The Weekly Update

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News from the Duke Department of Medicine
Updated: 10 hours 52 min ago

New internal medicine book club starting Jan. 28

Mon, 01/26/2015 - 11:45

The book club’s first meeting is scheduled for Wed, Jan. 28 from 7-9 p.m. in the Duke Medicine Faculty Center (Seeley G. Mudd Building) to discuss Atul Gawande’s latest book, Being Mortal.

Laura Caputo, MD, medical instructor in the Division of General Internal Medicine, and Alicia Clark, MD, assistant professor of medicine (Hospital Medicine Program) and associate program director for the Internal Medicine Residency Program, invite faculty and trainees to participate in a new book club.

“Our goal is to read and reflect on books addressing issues relevant to the modern physician including medical ethics, gender equality, career development and sustainability,” said Dr. Clark. “We are open to suggestions for the book list and hope that this program will help foster relationships between faculty and house staff.”

Please contact Dr. Clark (alicia.clark@dm.duke.edu) if you plan to attend the Jan. 28 meeting.

Internal Medicine Residency News, January 26, 2015

Mon, 01/26/2015 - 11:02
From the Director

A momentous week! Coach K gets his 1000th win, we finish recruitment and the CLER visit went smoothly! Looking forward to hearing what the site visitors had to say about our health system! Thanks to everyone who helped out with the visit – residents, faculty, nurses, program administration, etc!  Also a big thanks to Lish Clark, Susan Gurley and the Stead Leaders for organizing a fantastic and VERY well attended faculty meet and greet on Thursday.  Special thanks to Andrew Muir, Tom Owens, Loretta Que, and Daniella Zipkin for talking to residents about their “career stories” and teaching us how to build careers in research, administration, education and primary care.

Upcoming events include the first Internal Medicine Book Club (thanks Laura Caputo and Lish Clark!), the Charity Auction, the NC ACP meeting and the Duke UNC basketball game.  Keep an eye on the calendar for dates and locations.  JARs, we will also be planning a night to meet the division chiefs as well as interview coaching with communications specialist Dr. Kat Pollack.  Are there other mentoring, community service, resilience building or social functions you are interested in? Please talk to me, Erin or your residency council reps to let us know what ideas you have.

Kudos this week to the AMAZING “Choosing Wisely” teams who presented at noon conference……Sam Lindner, Jenny Van Kirk, Andrea Sitlinger, Ryan Huey and Monica Tang were our presenters, and there are many others helping out with these important and fun projects.  Check in with Lish Clark and Aaron Mitchell to get involved.  That was one of the best noon conferences in a long time! And also kudos to Amit “Bassem” Bhaskar for a great chair’s conference.  Kudos also to Joanne Wyrembak from Liz Campbell for great work on Endocrine consults and to Fumiko Chino, Tim Hinohara and Rachel Hughes from the nursing staff and Alyssa Stephany for always involving the care nurses in team rounds on Duke Gen Med.  A belated kudos to Mike Dorry from Tom Gehrig and the nursing staff on CAD as well for great communication during a challenging patient event.

Also kudos to Eric Fountain for completing 8 PEAC modules!  In this week’s JGME, there was an article linking completion of PEAC modules with improved scores on the ITE and boards. Hmmmm……Many of you have completed the assigned two modules and the rest of you have until the end of the month to get them completed.  I have to get mine done too, and there is STILL TIME before Feb 1.

SARs, if you haven’t registered for ABIM boards, please don’t forget to do so! The price goes up soon so don’t pay more than you have to!

This weeks pubmed from the program goes to Brian Wasserman for his NC ACP Clinical Vignette poster … Acute ST Elevation Myocardial Infarction: A Statin and a Steroid?

 

Have a great week

Aimee

What Did I Read This Week?

Reference:

Hicks, L et al. Five hematologic tests and treatments to question. Blood. 2014 Dec 4;124(24):3524-8

http://www.bloodjournal.org/content/bloodjournal/124/24/3524.full.pdf

Background:

This article represents updated recommendations from the American Society of Hematology (ASH) Choosing Wisely Work Group. The American Board of Internal Medicine initiated the “Choosing Wisely” campaign in 2012 in collaboration with the medical societies to encourage medical stewardship and quality improvement. The medical societies have gathered clinical experts to review the literature and put forth a list of tests or treatments under the category of “Things Physicians and Providers should question”. The first 5 recommendations from the ASH Choosing Wisely Work Group were published in Blood at the end of 2013. The list included items recommending against thrombophilia testing in the presence of major reversible risk factors, use of plasma for vitamin K antagonist reversal in the absence of ICH, bleeding or emergent surgery, use of IVC filters for acute VTE and use of surveillance CT scans after successful treatment of aggressive lymphoma.   It encouraged a conservative transfusion strategy which has been echoed in other society’s recommendations. In this article, ASH reports their process of selecting 5 additional recommendations that are now displayed on the ABIM choosing wisely website.

http://www.choosingwisely.org/doctor-patient-lists/

Why did I read it?

The Choosing Wisely initiative is something that I am particularly interested in and I have been trying to follow as different medical societies put forth their recommendations about how to be more cost effective and patient centered. It is helpful to hear from different groups about which tests and interventions have little benefit and potential harm from their perspective.   Reviewing these recommendations and the associated literature helps me think about how to deliver more high value care and lends support for my discussions with patients and colleagues.

Results:

The ASH Choosing Wisely Work Group solicited suggestions for tests, procedures or treatments that should be questioned. The selection process was anchored on 6 core principles. The recommendations should be evidence based, reduce harm, aim to decrease cost, target common practices, remain within the clinical scope of hematology and prioritize items that would have a greater potential impact on practice. From 93 recommendations, they pared it down to 10 semifinalists. A systematic review of the evidence for these ten recommendations was performed and based on the evidence, a following list of recommendations was submitted.

  1. Do not treat with an anticoagulant for more than 3 months in a patient with a first VTE

occurring in the setting of a major transient risk factor.

  1. Do not routinely transfuse patients with SCD for chronic anemia or uncomplicated pain crisis

without an appropriate clinical indication.

  1. Do not perform baseline or routine surveillance CT scans in patients with asymptomatic, early stage CLL.
  2. Do not test or treat for suspected HIT in patients with a low pretest probability of HIT.
  3. Do not treat patients with ITP in the absence of bleeding or a very low platelet count.

 

Discussion:

It is important to note that for #1 their definition of major transient risk factor was strict and did not include hormone therapy, pregnancy or travel associated immobility.   It was felt that the duration of therapy for these cases should be considered on a case by case basis.   We often see the complications of iron overload and allo-immunization in our SCD patient population making recommendation #2 very appropriate.   The discussion of recommendation #4 refers to the strong negative predictive value of a low 4Ts score and the high risk, cost and potential harm associated with incorrectly diagnosing HIT.   I suspect that non-hematologists will be conferring with specialists when pursuing staging of CLL and management of chronic ITP but it is interesting to note that there is evidence to support less intervention in both cases.  Finally, their discussion refers to the relative paucity of recommendations for “malignant hematology” which seems to be multifactorial but potentially infers a lack of evidence and potential impact.

Overall, these recommendations are not groundbreaking but they do provide us additional support for when we are having informed discussions with patients or colleagues about when it is not only okay but evidence based to do less. If this article piques your interest, I encourage you to visit the Choosing Wisely link above to review other society’s recommendations

 

QI Corner

GREAT QI CONFERENCE LAST WEEK! Thanks to everyone who came to hear about the new Choosing Wisely projects that our underway. And especially a huge thanks to the residents on the project teams – Andrea, Sam, Jenny, Ryan, and Monica – for the awesome job you did in leading the conference. I have never seen so many great 1990s memes in one place before.

I, and Ryan, stand corrected – Nelly’s Country Grammar was indeed released in 2000, not the 1990s. Never, ever doubt Bonike.

To summarize, we are trying to cut back on the amount of unnecessary “daily lab” monitoring, as well as kill the phrase “Full Fever Workup” in signouts everywhere. Daily labs are often done reflexively and are often low yield, and our preliminary data have already shown that having the letters “FFWU” on signouts makes it more likely that your peers will order low-yield tests on your patients.

In broad terms, we would like everyone to at least stop and think before ordering any test. These tests are vital in the right circumstances, but are not helpful when we are using them only as automatic, daily checky-boxes without considering our patients’ needs. We are all smarter than that!

Even as our own Choosing Wisely projects get underway, the American College of Physicians is rolling out a new fellowship program for residents and fellows interesting in pursuing projects like this. This doesn’t seem like an exclusive fellowship based on my read – awardees will get to go to NYC for a conference, and then be responsible for writing and presenting their Choosing Wisely project. If any of you are interested in spinning a current (or future) Choosing Wisely project into an application to this program, we’d be glad to help! Read more here:

https://forms.acponline.org/webform/hvc-fellowship-grant-application

 

Clinic Corner

Chronic Pain/Opioid Safety

All residents should by now have signed up for the NC Controlled Substance Reporting System which allows for review of prescriptions filled for opioids and benzos within the past year.  If you are one of the few who have not yet done this, you can now do it online via the Medical Board (http://www.ncmedboard.org/notices/detail/ncmb-partners-with-nc-controlled-substances-reporting-system-to-allow-onlin).  No notary or photocopier needed.  It should take 5 minutes.  Be on the lookout for new DUHS opioid prescribing guidelines and tools that are designed to help you keep your patients safe and to comply with new guidelines from the NC Medical Board.  These will come out this spring.  In the meantime, evaluate the impact of opioid therapy on functional status and stress the importance of not sharing, keeping medication locked away, and sticking to prescribed doses.  Opioid overdose deaths remain quite high and now exceed deaths from motor vehicle crashes.

Treating The Common Cold

Being harassed by your patients to prescribe something to “knock out” their cold symptoms?  So am I!  Take the 5 minutes and explain why this practice can harm them and won’t help them improve any faster.  Know your OTC cold remedies-dextromethorphan is now available in a  12 hour sustained release suspension, pseudoephedrine needs to be signed out from behind the counter, and acetaminophen comes in 325 mg, 500 mg, and even 650 mg ER preparations.  My mother would recommend plenty of fluids and some chicken soup (Jewish Penicillin).  25% of colds will have symptoms lasting 14 days or longer so providing information on duration can help prevent your patient from going to Urgent Care unnecessarily.

Larry Greenblatt, MD

 

From the Chief Residents Grand Rounds

Fri., January 30th:Complications of Hepatic Cirrhosis, Visiting Speaker Dr. Guadalupe Garcia-Tsao

Noon Conference Date Topic Lecturer Time Vendor 1/26/15  MKSAP Mondays: Infectious Disease  N. Patel  12:15  Subway 1/27/15  Community Acquired Pneumonia/Amb Module Review  Aimee Zaas 12:15  Chick Fil A 1/28/15  Upper Respiratory Tract Infections/Amb Module Review  Daniella Zipkin 12:15/2001  Cosmic Cantina 1/29/15  Common Curbside Questions: ID  Christopher Hostler 12:15  Sushi  1/30/15  Research Conference  12:00/2002  Panera                       From the Residency Office ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!   Upcoming Events

First Medicine Book Club Event

Jan 28th from 7-9pm in the faculty lounge.  We will be discussing Atul Gawande’s “Being Mortal”.  There are a small number of free books still available for housestaff- please email Alicia Clark/Laura Caputo to RSVP.

Save the Date – Parents Weekend!!

The residency program is proud to announce plans for our first Parents Weekend, May 28 – 31, 2015!  Activities will include Resident Research Night, a special Grand Rounds “State of the Program” by Dr. Zaas, tours and informational sessions as well as a brunch on May 30th and optional social events in the evenings.  Please mark your calendars and stay tuned for more details to come!

 Urgent Data Security Announcement and Required Action: Multi-Factor Authentication (MFA)

Recently, we have seen an increasing number of attempts by hackers to gain access to the usernames and passwords of Duke personnel. Oftentimes, this occurs through sophisticated “phishing” attacks, which are fraudulent emails intended to fool readers into providing their login credentials. As Duke exposes many of its systems, including Maestro Care, to the Internet to facilitate remote work by employees, the threat of a hacker gaining access to Duke systems has drastically increased. Duke is not alone in experiencing these phishing attacks; other universities and academic medical centers have experienced similar intrusions.

To address this risk, Duke has implemented a Multi-Factor Authentication (MFA) system that is designed to provide an additional layer of security for accessing our systems.  When using MFA, a user is required to enter a password and also authenticate using a second factor, typically a smartphone or hardware token, that provides a random, one-time use code that is used to approve access for that login session. With MFA enabled, even if a hacker gains access to the user’s password, he or she would not be able to login to the user’s account.

In order to prepare for this change, it is critical that you proactively enroll in MFA, and at minimum enable it to secure your access to Duke@Work. The enrollment process has been recently streamlined to make the process more efficient for users. To find out more about MFA, please visit the following web site by copying the following link into a browser window:

http://oit.duke.edu/mfa

From that web site, you can also sign up for MFA by clicking on the “Register Here” link.

We all need to be more diligent than ever in evaluating any solicitation of our confidential data. DHTS, Maestro Care, OIT, Financial Services or Human Resources will never request your network password or other authentication information by email or telephone. Please report any suspicious email or messages requesting your confidential information via email to security@duke.edu

Over the past year, MFA has been implemented broadly throughout the campus for a number of systems.    In coming months, Duke Medicine will be enabling MFA for remote access into clinical systems, including Maestro Care and VPN. Once enabled, MFA will become a required step for anyone who needs to access clinical systems from outside of the Duke Medicine network, or using a non-PIN workstation.  Please note that MFA will not be required when using desktop computers located on our hospital wards and in our clinics.

Your commitment to following the steps outlined in this memo can help protect the personal information of our patients, their loved ones, and each other. If you have any questions about MFA, please contact the Duke Medicine Service Desk at 684-2243 or the OIT Service Desk at  (919) 684-2200.

AAMC 2015 IQ Call for Abstracts

https://www.aamc.org/initiatives/quality/meeting/419952/2015iqcallforabstracts.html

 

Information/Opportunities

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

RM Medical Search

Opportunities in Chicago

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

  Useful links

Internal Medicine Residency News, January 20, 2015

Tue, 01/20/2015 - 11:27
From the Director

Hi everyone!

Thank you to all the rising JARs and SARs who turned in schedule requests.  The chiefs are really excited to get started on next year’s schedule! Plus Friday is our last recruitment day of the season! Hard to believe but we are almost there.  You all have been amazing at showing the applicants our program and we are very much looking forward to an outstanding new intern class.

This is a busy week with the CLER visit starting on Wednesday and continuing through Friday.  Questions? Check out the CLER Corner on MedHub or talk with me, Jen or your GME rep Nick Rohrhoff.  The most important things to remember are to go about caring for patients as you normally would, and if a CLER team comes to observe or talk with you while you are working, stop and answer their questions.  The six focus areas are transitions of care, duty hours/fatigue, patient safety, quality improvement, professionalism and resident supervision.  Thank you again to our representatives at the resident forums and to our ambassadors who will be leading the teams around Duke.

Many kudos this week…..to Rachel Hu from Nick Rohrhoff for compassionate care on 9300, to Coco Fraiche, Jordan Pomeroy, Kahli Zietlow and Sam Lindner from Laura Musselwhite for their teamwork and care on 9100, to Mike Woodworth, Angela Lowenstern, Dinushika Mohottige, Ben Peterson, Titus Ngeno,  Lauren Collins, Kirema Garcia-Reyes, Sarah Goldstein and Lauren Collins  for #mytake.

Other kudos to Dinushika Mohottige for her outstanding chairs conference and to Adam Banks for getting the diagnosis.  I really appreciated the high level of discussion and participation in the case as well!

Congratulations to Titus Ngeno for his acceptance into the Global Health Residency!

This week, Lish Clarke, the Stead Leaders and the PWIM are hosting a get together with faculty on Thursday at 6:00 in the faculty lounge.  Come, grab some snacks and hear from faculty members about career development, work-life balance and more!

This week’s pubmed from the program goes to VA QI Chief Aaron Mitchell – Deferred Systemic Therapy in Patients with Metastatic Renal Cell Carcinoma
Aaron P. Mitchell, Bradford R. Hirsch, Michael R. Harrison, Amy P. Abernethy, Daniel J. George Clinical Genitourinary Cancer, Dec 31 2014

http://www.sciencedirect.com/science/article/pii/S1558767314002912

Have a great week

Aimee

What Did I Read This Week?

Nilesh Patel, MD, MS

Lactic Acidosis

Kraut JA. N Engl J Med. 2014 Dec 11;371(24):2309-19.

The New England Journal reviews tend to be well done—and this past December they reviewed hyperlactatemia; a topic that we all have clinically seen, but perhaps haven’t paid full attention to.

Hyperlactatemia is a consequence of either increased lactate production (lactate is byproduct of tissue glycolysis via LDH (the A subunit—or in the review, LDHA)) or diminished lactate clearance (via gluconeogenesis, oxidative phosphorylation, or the TCA cycle). Lactate production happens in glycolytic tissues like skeletal muscle and lactate clearance happens via various pathways in the liver, kidney, muscle, and other tissues. So, clinically, we can think of hyperlactemia as:

  1. Tissue Hypoxemia (Macrocirculatory or Microcirculatory) = Increased lactate production as a result of mitochondrial dysfunction + decreased lactate clearance by the liver as a result of academia

Cardiogenic shock

Hypovolemic shock

Trauma

PaO2<30

Hb<5

CO poisoning

Cocaine

  1. Increased aerobic glycolysis from epinephrine-dependent stimula- tion of the β2-adrenoceptor (independent of hypoxemia or with it)

Sepsis

Severe Asthma

Trauma, cardiogenic shock, hypovolemic shock

Pheo

Cocaine

Beta agonists

  1. Drugs that impair oxidative phosphorylation

Antiretrovirals

Propofol

Metformin (also suppresses hepatic gluconeogenesis)

Salicylates

Cyanide

  1. Liver Dysfunction (Liver accounts for 70% of lactate clearance, but in absence of other driving factors, liver dysfunction or cirrhosis alone should not lead to significantly elevated lactate levels.)
  1. Other:

Diabetes can contribute for unknown reasons

d-Lactate and l-lactate are normal products of metabolism of propylene glycol

Cancer cells are programmed to use aerobic glycolysis and lactate production as their main energy source (the Warburg effect)

Management of hyperlactatemia is of course management of the underlying condition(s).

Bicarbonate infusions are unproven.

NHE1 inhibitors can attenuate lactic acidosis and hypotension, improve myocardial performance, and reduced mortality in experimental models and may be a potential future therapy.

Inhibitors of LDH and MCT lactate transporters are being investigated as promising cancer therapies.

But the question remains, is blood lactate a useful tool to guide therapy?

Sustained hyperlactatemia in hospitalized patients is associated with a large increase in mortality, regardless of status with respect to shock or hypotension.

In a randomized, controlled study, a reduction of at least 20% in serum lactate levels every 2 hours was targeted for the first 8 hours of resuscitation; achievement of this target of lactate clearance was associated with decreased morbidity and mortality.

All in all, more investigation is needed.

QI Corner

Hey Everyone! The big heads-up for this week will be noon conference on Thursday. This is one of the lectures in the Choosing Wisely series, which should give us a chance to discuss all of the ongoing projects here in Duke IM.

The other news is that you guys continue to CRUSH IT regarding the ED consultation times for the GME incentive program. December was again well below our program-specific target of 30 minutes.

Here is us compared to all of the other GME programs. See us in the dotted dark blue way down at the bottom? See everyone else (besides peds and onc) nowhere even close?!?!?! Awesome job! We will have to see how things go now that Distinguished Professor Wagener has given up the afternoon 1010 pager, but you guys are definitely on track to get the $$$ so far.

Clinic Corner

Sonal Patel, MD – VA PRIME

PRIME residents,

How many of you know about the sticky note option in CPRS?  I absolutely love the idea of a sticky note.  Sticky notes have revolutionized how people in offices use reminders to get through the work day.  Now we have that option in CPRS.  For all of those who use unsigned addendums that clutter up your alert box (and the medical records committee “asks” you to complete) we now have another option!

Enter Sticky Note 2.0

You can now “color” coordinate your reminders to yourself

STICKY NOTE RED

STICKY NOTE YELLOW

STICKY NOTE GREEN

Color coordinating the sticky notes  just like we do in our outlook inboxes or with traditional paper sticky notes that are different colors.  The color coordination allows providers to manage and prioritize patient follow-up and day to day tasks more easily.  You can categorize your reminders by assign a color for in what time period to get back to a patient or with inpatient versus outpatient reminders or lab versus radiology reminders.  You get to choose how to use the different “colored” sticky notes.

Sticky Note Business Rules:

  1. It cannot be signed, but it can be edited, saved and deleted.
  2. It is not part of the medical record, thus the reason it cannot be signed.  It should not contain any new pertinent medical information that would be intended for the medical record.
  3. It will have a deadline of 6 months.  This note would be allowed to be in unsigned status for 6months prior to medical record committee review for number of  unsigned notes.

Have a great week and remember to let me us know if you need anything or have any ideas for making PRIME even better.

Sonal Patel

From the Chief Residents Grand Rounds

Fri., January 23rd: Gastroenterology, Dr. Nancy McGreal

Noon Conference Date Topic Lecturer Time Vendor 1/19/15 MLK Holiday 1/20/15 MKSAP ID Christine Bestvina 12:15/2002  Mediterra 1/21/15 Sneezes and Wheezes: Surviving the Flu Season Cameron Wolfe 12:15/2002  China King 1/22/15  QI Patient Safety Noon Conference  QI Team 12:15/2001 Dominos  1/23/15  Interview Day  Lunch w/ applicants  12:00/MedRes                       From the Residency Office CLER Visit Scheduled for January 21-23rd

Our first institutional Clinical Learning Environment Review (CLER) visit has been scheduled for later this month. This visit will involve Site Visitors from the ACGME coming to learn about the outstanding clinical, patient safety, and education efforts of our GME programs.  Many of you will be asked to participate in meetings with the visitors, and if you are, you will soon be contacted separately.  The CLER visit will target 6 focus areas:

Patient Safety
Health Care Quality
Care Transitions
Supervision
Duty Hours/Fatigue Management and Mitigation
Professionalism

Within the 6 focus areas, there are a number of categories. In anticipation of the visit, please consider how your program addresses the following:

Patient Safety
Resident/fellow experience in patient safety investigations/follow up
Cliical site monitoring of resident/fellow engagement in patient safety

Health Care Quality
Resident/fellow engagement in planning for quality improvement

Care Transitions
Resident/fellow and faculty engagement in patient transfers between services and locations
Faculty member engagement in assessing resident/fellow related patient transitions of care

Supervision
Faculty member perception of the adequacy of fellow/resident supervision

Duty Hours/Fatigue Management/Mitigation
Resident/fellow engagement in fatigue management and mitigation

Professionalism
Faculty engagement in training on professionalism

We would encourage you to think about these issues, visit the CLER CORNER of MedHub, and if you have questions about how the focus areas are taught or addressed in your programs, contact your program director, core faculty, Dr. Cathy Kuhn, or Dr. David Turner.

Welcome Theodore Greene!

Please join us in congratulating John and Emily Greene on their new arrival!

 

ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!    Upcoming Events

Combined Stead Society/PWIM and Office of Faculty Development Event

Jan 22nd from 5:30-8pm in the faculty lounge.  Drinks/appetizers will be served and mingling encouraged.  We will have a few faculty members coming to share their “stories”.   Hope you can make it- please email Alicia Clark with RSVP.

First Medicine Book Club Event

Jan 28th from 7-9pm in the faculty lounge.  We will be discussing Atul Gawande’s “Being Mortal”.  There are a small number of free books still available for housestaff- please email Alicia Clark/Laura Caputo to RSVP.

AAMC 2015 IQ Call for Abstracts

https://www.aamc.org/initiatives/quality/meeting/419952/2015iqcallforabstracts.html

 

Information/Opportunities

RM Medical Search

Opportunities in Chicago

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

  Useful links

Internal Medicine Residency News, January 12, 2015

Mon, 01/12/2015 - 15:37
From the Director

It’s almost here! What? The ACGME CLER visit is coming to Duke! What is the CLER visit? The Clinical Learning Environment Review, of course! The ACGME team will be here on Jan 21-23, meeting with the big shots of the hospital, with program directors, with faculty and with residents.  They will also be walking around and observing how we care for patients, do handoffs, etc.  What can you do for the CLER visit?  Inform yourself about the CLER focus areas — see the CLER corner on Medhub or talk to me, the chiefs or the APDs for more information.

Upcoming as well is the NC ACP meeting.  Nick Turner, Paul St. Romain and Peter Hu will be representing us in the trivia competition and MANY of you have posters accepted to the meeting.  This is great – we are so excited about your participation.  Jenny Van Kirk is our housestaff rep and Josh Rivenbark is our med student rep to the ACP as well. We are closing in on the end of recruitment…thanks so much to our #mytake! residents who spoke to applicants last week: John Musgrove, Dinushika Mohottige, Angela Lowenstern, Joy Bhosai, Myles Nickolich and Ryan Huey.  Kudos also this week to Tim Mercer from Jesse Tucker for great MICU care at the VA and to Ragnar Palsson from Tony Lozano for being helpful overnight on call.  Other kudos to Rachel Titerence Hughes, Jessie Seidelman and Christine Bates for being the first three to finish the PEAC modules for this month.  We will be releasing all modules to everyone so that you can go at your own pace, but we will still assign certain modules that are required to be completed. Thanks again to Bonike, Katie and the ambulatory group for making this happen! Thank you to Lynn Bowlby for letting us know about the ONLINE HIGH VALUE CARE CASES! Check out https://hvc.acponline.org/physres_cases.html for details.  These should be very applicable to the boards HVC questions.

This week’s pubmed from the program goes to Rajiv Agarwal for his NC ACP poster “Confusion and Respiratory Distress in Sickle Cell Disease: The Voyage of Bone Marrow Fat.” Of the 75 NCACP posters, 30 are from Duke! Look for yours in Med Res News soon!

Have a great week!

Aimee

HAPPY BIRTHDAY CORAL!!!

What Did I Read This Week?

 

Coming Soon!

 

 

QI Corner

Hey Guys!

Just a reminder about the Patient Safety and Quality Council meeting on Wednesday at 5:30 in the med res library. This will be to talk about any patient safety and QI ideas you’ve had, as usual, but especially for everyone involved (or who wants to get involved!) in the Choosing Wisely projects to work on designing the cost-saving interventions.

Clinic Corner

Welcome back to clinic and happy new year. We have some new and exciting changes at Pickett Road.

Welcome first of all the Dr. Audrey Metz who started Monday January 5th as an attending!She will start attending March 1. Until then Thursday afternoon clinic has been closed with Dr. Wolf’s departure.

There will be a shift of attendings starting March 1:

Tuesday morning Dr. Boinapally

Wednesday morning Dr. Metz

Thursday afternoon Dr. Brown

Starting January, interns will start seeing 5 patients, JARS and SARs 7 patients.

SARS should not be getting any new patients. If you are please let me know.

If the Intern has had 3 mini cex they are able to start seeing patients on their own.

If the JAR and SAR have had 3 mini cex they can start patch signing out patients.

We are at wave 3 for mini cex and should be able to complete these this month. Please pay attention when you are scheduled and be proactive with picking an appropriate patient and reminding your attending.

Make sure you are attached to the Pickett Road Resident inbox: Edit Pools. IF you are not there (due to one of the upgrades), reattach yourself:

Epic

Tool

Patient care tools

Inbasket Class

Choose Pickett Road Primary Care Residents

Remember this is flu season. The vaccine is only 33% effective.  We still recommend the flu vaccine to all patients. Please be mindful when treating patients suspected for the flu. If you have high suspicion you can treat them. If they present in 48 hours and follow the CDC guidelines on who needs the Tamiflu. The tests for influenza are in high demand so choose if you need to check for flu or if you will diagnose clinically and chose to treat.

Sincerely,

Sharon Rubin, MD, FACP

 The Ambulatory Care Leadership Track:

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

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

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

ACLT application form – 2014-15

 

From the Chief Residents Grand Rounds

Fri., January 16th: MLK Speaker – Dr. Courtney Fitzhugh, Sickle Cell Research

Noon Conference Date Topic Lecturer Time Vendor 1/12/15 Interview Day  Lunch with applicants 12:00/MedRes  Bull Street Market 1/13/15  Essentials of Antifungal Therapy  Aimee Zaas 12:15/MedRes 2002  Chick Fil A 1/14/15  Essentials of CNS Infections  Nilesh Patel 12:15/Room 2001  Cosmic 1/15/15  Essentials of TB  Jason Stout 12:15/2001 Dominos  1/16/15  Interview Day  Lunch w/ applicants  12:00/MedRes  Jason’s Deli                     From the Residency Office ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!    Upcoming Events

Combined Stead Society/PWIM and Office of Faculty Development Event

Jan 22nd from 5:30-8pm in the faculty lounge.  Drinks/appetizers will be served and mingling encouraged.  We will have a few faculty members coming to share their “stories”.   Hope you can make it- please email Alicia Clark with RSVP.

First Medicine Book Club Event

Jan 28th from 7-9pm in the faculty lounge.  We will be discussing Atul Gawande’s “Being Mortal”.  There are a small number of free books still available for housestaff- please email Alicia Clark/Laura Caputo to RSVP.

AAMC 2015 IQ Call for Abstracts

https://www.aamc.org/initiatives/quality/meeting/419952/2015iqcallforabstracts.html

 

Welcome Jack Feeney!

Please join me is wishing Colby and John congratulations on the arrival of Jack!

He was born on Sat Jan 3. All are doing well.

Sue Woods

 

Information/Opportunities

RM Medical Search

Opportunities in Chicago

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

  Useful links

Internal Medicine Residency News, January 5, 2015

Mon, 01/05/2015 - 10:09
From the Director

Happy 2015 everyone! I hope you all had a chance to enjoy your time away, and, of course, thanks to all for your hard work over the Christmas and New Year’s weeks.  Given the rapid surge of the flu season, it is going to be a busy few weeks on both sides of the street.  This week marks the return of RECRUITMENT! Reminders for VA and Duke Gen Med residents – report is at 1 pm at Duke on Mondays and for all, chairs is at 11:30 on Fridays.  We are in the home stretch, and your continued hospitality and enthusiasm is much appreciated.

Kudos came over the break to Jason Bethea (and his wife!) for helping out a colleague in need, to Jason Zhu from Peter Hu for great team leadership at the VA, and to the entire team of VA interns from their peers: Peter Hu, Rachel Hu, Linda Koshy, Coco Fraiche, Lauren Collins, Taylor Bazemore, Kirema Garcia-Reyes, and Sweta Sengupta.

What to expect for 2015?  Please read the email from Bonike about the new Ambulatory PEAC Curriculum.  We are really excited to bring you this online ambulatory curriculum (much thanks to Katie Broderick-Forsgren, Sue Woods, Dani Zipkin and Alex Cho as well) and look forward to enhancing your ambulatory knowledge through a well-done and user-friendly online site.  Let’s make Lynsey’s job easier and just complete the assigned modules so that she doesn’t have to email and remind you!

Schedule requests! Make sure to get these filled out so that we can start working on the 2015-16 schedule.  ACR “nomination” ballots will come out this week…you can anonymously nominate yourself (rising SARs) or another resident.  We will contact those who are nominated to accept the nomination and give us site preferences prior to the ACR selection process.  THIS IS NOT A VOTE, so it doesn’t matter if you are nominated once or 10 times, but we hope this is more useful than the previous application process.

Back 2 Basics curriculum – please continue to sign up for topics.  We will be contacting those who signed up to give further instructions this week!

Choosing Wisely – get involved by attending the PSQC meetings!

Humanities night and the Charity Auction are highlights of the second half of the year.  Adrienne Belasco is chairing the Auction Committee. Please check with her if you would like to get involved.

Here’s to a GREAT year!

Aimee

What Did I Read This Week?

Aaron Mitchell, MD

Submitted by: Aaron Mitchell, MD

Reference:

Justin E. Bekelman, Gosia Sylwestrzak, John Barron, Jinan Liu, Andrew J. Epstein,

Gary Freedman, Jennifer Malin, Ezekiel J. Emanuel. Uptake and Costs of Hypofractionated vs Conventional Whole Breast Irradiation After Breast Conserving Surgery in the United States, 2008–2013. JAMA. 2014;312(23):2542-2550.

Why did I read this:

One of my biggest interests in health care policy is the cost of care, and how “fee for service medicine” (where doctors get paid for each treatment they provide) incentivizes us to provide unneeded and unnecessary treatments. This article examines that dynamic in the world of oncology, which is also of particular interest to me.

Background:

  1. Breast-conserving therapy is the most common treatment for early-stage breast cancer. Whole

breast irradiation (WBI) is recommended for most women after breast conserving surgery, as it reduces local recurrence and improves survival.

  1. WBI has typically been given in “fractions,” or doses, spaced over 5 weeks. However, hypofractionated WBI (hypo-WBI) – giving higher doses of radiation but over 3 weeks instead of 5 – is now widely accepted to be equally effective. In addition, because it involves fewer treatments, it costs less and is far more convenient to the patient. Therefore, hypo-WBI is now the standard of care in many countries.

However, as in many things related to health care, the USA is an outlier. Adoption of hypo-WBI has been slow here. Using an insurance claims database, the authors of this paper set out to measure the usage of hypo-WBI, and the potential cost-savings.

Results:

While the usage of hypo-WBI is increasing, as of 2013 only 34.5% of breast cancer patients in the United States who are recommended candidates are receiving it. This is compared to rates of over 70% in Canada, for example. Cost savings would be around $3,000 for each patient who receives hypo-WBI compared to longer dosing schedules.

Discussion:

While the authors do not say so directly, the between-the-lines message here is that in the USA, we have an incentive to give people more treatments than they need. We know that hypo-WBI is just as good, but keeping patients around for only 3 weeks instead of 5 will cut into the cash flow of radiation centers, and they know that. Wherever less-is-more medicine is the right decision, fee-for-service medicine puts our financial interests in conflict with our patient’s best interests.

I don’t know about you, but I like to play on the same team as my patients! Sounds like it’s time to change how doctors get paid in this country.

Clinic Corner

DOC Clinic Corner 1/5/15

Happy New Year everyone! We hope everyone enjoyed their holiday break. At the DOC, we are very excited about 2015. The HomeBase program, for our highest utilizers, is going strong and is ready to enroll patients regardless of insurance status (this is a change from prior, when we could only enroll Medicaid patients). Email Dr. Cunningham to suggest a patient for enrollment. Jan has had her first knee surgery and is acing the rehab, progressing faster than projected and now walking with a cane. Our stellar nursing staff held down the fort during the holiday schedule and are anxiously awaiting your return in clinic. And Holly Causey has been hitting the gym hard – watch out, she is a lean, mean, pharmacist machine! (Except for the mean part :-).

Check out this month’s DOC Newsletter for important changes regarding clinic communications!! Special bonus – find out which DOC residents made it to the holiday party!! Gloria Manley organized the great party at West End Wine Bar, and Eric Westman’s band provided the tunes!

Another quick plug for the ACLT – Ambulatory Care Leadership Track. Rising JARs with an interest in ambulatory medicine (general medicine and subspecialties) as well as teaching, scholarship, and advocacy/health policy, should please contact Dani Zipkin, Alex Cho, or Bonike Oloruntoba. Please send in your applications by January 15th.

 

 The Ambulatory Care Leadership Track:

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

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

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

ACLT application form – 2014-15

 

From the Chief Residents Grand Rounds

Fri., January 9th: Infectious Disease, Dr. Vivian Chu

Noon Conference Date Topic Lecturer Time Vendor 1/5/15 Interview Day  Lunch with applicants 12:00/MedRes  Piper’s in the Park 1/6/15  MED PEDS INTERVIEW/ G Briefing Session  Lunch w/applicants 12:00/MedRes  Saladelia 1/7/15 Hopkins/PEAC Ambulatory Curriculum Overview B. Oloruntoba 12:00/Room 2002  China King 1/8/15 What to Do With ALL my $$$: Financial Planning  Molly Stanifer 12:15/2001  Mediterra  1/9/15  Interview Day  Lunch w/ applicants  12:00/MedRes  Panera                     From the Residency Office ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!   Do No Harm Project

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

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

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

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

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

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

Thank you,

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

 

Evidence-Based Medicine: A Cross-GME Course

Open to all Duke residents and fellows

January 7 – February 11

Wednesdays 5:30 – 7:00 PM

(Duke Medicine Pavilion Conference Rooms)

Dinner Served

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

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

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

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

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

 

Information/Opportunities

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

  Useful links

Internal Medicine Residency News, December 19, 2014

Fri, 12/19/2014 - 11:26
From the Director

It’s the last MED RES NEWS of 2014!  While some of the days (or nights) may have been long, the first half of the year seems to have flown by.  This is absolutely a credit to you all – there are so many people who benefit from your hard work and your care on a daily basis, and it is much appreciated by us all.  I hope that you get a chance to relax over the Christmas or New Year’s break with family and friends.

Things to note before the holiday time starts…..THANK YOU to everyone who donated to the Toys For Tots drive! We were able to deliver a very nice donation of toys to make the holiday brighter for kids in the Durham area.  From We Care Wednesdays to Thanksgiving to Christmas toys, we’ve done some good here this year!  Looking forward to our annual Charity Auction in 2015 as well as the 4th annual Stead Tread to extend our reach into the community.

Kudos this week to Jordan Pomeroy from Dr. Galanos for fantastic care in the CCU, and to Jason Zhu from Dr. Oddone for his work on VA Gen Med, and to our awesome ACRs John Wagener, Christine Bestvina and Iris Vance.  Other thanks to our “Resident Share/My Take” team of John Musgrove, Sajal Tanna and Ben Peterson on Monday.

Things to think about over the holidays (other than spending time with friends and family)…work on your schedule requests for next year (rising JAR and SAR), register for your boards (current SARs) and ask your family about coming to the FIRST ANNUAL DUKE MEDICINE RESIDENCY PARENTS’ WEEKEND! May 28-31, 2015!  We look forward to showing off for your parents with Resident Research Night, the State of the Residency Grand Rounds, a look into what exactly you do all day, as well as social events including dinner, a Bull’s game and brunch.  Please send us suggestions of anything you would like to add to the weekend.

This week’s Pubmed from the Program goes to your awesome DRH/ambulatory Chief Bonike Oloruntoba whose paper was just accepted!

Have a great week and a very happy, healthy, restful and rejuvenating holiday.

We’re back on the blog in 2016!

Aimee

Toys for Tots Donation!

What Did I Read This Week?

Submitted by: Aimee Zaas, MD

“The Darwin Awards: Sex Differences in Idiotic Behavior” from BMJ 2014; 349;g7094

What Did I Read? “The Darwin Awards: Sex Differences in Idiotic Behavior” from BMJ 2014; 349;g7094.

Why Did I Read This?  If you aren’t familiar with the British Medical Journal’s holiday edition, then you should be.  Nerd humor at its finest, responsible for classics such as comparing chicken soup recipes for their neutrophil killing properties, evaluating if James Bond had essential tremor, and an observational study of why Rudolph’s nose is red, the BMJ made headlines again this year with statistical support to show that men are more idiotic than women.

What Did the Authors Do?  The authors sought to evaluate whether or not the epidemiology around risk related illness and injury (men are far more likely to have sports related, occupational and accidental injuries than women) extended to “idiotic” risks — the type where the payoff is negligible and the outcome is often, as they say, final.  Researchers evaluated the winners of the Darwin Award for the past 20 years.  For those of you not familiar, the Darwin Award is given to the per on who dies in such an idiotic manner that “ their action ensures the long term survival of the species, by selectively allowing one less idiot to survive.”  (Representative samples can be seen on shows such as MTV’s Jack***). Examples of winners include a terrorist who posted a letter bomb with insufficient postage and then OPENED his letter when it was “returned to sender” and someone who dropped a large steel item on themselves while attempting to steal it.

Sample was the past 20 years of winners (1995-2014).  Excluded were urban legends that were not verified by the Darwin committee and those who, while demonstrating idiotic behavior, did not eliminate themselves from the gene pool. A chi square test was used to compare the observed vs expected male vs. female winners with the null hypothesis of “no difference”.  Of the 318/413 eligible Darwin awardee winners, 282 (88.7%) were males and 36 (11.3%) were females — chi square = 190.3, p < 0.0001).

Limitations of the study include its retrospective nature, as well as the inability to verify the role of alcohol in making the subjects feel “bulletproof”.  In fact, perhaps differences are explained by alcohol use differences between males and females, but this cannot be verified.

Ultimately, the authors conclude that this study supports the truth to “Male Idiot Theory”, and they plan to evaluate the role of alcohol in idiotic behavior in a semi-naturalistic holiday party setting.

 

Cheers!

 

 

From the Residency Office

The MedRes office would like to thank Randy Heffelfinger, and congratulate him on his retirement!  Randy has led our team for six years, and has been a part of the Duke family for 12 years.  His contributions to medical education have been immeasurable and his dedication to the program, it’s residents and staff has been constant and inspiring.  While it is with heavy hearts that we say goodbye, we are all so thrilled and excited for Randy, Mindy, Erin and Abby as they embark on their next adventures!  We love you Randy, and you will be so missed!

(In case you didn’t recognize him without his tie!) ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!  

 

Uniforms Ordering Closes December 31

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

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

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

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

Do No Harm Project

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

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

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

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

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

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

Thank you,

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

 

 

Evidence-Based Medicine: A Cross-GME Course

Open to all Duke residents and fellows

January 7 – February 11

Wednesdays 5:30 – 7:00 PM

(Duke Medicine Pavilion Conference Rooms)

Dinner Served

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

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

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

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

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

 

 

Information/Opportunities

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

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, December 15, 2014

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

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

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

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

 

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

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

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

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

Have a great week

Aimee

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

What Did I Read This Week?

Submitted by: Aimee Zaas, MD

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

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

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

What information did they learn from the literature?

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

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

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

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

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

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

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

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

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

Novel/Molecular Adverse Prognostic Factors

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

What about therapy?

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

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

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

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

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

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

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

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

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

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

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

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

 

Clinic Corner

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

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

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

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

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

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

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

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

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

Have a safe and happy holiday and new year!

Sincerely,

Sharon Rubin, MD, FACP

 

 

What? The Ambulatory Care Leadership Track:

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

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

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

ACLT application form – 2014-15

 

QI Corner

 

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

 

 

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

 

 

From the Chief Residents Grand Rounds

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

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

2014 Internal Medicine Residency Council Holiday Toy Drive

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

Details:

– Unwrapped

– New/Unused

– No guns

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

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

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

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

Best regards to all,

Murat and Aimee

 

Annual GME Holiday Celebration

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

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

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

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

 

Uniforms Ordering Closes December 31

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

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

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

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

Do No Harm Project

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

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

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

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

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

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

Thank you,

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

 

Evidence-Based Medicine: A Cross-GME Course

Open to all Duke residents and fellows

January 7 – February 11

Wednesdays 5:30 – 7:00 PM

(Duke Medicine Pavilion Conference Rooms)

Dinner Served

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

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

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

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

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

 

Information/Opportunities

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

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, December 8, 2014

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

Hi Everyone!

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

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

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

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

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

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

Have a great week

Aimee

MATCH DAY!

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

 

What Did I Read This Week?

Submitted by: Sue Woods, MD

Clinic-Community Linkages for High-Value Care

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

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

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

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

The strategy that the authors outline has the following components:

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

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

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

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

Challenges identified by the authors include:

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

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

Clinic Corner

DOC Clinic Corner 12/8/14

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

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

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

 

What? The Ambulatory Care Leadership Track:

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

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

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

ACLT application form – 2014-15

 

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

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

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

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

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

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

 

QI Corner

 

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

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

 

From the Chief Residents Grand Rounds

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

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

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

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

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

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

Best regards to all,

Murat and Aimee

ACP Abstracts Due!

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

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

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

Murat and Aimee

 

Annual GME Holiday Celebration

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

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

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

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

 

Uniforms Ordering Closes December 31

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

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

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

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

Do No Harm Project

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

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

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

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

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

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

Thank you,

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

 

AAMC-CDC Public Health Policy Fellowship

Public health policy experiential learning opportunities for early-career physicians

 

Information/Opportunities

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

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

December 13, 2014 – DoM Holiday Party

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Duke Heart Center launches new mobile app for cardiovascular education

Fri, 12/05/2014 - 11:19

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

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

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

 

Results posted for 2014-2015 fellowship match

Wed, 12/03/2014 - 16:15

The 2014-15 national fellowship match was announced today.

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

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

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

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

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

Internal Medicine Residency News, December 1, 2014

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

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

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

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

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

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

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

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

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

Have a great week

Aimee

What Did I Read This Week?

Submitted by: David Butterly, MD

ANCA-RituxNEJMNov2014

Rituximab versus Azathioprine for Maintenance in ANCA-Associated Vasculitis

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

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

Background:

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

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

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

Current Study:

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

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

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

Findings:

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

Conclusions:

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

Clinic Corner

 

Ambulatory Clinic Corner

Want more autonomy in the clinic?

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

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

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

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

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

 

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

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

 

Wanted: Future leaders in Ambulatory Care

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

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

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

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

ACLT application form – 2014-15

QI Corner

 

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

Aaron Mitchell

 

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

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

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

Thanks so much !

Lish Clark

 

From the Chief Residents Grand Rounds

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

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

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

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

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

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

Best regards to all,

Murat and Aimee

ACP Abstracts Due!

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

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

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

Murat and Aimee

Information/Opportunities

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

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

December 3, 2014 – SAR Match Party

December 13, 2014 – DoM Holiday Party

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, November 24, 2014

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

Hello Everyone,

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

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

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

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

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

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

Aimee

What Did I Read This Week?

Submitted by: Omobonike Oloruntoba, MD

Early versus On-Demand Nasoenteric Tube Feeding in Acute Pancreatitis

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

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

BACKGROUND:

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

METHODS:

Study Participants:

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

Study Design:

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

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

RESULTS:

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

CONCLUSION:

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

 

Clinic Corner

 

Hi everyone

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

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

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

Dr. Bhaskar- PRIME D great.

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

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

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

Dr. Palsson- follow-up of emergency room visit

 

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

Best,

Sonal Patel

VA PRIME

From the Chief Residents Grand Rounds

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

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

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

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

Best regards to all,

Murat and Aimee

ACP Abstracts Due!

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

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

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

Murat and Aimee

 

Partners In Health and BWH Hospitalist Program

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

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

Partners In Health and BWH Hospitalist Program

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

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

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

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

Qualifications:

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

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

Information/Opportunities

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

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

 

 

Upcoming Dates and Events

November 27, 2014 – Turkey Bowl

December 3, 2014 – SAR Match Party

December 13, 2014 – DoM Holiday Party

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, November 17, 2014

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

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

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

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

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

 

Have a great week

Aimee

What Did I Read This Week?

Submitted by: Coral Giovacchini, MD

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

Why Did I Read This:

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

Background:

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

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

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

What We Know – Mechanisms of Allergic Inflammation:

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

What We’re Figuring Out – Immune Tolerance:

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

Clinical Use of AIT:

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

The Future Of AIT:

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

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

Clinic Corner

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

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

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

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

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

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

For faster sign out – ask your preceptor for

SNAPPS Model of Learning Center Precepting

Summarize briefly the history and findings

Narrow the differential to 2 or 3 possibilities

Analyze the differential by comparing and contrasting the possibilities

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

Plan management for patient medical issues

Select a case related issue for self-directed learning

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

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

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

Learner and preceptor focus on patient management issues

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

Sincerely,

Sharon Rubin, MD, FACP

 

QI Corner

Aaron Mitchell, MD

A lot of news this week!

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

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

– These 66 represented about 17% of gen med patients

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

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

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

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

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

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

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

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

5) Go Jets!

 

From the Chief Residents Grand Rounds

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

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

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

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

Best regards to all,

Murat and Aimee

 

Chronic Hepatitis C Infection: Making the Decision to Treat

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

ACP Abstracts Due!

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

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

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

Murat and Aimee

 

Partners In Health and BWH Hospitalist Program

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

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

Partners In Health and BWH Hospitalist Program

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

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

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

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

Qualifications:

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

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

Information/Opportunities

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

Internal Medicine Opportunities

MD Fellowship Flyer V5

Financial Planning Webinar for New Physicians – CST

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

 

Upcoming Dates and Events

November 27, 2014 – Turkey Bowl

December 3, 2014 – SAR Match Party

December 13, 2014 – DoM Holiday Party

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, November 10, 2014

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

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

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

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

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

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

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

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

Have a great week

Aimee

 

What Did I Read This Week?

Submitted by: Lynn Bowlby, MD

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

Review Article : Microcytic Anemia

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

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

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

  1. Thalassemia-

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

  1. Inflammation-

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

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

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

Diagnosis:

MCV < 70 rare in inflammation

Anemia of inflammation is one of exclusion.

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

Treatment:

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

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

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

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

Clinic Corner

Hello Team DOC!

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

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

Take care,

Dani

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

 

QI Corner

Aaron Mitchell, MD

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

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

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

 

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

 

From the Chief Residents Grand Rounds

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

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

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


Pin Station Re-located

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

 

Duke AHEAD Announcement

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

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

Thank you for your continued support of Duke AHEAD!

Kristin Dickerson

Duke AHEAD

Chronic Hepatitis C Infection: Making the Decision to Treat

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

ACP Abstracts Due!

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

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

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

Murat and Aimee

 

Partners In Health and BWH Hospitalist Program

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

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

Partners In Health and BWH Hospitalist Program

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

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

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

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

Qualifications:

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

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

Information/Opportunities

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

MD Fellowship Flyer V5

Financial Planning Webinar for New Physicians – CST

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

 

 

Upcoming Dates and Events

November 27, 2014 – Turkey Bowl

December 13, 2014 – DoM Holiday Party

Useful links

Internal Medicine Residency News, November 3, 2014

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

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

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

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

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

Have a great week!

Aimee

What Did I Read This Week?

Submitted by: Aaron Mitchell, MD

Aaron Mitchell, MD

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

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

Why did I read this:

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

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

Background:

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

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

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

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

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

Results:

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

 

Conclusions:

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

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

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

 

From the Chief Residents Grand Rounds

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

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

 

Pin Station Re-located

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

 

Open Enrollment for Benefits Begins 10/27/14!

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

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

Housestaff Healthcare, Dental and Vision Premiums 2015

Open Enrollment Information

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

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

Qualifying events include, but are not limited to:

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

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

Thanks for Another Amazing Doctoberfest!

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

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

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

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

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

Trent Center Colloquium Series

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

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

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

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

 

Ebola Virus Updates in MedHub

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

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

Partners In Health and BWH Hospitalist Program

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

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

Partners In Health and BWH Hospitalist Program

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

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

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

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

Qualifications:

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

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

Information/Opportunities

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

Career Fair-Chapel Hill

Financial Planning Webinar for New Physicians – CST

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

 

Upcoming Dates and Events

November 27, 2014 – Turkey Bowl

December 13, 2014 – DoM Holiday Party

Useful links

Internal Medicine Residency News, October 27, 2014

Mon, 10/27/2014 - 10:32

 

From the Director

Hi everyone!

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

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

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

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

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

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

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

 

Have a great week!

Aimee

What Did I Read This Week?

Submitted by: Saumil Chudgar, MD

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

Legionella Score in CAP

WHAT I READ THIS WEEK

 

What I read:

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

Legionella Score in CAP

Why did I read this?

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

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

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

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

Clinic Corner

Clinic Corner

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

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

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

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

 

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

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

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

 

 

 

 

 

 

*p-value <0.05

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

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

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

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

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

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

METHODS:

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

 

 

From the Chief Residents Grand Rounds

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

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

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

 

Open Enrollment for Benefits Begins 10/27/14!

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

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

Housestaff Healthcare, Dental and Vision Premiums 2015

Open Enrollment Information

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

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

Qualifying events include, but are not limited to:

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

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

 

New Badge-Backers Required by GME

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

 

CLER Visit Information

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

 

Doctoberfest is Coming to an End!

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

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

Fun Lunch Day -Taco Tuesday

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

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

 

Flu Vaccination Update

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

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

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

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

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

 

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

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

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

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

 

 

Trent Center Colloquium Series

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

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

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

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

 

Information/Opportunities

Career Fair-Chapel Hill

Biomedical Informatics Research Training Opportunity

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

 

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

November 27, 2014 – Turkey Bowl

Useful links

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

Tue, 10/21/2014 - 13:39

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

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

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

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

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

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

Internal Medicine Residency News, October 20, 2014

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

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

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

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

 

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

Date: Saturday, November 15, 2014

Time:8:15 am – 6:00 pm

Location:Duke University, the Fuqua School of Business

Register:Please visit the conference website

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

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

Have a great week

Aimee

What Did I Read This Week?

Submitted by: Sharon Rubin, MD

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

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

What I Read This Week:

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

Why the change in recommendation?

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

Sequential administration and recommended intervals

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

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

For review ACIP recommendations for PCV13

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

For review ACIP recommendations for PPSV23

Pneumovax

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

 

Clinic Corner

Will return next week…stay tuned!!

QI Corner

Aaron Mitchell, MD

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

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

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

Aaron P. Mitchell

Chief Resident for Quality and Patient Safety

Durham VA Medical Center

From the Chief Residents Grand Rounds

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

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

 

Kudos from Dr. Rivelli for the MedPsych Team!

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

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

New Badge-Backers Required by GME

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

CLER Visit Information

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

Doctoberfest is Going Strong!

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

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

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

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

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

October 21 is “Taco Tuesday!”

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

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

Flu Vaccination Update

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

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

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

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

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

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

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

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

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

 

Trent Center Colloquium Series

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

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

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

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

Open Enrollemnt for Benefits Begins 10/27/14!

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

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

Housestaff Healthcare, Dental and Vision Premiums 2015

Open Enrollment Information

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

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

Qualifying events include, but are not limited to:

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

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

 

Movember is Coming!

Colleagues and Friends,

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

 

Information/Opportunities

Biomedical Informatics Research Training Opportunity

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

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

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

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

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

http://www.summitsps.com/

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

November 27, 2014 – Turkey Bowl

Useful links

Internal Medicine Residency News, October 13, 2014

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

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

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

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

Grand rounds attendance:

Pascale Khairallah and David Kopin– 8 each

Marc Samsky– 7

Michael Woodworth– 5

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

Michael Dorry—42!!!! WOW!

Amy Jones—21

Carli Lehr—25

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

What Did I Read This Week?

Submitted by: Aimee Zaas, MD

Clinical Management of Staphylococcus aureus Bacteremia

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

What I Read This Week:

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

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

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

What Did They Find?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinic Corner

Remember to wear pink this month for Breast Cancer awareness!

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

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

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

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

Have a great weekend and see you next week!

Sincerely

Sharon

QI Corner

Aaron Mitchell, MD

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

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

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

From the Chief Residents Grand Rounds

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

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

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

Doctoberfest is off to a great start!

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

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

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

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

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

October 15 A special German beer garden-style treat!

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

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

Flu Vaccination Update

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

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

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

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

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

The VA PRIME Clinic 20th Anniversary Celebration

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

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

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

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

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

 

Women In Medicine Event

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

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

Great Hall, Trent Semans Center for Health Education

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

ETHOS for Noon Conference Attendance Tracking!

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

 

Information/Opportunities

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

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

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

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

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

http://www.summitsps.com/

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

November 27, 2014 – Turkey Bowl

Useful links