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News from the Duke Department of Medicine
Updated: 7 hours 19 min ago

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

Internal Medicine Residency News – August 25, 2014

Mon, 08/25/2014 - 10:45
From the Director

Hello everyone! It’s intern block 3!!!! Hang in there JARs and SARs, block 3 for you is in a week. Thanks to all for making the first two blocks run so smoothly.

It was great to see so many JARs and SARs at our JAR/SAR liver rounds. Also saw some great pics from the Kerby Society baseball game. This week, hope to see everyone at the Warren Society trivia night. Don’t forget there is Duke employee appreciation day at the Duke football game. Come see honorary captain Tony Galanos and enjoy the slightly injured but vastly improved Duke football team.

Kudos this week to Tony Lozano from Jess Morris and Aly Shogan for being an amazing VA dayfloat and to Jay Mast from Peter Hu and Linda Koshy for his leadership as a Gen Med SAR. Also to Aparna Swaminathan for an awesome chairs conference and to Mike Woodworth and Paul St. Romain for pushing us to the answer.

Congrats to alumni Mandar and Mallika (Dhawan) Aras on their wedding. Check out the beautiful picture sent by Sajal Tanna.

 

While it is great to celebrate all the good things, this job can be very stressful. Please remember all the resources available – the chiefs, the APDs, me, other residents and the FREE confidential Personal Assistance Service (PAS)  (919) 416-1PAS who are always available to listen and help out.

This weeks pubmed from the program goes to our DOC attending and ambulatory curriculum leader Daniella Zipkin:

http://annals.org/article.aspx?articleid=1897104&atab=1

Have a great week

Aimee

What Did I Read This Week? submitted by: Omobonike Oloruntoba, MD

Reference: N Engl J Med. 2014 Apr 3;370(14):1287-97. doi: 10.1056/NEJMoa1311194.

What I Read (Last) Week: FDA Approves Cologuard for Colorectal Cancer Screening

Although colorectal cancer screening with FOBT, sigmoidoscopy and colonoscopy has reduced the number of deaths from CRC, a substantial proportion of the US population is not up to date with screening. It is thought that a simple, non-invasive test with high sensitivity for CRC and advanced adenomas may increase adherence and improve clinical outcomes.

On Aug. 12, FDA approved Cologuard, a multitarget stool DNA test for the screening of colorectal cancer (CRC).

What are stool tests are available for CRC screening?

Method Advantage Disadvantage Fecal Occult Blood Test (FOBT) Identifies hemoglobin by the presence of a peroxidase reaction that turns guaiac-impregnated paper blue. - Noninvasive- Cheap - High False Positives- Multiple Samples (3)- Not the best for polyp detection (which do not usually bleed) Fecal Immunochemistry (FIT) Detects hemoglobin with an antibody specific to undegraded human hemoglobin (more specific for bleeding from the lower GI tract) - Noninvasive- Fewer samples (1-2)- Fewer false positives More expensiveSensitivity declines with delay in mailing or processing after sampling

So What Is Cologuard?

Multitarget stool DNA test that analyzes stool specimens to detect hemoglobin, multiple DNA methylation and mutational markers, and the total amount of human DNA contained in cells that are shed by CRC or advanced adenomas into the colon.

In essence, this stool DNA test detects the presence of colorectal cancer associated DNA and presence of occult blood which, when positive, may indicated the presence of CRC or an advanced adenoma.

How does it compare?

A cross sectional study published in the NEJM in April (and funded by Exact Sciences, makers of Cologuard) found that Cologuard was more sensitive than the fecal immunochemical test in detecting CRC (92% vs 74%; P = .002) and advanced precancerous lesions (adenomas and sessile serrated polyps) (42% vs 24%; P < .001). However the specificities with Cologuard and FIT were 86.6% and 94.9%, respectively, among participants with nonadvanced or negative findings (P<0.001) and 89.8% and 96.4%, respectively, among those with negative results on colonoscopy (P<0.001).

In the clinic:

  1. Fecal DNA is NOT currently recommended as a method to screen CRC by the United States Preventative Services Task Force
  2. Cologuard is only indicated in patients aged 50 to 85 to screen patients of AVERAGE risk (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s disease and ulcerative colitis; no family history of colorectal cancers or an adenomatous polyp, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer) and a positive test warrants a diagnostic colonoscopy.
  3. CMS proposes to cover theCologuard test once every three years for Medicare beneficiaries who meet all of the following criteria:
    1. Age 50 to 85 years,
    2. Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and
    3. Average risk of developing colorectal cancer (no personal history of adenomatous polyps, of colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or an adenomatous polyp, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).
  4. COSTS:
    1. FOBT: ~$5
    2. FIT: ~$30
    3. Cologuard: $300-600

Reference: N Engl J Med. 2014 Apr 3;370(14):1287-97. doi: 10.1056/NEJMoa1311194.

Clinic Corner

Want to know what’s on The Test?

The American Board of Internal Medicine (ABIM) Certification Exam (aka the Boards), that is. You can!

Not to say that anyone reading this was one of those gunners the rest of us were secretly grateful to have in class, who was bold enough to ask what was going to be on the next test. But perhaps someone at the ABIM was. The ABIM actually publishes a “blueprint” of the content breakdown on the Boards, listing the percentage of exam questions that are supposed to fall in different medical content categories – which, conveniently enough, correlate in the main with the major MKSAP topics.

There is even a more detailed breakdown of the number of questions by specific subtopic one might expect on a typical exam. (This Excel spreadsheet lists all subtopics said to have at least one question on said exam.)

The written explanation accompanying the blueprint goes on to say that “the setting of the encounters reflect current medical practice, so most take place in an outpatient or emergency department setting (roughly 75 percent); the remainder occur in inpatient settings, ranging from the intensive care unit to the nursing home.”

Finally, through a herculean scheduling effort on the part of the chiefs and the Residency Program Office, each year every resident is given the opportunity to diagnose one’s own medical knowledge strengths and weaknesses, on the Internal Medicine In-Training Exam (ITE). These results provide both the percentage of questions answered correctly by content area, as well as how this stacks up relative to one’s peers nationally – which again can be diagnostic of areas warranting further study. Be sure to use them – and happy reading and MKSAPing!

Alex Cho, MD

From the Chief Residents Grand Rounds

Fri., Aug. 29, 2014 at 8 a.m.

Great Hall, Mary Duke Biddle Trent Semans Center for Health Education

Robert A. McDonald
U.S. Secretary of Veterans Affairs

Noon Conference Date Topic Lecturer Time Vendor 8/25/14 SAR Emergency Series: Rheumatologic Emergencies Fola Babatunde 12:15 Picnic Basket 8/26/14 SAR Emergency Series: Sickle Cell Crises Tony Lozano 12:15 Dominos 8/27/14 SAR Emergency Series: Hyponatremia and Hypernatremia Benjamin Lloyd 12:15 China King 8/28/14 SAR Emergency Series: Acute Pain Management Chris Merrick 12:15 Sushi 8/29/14 Chair’s Conference Chiefs 12:00 Mediterra     From the Residency Office

 

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

 

Mini CEXs Assigned to Gen Med Attendings

As of today, the Med Res office will be assigning Mini CEXs to the attendings on Gen Med rotations at Duke, the VA and DRH at the beginning of each block.  Our hope is that this will increase the number of inpatient Mini CEXs done (we require 3 Inpatient and 3 Outpatient per training year) and simplify the process for all.  If faculty or house staff have any questions, please feel free to contact Jen Averitt in the Med Res office.

 

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.

 

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

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.

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:

 

 

Stead Society Trivia Night

The Warren Society would like to invite house staff and Stead preceptors from all the Stead groups to Stead Trivia Night, held starting at 7:30PM (dinner at 7:30, trivia at 9) on Wednesday, August 27, at Bull McCabes (427 West Main St., Durham).  If you come, we will feed you dinner and provide you with tasty beverages of your choice.  The trivia is really just an excuse to gather the residency class, so there is no need to be a trivia buff to participate.  Please come and chat with your resident colleagues in a relaxed atmosphere.  Also, please feel free to bring your families and significant others.

Sincerely,

Steven Crowley on behalf of the Warren Society

 

Information/Opportunities

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

www.mercydesmoines.org

Optional Survey from UC San Diego

Please complete a 2-minute survey about smartphone and tablet use in hospitals. Link HERE.   All data is anonymous and results will be publicly available.

Thank you for your help,
Orrin Franko, MD
Resident Physician, Post-Graduate Year 6
University of California, San Diego

Once again:  SURVEY LINK HERE
Survey: https://docs.google.com/spreadsheet/viewform?usp=drive_web&formkey=dElCcmh0dFhyNE9HNjJNNHBERU9WZGc6MA#gid=0

 

Upcoming Dates and Events

August 27th – Drs. Schuyler Jones and Manesh Patel at Alivia’s  – Careers in Cardiology

August 27th – Stead Society Trivia Night, Bull McCabes (427 West Main St., Durham)

 

Useful links

Internal Medicine Residency News – August 18, 2014

Mon, 08/18/2014 - 09:56
From the Director

Only a few Seersucker Tuesday’s left…make sure to wear the stripes while you can (for you Northerners, no seersucker after Labor Day!). We have a busy week of events, including the Kerby Society Durham Bulls Game, and the JAR/SAR liver rounds with the chiefs!  Mock interviews are in full swing (thanks Heather!) as well.  Rumor has it that the HOLIDAY SCHEDULE is almost finalized so be on the lookout for that as well.

Kudos this week to Ryan Huey, Brian Kincaid, Kedar Kirtane and Nina Beri for their SAR talks – excellent job! Also to medical student Mark Draelos from former Duke med student and now anesthesia resident Teresa Crowgey for excellent work on his clerkship, to Kahli Zietlow from medical student Lauren Sayres for being a great intern and teaching on VA Gen Med and to Angela Lowenstern from Cards fellow and future chief Jenn Rymer for managing a very sick CCU as the teaching resident.  Also to 9100 interns Logan Eberly, Stephanie Li, Bill McManigle and Jenny Van Kirk – I got to see first hand their excellent care of some very sick patients as the Transplant ID consultant this week with awesome ID fellow and former Duke resident Meredith Clement.

I hope many of you took advantage of the opportunity to order MKSAP’s…one per three years is paid for by the program.  There are also MKSAP books to borrow from Jen’s office as well, donated last year by Cardiology Fellowship Director Andrew Wang.

We are excited about all the opportunities for QI events this year.  Having Dr. Daisy Smith give Grand Rounds on High Value Care was outstanding, and Lish Clark and the QI team will be bringing many future opportunities to the group.  The GME incentive program is in full swing, so look for updates on this exciting program as well.

This week’s Pubmed from the Program goes to Amanda Elliott.  Dastani Z, Hivert MF, Timpson N, Perry JR, Yuan X, Scott RA, …, Elliott AL, …, Munroe PB, Kooner JS, Tall AR, Hegele RA, Kastelein JJ, Schadt EE, Strachan DP, Reilly MP, Samani NJ, Schunkert H, Cupples LA, Sandhu MS, Ridker PM, Rader DJ, Kathiresan S.. Novel loci for adiponectin levels and their influence on type 2 diabetes and metabolic traits: a multi-ethnic meta-analysis of 45,891 individuals. PLoS Genet.. 2012 Mar; 8(3): e1002607.

Planning on studying for boards?  I found this while I was doing some research for our curriculum “Back to Basics” project…the NEJM Knowledge+ package …https://secureknowledgeplus.nejm.org/

It is an interactive board review package with study strategies, questions, etc.  Looks quite good.  Pricey ($310) for residents and fellows, but some people may consider this for their ongoing study and review.  If you decide to try it, let us know what you think.  We will also be talking about it in our GME meetings as perhaps an adjunct to MKSAP Mondays…gives us a new question bank to try out and some new formats.

Have a great week!

Aimee

What Did I Read This Week? submitted by: Nilesh Patel, MD

Nilesh Patel, MD, MS

This week, two cases on sign outs revolved around questions of pulmonary hypertension in general. Though the cases were not, in one case, pulmonary arterial hypertension and, in the other, a case with a single clear cause, the timing of the cases this month do coincide with new guidelines in Chest (Chest. 2014;146(2):449-475) about pharmacologic management of pulmonary hypertension.

For our interns, pulmonary hypertension is divided into five groups: pulmonary arterial hypertension (PAH, group 1), pulmonary hypertension due to left-sided heart disease (group 2), pulmonary hypertension due to lung diseases and/or hypoxia (group 3), pulmonary hypertension due to chronic thromboembolic pulmonary hypertension (CTEPH, group 4), or pulmonary hypertension due to unclear multifactorial mechanisms (group 5). These guidelines are specific to patients with pulmonary arterial hypertension (PAH), and cannot be applied to the other groups of pulmonary hypertension.

One important point to remember is that no approved therapy for PAH has been shown to prevent progression of the underlying pulmonary vascular disease. PAH remains an incurable disease; the goal of treatment is to reduce symptoms, improve function, improve hemodynamics, and potentially slow progression of disease.

The first category of patient is the asymptomatic patient with pulmonary hypertension, who in truth is rarely identified. If stable, asymptomatic disease, no treatment is recommended (though there is no consensus recommendation on how to define stability).

For patients with symptomatic pulmonary hypertension, the guidelines recommend vasoreactivity testing (a challenge of inhaled nitric oxide or IV acetycholine, epoprostanol, or adenosine to determine if the pulmonary arterial pressure lowers as a result). First line treatment for patients who demonstrate acute vasoreactivity and have no contraindications (hypotension, right heart failure) is an oral calcium channel blockers (CCB).

Symptomatic patients are divided into WHO class II (slight limitation, comfortable at rest), class III (marked limitation, comfortable at rest), and class IV (inability to carry out any activity without symptoms). For class II patients who failed CCBs, approved therapies include:

-       Endothelin receptor antagonists (bosentan, ambrisentan), which improve 6 minute walk times and in some cases are thought to improve cardiopulmonary hemodynamics and delay time to clinical worsening.

-       PDE-5 inhibitors (sildenafil, tadalafil), which improve 6 minute walk times.

-       Or Riociguat, which was pulished about last month in the NEJM. It is a member of a new class of compounds  (soluble guanylate cyclase stimulators), may improve 6 minute walk times, may improve hemodymanics, and, interestingly, may be of benefit not only in PAH but in chronic thromboembolic pulmonary hypertension (CTEPH, group 4 PH). (NEJM 2013;369(4):319-29).

For class III and IV disease the above medications are indicated. However, for worsening/progressive WHO Class III disease, an inhaled (iloprost) or IV (epoprostenol, treprostinil) prostacyclin should be initated. For those with class IV disease, and intravenous prostenacyclin should be used. These drugs are not indicated in WHO Class II disease because of their side effects, complications of continuous infusions, and overall cost.

Clinic Corner

PRIME Clinic Corner

Hi PRIME team:

Thanks to everyone for working with staff to make this year’s transition go smoother.  Just remember to ask your team’s interns if they need any assistance with juggling clinic and other responsibilities.  The ACS messages can be confusing if it is not a straight forward refill. If you have not met with your team and your team attending to work out coverage for the year  and review expectations please send out an email and get a meeting scheduled.

Joshua Briscoe is working on a ROS sheet to hand out to patients when they check-in, please let either of us know if you are interested in helping or providing feedback.  The COMP narcotic spreadsheet should be assisting all of you in managing your patients with chronic pain. Please let me know if you have any suggestions.

We are working on starting  health and wellness group class in the near future for our Prime patients and  a pain psychology class for our patients with chronic pain in a few months.  Will keep you posted on the details. We are all excited about another year together.  Please stop and say Hi to our now COMPLETE family.  We have many new faces that have started working in the last few weeks.

Have a great week!

Sonal

QI Corner

Great to hear all of your ideas at last week’s PSQC meeting. Stay tuned for a home-grown “Choosing Wisely” campaign to improve the value of care that we Duke residents provide. As always, get in touch with me if you want to join the team in making this happen.

Here is an update on SRS reporting, one of the measures for this year’s GME incentive program. To get the $200, there needs to be a total of 1972 SRS reports from residents during this academic year. See below. Residents submitted a total of 23 in July, which is on pace to be WAY more than in 2013-2014, but still not enough to get us on track for the $200 goal. But you can change that! SRS reports don’t take long, and they have impact. Let’s get in the habit of doing a LOT of them.

 

Jul-14 SRS Total 1447 SRS by Trainees 23 % by Trainees 2% Total Submitted by Trainees (YTD) 23 Total Trainees 986 Average # of SRS per trainee 0.0233 Goal (2.0/trainee) 1972 Total Remaining Needed 1949 From the Chief Residents Grand Rounds

Friday, August 22 – Dr. Christopher Granger, Cardiology (Novel Anticoagulants)

Noon Conference Date Topic Lecturer Time Vendor 8/18/14 SAR Emergency Series: Pearls from Dr. G Dr. Galanos 12:15 Subway 8/19/14 MED-PEDS Combined Tim Mercer 12:15 Dominos 8/20/14 Resident M&M QI Team 12:15 Cosmic Cantina 8/21/14 QI Patient Safety Noon Conference 12:15 Rudino’s 8/22/14 Chair’s Conference  Chiefs 12:00 Chick Fil A     From the Residency Office Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

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.

New System for Requesting Interpreters

As a reminder, Duke University Health System is implementing a new web-based system to request the services of a medical interpreter. Beginning on Aug. 18, 2014, Duke University Hospital, PDC and hospital-based clinics that are currently being serviced by interpreters from International Patient Services (919-681-3007) will be able to use a website to request an interpreter via an icon on PIN and non-PIN workstations.

The system, called ServiceHub (https://q.servicehub.com/sso/duhs/r2 ), will simplify and streamline requests for language assistance and will enable 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 will also enhance 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 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. Please share this information with any members of your staff who may request interpreters. 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

 

New Jackets/Fleeces for 2014!

Today, AUGUST 18, is THE LAST DAY TO ORDER AND PAY FOR YOUR JACKET!  Please contact Lynsey Michnowicz in the MedRes office if you have any questions!

https://duke.qualtrics.com/SE/?SID=SV_eV6magzZYP906CV

Jacket will be Black with the Duke Medicine logo.

Stead Society Trivia Night

The Warren Society would like to invite house staff and Stead preceptors from all the Stead groups to Stead Trivia Night, held starting at 7:30PM (dinner at 7:30, trivia at 9) on Wednesday, August 27, at Bull McCabes (427 West Main St., Durham).  If you come, we will feed you dinner and provide you with tasty beverages of your choice.  The trivia is really just an excuse to gather the residency class, so there is no need to be a trivia buff to participate.  Please come and chat with your resident colleagues in a relaxed atmosphere.  Also, please feel free to bring your families and significant others.

Sincerely,

Steven Crowley on behalf of the Warren Society

Information/Opportunities

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

www.mercydesmoines.org

 

 

Upcoming Dates and Events

August 19th – Liver Rounds, Tyler’s Tap Room

August 27th – Drs. Schuyler Jones and Manesh Patel at Alivia’s  – Careers in Cardiology

August 27th – Stead Society Trivia Night, Bull McCabes (427 West Main St., Durham)

 

Useful links

Faculty mentoring for residents

Wed, 08/13/2014 - 09:00

Murat Arcasoy, MD, associate program director for the Duke Internal Medicine Residency Program, is creating a directory of Medicine  faculty who are willing to mentor residents (and medical students) in their research activities.

Please complete the form below to indicate your interest.

Learn more about resident research activities.

  • Your nameFirstLast
  • Your email
  • Your primary divisionPlease choose your primary divisionCardiologyClinical PharmacologyEndocrinology, Metabolism, and NutritionGastroenterologyGeneral Internal MedicineGeriatricsHematological Malignancies and Cellular TherapyHematologyInfectious DiseasesMedical GeneticsMedical OncologyNephrologyPulmonary, Allergy, and Critical Care MedicineRheumatology and ImmunologyOther
  • What type of science is your research?
    • Basic
    • Clinical
    • Translational
  • What model do you use to conduct your research?
    • Human
    • Animal
    • Cell
    • In silico
  • What techniques do you use to conduct your research?
    • Biochemical
    • Imaging
    • Genetic
    • Electrophysiology
    • Other
  • What pathway do you study?
    • Metabolomics
    • Proteomics
    • Biomarkers
    • Other
  • With which Basic Science departments do you collaborate?
    • Biochemistry
    • Biostatistics & Bioinformatics
    • Cell Biology
    • Immunology
    • Molecular Genetics & Microbiology
    • Neurobiology
    • Pharmacology & Cancer Biology
  • With which Clinical departments do you collaborate?
    • Anesthesiology
    • Community & Family Medicine
    • Dermatology
    • Neurology
    • Obstetrics & Gynecology
    • Ophthalmology
    • Orthopaedic Surgery
    • Pathology
    • Pediatrics
    • Psychiatry & Behavioral Sciences
    • Radiation Oncology
    • Radiology
    • Surgery
  • With which other Duke schools or departments do you collaborate?
  • To which centers or institutes do you belong? (If applicable.)
    • Duke Cancer Institute
    • Duke Center for Aging
    • Duke Center for AIDS Research
    • Duke Clinical Research Institute
    • Duke Global Health Institute
    • Duke Human Vaccine Institute
    • Duke Institute for Health Innovations
    • Duke Molecular Physiology Institute
    • Duke O'Brien Center for Kidney Research
  • Which human diseases do you primarily study?
  • Your clinical and research interestsAdd keywords related to your research, or copy and paste an overview of your research activities and portfolio.
  • Which of these scholarly projects are you willing to assist residents on?
    • Original clinical research (prospective or retrospective)
    • Basic science or translational research
    • Medical education research
    • Preparation of resident research grants
    • Coauthoring a review article
    • Systematic literature review
    • Coauthoring a case report
    • Clinical vignette presentation at regional or national meetings
    • Research or case presentation at local Duke conferences (annual School of Medicine Clinical Science Day, Internal Medicine Resident Research Night)
    • Senior Assistant Resident presentations
    • Quality Improvement
    • Health systems research
  • Would you be interested in working with third-year Duke medical students?
    • Yes
    • No
  • Please list names of current or past residents and medical students you have mentored.
  • Each Department of Medicine faculty member has a profile in the Scholars@Duke system. Keeping this profile up to date remains one of the best ways for you to share your research activities with your colleagues, trainees and those beyond Duke.
  • Have you updated your Scholars@Duke faculty profile in the last 3 months?
    • Yes, I have updated my profile
    • No, but I will update my profile in the next 30 days
    • No, but I will delegate this to an assistant
    • No, but I'd like more information about how to do this
jQuery(document).ready(function(){jQuery(document).trigger('gform_post_render', [49, 1]) } );

Internal Medicine Residency News, August 11, 2014

Mon, 08/11/2014 - 09:51
From the Director

Hope everyone had a great week!  Thanks to Bill H., Murat, Dave B., Alex, Lish, the Chiefs, Jen, Erin, Lynsey, and Lauren for holding down the fort while our family snuck away for vacation.  Also, much appreciation to the chiefs for holding our first TOWN HALL on Friday.  August and September are very busy months, with the In Training Exams (ITE) and SAR Interviews, so please keep the lines of communication open as schedules change.  We will be giving you more information about times and locations of the medicine ITE in the coming weeks — the big news is that we will be taking the test on computers this year instead of using pencils and scan tron sheets (wow, welcome to 2014!).  another little known fact is that we pay $110 per person to take the ITE…another big ticket item in our annual budget.

Kudos this week to our SARs who gave their talks for the intern emergency lecture series..Erin Boehm, Adrienne Belasco and Aparna Swaminathan.  I’m sorry to have missed them, but I hear that they were fantastic!  Also, kudos to Juan Sanchez from ID attending Steve Taylor for great work in the VA ID Clinic, to Andrea Sitlinger and Drew DeMaio from Chris Hostler for being a huge help on ID consults Friday, to Jason Zhu from Jess Morris for excellent transitions of care at the VA, to Hal Boutte from Sajal Tanna for being a great DRH Day Float, to med student Lawrence Ngo from Jesse Tucker for his excellent work as a sub-I at the VA, and to the imcomparable TONY GALANOS for being selected as the honorary Duke football captain for the August 30th game!!  Thanks to everyone who contributed to nominating Dr. G!!  And a congratulations to Duke Med Alum Bobby Aertker (and Andrea and Alan) on the birth of Riley!

Thanks to Kerby Society head honcho Heather Whitson for organizing the following activities…MOCK INTERVIEWS:  Drs. Ralph Corey and Richard Reidel will be offering mock interviews again this year for Kerby-ites who are entering the fellowship match or job interview process this year.  The mock interviews will occur in late August through mid September.  Expect an email from me next week with available times– you will be able to sign up for a 1-hour slot on a first come, first served basis and DURHAM BULLS GAME: August 17th.

Thanks to Warren Society Leader Steve Crowley for organzing TRIVIA NIGHT on August 27th at Bull McCabe’s.  I hear that there are some interns who are AWESOME at trivia..(that means you Rachel, Peter, Christine, et al) so hope to see you there!

Things are shaping up for the iCOMPARE duty hours study.  We have submitted our application and are under consideration as a site for the study.  Originally, this was supposed to be a two year cross over study, with one year allowing 24+4 hours for interns, and one year at 16 hours for interns.  the new study design is now a one year study where you are randomized to either intervention (80 hours max per week, 1 day off in 7 averaged over 28 and q3 as most frequent allowed call cycle) versus control (today’s rules), and a duty hour waiver through July 2019 for all participating sites.  I hope to know soon if we are accepted into the study, which is scheduled to start July 2015.  See the iCOMPAREstudy.com website for more details.

Don’t forget to order your DUKE MED fleece!!  Deadline to order/pay is August 18th!!

This week’s pubmed from the program goes to Bronwen Garner for her review article accepted for publication in Trends in Molecular Medicine..Garner B, Tsalik E, Burke T, Woods C, Ginsburg GA and Zaas AK.  “The Current Epidemiology and Clinical Decisions Surrounding Acute Respiratory Infections”

Have a Great Week!!
Aimee

Clinic Corner

Pickett Clinic Corner

Is it August or October? the weather is nice but I bet will start heating up soon.

Tramadol will be moved to Schedule IV controlled substance after 8/18/14. This med must be written for with refills and cannot be called in.

We are happy to welcome Lauren as one of our new CMA! She was the student that worked with the residents. Sadly Nahza our CMA and Linda in the lab are leaving for another clinic. We have Kay as the Nurse manager is available on Wednesday and Fridays and Donna RN from Durham Medical center helping us out. EPIC stuff Upgrade on Sunday. Ask Marie for any questions NOTES: the default FONT needs to be in ARIAL. I tried to print out a resident note in a different font and got Matrix characters! Do not order LDL direct! not getting covered by insurance. M&M and Rats: make sure you eat all the M&Ms. We have rats and sometimes they eat the M&Ms. We are looking at other ways to keep the M&M dispenser Inbox messages: as a curtosy to your fellow residents, please try to do as many of the inbasket message and the black folder message. I know this is hard if the messages get put in the box after 4pm (the RNs usual drop off time). At least try to triage if needs to be done or can be held until the next day.

Mini cex- let me know if your attending has done these especially if there is no evaluation in medhub. September and August onto 2nd Mini cex

 

Resident Attending 1st CEX Plan for CEX Black-Maier Boinapally 7/9/2014 Hinohara Brown 8/19/14 Hu/La Voy ? Rookwood 7/25/14 Khairallah Boinapally 7/9/2014 Kopin TBA Musgrove   Boinapally  8/6/14 Cupp Boinapally 7/16/2014 Eisenberg  Waite  8/6/14 Erdmann Peyser 9/4/14 Matta Rookwood 7/11/2014 Ng’eno  Wolf   8/7/14 Nicklolich Rubin 7/1/2014 Ray Ray 7/10/2014 Verma ?Boinapally 7/9, 7/23? Rookwood 8/15/14 Zhu Rubin` 8/4/2014 Beri Brown 8/5/2014 Boehm TBA Lehr Wolf 7/31/2014 Lloyd Rubin 7/7/2014 Kirtane Waite 8/13/14   QI Corner

Aaron Mitchell, MD

We have what should be a great Grand Rounds lecture coming up this Friday. Daisy Smith, one of the minds behind the High Value, Cost-Conscious Care campaign at the American College of Physicians, will be here to discuss her work with this program.

Also on the topic of High Value, Cost-Conscious Care (HVCC), there have been a lot of ideas to reduce wasteful health care spending coming from you all. If you want to get involved in putting some of these into action, come to this week’s PSQC meeting, 5:30pm on Wednesday.

One of our big patient safety efforts of this year is to increase our use of the Morbidity and Mortality conferences to raise awareness of easy-to-miss diagnoses and call attention to systems problems endangering our patients. The goal will be to have M&M at noon lecture once a month. Which means, we will need cases! This will be a great chance to bring up important topics and present to your peers. If you have been involved in any cases where there was a “near miss,” a preventable bad outcome, or a dangerous system issue that you would like to share, then get in touch with me or Dr. Alicia Clark.

From the Chief Residents Grand Rounds

Friday, August 15th: Daisy Smith

Noon Conference Monday 8/11/2014 SAR Emergency Series: Toxidromes Brian Kincaid 12:15 Nosh Tuesday 8/12/2014 SAR Emergency Series: Acute seizure management Kedar Kirtane 12:15 Domino’s Wednesday 8/13/2014 SAR Emergency Series: Oncologic Emergencies Ryan Huey 12:15 China King Thursday 8/14/2014 SAR Emergency Series: Approach to the anemic patient Nina Beri 12:15 Sushi Friday 8/15/2014 Chair’s Conference Chiefs 12:00 Mediterra     From the Residency Office

 

MKSAP Ordering Now Open!

Please use the link below to order your MKSAP materials.  Just a reminder, you must be a current ACP member to order, and the program will only purchase one (1) copy per resident during residency.  The link to order (below) will be available until 8/22/14.  If you have any questions, please feel free to contact Erin Payne in the MedRes office.

https://duke.qualtrics.com/SE/?SID=SV_6gIBENn00rxo6G1

 

TSMA/Moonlighting Policy for Internal Medicine Residents

Please note that due to some confusion around the TSMA/Policy for the program, an updated policy has been posted as a Learning Module in MedHub.  This policy will be “assigned” to all current JARs/SARs in the program via MedHub and anyone interested in moonlighting will be required to review and accept the policy (electronically.)  Please look for an email from Jen Averitt this week with more details.

 

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

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.

New Jackets/Fleeces for 2014!

To Order your 2014 Duke Medicine Jacket please use this link:

https://duke.qualtrics.com/SE/?SID=SV_eV6magzZYP906CV

Jackets will be $52.50 each and monogramming will be an additional $2.75 per jacket!!  We will have samples in the Med Res Office to try on until August 18th!  Deadline to order and pay is August 18th!!

Jacket will be Black with the Duke Medicine logo.

 

 

Information/Opportunities

 

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

Community Health Network

Upcoming Dates and Events

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

August 27th – Drs. Schuyler Jones and Manesh Patel at Alivia’s  – Careers in Cardiology

August 27th – Warren Society Stead Trivia Night at Bull McCabe’s Irish Pub

Useful links

Meet your chief resident: Aaron Mitchell, MD

Fri, 08/08/2014 - 08:21

Aaron Mitchell, MD

Aaron Mitchell, MD, began his role as the Durham VA Medical Center’s third chief resident for quality improvement and patient safety in July. As chief resident, Dr. Mitchell will lead quality improvement and patient safety initiatives at the Durham VA and lead morbidity and mortality conferences at Duke. For his chief resident year, Mitchell said he is looking forward to continuing his quality improvement research, starting new projects and stepping into teaching and attending physician roles.

Mitchell began preparing for his chief resident year in January, attending regular seminars on quality improvement theory led by Dave Simel, MD, vice chair for Veterans Affairs in the Department of Medicine.

Mitchell is one of 32 quality improvement and patient safety chief residents at VA medical centers across the country who will be leading quality improvement projects, receiving training from mentors and participating in a national curriculum meant to help usher in a new generation of quality improvement leaders who will help residents implement quality improvement initiatives.

For Mitchell, his interest in quality improvement and patient safety grew during residency at Duke. Mitchell said seeing the work of Ryan Schulteis, MD, the Durham VA’s first chief resident for quality improvement and patient safety, and Jonathan Bae, MD, who led the residency program’s quality improvement initiatives until July, sparked his interest, and Mitchell found that quality improvement and patient safety research was a good fit with his broader research interest.

“What I’m planning on doing in my career down the road is health services research, which is studying the whole health care system, seeing how good a job it does in terms of what we are able to deliver to patients, and studying its shortcomings for potential ways to make improvements,” Mitchell said.

Mitchell said his interest in studying how physicians use the available tools to treat patients is complementary to quality improvement research because both research areas look at “making sure physicians are using the proper tools and technologies for our patients.”

Quality improvement research is not new to Mitchell. As a resident, Mitchell worked on several quality improvement projects, including one that looked at the inter-hospital transfer protocol for patients coming to Duke from other hospitals.

Mitchell said the project grew out of dissatisfaction on the part of Duke residents, who felt that they were often caring for patients without knowledge of the patients’ full clinical record. Working with fellow resident Kevin Shah, MD, MBA, and others, Mitchell said the residents were able to redesign the process so that residents were more prepared when accepting patients from outside hospitals.

Mitchell’s quality improvement research, working with pediatrics resident Deana Miller, MD, has also looked at shift-to-shift handoffs and how the information that is conveyed during a handoff prepares residents to react to emerging patient changes, such as code situations.

Mitchell said he is looking forward to finding and answering new quality improvement questions during his chief resident year. He is already mining the VA database to look at patterns of care within the VA system and finding interesting questions to investigate.

So far, he has been involved in tracking and measuring changes in patient flow through the internal medicine service at the Durham VA that have resulted from the recent reorganization of the general medicine team structures there, where resident shifts are now following a 24-hour call system rather than a 12-hour call system.

Other areas that he has begun to investigate include proper vaccination of post-splenectomy patients and preventable readmissions for obstructive pulmonary disease. Either of these investigations could turn into longer-term projects, Mitchell said, depending on whether he identifies any areas for improvement. A longer-term project will likely be to study the timeliness of care provided to cancer patients at the Durham VA.

“I’m also looking forward to the teaching roles that come with this position, specifically getting to organize the morbidity and mortality conferences and the quality improvement conferences for senior residents on the VA’s general medicine service,” he said.

Mitchell also hopes to play more of a leadership role in the cost conscious medicine series that the residency program has incorporated into their noon conference series.

“I am excited to be an attending physician for the first time and to be a leader for new interns and second-year residents,” he said.

Mitchell did not always want to go into medicine. As an undergraduate at Yale University, he initially thought he would study theoretical physics. His interests moved to biology, with the intention of doing bench research, but a health care mission trip to Bolivia showed Mitchell the value of interacting with patients.

Mitchell attended New York University for medical school and came to Duke for his internal medicine residency. He said when he interviewed for residency at Duke he was “blown away by the program.”

“I spent time here as a fourth-year medical student on the hematology service and found the level of intellectual capability and friendliness on the part of the faculty to be something I hadn’t experienced at my medical school institution or others where I interviewed,” Mitchell said. “You could say choosing a program was a hard decision because I interviewed at a lot of places, but there was never really any competition.”

In his free time, Mitchell likes to play soccer and enjoys distance running. He said he tries to visit his parents, who live near Asheville, as often as he can. After his chief resident year, Mitchell plans to complete a fellowship in oncology and continue to do health services research.

“I hope to be someone with a split time schedule, with some clinical days but to a large extent doing outcomes research and health services research in oncology,” he said.

Meet the chief residents:

Internal Medicine Residency News, August 4, 2014

Mon, 08/04/2014 - 09:32
From the Director

Happy August! Thank you to the JARs and SARs for your work in the 5 week “Block 1″ – amazing job stepping up to your new roles.  I hope the interns have enjoyed their first week on new services – have heard some excellent compliments on great work by many of you! Kudos this week go to Matt Atkins and Ryan Huey for putting together pearls for us to learn from before the sessions, to Jake Feigal, Andy Mumm, Tim Mercer, and Adam Banks for serving as “models”, and to Murat Arcasoy for planning the week! Other kudos this week go to Jesse Tucker from Coral Giovacchini for an “uber”-great job on VA Gen Med, to Ryan Jessee from Aimee Chung who heard from her patient that he provided great care while in the ED, to Dinushika Mohottige from Ann Marie Navar Boggan for great care of a cardiology patient, and to Sneha Vakamudi for spearheading the new AMAZING Duke Med jacket ordering for this year.  Kudos also to Dinushika Mohottige from Lakshmi Krishnan for helping care for a very sick patient and to Alan Erdmann from Ani Kumar for being an amazing VA JAR. And thank you to Drs. Greenfield and Corey for organizing our visiting professor, invited by 2013-14 Chief Resident Stephen Bergin. We all enjoyed meeting with Dr. Kollef and hearing a great grand rounds.

Please keep sending me the great things your co-residents are doing…

Thank you to Sharon Rubin for organizing the upcoming “How to Interview” seminar. Please see the bottom of Med Res News for more information. Also, if you are interested in a career in Cardiology, mark your calendars for August 27th at 5pm to meet Drs. Schuyler Jones and Manesh Patel at Alivia’s to discuss careers in cardiology.  Interns, JARs and SARs are welcome.

We are still working on getting the microphones fixed in the Med Res library…thank you for your patience as we work this out. We were hopeful to be able to broadcast to DRH by today, but we have another visit from the company this week, as two prior visits have not yet solved the issues.

This past week the IOM published it’s paper on GME reform and GME funding.  If you have a chance to read the summary, I’d recommend it highly.  We are working through what it means for us here, and GME in general and will certainly keep you posted on what is happening at the “big” GME level here, and to the program.  In our ongoing planning, we are working on how to continue to incorporate quality and outcomes into our assessments of our training program, and how to get more outstanding ambulatory experiences to be part of your training

This week’s pubmed from the program goes to 2013-14 VA QI Chief Joel Boggan for his article in the Journal of Graduate Medical Education! We are excited to see the story of “Sharepoint” in print!

A Novel Approach to Practice-Based Learning and Improvement Using a Web-Based Audit and Feedback Module

Joel C. Boggan, George Cheely, Bimal R. Shah, Randy Heffelfinger, Deanna Springall, Samantha M. Thomas, Aimee Zaas and Jonathan Bae

JGME July 9, 2014.

Have a great week!

Aimee

What Did I Read This Week? submitted by: Saumil Chudgar, MD

An Innovation Report: Angus S, Vu TR, Halvorsen AJ, Aiyer M, et al. “What Skills Should New Internal Medicine Interns Have In July? A National Survey of Internal Medicine Residency Directors.” Academic Medicine 2014; 89: 432-35.

AND

 NY Times article

Denise Grady. “The Drawn-Out Medical Degree.” New York Times. Aug 1, 2014. Available at

http://www.nytimes.com/2014/08/03/education/edlife/the-drawn-out-medical-degree.html

Why did I read these?

July is always an exciting time of year – congratulations to our interns for one month down! I ran across this article as I was reviewing the literature about the fourth year of medical school. Current interns remember well that the fourth year is what you make of it – you can coast through or make it fairly rigorous. There is more variation in expectations among schools as compared to the third year. With that in place, what do residency directors expect you to know when you start? And, as someone with a lot of interest in medical student education, what should we (as both attendings and residents) be teaching our students to get them ready for residency? It is the peak of sub-I season – how can you as residents help make our future interns ready? On the heels of this article was a perspective in the NYT that describes changes at some medical schools – including shortening medical school to three years. What does that mean for us – will students be ready to be interns?

What I learned from reading these/thoughts on the articles?

This study was a collaboration between the Internal Medicine Clerkship Director group and the Program Director group. The study design was fairly simple – a yearly survey goes out to residency program directors; one section of the survey focused on this topic where PD were asked to rate how important they felt a skill was for an incoming intern. Response rate was 75%, which is quite strong for a survey study. I think many of us could have predicted the skills found to be most important – listed below with the percentage that ranked it as “high priority” – corresponding to a 4 or 5 on a 5-point scale.

  1. “Knowing when to see assistance” – 95.7%
  2. “Communicating with nurse/nurse triage” – 89.0%
  3. “Time management” – 84.8%
  4. “Communicating in a culturally sensitive manner” – 80.5%
  5. “Information management – prioritizing skills” – 80.1%

Residency directors were also asked to give free-text responses of the two most importance skills an intern should possess. The top two among those were organization/prioritization/time management and clinical skills/history and physical examination. I found it interesting that medical knowledge and procedural skills fell much lower on this list; perhaps it is assumed that we can teach you this if needed once you’re here – the other skills are more complex to learn.

Interestingly, another method could have been considered to rank these topics – Q methodology. Drs. Hargett and Zaas have used this effectively and published some interesting data – it is essentially a forced prioritization of a list of items. Some of you may have seen or done this before.

This article along with several others start to define the level we hope a new intern/graduating medical student will be. The AAMC recently released the Core Entrustable Professional Activities for Entering Residency – 13 things medical schools should be able to show that their graduates can do. In the face of this increased accountability, the New York Times article discusses that some medical schools are advocating for shortening training. It is an interesting read if you have time. NYU enrolled 16 medical students into a 3-year track last summer – they must know what specialty they want to pursue when they start and will be guaranteed a residency slot in that specialty at NYU. It is a little reminiscent of the combined 6 or 7 year undergrad-medical school programs.

The articles and others taken together make me consider how medical education is changing – we are asking for more defined expectations of graduating medical students at the same time that there are calls for shortened training. The next few years will be quite interesting to see how these two seemingly divergent ideas will come together.

Clinic Corner

DOC Clinic Corner

Hi Team!Thanks for making this a great start to the year. We realize that navigating Maestro in clinic, figuring out how to support our patients’ multiple needs, and learning where the bathroom is can be overwhelming when you’re also trying to learn clinical medicine!! You’re all doing it with grace and professionalism The DOC Newsletter 2014 August  is attached here! Please read!Here are some other key pearls: From the “Resource file”, Larry Greenblatt recommends this website as an entry point for a terrific set of on line resources, templates, guidelines, and tools amassed and organized by Community Care North Carolina (i.e. Medicaid care management) with Dr. Holly Biola as the lead. Check it out! http://communitycarenc.com/provider-tools/ From the Pharmacy: Seeing a patient for a hospital follow-up visit? Look for telephone encounters in Maestro labeled “hospital follow-up” from Holly and Jan. We review the patient’s chart and sometimes call the patients for medication reviews prior to their visit with you! Important info! Maestro Pearls: Get those notes done in 24 hrs! You KNOW you hate is when they stack up. Plus, we’ve got rules to follow Please cc your attending in the follow-up section, AND select your attending in the “providers” button in meds and orders. Yay!! Ordering labs while off site? Please always select “future” with no end date. Like, always. We may not know what the future holds, but, at least it can hold your labs.    Thanks so much! See you back at the homestead Dani From the Chief Residents Grand Rounds

Friday, August 8 – Dr. Joe Rogers, Cardiology

Noon Conference Date Topic Lecturer Time Vendor 8/4/14 SAR Emergency Series: Acute Renal Failure Erin Boehm 12:15 Subway 8/5/14 SAR Emergency Series: Hip Fracture and Perioperative Mgmt Adrienne Belasco 12:15 Dominos 8/6/14 SAR Emergency Series: EKG Interpretation/Ischemia Aparna Swaminathan 12:15 Cosmic Cantina 8/7/14 IM-ED Combined Conference: Improving STEMI Care Michael Ward 12:15 Picnic Basket 8/8/14 AR Town Hall: Fellowship Interview Pearls  Chiefs 12:00 Chick Fil A     From the Residency Office

 

MKSAP Ordering Now Open!

Please use the link below to order your MKSAP materials.  Just a reminder, you must be a current ACP member to order, and the program will only purchase one (1) copy per resident during residency.  The link to order (below) will be available until 8/22/14.  If you have any questions, please feel free to contact Erin Payne in the MedRes office.

https://duke.qualtrics.com/SE/?SID=SV_6gIBENn00rxo6G1

 

TSMA/Moonlighting Policy for Internal Medicine Residents

Please note that due to some confusion around the TSMA/Policy for the program, an updated policy has been posted as a Learning Module in MedHub.  This policy will be “assigned” to all current JARs/SARs in the program via MedHub and anyone interested in moonlighting will be required to review and accept the policy (electronically.)  Please look for an email from Jen Averitt this week with more details.

 

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

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.

Provider Staff for House Staff

Thank you to Dr. Sue Woods for providing an updated list of Provider list for housestaff.  This list may also be found in the Resources/Documents area of MedHub.

New Jackets/Fleeces for 2014!

To Order your 2014 Duke Medicine Jacket please use this link:

https://duke.qualtrics.com/SE/?SID=SV_eV6magzZYP906CV

Jackets will be $52.50 each and monogramming will be an additional $2.75 per jacket!!  We will have samples in the Med Res Office to try on until August 18th!  Deadline to order and pay is August 18th!!

Jacket will be Black with the Duke Medicine logo.

Interview Skills

Whether you are going to interview for hospitalist position, primary care or attending position after fellowship, there are some skills to learn for the interview and essential questions to ask. Come to this session for dinner, sponsored by the North Carolina American College of Physicians, and get the answers you need before your job interview. Welcome to all medical students, residents, interns and fellows.

Panelists: Dr. Jon Bae, Dr. Saumil Chudgar, Dr. David Simel, Dr. Pooh Setji, Dr. Poonam Sharma, Dr. Bruce Peyser, Dr. Sharon Rubin

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

Please RSVP to Dr. Sharon Rubin by August 4, 2014

Sincerely,

Sharon Rubin, MD, FACP

Assistant Professor, Duke University Medical Center

Residency Director at Pickett Road

 

Information/Opportunities

The Winston-Salem CareerMD Career Fair: Event Details

Location
The Hawthorne Inn and Conference Center, 420 High Street, Winston-Salem, NC

Date & Time
Wednesday, August 06, 2014; arrive any time between 5:00 PM and 8:00 PM

Details
Attire is casual and a complimentary buffet will be provided

RSVP Requested
Residents and fellows who would like to attend this event are asked to RSVP to charles.howell@CareerMD.com or online at www.CareerMD.com/Winston-Salem

 

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

Community Health Network

Upcoming Dates and Events

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

August 27th – Drs. Schuyler Jones and Manesh Patel at Alivia’s  – Careers in Cardiology

Useful links

 

Ambulatory Care Leadership Track adds focus on legislative advocacy

Tue, 07/29/2014 - 08:27

From left: Residents Brice Lefler, Jeremy Halbe, Lauren Porras, Alexandra Clark, and faculty members Daniella Zipkin and Alex Cho visited Washington, D.C. as part of an opportunity to learn about legislative advocacy. Photo courtesy of Daniella Zipkin.

As part of the Duke Internal Medicine Residency Program’s Ambulatory Care Leadership Track (ACLT), four Duke internal medicine residents traveled to Washington, D.C. last spring to meet with Congressional representatives and learn about legislative advocacy.

The trip was an opportunity for residents, Lauren Porras, MD; Jeremy Halbe, MD; Brice Lefler, MD; and Alexandra Clark, MD, to get practical experience in legislative advocacy. The residents are part of the residency program’s Ambulatory Care Leadership Track, a training pathway for physicians planning careers as leaders and clinicians in primary care or ambulatory subspecialty medicine.

While in Washington, the residents met with the staff of Congressional representatives for their hometowns – Houston, Miami, Durham and Jacksonville, N.C. – accompanied by Catherine Liao, assistant director for government relations in the Duke University Health System Office of Government Relations, who helped the residents prepare for the trip. In addition, the residents met with Paul Vick, associate vice president for government relations for the health system and medical center, to learn about what it is like to advocate on behalf of particular issues that are important to Duke Medicine.

From there, the residents were asked to come up with a short list of issues they would be interested in discussing with legislative staff in Washington, said Alex Cho, MD, MBA, assistant program director in the residency program and assistant professor of medicine (General Internal Medicine), who helped organize the trip along with Daniella Zipkin, MD, associate professor of medicine (General Internal Medicine).

Ultimately, the residents chose two issues to present to legislative staff: adjusting the methodology for the federal Hospital Readmission Reduction Program to include socioeconomic status as a factor when the Centers for Medicare and Medicaid Services assign penalties to hospitals for frequent rehospitalization of Medicare patients, and expanding the scope of health risks that qualify for reimbursement by Medicare for intensive behavioral counseling with a physician.

Both issues are ones the residents have encountered in their work at Duke. Dr. Lefler said she chose and researched Medicare’s hospital readmission penalties.

“As residents, we admit and discharge patients all the time,” Lefler said. “We work so hard to discharge a patient safely and despite our best efforts, some patients come back within a few days or a week.”

The residents researched and developed fact sheets on both issues that they presented, which described the issue and what they were asking Congress to do to address it. They also practiced their presentations with the help of fellow resident Nick Rohrhoff, MD, who, as a medical student, served as the American Medical Association’s Government Relations Advocacy Fellow, as well as Ms. Liao and Mr. Vick.

Lefler said because this was their first time meeting with Congressional staffers, the residents prepared a lot.

“I think our presentations were well received, especially because (staffers) were hearing from people on the ground who are affected by these problems every day,” Lefler said. “We shared patient stories to make it more real for our audience. It was easy to talk about our experiences as physicians.”

“The residents who went were incredibly polished and really impressed our government affairs office,” Cho said. “It is important for physicians to be able to explain an issue. We explain things all the time to our patients in the trusted role we are in as physicians but being able to do that on behalf of the public, our colleagues and patients is important.”

Lefler said though she is not very political, she is now more interested in being aware of the issues that affect her patients and medical practice.

“I feel more empowered and confident that I can advocate for myself and my patients,” she said. “It was fun to work with residents and faculty in a very different kind of arena.”

Cho said there are several things he hopes the residents learned from the trip, including how approachable the halls of power are, how to frame an issue in a way that is digestible and persuasive, a better understanding of the breadth and limitations of elected officials’ options for actions, a greater knowledge of how the system of government works, and an appreciation for how important it can be for physicians to be vocal participants in the representative democracy.

“The chance to do legislative advocacy really rounds out the ACLT experience,” Cho said. “There is a real need for physicians to be leaders in their practices and institutions, but physicians are generally so busy taking care of patients, and learning how to read a budget or advocate for your profession and patients is not usually part of training. This is an opportunity to fill part of that gap in residency education.”

Next year, Cho said he would like to see the ACLT program add a similar experience where residents in the ACLT pathway meet with members of the North Carolina General Assembly in Raleigh.

“ACLT is young and evolving; we’re just wrapping up our second year,” Cho said. “We are thrilled that we are able to continue to add to the portfolio of experiences that are available to the ACLT residents.”

From left: Jeremy Halbe, Lauren Porras, Catherine Liao, Alex Cho, Brice Lefler and Alexandra Clark met with Congressional staff during an Ambulatory Care Leadership Track trip to Washington, D.C. Photo courtesy of Daniella Zipkin.

Internal Medicine Residency News – July 28, 2014

Mon, 07/28/2014 - 09:25
From the Director

Time flies….block 2 already for the interns starts today! Hard to believe it is almost August.  It was great to celebrate with everyone at Dr. Klotman’s house on Friday night..fantastic faculty and resident turn out! Special thanks to the Drs. Klotman for hosting, and to Erin Payne and Lynsey Michnowicz for all their help.  Kudos this week to Tanya Glaser, Anubha Agarwal, Rachel Hu and Lauren Ring from Nishant Shah for great work on CAD, and also to Rachel Hu from Chris Hostler for great work on ID consults, to Jess Morris from Matt Atkins for helping out at the DOC, and to Angela Lowenstern from her Duke Gen Med interns Mike Dorry and Maggie Infeld for great leadership.  Our SARs Jay Mast,  Amera Rahmatullah, Amit Bhaskar and Sajal Tanna continued the outstanding SAR-led emergency lecture series as well.

Phil Lehman sent us this picture … thanks Phil!

 

This week is the FOURTH ANNUAL PHYSICAL EXAM WEEK at noon conference! Led by Dr. Murat Arcasoy, this week long conference highlights the importance of the physical exam and features great faculty speakers such as Bill Hargett and Chet Patel! Conference will be held in 2002 Duke North…see you there!

Please wish the AMAZING Erin Payne a happy birthday today!

This weeks Pubmed from the Program goes to Duke Med Residency alum Dan Ong! Currently a cardiology fellow at Mass Gen, Dan is featured in the NEJM case of the week!  This is a shameless plug to also remind you that reading clinical reasoning cases like those that appear weekly in the NEJM is a great way to increase your diagnostic acumen!

Case 22-2014 — A 40-Year-Old Woman with Postpartum Dyspnea and Hypoxemia Zoltan P. Arany, M.D., Christopher M. Walker, M.D., and Lin Wang, M.D. N Engl J Med 2014; 371:261-269July 17, 2014DOI: 10.1056/NEJMcpc1304163

Have a great week,

Aimee 

 

What Did I Read This Week? submitted by: David Butterly, MD

Spironolactone Reduces Cardiovascular and Cerebrovascular Morbidity and Mortality in Hemodialysis Patients

JACC 63, 6 2014

Recently John Roberts reviewed this paper in our weekly Nephrology Journal Club. I think it brings up a very important clinical topic in our ESRD patients. I had not seen the paper when it was first published earlier this year and it gave me a chance to read and review it.

Despite the many advances in Nephrology over the last years, the mortality in patients with ESRD remains substantial, approaching 15-20% annually. Death from cardiovascular disease is the leading culprit, accounting for roughly 50% of patient deaths each year, and CV mortality is 15-30 times higher than the age adjusted mortality in the general population. Traditional risk factors are certainly part of the problem with diabetes, hypertension, and hyperlipidemia all prevalent in the ESRD patient population. It has been hard, however, to demonstrate treatment of these traditional risk factors leads to improvement. Results of the 4D (2005), AURORA (2009), and SHARP (2011) trials failed to show a benefit in ESRD patients treated with statins and the FOSIDAL trial (2006) failed to show a reduction in CV morbidity or mortality in hemodialysis patients treated with an ACE-I.

This paper tests the hypothesis that daily treatment with low dose spironolactone would reduce CCV mortality in patients with ESRD. This was a prospective, multicenter, randomized, controlled, open-labeled trial. Eligible patients were dialyzed at one of five centers in Japan, and received 4 hours, 3 times weekly treatments for at least 2 years. Patients had to have a serum potassium less than 6.5 and Urine output less than 500 ccs to qualify. Pre-enrollment ACE-I and ARBs and dialysis prescriptions were not altered.

Baseline characteristics of study patients are shown in Table 1, page 531. A total of 309 patients were randomized: 157 to Spironolactone and 152 in Control group. Both groups contained patients who had already been on dialysis for a substantial time (99 vs 127 months). A little more than 30% of the patients in each group had diabetes as the cause of their kidney failure, which is a bit lower than seen in the US. ACE-I’s were used in 9-10% and ARB’s in 40% of each group. The primary outcome of the study was a composite of death or hospitalization from CCV events. These included CHF, arrhythmias, MI, angina, stroke, TIA, and sudden cardiac death. Secondary outcome was death from any cause.

During the study, a total of 9 patients (5.7%) in the treatment group and 19 patients (12.5%) in the control group reached the primary outcome. Kaplan Meier curves (Figure 2A) show a lower event rate in Spironolactone treated patients. The unadjusted HR was 0.404 (CI of 0.2-0.8). There were 10 deaths in patients treated with Spironolactone compared to 30 in the control group (6.4 vs 19.7%) as shown in figure 2B. The unadjusted HR for death was 0.355 in the treatment group. Spironolactone appeared safe and did not significantly effect blood pressure or potassium. Only 3 patients over the course of the study discontinued due to hyperkalemia. Gynecomastia or breast pain was reported in 10%.

The main limitations of the study are that it was not blinded and represents a small sample size. The patients included had already survived on dialysis for a long time (99 and 127 months) and the causes of renal failure in this population differ some from what we see. However, CV morbidity and mortality is a huge problem in our patients and I believe these data are compelling and you will be hearing more about Spironolactone use in ESRD in the future.

Clinic Corner

Last week’s Weekly Updates alerted residents to the activation of the Resident Identify Supervisor (RIS) tool in MedHub for use immediately following a scheduled Ambulatory Block, to enable residents to identify at least one (1) attending with whom they’ve worked with frequently in continuity clinic, for evaluation during that block.  Attendings in the clinic will notice that this form is the same as the Summative Evaluation done three times a year.  (Here is a link to the form .)  This is intentional – through this identification process, residents who have an Ambulatory Block prior to when the Summative Evaluation would normally be due, get that Evaluation done by someone they have had frequent contact with over that concentrated period of time.  It is also the same form as the Ambulatory Mini CEX – which makes it possible to use Mini CEX results, to which clinic site directors and advisors have access, to inform the Evaluations.

Speaking of Mini CEXs, what’s in it for y’all to complete at least three (3) Ambulatory Mini CEXs a year?  Besides receiving pointers on how to get even better/faster in clinic, residents who complete at least this number and are rated to be at/above expectations for their stage of training, can be advanced in their level of autonomy in the clinic.  (Here is a link to a one-pager describing the three “precepting levels.”)  For interns, for example, this means being able to see patients without an attending following you into the room (after Medicare’s required six-month “waiting period” elapses).  Incidentally, Duke was part of the first multi-center study piloting the milestone-based “promotion” of interns to seeing patients independently in clinic, which was published in Academic Medicine (Acad Med 2013(Aug);88(8):1142-8. doi: 10.1097/ACM.0b013e31829a3967).

So happy Mini CEXing!

Alex Cho, MD

QI Corner

We had a great QI-related grand rounds last week with Dr. Jolly Graham presenting on handoff safety. Let me know if this is a topic that interests you – Joel Boggan and I are currently writing up an observational study of handoffs that we did last year, and a new initiative to improve handoff quality may be in the works this year. I have continued to have residents come to me with more ideas on how to increase quality and reduce wasteful care within our program, especially as it relates to lab ordering. Keep them coming! And we can meet and get a plan in place soon – let’s keep the momentum going and make some change on this issue!

Several people have been having technical problems with the Sharepoint website. Let me know if you do…we have been forwarding issues to one of our IT people which seems to be fixing things.

And lastly, a correction of the information I sent out last week regarding the GME incentives program – while we will have 4 separate targets, each of which will be worth $200, the maximum total bonus is $600 rather than $800 at the end of the year.

-Aaron

From the Chief Residents Grand Rounds

Friday, August 1 – Greenfield Visiting Lecturer, Dr. Marin Kollef, Washington University

“Infections in Critically Ill”

Noon Conference Date Topic Lecturer Time Vendor 7/28/14 PE Week – Introduction/Cardiovascular Exam Dr. Arcasoy / Dr. C. Patel 12:15 Picnic Basket 7/29/14 PE Week – Case Reviews Dr. Hargett / Dr. Arcasoy 12:15 Saladelia 7/30/14 PE Week – Neurologic Exam Dr. Morganlander 12:15 China King 7/31/14 PE Week – MSK Exam Dr. Irene Whitt 12:15 Chick-Fil-A 8/1/14 PE Week – Inpatient Daily Exam / New Clinic Pt Exam  Dr. Zaas / Dr. Arcasoy 12:00 Rudinos     From the Residency Office Duke List

Duke List is a valuable online resource that is just like Craigslist but exclusively for Duke faculty, staff and students. You can buy tickets to local events, furniture, even cars and houses from fellow Duke employees. Another helpful resource is the Lost and Found section of Duke List. You can look for an item you may have misplaced or post one that you found. Please take a look at a very helpful website that the wonderful Duke community offers!

http://dukelist.duke.edu/

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

New Jackets/Fleeces for 2014!

Please come by the MedRes office during normal business hours to try on the new jackets!  We are working on the new pricing structure, but Lynsey will be emailing additional details, with ordering instructions, directly to house staff and faculty this week!  Many thanks to Sneha Vakamudi for taking the lead on these new jackets, which will replace the the fleece jackets we have ordered previously.

Interview Skills

Whether you are going to interview for hospitalist position, primary care or attending position after fellowship, there are some skills to learn for the interview and essential questions to ask. Come to this session for dinner, sponsored by the North Carolina American College of Physicians, and get the answers you need before your job interview. Welcome to all medical students, residents, interns and fellows.

Panelists: Dr. Jon Bae, Dr. Saumil Chudgar, Dr. David Simel, Dr. Pooh Setji, Dr. Poonam Sharma, Dr. Bruce Peyser, Dr. Sharon Rubin

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

Please RSVP to Dr. Sharon Rubin by August 4, 2014

Sincerely,

Sharon Rubin, MD, FACP

Assistant Professor, Duke University Medical Center

Residency Director at Pickett Road

 

Information/Opportunities

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Elkin Internal Medicine

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

Community Health Network

Upcoming Dates and Events

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

Meet your chief resident: Bonike Oloruntoba, MD

Tue, 07/22/2014 - 15:54

Bonike Oloruntoba, MD

Bonike Oloruntoba, MD, took over as chief resident for Duke Regional Hospital and Ambulatory Medicine this month. Going into her chief resident year, Dr. Oloruntoba is looking forward to serving as a mentor and teacher, to contributing to the residency program and working with her co-chief residents.

As chief resident, Oloruntoba will oversee residents at Duke Regional and the outpatient clinics.

“At Duke Regional, I’ll be working mostly with senior assistant residents and preliminary interns,” Oloruntoba said. “It’s an opportunity for the senior residents to learn how to run a team. There is a lot of autonomy at Duke Regional, and one of the challenges for the senior residents is teaching preliminary interns who are not necessarily as interested in pursuing internal medicine as a career as the categorical interns.

“On the ambulatory side, we focus on the outpatient setting, teaching residents how to take care of basic primary care issues and transitioning patients from the hospital to the outpatient setting,” she said. “It’s an opportunity for residents to focus on other providers and specialty services and to learn how to take care of patients outside of the hospital.”

Oloruntoba said her approach to teaching at Duke Regional when she was a senior resident was finding ways to engage interns. Oloruntoba would start off by asking her trainees what they wanted to gain from the rotation and then, throughout the rotation, she would try to give trainees opportunities to see how they progressed.

“I think that a way you learn medicine and learn it well is through repetition,” Oloruntoba said.

Though medical students and interns often want to work on unique cases, she said, Oloruntoba also encouraged her trainees to focus on more common cases, such as chronic obstructive pulmonary disease (COPD) and diagnosing and treating chest pains, so trainees could chart their progress.

“When I was a senior resident, I wanted my medical students to see at least two examples of each (common case) so they could see how much they were learning,” Oloruntoba said. “The first time they see a COPD exacerbation, it may take a whole day to do the work up, but by the time they do a second one it will be quicker.”

Oloruntoba said she has seen students light up at the end of the week when she’s pointed out their improvement. “I think this is a better way for medical students to feel like they are getting better and building on their experience,” she said.

As chief resident, Oloruntoba will help current senior residents become better teachers as they lead teams of medical students and interns. She hopes to encourage senior residents and help them see teaching as an opportunity to gain new skills.

“I really enjoy serving as a mentor. I think every physician wants to be a teacher,” Oloruntoba said. “It’s great to see the growth and development of your students. I enjoyed that as a senior resident, and it’s great to see my interns where they are now – they are like an extension of me.”

Oloruntoba said that confidence for trainees, like learning to practice medicine, comes with experience. She likes to be honest about the learning curve and her expectations but also reminds trainees that she has been where they are, too.

“Confidence comes with time,” she said. “It’s by telling them up front that it will take longer for you to work up a particular patient and letting them know that’s hard and that I’ve been through that. They will build up their confidence when they see how things end up at the end of the month, when they can actually tell the difference and see their progress.”

In addition to teaching and mentoring, Oloruntoba said she is looking forward to listening to resident feedback and making a contribution to the residency program.

“The residency program collects feedback and evaluations from residents, and they actually make changes,” Oloruntoba said. “In other programs, being a chief resident is more like being a figure head. Here you can get things done, so it makes it exciting to see what our contribution to the program will be. The changes always stem from the residents.”

Oloruntoba said the support and interest in resident feedback is something that set Duke apart for her, and having the flexibility to make changes will make her job as chief resident a little easier.

One goal Oloruntoba has set for herself during her chief resident year is improving and promoting the program’s diversity.

“One of the things that attracted me to Duke when I came here as an intern is the diversity of the program,” she said. “A lot of the applicants don’t see Duke’s diversity, not just in the internal medicine residency program, but across divisions and departments. Improving and promoting diversity is something I really want to focus on this year.”

Oloruntoba also said she is looking forward to working with her co-chief residents Nilesh Patel, Coral Giovacchini and Aaron Mitchell.

“Working with the other chiefs will be the best part,” she said. “We all knew each other as residents and respect each other. This year is an opportunity to get to know each other even better.”

Oloruntoba earned a bachelor’s degree from Washington University in St. Louis and attended the University of Maryland School of Medicine before coming to Duke for residency. She said growing up she never thought about a career outside of medicine.

“The people I looked up to were physicians, and I liked what they did and was able to shadow them when I was young,” she said. ‘That was when I made the decision, and I never really thought about doing anything else.”

Oloruntoba completed her first year of Gastroenterology fellowship at Duke last year, which she will continue after her chief resident year. She is interested in transplant hepatology and said her first year of fellowship really solidified what she wants to do.

In her spare time, Oloruntoba said she likes to shop, and she tries to plan one big trip each year. Oloruntoba traveled to Zanzibar in April and said one of her most memorable trips was one she took with her mother to Italy and Greece.

“I don’t know if it was the place or just that I had so much fun with my mom, but it was a very memorable experience.”

Meet the chief residents:

Internal Medicine Residency News – July 21, 2014

Mon, 07/21/2014 - 08:33
From the Director

Hi Everyone!

Thank you for doing your new RL Solutions SRS training modules! The new reporting mechanism for patient safety events is more user friendly than before, and a great resource to use if you notice a “near miss” or other event as you are caring for patients. We had another great QI conference this week as well – Thanks to Lish Clark and Aaron Mitchell for running our first M and M of the year.  We continued to have outstanding SAR talks…Allyson Pishko, Adam Banks and Hal Boutte, as well as a rock star chair’s conference by Gena Foster.  As heard by Dr. Corey “That was great!”  Titus N’geno got the diagnosis…nice work.  Other kudos go to Anubha Agarwal from Dr. Adrian Hernandez for making a great diagnosis on the Heart Txp service.  It’s been great to hear all the compliments about what amazing work everyone is doing.

We are looking forward to the Summer Celebration at Dr. Klotman’s on Friday, and also the first JAR dinner on Tuesday.  This Friday, Dr. Aubrey Jolly-Graham from Hospital Medicine is doing Grand Rounds on Handoffs.  Please be sure to come out and support what is certain to be a fantastic talk.

I’m looking forward to starting meetings with the interns — there is nothing to prepare, it’s just a great chance to catch up on how the year is going, and show you how to keep your portfolio, use Medhub, interpret evaluations, etc.

Are you interested in helping screen people for HIV? Join the VA in a great screening effort.  The ID section is planning to offer walk-in HIV testing on August 29, 2014 (Friday) as part of  HIV prevention effort.

Details of the HIV testing event:

Date: August 29, 2014

Location: 8B clinic (clinic rooms requested, awaiting approval)

Walk-in HIV testing: Appointment or registration not required

Providers’ role:  Provide counseling, obtain verbal consent and order HIV test in CPRS.  You can also check out the new rational clinical exam article on acute HIV in this weeks JAMA!

This weeks pubmed from the program goes to Aparna Swaminathan Lower Extremity Amputation in Peripheral Artery Disease: Improving Patient Outcomes, Swaminathan A, Vemulapalli S, Patel MR, Jones WS Published Date July 2014 Volume 2014:10 Pages 417 – 424

Have a great week!

Aimee

 

What Did I Read This Week? submitted by: Charles Hargett, MD

Gottlieb DJ et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med 2014 Jun 12; 370:2276. (http://dx.doi.org/10.1056/NEJMoa1306766)

Background/Clinical Question:

Obstructive sleep apnea (OSA) is a risk factor for hypertension, coronary heart disease, stroke, and death, and moderate-to-severe OSA is present in an estimated 4% and 9% of middle-aged women and men, respectively. Only about half of patients with OSA use the most effective therapy, continuous positive airway pressure (CPAP). For many patients declining CPAP, supplemental oxygen is employed in hopes of ameliorating nocturnal hypoxemia. However, although oxygen therapy improves arterial oxygen saturation during sleep, it increases the severity of apnea-hypopnea events.

In the Heart Biomarker Evaluation in Apnea Treatment (HeartBEAT) study, the authors sought to determine the effectiveness of both CPAP and supplemental oxygen as compared with usual care for reducing markers of cardiovascular risk in patients with OSA recruited from cardiology practices.

Reference: Gottlieb DJ et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med 2014 Jun 12; 370:2276. (http://dx.doi.org/10.1056/NEJMoa1306766)

Methods

Design – Randomized (stratified permuted block design), parallel-group clinical trial

Setting – Outpatient cardiology practices associated with 4 academic medical centers

Patient Population – Patients aged 45 to 75 years with established coronary heart disease or multiple cardiovascular risk factors were screened for OSA. 5747 patients assessed for eligibility, 1034 eligible for home sleep testing (846 enrolled), 318 with moderate to severe OSA and known cardiovascular disease or multiple cardiovascular risk factors underwent randomization

Intervention / Control – Participants were assigned to one of three interventions: healthy lifestyle and sleep education (HLSE) alone (control), CPAP with HLSE, or supplemental oxygen (2L via NC) with HLSE

Blinding – Unblinded

Analysis – ANCOVA model with adjustment for the baseline value and stratification variables (study site and the presence or absence of coronary artery disease). Due to outliers, a regression model was used to analyze values for C-reactive protein and N-terminal pro-BNP. A logistic-regression model was used to model the log-odds rate of non-dipping blood pressure at 12 weeks

Outcomes –The primary outcome measure was 24-hour mean arterial blood pressure. Patients were also assessed for systemic inflammation, reactive hyperemia, fasting glycemia, and dyslipidemia, and adherence to therapy was compared across the active treatment groups

Follow-up – Outcomes were measured at baseline and 12 weeks after randomization. 301 participants completedthe study, 281 (93%) underwent 24-hourblood-pressure monitoring at both baseline and 12 weeks

 Validity

Patients were randomized. Treatment groups generally similar at baseline. Patients accounted for at conclusion and analyzed in groups to which they were randomized. Again, patients and clinicians were not blinded. Groups were likely treated similarly outside of the intervention.

 Results

Both CPAP and nocturnal oxygen improved nighttime hypoxemia (had similar reductions in frequency of desaturation events and proportion of sleep time with oxygen saturation <90%). However, at 12 weeks, 24-hour MAP was significantly lower (by about 2.5 mm Hg) in the CPAP group than in the supplemental-oxygen or control groups.

 Comments

Even in a clinical setting in which cardiovascular risk factors (including blood pressure, average MAP 89 mm Hg at baseline), were well managed the present study shows that among patients with previously undiagnosed moderate-to-severe obstructive sleep apnea, treatment with CPAP resulted in reduced 24-hour mean arterial pressure. Though the reduction may seem modest, it’s certainly of a magnitude which has been associated with a meaningful reduction in cardiovascular risk. Of note, this was a unique population (not from sleep clinics but cardiology clinics) with a high risk for adverse consequences of OSA but who were not seeking treatment and he benefits were seen even in patients without daytime sleepiness. Additionally, there was no “threshold” for CPAP use, with a benefit from only 3.5 hours of use, and with a suggestion that each additional hour of use reduced BP by an additional 1 mm Hg systolic. There was also a suggestion of attenuation of relative nocturnal hypertension (aka “non-dipping” blood pressure), which has been shown to be more closely associated with target organ damage and worsened cardiovascular outcomes. From a physiologic POV, the reversal of intermittent hypoxemia doesn’t fully explain the blood pressure–lowering effect of CPAP in patients with OSA.

Future studies should be longer (e.g. 12 months) to assess sustainable changes and impact on clinical outcomes like MI. Also, these patients had relatively few symptoms and it would be interesting to see the effects on patients with worse sleep apnea and more poorly controlled variables (e.g. high BP) and who might perhaps have worsening surges in BP at night.

Bottom Line: Continuous positive airway pressure, but not oxygen, lowered mean arterial blood pressure.

Clinic Corner

Welcome new interns.  Looking forward to a great year.  Please meet with your team and review your schedules and let your attending and team know who will be covering your CPRS alerts and any issues you see coming up with your schedule.  Remember communication is key. Also please remember to reach out to your new intern(s) on your team, please give any pointers, quick tips, time saving ideas that will help make their lives easier.  If anyone has any questions please remember we are here for you in PRIME.

Just a couple of things to remind everyone:

  1.  Patients are scheduled at 15 and 45 on the hour for nurse check-in, residents are expected to see their patients on the hour and half hour, so for your am clinic, your first patient is scheduled for 8:45 for the nurse so that you can see the patient at 9am
  2. Remember, we now have walk-in PRIME psychiatry appointments at 11am and 3p every day EXCEPT Thursdays, please offer any patients that are having active psychiatric issues a same day appointment if you feel it would be beneficial
  3. The nurses wanted to remind everyone that they prioritize checking in patients before exit interviews, so remember to place the routing slips in the check –out bins and let patients know to sit in waiting room for exit interview, that way nurses can keep your clinic flowing
  4. Mini-CEX’s- please try to get them completed when clinic is not busy, this is a great way to receive feedback
  5. Don’t forget to huddle with your nurse when you arrive in clinic, they love chatting with you/getting to know you and also this is a great way for the nurses to get a heads up on any issues you foresee during your clinic
  6. Monday mornings we have a resident/staff meeting, this is the time for all of us to put our heads together to make PRIME great, if you are assigned to Monday morning continuity clinic please arrive by 8:45 for the meeting (your first appointment of the day should be blocked off)

Thank you for all that you do in taking care of our veterans and making PRIME all it can be.

Sonal Patel, MD

PRIME  Clinic Director

Durham VA Medical Center

 

QI Corner

We had a great kick-off meeting for the Patient Safety and Quality Council last week! Highlights of what we talked about that everyone should be aware of:

First, the GME incentive program: our performance on 4 different measures is going to be tracked over the academic year, at the end of which we will get a $200 bonus in our paycheck for each measure where we hit our target! That’s up to $800 on the table! The four measures for the year are:

Patient satisfaction score

30-day hospital readmission rate

Time responding to admission consults from the ED

Increased usage of SRS (Safety Reporting System)

I’ll be updating from time to time to let you know how our progress towards the $800 is going.

We also discussed the potential interest in getting personalized performance data for certain quality metrics. We already have the annual sharepoint ambulatory self-assessment tools, but would medicine housestaff like to see personalized feedback on an even higher level? Would you want to see readmission rates for the patients you took care of? Patient satisfaction scores? Use of DVT prophylaxis? If Maestro could be used to generate this feedback, would you find it useful?

If you have more ideas, or want to get involved in making a program like this work, let us know!

Another topic (as well as a treasure-trove of resident-led QI projects!) was the many areas of potential low hanging fruit to improve the quality of care at Duke by reducing the use of low-value tests and treatments. You will be learning more about this when the High-Value Cost-Conscious Care curriculum kicks of in September. But in the mean time, if you think Duke should be doing a better job by streamlining its biomarker testing for ACS, reducing inappropriate blood culturing, reducing routine daily lab ordering, or more judiciously treating asymptomatic hypertension (just a FEW of the ideas we’ve had thus far!), then let me know of your interest.

Finally, grand rounds this week will be on a patient safety topic – Dr. Jolly-Graham will be presenting on handoff safety. See you there!

-Aaron

From the Chief Residents Grand Rounds

Friday, July 25th – General Medicine/Hospitalist, Dr. Aubrey Jolly-Graham

“Consult Communication”

Noon Conference Date Topic Lecturer Time Vendor 7/21/14 SAR Emergency Series: Hyperkalemia and Hypercalcemia Jay Mast 12:15 Subway 7/22/14 SAR Emergency Series: Acute Liver Failure Amit Bhaskar 12:15 Pita Pit 7/23/14 SAR Emergency Series: ICU Admission Indications Amera Rahmatullah 12:15 Cosmic Burritos 7/24/14 SAR Emergency Series: DNR Discussions Sajal Tanna 12:15 Sushi 7/25/14 Chair’s Conference  Chiefs 12:00 Dominos     From the Residency Office Duke List

Duke List is a valuable online resource that is just like Craigslist but exclusively for Duke faculty, staff and students. You can buy tickets to local events, furniture, even cars and houses from fellow Duke employees. Another helpful resource is the Lost and Found section of Duke List. You can look for an item you may have misplaced or post one that you found. Please take a look at a very helpful website that the wonderful Duke community offers!

http://dukelist.duke.edu/

Survival Guides and End of Year Gifts – Please Pick Up by 7/25/14!

The 2014 Survival Guides are in and they are awesome.  If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours.  We can only provide one copy per resident.  If you are interested in purchasing a copy, please contact Jen Averitt.  An electronic version of the guide is currently in development and we should have more information on when that will be available soon!

For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!

Ambulatory Evaluations – Resident Identify Supervisor

As of July 1, 2014, we have activated the Resident Identify Supervisor (RIS) tool in MedHub for use during all ambulatory rotations.  What this means is that 7 days before the end of your ambulatory block, you will receive a request, via email/MedHub to identify a minimum of one (1) supervisor for evaluation during that block.  This is intended only for your continuity clinic experiences during the block!  If you are unable to identify at least one attending from your continuity clinic time during the block, or have recently submitted an evaluation request for the same attending, please email Jen Averitt and she will remove the requirement for you for that particular block.  Our hope is to increase the consistency with which your clinic experiences are evaluated, as well as your clinic attendings are evaluated.  If you have questions about how this system will work, please feel free to contact the MedRes office.

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

Interview Skills

Whether you are going to interview for hospitalist position, primary care or attending position after fellowship, there are some skills to learn for the interview and essential questions to ask. Come to this session for dinner, sponsored by the North Carolina American College of Physicians, and get the answers you need before your job interview. Welcome to all medical students, residents, interns and fellows.

Panelists: Dr. Jon Bae, Dr. Saumil Chudgar, Dr. David Simel, Dr. Pooh Setji, Dr. Poonam Sharma, Dr. Bruce Peyser, Dr. Sharon Rubin

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

Please RSVP to Dr. Sharon Rubin by August 4, 2014

Sincerely,

Sharon Rubin, MD, FACP

Assistant Professor, Duke University Medical Center

Residency Director at Pickett Road

 

Information/Opportunities

Announcement Geriatrician Opportunity

Elkin Hospitalist

Elkin Internal Medicine

Montana Hospitalist

Summit Placement Service

Upcoming Dates and Events

July 25th- Summer Celebration at Dr. Klotman’s House

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

Internal Medicine Residency News – July 14, 2014

Mon, 07/14/2014 - 09:22
From the Director

Week two is in the books! Thank you to all of the interns, JARs, SARs, chiefs, fellows and attendings for making the transition to our new year such a smooth one.  I have received so many compliments about the outstanding care and teaching you are all providing…kudos this week to Dinushika Mohottige from a patient’s family for outstanding care overnight, to Sajal Tanna from Carter Davis for great supervision on 9100 nights, to Jess Tucker, Andrea Sitlinger and Lakshmi Krishnan from Susan Gurley for great work at the VA, to Sneha Vakamudi and Alyson McGhan for outstanding SAR talks, to our former prelim intern now radiologist Mike Malinzak for his noon conference as well (and to Brian Griffith for the EPIC noon conference), and to Kevin Shah for chair’s conference.  Chair’s had really strong audience participation which was much appreciated as well.  Kevin Trulock and Brittany Dixon represented us at the ICGME (that is all the house staff programs) meeting on Wednesday…they are your GME representatives, and can provide you with information about what is being talked about at the institution level regarding GME.

Fellowship applications are able to be downloaded by fellowship programs starting JULY 15th! If anyone applying has last minute questions, please let me know.  Don’t forget to also register for the NRMP once you have uploaded your application to ERAS.  Mock interviews will be offered soon, so be on the lookout for information about this great opportunity as well.  Starting next week, we will be bringing program information to you right before noon conference starts..look for information about how we address issues that arise in rotation evaluations, confidential comments, and other program admin related issues.

Please don’t forget to do your RL Solutions (that’s the new SRS system) training! It is due July 15th for ALL MEMBERS OF THE MEDICAL STAFF (that’s you!).

This week’s pubmed from the program goes to Ragnar Palsson for his review written with Dr. Uptal Patel…Palsson R, Patel UD. Cardiovascular Complications of Diabetic Kidney Disease. Advances in Chronic Kidney Disease, May 2014 (in press).

Have a great week! Looking forward to seeing you at the upcoming summer celebration at Dr. Klotman’s on July 25th!

Aimee

What Did I Read This Week? submitted by: Aimee Zaas, MD

What I read this week is brought to you by some clinical questions we had on gen med 1.  Here are some short answers to a few items that came up for our team. 

Clinical questions from this week (with some answers)

Does my patient have iron deficiency anemia?

It can be difficult to tease out iron deficiency and anemia of chronic inflammation in hospitalized patients because they often have comorbidities making them “chronically inflammed”, thus there is often overlap between the two.  This is a nice paper from JGIM that studies a group of medically complex VA patients, comparing lab values with the gold standard of bone marrow biopsy for detecting iron deficiency.  The money is in the ferritin.  All the other parameters (MCV, TIBC, iron, % sat) are essentially equivocal.  The cutoff they come up with is 100.  If the serum ferritin is <100 then that gives a 65% sensitivity and 96% specificity for iron deficiency. (Thank you to VA ACR Tim Mercer for this information!)

What is cryptosporidiosis?

Cryptosporidium is a parasite that causes watery diarrhea, which is self limited in immunocompetent folks.  Diarrhea can last longer in the immune compromised, but there are still no effective treatments except time.  It is famous for an outbreak in the Milwaukee water supply in 1993, and has been detected in swimming pools, and other public water supplies.  We test for it using a stool antigen test, and this PLUS giardia are what you get with a standard “O and P” at Duke. I misspoke and it was cyclospora that was associated with a strawberry and raspberry associated diarrhea.

What are the anticoagulation guidelines after atrial fibrillation?

Cardioversion?

As Kevin Shah mentioned in chairs, the American College of Cardiology has great guidelines for all things cardiac, including post atrial fib anticoagulation. We were asking about post-chemical cardioversion duration of anticoagulation. Here are the Class 1 and II a recommendations..

6.1.1. Thromboembolism Prevention: Recommendations

Class I

1. For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0) is recommended for at least 3 weeks prior to and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the method (electrical or pharmacological) used to restore sinus rhythm (320-323).

(Level of Evidence: B)

2. For patients with AF or atrial flutter of more than 48 hours or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated.

(Level of Evidence: C)

3. For patients with AF or atrial flutter of less than 48-hour duration and with high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by longterm anticoagulation therapy.

(Level of Evidence: C)

4. Following cardioversion for AF of any duration, the decision regarding long-term anticoagulation therapy should be based on the thromboembolic risk profile (Section 4).

(Level of Evidence: C)

Class IIa

1. For patients with AF or atrial flutter of 48-hour duration or longer or of unknown duration who have not been anticoagulated for the preceding 3 weeks, it is reasonable to perform a TEE prior to cardioversion and proceed with cardioversion if no LA thrombus is identified, including in the LAA, provided that anticoagulation is achieved before TEE and maintained after cardioversion for at least 4 weeks (164). (Level of Evidence: B)

2. For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with dabigatran, rivaroxaban, or apixaban is reasonable for at least 3weeks prior to and 4 weeks after cardioversion (230, 324, 325).

(Level of Evidence: C)

What is the JAK-2 mutation and what does it signify?

We were discussing this in relation to polycythemia vera.  PCV, Essential thrombocythemia and primary myelofibrosis are all part of the “myeloproliferative disorders” or “myeloproliferative neoplasms”, and these three are the BCR-ABL mutation negative myeloproliferative neoplasms (CML is BCR-ABL positive). These are clonal marrow disorders, and all have a risk of transforming into acute myeloid leukemia. The JAK2-V617F mutation in exon 14 characterizes these disorders, and is present in 95% of PV, 50–70% of ET and 40-50% of MF. With this mutation, the JAK2 tyrosine kinase is activated constitutively, resulting in cellular proliferation.  This is an oversimplification of the pathogenesis, as There are other activating mutations found in these disorders within the JAK-STAT signaling cascade as well. Lowering thrombosis risk is the major goal in PV treatment  and Age and history of thrombosis are the prominent risk factors that predict future thrombosis risk. The efficacy and safety of low-dose aspirin (100mg daily) in PV has been assessed in the European Collaboration on Low-dose Aspirin in Polycythemia (ECLAP) double-blind, placebo-controlled, randomized clinical trial.

When do you treat candiduria?

The IDSA guidelines are a great place to look for how to manage various infections (www.idsociety.org). For asymptomatic candiduria, most individuals don’t require treatment. Recommendations are shown below.

Recommendations: asymptomatic candiduria

1. Treatment is not recommended unless the patient belongs to a group at high risk of dissemination (A-III). Elimination of predisposing factors often results in resolution of candiduria (A-III).

2. High-risk patients include neutropenic patients, infants with low birth weight, and patients who will undergo urologic manipulations. Neutropenic patients and neonates should be managed as described for invasive candidiasis. For those patients undergoing urologic procedures, fluconazole administered at a dosage of 200- 400 mg (3-6 mg/kg) daily or AmB-d administered at a dosage of 0.3-0.6 mg/kg daily for several days before and after the procedure is recommended (B-III).

3. Imaging of the kidneys and collecting system to exclude abscess, fungus ball, or urologic abnormality is prudent when treating asymptomatic patients with predisposing factors (B-III).

Recommendations: symptomatic candiduria

1. For candiduria with suspected disseminated candidiasis, treatment as described for candidemia is recommended (A-III).

2. For cystitis due to a fluconazole-susceptible Candida species, oral fluconazole at a dosage of 200 mg (3 mg/kg) daily for 2 weeks is recommended (A-III). For fluconazole-resistant organisms, AmB-d at a dosage of 0.3-0.6 mg/kg daily for 1-7 days or oral flucytosine at a dosage of 25 mg/kg 4 times daily for 7-10 days are alternatives (B-III). AmB-d bladder irrigation is generally not recommended.

3. For pyelonephritis due to fluconazole-susceptible organisms, oral fluconazole at a dosage of 200-400 mg (3-6 mg/kg) daily for 2 weeks is recommended (B-III). For patients with fluconazole-resistant Candida strains, especially C. glabrata, alternatives include AmB-d at a dosage of 0.5-0.7 mg/kg daily with or without flucytosine at a dosage of 25 mg/kg 4 times daily (B-III), or flucytosine alone at a dosage of 25 mg/kg 4 times daily (B-III) for 2 weeks.

And from Carli Lehr…

In our patient with DIABETES and probably OSTEOMYELITIS…how is our physical exam? Here is an article helping us decide if our patient has osteo. Our patient had ulcer > 2 cm and an abnormal X-ray. ESR is close to the cut-off here too.

Finding Likelihood Ratio Negative Likelihood Ratio Ulcers >2 cm2 7.2 (CI 1.1-49) 0.48 (CI 0.31-.076) Positive “probe to bone” test* 6.4 (CI 3.6-11) 0.39 (CI 0.20-0.76) ESR >70 11 (CI 1.6-79) 0.34 (CI 0.06-1.9) Abnormal plain X-ray** 2.3 (CI 1.6-3.3) 0.63 (CI 0.51-0.78) Abnormal MRI 3.8 (CI 2.5-5.8) 0.14 (CI 0.08-0.26)

 

*Probe to bone test: the examiner gently and in a sterile fashion, probes the ulcer with a steel probe to determine if the probe can advance to bone

**abnormal X-Ray findings include: focal loss of trabecular pattern, periosteal reaction, and frank bone destruction. 2 or 3 views can be selected

CMEonPCVandET

Iron Deficiency Anemia in Patients with Medical Problems – JGIM

milwaukeewatercryptosporidiosis

RCEfootulcer

Clinic Corner

Congratulations to the new Jars and Sars and welcome to the new interns. Welcome to Dr. Boinapally who is our new attending on Wednesday morning!

Renaming Pickett Road Resident Clinic: We are revamping the clinic here at Pickett and what better why to start out fresh but with a new name. Dr. Peyser is asking all the residents to nominate a NEW name for the Pickett Road Clinic. The top names will be selected and then voted on in August! Please send me an email with nomination for new clinic name. Jars and Sars will be paired with intern for their first day. Let the intern shadow you and give them pearls of advice to succeed in clinic.

Make sure to ADD the Interns: go to Inbasket, Attach, #2 Grant Access

Eric Black Maier EWB16

Dave Kopin DJK23

Tim Hinohara TTH10

John Musgrove JLM 138

Rachel La Voy/Hu REL 31

Pascale Khairallah PK110

Get ready for Mini CEX: for the interns our goal is to get one done in the first 4-5 visits you are here. Mini cex is observation of the history, PE or assessment part of the visit. I schedule these for when attendings: residents are 1:2. Congrats to Myles who completed the first CEX of the year! TBA is because you are not in clinic enough for CEX in July and August.

Resident Mini Cex 2014-2015 Resident Attending 1st CEX Plan for CEX Black-Maier Boinapally 7/9/14 Hinohara Brown 8/19/14 Hu/La Voy Rookwood 7/25/14 Khairallah Boinapally 7/9/14 Kopin TBA Musgrove Boinapally 8/6/14 Cupp Boinapally 7/16/14 Eisenberg Waite 8/6/14 Erdmann Rubin 7/29/14 Matta Rookwood 7/11/14 Ng’eno Wolf 8/7/14 Nicklolich Rubin 7/1/2014 Ray Peyser 7/10/14 Verma Rookwood 8/15/14 Zhu Rubin 8/11/14 Beri Brown 8/5/14 Boehm TBA Lehr Wolf 7/31/14 Lloyd Rubin 7/7/14 Kirtane Waite 8/13/14

For future lab orders:

It is the correct process to have all lab patients check in at the front desk in an effort to have their lab orders released prior to presenting to the lab. If you have not received your business cards please let Erin Payne know to order more. You can give out your cards to patients in the hospital and act as their Outpatient PCP.

Best,

Sharon Rubin

 

QI Corner

This week the internal medicine Patient Safety and Quality Council will be having its first meeting of the new academic year. Come by the medicine library at 5:30 on Wednesday to learn about what the group has done in the past, get connected for any QI ideas that you might have, and eat some pizza.
Time: Wednesday, July 16, 5:30pm
Place: Med Res Library

Confusingly, I also want to let everyone know about a similarly-named but separate group, the GME Patient Safety and Quality Council. For anyone interested in quality improvement, health care systems, or patient safety issues, this forum is a great place to get to sit down with some of the top safety officers at Duke. Meetings are monthly. If you are interested and would like to be know when the first meetings this year will be, let me know!
Next week will also be the first of our monthly Morbidity and Mortality noon conferences. Dr. Alicia Clark and I will be preparing a case for discussion. This is a great opportunity to learn from our collective past “experiences” – because we doctors never make “mistakes,” right? 
Time: Wednesday, July 16, 12pm
Place: Med Res Library

Have a good week everyone!
Aaron

 

From the Chief Residents Grand Rounds

Friday, July 18th – Palliative Care/Oncology, Dr. Amy Abernethy

Noon Conference Date Topic Lecturer Time Vendor 7/14/14 SAR Emergency Series: Delirium Hal Boutte 12:15 Picnic Basket 7/15/14 SAR Emergency Series: Undifferentiated Shock – Initial Mgmt Adam Banks 12:15 Rudinos 7/16/14 Resident M&M QI Team 12:15 China King 7/17/14 SAR Emergency Series: Inpatient Diabetes Management Allyson Pishko 12:15 Chick-Fil-A 7/18/14 Chair’s Conference  Chiefs  12:00 Dominos   Books4Cause This year the IM program will be participating in Books4Cause, a for-profit social venture with the mission to provide economic opportunities globally through education. The program is extending an opportunity to Help Build Libraries in Africa and are collecting now for a shipment in July to Swaziland. Books4Cause accepts any CD, DVD and book in good condition, Journals, periodicals, custom course manuals, old encyclopedias or magazines are not accepted. More information is found on the website.  Please drop your donation in the MedRes office by July 16th!Thanks!     From the Residency Office Survival Guides and End of Year Gifts

The 2014 Survival Guides are in and they are awesome.  If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours.  We can only provide one copy per resident.  If you are interested in purchasing a copy, please contact Jen Averitt.  An electronic version of the guide is currently in development and we should have more information on when that will be available soon!

For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

 

Interview Skills

Whether you are going to interview for hospitalist position, primary care or attending position after fellowship, there are some skills to learn for the interview and essential questions to ask. Come to this session for dinner, sponsored by the North Carolina American College of Physicians, and get the answers you need before your job interview. Welcome to all medical students, residents, interns and fellows.

Panelists: Dr. Jon Bae, Dr. Saumil Chudgar, Dr. David Simel, Dr. Pooh Setji, Dr. Poonam Sharma, Dr. Bruce Peyser, Dr. Sharon Rubin

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

Please RSVP to Dr. Sharon Rubin by August 4, 2014

 

Information/Opportunities

Announcement Geriatrician Opportunity

Elkin Hospitalist

Elkin Internal Medicine

Montana Hospitalist

Upcoming Dates and Events

July 25th- Summer Celebration at Dr. Klotman’s House

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

Meet your chief resident: Coral Giovacchini, MD

Fri, 07/11/2014 - 09:54

Coral Giovacchini, MD

Coral Giovacchini, MD, started in her new role as chief resident of internal medicine at the Durham VA Medical Center this month. Dr. Giovacchini says this is a role she is particularly excited about because it offers many teaching and learning opportunities.

There are several things that make the Durham VA a unique place for residents to train, Giovacchini said. This year, for example, rotations for junior assistant residents at the Durham VA will return to the 24-hour call structure, so JARS will have more continuity with their patients overnight.

“The Durham VA is an exciting place to train, because you get autonomy earlier, within a framework of support,” Giovacchini said. “Your attendings and chief resident are always available, but what I really enjoy most about being at the VA hospital is the fact that you have the opportunity to lead a team early in your career.”

This opportunity to lead is an example of the type of hands-on learning Giovacchini found valuable when she was a resident and, as a chief resident, still values, as a teaching tool.

This year residents will have another unique hands-on learning opportunity at the Durham VA in the newly established Simulation Center. In the Simulation Center, residents will have opportunities to run simulated procedures and other challenging clinical scenarios to better prepare them for work on the wards and in the ICU. The planned curriculum will include education on basic ultrasound skills, central venous catheter placement and a variety of other ultrasound guided procedures, Rapid Response and Code Blue simulations, as well as an optional emergency airway management course, among other things.

“Rather than getting thrown into learning how to do procedures in real time, we hope to help the residents develop a solid foundation of clinical tools in a safe environment prior to translating this into their practice on the wards. I hope that this will not only improve the residents’ clinical skills sets and confidence in patient care, but also improve resident-to-resident teaching for the future, and potentially even translate into improved patient outcomes,” Giovacchini said.

Giovacchini is looking forward to other teaching opportunities at the Durham VA, especially the one-on-one time she has with residents during evening “sign out” rounds that will allow her to focus on individual learning.

“Part of my role as chief resident is figuring out how other people learn,” Giovacchini said. “Teaching isn’t always about having a structured approach to teach one topic to everyone, but rather involves adapting to individual learning styles and finding how you can best teach each of your learners.”

Though residents also will have larger group learning sessions, Giovacchini hopes that the case-based learning during her one-on-one time with on-call teams will be beneficial.

Giovacchini said one of her goals for the year is making sure interns and residents know how approachable she is.

“I want to focus on making sure that education in our program is accessible. We have very high standards for our residents, but I hope to facilitate a friendly and functional environment in which people can ask questions and not feel like they are supposed to know everything about internal medicine walking in the door,” she said.

Giovacchini said she remembers what it feels like to make the transition from medical school to residency.

“As an intern, you’ve prepared, you’ve gone to medical school, you’ve done a lot of book learning and have some clinical experience, but all of a sudden you are thrown into this new role of being an actual doctor where you are the point person for your patient and that can be intimidating,” Giovacchini said. “It’s important for everyone to know that they have help. There is nothing wrong with asking for help when you need it.”

During Giovacchini’s first week as an intern at Duke, she remembers being on the general medicine ward and taking care of a very sick patient.

“I got called because my patient, who had been admitted for a urinary infection, had a low blood pressure” she said. “I remember working through my algorithm to resuscitate the patient, but I got to a point where I felt a bit in over my head as a first week intern.”

Giovacchini discussed the case with one of her chief residents, Brian Griffith, MD, who was happy to help, lending an extra set of eyes and hands during a critical patient care moment.

“I think everyone has that moment early in their career when you need a bit of reassurance and validation of your plan, and it is nice to know that, at Duke, you will always have back up when you need it.”

Besides encouraging residents to ask questions and seek out help when necessary, Giovacchini said she would also recommend that they try to find balance between medicine and their personal lives.

When Giovacchini was a resident, she said her goal was try to try to learn one thing every day and spend a previously set amount of time reading every day, then that was it.

“It is important to take care of yourself, so that you can continue to take good care of your patients. I think as long as you set ground rules for yourself coming in and make an effort to actually stick to them, it makes a big difference during residency and is an important skill going forward in your career.”

Outside of medicine, Giovacchini likes to spend time on creative interests, including photography, and staying active outdoors with her friends, husband and large dog, Sumo.

Giovacchini majored in anthropology at Harvard University and got interested in medicine when she studied evolutionary biology. Her undergraduate research involved the effects social interactions on physiologic responses of great apes. This ultimately branched into human endocrinology studies, and through that she became interested in human physiology and medicine. Giovacchini attended The Ohio State University for medical school and then came to Duke for internal medicine residency.

Giovacchini spent last year as a fellow in Pulmonary, Allergy and Critical Care Medicine. She will complete her fellowship after her chief resident year.

Meet the chief residents:

Internal Medicine Residency News – July 7, 2014

Mon, 07/07/2014 - 09:24
From the Director

Week one is in the books! Great job by our new interns, JARs and SARs (and chiefs and office team and attendings) – it is nice to have orientation done, and everyone settling in on the wards and in the clinics. It has been fun seeing the teams around the hospital, and many new interns, including Logan Eberly, were overheard teaching their MSII’s!  I hope you all could enjoy part of the holiday weekend outside of the hospital as well.  There was fun to be had at the VA on July 4th (See the photo proof!)

Kudos this week go to our fantastic SARs who set the bar very high for the new SAR talk/intern emergency lecture series…thank you to Angela Lowenstern, Kevin Trulock and Carli Lehr for fantastic talks! We are looking forward to more great teaching from our SARs.  Also kudos from George Cheely to Jesse Tucker for help on Gen Med and to Dave Kopin and med student Arthika Chandramohan from Adva Eisenberg for an awesome start on VA Gen Med, and as well to GI fellow Matt Kappus for his great email to the outgoing interns and JARS.  Kudos from (cardiology fellow!) Phil Lehman to Bhavana Singh and Adam Banks for great JAR/SAR level work in the CCU.  Also welcome to our ACRs – Alyson McGhan (Duke), Tim Mercer (VA) and Aparna Swaminathan (DRH/amb).  Thank you as well to Katie Broderick-Fosgren and Brittany Dixon for representing the residency council at our annual “Program Evaluation Committee” meeting last week.  We will be bringing you highlights from the meeting, as well as reporting our efforts to improve the program in a variety of venues, including before noon conference, in MedHub, at town halls and via the Med Res News.  Feel free to stop by the chiefs offices, my office, your advisors or APDs offices anytime to chat as well.

Congratulations also to Lynsey Michnowicz! She is officially the new program coordinator for Med-Psych. Lucky for us, she will still be in the office on the 8th floor, so stop by and say congratulations!

Coral and I had the opportunity to visit the new Simulation Center at the VA.  Dr. Park Chan and his team are excited to work with us to bring airway, line, and other simulation training to the medicine residents.  We will be planning times for you to go to the sim center as part of the ICU, procedures, VA gen med and ambulatory rotations.

I hope that you all like your new copy of “The Evidence”,  written by Cardiology Fellow Rob McGarrah. We are excited to bring you this great resource…and now you can get it on your phone! The iOS app is now available on the Apple app store for iPhone and iPad (easily found by searching “The Evidence: classic studies”).  It will be $0.99 during the first two weeks of July, priced for those of you who have the book.

This weeks pubmed from the program goes to John Wagener for his publication with Dr. Sunil Rao…. “Strategies to Avoid Bleeding in the Management of ACS.” Medscape Online. Released July 30, 2013.

Have a great week!

Aimee

What Did I Read This Week? submitted by: Sharon Rubin, MD

Bloomfield, Olson, Greer et al. “Screening Pelvic Examinations in Asymptomatic, Average Age Risk Adult Women: An Evidence Report for a Clinical Practice from the American College of Physicians.” Annals of Internal Medicine 2014; 161 (1):46-53.

 

 

When I was a medical student I could not believe a British patient who told me in England they do pelvic/pap smears every 5 years. Fast forward 10 years there is no supporting evidence to perform pelvic exam and due to improvements with technology and detection of HPV, pap smears interval can be increased to 5 years for women > 30 -65 with normal pap smear and negative HPV testing.

This was a systematic review article via Medline and Cochrane to evaluate the benefits and harms of routine screening pelvic exam and that focused the positive predictive value of pelvic exam to detect nonce rvical cancer, PID, other GYN conditions. They wanted to answer; does a pelvic exam reduce mortality and morbidity from any condition? What are the harms and benefits of a routine pelvic exam?

Results: Diagnostic Accuracy of Screening Pelvic exam: (only from 3 studies) only for ovarian cancer PPV was 1.2 to 3.6%. There were no studies that looked at morbidity or mortality benefits for detection of cancer or nonmalignant conditions. Harms: limited evidence suggested that women associate pelvic exam with pain, discomfort, fear, anxiety, embarrassment and 1 study showed indirect harm: screening pelvic exam led to unnecessary surgery in 1.5% of women. Importantly victims of sexual violence are more likely to avoid pelvic and Pap smear and would experience harm from a routine pelvic screening exam.

Split in recommendation: ACOG recommends annual routing pelvic exams but this is based on expert opinion. USPTSF recommend against pelvic exam for screen for ovarian cancer (Grade D recommendation). Many providers still perform pelvic exam: for screen for ovarian cancer, before prescribing hormonal contraception, to dx STDs or part of well woman visit.

High value care: Balancing clinical benefit with cost and harms with the goal of improving patient outcomes. From Medicare 2013 Pelvic exam #38.11 and pap $45.93. The estimated cost of preventative GYN exams + lab + radiology $2.6 billion. 1/3 = $850 billion spent on unnecessary cervical cancer screening in women < 21 years old; indeterminate % on other pelvic exams.

Conclusions: continue the Cervical cancer screening, there is evidence but consider stopping pelvic exam in asymptomatic women not at increased risk of gynecological cancer.

Clinic Corner

Hi guys! Welcome to the new year at the Duke Outpatient Clinic! We are excited to meet all of our new interns and welcome back our JARs and SARs in their new roles. The DOC is organized into three Firms, or Steads – Stead A is led by Lynn Bowlby, Stead B by Dani Zipkin, and Stead C by Larry Greenblatt. Each stead also has a nurse, one or more CNAs, and a front desk staff person linked to the group. Check out the posted, color-coded grid in clinic to see your group – it is also attached here. And, when you’re in clinic, ask us how to manage in-basket messages to be efficient and leverage the help of your Stead staff in connecting with patients and getting things done.

We will share information with you in emails, in the DOC Newsletter 2014 July (see attached here!!), and even on the Duke Outpatient Clinic Facebook page – which you can join without sharing your personal info. Contact Matt Atkins to get hooked up, or check it out on FB.

For Maestro Tips for the clinic, Dani Zipkin has created lots of helpful videos – check them out here:
http://news.medicine.duke.edu/2014/02/maestro-care-tips-from-your-colleague-zipkin-screensharing/

See you all soon!
Dani

From the Chief Residents Grand Rounds

Friday, July 11th – Duke University Health System – Kevin Sowers/Dr. Tom Owens

Noon Conference Date Topic Lecturer Time Vendor 7/7/14 SAR Emergency Series: Radiology Essentials Mike Malinzak 12:15 Subway 7/8/2014 SAR Emergency Series: Acute/Decompensated Heart Failure Sneha Vakamudi 12:15 Pita Pit 7/9/2014 SAR Emergency Series: EPIC/Maestro Care Brian Griffith 12:15 Cosmic-Quesadillas 7/10/2014 SAR Emergency Series: GIB Alyson McGhan 12:15 Sushi 7/11/2014 Chair’s Conference  Chiefs  12:00 Dominos   From the Residency Office Survival Guides and End of Year Gifts

The 2014 Survival Guides are in and they are awesome.  If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours.  We can only provide one copy per resident.  If you are interested in purchasing a copy, please contact Jen Averitt.  An electronic version of the guide is currently in development and we should have more information on when that will be available soon!

For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!

Change in Parking Location (continuing trainees)

Trainees who entered Duke in 2013-14 and are currently parking in the Research Drive lot, are being relocated to PG2 (across from Duke North),  effective July 1.  Continuing trainees currently in PG2 will remain in the PG2 Garage.  Parking Decals are in the mail and, per the parking office, should arrive at your home soon (to the address listed in duke at work).  Your current decal will remain active until July 11th  which will allow plenty of time for you to receive the new decal.  Exceptions to this are the departments of Dermatology (assigned to and remain in PG1)  and the departments of Ophthalmology and Nephrology (all trainees are assigned to and remain in Research Drive).

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents

We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities !

The applications due on September 1, 2014 for a funding start date on October 1, 2014.

Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application.

Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor.

http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support

Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues.

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

Information/Opportunities

www.summitsps.com

Upcoming Dates and Events

July 25th- Summer Celebration at Dr. Klotman’s House

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

Internal Medicine Residency News: June 30, 2014

Sun, 06/29/2014 - 11:48
From the Director

It’s here! Shadow day for the new interns is Monday, and first day on the rotation is Tuesday! A final congratulations and thank you to our graduating SARs and to the entire GME group for an amazing year.  We are really excited to get started, and Nilesh, Coral, Bonike and Aaron kicked off the year with their first week as chiefs! Not enough thanks can go to Jen Averitt, and the rest of our phenomenal team (Randy, Lynsey, Erin and Lauren) for a smoothly run and very informative orientation week.  Amazing work!! We had a lot of fun at the new intern party at the Pit, and a great “rising JARBQ” at our house on Saturday night.

Kudos this week go to many of you….to Matt Atkins for receiving a gold star, to Gena Foster and Alan Erdmann from Myles Nickolich for covering while he presented at a national meeting, to Nick Rohrhoff for an incredible Tom Holland lecture, to Joe Brogan from Vaishali for outstanding patient care, kudos love back and forth between Vaishali and Amera Ramatullah (Amera for stepping up for extra coverage and to Vaishali from Amera for generally being awesome all year), also from Vaishali to Chris Merrick, Jesse Tucker and Brian Kincaid for coverage at the VA, and to Carli Lehr from Ryan Schulteis for team leadership at the VA.  More kudos to Matt Atkins and Myles Nickolich for leading the effort on revising the Intern Survival Guide (and to all who wrote/revised the chapters), and to Sarah Goldstein, Joanne Wyrembak, Ryan Jessee, Jonathan Hansen, Paul St. Romain, Jon Buggey and Alan Erdmann for running a fabulous intern practicum.

We kick off our new SAR talks this week with the SARs leading the intern emergency lecture series.  Please make every effort to attend and support your colleagues and to GET YOUR INTERNS TO NOON CONFERENCE! Our new equipment is almost ready for use!

Fellowship application due dates are rapidly approaching! I promise to have all of your letters ready before July 15th! Please let me know if you have any questions about the process.  ERAS registration seems to be going smoothly for everyone, and applications can be opened by fellowships on July 15th.

A special thank you to Randy Heffelfinger for his work on “Med Res News” (aka Weekly Updates). What started as a group email has grown into a great way to get information out to everyone in the program.  Starting in July, look for the news at a NEW TIME of Monday morning.   Keep sending us your kudos, your publications and your announcements!

This week’s pubmed from the program goes to Kevin Trulock for his upcoming publication with Jonathan Piccini in JACC.  Rhythm Control in Heart Failure patients with Atrial Fibrillation: Contemporary Challenges including the role of Ablation.  Trulock, KM, MD, Narayan, SM, MD, PhD, Piccini, JP, MD, MHS.

Have a great FIRST WEEK OF JULY!!!

Aimee 

What Did I Read This Week? submitted by: Vaishali Patel, MD

Wunderink RG, Waterer GW.  Clinical Practice: Community-Acquired Pneumonia.  N Engl J Med 2014; 370:543-551.

Why did I read it? 

Even thought I’m going back to being a GI fellow next week, whether I’m seeing patients on Gen Med, in clinic, or moonlighting in the good ol’ VA ED (!!), community-acquired pneumonia (CAP) is EVERYWHERE!!  This article is a few months old, but nicely delineates why we do what we do for CAP (and a great review for the start of internship!).  Because of the economic cost and mortality associated with CAP, the Joint Commission and Center for Medicaid and Medicare services (CMS) have pushed for CAP-related QI measures, institutional reporting of outcomes, and pay-for-performance initiatives.  It is important, therefore, to review the data-driven interventions that reduce both mortality and cost.  This article is consistent with the most recent IDSA-ATS 2007 guidelines for CAP, with the exception of criteria/risk factors and antibiotic recommendations for HCAP and MDR pneumonia, which are driven by newer data.  Refer to the article for very helpful tables and figures.

  • CAP needs coverage of Streptococcus pneumoniae and atypicals (mycoplasma, chlamydophila, and legionella).  Atypical coverage is especially important for outpatients and young adults (macrolides, fluoroquinolones and doxycycline).
  • For inpatients, patients with comorbidities, or antibiotic use in the previous 90 days (use a different antibiotic class), use a respiratory fluoroquinolone (moxifloxacin or levofloxacin) or a combination of a second or third-generation cephalosporin and a macrolide (reduced mortality and decreased length-of-stay with these regiments).  S. pneumoniae is the most common cause of severe CAP requiring ICU admission (treat with combination cephalosporin with either fluoroquinolone or macrolide).
  • Retrospective data from Medicare databases suggests decreased mortality if the first dose of antibiotics is given within 4 hours of presentation to the ED; however, efforts to meet this quality metric has resulted in inappropriate antibiotic use and adverse events such as C diff infections.  The main point is that antibiotics should be given as soon as possible following the diagnosis of CAP; for patients in shock, antibiotics should ideally be given within an hour of onset of hypotension.
  • The recommended duration of antibiotic therapy is 5 to 7 days (no evidence that longer courses have better outcomes, even in severely ill patients, unless immunocompromised).
  • Patients at risk for health-care associated pneumonia (HCAP), MRSA and multi-drug resistant (MDR) gram-negative pathogens need broad-spectrum coverage (see Table 2 of article). However, there is now increasing recognition that using all of the original criteria as indications for broad-spectrum coverage has led to overtreatment (use of broad-spectrum treatment in up to half of the patients with CAP in some centers).  Studies of HCAP patients show low rates of MDR pathogens, and high rates of negative cultures.  While there may be some selection bias as an explanation for this, several multi-center studies have showed increased adverse events and even increased mortality in patients given broad-spectrum therapy compared to those who received standard CAP therapy.
  • Another group of patients not included in the original criteria that is at risk for drug-resistant pathogens are those with structural lung disease (bronchiectasis) or severe COPD who have received multiple outpatient courses of antibiotics.
  • A prospective, observational, multicenter Japanese study (Shindo et al. Am J Resp Crit Care Med, 2013) identified 6 pneumonia-specific risk factors that can be used to determine risk for MDR pathogens (hospitalization >=2 days or antibiotic use during previous 90 days, non-ambulatory status, tube feedings, immunocompromised status, and use of gastric acid suppressive agents).   Using these criteria, a patient who is from a nursing home but does not have one of these risk factors would not get broad-spectrum therapy.  The presence of one MRSA risk factor (prior MRSA infection or colonization, long-term hemodialysis, heart failure) warrants MRSA coverage.
  • There is increasing recognition of exotoxin-mediated pneumonia caused by community-acquired MRSA in previously healthy patients (see Table 3); combination of vancomycin and linezolid or clindamycin (suppress toxin production) has shown decreased mortality.
  • Influenza testing should be done in the appropriate season.
  • You can use the Pneumonia Severity Index to predict short-term mortality and help make admission decisions to reduce admissions of healthier patients; however, it requires the use of an online calculator.  The CURB-65 score (1 point each for confusion, BUN>20, RR>30, SBP<90, and age >65, with a score >=2 as a cutoff for possible admission) can also be used, though is not as well validated as the PSI.
  • The presence of three or more of nine IDSA-ATS minor criteria should prompt ICU evaluation (see Table 5).  Increased attention given to these patients in the ED results in decreased mortality and fewer floor-to-ICU transfers.

Welcome to the new interns!  Have a great year!

From the Chief Residents Grand Rounds

No grand rounds this week – Holiday

Noon Conference Date Topic Lecturer Time Vendor 6/30/2014 Chief’s Intro Chiefs 12:15 Picnic Basket 7/1/2014 SAR Emergency Series: Rheumatologic Emergencies Fola Babetunde 12:15 Saladelia Wraps 7/2/2014 Emergency Series: Micro Lab Essentials Aimee Zaas 12:15 China King 7/3/2014 SAR Emergency Series: Hyper and hyponatremia Benjamin Llyod 12:15 Chick-Fil-A 7/4/2014 HOLIDAY – No Conference Domino’s   From the Residency Office Survival Guides and End of Year Gifts

The 2014 Survival Guides are in and they are awesome.  If you are a continuing Internal Medicine resident, please come by the MedRes office and pick up your copy during normal business hours.  We can only provide one copy per resident.  If you are interested in purchasing a copy, please contact Jen Averitt.  An electronic version of the guide is currently in development and we should have more information on when that will be available soon!

For all continuing Internal Medicine residents, please also pick up your copy of “The Evidence – Classic and Influential Studies Every Medicine Resident Should Know” with the compliments of the program for a great year!

Change in Parking Location (continuing trainees)

Trainees who entered Duke in 2013-14 and are currently parking in the Research Drive lot, are being relocated to PG2 (across from Duke North),  effective July 1.  Continuing trainees currently in PG2 will remain in the PG2 Garage.  Parking Decals are in the mail and, per the parking office, should arrive at your home soon (to the address listed in duke at work).  Your current decal will remain active until July 11th  which will allow plenty of time for you to receive the new decal.  Exceptions to this are the departments of Dermatology (assigned to and remain in PG1)  and the departments of Ophthalmology and Nephrology (all trainees are assigned to and remain in Research Drive).

Information/Opportunities

 

Upcoming Dates and Events

November 8:  Clinical Science Day

Useful links

 

Meet your chief resident: Nilesh Patel, MD, MS

Tue, 06/24/2014 - 11:57

Nilesh Patel, MD, MS

Nilesh Patel, MD, MS, is stepping into his role as chief resident for Duke University Hospital this week. Going into the new academic year, he has been thinking about ways to improve patient care and better support Duke’s internal medicine residents.

Dr. Patel, who completed his residency at Duke, has spent the last year as a faculty member in Hospital Medicine, rounding on general medicine in Duke University Hospital, so he has had many opportunities to observe and think about patient care and the resident experience.

One thing Patel says he’s gotten interested in is how the chief residents can help educate and support residents when they are in the hospital overnight and don’t have all the resources that residents have during day shifts, such as access to conferences or having a consult service that is immediately available. Patel would like to find ways to make more resources available for residents working at night.

Patel said supporting and providing resources for residents in general is one of his, and the three other incoming chief residents’, top priorities for the year. Patel’s co-chief residents are Coral Giovacchini, MD; Bonike Oloruntoba, MD; and Aaron Mitchell, MD.

“Our biggest goal is to make sure that we are as approachable and supportive as possible,” Patel said. “If the residents need anything this year, whether it’s taking care of patients, problems in their personal lives or finding resources for advancing their careers, we want to be easily accessible.”

Patel said there should never be a time when residents feel like they don’t have a support system, from the chief residents who are available 24 hours a day, seven days a week, to the senior assistant residents and attending physicians.

“The thing that makes Duke special is that you have an incredible group of caring, compassionate, brilliant individuals who are dedicated to caring for our patients,” Patel said. “I expect to be at the hospital late in July, August and September, and many of our faculty do, too, so our interns and residents can transition into their new roles as quickly as possible.”

Providing educational opportunities is part of the support Patel would like the chief residents to provide this year.

“One of the greatest opportunities that we have is to teach our residents and medical students not only during the structured time, but during the enormous number of reports that the chief residents lead, the unstructured reviewing of cases,” Patel said. “These learning opportunities are something that the chief residents are intimately involved in, so we can teach not only the zebra cases, but also the day-to-day cases that our residents spend most of their time thinking about.”

Other areas Patel has been thinking about over the last year include rapid response codes and quality improvement projects.

He says he would like to develop a way for residents to approach rapid response triage (RRT), so that they have the opportunity to care for some of the sickest patients on the floor before the patients go to the ICU (these are patients who are not in cardiac arrest but who are either having a respiratory problem or who are becoming ill quickly).

Patel also has been thinking about quality improvement projects that would improve patient care and allow residents and faculty who are rounding on internal medicine services to be more efficient. Patel said he is working on a project on the paging culture here at Duke, but longer term he’d like to develop broader projects on how residents and faculty are using Maestro Care or changes in the way physicians transition patients.

Patel expects other challenges to come up. The four incoming chief residents have already identified duty hours, the bed expansion, and the increase in the number of patients residents see overnight as areas they will need to watch and troubleshoot.

“The question is how can we as chief residents continue to support and make sure residents have the time and the accessibility to what they need in order to learn as much as they were from each rotation before the changes took place,” Patel said.

Patel and his co-chief residents will have many opportunities to work together and find ways to make rotations, conferences and reports good learning opportunities for residents.

One thing that Patel feels does set up the chiefs for success is that they are all graduates of the residency program and good friends.

“The four of us have been fortunate enough to go through residency together and be friends long before this year started. We’ve been coming up with ideas on our own to hopefully move the residency program forward,” he said.

After his chief resident year, Patel, who attended Emory University School of Medicine, will return to Hospital Medicine at Duke. He says it’s a good fit for him because there are so many learning and clinical opportunities – two reasons he went into medicine. “Hospital Medicine has a brilliant group of clinical faculty who are invested in the quality of this hospital and taking care of patients,” he said.

In his down time, Patel enjoys running, spending time with family, and reading. He also looks forward to spending time outside of the hospital with his fellow chiefs and residents.

Internal Medicine Residency News: June 23, 2014

Sun, 06/22/2014 - 19:02
From the Director

It’s here! The new interns start orientation on Monday!

A tremendous thank you and kudos to our chiefs Krish, Vaishali, Stephen and Joel. Only at Duke would a post op day 1 chief come to his co chiefs grand rounds. Amazing grand rounds given by Stephen Bergin!  We all can’t thank you enough for a fantastic year.

And we welcome Nilesh, Coral, Bonike and Aaron to the ranks. They completed their first task – the pull list- so we are well on our way to an amazing year.

Kudos also to Ryan Jessee for a great chairs conference and to Aparna Swaminathan and Rebecca Sadun for covering some colleagues on Friday so they could attend the VERY FUN SAR-b-q at our house. Also to Brice Lefler and Katie B-F for replying.

The SAR b-q was a great send off to a legendary class. Double benefit that they bought it at the charity auction. Looking  forward to hosting the interns (aka almost JARs) on Saturday.

Congrats also to the outgoing chiefs and Lauren Dincher on their 5 year service awards,and a special congratulations to the award recipients presented at grand rounds!

  • Bruce Dixon AwardLindsay Boole (nominees included  John Stanifer, Chris Hostler, Matt Summers, Lindsay Boole, Jim Gentry, Armando Bedoya, Meredith  Clement)
  • Fellow Teaching Award:  Zach Healy (nominee included –  Tony Tran, Jacob Doll, Megan Diehl, Ann Marie Navar Boggan) 
  • Haskel Schiff Award:  Matt Summers (nominees included  Chris Hostler, Matt Summers, Lindsay Boole, Brian Miller, Armando Bedoya, Tim Mercer)
  • Outstanding Service Award:  Randy Heffelfinger

This week’s pubmed from the program goes to Myles Nickolich for his upcoming poster presentation: “WHAT BOTHERS LUNG CANCER PATIENTS THE MOST? A PROSPECTIVE, ELECTRONIC, PATIENT-REPORTED OUTCOMES STUDY IN ADVANCED NON-SMALL CELL LUNG CANCER”

Have a great week

Aimee

What Did I Read This Week? submitted by: Krish Patel, MD

Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014 Apr 10;370(15):1402-11

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1302097

Why I read this:

This week’s JAMA had several articles about thrombolysis in acute PE.  Mostly a meta-analysis and an editorial.  Those articles were interesting, but mostly served to remind me to look for the publication of a trial I’d heard about earlier this year from Vic Tapson called the PIETHO trial.

We see a lot of patients with acute pulmonary emboli and the spectrum of presentation can vary quite widely.  We see patients with shock from PEs that require lytics and ICU admisssions to patients with no symptoms and incidental PEs on imaging of the chest intended for other purposes.  One area of uncertainty that we commonly face is what to do with “large PEs” with suggestions of RV dysfunction, but without overt hemodynamic compromise (so called intermediate risk patients).  There is little data to guide us in that regard.  The PIETHO trial was designed and undertaken to help provide more guidance in this area of clinical uncertainty….

Design: 

This study was a multicenter (Europe) double blinded, randomized, controlled trial.  The trial enrolled adult patients (n=1006) with acute PE (<15 days) and RV dysfunction (defined by specific ECHO or CT dimensional criteria) with myocardial injury (positive Troponin).  Patients with contraindication to thrombolytics, with overt hemodynamic instability, or recent IVC filter placement or thrombectomy were excluded from participation.  Patients were randomized to either single bolus dose of tenecteplase + intravenous unfractionated heparin vs. placebo + intravenous UFH.  The primary outcome was the composite of death from any cause and hemodynamic collapse within 7 days of randomization.  Secondary endpoints included 30 day all-cause mortality, recurrence of PE within 7 days of randomization, and various 7 day bleeding rates (major bleeding, intracranial hemorrhage, major extracranial bleeding).  Overall, the groups were fairly balanced in baseline characteristics and had similar proportions achieving therapeutic PTT on UFH within 24 hours of randomization. 

Results: 

So what did they find? The primary outcome occurred less often in the group receiving tenectaplase + UFH (2.6% vs 5.6%; p=0.02). However, this was primarily driven by a difference in hemodynamic decompensation (1.6% vs. 5.0%; p=0.002).  The study was not powered to detect a difference in death rate and the death rates in both groups was quite low (1.2% vs 1.8%; p=0.42).  Hemodynamic decompensation included some meaningful events (cardiac arrest, need for catecholamines for BP support) but also a perhaps less meaningful one (SBP <90mm Hg for >15mins).  Nevertheless, the occurrence of each type of hemodynamic decompensation was numerically different in both groups (statistical significance not published).

How about safety endpoints?  Well as might be expected there was notably more bleeding and hemorrhagic stroke in the tenectaplase group in comparison to the placebo group.

What does this mean for us:

Well, this trial demonstrates that patients with acute PE, RV dysfunction and myocardial injury have an increased risk of hemodynamic decompensation and that single dose tenectaplase may mitigate that risk.  However, the risk of significant bleeding, including a 2% incidence (10x relative risk) of hemorrhagic stroke ,may outweigh the benefit of the reduction in hemodynamic compromise.  Overall, this trial also tells us that the risk of death in patients with acute PE, RV dysfunction, and myocardial injury is relatively low and these patients can be managed well with careful monitoring and anticoagulation (the placebo arm) and that thrombolysis perhaps should be reserved for patient’s who fail this initial approach.

From the Chief Residents Grand Rounds

Presenter:  Dr. Mary Klotman

Chair, Department of Medicine

Topic:   State of the Department of Medicine

Noon Conference Day Date Topic Lecturer Time Vendor Monday 6/23 MKSAP Mondays – Thrombocytopenia Chiefs 12:00 Subway Tuesday 6/24 Immunizations Review Anne Phelps 12:00 Sushi Wednesday 6/25 How to Give a Talk Zaas 12:00 Cosmic Cantina Thursday 6/26 Novel therapies for staph aureus infections Ralph Corey 12:15 Domino’s Friday 6/27 Tom Holland Lecture Chiefs 12:00 Chick-Fil-A   From the Residency Office GME Resident Council

The following are your peer selected representatives to the Resident Council for 2014-2015. The Resident Council has elected Dr. Michael Barfield, General Surgery, as Chair and Housestaff Representative and Dr. Nicholas Rohrhoff, Internal Medicine, as Vice-Chair.

  • Dr. Michael Barfield - General Surgery, Chair
  • Dr. Nicholas Rohrhoff - Internal Medicine, Vice-Chair
  • Dr. Eun Eoh Anesthesiology
  • Dr. Dinesh Kurian Anesthesiology
  • Dr. Jolene Jewell Dermatology
  • Dr. Manisha Bahl Diagnostic Radiology
  • Dr. Michael Malinzak Diagnostic Radiology
  • Dr. Lauren Siewny Emergency Medicine
  • Dr. Nikki Henry Family Medicine
  • Dr. Michael Barfield General Surgery
  • Dr. Brittany Dixon Internal Medicine
  • Dr. Nicholas Rohrhoff Internal Medicine
  • Dr. Kevin Trulock Internal Medicine
  • Dr. Jesse Tucker Internal Medicine
  • Dr. Colby Feeney Internal Medicine/Peds
  • Dr. Amy Newhouse Internal Medicine/Psych
  • Dr. Owoicho Adogwa Neurological Surgery
  • Dr. David Lerner Neurology
  • Dr. Joseph Dottino Obstetrics and Gynecology
  • Dr. Jaya Badhwar Ophthalmology
  • Dr. Norah Foster Orthopaedic Surgery
  • Dr. Robert Henderson Orthopaedic Surgery
  • Dr. Richard Rutherford, Jr. Orthopaedic Surgery
  • Dr. Russel Kahmke Otolaryngology
  • Dr. Alyssa Kraynie Pathology
  • Dr. Christopher Severyn Pediatrics
  • Dr. Robert Bahnsen, Jr. Psychiatry
  • Dr. Alexander Eksir Psychiatry
  • Dr. Christina Cramer Radiation Oncology
  • Dr. Brian Gulack Surgery Research Fellowship
  • Dr. Melissa Mendez Urology
  • Snyderman Award Winner
Snyderman Award

The Snyderman Award was presented to Dr. Lindsey Boole, MD by Dr. Catherine Kuhn at the June ICGME Meeting last week. The winning submission is titled “Residents finding their roots: Resident workshops to improve patient safety on the wards while teaching root cause analysis”. Dr. Boole will receive $1000 (after taxes) and her name on the Snyderman Plaque. Congratulations to Dr. Boole and all who submitted projects for Snyderman Award consideration. More information about the Snyderman Award can be found on the GME Web site.

Moonlighting

All Internal (TSMA) Moonlighting approvals will expire on June 30, 2014.
To record moonlighting activities within MedHub, the activity must be approved through the TSMA/Moonlighting Request Forms located in the Schedule Planning section of MedHub.

The following policies apply to the moonlighting opportunities that are available to trainees:

At no time may the hours allocated for TSMA activities negatively impact training or violate duty hour policies. Residents who would like to be considered for Temporary Special Medical Activity (TSMA) in Oncology, Emergency Medicine, Cardiology, or Student Health must meet the following:

  1. Program level – either JAR or SAR
  2. Successful completion of rotations on MICU and Gen Med
  3. Be in good standing and without any active corrective action
  4. Provide written support from their advisor supporting the trainee’s request. The advisor may send an email to the attention of the Program Director, copy to the Program Coordinator, confirming their approval (to be completed prior to initiating the online TSMA form).
  5. Initiate the online TSMA form found on MedHub.
  6. Meet any additional training requirements as specified by the sponsoring department.

On notification of approval by GME, the trainee may contact the service Director and request approval to participate in the TSMA service.

Please Note: TSMA is approved only for each academic year. If you are currently participating in TSMA and plan to continue after July 1, you will need to resubmit the required forms for approval.

Duke Ahead

Information/Opportunities

Albemarle Procurement

Upcoming Dates and Events
  • Intern Welcome Celebration:  June 27 @ the PIT
Useful links

Internal Medicine Residency Program recognizes faculty, trainees with annual awards

Fri, 06/20/2014 - 09:57

Over the last few weeks as the chief residents have presented at Medicine Grand Rounds, the following faculty, fellows and residents have been honored by the Internal Medicine Residency Program for their work. Please congratulate your colleagues:

Eugene Stead Award: Louis Diehl, MD

Durham Regional Teaching Award: Jessica Chia, MD

Outstanding Service Award: Randy Heffelfinger

Ambulatory Medicine Teaching Award: Lynn Bowlby, MD

VA Faculty Teaching Award: Micah McClain, MD, PhD

Fellow Teaching Award: Zach Healy, MD

The House Staff Community Service Award: Carling Ursem, MD

Lececq Award for Outstanding Senior Resident Talk: Rebecca Sadun, MD, PhD, Alex Fanaroff, MD, Lauren Porras, MD

Haskel Schiff Award: Matt Summers, MD

Bruce Dixon Award: Lindsay Boole, MD

Joseph McClellan Award: Stephen Bergin, MD

Grand Rounds 6/20/14: Rapid Diagnostics

Mon, 06/16/2014 - 08:40

Medicine Grand Rounds on Fri., June 20 at 8 a.m. in Duke Hospital room 2002 will feature Stephen Bergin, MD, chief resident for Duke Regional Hospital/Ambulatory Medicine.

Dr. Bergin will present Rapid Diagnostics: Emerging Methods of Optimizing Antimicrobial Therapy.

Video archives If you can’t make Medicine Grand Rounds this week, watch a live stream or view the archived video at http://bit.ly/RSlrBP (ignore the security certificate warning, then use your Duke NetID & password).

Internal Medicine Residency News: June 16, 2014

Sun, 06/15/2014 - 11:47
From the Director

T-1 week until the new interns arrive for orientation! We are looking forward to having the SARs at our house this weekend, and the current interns (the nearly JARs!) at our house on the 28th.  Current interns, we will be emailing you the name of the new intern who will be shadowing you for the day on June 30th this week.  They won’t have Duke email until next week, but it would be great if you could send them a quick note to introduce yourself.

Kudos this week go to Krish Patel for his outstanding Grand Rounds, and also to our many award winners and nominees.  Congratulations to our Appleseed Teaching Award winners (given by the med students — thanks Wynn Hunter for organizing!)

Interns:  Andrea Sitlinger, Cece Zhang, Eric Yoder, Jonathan Hansen,Paul St. Romain

PGY 2+Adrienne Belasco, Hal Boutte, Tyler Black, Michael Woodworth, Sneha Vakamundi, Armando Bedoya, Brian Miller, Carling Ursem, Jay Mast, Dana Clifton, Timothy Mercer

To the Duke Regional Teaching Award Winner Jessica Chia (nominees: Nijra Nugogo, Stan Branch, Christina Barkauskas)

The Ambulatory Teaching Award winner Lynn Bowlby (nominees: Anne Phelps, Daniella Zipkin, Sharon Rubin, Diana McNeil, William Yancy, Ken Lyles, John Rubin ).

The Community Service Award winner Carling Ursem (nominees:  Meredith Clement, Mandar Aras)

We also celebrated our ACLT graduates this weekend – Kim Bryan, Lauren Porras, Jodel Giraud, Jeremy Halbe and Alex Clark.  Thanks Larry Greenblatt for hosting and to Alex Cho and Sharon Rubin for organizing! More kudos to Ben Peterson for a great chair’s conference.  Also kudos to John Stanifer for receiving grant a sub-award from Dr. John Bartlett’s MEPI grant: Medical Educational Partnership Initiative (MEPI) (#T84-HA21123) Mentored Research Training Program (MTRP) sub-award. ($25,000) Moshi, Tanzania. June 2014.

We did receive a confidential comment line comment that the work rooms are really messy at both Duke and the VA.  Yes, they are! A reminder that Environmental Services is responsible for cleaning the floors and emptying the trash ONLY.  They cannot clean the counters or throw away anything that is not already in the trash cans.  So, please be sure to recycle any PHI that is no longer needed in the confidential recycling bins, and to throw away any trash into the trash cans.  If the trash cans are not being emptied when they are full, please let Randy, Jen or I know, and we can discuss with the EVS team.  For the next couple of weeks there will be members of the Respiratory Therapy team working in rooms 8214-16.  Please be sure to give them the space they need while they are there.

Pubmed from the program this week also goes to John Stanifer for his publication in Historia Medicinae..A Peculiar Type of Dyspnea: Kussmaul, Cheyne Stokes and Biot Respirations. 

Have a great week!

Aimee

What Did I Read This Week? NEJM 2014, 370:2211-2218  June 5, 2014 Review Article: Pregnancy and Infection submitted by: Lynn Bowlby, MD

One of my areas of interest is medical problems in pregnancy. Dating back to my med school years I have been lucky to be exposed to internists working in this area. I love thinking about the changes in physiology that occur in pregnancy and how that impacts all illnesses.

As a general internist, NEJM is a great source of both original work and review/summary pieces. I check out every issue and last week’s issue had a great summary of ID and pregnancy. The evidence is slim for many pregnancy issues, with expert opinion often being dominant, but this article is a great summary of the available evidence and current thinking.

Pregnant women have an increased risk of infection, but not all infections. As any of us who took care of pts. in 2009 were reminded with the H1N1 flu epidemic, mortality and morbidity was much higher.  Pregnant women are more severely affected with the flu, Hep E , HSV and malaria.

It seems that the cardiac and pulmonary changes, with reduced lung capacity, increased HR and SV as well as urinary stasis, of normal pregnancy may increase the severity of the response to infection.

There certainly may be bias in determining severity of illness in pregnancy since they likely have more testing and hospitalization.

One very interesting fact– 5% of the deaths from H1N1 in 2009 in the US were in pregnant women, who comprise just 1% of the US population.

There is increased mortality from HEV (SE Asia, Middle East and Africa).

Primary HSV carries an increased risk of dissemination and hepatitis in pregnancy.

Pregnant women have x3 the risk of severe malaria. Mean maternal mortality from malaria is 39% in parts of Asia/Pacific region.

Coccidioidomycosis does not seem carry the increased incidence in pregnancy that once was thought.

Varicella infection seemed to have increased mortality in pregnancy based on some studies, but more recent review of data showed no change in mortality.

Increased incidence of infection as well as increased severity are both an issue in pregnancy.

Increased incidence is the clearest for P falciparum and Listeria monocytogenes.

The changes in sex hormones and the immune system are felt to affect the risk of and response to infection. Estradiol seems to increase immunity response.  The concept that the pregnant woman is immune suppressed to avoid the loss of the fetus is likely oversimplified. Pregnant women are not susceptible to all infections.

From the Chief Residents Grand Rounds

Presenter:  Dr. Stephen Bergin

Duke Regional/Ambulatory Services Chief Resident Grand Rounds

Noon Conference Date Topic Lecturer Time Vendor 6/16 MKSAP Mondays – Healthcare Maint. Bergin / Chiefs 12:00 Picnic Basket 6/17 Resistant HTN Case Studies Bergin 12:00 Pita Pit 6/18 Primary Care Controversies Zipkin 12:00 China King 6/19 QI Patient Safety Noon Conference Bae / Clark 12:00 Rudino’s 6/20 Chair’s Conference Chiefs 12:00 Domino’s From the Residency Office C Diff Shedding Study

This study is being led by Luke Chen, MD, who is asking for your assistance to identify appropriate patients as noted below:

  • When you have a patient with – suspected C-difficile associated diarrhea (CDAD)

Or

  • –PCR +ve for C. difficile and starting treatment  for CDAD

Who is able to receive any of the 3 oral antibiotics  (metronidazole/vancomycin/fidaxomicin)

  • Exclusion criteria:

–  > 1 dose of CDAD therapy

–  Receiving Other CDAD therapy (e.g. IV metronidazole

Please page Kathy Ramadanovic, Clinical Research Coordinator (CRC) at 970-11773

C-Diff Shedding Ad.

 

Information/Opportunities

North Dakota Internal Medicine

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Practice in one of Americas happiest states

 

Upcoming Dates and Events
  • Intern Welcome Celebration:  June 27 @ the PIT
Useful links