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News from the Duke Department of Medicine
Updated: 14 min 29 sec ago

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

Tue, 10/21/2014 - 13:39

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

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

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

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

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

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

Internal Medicine Residency News, October 20, 2014

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

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

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

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

 

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

Date: Saturday, November 15, 2014

Time:8:15 am – 6:00 pm

Location:Duke University, the Fuqua School of Business

Register:Please visit the conference website

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

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

Have a great week

Aimee

What Did I Read This Week?

Submitted by: Sharon Rubin, MD

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

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

What I Read This Week:

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

Why the change in recommendation?

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

Sequential administration and recommended intervals

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

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

For review ACIP recommendations for PCV13

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

For review ACIP recommendations for PPSV23

Pneumovax

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

 

Clinic Corner

Will return next week…stay tuned!!

QI Corner

Aaron Mitchell, MD

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

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

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

Aaron P. Mitchell

Chief Resident for Quality and Patient Safety

Durham VA Medical Center

From the Chief Residents Grand Rounds

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

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

 

Kudos from Dr. Rivelli for the MedPsych Team!

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

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

New Badge-Backers Required by GME

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

CLER Visit Information

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

Doctoberfest is Going Strong!

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

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

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

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

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

October 21 is “Taco Tuesday!”

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

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

Flu Vaccination Update

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

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

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

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

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

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

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

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

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

 

Trent Center Colloquium Series

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

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

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

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

Open Enrollemnt for Benefits Begins 10/27/14!

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

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

Housestaff Healthcare, Dental and Vision Premiums 2015

Open Enrollment Information

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

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

Qualifying events include, but are not limited to:

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

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

 

Movember is Coming!

Colleagues and Friends,

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

 

Information/Opportunities

Biomedical Informatics Research Training Opportunity

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

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

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

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

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

http://www.summitsps.com/

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

November 27, 2014 – Turkey Bowl

Useful links

Internal Medicine Residency News, October 13, 2014

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

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

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

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

Grand rounds attendance:

Pascale Khairallah and David Kopin– 8 each

Marc Samsky– 7

Michael Woodworth– 5

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

Michael Dorry—42!!!! WOW!

Amy Jones—21

Carli Lehr—25

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

What Did I Read This Week?

Submitted by: Aimee Zaas, MD

Clinical Management of Staphylococcus aureus Bacteremia

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

What I Read This Week:

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

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

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

What Did They Find?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinic Corner

Remember to wear pink this month for Breast Cancer awareness!

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

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

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

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

Have a great weekend and see you next week!

Sincerely

Sharon

QI Corner

Aaron Mitchell, MD

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

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

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

From the Chief Residents Grand Rounds

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

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

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

Doctoberfest is off to a great start!

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

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

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

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

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

October 15 A special German beer garden-style treat!

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

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

Flu Vaccination Update

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

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

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

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

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

The VA PRIME Clinic 20th Anniversary Celebration

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

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

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

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

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

 

Women In Medicine Event

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

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

Great Hall, Trent Semans Center for Health Education

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

ETHOS for Noon Conference Attendance Tracking!

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

 

Information/Opportunities

Des Moines IM Opportunities

STL_NocturnistFlyer

STL__GenInternalMedicineFlyer

Internal Medicine opportunities

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

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

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

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

http://www.summitsps.com/

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

November 27, 2014 – Turkey Bowl

Useful links

Internal Medicine Residency News, October 6, 2014

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

Hello everyone!

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

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

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

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

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

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

Have a great week!

Aimee

What Did I Read This Week?

Submitted by: Murat Arcasoy, MD

Rethinking the Social History

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

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

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

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

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

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

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

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

 

Clinic Corner

Hello Team DOC!

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

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

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

See you back at the goose farm,

Dani

 

QI Corner

Aaron Mitchell, MD

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

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

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

 

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

 

From the Chief Residents Grand Rounds

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

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

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

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

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

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

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

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

October 22 A special German beer garden-style treat!

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

Flu Vaccination Update

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

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

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

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

 

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

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

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

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

 

Women In Medicine Event

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

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

Great Hall, Trent Semans Center for Health Education

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

 

Medical Education Grand Rounds Session

Healthcare Simulation: Past, Present & Future

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

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

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

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

Session Objectives: 

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

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

ETHOS for Noon Conference Attendance Tracking!

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

 

Provider List for Housestaff

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

 

Information/Opportunities

CJW – Hospitalist (9-26-2014)

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

http://www.merritthawkins.com/

www.mountainmedsearch.com

www.nhpartners.com

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

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

http://www.summitsps.com/

 

Upcoming Dates and Events

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

Useful links

Internal Medicine Residency News, September 29, 2014

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

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

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

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

 

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

Have a great week and HAPPY DOCTOBERFEST!

Aimee

What Did I Read This Week?

Submitted by: Alex Cho, MD, MBA

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

Background:

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

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

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

Purpose:

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

Methods:

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

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

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

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

Blinding – Blinded

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

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

Validity

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

Results

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

Comments

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

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

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

Clinic Corner

Ambulatory Clinic Corner

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

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

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

 

From the Chief Residents Grand Rounds

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

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

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

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

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

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

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

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

October 22 A special German beer garden-style treat!

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

Flu Vaccination Update

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

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

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

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

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

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

Martin – 93.3%

Warren – 94.6%

Orgain – 90.9%

Kerby – 100%

Kempner – 88.6%

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

 

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

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

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

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

 

Women In Medicine Event

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

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

Great Hall, Trent Semans Center for Health Education

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

 

Now Accepting Applications for Global Health Elective Rotations

 

 

 

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

Accepting Applications for Global Health Elective Rotations

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

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

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

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

The Basics

18 month extended residency encompassing:

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

The Benefits

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

Year, trainees benefit from:

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

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

ETHOS for Noon Conference Attendance Tracking!

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

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

How to register with Ethos

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

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

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

To add your Duke Unique ID to your account

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

 

Information/Opportunities

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

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

Duke Headache Specialist

http://www.summitsps.com/

 

Upcoming Dates and Events

October 1 – DOCTOBERFEST begins!

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

Useful links

 

Internal Medicine Residency News, September 22, 2014

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

Hope you are having a great weekend!

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

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

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

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

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

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

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

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

Have a great week!

Aimee

What Did I Read This Week?

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

Clinic Corner

VA PRIME Clinic Corner

 Hi everyone,

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

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

Dr. Brown

On every appointment

You are great and I noticed!!!

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

 

Dr. Boutte

On 07/07/2014

You are great and I noticed!!!

Prime visit, great service

 

Everyone

On 07/09/2014

You are great and I noticed!!!

Always have had excellent care with respect

 

Dr. Titerence

On 07/09/2014

You are great and I noticed!!!

Excellent attitude, very caring (Great Person)

 

Doctor Broderick

On 07/09/2014

You are great and I noticed!!!

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

 

Dr. Foster

On 07/21/2014

You are great and I noticed!!!

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

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

PRIME staff

QI Corner

Aaron Mitchell, MD

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

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

 

From the Chief Residents Grand Rounds

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

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

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

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

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

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

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

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

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

Martin – 63.3%

Warren – 43.2%

Orgain – 36.4%

Kerby – 36.4%

Kempner – 14.3%

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

 

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

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

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

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

 

Women In Medicine Event

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

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

Great Hall, Trent Semans Center for Health Education

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

 

 

The Residency Office is now Green Certified!

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

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

 

 

Now Accepting Applications for Global Health Elective Rotations

 

 

 

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

Accepting Applications for Global Health Elective Rotations

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

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

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

ETHOS for Noon Conference Attendance Tracking!

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

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

How to register with Ethos

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

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

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

To add your Duke Unique ID to your account

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

 

 

 

Information/Opportunities

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

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

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

Duke Headache Specialist

http://www.summitsps.com/

 

Upcoming Dates and Events

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

October 1 – DOCTOBERFEST begins!

October 27, 2014 – Recruitment Kick-Off Event

December 13, 2014 – DoM Holiday Party

Useful links

Internal Medicine Residency News, September 15, 2014

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

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

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

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

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

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

Have a great week

Aimee

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

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

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

Aaron Mitchell, MD

Why did I read this:

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

Background:

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

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

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

Results:

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

Just how large were the price differences?

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

Conclusions:

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

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

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

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

Clinic Corner

PICKETT Clinic Corner, 2014 September

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

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

Good luck on your in-training exams!

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

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

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

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

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

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


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

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

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

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

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

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

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

Sincerely,

Sharon Rubin, MD, FACP

QI Corner

Aaron Mitchell, MD

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

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

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

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

SRS reports by trainees in July:          23

SRS reports by trainees in August:     45

Total remaining needed for goal:        1,904

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

From the Chief Residents Grand Rounds

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

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

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

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

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

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

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

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

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

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

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

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

 

Women In Medicine Event

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

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

Great Hall, Trent Semans Center for Health Education

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

 

Maestro Care Update

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

Provider Education

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

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

Call for AbstractsClinical Science DayDeadline Extended to September 22nd

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

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

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

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

New System for Requesting Interpreters

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

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

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

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

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

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

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

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

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

International Patient Services

919-681-3007 or 919-668-2431

Nouria Belmouloud

Pager: 919-970-0387

 

ETHOS for Noon Conference Attendance Tracking!

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

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

How to register with Ethos

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

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

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

To add your Duke Unique ID to your account

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

 

Now Accepting Applications for Global Health Elective Rotations

 

 

 

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

Accepting Applications for Global Health Elective Rotations

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

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

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

 

ITEs Are in Full Swing!

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

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

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

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

 

Information/Opportunities

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

Duke Headache Specialist

Practice Link Career Fair – 9/23/14

 

Upcoming Dates and Events

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

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

October 27, 2014 – Recruitment Kick-Off Event

Useful links

Internal Medicine Residency News, September 8, 2014

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

It’s great to see the start of Turkey Bowl practices! And a 2-0 start for Duke football. Happy fall! Get ready for Doctoberfest coming up….details to follow. The ITE seems to be going well – thanks to everyone for being on time,and for covering your colleagues while they are testing. Kudos this week to our past two weeks of awesome SAR talks by Brice Lefler, Claire Kappa, Rachel Titerance, Fola Babatunde, Tony Lozano, Ben Lloyd and Chris Merrick.

Also kudos to our Med Res office for achieving Green Certification from Duke University!! We have met the many criteria to receive this designation – awesome job! Now keep recycling – there is a box for pager batteries in the office as well as a place for any plastic bottles in the med res library or outside the 8th floor elevators.

GET INVOLVED! Are you interested in helping with our curriculum project? Let me, Bill Hargett or Murat Arcasoy know. How about QI and patient safety? Let Lish Clark or Aaron Mitchell know. What about resident research and stats support? Talk to Murat Arcasoy! Community service? Talk to your Stead Leader or to Erin Payne and me.Looking forward to dinner with JARs this week.

Nick Rohrhoff has invited the SARs to the Zaas rental house for a SAR night, so stay tuned. It’s almost in acceptable shape for guests and I think it will feel more like home once you join us on the (not as cool as the last one) back porch.

Congratulations to Paul and Katherine St Romain on the birth of Elizabeth Ann, arriving Sept 6 at 1:51 am! Everyone is doing well.

This weeks pubmed from the program to Amit Bhaskar for his upcoming American College of Gastroenterology abstract with mentor Ziad Gellad…Title: Physician-Directed Bolus Sedation for Colonoscopy Improves Endoscopy Unit Efficiency Authors: Amit Bhaskar, MD, Ziad Gellad, MD, MPH, Duke University Medical Center, Durham, NC

Have a great week

Aimee

What Did I Read This Week? submitted by: Suzanne Woods , MD

Screening for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-analysis for the U.S. Preventive Service Task Force

Annals of Internal Medicine. 2014;161:336-346.

Author: Jonas et al.

Why did I read this article: On gen med I have been doing a lot of reading this week….notes, notes and more notes. Admission notes, daily progress notes and discharge summaries! But thanks to the efforts of Katrina Abril and Adam Barnett for getting these finished so expeditiously and thoroughly on a Saturday, I had time to look at the mail this week and this article caught my eye.

Background information:

Stoke is a leading cause of death and disability and affects an estimated 7% of US adults. Ischemic strokes are responsible for 90% of all strokes with carotid artery stenosis (CAS) causing ~10% of ischemic strokes in our country. Several studies have tried to estimate the rate of progression of asymptomatic CAS and predict subsequent neurologic events. The best available data revealed a 5-year risk for ipsilateral stroke of 5% for CAS of >70%. The goal of this review was to 1. evaluate the current evidence on whether screening asymptomatic adults for CAS reduces the risk for ipsilateral stroke

  1. evaluate harms associated with screening and interventions for CAS
  2. evaluate evidence on the incremental benefit of medical therapy and on risk-stratification tools

Methods:

Identified and reviewed articles using analytic framework. Included studies of Asx adults with CAS, RCT’s of screening for CAS, RCT’s and systematic reviews of treatment ineffectiveness, multi-institution trials or cohort studies that reported harms, and studies that attempted to externally validate risk-stratification tools.

Results and Discussion:

The results came from 78 published articles that reported on 56 studies.

  1. No eligible studies provided evidence on whether screening reduced ipsilateral stroke.
  2. Duplex ultrasonography is widely available and non-invasive but reliability is questionable due to differences in accuracy and this can result in many false positive test results. If acted upon, this can result in many unnecessary confirmatory tests (angiography or MRA).
  3. Hard to obtain an accurate estimate of potential benefits for the primary care population. CEA c/w medical therapy in their review showed reduction in perioperative stroke or death or any subsequent stroke. Challenge: medical therapy is not all standardized but should include the use of statins, antihypertensives, glycemic control for DM patients and use of antiplatelet drugs for vascular disease and risk reduction. Also the trials used highly selected surgeons with low complication rates.
  4. The benefits of surgery depend on the risk of the Asx lesion eventually resulting in stroke and that risk appears to be decreasing in the last few decades.
  5. Medical interventions have been determined to be 3-8x more cost-effective.
  6. No externally validated, reliable risk-stratification tools are available that can distinguish between patients with Asx CAS who are at increased or decreased risk for stroke caused by CAS despite current medical therapy vs those patients who have increased or decreased risk for harm with surgery.
  7. May be lack of underreporting of harms postoperatively such as nonfatal MI, cranial nerve damage, PE, infections etc or even psychological harm. Most commonly on harms including stroke or death were noted.
  8. Need to look at life expectancy and timing of events. Potential for surgical benefit decreases with advancing age.

This review was accompanied by the Clinical Guideline and US Preventive Services Task Force Recommendation Statement (pgs 356 – 362) . This was an update to the 2007 recommendation on screening for CAS and concludes with the reaffirmation of its previous statement against screening for ASx CAS in the general adult population (D recommendation).

And the editorial was written by Dr. Larry Goldstein of our own Neurology department! Check out pages 370-371 for his thoughts.

Clinic Corner

DOC Clinic Corner, 2014 September

Hello Team DOC!

Last year, we implemented several key changes at the DOC as part of our overall DOC redesign effort, lead by Alex Cho. The changes included establishing Natasha Cunningham as our Med-Psych medical director and launching the HomeBase program for our Medicaid patients who over-utilize the ED, Marigny Manson became the HomeBase case manager, Julia Gamble became our NP practitioner who can create better bridges in patients’ clinical care, and the Stead or Firm groupings began,s led by Lynn Bowlby, Dani Zipkin, and Larry Greenblatt.

Recently, Drs. Cho, Bowlby, Cunningham, Brandie Johnson and Gina Green presented to Dr. Klotman, Dr. Sowers, Dr. Zaas, and Chris Samples on our progress. Please see the slide deck attached for details!

The September DOC Newsletter is attached here! Please read!

And now, last but definitely not least…

 Maestro Rules: We are expected to close encounters in 24 HOURS!! That means, please finish your notes and route to your attending by the end of the clinic day so that we can close the encounters.

Thanks!

Dani

From the Chief Residents Grand Rounds

Fri., Sept.12, 2014: Dr. David D’Alessio, Endocrine

Noon Conference Date Topic Lecturer Time Vendor 9/8/14 SAR Emergency Series: Pneumonia/Debriefing Borderick-Forsgren 12:15 Picnic basket 9/9/14 SAR Emergency Series: DVT/PE John Wagener 12:15 Domino’s 9/10/14 Antibiotic Stewardship Clinical Pharnacist 12:15 China King 9/11/14 SAR Emergency Series: ABG Interpretation  Laura Musselwhite  12:15 Sushi  9/12/14  No conference- lunch only  Mediterra     From the Residency Office

 

ITEs Are in Full Swing!

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

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

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

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

ETHOS for Noon Conference Attendance Tracking!

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

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

How to register with Ethos

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

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

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

To add your Duke Unique ID to your account

  • Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
  • Enter your username and password. Click My Account in the upper right corner.
  • Under My Profile, click Edit
  • Scroll down until you see Duke Unique ID filed.  make sure it is correct
  • Save the changes to you My Profile page
Flu Vaccination Season 2014

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

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

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

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

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

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

 

Now Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016.

Application is open to residents from the Departments of Medicine and Pediatrics: Internal Medicine (PGY 2); Med-Peds (PGY 3); Med-Psych (PGY 4); Pediatrics (PGY 2).

The application is attached and available at http://dukeglobalhealth.org or submit online http://bit.do/HYC-submit.

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

Interviews will be held in October. For more information about this opportunity, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.

Application Deadline: September 30, 2014

Information/Opportunities

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

Carolinas HealthCare System Internal Medicine Opportunities 8-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

www.mercydesmoines.org

 

Upcoming Dates and Events

September 2 – 18: Internal Medicine In-Service Training Exams Testing Window

 

Useful links

Internal Medicine Residency News, September 2, 2014

Tue, 09/02/2014 - 08:51
From the Director

Hello! Happy September! I hope everyone had a chance to enjoy some part of the long weekend.  We had a number of fun events this week, starting with the attendings beating the residents at Stead Trivia Night at Bull McCabe’s.  Thanks Steve Crowley and the Warren Society for planning, and to the many attendings and residents who showed up! A number of our residents were able to meet with the newly appointed Secretary of Veteran’s Affairs, Robert McDonald – thanks to Ashley Bock, Aparna Swaminathan, Nick Rohrhoff, Chris Hostler, Coral Giovacchini, Tim Mercer, Katie Broderick and our Psychiatry colleague Nora Dennis for spending time discussing GME with our special guest.  Attendance at Grand Rounds was outstanding, and I hope you all had a chance to hear his inspirational talk.  Ragnar Palsson followed the outstanding grand rounds with a fantastic chair’s conference, proving once again that all that causes active urine sediments and renal failure is not Wegener’s.  Brice Lefler, Sneha Vakamudi, and Tim Mercer helped lead us along to (close) to the diagnosis.  Hopefully many of you also saw Dr G as the honorary Duke football coach this weekend as well!

Kudos also this week to Rajiv Agarwal from fellow night float resident Alan Erdmann for a great diagnosis and patient care, and to Alan Erdmann from Lish Clark for outstanding notes on night float! Additional big thanks to our outgoing ACRs Aparna Swaminathan, Tim Mercer (with a Med Res News hat-trick this week!) and Alyson McGhan for being PHENOMENAL ACR’s! Aparna helped revolutionize DRH AM report, Tim worked to improve our notes at the VA, and Alyson kept busy helping figure out the admission patterns on gen med so that we can optimize daytime admissions for the teams.  We look forward to having Kevin Trulock, Adam Banks and Claire Kappa at the helm!  Also kudos to the MICU Crew — Jonathan Buggey, Jonathan Hansen, Jason Zhu, Adva Eisenberg, Amy Lee and Myles Nickolich from MICU fellow Talal Dahhan for outstanding work.

Congratulations to Lauren Ring, Jenny Van Kirk, Jon Musgrove and Azalea Kim who were elected by their peers to the Residency Council.  Looking forward to working with you all.  Also congrats to Adrienne Belasco and Mitch Klement on their wedding this weekend!

This week kicks off our In Training Exams! Be on time, be relaxed, and for the first time, you can forget to bring a #2 pencil.  Welcome to the new age…tests are on campus in the computer labs.  Thanks to Jen Averitt, Lauren Dincher, Erin Payne and Lynsey Michnowicz for proctoring.  We also had the opportunity to turn in our “APEI” (that’s GME talk for Annual Program Evaluation and Improvement Plan) to Dr. Kuhn and her team this week.  This is an annual document that we prepare for the GME leadership that describes our educational efforts for the past year and what we would like to do next year.  We will post our progress and plans for you to view on Medhub – this year we are working on our EDUCATIONAL ENVIRONMENT (more on our “Back to Basics” curriculum overhaul soon), our AMBULATORY TRAINING (thanks Dani, Alex, et al for your work on the curriculum, noon conferences, and improved scheduling continuity) and our TRANSPARENCY (let us know other ways to reach you with program details in addition to the Med Res News, before conference, and in conversation).

This week’s first Pubmed from the Program goes to Adva Eisenberg for her upcoming presentation at the Southern Hospital Medicine Conference in Atlanta…“Fool Me Twice: A Case of Recurrent Bacterial Meningitis due to a Spontaneous CSF Leak” Adva Eisenberg, MD1, J Bradford Bertumen, MD2, and Gary Cox, MD2

Second Pubmed: Ryan Nipp, Aaron Mitchell, Allyson Pishko, and Ara Metjian. “Waldenstrom Macroglobulinemia in Hepatitis C: Case Report and Review of the Current Literature,” Case Reports in Oncological Medicine, vol. 2014, Article ID 165670, 2014.
http://www.hindawi.com/journals/crionm/2014/165670/

Have a great week!

Aimee

What Did I Read This Week? submitted by: Coral Giovacchini , MD

Reference:Rubin, LG and Schaffner, W. Care of the Asplenic Patient. N Engl J Med 2014; 371: 349-356.

Over the past few weeks, the care of asplenic patients has come up several times in sign outs, VA case conferences, and even alluded to during our recent SAR Emergency Lecture series and a Chair’s Conference Case this past month. This clinical practice review was recently published in the NEJM and is a nice summary of the clinical conundrum, treatment guidelines and management considerations in such patients.

Clinical Problem

Current estimates suggest that there are approximately 1 million total asplenic patients treated currently in the United States. In the article, the authors urge readers to consider the fact that the asplenic population is quite heterogeneous, including not only the typically thought of surgically asplenic patient, but also those with functional asplenic/hyposplenia seen in conference with diseases that we often treat at DUMC/DVAMC including sickle cell anemia, congenital heart disease (i.e. Ivemark Syndrome), untreated HIV, severe celiac disease, and even chronic GvHD. One of the main concerns in caring for these patients is the risk of “post-splenectomy sepsis”, which can carry up to a 50% mortality risk for all-comers, though generally is more fatal is surgically asplenic patients, and has been found to be an independent risk factor for hospitalization for pneumonia or meningitis in military veterans. The pathophysiology behind increased risk of sepsis includes impaired clearance of IgG-coated encapsulated bacteria from the blood stream (remember these are not opsonized as well!) and an overall decreased humoral immunity with lower levels of serum IgM antibodies as well as a lower number of memory B cells to produce IgM.

The pathogen classically associated with post-splenectomy sepsis is S. pneumoniae; however other organisms to be considered include H. influenzae b, N. meningitidis, Capnocytophagia canimorsis (after a dog bite), Bebasia (after a tick bite), and Bordatella holmesii. Despite the classical teaching, the most common organisms isolated from adults with bacteremia and underlying functional asplenia from sickle cell disease continue to include gram negative bacilli and S. aureus, often associated with indwelling catheter use.

Clincal Strategies

There are many areas of uncertainty that remain in the clinical treatment of asplenic patients, including the role of vaccination boosters, the role of prophylactic antibiotics, appropriate empiric antimicrobial treatment strategies and the role of screening for functional asplenia in associated diseases. The most important strategies in our clinical armatorium remain prevention, education, and the early and appropriate treatment of the signs of infection.

In 2000, the heptavalent pneumoncoccal conjugate vaccine (PCV7) was introduced, and has markedly reduced the incidence of invasive pneumococcal disease not only among children, but also within the entire US population, presumably via a herd immunity theory. Following this, the triskaidecavalent (PCV13, or Prevnar13) was introduced in 2010 with further reductions in pneumococcal disease in this patient population. Current recommendations for this population are to give PCV13, followed by PPSV23 8 weeks later (this is slightly different after surgical splenectomy, with a recommendation to wait at least 2 weeks after the operation prior to administering PPSV23; CDC.gov has a very comprehensive table on timing of these immunizations). All patients in this population are recommended to get a PPSV23 booster at a sequential 5 year interval. Other immunizations that are recommended including the Hib vaccine for those who were not immunized in childhood, the quadrivalent meningococcal conjugate vaccine (MenACWY), as well as an annual influenza vaccine.

With regards to antimicrobial prophylaxis, although this is recommended for all asplenic children <5 years old, this is not necessarily true for adults, and various organizations have published differing guidelines with suggestions ranging from no need for prophylaxis to a call for lifelong penicillin prophylaxis in all persons with surgical asplenia. Though there is not a clear consensus, adults in whom prophylaxis is generally recommended include any patient who has previously survived an episode of post-splenectomy sepsis, or any surgically or functionally asplenic adult who suffers a dog bite (given the risk of C. canimorsus).

Once a patient with known asplenia presents with a fever or other localizing signs of infection, prompt initiation of appropriate antimicrobial therapy is warranted (recommendations range from outpatient oral penicillin based regimen to IV 3rd generation or higher cephalosporins- most commonly ceftriaxone) with a goal of covering the above-mentioned organisms. Consideration can be given to adding vancomycin for additional MRSA coverage in the appropriate patient populations (i.e. your patients with indwelling lines, frequent healthcare access, etc), or if CNS disease/infectious meningitis is a concern. Interestingly, because of the high risk of progression to fulminant sepsis, many outpatient care providers have taken the strategy of providing a standing empiric antibiotic prescription for these patients to have available at the first sign of fever or infection.

 

Summary

  • Remember that “asplenia” can take several forms, including congenital, surgical and functional (i.e. our sickle cell patients!)
  • The clinical presentation of asplenic sepsis can be profound and carries up to a 50% mortality risk
  • Asplenic patients should be educated that any illness with fever or other localizing signs of infection needs prompt medical attention, and likely should receive prompt initiation of antimicrobial therapy (possibly even self-initiated in the outpatient setting)
  • Always be sure to cover encapsulated organisms in patients presenting with asplenic sepsis, with special attention to other environmental risk factors (i.e. dog bites)
  • All asplenic patients are recommended to have vaccinations against pneumococci, H. influenzae b, meningococci, as well as an annual influenza vaccine
  • Strongly consider lifelong prophylactic antimicrobial therapy in any adult having already survived an episode of asplenic sepsis with a typical organism
QI Corner

Aaron Mitchell, MD

Just a reminder to everyone: our next Morbidity and Mortality noon conference will be coming up on Wednesday, September 17. We are going to change the format this time, and present cases of procedure-related mishaps. But – we need the cases to come from you!

Have you ever hurt yourself or had a preventable blood exposure during a procedure? Caused a patient unnecessary discomfort by making an easy mistake? Had a bad complication you would like to share? Let us know! You do not have to present if you would feel uncomfortable, and the case can remain annonymous if you would like.

– Aaron and Lish

From the Chief Residents Grand Rounds

Fri., Sept.5, 2014: Dr. Richard Reidel, Oncology

Noon Conference Date Topic Lecturer Time Vendor 9/2/14 SAR Emergency Series: Pneumonia/Debriefing Titerence/Galanos 12:15 Dominos 9/3/14 SAR Emergency Series: Common HIV Management Questions Brice Lefler 12:15 Cosmic Cantina 9/4/14 SAR Emergency Series: Endocrine Emergencies Claire Kappa 12:15 Subway 9/5/14 ITEs – No Conference Chick-Fil-A     From the Residency Office

 

ITEs Start This Week!

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

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

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

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

ETHOS for Noon Conference Attendance Tracking!

After much work with the wonderful folks in the ETHOS offices, as of September 2, 2014 we will be able to track Internal Medicine Noon Conference attendance using the ETHOS system.  From September 2-5, we will continue to use the old badge swipe system in addition to ETHOS so everybody can get used to the process, but as of 9/8/14 we will ONLY use ETHOS for tracking attendance.  Most of you should already have an ETHOS account which you use for tracking your attendance at Grand Rounds, but EVERYONE should read the following instructions carefully, as it applies to new and current account holders.  you MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!

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

How to register with Ethos

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

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

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

To add your Duke Unique ID to your account

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

In an effort to further our “Go Green” initiative, we are now recycling batteries! We have a dead batteries collection box in the Med Res office (Duke North, Room 8254) so please feel free to bring in your dead batteries and we are happy to recycle them for you.  For more information click here.

Flu Vaccination Season 2014

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

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

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

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

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

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

 

Now Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016.

Application is open to residents from the Departments of Medicine and Pediatrics: Internal Medicine (PGY 2); Med-Peds (PGY 3); Med-Psych (PGY 4); Pediatrics (PGY 2).

The application is attached and available at http://dukeglobalhealth.org or submit online http://bit.do/HYC-submit.

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

Interviews will be held in October. For more information about this opportunity, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.

Application Deadline: September 30, 2014

What is the GME Incentive Program?

The GME Incentive program was started July 2012 as a collaboration between hospital, GME, and Internal Medicine program leadership in order to:

  • Engage trainees in hospital-based quality improvement
  • Provide exposure to models of pay for performance
  • Educate trainees in quality improvement
  • Provide a focus for ACGME program requirements and CLER visits

Each year, residents and hospital leadership select 3-4 measures at the hospital level. These typically mirror the priorities of the overall health system, with the targets for each specific measure based on prior performance data and also aligned with hospital targets (top quartile performance meets and top decile performance exceeds target).

For each target met, trainees are paid $200, for a maximum payout of $600.

Who is eligible?

All GME ACGME or ICGME trainees who have worked for at least 3 months leading up to June 2015.

What are the measures for this year (2014-2015)?

This year, with resident and leadership input, the following 4 measures have been selected:

  1. HCAHPS Patient Experience Measurement
  2. 30-day same hospital readmissions
  3. Emergency Department Median Consult Time (NEW)
  4. RL-6 Safety Event Reporting (NEW)

What is the reasoning behind these measures? What are the targets?

  1. HCAHPS: As all hospital systems continue to improve, the standards for patient satisfaction will continue to rise as well.
    Target: Meet the National Median of 87.5% (7 out of 8 dimensions).
  2. 30-day hospital readmissions: Trainees will have an additional opportunity to demonstrate improvement.
    Target: 13.05% (median of comparable health care systems on the UHC US News Honor Roll).
  3. Emergency Department Median Consult Time: Extended consult times in the ED contribute to increased Left Without Being Seen rate and decreased patient satisfaction and care.
    Target: Overall decrease in consult time by 10%.
  4. Safety Event Reporting in RL Solutions: Increasing trainee input and awareness for adverse outcomes or near-misses. Trainees only submitted 0.5 (74) of overall reports last year.
    Target: Increase trainee submitted reports for an average of 2 submissions per trainee.

What were our measures last year (2013-2014)?

Last year, we had 3 program measures encompassing the domains of patient satisfaction and quality and patient safety:

  1. HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) surveys: publicly reported data from patient surveys on hospital performance
  2. Duke Hospital 30-day hospital readmission rate
  3. Influenza vaccinations

Additionally, several programs chose program-specific measures:

  • Hand Hygiene: Internal Medicine, Pediatrics, General Surgery, Anesthesia, Neurology, Orthopedics
  • Left Without Being Seen Rate: Emergency Medicine
  • OB Trauma: Vaginal with Instrument: OB/GYN

How was our performance last year?

  1. HCAHPS: Target of 87.5% met
  2. 30-day hospital readmissions: data unavailable through much of the year
  3. Influenza vaccinations: data unavailable through much of the year
  4. Program specific measures: Pediatrics met their target with hand washing.

Trainees received the full pay-out of $600.

How will we be updated on our progress?

Performance Services will create monthly reports with up-to-date performance metrics that will be distributed to trainees and program directors.

Program representatives are also willing to present the program structure to your trainees; contact information is below.

What can we do with this information?

You can work with your program or peers to create a QI project or initiative to specifically address improving upon these measures.

How can I get involved?

To get involved or for more information, please contact one of the program co-chairs: Anjni Patel (anjni.patel@dm.duke.edu) or Sarah Dotson (sarah.dotson@dm.duke.edu).

Attachments:

 

Information/Opportunities

Carolinas HealthCare System Internal Medicine Opportunities 8-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

www.mercydesmoines.org

 

Upcoming Dates and Events

September 2 – 18: Internal Medicine In-Service Training Exams Testing Window

 

Useful links

Internal Medicine Residency News – August 25, 2014

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

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

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

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

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

 

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

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

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

Have a great week

Aimee

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

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

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

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

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

What are stool tests are available for CRC screening?

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

So What Is Cologuard?

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

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

How does it compare?

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

In the clinic:

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

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

Clinic Corner

Want to know what’s on The Test?

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

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

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

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

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

Alex Cho, MD

From the Chief Residents Grand Rounds

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

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

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

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

 

ETHOS for Noon Conference Attendance Tracking!

After much work with the wonderful folks in the ETHOS offices, as of September 2, 2014 we will be able to track Internal Medicine Noon Conference attendance using the ETHOS system.  From September 2-5, we will continue to use the old badge swipe system in addition to ETHOS so everybody can get used to the process, but as of 9/8/14 we will ONLY use ETHOS for tracking attendance.  Most of you should already have an ETHOS account which you use for tracking your attendance at Grand Rounds, but EVERYONE should read the following instructions carefully, as it applies to new and current account holders.  you MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!

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

How to register with Ethos

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

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

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

To add your Duke Unique ID to your account

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

 

Mini CEXs Assigned to Gen Med Attendings

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

 

Recycle Your Old Batteries

In an effort to further our “Go Green” initiative, we are now recycling batteries! We have a dead batteries collection box in the Med Res office (Duke North, Room 8254) so please feel free to bring in your dead batteries and we are happy to recycle them for you.

 

Stead Resident Research Grants- Request for Proposals

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

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

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

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

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

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

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

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

Flu Vaccination Season 2014

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

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

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

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

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

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

What is the GME Incentive Program?

The GME Incentive program was started July 2012 as a collaboration between hospital, GME, and Internal Medicine program leadership in order to:

  • Engage trainees in hospital-based quality improvement
  • Provide exposure to models of pay for performance
  • Educate trainees in quality improvement
  • Provide a focus for ACGME program requirements and CLER visits

Each year, residents and hospital leadership select 3-4 measures at the hospital level. These typically mirror the priorities of the overall health system, with the targets for each specific measure based on prior performance data and also aligned with hospital targets (top quartile performance meets and top decile performance exceeds target).

For each target met, trainees are paid $200, for a maximum payout of $600.

Who is eligible?

All GME ACGME or ICGME trainees who have worked for at least 3 months leading up to June 2015.

What are the measures for this year (2014-2015)?

This year, with resident and leadership input, the following 4 measures have been selected:

  1. HCAHPS Patient Experience Measurement
  2. 30-day same hospital readmissions
  3. Emergency Department Median Consult Time (NEW)
  4. RL-6 Safety Event Reporting (NEW)

What is the reasoning behind these measures? What are the targets?

  1. HCAHPS: As all hospital systems continue to improve, the standards for patient satisfaction will continue to rise as well.
    Target: Meet the National Median of 87.5% (7 out of 8 dimensions).
  2. 30-day hospital readmissions: Trainees will have an additional opportunity to demonstrate improvement.
    Target: 13.05% (median of comparable health care systems on the UHC US News Honor Roll).
  3. Emergency Department Median Consult Time: Extended consult times in the ED contribute to increased Left Without Being Seen rate and decreased patient satisfaction and care.
    Target: Overall decrease in consult time by 10%.
  4. Safety Event Reporting in RL Solutions: Increasing trainee input and awareness for adverse outcomes or near-misses. Trainees only submitted 0.5 (74) of overall reports last year.
    Target: Increase trainee submitted reports for an average of 2 submissions per trainee.

What were our measures last year (2013-2014)?

Last year, we had 3 program measures encompassing the domains of patient satisfaction and quality and patient safety:

  1. HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) surveys: publicly reported data from patient surveys on hospital performance
  2. Duke Hospital 30-day hospital readmission rate
  3. Influenza vaccinations

Additionally, several programs chose program-specific measures:

  • Hand Hygiene: Internal Medicine, Pediatrics, General Surgery, Anesthesia, Neurology, Orthopedics
  • Left Without Being Seen Rate: Emergency Medicine
  • OB Trauma: Vaginal with Instrument: OB/GYN

How was our performance last year?

  1. HCAHPS: Target of 87.5% met
  2. 30-day hospital readmissions: data unavailable through much of the year
  3. Influenza vaccinations: data unavailable through much of the year
  4. Program specific measures: Pediatrics met their target with hand washing.

Trainees received the full pay-out of $600.

How will we be updated on our progress?

Performance Services will create monthly reports with up-to-date performance metrics that will be distributed to trainees and program directors.

Program representatives are also willing to present the program structure to your trainees; contact information is below.

What can we do with this information?

You can work with your program or peers to create a QI project or initiative to specifically address improving upon these measures.

How can I get involved?

To get involved or for more information, please contact one of the program co-chairs: Anjni Patel (anjni.patel@dm.duke.edu) or Sarah Dotson (sarah.dotson@dm.duke.edu).

Attachments:

 

 

Stead Society Trivia Night

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

Sincerely,

Steven Crowley on behalf of the Warren Society

 

Information/Opportunities

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

www.mercydesmoines.org

Optional Survey from UC San Diego

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

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

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

 

Upcoming Dates and Events

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

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

 

Useful links

Internal Medicine Residency News – August 18, 2014

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

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

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

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

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

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

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

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

Have a great week!

Aimee

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

Nilesh Patel, MD, MS

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

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

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

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

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

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

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

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

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

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

Clinic Corner

PRIME Clinic Corner

Hi PRIME team:

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

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

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

Have a great week!

Sonal

QI Corner

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

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

 

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

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

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

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

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

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

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

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

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

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

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

Flu Vaccination Season 2014

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

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

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

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

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

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

New System for Requesting Interpreters

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

The system, called ServiceHub (https://q.servicehub.com/sso/duhs/r2 ), will simplify and streamline requests for language assistance and will enable users to track the process, including making medical interpreter requests and monitoring the status of requests to know when interpreters arrive on-site and complete the assignment. This system will also enhance the ability to monitor how interpreters are deployed, enabling users to better estimate response times and International Patient Services to provide additional support to areas in high demand for interpreter services. ServiceHub is intended to replace the language assistance request calls that are made to 919-681-3007.

While the system is designed to be user-friendly, training materials are available through the Learning Management System (LMS), accessed by logging onto Duke@Work

or via the following URL:

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

After logging in, search the LMS for “ServiceHub Interpreter Request System – Requester Training.” Hospitals that use ServiceHub to dispatch interpreters report dramatic improvement in response times and improved efficiency by an average of 30 percent. Please share this information with any members of your staff who may request interpreters. The International Patient Services team will be ready to assist and support you while we transition to this new dispatching system. For questions regarding the new ServiceHub interpreter request system, please contact:

International Patient Services

919-681-3007 or 919-668-2431

Nouria Belmouloud

Pager: 919-970-0387

 

New Jackets/Fleeces for 2014!

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

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

Jacket will be Black with the Duke Medicine logo.

Stead Society Trivia Night

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

Sincerely,

Steven Crowley on behalf of the Warren Society

Information/Opportunities

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

www.mercydesmoines.org

 

 

Upcoming Dates and Events

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

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

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

 

Useful links

Faculty mentoring for residents

Wed, 08/13/2014 - 09:00

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

Please complete the form below to indicate your interest.

Learn more about resident research activities.

  • Your nameFirstLast
  • Your email
  • Your primary divisionPlease choose your primary divisionCardiologyClinical PharmacologyEndocrinology, Metabolism, and NutritionGastroenterologyGeneral Internal MedicineGeriatricsHematological Malignancies and Cellular TherapyHematologyInfectious DiseasesMedical GeneticsMedical OncologyNephrologyPulmonary, Allergy, and Critical Care MedicineRheumatology and ImmunologyOther
  • What type of science is your research?
    • Basic
    • Clinical
    • Translational
  • What model do you use to conduct your research?
    • Human
    • Animal
    • Cell
    • In silico
  • What techniques do you use to conduct your research?
    • Biochemical
    • Imaging
    • Genetic
    • Electrophysiology
    • Other
  • What pathway do you study?
    • Metabolomics
    • Proteomics
    • Biomarkers
    • Other
  • With which Basic Science departments do you collaborate?
    • Biochemistry
    • Biostatistics & Bioinformatics
    • Cell Biology
    • Immunology
    • Molecular Genetics & Microbiology
    • Neurobiology
    • Pharmacology & Cancer Biology
  • With which Clinical departments do you collaborate?
    • Anesthesiology
    • Community & Family Medicine
    • Dermatology
    • Neurology
    • Obstetrics & Gynecology
    • Ophthalmology
    • Orthopaedic Surgery
    • Pathology
    • Pediatrics
    • Psychiatry & Behavioral Sciences
    • Radiation Oncology
    • Radiology
    • Surgery
  • With which other Duke schools or departments do you collaborate?
  • To which centers or institutes do you belong? (If applicable.)
    • Duke Cancer Institute
    • Duke Center for Aging
    • Duke Center for AIDS Research
    • Duke Clinical Research Institute
    • Duke Global Health Institute
    • Duke Human Vaccine Institute
    • Duke Institute for Health Innovations
    • Duke Molecular Physiology Institute
    • Duke O'Brien Center for Kidney Research
  • Which human diseases do you primarily study?
  • Your clinical and research interestsAdd keywords related to your research, or copy and paste an overview of your research activities and portfolio.
  • Which of these scholarly projects are you willing to assist residents on?
    • Original clinical research (prospective or retrospective)
    • Basic science or translational research
    • Medical education research
    • Preparation of resident research grants
    • Coauthoring a review article
    • Systematic literature review
    • Coauthoring a case report
    • Clinical vignette presentation at regional or national meetings
    • Research or case presentation at local Duke conferences (annual School of Medicine Clinical Science Day, Internal Medicine Resident Research Night)
    • Senior Assistant Resident presentations
    • Quality Improvement
    • Health systems research
  • Would you be interested in working with third-year Duke medical students?
    • Yes
    • No
  • Please list names of current or past residents and medical students you have mentored.
  • Each Department of Medicine faculty member has a profile in the Scholars@Duke system. Keeping this profile up to date remains one of the best ways for you to share your research activities with your colleagues, trainees and those beyond Duke.
  • Have you updated your Scholars@Duke faculty profile in the last 3 months?
    • Yes, I have updated my profile
    • No, but I will update my profile in the next 30 days
    • No, but I will delegate this to an assistant
    • No, but I'd like more information about how to do this
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Internal Medicine Residency News, August 11, 2014

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

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

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

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

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

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

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

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

Have a Great Week!!
Aimee

Clinic Corner

Pickett Clinic Corner

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

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

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

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

 

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

Aaron Mitchell, MD

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

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

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

From the Chief Residents Grand Rounds

Friday, August 15th: Daisy Smith

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

 

MKSAP Ordering Now Open!

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

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

 

TSMA/Moonlighting Policy for Internal Medicine Residents

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

 

Stead Resident Research Grants- Request for Proposals

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

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

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

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

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

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

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

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

Flu Vaccination Season 2014

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

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

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

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

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

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

New Jackets/Fleeces for 2014!

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

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

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

Jacket will be Black with the Duke Medicine logo.

 

 

Information/Opportunities

 

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

Community Health Network

Upcoming Dates and Events

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

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

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

Useful links

Meet your chief resident: Aaron Mitchell, MD

Fri, 08/08/2014 - 08:21

Aaron Mitchell, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Meet the chief residents:

Internal Medicine Residency News, August 4, 2014

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

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

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

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

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

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

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

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

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

JGME July 9, 2014.

Have a great week!

Aimee

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

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

AND

 NY Times article

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

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

Why did I read these?

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

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

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

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

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

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

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

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

Clinic Corner

DOC Clinic Corner

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

Friday, August 8 – Dr. Joe Rogers, Cardiology

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

 

MKSAP Ordering Now Open!

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

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

 

TSMA/Moonlighting Policy for Internal Medicine Residents

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

 

Stead Resident Research Grants- Request for Proposals

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

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

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

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

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

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

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

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

Flu Vaccination Season 2014

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

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

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

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

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

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

Provider Staff for House Staff

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

New Jackets/Fleeces for 2014!

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

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

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

Jacket will be Black with the Duke Medicine logo.

Interview Skills

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

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

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

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

Sincerely,

Sharon Rubin, MD, FACP

Assistant Professor, Duke University Medical Center

Residency Director at Pickett Road

 

Information/Opportunities

The Winston-Salem CareerMD Career Fair: Event Details

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

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

Details
Attire is casual and a complimentary buffet will be provided

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

 

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

Community Health Network

Upcoming Dates and Events

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

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

Useful links

 

Ambulatory Care Leadership Track adds focus on legislative advocacy

Tue, 07/29/2014 - 08:27

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Internal Medicine Residency News – July 28, 2014

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

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

Phil Lehman sent us this picture … thanks Phil!

 

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

Please wish the AMAZING Erin Payne a happy birthday today!

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

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

Have a great week,

Aimee 

 

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

Spironolactone Reduces Cardiovascular and Cerebrovascular Morbidity and Mortality in Hemodialysis Patients

JACC 63, 6 2014

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

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

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

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

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

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

Clinic Corner

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

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

So happy Mini CEXing!

Alex Cho, MD

QI Corner

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

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

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

-Aaron

From the Chief Residents Grand Rounds

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

“Infections in Critically Ill”

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

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

http://dukelist.duke.edu/

Stead Resident Research Grants- Request for Proposals

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

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

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

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

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

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

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

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

New Jackets/Fleeces for 2014!

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

Interview Skills

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

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

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

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

Sincerely,

Sharon Rubin, MD, FACP

Assistant Professor, Duke University Medical Center

Residency Director at Pickett Road

 

Information/Opportunities

Hospitalists Practice Opportunity in PA 7-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Elkin Internal Medicine

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities

Community Health Network

Upcoming Dates and Events

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

Meet your chief resident: Bonike Oloruntoba, MD

Tue, 07/22/2014 - 15:54

Bonike Oloruntoba, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Meet the chief residents:

Internal Medicine Residency News – July 21, 2014

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

Hi Everyone!

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

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

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

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

Details of the HIV testing event:

Date: August 29, 2014

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

Walk-in HIV testing: Appointment or registration not required

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

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

Have a great week!

Aimee

 

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

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

Background/Clinical Question:

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

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

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

Methods

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

Setting – Outpatient cardiology practices associated with 4 academic medical centers

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

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

Blinding – Unblinded

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

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

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

 Validity

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

 Results

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

 Comments

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

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

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

Clinic Corner

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

Just a couple of things to remind everyone:

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

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

Sonal Patel, MD

PRIME  Clinic Director

Durham VA Medical Center

 

QI Corner

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

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

Patient satisfaction score

30-day hospital readmission rate

Time responding to admission consults from the ED

Increased usage of SRS (Safety Reporting System)

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

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

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

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

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

-Aaron

From the Chief Residents Grand Rounds

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

“Consult Communication”

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

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

http://dukelist.duke.edu/

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

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

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

Ambulatory Evaluations – Resident Identify Supervisor

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

Stead Resident Research Grants- Request for Proposals

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

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

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

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

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

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

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

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

Interview Skills

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

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

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

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

Sincerely,

Sharon Rubin, MD, FACP

Assistant Professor, Duke University Medical Center

Residency Director at Pickett Road

 

Information/Opportunities

Announcement Geriatrician Opportunity

Elkin Hospitalist

Elkin Internal Medicine

Montana Hospitalist

Summit Placement Service

Upcoming Dates and Events

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

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links

 

Internal Medicine Residency News – July 14, 2014

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

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

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

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

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

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

Aimee

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

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

Clinical questions from this week (with some answers)

Does my patient have iron deficiency anemia?

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

What is cryptosporidiosis?

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

What are the anticoagulation guidelines after atrial fibrillation?

Cardioversion?

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

6.1.1. Thromboembolism Prevention: Recommendations

Class I

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

(Level of Evidence: B)

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

(Level of Evidence: C)

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

(Level of Evidence: C)

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

(Level of Evidence: C)

Class IIa

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

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

(Level of Evidence: C)

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

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

When do you treat candiduria?

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

Recommendations: asymptomatic candiduria

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

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

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

Recommendations: symptomatic candiduria

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

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

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

And from Carli Lehr…

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

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

 

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

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

CMEonPCVandET

Iron Deficiency Anemia in Patients with Medical Problems – JGIM

milwaukeewatercryptosporidiosis

RCEfootulcer

Clinic Corner

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

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

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

Eric Black Maier EWB16

Dave Kopin DJK23

Tim Hinohara TTH10

John Musgrove JLM 138

Rachel La Voy/Hu REL 31

Pascale Khairallah PK110

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

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

For future lab orders:

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

Best,

Sharon Rubin

 

QI Corner

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

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

Have a good week everyone!
Aaron

 

From the Chief Residents Grand Rounds

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

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

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

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

Stead Resident Research Grants- Request for Proposals

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

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

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

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

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

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

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

Wishing you continued success with your research projects !

Murat Arcasoy and Aimee Zaas

 

 

Interview Skills

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

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

Location: Duke Internal Medicine Library, Durham, NC

Date: Wednesday August 6, 2014

Time: 7:00 PM to 8:30 PM

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

 

Information/Opportunities

Announcement Geriatrician Opportunity

Elkin Hospitalist

Elkin Internal Medicine

Montana Hospitalist

Upcoming Dates and Events

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

August 6th- Interview Skills Session

August 17th- Kerby Society Hosting Durham Bulls Game Gathering

Useful links