, Hitz F, Graedael L, Batschwaroff M, et al. “Ruling Out Legionella in Community-Acquired Pneumonia.” Am J Med 2014; 127: 1010e11-1010e19.

Legionella Score in CAP

Why did I read this?

I was recently on the Duke GM wards, and we had several patients with CAP. As per IDSA guidelines, we treated them either Ceftriaxone + Azithro/Doxy or with a respiratory FQ like Moxi or Levo. The causes of CAP (typicals versus atypicals) and therapy for CAP is one of my favorite questions to ask medical students. We always check people for Legionella even without risk factors and end up including therapy for it with the Azithro or the respiratory FQ. I saw this article so read it to see if it provides an easy method to exclude Legionella.

What I learned from reading this/thoughts on the article?

The authors sought to validate a predictive score proposed in 2009 that used 6 dichotomous risk factors: Temp > 39.4C, CRP > 189 mg/L, LDH > 225 mmol/L, Platelet count < 171, Na < 133, and “dry cough.” They used a preexisting database and had 1939 eligible patients who had at least 5 of the 6 variables available/recorded. Thirty-seven of these patients were diagnosed with Legionella (1.9%). 34/37 was diagnosed by positive urine Ag, 2 by positive respiratory culture, and 1 by blood culture. Univariate analysis was done with calculated AUC – 5 of the 6 variables had a strong association with Legionella (all but dry cough). Having a score of < 2 (none or only one factor present) had a sensitivity of 94.4% to rule out Legionella in CAP (NPV of 99.6%). The urinary antigen test has a sensitivity of 64 to 88%.

The authors suggest that in patients with a score < 2, further testing and coverage for Legionella only be used if the patient is felt to be high-risk for mortality or has a contributory history. I started the article very excited at the idea of a predictive score, but I do not think I am yet ready to use this in clinical practice. I only routinely obtain 4 of these 6 parameters in most patients with CAP whom I take care of – specifically, I rarely get an LDH or CRP unless there is another clinical indication to do so. I am not sure if it is worth adding those on versus getting a urinary Legionella antigen. One could argue the model has a higher sensitivity, but in practice, we do not tend to stop the macrolide if the patient is Legionella negative. So, does “ruling out” Legionella change our practice? The authors appropriately acknowledge studies that have shown potential anti-inflammatory benefits of macrolides even without atypical pneumonia present. I am interested to see how this score is applied further and what impact it may have on clinical practice.

Clinic Corner

Clinic Corner

Wanted to take this opportunity to share some results from last year’s Ambulatory QI project: “We Follow Up,” regarding the documented follow-up of laboratory and other testing ordered by y’all in your continuity clinics. This project was led, organized, and conducted by Jon Bae and Joel Boggan, with help from George Cheely as well as the Residency Program Office. And made possible, of course, by the JARs and SARs who did the SharePoint self-assessments. Aparna Swaminathan is currently working on writing these results up with Jon and Joel.

The objectives of the SharePoint individual performance Improvement modules in general are to give residents an opportunity their performance around a quality measure; encourage creative thinking about how to improve one’s own performance; to meet ACGME requirements of Practice-Based Learning and Improvement and Systems Based Practice; to provide skill-based training in quality improvement; and to improve the quality of the care we deliver to our patients.

This particular project was spurred in part in response to prodding from David Simel at the VA and others, and developed with the input of the Ambulatory Care Leadership Track (ACLT) residents and continuity clinic site directors at PRIME, Pickett Rd, and DOC.

METHODS: For the project, JARs and SARs were asked to review 20 clinic patient encounters during or after which they ordered any tests (excluding point-of-care), 10 of which had “significant” (i.e., abnormal, see table below) results; and to look for documentation or other charted evidence (e.g., web portal annotations) of communication with patients regarding these results in line with the following expectations:

 

All eligible test results should be followed-up, communicated to patient, and documented at a maximum of within 14 days of result.

All eligible test results with significant/abnormal results should be communicated to patient and documented within no more then 72 hours of test result

RESULTS: 68 second- and third-year residents completed both initial and follow-up self-assessments. A total of 3222 patient encounters with tests ordered by these residents in their own continuity clinics were reviewed; 1713 initially, 1509 in follow-up. Nearly a third (32%) of patients had “significant” results. All three clinics showed improvement; two of three with gains that were statistically significant.

 

 

 

 

 

 

*p-value <0.05

DISCUSSION: The failure to review and follow up on outpatient test results in a timely manner represents a patient safety and malpractice concern. Failures to document follow-up abnormal test results are also common in ambulatory care, averaging 7.1% in one review of 5400 primary care patients, ranging from 1-62% across studies included in a systematic review published in JGIM.

Surveys have found widespread dissatisfaction by primary care providers with their current systems to manage abnormal test results. Physicians who actively tracked their test orders to completion were also more likely to report being satisfied.

The good news is that when confronted with these facts in their own practice, however, residents responded by working to improve that practice – and succeeding!

(Sources: Int J Med Inform. 2003;71(2-3):137-49. Arch Intern Med. 2009;169(12):1123. J Gen Intern Med. 2011;27(10):1334.)

A cross-sectional survey of 216 primary care physicians (PCPs) that utilize a single electronic medical record (EMR) without computer-based clinical decision support.

The overall response rate was 65% (140/216Therefore, we sought to identify problems in current test result management systems and possible ways to improve these systems.

METHODS:

We surveyed 262 physicians working in 15 internal medicine practices affiliated with 2 large urban teaching hospitals (response rate, 64%). We asked physicians about systems they used and the amount of time they spent managing test results. We asked them to report delays in reviewing test results and their overall satisfaction with their management of test results. We also asked physicians to rate features they would find useful in a new test result management system.

 

 

From the Chief Residents Grand Rounds

Fri., Oct. 31: General Medicine, Dr. David Edelman

Noon Conference Date Topic Lecturer Time Vendor 10/27/14  Ebola  Cameron Wolfe 12:15/Room 2002 Rudinos 10/28/14  JAMA Editor In Chief  Howard Bauchner 12:00/Room 2002 Dominos 10/29/14  Inpatient Geriatric Medicine: Management & Pearls  H. Whitson 12:15/Room 2002 We Care Wednesday 10/30/14  Library Overview  Megan Von Isenburg  12:00/Room 2001  Subway  10/31/14  Research Conference  12:00/Room 2002  Panera                   From the Residency Office Recruitment Kick-Off! October 27th- Recruitment Kick Off Tonight! Join us at City Beverage at 7pm for appetizers, drinks, and a fun start to this season. We hope you can make it! Pin Station Re-located

The pin station is the MedRes library has been re-configured so that images can be projected on the large screen for report.  If you need an individual pin station for work, please feel free to use the one in the front cubicle of the MedRes office, suite 8254.

 

Open Enrollment for Benefits Begins 10/27/14!

Enrollment Period is from October 27th – November 7th 2014.

Open Enrollment is the only time of year when all Duke employees can enroll in or change their medical, dental, vision and reimbursement account benefit selections. If you have questions about Open Enrollment, please contact Jill Watkins at 684-2897.

Housestaff Healthcare, Dental and Vision Premiums 2015

Open Enrollment Information

If you take no action during Open Enrollment, the selections you made for 2014 for your medical, dental, and vision coverage will continue for 2015. However, to continue to use a reimbursement account, you must re-enroll for 2015.

Reminder: Your coverage term for benefits through Duke HR is one year. Changes in plan coverage can only be made outside of the Open Enrollment period for life changing events.

Qualifying events include, but are not limited to:

  • Marriage, divorce, or legal separation,
  • Birth or adoption (or placement of adoption) of a child,
  • Death of a covered dependent,
  • Loss or gain of eligibility for insurance coverage for you or a covered dependent (coverage must not be a student or individual policy),
  • Change in spouse’s employment status, and
  • Change in health insurance eligibility due to a relocation of residence or work place.
  • Change in your child’s full-time student status(marriage, death, baby, job, etc).

Job changes within Duke (e.g. GME to Duke Faculty) are not considered a life changing event. Please keep this in mind when you finalize your enrollment.

 

New Badge-Backers Required by GME

If you have not already done so, please come by the MedRes office as soon as possible and pick up your new badge backer that is required by GME.  The backers indicate your level of training via a color-coded system and are necessary to ensure appropriate levels of supervision are in place at all times.  In addition, they more clearly ID you as a Doctor to all patients, visitors and staff!

 

CLER Visit Information

As part of the ACGME Accreditation System, we will participate in a CLER (Clinical Learning Environment Review) at some point during the current academic year.  We will only be given 2-weeks notice prior to the visit.  There is a large amount of helpful information, for both faculty and trainees, located in the Resource/Documents area of MedHub, as well as this great informational flyer put together by the GME office.  Please take time to review it and if you have any questions about the visit, do not hesitate to contact the MedRes office or the GME office.

 

Doctoberfest is Coming to an End!

DOCTOBERFEST IS HERE! “This is OUR Community” October 1-31, 2014

Thank you to everyone who has planned for an participated in our annual Doctoberfest celebration!  Look for some special treats on Halloween as we mark the end of Doctoberfest and the beginning of Recruitment!

Fun Lunch Day -Taco Tuesday

How Do YOU Go Green? – Ride a bike to work? Use a recyclable water bottle? We want to hear how YOU Go Green both at home and at work! Please feel free to come by the MedRes office and post your ideas on our Go Green wall, or submit them online using the link below. All submissions will be entered in our weekly drawings for gifts and prizes and all of the ideas will be compiled and shared at the end of the month. Bleed Blue/Live Green!!

https://duke.qualtrics.com/SE/?SID=SV_9TBHGku53op13uJ

 

Flu Vaccination Update

**Please Note: There has been an issue with the EOHW reporting system not showing compliance even if you got your shot at a Duke facility.  If you have gotten your flu shot but are still showing as non-compliant, please contact the MedRes office.

If you have not yet gotten your shot, please see the information below for locations where you can have it done.  If you have any questions, please call EOHW 684-3136

A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

 

Register Now for BLS Blitz – November 10-14, 2014

Use the Swank system to register for BLS classes.  If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account.  You may register for one session.  Detailed Registration Instructions and Informational Flyer
When you attend class, arrive 15 minutes before session begins and you must have your:

  • Class Registration Confirmation
  • Duke ID Badge
  • AHA BLS Healthcare Provider Manual 2010

All sessions are held at Hock Plaza – G07 Auditorium.
Parking is not available at Hock Plaza.
No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.

 

 

Trent Center Colloquium Series

Please join us at the Trent Semans Center for Health Education, Room 4030 for this upcoming colloquium and forward to interested faculty, students, residents and fellows. Space is limited. RSVP by Wednesday, November 5: trent-center@duke.edu.

The slow food movement has transformed the ways we think about eating. Could a ”slow medicine” movement transform the ways we think about illness and health?  In this discussion of the work of the physician, historian, and writer, Victoria Sweet, we will consider what it means to renew the practice of medicine.

Abraham Nussbaum, MD, MA directs the adult inpatient psychiatric service at Denver Health. His research interests include the history of psychiatry, medical professionalism, psychiatric diagnosis, and the treatment of people with schizophrenia.

The Trent Center Colloquium Series explores interdisciplinary topics in ethics and the social and cultural aspects of medicine. It is an opportunity for interested faculty, students, residents and fellows to both engage with current scholarship and, through informal, lively conversation, find avenues for collaborative exchange. This talk is also part of the Theology, Culture and Medicine Seminar Series co-sponsored by the Duke Divinity School and the Trent Center.

 

Information/Opportunities

Career Fair-Chapel Hill

Biomedical Informatics Research Training Opportunity

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

 

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

November 27, 2014 – Turkey Bowl

Useful links

Boole selected as 2015-16 VA chief resident for quality improvement and patient safety

Tue, 10/21/2014 - 13:39

Lindsay Boole, MD, MPH, senior assistant resident, has been chosen to serve as the Durham VA Medical Center chief resident for quality improvement and patient safety for 2015-16.

Dr. Boole will be part of a network of such chief residents across the country who lead quality improvement (QI) projects and receive expert training from mentors. She will also participate in a national curriculum meant to help usher in a new generation of QI leaders who will help residents implement QI initiatives.

Boole will work closely with David Simel, MD, vice chair for Veterans Affairs in the Department of Medicine, and her predecessors Ryan Schulteis, MD, Joel Boggan, MD, MPH and Aaron Mitchell, MD.

“Lindsay has excellent quantitative skills already, and brings to the chief residency her interest in global health,” said Dr. Simel. “Her clinical interest is in sepsis, as she recognizes that the best way to prevent deaths from sepsis in both the developing work and at home is prevention. This creates nice opportunities for her to learn and teach quality improvement, and the QI techniques will strengthen and help formulate her role in future studies.”

Boole earned her MD and masters of public health (Epidemiology) degrees, with summa cum laude and Alpha Omega Alpha honors, from Emory University. During medical school, she conducted research in Haiti and Zambia, and she is currently an Internal Medicine resident in Duke’s unique Global Health Residency and Fellowship Pathway. She will be spending the next several months as a Fogarty Fellow at Moi University in Kenya, where she will conduct a clinical trial of an algorithm for management of severe sepsis.

Boole will begin as chief resident for quality improvement and patient safety in July 2015. After her year as chief resident, she intends to pursue fellowship training in Pulmonary and Critical Care Medicine, with a research focus on implementation science and the management of sepsis in critical care and low resource settings.

Internal Medicine Residency News, October 20, 2014

Mon, 10/20/2014 - 11:05
From the Director

It’s getting really close to recruitment time….prelim intern day is Oct 31, and the first categorical applicants (aka “future Duke residents”) join us on Monday Nov 3. I took a few minutes to read through all of your profiles on the website the other day – it looks fantastic! We are really excited about the upcoming recruitment season, and look forward to showing what makes the Duke Medicine residency family so great.  Interns are starting BLOCK 5 tomorrow…officially 1/3 down!  Plus it was a beautiful weekend  for a Duke win and some turkey bowl practice!  Glad to hear our “choosing wisely” teams are off to a great start, led by Lish Clark and Aaron Mitchell.

Kudos this week to Venu Reddy from his VA team (Amanda Verma, Alana Lewis and Maggie Infeld) for being a great teacher and help on day float, to Marc Samsky for an excellent chair’s conference, to Brian Andonian from Bassem Matta for great work at the VA, and to Cards fellow Alex Fanaroff from the CCU teams.  Also congrats to Jenny Van Kirk for being our “Go Green” Doctoberfest winner of the week.

We had a fantastic celebration this week of the 20th Anniversary of the VA PRIME Clinic.  What started as the brainchild of Dr David Simel and former Duke/DVAMC attending Dr. Sheri Keitz has grown into a 52 resident clinic serving > 2500 patients.  Hearing one of the PRIME patients speak about what the clinic means to him was very powerful, and it was wonderful to see the whole PRIME team there celebrating.  See some of the attached pictures, including resident speaker Kevin Trulock!

 

Interested in health care? (that should be a rhetorical question, folks)…if you are able, please join Kevin Shah and others at the 2014 Duke MBA Health Care Conference Curing Health Care Through Innovation

Date: Saturday, November 15, 2014

Time:8:15 am – 6:00 pm

Location:Duke University, the Fuqua School of Business

Register:Please visit the conference website

*Admission is FREE and open to the public, but space is limited

This week’s Pubmed from the program goes to Dinushika Mohottige for her incredible work on residentmurmurs.org.  One of the best parts of working with you all is finding out new things about you – this is yet another on my list of how you all amaze me!

Have a great week

Aimee

What Did I Read This Week?

Submitted by: Sharon Rubin, MD

Use of 13- Valent Pneumococcal Conjugate vaccine and 23- Valent Pneumoccocal Polysaccharide vaccine Adults Aged > 65 years: Recommendations of the Advisory Committee on Immunization Practices (ACIP)” page 822 in Morbidity and Mortality Weekly Report, from Centers for Disease Control and Prevention, Volume 63, No. 37, September 19, 2014.

http://www.cdc.gov/mmwr/pdf/wk/mm6337.pdf

What I Read This Week:

We discussed at the ambulatory meeting the need to educate all internal medicine residents of the new CDC recommendations for 13-Valent pneumococcal vaccine (PCV13/Prevnar 13) and when to vaccinate in relation to 23-Valent pneumococcal vaccine (PPSV23/Pneumovax23).

Why the change in recommendation?

Since the introduction of PCV13 vaccination in children, this has reduced pneumococcal infections directly and indirectly in children and INDIRECTLY in adults (almost 50%). But there were some pneumonia cases still caused by PCV13 strains that could have been prevented if patients were vaccinated. The CAPiTA Trial conducted in the Netherlands in 2008-2013 in 85,000 adults age >65 verified 45.6% efficacy of PCV13 in preventing pneumococcal pneumonia. 2 randomized, multi centered studies showed PCV13 was able to elicit more immune response than PPSV23. Studies show better immune response when PCV13 is given first then 1 year later give PPSV23. Probablistic models show decreased pneumonias and additional health benefits. PCV 13 + PPSV23 gives broader coverage of more bacteria subtypes.

Sequential administration and recommended intervals

  • Age> 65, if it has been 12 months since their last PPSV23 OR if they are due for a PPSV23, administer the PCV-13 first and then administer PPSV23 6-12 months later.
  • If they received  Pneumovax 23 at age <65, it should be 6-12 months before they receive PCV-13 after the age of 65.  Then 5 years since first PPSV23, revaccinate with PPSV23.

Practicality/Cost: Medicare will only pay for 1 pneumonia vaccine.  So if patients have already received Pneumovax and they are given PCV-13, you should ask them to sign an ABN and let them know they may receive a bill for this.  At Pickett we have been printing out the PCV13 prescription and allowing patients to obtain at pharmacies for ~$100.

For review ACIP recommendations for PCV13

  • in adults >19 years with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid leak or cochlear implants. Immunize with PCV13 first then 8 weeks later, immunize with PPSV23.
  • Adults aged 19 years or older with the aforementioned conditions who have previously received one or more doses of PPSV23 should receive a dose of PCV13 one or more years after the last PPSV23 dose was received. For those that require additional doses of PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years since the most recent dose of PPSV23.
  • When indicated, PCV13 should be administered to patients who are uncertain of their vaccination status history and there is no record of previous vaccination.

For review ACIP recommendations for PPSV23

Pneumovax

  • Adults younger than age 65 years with chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma); chronic cardiovascular diseases; diabetes mellitus; chronic renal failure; nephrotic syndrome; chronic liver disease (including cirrhosis); alcoholism; cochlear implants; cerebrospinal fluid leaks; immunocompromising conditions; and functional or anatomic asplenia (eg, sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least two weeks before surgery]);
    — Residents of nursing homes or long-term care facilities; and
    — Adults who smoke cigarettes.
  • Revaccination with PPSV23
  • One-time revaccination 5 years after the first dose is recommended for persons aged 19 through 64 years with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (eg, sickle cell disease or splenectomy); and for persons with immunocompromising conditions.
  • Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis.
  • When cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be at least two weeks. Vaccination during chemotherapy or radiation therapy should be avoided.

 

Clinic Corner

Will return next week…stay tuned!!

QI Corner

Aaron Mitchell, MD

A big thank-you to everyone on the Choosing Wisely team. We are off to a great start already!

This week we will be having our first department-wide Morbidity and Mortality conference of the academic year. This will be in the Grand Rounds time slot on Friday morning. We have a great case to discuss, so I look forward to seeing everyone there.

In a note that has nothing at all to do with quality improvement, I wanted to make sure that everyone knows that the state fair is happening all this week in Raleigh! Especially for everyone who is new to NC, take this opportunity get out, have some fun, learn about your new home state, and eat some deep-fried Oreo cookies.”

Aaron P. Mitchell

Chief Resident for Quality and Patient Safety

Durham VA Medical Center

From the Chief Residents Grand Rounds

Fri., Oct. 17: Stead Speaker/Alumni Weekend, Dr. John B. Simpson (Avinger)

Noon Conference Date Topic Lecturer Time Vendor 10/20/14 Interpretation of PFTs C. Giovacchini/Hargett 12:15 Dominos 10/21/14 Fun Lunch 12:00 10/22/14 COPD Management & Pearls Scialla 12:15 We Care Wednesday 10/23/14 SAR Emergency Series: Diabetes Emergencies Deng Madut  12:00  China King  10/24/14  Chair’s Conference Chiefs  12:00  Picnic Basket                   From the Residency Office

 

Kudos from Dr. Rivelli for the MedPsych Team!

Duke Medicine-Psychiatry had an exceptionally strong showing at the national Association of Medicine and Psychiatry Oct 10-11th.  Jim Lefler (PGY3) won 1st place in the Vignette Competition and Greg Brown (PGY4) won the Best Poster Award.  Both very well deserved!  Also thanks go to Jane Gagliardi for organizing a great meeting.  There were also excellent oral presentations by MedPsych faculty Wei Jiang, Chris Kenedi, Kristen Shirey and Jason Webb.

Many Thanks to Dr. Eugene Oddone! I wanted to share with you that Dr. Eugene Oddone recently made a very generous donation to SENIOR PHARMASSIST in our name, in honor of The Kerby Society’s win last year for having the highest response rates on the housestaff survey.  And even better news – his donation was matched by another donor.  Thank you , Dr. Oddone!!Best,Heather E. Whitson, MD, MHS

New Badge-Backers Required by GME

If you have not already done so, please come by the MedRes office as soon as possible and pick up your new badge backer that is required by GME.  The backers indicate your level of training via a color-coded system and are necessary to ensure appropriate levels of supervision are in place at all times.  In addition, they more clearly ID you as a Doctor to all patients, visitors and staff!

CLER Visit Information

As part of the ACGME Accreditation System, we will participate in a CLER (Clinical Learning Environment Review) at some point during the current academic year.  We will only be given 2-weeks notice prior to the visit.  There is a large amount of helpful information, for both faculty and trainees, located in the Resource/Documents area of MedHub, as well as this great informational flyer put together by the GME office.  Please take time to review it and if you have any questions about the visit, do not hesitate to contact the MedRes office or the GME office.

Doctoberfest is Going Strong!

DOCTOBERFEST IS HERE! “This is OUR Community” October 1-31, 2014

Join the Internal Medicine Residency Program in our 3rd annual Doctoberfest celebration! This year our continued focus will be on building and strengthening our community – both locally and on a global scale!

October 1, 2014 will mark the start of our Doctoberfest celebration with “We Care Wednesdays.” A special treat will be provided during Noon Conference to kick things off!

How Do YOU Go Green? – Ride a bike to work? Use a recyclable water bottle? We want to hear how YOU Go Green both at home and at work! Please feel free to come by the MedRes office and post your ideas on our Go Green wall, or submit them online using the link below. All submissions will be entered in our weekly drawings for gifts and prizes and all of the ideas will be compiled and shared at the end of the month. Bleed Blue/Live Green!!

https://duke.qualtrics.com/SE/?SID=SV_9TBHGku53op13uJ

October 21 is “Taco Tuesday!”

Join us in the Duke Hospital Courtyard (across from Starbucks) for a special lunch to honor our house staff. Eat, relax and re-connect with your friends and colleagues!

October 31 As Doctoberfest 2014 draws to a close, enjoy some Halloween treats of donuts and cider as we welcome our first group of applicants on our 1st official recruiting day!

Flu Vaccination Update

**Please Note: There has been an issue with the EOHW reporting system not showing compliance even if you got your shot at a Duke facility.  If you have gotten your flu shot but are still showing as non-compliant, please contact the MedRes office.

If you have not yet gotten your shot, please see the information below for locations where you can have it done.  If you have any questions, please call EOHW 684-3136

A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

Register Now for BLS Blitz – November 10-14, 2014

Use the Swank system to register for BLS classes.  If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account.  You may register for one session.  Detailed Registration Instructions and Informational Flyer
When you attend class, arrive 15 minutes before session begins and you must have your:

  • Class Registration Confirmation
  • Duke ID Badge
  • AHA BLS Healthcare Provider Manual 2010

All sessions are held at Hock Plaza – G07 Auditorium.
Parking is not available at Hock Plaza.
No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.

 

Trent Center Colloquium Series

Please join us at the Trent Semans Center for Health Education, Room 4030 for this upcoming colloquium and forward to interested faculty, students, residents and fellows. Space is limited. RSVP by Wednesday, November 5: trent-center@duke.edu.

The slow food movement has transformed the ways we think about eating. Could a ”slow medicine” movement transform the ways we think about illness and health?  In this discussion of the work of the physician, historian, and writer, Victoria Sweet, we will consider what it means to renew the practice of medicine.

Abraham Nussbaum, MD, MA directs the adult inpatient psychiatric service at Denver Health. His research interests include the history of psychiatry, medical professionalism, psychiatric diagnosis, and the treatment of people with schizophrenia.

The Trent Center Colloquium Series explores interdisciplinary topics in ethics and the social and cultural aspects of medicine. It is an opportunity for interested faculty, students, residents and fellows to both engage with current scholarship and, through informal, lively conversation, find avenues for collaborative exchange. This talk is also part of the Theology, Culture and Medicine Seminar Series co-sponsored by the Duke Divinity School and the Trent Center.

Open Enrollemnt for Benefits Begins 10/27/14!

Enrollment Period is from October 27th – November 7th 2014.

Open Enrollment is the only time of year when all Duke employees can enroll in or change their medical, dental, vision and reimbursement account benefit selections. If you have questions about Open Enrollment, please contact Jill Watkins at 684-2897.

Housestaff Healthcare, Dental and Vision Premiums 2015

Open Enrollment Information

If you take no action during Open Enrollment, the selections you made for 2014 for your medical, dental, and vision coverage will continue for 2015. However, to continue to use a reimbursement account, you must re-enroll for 2015.

Reminder: Your coverage term for benefits through Duke HR is one year. Changes in plan coverage can only be made outside of the Open Enrollment period for life changing events.

Qualifying events include, but are not limited to:

  • Marriage, divorce, or legal separation,
  • Birth or adoption (or placement of adoption) of a child,
  • Death of a covered dependent,
  • Loss or gain of eligibility for insurance coverage for you or a covered dependent (coverage must not be a student or individual policy),
  • Change in spouse’s employment status, and
  • Change in health insurance eligibility due to a relocation of residence or work place.
  • Change in your child’s full-time student status(marriage, death, baby, job, etc).

Job changes within Duke (e.g. GME to Duke Faculty) are not considered a life changing event. Please keep this in mind when you finalize your enrollment.

 

Movember is Coming!

Colleagues and Friends,

November is nearly upon us – a time of fall leaves, turkey bowl, and most importantly hideous facial hair.  For the past 3 years, Duke internal medicine residents have grown mustaches for Movember. This year, our Urology colleagues have asked us to formally join them in this endeavor and raise money for a good cause.  Please contact Dr Kevin Shah <kevin.shah@dm.duke.edu> if you’d like to participate!

 

Information/Opportunities

Biomedical Informatics Research Training Opportunity

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

http://www.endocrine.org/meetings/regional/endocrine-essentials-live/charlotte-october-25

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

September 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2

2015 – 2017 Kraft Fellowship in Community Health (Deadline 10/15/14)

http://www.summitsps.com/

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

November 27, 2014 – Turkey Bowl

Useful links

Internal Medicine Residency News, October 13, 2014

Mon, 10/13/2014 - 09:19
From the Director

Hello everyone! Lots of great GME news this week…..first of all….the cafeteria is re-opening at night! We learned on Wednesday at the ICGME meeting that starting in November, the Duke North cafeteria will have nighttime hours, with both hot food and “grab-and-go” items.  Many thanks to the GME reps, Dr. Kuhn and Carolyn Carpenter (DUHS) for making this happen.  Also, the ACGME-sponsored iCOMPARE duty hours study has been approved and we are one of the sites, along with 57 other IM programs nationwide.  We will hear more in the coming weeks which arm we are randomized to for next year, so we will keep you all posted on what to expect.  As a reminder, the study is a one-year randomized trial of current duty hours rules versus duty hours flexibility (keeping the 80 hour work week, no more frequent call than q3 and also 1 day off in 7).  Once we know more, I look forward to thoughtful discussions with you all regarding what changes we would make in the schedule.

Kudos this week go to our global health presenters Dan Pugmire, Iris Vance, Joe Brogan for presenting at Global Health Gallops, and to Adrienne Belasco for a great chair’s conference.  Other kudos to Kahli Zietlow, overheard teaching her medical student on gen med, and from Alicia Clarke to our night float team of Ryan Jessee, Brian Sullivan, Kristen Glisinski, Matt Turrissini and Eric Yoder for great work on a busy night, also to Brian Sullivan from Steve Telloni for a fantastic transfer note.  Kudos also to Jenny Van Kirk from the 7100 and 7300 teams for great patient care and communication! And, kudos to Winn Seay from Devi Desai on 9300 for excellent work with the prm team!

It’s getting seriously close to Turkey Bowl….thank you to Jay Mast for continuing to organize practices.  The game will be at the Githens Field again this year, we look forward to having a great game and a big supporting crowd in the “stands”.  Doctoberfest continues as well. Congrats to Myles Nickolich as our “Go Green” winner last week.  Also congratulations to our conference attendance winners for the first quarter….stop by the office for your prizes.

Grand rounds attendance:

Pascale Khairallah and David Kopin– 8 each

Marc Samsky– 7

Michael Woodworth– 5

Noon Conference attendance (ACRs don’t count!) :

Michael Dorry—42!!!! WOW!

Amy Jones—21

Carli Lehr—25

This week’s pubmed from the program goes to MSIV and current sub-I Allison Webb for her article in Academic Medicine!  A First Step Toward Understanding Best Practices in Leadership Training in Undergraduate Medical Education: A Systematic Review Allison M.B. Webb, MAT, Nicholas E. Tsipis, Taylor R. McClellan, Michael J. McNeil, MengMeng Xu, Joseph Doty, PhD, and Dean Taylor, MD

What Did I Read This Week?

Submitted by: Aimee Zaas, MD

Clinical Management of Staphylococcus aureus Bacteremia

by Tom Holland, Chris Arnold and Vance Fowler. This article was published in JAMA 2014;312(13)1330-41.

What I Read This Week:

I read “Clinical Management of Staphylococcus aureus Bacteremia” by our very own Tom Holland, Chris Arnold and Vance Fowler. This article was published in JAMA 2014;312(13)1330-41.

Why did I read this? A number of reasons….we see A LOT of S. aureus bacteremia here, the attributable mortality is high, it is a required ID consult and in support of our colleagues who wrote a very high impact article.

What Did the Authors Do? This is a review article, performed in a rigorous manner. To find appropriate articles, the authors did two literature searches: 1) Pubmed 1968-May 2014, to find studies addressing the fundamental question of “What is the role of echocardiography in the management of SAB?” and 2) Pubmed, EMBASE and Cochrane Library to address the question of “What is the optimal treatment of SAB?” They then used the well accepted Grades of Recommendation, Assessment, Development and Evaluation system, with two authors needing to form a consensus opinion on the quality of evidence.

What Did They Find?

Background: The annual incidence of SAB is 4.3-38.2 per 100000 person years. 30 day all cause mortality is 20%.

It is well established that all patients with SAB should undergo the following

  • thorough history and physical exam, with attention to finding metastatic foci of infection
  • obtaining follow up bcx to document clearance of infection
  • “source control” – drain abscess and remove infected prosthetic material

The role of Transthoracic (TTE) vs transesophageal (TEE) echocardiography is more nuanced. Infective endocarditis (IE) is a serious complication of SAB that affects treatment and prognosis, however can be difficult to distinguish clinically from uncomplicated SAB. In all patients with SAB, you should ask the question “Does my patient have IE?”

To address the question regarding TTE vs TEE, 79 publications were identified, with 9 (totaling 4050 patients) met the predefined inclusion criteria. Despite this, the 9 studies were rated as being low or very low quality, as they were observational and limited by sampling bias (patients who undergo TEE have a higher pretest probability of IE than those who don’t).   Nonetheless, among the 6 studies that used both TTE and TEE, TEE identified IE in 14-28% of patients compared to TTE (2-15%). Two single center studies (rated as low quality) showed that TEE reclassified patients with negative TTE approximately 15-19% of the time.

Importantly, low risk criteria for having IE (and thus avoiding TEE if TTE is negative) were shown in 5 studies. These factors are lack of intracardiac device (pacer, ICD), sterile follow up bcx 4 days after initial set, not on HD, nosocomial acquisition of SAB, absence of secondary foci of infection and no clinical signs of IE. NPV for these ranged from 93-100%.

SO…what is the role of echocardiography in SAB? All patients should get some type of echo (TEE vs TTE). Choice of TTE instead of TEE may be made if your patient falls in the low risk category. Additionally, if other factors (osteo, abscess) dictate longer therapy AND bacteremia is resolved, perhaps TEE is not necessary as well.

To address the question of therapy for MRSA IE, 81 of 1876 studies found met inclusion criteria. Again, evidence quality was not great, with 1 study as high quality, 3 moderate, 22 low and 55 very low. The high quality trial was the NEJM comparison of vancomycin versus daptomycin for SAB and right sided IE. In this study, vancomycin plus short course low dose gentamicin was compared to either antistaphyloccal PCN + gent (MSSA) or daptomycin. Treatment with daptomycin was deemed noninferior (44% vs 42% success rate) to the other therapies.

Authors did not find evidence to support the idea that daptomycin (standard or high dose) was superior to vancomycin for SAB with higher vancomycin MICs. Linezolid has also been studied and was noninferior to vancomycin in open label study of suspected catheter related BSI. However, there is a black box warning for empiric use of linezolid in catheter related BSI if gram negatives are suspected due to a higher overall death rate in the linezolid arm. There is limited low quality data for use of TMP SMX, telavancin, ceftaroline and dalbavancin.

Evidence suggests that vancomycin or daptomycin are first line therapy for MRSA BSI.

Duration of treatment for uncomplicated SAB (no ID, no devices, follow up bcx are negative at 2-4 days, defervesce at 72 hours and no metastatic infection) can likely be treated for 14 days past the last positive blood culture. Complicated SAB should have 4-6 weeks of treatment.

Other pearls: for MRSA, you do not need to add gent or rifampin.

For MSSA, while the quality of evidence is low to suggest that anti-staph beta lactams are better than vanc, however if your patient reports PCN allergy, you may consider skin testing as a cost effective alternative to vancomycin treatment.

Overall, this article provides well-written and clear guidance for workup and treatment of SAB, answering (to the best of the current evidence), the status quo for SAB. It is interesting to note that the articles we quote regularly around here regarding diagnosis and management of SAB, while they are the best we have, often do not meet the GRADE criteria for high or moderate quality evidence. As they say in most papers, more studies are needed!

Clinic Corner

Remember to wear pink this month for Breast Cancer awareness!

Pickett road has had some additions! Christine Mitchell has moved from the front desk as a PSA to the CMA position. Kelly Sullivan will start as our new LPN in Triage in November. There will a shuffle of attendings in March 2015. We welcome Dr. Audrey Metz to Wednesday morning, Dr. Boinapally to Tuesday morning, Dr. Brown to Thursday afternoon.

Pickett Road has been piloting Lunch Topics this past month. We have discussed vaccines, the new indications for pneumovax 13/Prevnar, What to do with abnormal Paps and next week will be the complicated topic of chronic narcotics.

October is Mini CEX is month. We are doing well and most residents are on their 2nd mini cex. We always can be better with our style and this is a good way to get feedback. Interns- this is so in January you need 3 in order to see patients alone. Jars and SARs this is for multiple sign out.

Beaker transition has been as expected, an adjustment. I forwarded 7 POC orders from Marie, our Super User. Not much has changed other than the printing process is a work in progress for the rooming nurses- have patience with them! Ask Marie or Valencia if there are questions.

Have a great weekend and see you next week!

Sincerely

Sharon

QI Corner

Aaron Mitchell, MD

Thanks to everyone who came to last week’s PSQC meeting! We were able to identify the three areas of care that residents felt are the best “low hanging fruit” to go after to reduce wasteful care within Duke Internal Medicine. Those three areas are:

  1. Excessive ordering of daily labs
  2. Unnecessary telemetry
  3. Reflexive “FFWU” leading to low-yield testing

Each of these projects has a team of residents that will be working on it. We are going to be meeting again this week, 5:30pm on Wednesday, to divide into teams and get the projects moving. If you would like to get involved in one of these initiatives from the beginning and haven’t already signed up, let me know or come join us on Wednesday.

From the Chief Residents Grand Rounds

Fri., Oct. 17: Stead Speaker/Alumni Weekend, Dr. John B. Simpson (Avinger)

Noon Conference Date Topic Lecturer Time Vendor 10/13/14 MKSAP Mondays: Benign Hematology: Anemia/Thrombocytopenia A. Mitchell 12:15 Nosh 10/14/14 Review of Peripheral Blood Films M. Arcasoy 12:15  Domino’s 10/15/14 Approach to Anemia  A. Mitchell 12:15 We Care Wednesday 10/16/14  Approach to Thrombocytopenia A. Mitchell/Metjian  12:00  Sushi  10/17/14  Chair’s Conference Chiefs  12:00  Chick-Fil-A                   From the Residency Office

A BIG “Thank You” from Dr. Arcasoy to Lynsey Michnowicz in the Med Res office for her help in putting together a comprehensive mentorship database for the residency program!

Doctoberfest is off to a great start!

DOCTOBERFEST IS HERE! “This is OUR Community” October 1-31, 2014

Join the Internal Medicine Residency Program in our 3rd annual Doctoberfest celebration! This year our continued focus will be on building and strengthening our community – both locally and on a global scale!

October 1, 2014 will mark the start of our Doctoberfest celebration with “We Care Wednesdays.” A special treat will be provided during Noon Conference to kick things off!

How Do YOU Go Green? – Ride a bike to work? Use a recyclable water bottle? We want to hear how YOU Go Green both at home and at work! Please feel free to come by the MedRes office and post your ideas on our Go Green wall, or submit them online using the link below. All submissions will be entered in our weekly drawings for gifts and prizes and all of the ideas will be compiled and shared at the end of the month. Bleed Blue/Live Green!!

https://duke.qualtrics.com/SE/?SID=SV_9TBHGku53op13uJ

October 15 A special German beer garden-style treat!

October 21 Join us for a special lunch to honor our house staff. Eat, relax and re-connect with your friends and colleagues!  More details to follow!

October 31 As Doctoberfest 2014 draws to a close, enjoy some Halloween treats of donuts and cider as we welcome our first group of applicants on our 1st official recruiting day!

Flu Vaccination Update

**Please Note: There has been an issue with the EOHW reporting system not showing compliance even if you got your shot at a Duke facility.  If you have gotten your flu shot but are still showing as non-compliant, please contact the MedRes office.

If you have not yet gotten your shot, please see the information below for locations where you can have it done.  If you have any questions, please call EOHW 684-3136

A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

The VA PRIME Clinic 20th Anniversary Celebration

Please join us for the celebration, Friday, October 17th, from 11:30am – 1:00 pm.  Please the flyer for more details!

Register Now for BLS Blitz – November 10-14, 2014

Use the Swank system to register for BLS classes.  If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account.  You may register for one session.  Detailed Registration Instructions and Informational Flyer
When you attend class, arrive 15 minutes before session begins and you must have your:

  • Class Registration Confirmation
  • Duke ID Badge
  • AHA BLS Healthcare Provider Manual 2010

All sessions are held at Hock Plaza – G07 Auditorium.
Parking is not available at Hock Plaza.
No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.

 

Women In Medicine Event

The Duke Medical Alumni Association invites you to join us for the inaugural Women in Medicine Luncheon and Program

Friday, October 17, 2014  |  11:45am-1:45pm

Great Hall, Trent Semans Center for Health Education

The luncheon program features a panel discussion of Duke Medicine alumnae followed by roundtable conversations on issues specific to women in medicine.

ETHOS for Noon Conference Attendance Tracking!

You MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!  Please make sure that you enter your Duke Unique ID and NOT your Net ID!  If your unique ID is entered incorrectly, you will not get credit for attending the conference!

 

Information/Opportunities

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

http://www.endocrine.org/meetings/regional/endocrine-essentials-live/charlotte-october-25

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

September 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2

2015 – 2017 Kraft Fellowship in Community Health (Deadline 10/15/14)

http://www.summitsps.com/

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

November 27, 2014 – Turkey Bowl

Useful links

Internal Medicine Residency News, October 6, 2014

Mon, 10/06/2014 - 11:59
From the Director

Hello everyone!

Happy Week 2 of Doctoberfest! What a beautiful weekend for Turkey Bowl practice! Our “Go Green” tree and our recycling corner in the med res office look great — stop in and let us know what you do to “Go Green”.  We will be having some drawings for prizes from the “Bleed Blue, Go Green” team at Duke. Other Doctoberfest prizes will go to those with best attendance at noon conferences and Grand Rounds.  Don’t forget “We Care Wednesday” this week –we will announce the winners of our charity vote.  And, of course, more trivia!

Believe it or not, less than one month til recruitment officially begins! Please look for emails from Erin regarding signing up for dinners, for resident share, and for sending in pictures for our lunchtime slideshow.  If you haven’t updated your profile on the website, now is a great time to do so!

Congratulations this week to our recipients of the first annual Stead Research Grant Awards, sponsored by the Stead Scholarship Fund.  Special thanks to Chris Woods, Ravi Karra and Karen Alexander for offering us this fantastic opportunity.  Our recipients this year are Dinushika Mohottige, Kahli Zietlow, Ben Peterson, Lindsay Boole, Ryan Jessee, Jessie Seidelman, Julia Cupp, Aparna Swaminathan and Amanda Verma.  Fantastic work, and thank you to your mentors Dani Zipkin, Ebony Boulware, Mitch Heflin, Al Sun, Nathan Thielman, Kim Huffman, Cary Ward, Jeffrey Crawford, Jon Bae and Mike Felker.

Other kudos this week to Brian Sullivan from Steve Telloni for an outstanding transfer summary, as well to Ryan Jessee and Paul St Romain for outstanding work at the DOC.

Also please welcome the newest member of the Duke Family….Ezra Oliver Peterson! The whole family is doing great.

This week’s pubmed from the program goes to Allyson Pishko for her abstract acceptance at the annual American Society of Hematology meeting with mentor Gow Arepally “Predicting the Temporal Course of Laboratory Abnormality Resolution in Patients with Thrombotic Microangiopathy”

Have a great week!

Aimee

What Did I Read This Week?

Submitted by: Murat Arcasoy, MD

Rethinking the Social History

Behrorouz et al. NEJM 371:1277, 2014 October 2

This was a wonderful article in last week’s NEJM discussing how social factors may influence the effectiveness of health care delivery. In our busy daily practices, pressed for time, we frequently focus on racial/ethnic background, occupation, and the common “TED” questions ie the use of tobacco, ethanol, and drugs, as major social determinants of health. All too often, other important social factors that may influence health outcomes may not be discussed during patient encounters.

In this article, the authors advocate for adopting “ the social medicine framework- that enables us to contextualize patient care to achieve more sustainable and equitable health outcomes.” The task of social medicine as described by the authors is “ to elucidate how patients’ environments influence their attitudes and behaviors and how patients’ agency- the ability to act in accordance with their free choice- is constrained by challenging social environments.”

The authors recommend that we as providers obtain a more comprehensive social history to strengthen our therapeutic alliance with patients and in turn improve health outcomes. The list of topics is quite extensive, so I listed a few examples, grouped under 6 categories: 1-individual characteristics (self-defined race, language, literacy…) 2- life circumstances (family structure, housing environment, legal/immigration issues..), 3-emotional health (emotional state, stressors..) , 4-perception of health care (life goals and priorities, alternative care practices..), 5-health-related behaviors (diet and exercise, barriers to medication adherence…), 6-access to and utilization of health care (insurance status, medication access and affordability..)

There are many challenges (other than being pressed for time) for the clinician to obtain a more comprehensive and proper social history. What is the appropriate timing, first visit, return appointment, annually…? Have we explored our own prejudices that influence our ability to obtain proper social history ? Do we possess (or have we been taught) the interviewing skills to deliberately extract this information from patients?

This article encourages me to pay more in-depth attention to the social forces that influence my patients’ lives and their health outcomes and serve as better advocates for them. I hope I can take advantage of every opportunity to provide more personalized care through effective shared decision making, taking into account my patients’ complex social environments.

Rudolph Virchow, while contributing greatly to our understanding of cells and pathology, was also concerned with improving public health. He wrote “ if medicine is to fulfill her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society? ”

The authors end their article with a quote by William Osler: “The good physician treats the disease; the great physician treats the patient who has the disease”

 

Clinic Corner

Hello Team DOC!

You may have noticed that morale among our amazing nursing staff is running a bit low. They have been understaffed lately, and they are working really hard to get everything done for the clinic – which is especially tough with flu shot season in full swing, plus the usual steady stream of messages and refills and on-site needs. Please give them some props for their hard work (and keep up with your in-basket messages!!).

Beginning in October, the DOC is assigning an employee of the month, and the winner this month is ROBIN CLAUD-EVERETT!! Please pat Robin on the pat, tell her she’s doing great, or bring her a treat. Thanks so much!! We know that you are all overworked too, and that you all deserve the same kindness. Let’s spread it around all over the place!

Attached, please find the DOC Newsletter for October 2014, with a psychiatry services theme, and Natasha’s alcohol abuse algorithm.

See you back at the goose farm,

Dani

 

QI Corner

Aaron Mitchell, MD

First, I want to give a “final” call for anyone who is interested in leading a project for the Duke Choosing Wisely campaign. Several of the low-value items that your peer residents have named as important areas to target as improvement include excessive daily labs, overuse of telemetry, and non-indicated hyper-coagulability workups, to name a few. If you want to join in the effort to cut out the waste and improve patient care, please let me know ASAP.

Second, a reminder that the next PSQC meeting will be this week, Wednesday at 5:30pm in the med res library. We will probably spend a good amount of the time organizing for the Choosing Wisely campaign, so this would be another great way to get involved.

Finally, an update on the SRS reporting for the GME incentive program. Through September, we are up to 110 total SRS reports by trainees…but that leaves 1,862 more for the rest of the year to reach our goal (and get the $200). They don’t take much time at all to do, and you don’t have to wait until something bad actually happens to submit! You can use them for near-misses and unsafe situations as well.

 

Jul-14 Aug-14 Sep-14 SRS by Trainee 23 45 42 SRS ALL 1447 1459 1398 % by Trainee 2% 3% 3% Total Submitted by Trainees (YTD) 23 68 110 Total Trainees 986 Average report per trainee 0.023326572 0.068965517 0.111561866 Goal (2/trainee) 1972 Total Remaining Needed 1949 1904 1862

 

From the Chief Residents Grand Rounds

Fri., Oct. 10: Hematology, Dr. Thomas Ortel

Noon Conference Date Topic Lecturer Time Vendor 10/6/14  MKSAP Mondays: Hepatology  B.Oloruntoba 12:15  Cosmic Cantina 10/7/14  MED-PEDS Combined: Global Health GallopsDr. G’s Briefing Dr. Galanos 12:1512:15  Domino’sRm. 8277 10/8/14  Approach to Abnormal LFTS  V. Patel 12:15 We Care Wednesday 10/9/14  Complications of Cirrhosis: Management & Pearls  B.Oloruntoba  12:00  China King  10/10/14  Chair’s Conference Chiefs  12:00  Mediterra                   From the Residency Office Doctoberfest is Here!

DOCTOBERFEST IS HERE! “This is OUR Community” October 1-31, 2014

Join the Internal Medicine Residency Program in our 3rd annual Doctoberfest celebration! This year our continued focus will be on building and strengthening our community – both locally and on a global scale!

October 1, 2014 will mark the start of our Doctoberfest celebration with “We Care Wednesdays.” A special treat will be provided during Noon Conference to kick things off!

How Do YOU Go Green? – Ride a bike to work? Use a recyclable water bottle? We want to hear how YOU Go Green both at home and at work! Please feel free to come by the MedRes office and post your ideas on our Go Green wall, or submit them online using the link below. All submissions will be entered in our weekly drawings for gifts and prizes and all of the ideas will be compiled and shared at the end of the month. Bleed Blue/Live Green!!

https://duke.qualtrics.com/SE/?SID=SV_9TBHGku53op13uJ

October 20 Join us for a special lunch to honor our house staff. Eat, relax and re-connect with your friends and colleagues!  More details to follow!

October 22 A special German beer garden-style treat!

October 31 As Doctoberfest 2014 draws to a close, enjoy some Halloween treats of donuts and cider as we welcome our first group of applicants on our 1st official recruiting day!

Flu Vaccination Update

 If you have not yet gotten your shot, please see the information below for locations where you can have it done.  If you have any questions, please call EOHW 684-3136

A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

 

Register Now for BLS Blitz – November 10-14, 2014

Use the Swank system to register for BLS classes.  If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account.  You may register for one session.  Detailed Registration Instructions and Informational Flyer
When you attend class, arrive 15 minutes before session begins and you must have your:

  • Class Registration Confirmation
  • Duke ID Badge
  • AHA BLS Healthcare Provider Manual 2010

All sessions are held at Hock Plaza – G07 Auditorium.
Parking is not available at Hock Plaza.
No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.

 

Women In Medicine Event

The Duke Medical Alumni Association invites you to join us for the inaugural Women in Medicine Luncheon and Program

Friday, October 17, 2014  |  11:45am-1:45pm

Great Hall, Trent Semans Center for Health Education

The luncheon program features a panel discussion of Duke Medicine alumnae followed by roundtable conversations on issues specific to women in medicine.

 

Medical Education Grand Rounds Session

Healthcare Simulation: Past, Present & Future

with Dr. Jeffrey Taekman (Assistant Dean for Educational Technology; Director, Human Simulation and Patient Safety Center)

Tuesday, October 7th 4pm – 5pm (DMP 2W96)

Wednesday, October 8th 12noon – 1pm (DMP 2W96)

Thursday, October 9th 7am – 8am (DMP 2W96)

Session Objectives: 

  • Discuss the essential features that define a MOOC (massive open online course).
  • Discuss the opportunities for Duke Medicine faculty to participate in MOOCs as learner or instructor.
  • Characterize the impact of the initial MOOCs for medical education.

If you haven’t already done so, register using the following link: https://duke.qualtrics.com/SE/?SID=SV_dijxCxDP2C9H6M5 

ETHOS for Noon Conference Attendance Tracking!

You MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!  Please make sure that you enter your Duke Unique ID and NOT your Net ID!  If your unique ID is entered incorrectly, you will not get credit for attending the conference!

 

Provider List for Housestaff

Just a reminder that a list of healthcare and dental services providers for house staff his provide here, as well as in the Resources area of MedHub.  Many thanks to Dr. Sue Woods for her assistance in compiling this list!

 

Information/Opportunities

CJW – Hospitalist (9-26-2014)

http://www.endocrine.org/meetings/regional/endocrine-essentials-live/charlotte-october-25

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

September 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2

2015 – 2017 Kraft Fellowship in Community Health (Deadline 10/15/14)

http://www.summitsps.com/

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

Useful links

Internal Medicine Residency News, September 29, 2014

Mon, 09/29/2014 - 10:23
From the Director

Doctoberfest begins this week! We are looking forward to a month of building community, within and outside the residency program.  We will kickoff on Wednesday with our first “We Care Wednesday”..thank you to Residency Council Chairs Nick and Katie for helping us choose our charitable donation sites.  Trivia starts Wednesday as well, so keep a lookout in your emails for the (almost) daily questions.  I have my re-certification for ID at the end of the month, so I will do my best not to make it entirely ID themed!

Kudos this week go to the MICU team of Myles Nickolich, Amy Lee, Jon Buggey, Jon Hansen, Adva Eisenberg and Jason Zhu from Talal Dahhan and Craig Rackley.  7 weeks with a STELLAR crew.  Also kudos to Mike Woodworth and Nick Wisnoski for their excellent SAR talks.  Thank you also to Matt Hitchcock for encouraging Martin Society to get their flu shots.  However….Kerby has done it again! The Kerby Society maintains their title of the Fastest Flu Shots in the Program…see the photo of Kerby leader Heather Whitson and her kids getting shots (no tears!) as well as the incredible team spirit of our APD for QI and Patient Safety Lish Clark… makes all of those other flu shot posters look bad! Congratulations to Kerby Society as well as to Lish and Alan on their wedding this past weekend.

Regardless of winning or not, GO GET THAT FLU SHOT! 

 

This weeks pubmed from the program goes to Nick Rohrhoff….Rohrhoff N, Vavalle JP, Halim S, Kiefer TL, Harrison JK. Current status of percutaneous PFO closure. Curr Cardiol Rep. 2014 May;16(5):477.

Have a great week and HAPPY DOCTOBERFEST!

Aimee

What Did I Read This Week?

Submitted by: Alex Cho, MD, MBA

Feinglos MN, Thacker CR, Lobaugh B, DeAtkine DD, McNeill DB, English JS. Combination insulin and sulfonylurea therapy in insulin-requiring type 2 diabetes mellitus. Diabetes Research & Clinical Practice 1998;39(3):193-99. (http://www.sciencedirect.com/science/article/pii/S0168822798000035)

Background:

It is not uncommon for patients, particularly very obese patients with Type 2 diabetes, to require high daily doses of insulin, sometimes totaling >100 U a day. However, the administration of large boluses of exogenous insulin may have its own deleterious effects, including weight gain from appetite stimulation and even atherosclerosis from the resulting hyperinsulinemic state. Thus, combinations of therapies that can reduce a patient’s insulin total insulin requirement would appear to be desirable, and may actually lead to superior control over time.

As a result, the combination of certain oral agents (i.e., metformin) with insulin in general has also become commonplace, but as the slow emergence of the use of newer GLP-1 agonists alongside long-acting insulins suggests, these combinations are not necessarily self-evident.

In this classic RCT conducted right here at Duke, Drs Feinglos, McNeill and colleagues sought to address the very important safety and efficacy questions associated with the use of insulin secretagogues such as glipizide alongside NPH and regular insulin – a combination that may strike some as odd, and perhaps potentially unsafe, but presents for our uninsured patients at the DOC a more affordable option, potentially, than even glargine insulin.

Purpose:

“To determine the effect(s) on glucose control, insulin dose, and circulating insulin levels of the addition of a sulfonylurea (glipizide) to the treatment regimen of patients with insulin-requiring type 2 diabetes mellitus.”

Methods:

Design – Randomized, double-blind, placebo-controlled, crossover clinical trial

Patient Population – Patients were recruited at large from the Duke University Medical Center and Durham community. They were majority female, with a mean age of 56, mean BMI was 32.7, mean total daily insulin dose was 80.8 U, and mean glycated hemoglobin was 12.1%.

Intervention / Control – Participants were assigned to one of two conditions: current insulin regimen + glipizide vs. current insulin regimen + placebo, for an initial 3-month treatment period. This was followed by a one-month “wash-out” period, prior to initiating a second 3-month treatment period, with crossover to the other study drug (glipizide vs. placebo). Participants were hospitalized (in the Duke Clinical Research Unit) at the beginning and end of each three-month treatment period for initiation of treatment, measurements, and titration of insulin regimens; followed by weekly telephone calls and monthly outpatient visits.

Regimens were titrated based on patients response to therapy, resulting in glipizide doses from 5 to 40mg daily, and 1-3 NPH and regular insulin injections daily, with total daily doses ranging from 40 to 210 U.

Blinding – Blinded

Analysis – Repeated measures multi-factor analysis of variance design, which included the sequence of treatment conditions as a factor. Analysis limited to the 29 patients who demonstrated a significant C-peptide response to a test meal.

Outcomes – Fasting plasma glucose, mean 24-hour plasma glucose, glycated hemoglobin, total daily insulin dose, free insulin, BMI.

Validity

Patients were blinded and randomized, with a wash-out period in-between treatment conditions. They were also very intensively followed. Overall numbers were small, but the crossover condition guaranteed the treatment groups were more or less identical. A subset of patients was selected for analysis based on biological factors (production of endogenous insulin). The effect of treatment sequence was assessed and found not to be a significant factor.

Results

“The fasting plasma glucose in the I+G arm was 6.8 (121.8 mg/dl) vs. 8.7 mmol/L (156.0 mg/dl) in the I+P arm, P<0.001. Mean plasma glucose over 24 hours was 9.8 (176.9 mg/dl) for I+G vs. 11.3 mmol/L (203.8 mg/dl) for I+P, P<0.00l. Glycated hemoglobin was significantly different (9.8 I+G vs. 11.4% I+P, P<0.008). The total daily insulin dose required was significantly lower with I+G (69.1 vs. 87.3 U, P<0.0005). However, there were no significant differences in free insulin levels.” BMI was also not statistically different between the two groups. Sixty-nine episodes of mild hypoglycemia were recorded, with only six instances of moderate symptomatic hypoglycemia, and only one of these required assistance from another individual.

Comments

The results of this well-done RCT show that for patients with insulin-requiring diabetes, the combination of a sulfonylurea and insulin can lead to lower total insulin requirements and improved control, and can be safely administered. An important caveat is that in order for sulfonylureas to be effective, a patient still has to be making their own endogenous insulin (this is also true for the newer GLP-1 agonists); which suggests that this option be considered relatively early in a patient with Type 2 diabetes whose insulin requirements appear to be rapidly accelerating.

One particular use case Dr Feinglos offers would be for patients whose sugars appear to spike in the early AM, to combine bedtime NPH and an oral sulfonylurea with breakfast. One also wonders if the results of this study and others that have demonstrated the long-term superiority of metformin + insulin regimens vs. insulin-only ones also suggest that closely monitored “triple therapy,” might not only be possible, but preferable.

Bottom Line:
For patients with insulin-requiring diabetes who still make their own insulin, the combination of a sulfonylurea and insulin appears to lead to lower total insulin requirements and improved control. This regimen has the added benefit for uninsured or low-income patients of being considerably more affordable.

Clinic Corner

Ambulatory Clinic Corner

Interested in doing a QI or research project in one of the continuity clinics?

Just wanted to advertise the availability of a couple of different data sets from your clinics for possible resident projects. In VA PRIME, Sonal Patel worked with NC State industrial engineering professor Javad Taheri to gather time-stamp data on clinic workflow; and produce modeling of the different steps in the patient visit. This work has informed some of the staffing requests that Sonal has made for PRIME, but could potentially answer other questions as well. Contact Sonal for more information.

At the DOC, third-year Duke medical student and MPP candidate Mark Dakkak has helped construct a database of over 250 clinical and other variables on the over 4000 patients who receive their primary care there, plus AHRQ and other “groupers” that allow the categorization of patients into relevant groups. Contact Alex Cho for more information.

 

From the Chief Residents Grand Rounds

Fri., Oct. 3: Oncology, Dr. Andrew Armstrong

Noon Conference Date Topic Lecturer Time Vendor 9/29/14 MKSAP Mondays- Endocrine/Diabetes Chiefs 12:15 Nosh 9/30/14 SAR Talks: CV Complications of Diabetic CKD Ragnar Palsson 12:15 Dominos 10/1/14 Essentials of Oral Hypoglycemics: Case Studies Diana McNeill 12:15 We Care Wednesday 10/2/14 IM-ED Combined Conference: Healthcare waste and excessive testing Dr. Kaplan/Room 2001  12:00 Subway  10/3/14  Chair’s Conference Chiefs  12:00 Chick Fil A                   From the Residency Office Doctoberfest is Here!

DOCTOBERFEST IS HERE! “This is OUR Community” October 1-31, 2014

Join the Internal Medicine Residency Program in our 3rd annual Doctoberfest celebration! This year our continued focus will be on building and strengthening our community – both locally and on a global scale!

October 1, 2014 will mark the start of our Doctoberfest celebration with “We Care Wednesdays.” A special treat will be provided during Noon Conference to kick things off!

How Do YOU Go Green? – Ride a bike to work? Use a recyclable water bottle? We want to hear how YOU Go Green both at home and at work! Please feel free to come by the MedRes office and post your ideas on our Go Green wall, or submit them online using the link below. All submissions will be entered in our weekly drawings for gifts and prizes and all of the ideas will be compiled and shared at the end of the month. Bleed Blue/Live Green!!

https://duke.qualtrics.com/SE/?SID=SV_9TBHGku53op13uJ

October 20 Join us for a special lunch to honor our house staff. Eat, relax and re-connect with your friends and colleagues!  More details to follow!

October 22 A special German beer garden-style treat!

October 31 As Doctoberfest 2014 draws to a close, enjoy some Halloween treats of donuts and cider as we welcome our first group of applicants on our 1st official recruiting day!

Flu Vaccination Update

Congratulations to the Kerby Society for reaching 100% as of 9/26/14!

As a program, you all have done an AMAZING job getting your flus shots!  As of today, 9/29/14, we are at 93.4% compliant across the program – FABULOUS job!  If you have not yet gotten your shot, please see the information below for locations where you can have it done.  If you have any questions, please call EOHW 684-3136

A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

Flu Vaccination Rates by Stead Society as of 9/29/14:

Martin – 93.3%

Warren – 94.6%

Orgain – 90.9%

Kerby – 100%

Kempner – 88.6%

Program as a whole (including all combined programs)  – 93.4%

 

Register Now for BLS Blitz – November 10-14, 2014

Use the Swank system to register for BLS classes.  If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account.  You may register for one session.  Detailed Registration Instructions and Informational Flyer
When you attend class, arrive 15 minutes before session begins and you must have your:

  • Class Registration Confirmation
  • Duke ID Badge
  • AHA BLS Healthcare Provider Manual 2010

All sessions are held at Hock Plaza – G07 Auditorium.
Parking is not available at Hock Plaza.
No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.

 

Women In Medicine Event

The Duke Medical Alumni Association invites you to join us for the inaugural Women in Medicine Luncheon and Program

Friday, October 17, 2014  |  11:45am-1:45pm

Great Hall, Trent Semans Center for Health Education

The luncheon program features a panel discussion of Duke Medicine alumnae followed by roundtable conversations on issues specific to women in medicine.

 

Now Accepting Applications for Global Health Elective Rotations

 

 

 

Developing the next generation of globally educated, socially responsible healthcare professionals dedicated to improving the health of disadvantaged populations.

Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016. Application is open to residents from Departments of Medicine: Internal Medicine (PGY 2); Med-Peds (PGY 3) and Med-Psych (PGY 4). Access the application form and FAQ at http://dukeglobalhealth.org or submit online http://bit.do/HYC-submit.

(Application addendum is available by request – tara.pemble@duke.edu)

Application deadline is September 30, 2014. Interviews held during October. We strongly encourage you to speak with past participants to get a better idea of what daily life is like on the wards of your top sites. For more information, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.

Duke Global Health Internal Medicine Pathway applications are due October 1, 2014!

The Basics

18 month extended residency encompassing:

  • 9 months enrolled in Duke’s Master of Science in Global Health degree program
  • 9 months providing clinical care and conducting mentored research overseas

The Benefits

In addition to the standard salary and benefits package commensurate with post-graduate

Year, trainees benefit from:

  • Masters of Science in Global Health degree tuition covered by the program ($50,000)
  • $6,500 international travel stipend which also covers immunizations, passport and visa fees, foreign medical license fees, and foreign language training
  • $7,450 in research grant funds for fellows enrolled in the MSc-GH

Please visit our website for an in-depth description of the core curriculum including rotations, global health competencies, and program requirements:  www.dukeglobalhealth.org

ETHOS for Noon Conference Attendance Tracking!

You MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!  Please make sure that you enter your Duke Unique ID and NOT your Net ID!  If your unique ID is entered incorrectly, you will not get credit for attending the conference!

How do I Set up an ETHOS account for the first time?

How to register with Ethos

  • Go to the Duke Continuing Medical Education home page.
  • In the upper right corner, click Join. The Account Information page opens.
  • Complete the fields on the screen. A field with an asterisk is required.
  • NOTE:  Please make sure you include your Duke Unique ID– even though it does not show as a required field.
  • Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
  • At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you provided.
  • Open the email (from dcri.cme@dm.duke.edu) and click the top link in the body of the message.
  • In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
  • In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
  • Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
  • Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.

To record your CME attendance via text message, follow these steps

  • The 6-character SMS code will be provided on a slide during your CME event.
  • Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
  • In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
  • In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
  • Press send.
  • If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”

To add your Duke Unique ID to your account

  • Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
  • Enter your username and password. Click My Account in the upper right corner.
  • Under My Profile, click Edit
  • Scroll down until you see Duke Unique ID filed.  make sure it is correct
  • Save the changes to you My Profile page

 

Information/Opportunities

September 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2

2015 – 2017 Kraft Fellowship in Community Health (Deadline 10/15/14)

Duke Headache Specialist

http://www.summitsps.com/

 

Upcoming Dates and Events

October 1 – DOCTOBERFEST begins!

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

Useful links

 

Internal Medicine Residency News, September 22, 2014

Mon, 09/22/2014 - 10:14
From the Director

Hope you are having a great weekend!

Block 4 for interns starts today! The ERAS applications opened this week and we already have over 2800 intern applicants.  Turkey Bowl practice is in full swing (thank you to JAY MAST for keeping everyone organized and excited for the upcoming VA vs Duke annual match-up).  Right now, the flu shot competition is ongoing….help your Stead Society be the first to get 100% vaccinated.  Last year, our entire residency was vaccinated in 10 days! Can we beat it?  See below for current standings!

Shots available at Duke, DRH and the clinics to all Duke employees – bring your ID! Lish Clarke may even use her blue flu shot bandaid as “something blue” in her upcoming wedding (well, maybe not, but that is a sign of how dedicated we are to STOPPING THE FLU!)

Kudos this week go to Joanne Wyrembak for an outstanding chair’s conference of a case of a gentleman with Pott’s disease.  Other kudos go to Amy Jones for offering 3 Duke football tickets to everyone (as well as a belated thanks to Dr. Chris O’Connor for offering tickets the past few weeks) and to Matt Atkins from Pascale Khairallah for being an outstanding team leader at the VA.   Also kudos to all who presented at our resident M and M this week – great discussion led by Lish and Aaron, with outstanding presentations by many of you.  Your participation and willingness to share is much appreciated and truly helps us build a culture of safety here in our program.  We are also excited about the upcoming Choosing Wisely-Duke Med Res initiative – the meeting was well attended with support from Lish, Aaron and Dr. Woods, and some fantastic ideas for our campaign were discussed.

Thank you also to everyone who has updated their resident profile for the website.  Applicants tell us that the #1 thing they look at in a program is the residents, and we want to keep getting outstanding people like you into the program!

Thank you to Sarah Rivelli for compiling a list of support resources for house staff.  The list can be found in Medhub in a resource folder labeled “Support”.  We also have our upcoming “G-briefing” of difficult cases with Dr. Galanos on Friday at noon.  Please feel free to attend!

Get ready for the Fourth Annual DOCTOBERFEST: This is OUR Community, October 1 – 31, 2014

We are working to build our community, within the program, within Durham and globally.  Highlights will include daily trivia, peer recognition, donation of some of our food dollars to local hunger related charities and increased focus on our “Go Green” initiative.  If you have ideas about how we can further build our community, whether within the program, in Durham or globally, please let me or Jen Averitt know and we will work to incorporate those ideas into Doctoberfest!

This week’s pubmed from the program goes to Ani Kumar for his upcoming ORAL ABSTRACT PRESENTATION at the American Heart Association annual meeting “Persistent Thrombocytopenia after Myocardial Infarction is Associated with Increased Short- and Long-Term Mortality”.

Have a great week!

Aimee

What Did I Read This Week?

The “What Did I Read This Week” feature will return next week!

Clinic Corner

VA PRIME Clinic Corner

 Hi everyone,

PRIME clinic is celebrating its 20th year of service providing resident education and care to our veterans.  There will be an open house on October 17th at 11-1pm.   Please stop by and join in the celebration.

Also for those of you that were not aware… we are collecting patient and staff feedback in the form of “WOW” awards.  Each month we tally the comments and present an ImPACT award to the person with that shows caring and dedication to PRIME clinic and helping our veterans.  For the month of August,  Marc Samsky won!  Please stop and congratulate him when you see him next.   I also wanted to share some positive comments that we have received:

Dr. Brown

On every appointment

You are great and I noticed!!!

Professional, caring Doctor always listens and helps with meds.  Enjoy my relationship with the VA and prime D people.

 

Dr. Boutte

On 07/07/2014

You are great and I noticed!!!

Prime visit, great service

 

Everyone

On 07/09/2014

You are great and I noticed!!!

Always have had excellent care with respect

 

Dr. Titerence

On 07/09/2014

You are great and I noticed!!!

Excellent attitude, very caring (Great Person)

 

Doctor Broderick

On 07/09/2014

You are great and I noticed!!!

Very good doctor take time to explain everything to me and she cares about my health.

 

Dr. Foster

On 07/21/2014

You are great and I noticed!!!

Dr. Foster is a credit to the VA-shows great concern for me the patient and explains clearly diagnosis and possible remedies-Great lady!

Please know that your passion for PRIME clinic does NOT go unnoticed.  Staff and veterans are so honored to work with you as you complete your residency.  Thank you for all that you do and please stop by to celebrate 20 years of excellent service.

PRIME staff

QI Corner

Aaron Mitchell, MD

Thanks to everyone who came out this week for our M&M “special edition” of procedure-related events. And, of course, an even bigger thanks to Matt, Jonathan, Jay, Aparna, Adam, and Marc for volunteering to discuss their cases with us. Remember – always confirm you are in the vein before dilating, and NEVER recap a sharp!

The high-value care team also had a great meeting this week, and came up with some great ideas for ways to reign in wasteful testing and spending here at Duke. Stay tuned as these plans start to get underway.

 

From the Chief Residents Grand Rounds

Fri., Sept.26, 2014: Neurology, Dr. Richard Bedlack: ALS and Patient Advocacy

Noon Conference Date Topic Lecturer Time Vendor 9/22/14 SAR Emergency Series: Alcohol Withdrawal Nick Wisnoski 12:15 Picnic Basket 9/23/14 SAR Emergency Series: Septic Shock Mike Woodworth 12:15 Domino’s 9/24/14 Residency Council Town Hall Residency Council 12:15 Cosmic Cantina 9/25/14 Videoconference: Ebola in Nigeria Faisal Shuaib  12:15 Subway  9/26/14  Research Conference/Debriefing  Room 2002  12:00 Panera                   From the Residency Office Flu Vaccination Blitz is On!!

As you know, Duke University Health System (DUHS) requires all healthcare workers who perform their duties in a DUHS facility or a community home-based setting to be vaccinated annually against the flu. This is in alignment with our core value of “caring for our patients, their loved ones and each other.” Annual vaccination against influenza, or policy compliance through a granted medical or religious exemption, is a condition of employment for all DUHS employees. Annual vaccination or policy compliance is also a condition of access to Duke Medicine facilities for those holding clinical privileges in a Duke Medicine facility and learners who wish to train in our facilities.

With this in mind, please note these key dates for this flu vaccination season:

  • Start of Flu Vaccination Season: Thursday, September 18, 2014
  • Applications for Medical or Religious Exemption should be submitted before Friday, October 17, 2014.  This will allow sufficient time for review and for communication of the review decision. Please note: Due to the availability of an egg-free formulation of the flu vaccine, egg allergy will no longer be a valid reason for a medical exemption.
  • Policy compliance through vaccination or granted exemption by Monday, November 17, 2014

A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

Flu Vaccination Rates by Stead Society as of 9/22/14:

Martin – 63.3%

Warren – 43.2%

Orgain – 36.4%

Kerby – 36.4%

Kempner – 14.3%

Program as a whole (including all combined programs)  – 38.1%

 

Register Now for BLS Blitz – November 10-14, 2014

Use the Swank system to register for BLS classes.  If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account.  You may register for one session.  Detailed Registration Instructions and Informational Flyer
When you attend class, arrive 15 minutes before session begins and you must have your:

  • Class Registration Confirmation
  • Duke ID Badge
  • AHA BLS Healthcare Provider Manual 2010

All sessions are held at Hock Plaza – G07 Auditorium.
Parking is not available at Hock Plaza.
No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.

 

Women In Medicine Event

The Duke Medical Alumni Association invites you to join us for the inaugural Women in Medicine Luncheon and Program

Friday, October 17, 2014  |  11:45am-1:45pm

Great Hall, Trent Semans Center for Health Education

The luncheon program features a panel discussion of Duke Medicine alumnae followed by roundtable conversations on issues specific to women in medicine.

 

 

The Residency Office is now Green Certified!

Thanks to efforts led by Lauren Dincher, our office is now a certified a Duke Green Workplace!

We will be including more information about how everyone can become more involved with improving your home and work environments in the coming weeks as part of DOCTOBERFEST - stay tuned!

 

 

Now Accepting Applications for Global Health Elective Rotations

 

 

 

Developing the next generation of globally educated, socially responsible healthcare professionals dedicated to improving the health of disadvantaged populations.

Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016. Application is open to residents from Departments of Medicine: Internal Medicine (PGY 2); Med-Peds (PGY 3) and Med-Psych (PGY 4). Access the application form and FAQ at http://dukeglobalhealth.org or submit online http://bit.do/HYC-submit.

(Application addendum is available by request – tara.pemble@duke.edu)

Application deadline is September 30, 2014. Interviews held during October. We strongly encourage you to speak with past participants to get a better idea of what daily life is like on the wards of your top sites. For more information, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.

ETHOS for Noon Conference Attendance Tracking!

AS of 9/8/14 we now ONLY use ETHOS for tracking attendance.  Most of you should already have an ETHOS account which you use for tracking your attendance at Grand Rounds, but EVERYONE should read the following instructions carefully, as it applies to new and current account holders.  You MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!  Please make sure that you enter your Duke Unique ID and NOT your Net ID!  If your unique ID is entered incorrectly, you will not get credit for attending the conference!

How do I Set up an ETHOS account for the first time?

How to register with Ethos

  • Go to the Duke Continuing Medical Education home page.
  • In the upper right corner, click Join. The Account Information page opens.
  • Complete the fields on the screen. A field with an asterisk is required.
  • NOTE:  Please make sure you include your Duke Unique ID– even though it does not show as a required field.
  • Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
  • At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you provided.
  • Open the email (from dcri.cme@dm.duke.edu) and click the top link in the body of the message.
  • In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
  • In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
  • Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
  • Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.

To record your CME attendance via text message, follow these steps

  • The 6-character SMS code will be provided on a slide during your CME event.
  • Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
  • In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
  • In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
  • Press send.
  • If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”

To add your Duke Unique ID to your account

  • Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
  • Enter your username and password. Click My Account in the upper right corner.
  • Under My Profile, click Edit
  • Scroll down until you see Duke Unique ID filed.  make sure it is correct
  • Save the changes to you My Profile page

 

 

 

Information/Opportunities

September 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2

Physician Career Advancement and Workshop – 9/23/14, Chapel Hill

2015 – 2017 Kraft Fellowship in Community Health (Deadline 10/15/14)

Duke Headache Specialist

http://www.summitsps.com/

 

Upcoming Dates and Events

September 26 – “The G-Briefing” with Dr. Galanos

October 1 – DOCTOBERFEST begins!

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

Useful links

Internal Medicine Residency News, September 15, 2014

Mon, 09/15/2014 - 10:01
From the Director

Happy Monday! Hope you all had a good weekend – turkey bowl practice, Duke win over Kansas, Gen Med, etc!

The Duke team had a great time in DC at the APDIM/CDIM meeting and have brought back lots of information and ideas to share. And it is the first official day of the recruitment season – ERAS opens for fourth year med students today! Time flies, that’s for sure. Looking forward to a special noon conference on 9/25/14 when we can hear a telecast of the Nigerian health minister discuss the response to Ebola in Africa! Details to follow soon and a special thanks to Deng Madut for rescheduling his SAR talk so that we could take advantage of this great opportunity.

Kudos this week to our SAR talks from Laura Musselwhite, Katie Broderick and John Wagener, to Adrienne Belasco from Sneha Vakamudi for filling in in Duke Gen Med, to Sarah Nelson and Olinda Pineda also from Sneha for great work on Gen Med and to Olinda Pineda, Ryan Jessee and Nick Rohrhoff for gold stars this week. Gold stars are given when a patient mentions your name on a patient survey sent to the hospital!

Had a great time at JAR dinner with Titus Ng’eno, Myles Nickolich, Gena Foster and Brian Sullivan. Signups for October coming soon. Dr Klotman is starting her SAR lunches, so look for an email from Erin and Donna Salvo to sign up.

This weeks pubmed from the program goes to Joy Bhosai who just presented at the TedMED conference. Spotted there was former chancellor Dr Victor Dzau!

Have a great week

Aimee

What Did I Read This Week? submitted by: Aaron Mitchell , MD

Hsia RY, Akosa Antwi Y, Nath JP. Variation in charges for 10 common blood tests in California hospitals: a cross-sectional analysis. BMJ Open. 2014 Aug 14;4(8):e005482

http://bmjopen.bmj.com/content/4/8/e005482.full

Aaron Mitchell, MD

Why did I read this:

Health services research (HSR) is my game. That term applies to most research that studies health care delivery, but does not investigate specific new treatments per se. Think of it as “clinical trials for the health care system.” I encountered this particular article in assembling my weekly email summary of health care policy articles. Let me know if you want to subscribe!

Background:

The United States has a serious problem with health care costs. We spend about 18% of our GDP on health care, compared to 9-12% for most other developed countries. As the Baby Boom generation ages and we docs continue to discover new and expensive treatments, the public financing of medical care is putting an increasing strain on federal coffers.

One feature of American health care that contributes greatly to the cost of care is our lack of “price transparency.” Hospitals do not publically release their prices, so it is well-nigh impossible to know how much your bill will come to ahead of time. This contributes to a related problem – the lack of standardization of care. Imagine trying to shop at a grocery store or a clothing store where no prices were on display. How could you possibly hunt for bargains? As long as health care prices remain hidden, providers can charge whatever they want and patients are unable to “shop around” for better deals.

To investigate the extent of this problem, the authors of this study simply looked at the variation in the prices of basic lab tests at different hospitals.

Results:

The primary outcome measure in this study was “the average charge at each hospital for the blood test…the total dollar amount billed by the hospital to the patient or to their insurance provider.” They found a HUGE amount of variation. The prices between different hospitals for the same test (a lipid panel, say) differed not just by multiples, but by orders of magnitude. The main figure in the study reports the 95% price range for the lab tests they examined.

Just how large were the price differences?

As an example, a single comprehensive metabolic panel cost anywhere from $35 to $7,303 (yes, over seven thousand dollars!) depending on which hospital you went to.

Conclusions:

The lack of price transparency in US health care is a big obstacle for health care reform and cost control.

In many other countries, there is some level of top-down price setting. Patients can expect to pay the same price for the same test or procedure no matter where they go. This may be one contributing factor to how other countries are able to control overall costs so much better than we are.

In the USA, though, we tend to prefer free-market solutions to our problems, rather than government mandates. In a functioning free market, consumers (ie, patients) seek out the best deals for their money, forcing sellers (hospitals, doctors) to compete on prices and thus keep their prices low. However, when prices are invisible to the consumer (as they are for health care), this mechanism cannot work, and prices are higher than they would be if hospitals truly had to compete.

It is time to “shed some light” on health care prices!

Clinic Corner

PICKETT Clinic Corner, 2014 September

Changes at Pickett Road
Welcome Lauren our new CMA and Yolanda our Lab Tech (picture below). Nicole will be changing job role from Service Access Manager to Patient Service Agent. Sadly Dr. Wolf will be leaving Pickett Road for Signature Care. He is going to leave end of December 2014. Thursday Afternoon resident clinic will be on hold until March when Dr. Audrey Metz will be taking over! (she starts January 1, 2015).

If your templates are not defaulted to ARIAL and you have to print a patient note, it will not be legible! So note to self, change arial as default font!

Good luck on your in-training exams!

I have complied the first lunch time topic. Due to so many of you completing the In-training exam, clinic is very light with residents for the first 3 weeks. I think Vaccines can cover that time and next topic to begin 9/22/14.

http://annals.org/article.aspx?articleid=1567229

This is the original article printed and posted in the resident room

Interns: please remember to CC your notes to your attendings. In the FOLLOW UP Box there is an area to ROUTE your note to the attending. PLEASE do this even if your note is not finished. Please try to fill out the forms that come in the black box and not put them in other resident’s boxes. They may not be here for months and if pts needs medical forms filled out, please do your best to help them.

All pts need to check out at the front desk (no more fly bys). This is due to the number of patients who do leave, who do not get their vaccines or labs or xrays done.

The order for Rapid Flu testing is LAB7959, please add this to your favorites!!


Process for getting access to NC Controlled substances (Thank you Julia Cupp!)
Through NC Medical Board:

Go to the medical board website http://www.ncmedboard.org/

1) Look under the “Quick Links” menu and click on the second option, “Update Licensee Info Page”.

2) Scroll down to the bottom of this page and sign in using your File ID# and DOB. If you have forgotten your File ID#, just click the box that says “Recover File ID” to retrieve this information. All you need to retrieve is the last 4 digits of your social security number and your DOB.

3) Once you have successfully logged into the licensee page you will look for the menu option “Training and CSRS”. Once you click this option scroll down to the section on the CSRS. There will be a blue “Click Here” button to register for the NC CSRS.

4) Fill out the required information and submit. You will need your full DEA number. The password must be exactly 8 characters with one capital letter and one number. Do NOT use any symbols.

*Health Information Designs, Inc. will notify you by e-mail with your confirmation login information. Please be sure to add nccsrs-info@hidinc.com to your email contacts or acceptance list to prevent your notification emails from being rejected or sent to your spam folder.

Sincerely,

Sharon Rubin, MD, FACP

QI Corner

Aaron Mitchell, MD

First, a reminder this week that Wednesday noon conference will be our monthly Morbidity and Mortality conference. We are trying something different this month, and will be focusing on procedure-related “learning opportunities,” presented by your fellow residents! Come learn about some of the easy pitfalls of doing procedures, and how to protect both your patients and yourself while doing them.

Next, and update on the GME incentive program. We now have 2 months of data on the ED consultation time measure. Just as a reminder, this is being tracked according to department, and the goal for each department is a 10% decrease from its 2013-2014 average. Check out the data below!

The “goal” for each department is the green bar. Gen Med (that’s us!) is over on the far left. As you can see, we are not at our goal yet, but we are heading in the right direction! We are at 36 minutes from 38 in July, down towards our goal of 30! Our median consult time in August is on the way down from July – not many of the other programs have been able to achieve that.

And then for the SRS reporting, here are the numbers:

SRS reports by trainees in July:          23

SRS reports by trainees in August:     45

Total remaining needed for goal:        1,904

That’s still a lot of ground to cover, but SRS reporting is very easy! Did your patient miss a dose of a medication? Did they have a fever or another event that you weren’t informed of? Those are all reportable events.

From the Chief Residents Grand Rounds

Fri., Sept.19, 2014: GI, Dr. Alastair Smith

Noon Conference Date Topic Lecturer Time Vendor 9/15/14 ITE No conference- lunch only 12:15 Nosh 9/16/14 MED-PEDS Combined: ADHD Richard D’Alli 12:15 Dominos 9/17/14 Resident M&M QI Team 12:15 Cosmic Cantina 9/18/14 IM-ED Combined Conference: HVCC Intro Jon Bae  12:15 Rudinos  9/19/14  Chair’s Conference  Chiefs  12:00  Chick-Fil-A                   From the Residency Office Flu Vaccination Blitz Starts September 18!

As you know, Duke University Health System (DUHS) requires all healthcare workers who perform their duties in a DUHS facility or a community home-based setting to be vaccinated annually against the flu. This is in alignment with our core value of “caring for our patients, their loved ones and each other.” Annual vaccination against influenza, or policy compliance through a granted medical or religious exemption, is a condition of employment for all DUHS employees. Annual vaccination or policy compliance is also a condition of access to Duke Medicine facilities for those holding clinical privileges in a Duke Medicine facility and learners who wish to train in our facilities.

With this in mind, please note these key dates for this flu vaccination season:

  • Start of Flu Vaccination Season: Thursday, September 18, 2014
  • Applications for Medical or Religious Exemption should be submitted before Friday, October 17, 2014.  This will allow sufficient time for review and for communication of the review decision. Please note: Due to the availability of an egg-free formulation of the flu vaccine, egg allergy will no longer be a valid reason for a medical exemption.
  • Policy compliance through vaccination or granted exemption by Monday, November 17, 2014

We will kick off our annual flu vaccination campaign with a 24-hour Duke Medicine Mass Flu Vaccination drill. The drill will begin on Thursday, September 18, 2014. Mass vaccination clinics will be available at each of the hospitals with peer vaccination available throughout DUHS. Following the drill, we will begin our annual flu vaccination program, during which time we will provide many additional opportunities for you to get vaccinated. A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

Register Now for BLS Blitz – November 10-14, 2014

Use the Swank system to register for BLS classes.  If you do not have an account in Swank contact the DHTS Service Desk 919-684-2243 to establish an account.  You may register for one session.  Detailed Registration Instructions and Informational Flyer
When you attend class, arrive 15 minutes before session begins and you must have your:

  • Class Registration Confirmation
  • Duke ID Badge
  • AHA BLS Healthcare Provider Manual 2010

All sessions are held at Hock Plaza – G07 Auditorium.
Parking is not available at Hock Plaza.
No one will be admitted to the session after it starts or if you do not have your AHA BLS manual.

 

Women In Medicine Event

The Duke Medical Alumni Association invites you to join us for the inaugural Women in Medicine Luncheon and Program

Friday, October 17, 2014  |  11:45am-1:45pm

Great Hall, Trent Semans Center for Health Education

The luncheon program features a panel discussion of Duke Medicine alumnae followed by roundtable conversations on issues specific to women in medicine.

 

Maestro Care Update

As part of the continuing commitment to advance patient safety throughout Duke University Health System (DUHS), Beaker, the lab application for Maestro Care, will be implemented at on September 20, 2014.  The Beaker implementation will impact all trainees who collect specimens (of any type) and print labels.

Provider Education

  • It is recommended that all providers in inpatient and ambulatory settings complete a WebEx  that includes videos outlining the process for collecting, labeling and sending specimens to the lab. The WebEx is located on the Physician Concierge website maestro.duke.edu/provideradoption or by accessing the following:
  • Resources

To access and self-register for these required modules, employees may visit the DUHS Intranet (intranet.dm.duke.edu), click on “Duke LMS” under the Quick Links menu, and then perform a Catalog Search using the term “Specimen Collection – Beaker Rollout.”

Call for AbstractsClinical Science DayDeadline Extended to September 22nd

Duke University School of Medicine’s Clinical Science Day will be held on Saturday, November 8, 2014, in the Great Hall of the Mary Duke Biddle Trent Semans Center. This half-day event features five Duke University School of Medicine faculty speakers, a keynote speaker, and a poster session for residents, fellows, and health professions students. Clinical Science Day is an annual event that brings together faculty, staff, trainees, and students to celebrate clinical research and the vast and diverse array of activities taking place across our medical campus, and to facilitate collaborations.

We strongly encourage all residents, fellows, and health professions students to participate in the Clinical Science Day poster session by submitting an abstract.  The benefits of presenting at Clinical Science Day are to teach others about your work, gain experience presenting your work in a format similar to national meetings, and receive input and feedback from faculty members.  ALL submissions will be accepted, and monetary awards will be presented to the first, second, and third place winners of the competition. Dean Nancy Andrews will be the honorary poster judge.  For those residents and  fellows participating in the poster session, their presence at the event is required from 10 a.m. to 12:30 p.m. 

The deadline for the abstracts has been extended to September 22, 2014. Please submit abstracts to jill.boy@duke.edu

http://medschool.duke.edu/research/clinical-and-translational-research/clinical-science-day

New System for Requesting Interpreters

Duke University Health System has implemented a new, web-based system to request the services of medical interpreters. Duke University Hospital, PDC and hospital-based clinics that are currently being serviced by interpreters from International Patient Services (919-681-3007) can use a website to request an interpreter via an icon on PIN and non-PIN workstations.

The system, called ServiceHub, simplifies and streamlines requests for language assistance and enables users to track the process, including making medical interpreter requests and monitoring the status of requests to know when interpreters arrive on-site and complete the assignment. This system also enhances the ability to monitor how interpreters are deployed, enabling users to better estimate response times and International Patient Services to provide additional support to areas in high demand for interpreter services.

ServiceHub is intended to replace the language assistance request calls that are made to 919-681-3007.

While the system is designed to be user-friendly, training is mandatory to be granted access. Training materials are available through the Learning Management System (LMS), accessed by logging onto Duke@Work or via the following URL:

https://vmw-lmsweb.duhs.duke.edu/SabaLogin 

After logging in, search the LMS for “ServiceHub Interpreter Request System – Requester Training.”  

Hospitals that use ServiceHub to dispatch interpreters report dramatic improvement in response times and improved efficiency by an average of 30 percent.  

The International Patient Services team will be ready to assist and support you while we transition to this new dispatching system. 

For questions regarding the new ServiceHub interpreter request system, please contact:

International Patient Services

919-681-3007 or 919-668-2431

Nouria Belmouloud

Pager: 919-970-0387

 

ETHOS for Noon Conference Attendance Tracking!

AS of 9/8/14 we now ONLY use ETHOS for tracking attendance.  Most of you should already have an ETHOS account which you use for tracking your attendance at Grand Rounds, but EVERYONE should read the following instructions carefully, as it applies to new and current account holders.  You MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!  Please make sure that you enter your Duke Unique ID and NOT your Net ID!  If your unique ID is entered incorrectly, you will not get credit for attending the conference!

How do I Set up an ETHOS account for the first time?

How to register with Ethos

  • Go to the Duke Continuing Medical Education home page.
  • In the upper right corner, click Join. The Account Information page opens.
  • Complete the fields on the screen. A field with an asterisk is required.
  • NOTE:  Please make sure you include your Duke Unique ID– even though it does not show as a required field.
  • Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
  • At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you provided.
  • Open the email (from dcri.cme@dm.duke.edu) and click the top link in the body of the message.
  • In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
  • In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
  • Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
  • Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.

To record your CME attendance via text message, follow these steps

  • The 6-character SMS code will be provided on a slide during your CME event.
  • Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
  • In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
  • In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
  • Press send.
  • If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”

To add your Duke Unique ID to your account

  • Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
  • Enter your username and password. Click My Account in the upper right corner.
  • Under My Profile, click Edit
  • Scroll down until you see Duke Unique ID filed.  make sure it is correct
  • Save the changes to you My Profile page

 

Now Accepting Applications for Global Health Elective Rotations

 

 

 

Developing the next generation of globally educated, socially responsible healthcare professionals dedicated to improving the health of disadvantaged populations.

Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016. Application is open to residents from Departments of Medicine: Internal Medicine (PGY 2); Med-Peds (PGY 3) and Med-Psych (PGY 4). Access the application form and FAQ at http://dukeglobalhealth.org or submit online http://bit.do/HYC-submit.

(Application addendum is available by request – tara.pemble@duke.edu)

Application deadline is September 30, 2014. Interviews held during October. We strongly encourage you to speak with past participants to get a better idea of what daily life is like on the wards of your top sites. For more information, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.

 

ITEs Are in Full Swing!

Friday, September 5th marked the first testing date for the ITEs!  House staff – please check your Amion to know what date you are scheduled to take the exam.  As a reminder, the exams are being administered electronically this year!  Please be sure to review the information below and contact Jen Averitt in the MedRes office if you have any questions.  Good luck!!

The following is important information – PLEASE REVIEW CAREFULLY BEFORE your test date!

  • Please take a few minutes to take a practice test at http://acp.startpractice.com  Please try and practice BEFORE 9/2/14 as the test may become unavailable after the national testing window opens
  • The testing center is located at 406 Oregon St, Lab 101, Durham  There is free parking in front of the building
  • Please be at the testing center NO LATER THAN 8:00 am on test day!!
  • There is no food allowed inside the testing room, but a boxed lunch will be provided for you in the building.  You will be allowed a 30 minute lunch break.

If you are unable, for any reason, to make your test date, YOU MUST CONTACT EITHER JEN AVERITT OR A CHIEF RESIDENT AS YOU WILL NEED TO HAVE YOUR TESTING DATE RE SCHEDULED!

 

Information/Opportunities

September 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2

Duke Headache Specialist

Practice Link Career Fair – 9/23/14

 

Upcoming Dates and Events

September 18: Internal Medicine In-Service Training Exams Testing Window – Last Day

September 26 – “The G-Briefing” with Dr. Galanos

October 27, 2014 – Recruitment Kick-Off Event

Useful links

Internal Medicine Residency News, September 8, 2014

Mon, 09/08/2014 - 12:19
From the Director

It’s great to see the start of Turkey Bowl practices! And a 2-0 start for Duke football. Happy fall! Get ready for Doctoberfest coming up….details to follow. The ITE seems to be going well – thanks to everyone for being on time,and for covering your colleagues while they are testing. Kudos this week to our past two weeks of awesome SAR talks by Brice Lefler, Claire Kappa, Rachel Titerance, Fola Babatunde, Tony Lozano, Ben Lloyd and Chris Merrick.

Also kudos to our Med Res office for achieving Green Certification from Duke University!! We have met the many criteria to receive this designation – awesome job! Now keep recycling – there is a box for pager batteries in the office as well as a place for any plastic bottles in the med res library or outside the 8th floor elevators.

GET INVOLVED! Are you interested in helping with our curriculum project? Let me, Bill Hargett or Murat Arcasoy know. How about QI and patient safety? Let Lish Clark or Aaron Mitchell know. What about resident research and stats support? Talk to Murat Arcasoy! Community service? Talk to your Stead Leader or to Erin Payne and me.Looking forward to dinner with JARs this week.

Nick Rohrhoff has invited the SARs to the Zaas rental house for a SAR night, so stay tuned. It’s almost in acceptable shape for guests and I think it will feel more like home once you join us on the (not as cool as the last one) back porch.

Congratulations to Paul and Katherine St Romain on the birth of Elizabeth Ann, arriving Sept 6 at 1:51 am! Everyone is doing well.

This weeks pubmed from the program to Amit Bhaskar for his upcoming American College of Gastroenterology abstract with mentor Ziad Gellad…Title: Physician-Directed Bolus Sedation for Colonoscopy Improves Endoscopy Unit Efficiency Authors: Amit Bhaskar, MD, Ziad Gellad, MD, MPH, Duke University Medical Center, Durham, NC

Have a great week

Aimee

What Did I Read This Week? submitted by: Suzanne Woods , MD

Screening for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-analysis for the U.S. Preventive Service Task Force

Annals of Internal Medicine. 2014;161:336-346.

Author: Jonas et al.

Why did I read this article: On gen med I have been doing a lot of reading this week….notes, notes and more notes. Admission notes, daily progress notes and discharge summaries! But thanks to the efforts of Katrina Abril and Adam Barnett for getting these finished so expeditiously and thoroughly on a Saturday, I had time to look at the mail this week and this article caught my eye.

Background information:

Stoke is a leading cause of death and disability and affects an estimated 7% of US adults. Ischemic strokes are responsible for 90% of all strokes with carotid artery stenosis (CAS) causing ~10% of ischemic strokes in our country. Several studies have tried to estimate the rate of progression of asymptomatic CAS and predict subsequent neurologic events. The best available data revealed a 5-year risk for ipsilateral stroke of 5% for CAS of >70%. The goal of this review was to 1. evaluate the current evidence on whether screening asymptomatic adults for CAS reduces the risk for ipsilateral stroke

  1. evaluate harms associated with screening and interventions for CAS
  2. evaluate evidence on the incremental benefit of medical therapy and on risk-stratification tools

Methods:

Identified and reviewed articles using analytic framework. Included studies of Asx adults with CAS, RCT’s of screening for CAS, RCT’s and systematic reviews of treatment ineffectiveness, multi-institution trials or cohort studies that reported harms, and studies that attempted to externally validate risk-stratification tools.

Results and Discussion:

The results came from 78 published articles that reported on 56 studies.

  1. No eligible studies provided evidence on whether screening reduced ipsilateral stroke.
  2. Duplex ultrasonography is widely available and non-invasive but reliability is questionable due to differences in accuracy and this can result in many false positive test results. If acted upon, this can result in many unnecessary confirmatory tests (angiography or MRA).
  3. Hard to obtain an accurate estimate of potential benefits for the primary care population. CEA c/w medical therapy in their review showed reduction in perioperative stroke or death or any subsequent stroke. Challenge: medical therapy is not all standardized but should include the use of statins, antihypertensives, glycemic control for DM patients and use of antiplatelet drugs for vascular disease and risk reduction. Also the trials used highly selected surgeons with low complication rates.
  4. The benefits of surgery depend on the risk of the Asx lesion eventually resulting in stroke and that risk appears to be decreasing in the last few decades.
  5. Medical interventions have been determined to be 3-8x more cost-effective.
  6. No externally validated, reliable risk-stratification tools are available that can distinguish between patients with Asx CAS who are at increased or decreased risk for stroke caused by CAS despite current medical therapy vs those patients who have increased or decreased risk for harm with surgery.
  7. May be lack of underreporting of harms postoperatively such as nonfatal MI, cranial nerve damage, PE, infections etc or even psychological harm. Most commonly on harms including stroke or death were noted.
  8. Need to look at life expectancy and timing of events. Potential for surgical benefit decreases with advancing age.

This review was accompanied by the Clinical Guideline and US Preventive Services Task Force Recommendation Statement (pgs 356 – 362) . This was an update to the 2007 recommendation on screening for CAS and concludes with the reaffirmation of its previous statement against screening for ASx CAS in the general adult population (D recommendation).

And the editorial was written by Dr. Larry Goldstein of our own Neurology department! Check out pages 370-371 for his thoughts.

Clinic Corner

DOC Clinic Corner, 2014 September

Hello Team DOC!

Last year, we implemented several key changes at the DOC as part of our overall DOC redesign effort, lead by Alex Cho. The changes included establishing Natasha Cunningham as our Med-Psych medical director and launching the HomeBase program for our Medicaid patients who over-utilize the ED, Marigny Manson became the HomeBase case manager, Julia Gamble became our NP practitioner who can create better bridges in patients’ clinical care, and the Stead or Firm groupings began,s led by Lynn Bowlby, Dani Zipkin, and Larry Greenblatt.

Recently, Drs. Cho, Bowlby, Cunningham, Brandie Johnson and Gina Green presented to Dr. Klotman, Dr. Sowers, Dr. Zaas, and Chris Samples on our progress. Please see the slide deck attached for details!

The September DOC Newsletter is attached here! Please read!

And now, last but definitely not least…

 Maestro Rules: We are expected to close encounters in 24 HOURS!! That means, please finish your notes and route to your attending by the end of the clinic day so that we can close the encounters.

Thanks!

Dani

From the Chief Residents Grand Rounds

Fri., Sept.12, 2014: Dr. David D’Alessio, Endocrine

Noon Conference Date Topic Lecturer Time Vendor 9/8/14 SAR Emergency Series: Pneumonia/Debriefing Borderick-Forsgren 12:15 Picnic basket 9/9/14 SAR Emergency Series: DVT/PE John Wagener 12:15 Domino’s 9/10/14 Antibiotic Stewardship Clinical Pharnacist 12:15 China King 9/11/14 SAR Emergency Series: ABG Interpretation  Laura Musselwhite  12:15 Sushi  9/12/14  No conference- lunch only  Mediterra     From the Residency Office

 

ITEs Are in Full Swing!

Friday, September 5th marked the first testing date for the ITEs!  House staff – please check your Amion to know what date you are scheduled to take the exam.  As a reminder, the exams are being administered electronically this year!  Please be sure to review the information below and contact Jen Averitt in the MedRes office if you have any questions.  Good luck!!

The following is important information – PLEASE REVIEW CAREFULLY BEFORE your test date!

  • Please take a few minutes to take a practice test at http://acp.startpractice.com  Please try and practice BEFORE 9/2/14 as the test may become unavailable after the national testing window opens
  • The testing center is located at 406 Oregon St, Lab 101, Durham  There is free parking in front of the building
  • Please be at the testing center NO LATER THAN 8:00 am on test day!!
  • There is no food allowed inside the testing room, but a boxed lunch will be provided for you in the building.  You will be allowed a 30 minute lunch break.

If you are unable, for any reason, to make your test date, YOU MUST CONTACT EITHER JEN AVERITT OR A CHIEF RESIDENT AS YOU WILL NEED TO HAVE YOUR TESTING DATE RE SCHEDULED!

ETHOS for Noon Conference Attendance Tracking!

AS of 9/8/14 we now ONLY use ETHOS for tracking attendance.  Most of you should already have an ETHOS account which you use for tracking your attendance at Grand Rounds, but EVERYONE should read the following instructions carefully, as it applies to new and current account holders.  You MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!  Please make sure that you enter your Duke Unique ID and NOT your Net ID!  If your unique ID is entered incorrectly, you will not get credit for attending the conference!

How do I Set up an ETHOS account for the first time?

How to register with Ethos

  • Go to the Duke Continuing Medical Education home page.
  • In the upper right corner, click Join. The Account Information page opens.
  • Complete the fields on the screen. A field with an asterisk is required.
  • NOTE:  Please make sure you include your Duke Unique ID– even though it does not show as a required field.
  • Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
  • At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you provided.
  • Open the email (from dcri.cme@dm.duke.edu) and click the top link in the body of the message.
  • In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
  • In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
  • Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
  • Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.

To record your CME attendance via text message, follow these steps

  • The 6-character SMS code will be provided on a slide during your CME event.
  • Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
  • In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
  • In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
  • Press send.
  • If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”

To add your Duke Unique ID to your account

  • Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
  • Enter your username and password. Click My Account in the upper right corner.
  • Under My Profile, click Edit
  • Scroll down until you see Duke Unique ID filed.  make sure it is correct
  • Save the changes to you My Profile page
Flu Vaccination Season 2014

As you know, Duke University Health System (DUHS) requires all healthcare workers who perform their duties in a DUHS facility or a community home-based setting to be vaccinated annually against the flu. This is in alignment with our core value of “caring for our patients, their loved ones and each other.” Annual vaccination against influenza, or policy compliance through a granted medical or religious exemption, is a condition of employment for all DUHS employees. Annual vaccination or policy compliance is also a condition of access to Duke Medicine facilities for those holding clinical privileges in a Duke Medicine facility and learners who wish to train in our facilities.

With this in mind, please note these key dates for this flu vaccination season:

  • Start of Flu Vaccination Season: Thursday, September 18, 2014
  • Applications for Medical or Religious Exemption should be submitted before Friday, October 17, 2014.  This will allow sufficient time for review and for communication of the review decision. Please note: Due to the availability of an egg-free formulation of the flu vaccine, egg allergy will no longer be a valid reason for a medical exemption.
  • Policy compliance through vaccination or granted exemption by Monday, November 17, 2014

We will kick off our annual flu vaccination campaign with a 24-hour Duke Medicine Mass Flu Vaccination drill. The drill will begin on Thursday, September 18, 2014. Mass vaccination clinics will be available at each of the hospitals with peer vaccination available throughout DUHS. Following the drill, we will begin our annual flu vaccination program, during which time we will provide many additional opportunities for you to get vaccinated. A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

 

Now Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016.

Application is open to residents from the Departments of Medicine and Pediatrics: Internal Medicine (PGY 2); Med-Peds (PGY 3); Med-Psych (PGY 4); Pediatrics (PGY 2).

The application is attached and available at http://dukeglobalhealth.org or submit online http://bit.do/HYC-submit.

(Application addendum is available by request – tara.pemble@duke.edu).

Interviews will be held in October. For more information about this opportunity, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.

Application Deadline: September 30, 2014

Information/Opportunities

September 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2

Carolinas HealthCare System Internal Medicine Opportunities 8-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

www.mercydesmoines.org

 

Upcoming Dates and Events

September 2 – 18: Internal Medicine In-Service Training Exams Testing Window

 

Useful links

Internal Medicine Residency News, September 2, 2014

Tue, 09/02/2014 - 08:51
From the Director

Hello! Happy September! I hope everyone had a chance to enjoy some part of the long weekend.  We had a number of fun events this week, starting with the attendings beating the residents at Stead Trivia Night at Bull McCabe’s.  Thanks Steve Crowley and the Warren Society for planning, and to the many attendings and residents who showed up! A number of our residents were able to meet with the newly appointed Secretary of Veteran’s Affairs, Robert McDonald – thanks to Ashley Bock, Aparna Swaminathan, Nick Rohrhoff, Chris Hostler, Coral Giovacchini, Tim Mercer, Katie Broderick and our Psychiatry colleague Nora Dennis for spending time discussing GME with our special guest.  Attendance at Grand Rounds was outstanding, and I hope you all had a chance to hear his inspirational talk.  Ragnar Palsson followed the outstanding grand rounds with a fantastic chair’s conference, proving once again that all that causes active urine sediments and renal failure is not Wegener’s.  Brice Lefler, Sneha Vakamudi, and Tim Mercer helped lead us along to (close) to the diagnosis.  Hopefully many of you also saw Dr G as the honorary Duke football coach this weekend as well!

Kudos also this week to Rajiv Agarwal from fellow night float resident Alan Erdmann for a great diagnosis and patient care, and to Alan Erdmann from Lish Clark for outstanding notes on night float! Additional big thanks to our outgoing ACRs Aparna Swaminathan, Tim Mercer (with a Med Res News hat-trick this week!) and Alyson McGhan for being PHENOMENAL ACR’s! Aparna helped revolutionize DRH AM report, Tim worked to improve our notes at the VA, and Alyson kept busy helping figure out the admission patterns on gen med so that we can optimize daytime admissions for the teams.  We look forward to having Kevin Trulock, Adam Banks and Claire Kappa at the helm!  Also kudos to the MICU Crew — Jonathan Buggey, Jonathan Hansen, Jason Zhu, Adva Eisenberg, Amy Lee and Myles Nickolich from MICU fellow Talal Dahhan for outstanding work.

Congratulations to Lauren Ring, Jenny Van Kirk, Jon Musgrove and Azalea Kim who were elected by their peers to the Residency Council.  Looking forward to working with you all.  Also congrats to Adrienne Belasco and Mitch Klement on their wedding this weekend!

This week kicks off our In Training Exams! Be on time, be relaxed, and for the first time, you can forget to bring a #2 pencil.  Welcome to the new age…tests are on campus in the computer labs.  Thanks to Jen Averitt, Lauren Dincher, Erin Payne and Lynsey Michnowicz for proctoring.  We also had the opportunity to turn in our “APEI” (that’s GME talk for Annual Program Evaluation and Improvement Plan) to Dr. Kuhn and her team this week.  This is an annual document that we prepare for the GME leadership that describes our educational efforts for the past year and what we would like to do next year.  We will post our progress and plans for you to view on Medhub – this year we are working on our EDUCATIONAL ENVIRONMENT (more on our “Back to Basics” curriculum overhaul soon), our AMBULATORY TRAINING (thanks Dani, Alex, et al for your work on the curriculum, noon conferences, and improved scheduling continuity) and our TRANSPARENCY (let us know other ways to reach you with program details in addition to the Med Res News, before conference, and in conversation).

This week’s first Pubmed from the Program goes to Adva Eisenberg for her upcoming presentation at the Southern Hospital Medicine Conference in Atlanta…“Fool Me Twice: A Case of Recurrent Bacterial Meningitis due to a Spontaneous CSF Leak” Adva Eisenberg, MD1, J Bradford Bertumen, MD2, and Gary Cox, MD2

Second Pubmed: Ryan Nipp, Aaron Mitchell, Allyson Pishko, and Ara Metjian. “Waldenstrom Macroglobulinemia in Hepatitis C: Case Report and Review of the Current Literature,” Case Reports in Oncological Medicine, vol. 2014, Article ID 165670, 2014.
http://www.hindawi.com/journals/crionm/2014/165670/

Have a great week!

Aimee

What Did I Read This Week? submitted by: Coral Giovacchini , MD

Reference:Rubin, LG and Schaffner, W. Care of the Asplenic Patient. N Engl J Med 2014; 371: 349-356.

Over the past few weeks, the care of asplenic patients has come up several times in sign outs, VA case conferences, and even alluded to during our recent SAR Emergency Lecture series and a Chair’s Conference Case this past month. This clinical practice review was recently published in the NEJM and is a nice summary of the clinical conundrum, treatment guidelines and management considerations in such patients.

Clinical Problem

Current estimates suggest that there are approximately 1 million total asplenic patients treated currently in the United States. In the article, the authors urge readers to consider the fact that the asplenic population is quite heterogeneous, including not only the typically thought of surgically asplenic patient, but also those with functional asplenic/hyposplenia seen in conference with diseases that we often treat at DUMC/DVAMC including sickle cell anemia, congenital heart disease (i.e. Ivemark Syndrome), untreated HIV, severe celiac disease, and even chronic GvHD. One of the main concerns in caring for these patients is the risk of “post-splenectomy sepsis”, which can carry up to a 50% mortality risk for all-comers, though generally is more fatal is surgically asplenic patients, and has been found to be an independent risk factor for hospitalization for pneumonia or meningitis in military veterans. The pathophysiology behind increased risk of sepsis includes impaired clearance of IgG-coated encapsulated bacteria from the blood stream (remember these are not opsonized as well!) and an overall decreased humoral immunity with lower levels of serum IgM antibodies as well as a lower number of memory B cells to produce IgM.

The pathogen classically associated with post-splenectomy sepsis is S. pneumoniae; however other organisms to be considered include H. influenzae b, N. meningitidis, Capnocytophagia canimorsis (after a dog bite), Bebasia (after a tick bite), and Bordatella holmesii. Despite the classical teaching, the most common organisms isolated from adults with bacteremia and underlying functional asplenia from sickle cell disease continue to include gram negative bacilli and S. aureus, often associated with indwelling catheter use.

Clincal Strategies

There are many areas of uncertainty that remain in the clinical treatment of asplenic patients, including the role of vaccination boosters, the role of prophylactic antibiotics, appropriate empiric antimicrobial treatment strategies and the role of screening for functional asplenia in associated diseases. The most important strategies in our clinical armatorium remain prevention, education, and the early and appropriate treatment of the signs of infection.

In 2000, the heptavalent pneumoncoccal conjugate vaccine (PCV7) was introduced, and has markedly reduced the incidence of invasive pneumococcal disease not only among children, but also within the entire US population, presumably via a herd immunity theory. Following this, the triskaidecavalent (PCV13, or Prevnar13) was introduced in 2010 with further reductions in pneumococcal disease in this patient population. Current recommendations for this population are to give PCV13, followed by PPSV23 8 weeks later (this is slightly different after surgical splenectomy, with a recommendation to wait at least 2 weeks after the operation prior to administering PPSV23; CDC.gov has a very comprehensive table on timing of these immunizations). All patients in this population are recommended to get a PPSV23 booster at a sequential 5 year interval. Other immunizations that are recommended including the Hib vaccine for those who were not immunized in childhood, the quadrivalent meningococcal conjugate vaccine (MenACWY), as well as an annual influenza vaccine.

With regards to antimicrobial prophylaxis, although this is recommended for all asplenic children <5 years old, this is not necessarily true for adults, and various organizations have published differing guidelines with suggestions ranging from no need for prophylaxis to a call for lifelong penicillin prophylaxis in all persons with surgical asplenia. Though there is not a clear consensus, adults in whom prophylaxis is generally recommended include any patient who has previously survived an episode of post-splenectomy sepsis, or any surgically or functionally asplenic adult who suffers a dog bite (given the risk of C. canimorsus).

Once a patient with known asplenia presents with a fever or other localizing signs of infection, prompt initiation of appropriate antimicrobial therapy is warranted (recommendations range from outpatient oral penicillin based regimen to IV 3rd generation or higher cephalosporins- most commonly ceftriaxone) with a goal of covering the above-mentioned organisms. Consideration can be given to adding vancomycin for additional MRSA coverage in the appropriate patient populations (i.e. your patients with indwelling lines, frequent healthcare access, etc), or if CNS disease/infectious meningitis is a concern. Interestingly, because of the high risk of progression to fulminant sepsis, many outpatient care providers have taken the strategy of providing a standing empiric antibiotic prescription for these patients to have available at the first sign of fever or infection.

 

Summary

  • Remember that “asplenia” can take several forms, including congenital, surgical and functional (i.e. our sickle cell patients!)
  • The clinical presentation of asplenic sepsis can be profound and carries up to a 50% mortality risk
  • Asplenic patients should be educated that any illness with fever or other localizing signs of infection needs prompt medical attention, and likely should receive prompt initiation of antimicrobial therapy (possibly even self-initiated in the outpatient setting)
  • Always be sure to cover encapsulated organisms in patients presenting with asplenic sepsis, with special attention to other environmental risk factors (i.e. dog bites)
  • All asplenic patients are recommended to have vaccinations against pneumococci, H. influenzae b, meningococci, as well as an annual influenza vaccine
  • Strongly consider lifelong prophylactic antimicrobial therapy in any adult having already survived an episode of asplenic sepsis with a typical organism
QI Corner

Aaron Mitchell, MD

Just a reminder to everyone: our next Morbidity and Mortality noon conference will be coming up on Wednesday, September 17. We are going to change the format this time, and present cases of procedure-related mishaps. But – we need the cases to come from you!

Have you ever hurt yourself or had a preventable blood exposure during a procedure? Caused a patient unnecessary discomfort by making an easy mistake? Had a bad complication you would like to share? Let us know! You do not have to present if you would feel uncomfortable, and the case can remain annonymous if you would like.

– Aaron and Lish

From the Chief Residents Grand Rounds

Fri., Sept.5, 2014: Dr. Richard Reidel, Oncology

Noon Conference Date Topic Lecturer Time Vendor 9/2/14 SAR Emergency Series: Pneumonia/Debriefing Titerence/Galanos 12:15 Dominos 9/3/14 SAR Emergency Series: Common HIV Management Questions Brice Lefler 12:15 Cosmic Cantina 9/4/14 SAR Emergency Series: Endocrine Emergencies Claire Kappa 12:15 Subway 9/5/14 ITEs – No Conference Chick-Fil-A     From the Residency Office

 

ITEs Start This Week!

Friday, September 5th marks the first testing date for the ITEs!  House staff – please check your Amion to know what date you are scheduled to take the exam.  As a reminder, the exams are being administered electronically this year!  Please be sure to review the information below and contact Jen Averitt in the MedRes office if you have any questions.  Good luck!!

The following is important information – PLEASE REVIEW CAREFULLY BEFORE your test date!

  • Please take a few minutes to take a practice test at http://acp.startpractice.com  Please try and practice BEFORE 9/2/14 as the test may become unavailable after the national testing window opens
  • The testing center is located at 406 Oregon St, Lab 101, Durham  There is free parking in front of the building
  • Please be at the testing center NO LATER THAN 8:00 am on test day!!
  • There is no food allowed inside the testing room, but a boxed lunch will be provided for you in the building.  You will be allowed a 30 minute lunch break.

If you are unable, for any reason, to make your test date, YOU MUST CONTACT EITHER JEN AVERITT OR A CHIEF RESIDENT AS YOU WILL NEED TO HAVE YOUR TESTING DATE RE SCHEDULED!

ETHOS for Noon Conference Attendance Tracking!

After much work with the wonderful folks in the ETHOS offices, as of September 2, 2014 we will be able to track Internal Medicine Noon Conference attendance using the ETHOS system.  From September 2-5, we will continue to use the old badge swipe system in addition to ETHOS so everybody can get used to the process, but as of 9/8/14 we will ONLY use ETHOS for tracking attendance.  Most of you should already have an ETHOS account which you use for tracking your attendance at Grand Rounds, but EVERYONE should read the following instructions carefully, as it applies to new and current account holders.  you MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!

How do I Set up an ETHOS account for the first time?

How to register with Ethos

  • Go to the Duke Continuing Medical Education home page.
  • In the upper right corner, click Join. The Account Information page opens.
  • Complete the fields on the screen. A field with an asterisk is required.
  • NOTE:  Please make sure you include your Duke Unique ID– even though it does not show as a required field.
  • Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
  • At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you provided.
  • Open the email (from dcri.cme@dm.duke.edu) and click the top link in the body of the message.
  • In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
  • In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
  • Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
  • Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.

To record your CME attendance via text message, follow these steps

  • The 6-character SMS code will be provided on a slide during your CME event.
  • Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
  • In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
  • In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
  • Press send.
  • If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”

To add your Duke Unique ID to your account

  • Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
  • Enter your username and password. Click My Account in the upper right corner.
  • Under My Profile, click Edit
  • Scroll down until you see Duke Unique ID filed.  make sure it is correct
  • Save the changes to you My Profile page
Recycle Your Old Batteries

In an effort to further our “Go Green” initiative, we are now recycling batteries! We have a dead batteries collection box in the Med Res office (Duke North, Room 8254) so please feel free to bring in your dead batteries and we are happy to recycle them for you.  For more information click here.

Flu Vaccination Season 2014

As you know, Duke University Health System (DUHS) requires all healthcare workers who perform their duties in a DUHS facility or a community home-based setting to be vaccinated annually against the flu. This is in alignment with our core value of “caring for our patients, their loved ones and each other.” Annual vaccination against influenza, or policy compliance through a granted medical or religious exemption, is a condition of employment for all DUHS employees. Annual vaccination or policy compliance is also a condition of access to Duke Medicine facilities for those holding clinical privileges in a Duke Medicine facility and learners who wish to train in our facilities.

With this in mind, please note these key dates for this flu vaccination season:

  • Start of Flu Vaccination Season: Thursday, September 18, 2014
  • Applications for Medical or Religious Exemption should be submitted before Friday, October 17, 2014.  This will allow sufficient time for review and for communication of the review decision. Please note: Due to the availability of an egg-free formulation of the flu vaccine, egg allergy will no longer be a valid reason for a medical exemption.
  • Policy compliance through vaccination or granted exemption by Monday, November 17, 2014

We will kick off our annual flu vaccination campaign with a 24-hour Duke Medicine Mass Flu Vaccination drill. The drill will begin on Thursday, September 18, 2014. Mass vaccination clinics will be available at each of the hospitals with peer vaccination available throughout DUHS. Following the drill, we will begin our annual flu vaccination program, during which time we will provide many additional opportunities for you to get vaccinated. A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.

Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

 

Now Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016.

Application is open to residents from the Departments of Medicine and Pediatrics: Internal Medicine (PGY 2); Med-Peds (PGY 3); Med-Psych (PGY 4); Pediatrics (PGY 2).

The application is attached and available at http://dukeglobalhealth.org or submit online http://bit.do/HYC-submit.

(Application addendum is available by request – tara.pemble@duke.edu).

Interviews will be held in October. For more information about this opportunity, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.

Application Deadline: September 30, 2014

What is the GME Incentive Program?

The GME Incentive program was started July 2012 as a collaboration between hospital, GME, and Internal Medicine program leadership in order to:

  • Engage trainees in hospital-based quality improvement
  • Provide exposure to models of pay for performance
  • Educate trainees in quality improvement
  • Provide a focus for ACGME program requirements and CLER visits

Each year, residents and hospital leadership select 3-4 measures at the hospital level. These typically mirror the priorities of the overall health system, with the targets for each specific measure based on prior performance data and also aligned with hospital targets (top quartile performance meets and top decile performance exceeds target).

For each target met, trainees are paid $200, for a maximum payout of $600.

Who is eligible?

All GME ACGME or ICGME trainees who have worked for at least 3 months leading up to June 2015.

What are the measures for this year (2014-2015)?

This year, with resident and leadership input, the following 4 measures have been selected:

  1. HCAHPS Patient Experience Measurement
  2. 30-day same hospital readmissions
  3. Emergency Department Median Consult Time (NEW)
  4. RL-6 Safety Event Reporting (NEW)

What is the reasoning behind these measures? What are the targets?

  1. HCAHPS: As all hospital systems continue to improve, the standards for patient satisfaction will continue to rise as well.
    Target: Meet the National Median of 87.5% (7 out of 8 dimensions).
  2. 30-day hospital readmissions: Trainees will have an additional opportunity to demonstrate improvement.
    Target: 13.05% (median of comparable health care systems on the UHC US News Honor Roll).
  3. Emergency Department Median Consult Time: Extended consult times in the ED contribute to increased Left Without Being Seen rate and decreased patient satisfaction and care.
    Target: Overall decrease in consult time by 10%.
  4. Safety Event Reporting in RL Solutions: Increasing trainee input and awareness for adverse outcomes or near-misses. Trainees only submitted 0.5 (74) of overall reports last year.
    Target: Increase trainee submitted reports for an average of 2 submissions per trainee.

What were our measures last year (2013-2014)?

Last year, we had 3 program measures encompassing the domains of patient satisfaction and quality and patient safety:

  1. HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) surveys: publicly reported data from patient surveys on hospital performance
  2. Duke Hospital 30-day hospital readmission rate
  3. Influenza vaccinations

Additionally, several programs chose program-specific measures:

  • Hand Hygiene: Internal Medicine, Pediatrics, General Surgery, Anesthesia, Neurology, Orthopedics
  • Left Without Being Seen Rate: Emergency Medicine
  • OB Trauma: Vaginal with Instrument: OB/GYN

How was our performance last year?

  1. HCAHPS: Target of 87.5% met
  2. 30-day hospital readmissions: data unavailable through much of the year
  3. Influenza vaccinations: data unavailable through much of the year
  4. Program specific measures: Pediatrics met their target with hand washing.

Trainees received the full pay-out of $600.

How will we be updated on our progress?

Performance Services will create monthly reports with up-to-date performance metrics that will be distributed to trainees and program directors.

Program representatives are also willing to present the program structure to your trainees; contact information is below.

What can we do with this information?

You can work with your program or peers to create a QI project or initiative to specifically address improving upon these measures.

How can I get involved?

To get involved or for more information, please contact one of the program co-chairs: Anjni Patel (anjni.patel@dm.duke.edu) or Sarah Dotson (sarah.dotson@dm.duke.edu).

Attachments:

 

Information/Opportunities

Carolinas HealthCare System Internal Medicine Opportunities 8-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

www.mercydesmoines.org

 

Upcoming Dates and Events

September 2 – 18: Internal Medicine In-Service Training Exams Testing Window

 

Useful links