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Internal Medicine Residency News, April 27, 2015

Mon, 04/27/2015 - 10:03
From the Director

Hi Everyone!!

Another busy week is here…Jen, Lish, and I are at the Program Director’s meeting in Houston and hope to bring back some information about iCOMPARE and other things happening around the country in medical education!  The Faculty-Resident basketball game is Wednesday night in CAMERON INDOOR (home of the 2015 NCAA Champions).  Who will rise the banner for us this  year – faculty or residents???  We also had some alumni visitors this week…greetings from Adam Garber and Howie Lee – great to see you both.  Eric Pollack, Bassem Matta, Bhavana Singh, Myles Nickolich, and Andrea Sitlinger joined me for a very fun JAR dinner at the new “off the beaten path” Durham hotspot of Gioccolina as well.  One more JAR dinner for the year….Erin will send out the details this week.  Congrats also to Azalea Kim and Joy Bhosai on their acceptance to the MLPR Program!!

Don’t forget to DO YOUR ACGME SURVEY!!  That way, I don’t have to send you emails bugging you to complete it.  And also, remember to RSVP for Parent’s/Family Weekend –  you can email Erin or me with your RSVP.

Kudos this week are to Coco Fraiche from Erin Boehm for outstanding discharge instructions/summaries on Duke Gen Med, to Div Patel from Kahli Zeitlow for helping out when she was very busy, to Bassem Matta for an awesome chair’s conference and to Lauren Collins from med student Mimi Xu for excellent leadership and teaching on Gen Med.

Congratulations to Cece Zhang on her wedding!  The pictures are amazing!

This week’s pubmed from the program goes to Med Res alum and renal fellow John Stanifer for his recent publications related to his resident and fellow research projects.  Published recently in PlosONE is Development and Validation of a Cross-Cultural Knowledge, Attitudes, and Practices Survey Instrument for Chronic Kidney Disease in a Swahili-Speaking Population, John W. Stanifer, Francis Karia, Corrine I. Voils, Elizabeth L. TurnerVenance Maro, Dionis Shimbi, Humphrey Kilawe, Matayo Lazaro, Uptal D. Patel

Have a great week

Aimee

What Did I Read This Week?

What Did I Read This Week

(submitted by Murat Arcasoy, MD)

“Challenges for Internal Medicine as the American College of Physicians Celebrates its 100th Anniversary” 

by:  Steven E. Weinberger, MD

Annals of Internal Medicine 162:585, 2015. 

Why I Read this Article:

I regulary read the Annals since I became a meember of the ACP in 1988.  The author is the Executive VP and CEO of the ACP since 2010.  He highlights 3 main issues he envisions for Internal Medicine and the ACP as it enters its second century, to meet the goals of ACP’s updated motto: “Leading Internal Medicine, Improving Lives” and the needs of patients, physicians and broader society.

What are the Key Issues/Challenges to Internal Medicine according to the ACP?

  • Defining the role of Internal Medicine within the health care system
  • Addressing challenges to our professional satisfaction
  • Meeting our responsibility to control health care costs

What are Key Points Regarding the Role of Internal Medicine within the Healthcare System?

The author briefly discusses longstanding uncertainties about the relation between “generalism and specialism”, primary care and subspecialties, and internal medicine and general medicine, as well as hospital medicine, family medicine, the role of non-physician clinicians, and the current focus on team-based care delivery.

The ACP has recently attempted to identify the common ground that binds all internists: “specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness”.

The distinguishing features of the non-specialist, primary care general internist are: 1)- their diagnostic skills for patients with undifferentiated or complicated presentations and 2)- their ability to provide and coordinate acute and chronic care for patients with complicated and often multiple clinical problems.

How to Address the Challenges to Professional Satisfaction?

The major unifying stressor is time: Pressure to increase productivity means less time per patient, regulatory requirements that do not add value or improve quality of care, burdensome paperwork, electronic health records typically not designed for optimal usability, expansion of work time time leading to negative effect on work-life balance.

The ACP has implemented a “Practice Enjoyment” initiative a component of which is “Patients before paperwork”, focusing on reducing time-consuming administrative and types of other burdens.

What about our Responsibility to Control Healthcare Costs?

Health care consumes nearly 20% of our GDP, and the US spends more per capita on health care than any other country, without betterment of quality and mortality measures. It is estimated that 30 cents of every dollar is “wasted” ie. adding to the cost without benefiting patients.

As you are all well aware, the ACP’s High Value Care Initiative and ABIM Choosing Wisely campaign have targeted reduction of overuse and mis-use of care.  You are already taking part in these initiatives as you acquire clinical and professional skills to become outstanding Internists and expert non-subspecialist consultants. We must continue to learn and educate one another on how to focus on evidence-based, patient-centered practice of Internal Medicine while avoiding low- or no-value decisions, as we take care of patients every day.

Clinic Corner

Content for this week’s Clinic Corner comes courtesy of Julia Gamble, NP at DOC involved in our complex care programs and long-time housing advocate:

Have gently used furniture (beds, chairs, kitchen stuff, sheets, appliances, rugs, etc.)?  Want to give them to people who could use them?  The Furniture Project of Durham connects your stuff to people moving out of homelessness into housing – and volunteers will pick it up!  Call David McNeil at 919-589-3763 or email furnitureprojectofdurham@gmail.com.  And if you want to volunteer, let him know too.  Thanks!

 “How do I …”   Refer a homeless patient for medical respite services?  The concept of medical respite is to provide temporary housing for homeless patients being discharged after being hospitalized or undergoing an elective procedure, who require a clean, safe space where they can recuperate (e.g., are non-weight-bearing) and/or receive skilled nursing and other home services (e.g., IV antibiotics) for an extended period of time (generally 6-8 weeks or less).  Respite also provides an enhanced opportunity for these patients to be connected to mental health and other services, complete applications for housing assistance, etc.

With support from Durham County, Lincoln Community Health Center, and Project Access of Durham County, a year-long medical respite pilot has been ongoing that has resulted in seven of nine patients being transitioned to housing other than shelter, after completing their respite stay.  And with a preliminary commitment of support from the health system and utilizing some of the proceeds from this year’s awesome Residents’ Charity Auction (thanks!), in addition to continuing support from the County, plans are for this program to continue and expand.

So if you have a DOC clinic patient who is homeless and needs a home-like environment to recover from an acute illness or to prepare for a badly needed procedure, send an In Basket message or talk to Julia Gamble to review for entry into the Durham Medical Respite Program.

Preparing to discharge a hospital patient (at DUH or Duke Regional) who is homeless and needs a home-like environment to recover?  Talk to your PRM about getting in touch with Gay Bonds, complex care PRM, for assessment of appropriateness for the Durham Medical Respite Program.

(At the Durham VA, be sure to engage your social worker, and the long-time homeless veteran coordinator is Bob Williamson, x6045.)

From the Chief Residents Grand Rounds

Fri., May 1: Dr. Nathan Thielman

Noon Conference Date Topic Lecturer Time 4/27/15  Conversation about Race  Dean Nancy Andrews  12:00/Learning Hall; Trent Semans  Saladelia 4/28/15  MKSAP 12:00/Med Res  Chick-Fil-A 4/29/15  Approach to Osteoporosis  Ken Lyles 12:00/MedRes Cosmic Cantina 4/30/15  Female Reproductive Disorders: PCOS & Amenorrhea  Ann Brown 12:00/MedRes Dominos 5/1/15  Chair’s  Chiefs  12:00/2002  Picnic Basket                         From the Residency Office Residents vs Faculty Basketball Game!

Residents vs Faculty Basketball Game is this Wednesday, April 29th!!  Warm Ups start at 6pm and the game will begin at 6:30pm in Cameron Indoor Stadium!  If you are interested in playing and haven’t already, please contact Nick Rohrhoff to join the team!  Last year faculty won by 1 point… We don’t want that to happen again!!

Resident Research Night and Califf Research Awards

Dear Internal Medicine, Med-Peds, and Med-Psych Residents,We would like to invite you to submit an abstract of your research project(s) for:The annual Califf Medicine Resident Research Award competition Abstracts are due on May 5, 2015Please see the request for applications and abstract preparation instructions.All abstracts submitted for competition will also be presented as posters during Resident Research Night on May 28, 2015 at the TRENT SEMANS Center Great Hall  5 pm – 7 pm            The top 3 abstracts will be selected by a faculty committee for the Califf Research Awards and these research projects will be presented as 15 minute talks.Two best posters (poster template – white, poster template-blue) will be selected (Research poster and QI poster) by the Chief Residents during the poster viewing session.

            In addition, we invite all of you to present your scholarly activities during Resident Research Night as posters (see attached templates) :

            1- Basic, clinical and translational research projects

            2- Case studies / vignettes

            3- QI projects

            Please plan on presenting your posters from the NC ACP meeting in 2014 as well as posters that you have presented previously at a national scientific meeting.

To discuss any issues related to the application process or once you have decided to submit an abstract, please e-mail murat.arcasoy@mc.duke.edu to declare your intention to submit, your research mentor’s name and the title of your poster.  Please contact the MedRes office staff (Ms. Lynsey Michnowicz) for assistance with the poster preparation process.

Wishing you success with your projects !

Murat O. Arcasoy, MD, FACP                            Aimee K. Zaas, MD, MHS
Associate Professor of Medicine                        Associate Professor of Medicine
Associate Program Director                              Director, Duke Internal Medicine Residency Program

Stead Society Events – Warren Society

This year, the Warren Society will again sponsor serving dinner at the Ronald McDonald house (506 Alexander Avenue, 3 blocks away from DUMC) on Tuesday, April 28.  Dinner is served at 6pm, and anyone who can come early to help prepare the tacos would be most welcome.  I’ll plan to get there by 4pm and begin cooking. Ken Lyles will be there with his fabulous pound cakes, so dessert is guaranteed to be a hit.

Second, on Friday May 1 (that same week), any medicine housestaff and their families are welcome to stop Steve Crowley’s house for dinner and beverages, sponsored by the Warren Society, on the way home from work. We can start that at 6PM as well and continue until everyone leaves and the food and spirits are consumed. Please come even if you can only stay for a few minutes.  Please email Steven Crowley <steven.d.crowley@dm.duke.edu> for directions. For those of you who have missed trivia, Fumiko Chino has offered to bring homemade questions.  However, trivia is not a required part of the agenda, and there is no agenda!

Steve Crowley

Housing Resources

Just as a reminder that there is a folder on MedHub, under “Resources/Documents” that contains information on some available housing opportunities forwarded to us by members of the Duke community.

SAR’s

Please know there is an excellent opportunity to hone your interviewing skills.  Dr. Kathryn Pollak who is a communication coach and faculty member in the SoM will provide 4  1-hour sessions from which you can choose. In the session, Dr. Pollak will cover tips to finesse interviewing skills as well and give some a chance to role play.  She also will be available for practice for their interviews in September and October.

The four sessions will be held the following dates and times:

Monday, August 17th: 12:00 noon to 1:00pm

Tuesday, August 18th: 4:00 to 5:00pm

Wednesday, August 26th: 12:00 to 12:00pm

Thursday, August 27th: 4:00 to 5:00pm

Each session will be 10 people or less, that way it’s more personalized. Please let me know as soon as possible which session you would like to sign up for. This is a very valuable tool being offered!

You’re Invited..

Please save the date for the 1st Annual Duke University Transplant Infectious Diseases Symposium.

The focus of this program will be building Transdisciplinary training programs in Transplant ID for physician scientists and exploring new frontiers in transplantation, with a special focus on HIV and HCV-infected populations.

A world-renowned panel of experts will be leading an afternoon of rich discussion and multidisciplinary exchange.

Full details are included in the attached brochure. Please contact Kelly Stanly @ k.smith@dm.duke.edu with any questions and to register for this NIH sponsored event.

We hope you can join us. Please forward this information along to any medical students, residents, fellows, or faculty who may be interested in attending.

Date:  Friday, June 19, 2015 from 12:30pm-5:00pm

Location: Great Hall, Trent Semans Center, Duke University

http://medschool.duke.edu/about-us/trent-semans-center

GME Concentrations

We are excited to begin accepting applications for the July 2015 cohort of Duke GME Concentration participants. 

GME Concentrations were developed  as a supplemental educational experience, comparable to an undergraduate “minor,” for residents and fellows (PGY level 2 and above across all specialties) to provide critical content to better prepare trainees for practice in the current & future health care environment.

Concentration Participants will engage in a number of educational opportunities related to their concentration and develop a personal project with an identified mentor. Program Directors must approve participation in order to ensure their commitment to supporting participation and that the concentration fits with the individual trainee’s overall educational program.

Concentrations include:

  • Resident as Teacher
  • Patient Safety & Quality Improvement
  • Law, Ethics & Health Policy
  • Leaders in Medicine

Trainees, please use the following link to submit Part One of your application by Friday, May 29th – 

https://www.surveymonkey.com/s/GMEConcentrationInitialApplication 

For additional information, please see the attached Concentrations brochure, visit the GME Concentration website or contact Mariah Rudd (mariah.rudd@duke.edu).

If you have an interest in completing a Concentration different than those currently offered, please submit your idea or topic of interest here for consideration.

 2015 Family Weekend

Invitations have been sent to the addresses you provided! When you speak to your families, please remind them to RSVP using the following link: http://bit.ly/DUKEFAMILY​   by May 8th.

If you didn’t provide an address but would like to invite family members, it’s not too late. Please let Erin Payne know and she is happy to mail an invitation or email your family member the details!

We are really looking forward to this exciting new tradition!

   Information/Opportunities

Hospitalist Fellowship Opening

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

 

  Upcoming Dates and Events

April 29 – Faculty/Resident Basketball Game

May 28-30 – Family Weekend

June 6th – SAR Dinner, Hope Valley Country Club

June 13 – Spring Picnic

June 19 – 1st Annual Transplant Infectious Disease Symposium

   Useful links

4/29/15: Faculty vs. Residents basketball game

Mon, 04/20/2015 - 12:56

Mark your calendars: The annual Faculty vs. Housestaff basketball game will take place Wed., April 29 in Cameron Indoor Stadium.

Optional warm ups begin at 6:00 pm and the game will start at 6:30 pm.

Residents who are interested in playing should contact Nick Rohrhoff.

Faculty can sign up with Harvey Cohen or Anthony Galanos.

Internal Medicine Residency News, April 20, 2015

Mon, 04/20/2015 - 10:05
From the Director

JAR and SAR schedules are out, new interns are signing their contracts, SARs are logging those last few procedures…it’s getting to be a very busy time of year.  We have also just scheduled the FACULTY RESIDENT BASKETBALL GAME in Cameron Indoor for Wednesday April 29th.  It’s a good thing that I am an absolutely useless basketball player since I will be flying back from our spring Program Director’s meeting, but please see resident captain Nick Rohroff or faculty captain Harvey Cohen for playing time.  Even if you aren’t even a weekend warrior, come on out to the best college basketball venue in the country to see your friends and attendings play.

We have a record number of Faculty Resident Research Grants! Thanks to Dr. Arcasoy, Lynsey and Tia for getting all the information together and out to our faculty reviewers!  Great work by all.

Kudos this week go to Dinushika Mohottige from Phil Choi for outstanding work in the MICU, to Maggie Infeld from the entire 7800 staff for amazing patient care (thanks Katina Walline for sending me a note!), to Ashley Hanlon from the CAD team for fantastic work and team communication, and to Caroline Lee and Dan Pugmire for great Med Peds SAR talks.  Kudos also to Iris Vance for her presentation at the residency program QI M and M conference, with great discussants Aaron Mitchell, Lynn Bowlby and Lish Clark!

Do you know of a colleague who did something really well?  Let me or the chiefs know — we have a season ticket package to the Durham Bulls and would like to give out tickets to those who you all think are “unsung heroes” of the program.

JARs, keep setting up your fellowship/career meetings.  It has been fun talking with you and getting this process started.

This week’s pubmed from the program goes to Div Patel for his review that was just accepted for publication.  Great work Div, and mentor Dr. Sana Al-Khatib!

Zeitler E, Patel D, Hasselblad V, Sanders S, Al-Khatib S. Complications from prophylactic replacement of cardiac implantable electronic device generators in response to FDA recall: a systematic review and meta-analysis. Accepted for publication to Heart Rhythm on March 28, 2015.

Have a great week

Aimee

What Did I Read This Week?

What Did I Read This Week

(submitted by Bonike Oloruntoba, MD)

Functional Impairment and Hospital Readmission in Medicare Seniors 

JAMA Intern Med. 2015;175(4):559-565. doi:10.1001/jamainternmed.2014.7756. 

BACKGROUND:

We are all familiar with it… the dreaded bounceback admission. Unplanned hospital readmission affects 15-30% of Medicare patients which has lead to the CMS focusing on efforts to reduce hospital readmission rates. Despite valiant efforts, recognizing risk factors for readmission remains imprecise and is suggestive of unmeasured patient related factors that may be the cornerstone of hospital readmissions. Functional impairment and its association with acute care use and mortality has been well studied. Functional status has also been linked to nursing home placement and death within 1 year amongst hospitalized older adults. However, few studies have examined the role of functional impairment on readmission. This study assessed the effects of functional impairment on Medicare hospital readmissions. The study group hypothesized that functional impairment would be associated with 30-day readmission and that severity of impairment would be correlated with higher odds for readmission.

METHODS:

The Health and Retirement Study (HRS) is an ongoing, nationally representative longitudinal study of participants 50 years  or older designed to examine changes in health and wealth as people age. Surveys are administered to participants in waves every 2 years with response rates ranging from 80-90%.

Study Participants:

  • Nationally representative cohort of 7854 community-dwelling seniors in HRS, with 22 289 Medicare hospitalizations from January 1, 2000, through December 31, 2010.
  • Excluded admissions for the following reasons:
  • Transition to health maintenance organization plan within 30 days of discharge
  • Death in hospital or within 30 days of discharge
  • Transfer to another acute care facility before discharge
  • Less than 12 months of Medicare claims before hospital admission

Study Measure: Functional Impairment

In order to assess for functional impairment, study used activities of daily living (ADL) and instrumental activities of daily living (IADL) which was obtained from the Health and Retirement Study (HRS) interview immediately preceding the hospital admission.

 

ADL Scale (Self care activities) IADL Bathing,Dressing

Transferring (eg, moving from bed to chair)

Toileting

Eating Taking medications as prescribedManaging finances

Shopping for groceries or clothing

Preparing meals

Using the telephone

Using transportation within the community

To reflect the clinical continuum of functional status and typical natural history of impairment, an ordinal 5 level classification was generated to integrate IADL and ADL difficulty and dependency as predictors of readmission:

  1. No functional impairments
  1. Difficulty with 1 or more IADL
  1. Difficulty with 1 or more ADL
  1. Dependency in 1 to 2 ADLs,
  1. Dependency in 3 or more ADLs.

Study Outcome: 30 day readmission

RESULTS:

  • Overall, 15.5% of hospital admis- sions had a readmission within 30 days.
  • 48.3% of patients had some level of functional im- pairment before hospital admission
  • There was a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased:
  • 13.5% with no functional impairment
  • 14.3% with difficulty with 1 or more instrumental activities of daily living (odds ratio [OR], 1.06; 95% CI, 0.94-1.20)
  • 14.4% with difficulty with 1 or more ADL (OR, 1.08; 95% CI, 0.96-1.21)
  • 16.5% with dependency in 1 to 2 ADLs (OR, 1.26; 95% CI, 1.11-1.44)
  • 18.2% with dependency in 3 or more ADLs (OR, 1.42; 95% CI, 1.20-1.69).
  • In a subanalysis restricted to patients admitted with conditions targeted by the current Medicare HRRP (ie, heart failure, myocardial infarction, and pneumonia), 19.2% of admissions were associated with a 30-day readmission.
  • 16.9% with no functional impairment
  • 16.5% with 1 or more IADL difficulty (OR, 0.97; 95% CI, 0.66-1.44)
  • 18.8% with 1 or more ADL difficulty (OR, 1.14; 95% CI, 0.82-1.58)
  • 18.4% with dependency in 1 to 2 ADLs (OR, 1.11; 95% CI, 0.77-1.61)
  • 25.7% for dependency in 3 or more ADLs (OR, 1.70; 95% CI, 1.04-2.78)

CONCLUSION:

Functional impairment is associated with increased risk of 30 day all cause hospital readmission in Medicare seniors. Functional impairment has a larger effect on Medicare seniors admitted with heart failure, MI or pneumonia. Assessing functional status on the day of admission is easy (often obtained in nursing intake assessment) and targeting interventions on patients with functional impairments may possibly reduce your bounce back rate.

 

From the Chief Residents Grand Rounds

Fri., April 24: Dr. Sarah Connelly , Guest Speaker

Noon Conference Date Topic Lecturer Time 4/20/15  Approach to Menopause  Diana McNeill  12:00/2002  Rudinos 4/21/15  Internist Guide to Contraception  Sharon Rubin 12:00/2002  Subway 4/22/15  Approach to Dysfunctional Uterine Bleeding  Suheil Muasher 12:00/MedRes China King 4/23/15  PEAC Study Hall  Chiefs 12:00/MedRes Dominos 4/24/15  Chair’s  Bassem Matta  12:00/2002  Panera                   From the Residency Office

 

Resident Research Night and Califf Research Awards

Dear Internal Medicine, Med-Peds, and Med-Psych Residents,

We would like to invite you to submit an abstract of your research project(s) for:

The annual Califf Medicine Resident Research Award competition 

Abstracts are due on May 5, 2015

Please see the request for applications and abstract preparation instructions.

All abstracts submitted for competition will also be presented as posters during Resident Research Night on May 28, 2015 at the TRENT SEMANS Center Great Hall  5 pm – 7 pm

            The top 3 abstracts will be selected by a faculty committee for the Califf Research Awards and these research projects will be presented as 15 minute talks.

Two best posters (poster template – white, poster template-blue) will be selected (Research poster and QI poster) by the Chief Residents during the poster viewing session.

            In addition, we invite all of you to present your scholarly activities during Resident Research Night as posters (see attached templates) :

            1- Basic, clinical and translational research projects

            2- Case studies / vignettes

            3- QI projects

            Please plan on presenting your posters from the NC ACP meeting in 2014 as well as posters that you have presented previously at a national scientific meeting.

To discuss any issues related to the application process or once you have decided to submit an abstract, please e-mail murat.arcasoy@mc.duke.edu to declare your intention to submit, your research mentor’s name and the title of your poster.  Please contact the MedRes office staff (Ms. Lynsey Michnowicz) for assistance with the poster preparation process.

Wishing you success with your projects !

Murat O. Arcasoy, MD, FACP                            Aimee K. Zaas, MD, MHS
Associate Professor of Medicine                        Associate Professor of Medicine
Associate Program Director                              Director, Duke Internal Medicine Residency Program

Stead Society Events – Warren Society

This year, the Warren Society will again sponsor serving dinner at the Ronald McDonald house (506 Alexander Avenue, 3 blocks away from DUMC) on Tuesday, April 28.  Dinner is served at 6pm, and anyone who can come early to help prepare the tacos would be most welcome.  I’ll plan to get there by 4pm and begin cooking. Ken Lyles will be there with his fabulous pound cakes, so dessert is guaranteed to be a hit.

Second, on Friday May 1 (that same week), any medicine housestaff and their families are welcome to stop Steve Crowley’s house for dinner and beverages, sponsored by the Warren Society, on the way home from work. We can start that at 6PM as well and continue until everyone leaves and the food and spirits are consumed. Please come even if you can only stay for a few minutes.  Please email Steven Crowley <steven.d.crowley@dm.duke.edu> for directions. For those of you who have missed trivia, Fumiko Chino has offered to bring homemade questions.  However, trivia is not a required part of the agenda, and there is no agenda!

Steve Crowley

Housing Resources

Just as a reminder that there is a folder on MedHub, under “Resources/Documents” that contains information on some available housing opportunities forwarded to us by members of the Duke community.

 

Hematology/Oncology Fellowship Program Info Session

Dr. DeCastro and Dr. Riedel will be meeting with anyone interested in Hematology/Oncology Fellowship on Tuesday, April 21st at 4 p.m. in 405 Seeley G. Mudd Conference Room – refreshments provided.

Join them to find out more about the Hematology/Oncology Fellowship Program!

GME Concentrations

We are excited to begin accepting applications for the July 2015 cohort of Duke GME Concentration participants. 

GME Concentrations were developed  as a supplemental educational experience, comparable to an undergraduate “minor,” for residents and fellows (PGY level 2 and above across all specialties) to provide critical content to better prepare trainees for practice in the current & future health care environment.

Concentration Participants will engage in a number of educational opportunities related to their concentration and develop a personal project with an identified mentor. Program Directors must approve participation in order to ensure their commitment to supporting participation and that the concentration fits with the individual trainee’s overall educational program.

Concentrations include:

  • Resident as Teacher
  • Patient Safety & Quality Improvement
  • Law, Ethics & Health Policy
  • Leaders in Medicine

Trainees, please use the following link to submit Part One of your application by Friday, May 29th – 

https://www.surveymonkey.com/s/GMEConcentrationInitialApplication 

For additional information, please see the attached Concentrations brochure, visit the GME Concentration website or contact Mariah Rudd (mariah.rudd@duke.edu).

If you have an interest in completing a Concentration different than those currently offered, please submit your idea or topic of interest here for consideration.

2015 Family Weekend

Invitations have been sent to the addresses you provided! When you speak to your families, please remind them to RSVP using the following link: http://bit.ly/DUKEFAMILY​   by May 8th.

If you didn’t provide an address but would like to invite family members, it’s not too late. Please let Erin Payne know and she is happy to mail an invitation or email your family member the details!

We are really looking forward to this exciting new tradition!

    Information/Opportunities

Hospitalist Fellowship Opening

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

 

  Upcoming Dates and Events

April 29 – Faculty/Resident Basketball Game

May 28-30 – Family Weekend

June 6th – SAR Dinner, Hope Valley Country Club

June 13 – Spring Picnic

  Useful links

Internal Medicine Residency News, April 13, 2015

Mon, 04/13/2015 - 11:38
From the Director

Spring seems to finally be here! I hope everyone got a few minutes or more to spend outside this weekend. We had a busy week, and the schedule will be pretty packed from here on out.  Incoming interns are starting to drop in and say hi as well — hard to believe they will start soon.

This week, we had our first fellowship prep meeting, and the next one is TONIGHT!  See you there if you can make it, and I look forward to meeting with all applicants individually as well.  If you are considering a career in hospital medicine or primary care, please also set up a time to meet so we can discuss your plan/timeline.  We also had a great kickoff meeting for the SOCIAL ACTION COUNCIL! Be on the lookout for more emails about our steering committee and projects…even if you missed the meeting, there is plenty of opportunity to get involved.  REMIND YOUR PARENTS/FAMILIES to RSVP for the FIRST ANNUAL DUKE IM FAMILY WEEKEND! My mom struggled to figure out how to use RSVP email so if you need to, just email Erin and me directly that they are coming.   We will also get the date set for our HOUSESTAFF-FACULTY basketball game.  While I don’t think we are allowed to cut the net, it is still pretty cool to play in the home court of the 2015 National Champions.  Kudos to Jonathan Hansen from Christine Bestvina for great work during a high pressure situation at the VA, and to Amy Jones, Dinushika Mottoghie, Lakshmi Krishnan and Anubha Agarwal for getting the GME Narrative Medicine Project funded through the GME Innovations (with Peter Kussin, Frank Neelon, David Pisetsky, Saumil Chudgar, Jane Gagliardi and me). Can’t wait to get started on it!  Also kudos to everyone who submitted their faculty-resident research grant!

This week’s pubmed from the program goes to Anubha Agarwal for her article in the Journal of the American Heart Association –

Disparities in Cardiovascular Research Output and Citations From 52 African Countries: A Time-Trend, Bibliometric Analysis (1999–2008)Gerald S. Bloomfield, MD, MPH; Abigail Baldridge, MS; Anubha Agarwal, MD; Mark D. Huffman, MD, MPH; Lisandro D. Colantonio, MD, MSc; Ehete Bahiru, MD; Vamadevan S. Ajay, MPH; Poornima Prabhakaran, PhD; Grant Lewison, PhD; Dorairaj Prabhakaran, MD, DM, MSc

 

Have a great week

Aimee

What Did I Read This Week?

What Did I Read This Week

(submitted by Suzanne Woods, MD)

Duration of Menopausal Vasomotor Symptoms over the Menopause Transition

JAMA Internal Medicine April 2015; 175 (4): 531-539

 

Authors:  Nancy A. Avis, PhD et al for the Study of Women’s Health Across the Nation (SWAN)

Why did I read this: Bonike recently emailed the assigned modules for the month of April which are Gynecology and Menopause and Hormone Replacement Therapy. So when I saw this article I thought it would be great to support more reading for the PEAC ambulatory topics.

Background:

  • Vasomotor symptoms (VMS) include hot flashes and night sweats and commonly signal menopausal transition.
  • These sx can significantly affect a patient’s quality of life and affects up to 80% of women, and are classified as moderate to severe.
  • Sx are one of the most common gynecologic reasons women seek medical attention.
  • The SWAN study group results suggest these VMS are independently associated with multiple indicators of elevated cardiovascular risk, greater bone loss and higher bone turnover.
  • There is little data about how long VMS last.

Methods

  • SWAN is a multiracial – multiethnic observational study characterizing biological and psychosocial changes occurring during the menopausal transition.
  • Recruitment started in 1995 and includes women between 42-52yo, presence of an intact uterus and at least 1 ovary, report of a menstrual cycle in the 3 months prior to screening, absence of pregnancy/lactation/OCP or HRT use.
  • 881 patients met criteria and were followed between 12-17 years.

Results

  • Median duration of vasomotor symptoms was 7.4 years
  • Median post final menstrual period persistence of sx was 4.5 years
  • Postmenopausal women at the onset of VMS had shortest duration of sx with median of 3.4 years
  • African American women reported the longest duration of sx, median 10.1 years
  • Additional factors related to longer duration of VMS were: younger age, lower educational level, greater perceived stress and symptom severity, higher depressive symptoms and anxiety at the first report of VMS

Conclusion

  • Clinical guidelines often underestimate the duration of VMS.
  • Findings in this study can help providers counsel patients about expectations of the duration of symptoms and assist women in making decisions about treatment. Given the lengthy duration of sx in some patients, the need to identify safe long term therapies is important to consider.

 

From the Chief Residents Grand Rounds

Fri., April 17: Dr. Daniel Sterman, Visiting Speaker

Noon Conference Date Topic Lecturer Time 4/13/15 MKSAP Mondays  12:00  Picnic Basket 4/14/15 MED-PEDS Combined: SAR Talk Pugmire/Lee 12:00/2002  Chick-Fil-A 4/15/15 Resident M&M  QI Team 12:00 Cosmic Cantina 4/16/15 QI Patient Safety Noon Conference 12:00 Dominos 4/17/15  Chair’s Conference  Chiefs  12:00  Rudinos                   From the Residency Office

 

Resident Research Night and Califf Research Awards

Dear Internal Medicine, Med-Peds, and Med-Psych Residents,

We would like to invite you to submit an abstract of your research project(s) for:

The annual Califf Medicine Resident Research Award competition 

Abstracts are due on May 5, 2015

Please see the request for applications and abstract preparation instructions.

All abstracts submitted for competition will also be presented as posters during Resident Research Night on May 28, 2015 at the TRENT SEMANS Center Great Hall  5 pm – 7 pm

            The top 3 abstracts will be selected by a faculty committee for the Califf Research Awards and these research projects will be presented as 15 minute talks.

Two best posters (poster template – white, poster template-blue) will be selected (Research poster and QI poster) by the Chief Residents during the poster viewing session.

            In addition, we invite all of you to present your scholarly activities during Resident Research Night as posters (see attached templates) :

            1- Basic, clinical and translational research projects

            2- Case studies / vignettes

            3- QI projects

            Please plan on presenting your posters from the NC ACP meeting in 2014 as well as posters that you have presented previously at a national scientific meeting.

To discuss any issues related to the application process or once you have decided to submit an abstract, please e-mail murat.arcasoy@mc.duke.edu to declare your intention to submit, your research mentor’s name and the title of your poster.  Please contact the MedRes office staff (Ms. Lynsey Michnowicz) for assistance with the poster preparation process.

Wishing you success with your projects !

Murat O. Arcasoy, MD, FACP                            Aimee K. Zaas, MD, MHS
Associate Professor of Medicine                        Associate Professor of Medicine
Associate Program Director                              Director, Duke Internal Medicine Residency Program

Stead Society Events – Warren Society

This year, the Warren Society will again sponsor serving dinner at the Ronald McDonald house (506 Alexander Avenue, 3 blocks away from DUMC) on Tuesday, April 28.  Dinner is served at 6pm, and anyone who can come early to help prepare the tacos would be most welcome.  I’ll plan to get there by 4pm and begin cooking. Ken Lyles will be there with his fabulous pound cakes, so dessert is guaranteed to be a hit.

Second, on Friday May 1 (that same week), any medicine housestaff and their families are welcome to stop Steve Crowley’s house for dinner and beverages, sponsored by the Warren Society, on the way home from work. We can start that at 6PM as well and continue until everyone leaves and the food and spirits are consumed. Please come even if you can only stay for a few minutes.  Please email Steven Crowley <steven.d.crowley@dm.duke.edu> for directions. For those of you who have missed trivia, Fumiko Chino has offered to bring homemade questions.  However, trivia is not a required part of the agenda, and there is no agenda!

Steve Crowley

Housing Resources

Just as a reminder that there is a folder on MedHub, under “Resources/Documents” that contains information on some available housing opportunities forwarded to us by members of the Duke community.

 

Hematology/Oncology Fellowship Program Info Session

Dr. DeCastro and Dr. Riedel will be meeting with anyone interested in Hematology/Oncology Fellowship on Tuesday, April 21st at 4 p.m. in 405 Seeley G. Mudd Conference Room – refreshments provided.

Join them to find out more about the Hematology/Oncology Fellowship Program!

2015 Family Weekend

Invitations have been sent to the addresses you provided! When you speak to your families, please remind them to RSVP using the following link: http://bit.ly/DUKEFAMILY​   by May 8th.

If you didn’t provide an address but would like to invite family members, it’s not too late. Please let Erin Payne know and she is happy to mail an invitation or email your family member the details!

We are really looking forward to this exciting new tradition!

    Information/Opportunities

Hospitalist Fellowship Opening

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

 

  Upcoming Dates and Events

May 28-30 – Family Weekend

June 6th – SAR Dinner, Hope Valley Country Club

June 13 – Spring Picnic

  Useful links

Internal Medicine Residency Updates, April 6, 2015

Mon, 04/06/2015 - 14:01
From the Director

Happy Easter! Happy Passover! Happy National Championship game! Happy 3/4 of the year is now “in the books”, and it is still light out after sign-outs!  We close out MiniCEX Madness tomorrow because for Duke, March Madness is still going on…so, keep on getting those MiniCEX’s done in the clinic and on the wards.  We will announce the last winner tomorrow.

Kudos this week to Ryan Huey for a great Chair’s conference with Eric Black-Maier and Titus Ng’eno figuring out the diagnosis.  Other kudos to Myles Nickolich from Carter Davis for patient care at the VA,  and to Bonike and Alyson McGhan for representing at the SNMA Conference this week in New Orleans.  Huge kudos to the chiefs for an EPIC April Fool’s joke as well.  #wellplayed.  This week we also had a fun JAR dinner checking out the patio at JuJu – thanks to Alyson Shogan, Katie Qin, Amy Jones, Dinushika Mottoghie, and Kristen Glisinski for joining me! Events coming up in the next few weeks – come meet and learn about applying for fellowships if you plan to apply this summer – Wednesday at 6:15 in the Med Res Library.  Come also to our first Social Action Council meeting on Thursday at 6 pm in the Med Res Library as well.

It is very hard to figure out where to place this next piece among what is generally a lighthearted and hopefully informational blog…however, the event that occurred on Duke’s campus last week certainly unsettled and disturbed us all.  Thank you to the many who went to the gathering on the quad to represent for themselves and for those who wanted to go but could not due to patient care responsibilities.  Dr. Kuhn and the GME Leadership have let us know about an upcoming event that will happen on campus that we are all welcome to attend on April 27, from 12-1:30 pm in the Learning Hall, Trent Semans Center.  There will be a forum “A Conversation about Race”, with Dean Andrews, Ben Reese, from the University’s Office of Institutional Equity, and Judy Seidenstein, Chief Diversity Officer of the School of Medicine.

This week’s Pubmed from the Program goes to Doran Bostwick and CeCe Zhang for their article with Tom Holland “Bacteremia Caused by Kerstersia gyiorum: a Case Report and Review of the Literature” published in the Journal of Clinical Microbiology March 2015. doi:10.1128/JCM.03625-14

Have a great week!

Aimee

What Did I Read This Week?

Aaron Mitchell, MD

What Did I Read This Week

(submitted by Aaron Mitchell, MD)

Reference: Samir Soneji and JaeWon Yang. New Analysis Reexamines The Value Of Cancer Care In The United States Compared To Western Europe. Health Affairs, 34, NO. 3 (2015): 390–399

Why did I read this:

I am very interested in the cost of health care, and the cost of cancer care in particular. Here in the USA, we like to think that we deliver cutting-edge cancer care, especially compared to other countries that spend less money. This article caught my eye, as it attempts to answer the question of whether the care we provide is actually cost-effective.

Background:

Since the 1980s, cancer mortality rates have been declining modestly, and perhaps a little bit faster in the United States than in Europe. Over the same time, health care spending on cancer in the US has skyrocketed. Assuming that the increased spending is driving the decrease in mortality, what is our bang for the buck? Is the additional spending on cancer care in the US actually cost-effective?

The authors of this paper compared cancer mortality rates and spending rates between the US and Western European countries. From these, they were able to determine the price per each Quality-Adjusted Life Year (QALY) gained in the US by health care spending. Traditionally, $50,000 or LESS per QALY is considered to be “cost effective.”

Results:

The cost per QALY for several common cancers was determined. Compared to Europe, the cost per QALY in the USA was $402,369 for breast cancer, $110,009 for colorectal cancer, and $1,978,542 for prostate cancer. None of these figures are close to being cost-effective.

Discussion:

Health care costs are particularly high for cancer, and, compared to other places in the developed world, we are not getting much for all the additional money we spend. Our cancer mortality rates may be slightly lower, but the poor cost-effectiveness found here suggests that we could be better spending a lot of that money elsewhere. The authors indicated end-of-life care, imaging, and chemotherapy as areas where costs may be reduced, and advocate for most cost-effective interventions such as early palliative care.

 

QI CORNER

Aaron Mitchell, MD

 

It has been a while since I sent updates on the GME incentive program, and how we are doing at meeting out medicine-specific quality measures…and earning those year-end $200 bonuses. So, here you go: all good news!

 

First, medicine continues to crush it in terms of the ED consult time compared to all the other departments…with the exception of peds, who manage to be able to see ED patients in just 8 minutes? Wow.

 

 

And, we continue to be below our program-specific goal of 30 minutes to complete a consult. If we can keep it there for just a few more months, then we’re looking at that $200!

 

 

One of the other quality measures we have been tracking is RL6 reporting, AKA “SRS.” While the Duke residency programs in general still are lagging here, medicine is one of only 3 programs (out of all 110+ of them!), along with peds and med-psych, that is hitting its quota. We’ve submitted 180 reports through March – exactly our target on the dot! Three more months to get those last 60 reports to hit our year-end target; keep up the great work!

 

CLINIC CORNER

 

Highlights from Duke Outpatient Clinic-We hope you had a chance attend the March 20 Medicine Grand Rounds on DOC Redesign.  The presentation was enthusiastically received and our work over the last 2 years held up as a model.  If you were not able to make it, you can still view it online here: http://meded-media.duhs.duke.edu/Mediasite/Catalog/Full/80e6c8ac20b04a88bee5c9fec486c7c721/?state=sX1EcDKPbaFbRH0M0waS

In this weeks DOC Newsletter-an introduction to Duke’s own Medicare ACO, Duke Connected Care.  Also, reporting on our latest home visit with Dr. Bhavana Singh.    Also, a cute photo of our latest addition to the staff with a cute puppy (who needs YouTube?).  Check it out.

Larry Greenblatt

 

From the Chief Residents Grand Rounds

Fri., April 10: Dr. Stefanie Sarantopoulos. Heme/Cellular Therapy

Noon Conference Date Topic Lecturer Time 4/6/15 Documentation in the Era of EMR: The Good, The Bad, The Ugly Wahidi/Squatriglia  12:00  Nosh 4/7/15 Controversies in Screening Mammography Daniel Bowers 12:00  Subway 4/8/15 ACGME Survey  Aimee Zaas 12:00 China King 4/9/15 Men’s Health: BPH/Prostatitis/Erectile Dysfunction  Lawrence Greenblatt 12:00/2002  Dominos 4/10/15  Chair’s Conference  Chiefs  12:00  Mediterra                   From the Residency Office

 

Faculty-Resident Research

This is a reminder to those of you involved in research and QI projects to consider applying for the annual “Faculty-Resident Research Grant” applications.

The applications due on April 12, 2015 for a funding start date on July 1, 2015.

Please find here the application instructions, forms, and new NIH format sample biosketch. Please include your mentor’s NIH Biosketch and signed support letter with your application.

Please see attached link 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

For a list of previously funded projects since 2011

http://residency.medicine.duke.edu/duke-program/resident-research/research-funding

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.

For any questions, please contact murat.arcasoy@dm.duke.edu

Wishing you continued success with your projects !

Murat and Aimee

 

Social Action Committee

The Internal Medicine Program is thrilled to announce the establishment of a Social Action Council!

This group will be dedicated to better knowing the needs of our local community, and engaging in activities aimed at improving the lives of our neighbors here in Durham as well as surrounding communities.  Members and participants will have the opportunity to join together, serve, and seek a more just community through causes and social issues about which they are passionate.

If you are interested, please join us for our first meeting, Thursday, April 9th. Come prepared to share your thoughts and ideas about how we as a group, and individuals, can offer our gifts and passions to the work of justice in our community.

Details:

Who’s Invited: All Medicine Residents, Fellows, and Faculty

Date: Thursday, April 9th

Time: 6:00 to 7:00pm

Location: Med Res Library, Duke North Hospital, Room 8253

*Light refreshments will be served

If you are interested in being a part of this group but unable to attend the interest meeting, please email Erin Payne at erin.payne@duke.edu and she will make sure to keep you plugged in on all that’s discussed and opportunities ahead!

Housing Resources

Just as a reminder that there is a folder on MedHub, under “Resources/Documents” that contains information on some available housing opportunities forwarded to us by members of the Duke community.

Rheumatology Fellowship Information Session

Wednesday, April 8, 6:30 pm at the Federal (914 W. Main Street).  Thinking about a rheumatology fellowhsip? Join faculty and fellows for a casual dinner and discussion about careers in rheumatology.  Learn why rheumatologists are the happiest medicine subspecialists!

Lisa Criscione-Schreiber, MD, MEd
Associate Professor of Medicine
Rheumatology Training Program Director

 

Hematology/Oncology Fellowship Program Info Session

Dr. DeCastro and Dr. Riedel will be meeting with anyone interested in Hematology/Oncology Fellowship on Tuesday, April 21st at 4 p.m. in 405 Seeley G. Mudd Conference Room – refreshments provided.

Join them to find out more about the Hematology/Oncology Fellowship Program!

2015 Family Weekend

Invitations have been sent to the addresses you provided! When you speak to your families, please remind them to RSVP using the following link: bit.ly/dukefamily by May 8th.

If you didn’t provide an address but would like to invite family members, it’s not too late. Please let Erin Payne know and she is happy to mail an invitation or email your family member the details!

We are really looking forward to this exciting new tradition!

    Information/Opportunities

Hospitalist Fellowship Opening

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

 

  Upcoming Dates and Events

Preserving Antibiotics – April 8, 2015

May 28-30 – Family Weekend

June 6th – SAR Dinner, Hope Valley Country Club

June 13 – Spring Picnic

  Useful links

4/9/15: Join the residency program for first social action council meeting

Wed, 04/01/2015 - 08:13

The Internal Medicine Residency Program will hold an interest meeting at 6 p.m. Thur., April 9 for its newly established Social Action Council. All faculty and trainees are invited to attend.

The council will be dedicated to better knowing the needs of our local community and engaging in activities aimed at improving the lives of our neighbors here in Durham as well as surrounding communities.  Members and participants will have the opportunity to join together, serve, and seek a more just community through causes and social issues about which they are passionate.

If you are interested, please join us for our first meeting, Thur., April 9. Come prepared to share your thoughts and ideas about how we as a group, and individuals, can offer our gifts and passions to the work of justice in our community.

Details:

Who’s Invited: All Medicine Residents, Fellows, and Faculty
Date: Thursday, April 9
Time: 6-7 p.m.
Location: Med Res Library, Duke North Hospital, Room 8253

*Light refreshments will be served

If you are interested in being a part of this group but unable to attend the interest meeting, please email Erin Payne at erin.payne@duke.edu and she will make sure to keep you plugged in on all that’s discussed and opportunities ahead!

Internal Medicine Residency News, March 30, 2015

Mon, 03/30/2015 - 10:45
From the Director

Final Four!!  And Duke was featured on 60 Minutes for the amazing brain tumor work happening right here.  What a fantastic place to work!

As March Madness heats up, we are closing out MiniCEX Madness! While you can get a MiniCEX done anytime by your friendly attendings, try to get a few more in this week to be eligible for our last MiniCEX Madness drawing.  Duke is still playing, and MiniCEX Madness extends until National Championship day on April 6.  This week’s winner was Kahli Zeitlow!

Welcome our newest member of the Duke Residency family …. Keerthi Krishnan! Proud parents Aparna Swaminathan and Sri Krishnan are doing great as well.

Hopefully everyone had a chance to wish Bonike a happy birthday last week!  And kudos this week to Div Patel from Amy Lee for great work at the VA, to Myles Nickolich from Lish Clark for coming in on a Sunday to speak with his clinic patient and family,  and to my team’s night resident Amanda Verma for making a life-saving diagnosis. Congratulations also to Duke Med Peds alum and current cardiology fellow Ann Marie Navvar for her election to AOA!

JARs, get ready for the upcoming fellowship planning meetings with Bill Hargett and me…Erin will be sending out announcements about the informational meetings … timelines, personal statements, letters of recommendation, etc.  Applying in primary care or hospital medicine?  Dr. Klotman and Dr. Svetkey have graciously funded the time of communications specialist Dr. Kat Pollack to host sessions on interview skills for hospital medicine and primary care jobs.  Stay tuned for more information about location and time of these valuable sessions.

Resident research grants are almost due! Questions…contact Dr. Arcasoy or me.

This week’s pubmed from the program goes to Joanne Wyrembak for her presentation on the Duke Cardiology Handoff Project at the Duke Patient Safety Symposium.  Kudos were sent by Cary Ward for her outstanding presentation of this great work, along with Jacob Doll, Jessie Seidelman, Jesse Tucker and Jonathan Buggey.  Excellent work!

 

Have a great week!

Aimee

Welcome Keerthi Krishnan!

 

What Did I Read This Week?

What Did I Read This Week

(submitted by Charles Hargett, MD)

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)

 

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.

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 completed the study, 281 (93%) underwent 24-hour blood-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.

QI CORNER

Aaron Mitchell, MD

 

After a brief hiatus, time for an update on the daily labs Choosing Wisely project. Last time I had checked in, during block 9 on Duke Gen Med there had been an increase in lab ordering compared to block 8. However, in the last couple of weeks, the block 9 interns kicked into high gear and started seriously cutting back on the number of routine labs they ordered. After being around 60% (of patients getting BOTH a CBC and a BMP each day) for the first two weeks, they dropped all the way to 45% in the last 2 weeks.

Great job guys! Special congrats are due to a couple of you in particular. Sommer Ebdlahad had the lowest rate of both tests per day at only 26.9%, which is just 0.1% shy of Winn Seay’s record from block 8! Eric Black-Maier had the lowest rate of patients getting EITHER test on a give day, at 63.2%.

From the Chief Residents Grand Rounds

Fri., April 3: Oncology, Dr. Herbert Hurwitz

Noon Conference Date Topic Lecturer Time 3/30/15 MKSAP Mondays: Hypertension Bonike Oloruntoba  12:00  Mediterra 3/31/15 Approach to Acid-Base Disorders Joe Govert 12:00  Chick Fil A 4/1/15 Renal Disease in Pregnancy  David Butterly 12:00  Cosmic 4/2/15 IM-ED Combined Conference: US Health Care System – Real Problems, Fake Solutions  Aaron Mitchell 12:00/2002  Dominos 4/3/15  Chair’s Conference  Chiefs  12:00  Saladelia                   From the Residency Office Faculty-Resident Research

This is a reminder to those of you involved in research and QI projects to consider applying for the annual “Faculty-Resident Research Grant” applications.

The applications due on April 12, 2015 for a funding start date on July 1, 2015.

Please find here the application instructions, forms, and new NIH format sample biosketch. Please include your mentor’s NIH Biosketch and signed support letter with your application.

Please see attached link 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

For a list of previously funded projects since 2011

http://residency.medicine.duke.edu/duke-program/resident-research/research-funding

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.

For any questions, please contact murat.arcasoy@dm.duke.edu

Wishing you continued success with your projects !

Murat and Aimee

 

Patient Experience Resources

Patient Experience Resources were added to Med Hub to aide all Residents with patient-provider communication.  For example, if you have a patient who waited for a really long in in the ED and is coming upstairs already upset, you may want to peruse the resources on Med Hubfirst before going to see the patient. There are about a dozen specific scenarios to choose from (e.g. Breaking Bad News, Refusing to Discharge to Rehab Facility, Medically Cleared but Pt Doesn’t want to Leave) so a few of them may apply to a patient scenario that one of you may be dealing with right now. Please see the attached reference document  to guide you to this particular link on the website.

MiniCEX MADNESS!

MiniCEX Madness will run through the end of March!  Our goal is to have everyone complete at least two (2) MiniCEX’s (inpatient or outpatient) by the end of the month.  Each Friday, the MedRes office will do a drawing of everyone who has had a MiniCEX completed on them for the prior week and the lucky winner will win a special prize!

As a reminder, MiniCEX’s evaluations are assigned to GenMed attendings at the start of each block, and the program requires each trainee to complete a total of six (6) MiniCEX’s each year, 3-inpatient and 3-outpatient.  Please remind faculty that they can complete the evaluation online in MedHub as a faculty-initiated evaluation.  Please see this week’s Clinic Corner (above) for more information on the MiniCEX process in the ambulatory setting.

The Changing Landscape of HIV/AIDS

Summary:

What: The Changing Landscape of HIV/AIDS

When: Tuesday April 7th (04/07/15) @ 5:30 pm

Where: Classroom 3 in TSCHE

RSVP: http://goo.gl/forms/kssrea7a82

Panelists:

  • Kevin SowersRN, MSN, President of Duke University Hospital
  • Neil ProseMD, Professor of Dermatology & Pediatrics
  • John Bartlett MD, Professorof Medicine, Global Health and Nursing at DUMC, and Professor of Medicine, Kilimanjaro Christian Medical Centre

————————————————————————————————————

Event Description:

This will be an interactive panel discussion to explore the narrative of healthcare workers during the HIV/AIDS crisis of the 1980s and the 1990s. The event will focus on the evolution of the disease from its initial notoriety and the stigma associated with providers willing to care for HIV patients, to present day advances in treating the disease. We will discuss the history of HIV/AIDS care at Duke and other institutions, the current state of HIV treatment and vaccines, and the recent advent of Pre-Exposure Prophylaxis (PrEP).

Please RSVP at the following link by Friday March 27th @5pm, http://goo.gl/forms/kssrea7a82 with your name, email, class year/affiliation and any dietary restrictions.

2015 Family Weekend

Invitations have been sent to the addresses you provided! When you speak to your families, please remind them to RSVP using the following link: bit.ly/dukefamily by May 8th.

If you didn’t provide an address but would like to invite family members, it’s not too late. Please let Erin Payne know and she is happy to mail an invitation or email your family member the details!

We are really looking forward to this exciting new tradition!

  Information/Opportunities

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

 

  Upcoming Dates and Events

May 28-30 – Family Weekend

June 6th – SAR Dinner, Hope Valley Country Club

June 13 – Spring Picnic

  Useful links

Internal Medicine Residency News, March 23, 2015

Mon, 03/23/2015 - 10:13
From the Director

What a great week! We are so excited to welcome the new intern class – and a big thank you to everyone for making this the #bestprogramever! We have an amazing group joining us in July, and it is a huge credit to all of you for bringing them here! If you haven’t seen the list yet, check it out here!

Kudos also this week to Ragnar Palsson from Joe Brogan for going “above and beyond” as DRH day float, to Linda Koshy from Cece Zhang for great work at the VA, and to both Linda and Cece from Aaron Mitchell on behalf of a few VA patients, to Coco Fraiche and Lauren Collins for great VA H & Ps, to Hal Boutte, Mike Dorry and med student Andrew Atia for earning gold stars from our patient last month on Gen Med, and to Joy Bhosai for winning the MiniCEX madness contest for this week. Kudos also to Ashley Hanlon, from Jane Trinh, for great work with a diagnosis in continuity clinic this week.

Thanks also to John Greene and Tim Mercer for outstanding SAR talks, and to all who participated in the Duke Patient Safety Summit.  Adrienne Belasco presented her work on “G-briefing” – great job.

We are gearing up for the annual ACGME survey – stay tuned for more information!

This week’s pubmed from the program goes to Brian Kincaid for his article in Family Medicine and Medical Science Research “Manifestations of Anxiety? Explaining Tachycardia and Hypertension in a Patient with POTS” Brian B Kincaid, Andrew J Muzyk*, Ronald J Kanter and Xavier A Preud’homme

Have a great week and GO DUKE!

Aimee

 

Match Day Excitement!

Incoming IM Intern Jon O’Donnell

Match Day Celebration at West End Billiards

What Did I Read This Week?

What Did I Read This Week

(submitted by Lynn Bowlby, MD)

Annals of Internal Medicine. Vol 162  No 4  2/17/15  pp 295-300

NIH Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain.

Chronic pain is one of the most challenging clinical issues we face as physicians. Ask any DOC resident—we see it every day and it is challenging!

This NIH workshop in September—with a panel of 7 experts and systematic review by the Pacific Norwest Evidence Based Practice Center (EPC)—addressed the major issue.

How can we manage chronic pain to “ maximize effectiveness and minimize harm? Pain is a huge issue both for clinicians as well as our culture.

Pain is the number one reason for disability claims. Opioids scripts have dramatically increased in the past 20 yrs, along with overdose and treatment for addiction. There are concerns for both over and under treating pain.

The panel dealt with many of the complex issues surrounding opioids and chronic pain. While some patients do benefit from opioids, it is now clear there are many problems. A 2013 National survey showed 53% of those older than 12 abusing analgesics obtained them free from a friend or relative. We have certainly seen this at the DOC.

The absence of evidence in many areas of opioids use and pain management is startling. Extended release opioids were approved for use  based on 12 week efficacy studies, yet we prescribe them for some patients for years. MDs are often unable to distinguish who would benefit from opioids and despite risk management tools there is little evidence to guide clinicians.

It does seem clear that chronic pain needs an individualized and multifaceted approach. Patients will respond differently to pain and clinicians will respond differently to patients in pain. There is a subset of pts, where opioids, given in a structured way, seems to help. There is no data on how to select appropriate patients, and ironically those at highest risk are the most likely to be prescribed opioids.

There do seem to be 3 distinct pain mechanisms—peripheral nociceptive (tissue damage or inflammation), peripheral neuropathic (peripheral n. damage), or centralized (disturbance in the processing of pain by brain/SC).

There is some evidence to suggest that the treatment of fibromyalgia with opioids may cause a worse long term course of pain. All chronic pain seems to have a centralized component and opioids may promote a progession from acute nociceptive pain to centralized pain. There is no evidence for rotating narcotics as some do, and opioid conversion scales vary widely. There is no data for how to reduce or stop opioid treatment. Harms of opioid use also include risk for falls and fracture, sexual dysfunction and MI.

The use of a more effective chronic disease management model may be helpful. While many other treatment options exist for pain management, the reality of primary care practices, where most treatment is given, often resorts to the quick option of writing a prescription. At the DOC we certainly see how much time and effort it takes to say no, or evaluate in detail the patients pain and other treatment options. The EPC report notes that most of the literature was of poor quality. There are many definitions even of chronic pain itself. Many researchers compare chronic non cancer with chronic cancer pain, but the 2 groups are still very heterogenous.  There is a need for longitudinal studies, but would be large and expensive.

And the final panel recommendations and summary included this—

“Particularly striking to the panel was the realization that evidence is insufficient for every clinical decision that a provider needs to make about the use opioids for chronic pain, leaving the provider to rely on his or her own clinical experience.”

Imagine if that were the case for antibiotics in pneumonia. There is a lot of work to do to learn more about how best to treat chronic pain.

 

 

From the Chief Residents Grand Rounds

Fri., March 27: Nephrology, Dr. Ruediger Lehrich

Noon Conference Date Topic Lecturer Time 3/23/15 MKSAP Mondays: Fluid and Electrolytes Steve Crowley/Chiefs  12:00 3/24/15 Obesity & Weight Management William Yancey 12:00 3/25/15 Diabetic Nephropathy  Susan Gurley 12:00/2001 3/26/15 Palliative Care Management of Chronic Medical Disease: COPD & CHF  Jason Webb 12:00/2001 3/27/15  Research Conference  12:00/2002                   From the Residency Office Faculty-Resident Research

This is a reminder to those of you involved in research and QI projects to consider applying for the annual “Faculty-Resident Research Grant” applications.

The applications due on April 12, 2015 for a funding start date on July 1, 2015.

Please find here the application instructions, forms, and new NIH format sample biosketch. Please include your mentor’s NIH Biosketch and signed support letter with your application.

Please see attached link 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

For a list of previously funded projects since 2011

http://residency.medicine.duke.edu/duke-program/resident-research/research-funding

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.

For any questions, please contact murat.arcasoy@dm.duke.edu

Wishing you continued success with your projects !

Murat and Aimee

 

MiniCEX MADNESS!

MiniCEX Madness will run through the end of March!  Our goal is to have everyone complete at least two (2) MiniCEX’s (inpatient or outpatient) by the end of the month.  Each Friday, the MedRes office will do a drawing of everyone who has had a MiniCEX completed on them for the prior week and the lucky winner will win a special prize!

As a reminder, MiniCEX’s evaluations are assigned to GenMed attendings at the start of each block, and the program requires each trainee to complete a total of six (6) MiniCEX’s each year, 3-inpatient and 3-outpatient.  Please remind faculty that they can complete the evaluation online in MedHub as a faculty-initiated evaluation.  Please see this week’s Clinic Corner (above) for more information on the MiniCEX process in the ambulatory setting.

Next Book Club Event

When: March 25th, 7-9 pm

Where: Searle Center Faculty Lounge

What book: The Spirit Catches You and You Fall Down by Anne Fadiman. This book tackles the conflict of Eastern v Western medicine through the true story of Lia Lee and her family, Hmong refugees from a war-torn Laos who relocated to California in the 1980s.

Similar to last time, snacks and drinks (yes, still wine) will be provided so let us know if you’re planning on attending so we have enough to go around.  Additionally, we again have a limited supply of FREE BOOKS for the first residents to RSVP.  The books have already been ordered so get back to us ASAP to reserve your free copy, we’ll be sending an email to the whole program soon!

We’re looking forward to seeing you all there!​

Thank you!

Laura M. Caputo, MD

laura.caputo@va.gov

laura.caputo@duke.edu

Back to Basics Curriculum

Dear Internal Medicine, Med-Peds and Med-Psych Residents,

We would like to invite you to participate in the creation of a core “Back to Basics” curriculum that contains foundational Internal Medicine subspecialty content for the Internist.

The objectives of this project are to:

1)- Build standard, core curriculum content for each subspecialty, geared towards the internist

2)- Generate teaching scripts for core topic that can be shared among residents, medical students, and teaching faculty (see the topics and slide set examples attached)

3)- Develop and amass supplemental teaching tools for each topic

4)- Engage subspecialty faculty (and fellows) to develop, share, maintain and deliver the teaching material during each rotation

5)- Create a valuable learning resource for residents by compiling the teaching scripts and supplemental tools in the form of a manual

www.SignUpGenius.com/go/20F0F44AEAA2AA4F85-back/23016617

 

 

Information/Opportunities

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

 

  Upcoming Dates and Events

May 28-30 – Family Weekend

June 6th – SAR Dinner, Hope Valley Country Club

June 13 – Spring Picnic

  Useful links

Celebrating Match Day 2015

Fri, 03/20/2015 - 16:29

Jon O’Donnell talks with internal medicine residency program director Aimee Zaas, MD, at Duke School of Medicine’s 2015 Match Day celebration. O’Donnell will join the residency program as a categorical intern this summer.

The Internal Medicine Residency Program filled all of its spots – 41 categorical, 11 preliminary (5 neurology, 2 dermatology, 2 radiation oncology, 1 anesthesiology, 1 ophthalmology), 6 med/peds and 2 med/psych – with outstanding applicants.

The categorical interns will come from 29 different institutions, including four from Duke, one from Duke-NUS and one from Nairobi. Sixteen of the categorical interns are female, 25 are male.

Internal Medicine Residency News, March 16, 2015

Mon, 03/16/2015 - 09:54
From the Director

It’s MATCH WEEK! Get ready to welcome the amazing new intern class — announcement will be just after 1 pm on Friday.  Reminder, there is no chair’s conference on Friday to get ready for the Duke med student match unveiling.  What does this mean? Well, you will get a chance to eat with your friends and colleagues.  And you will have ONE LESS HOUR of conference on Friday so there is no excuse for missing GRAND ROUNDS.  I know its hard to fit in all the conferences with the clinical care, but our attendance was pretty poor last Friday (and kudos to Adva Eisenberg for a great case presentation), so let’s give some support to our GR speakers!  Then we can all go celebrate the new interns at West End on Friday night.

Kudos this week go to Casey Farin from Josh Broder for great work in the ED, to Coco Fraiche from David Simel for excellent overnight admit notes, to Gena Foster from Ara Metjian for an excellent consult and to Matt Atkins from Lynn Bowlby for great care at the DOC.  Great case presented by Jesse Tucker during chair’s conference, with Brian Sullivan, Vedran Oruc, Gena Foster and others offering up some great suggestions for the differential.

This week’s MINICEX Madness winner is Aparna Swaminathan!  Thanks also to Anubha Agarwal, Bill McManigle, Jessica Morris, Nick Rohrhoff, Marc Samsky, Eric Ypder, Cecelia Zhang and Kahli Zietlow for having minicex’s completed this past week.

BRACKETS are here! Pay attention to your email for the Duke IM bracket so you can enter.

SARs, please check your procedure logs – it’s time to get them updated, and make some plans to complete anything that you haven’t done.  Yes, reading ECGs is on there.

Get ready for the newest way to get involved – the Duke IM Social Action Council.  Erin Payne is taking the lead in forming a group of residents, fellows and faculty who would like to come together to organize our service to the community. First meeting will be coming up in April – if you have questions, please contact Erin or me.

This week’s pubmed from the program goes to Ben Peterson who will be presenting his abstract “Rate Control Alone Is Insufficient to Treat Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy” at the upcoming Heart Rhythm Society Meeting.  Co-authors include  Sean Pokorney, MD, Andrew Wang, MD, Dagny Noeth, MD, James P. Daubert, MD, FHRS and Albert Y. Sun, MD

Have a great MATCH and MARCH MADNESS week!

Aimee

What Did I Read This Week?

Bonike Oloruntoba, MD

What Did I Read This Week

(submitted by Omobonike Oloruntoba, MD)

WHAT I READ THIS WEEK: False Positive Test Results in a Patient with Severe Hepatitis: The Risk of Treating the Numbers

JAMA Intern Med. 2015;175(2):161-162. doi:10.1001/jamainternmed.2014.6686.

In September 2013, JAMA Internal Medicine called “Teachable Moments” as a result of the Do No Harm Project dedicated to publishing vignettes describing harms from overuse from trainees around the country.

CASE PRESENTATION:

A previously healthy married man in his early 50s presented with a 1-week history of epigastric pain, jaundice, dark urine, and pale stools. His investigations revealed severe hepatitis (aspartate aminotransferase [AST] level, 3948 U/L; alanine aminotransferase [ALT] level, 6502 U/L), early hepatic dysfunction (bilirubin level, 11.11 mg/dL; international normalized ratio, 1.62), and a slightly elevated acetaminophen level (9.53 µg/mL). The emergency physician, admitting internist, and consulting hepatologist repeatedly asked him whether he had ingested any acetaminophen, each time with increasing insistence about being truthful. He adamantly denied taking any acetaminophen and stated that there was certainly no attempt to overdose. However, given the degree of hepatic dysfunction, the team, in consultation with the local poison control center, initiated a delayed ingestion N-acetylcysteine protocol (140 mg/kg over the first hour followed by 70 mg/kg). (To convert AST and ALT to microkatals per liter, multiply by 0.0167; to convert bilirubin to micromoles per liter, multiply by 17.104; to convert acetaminophen to micromoles per liter, multiply by 6.614.)

Several hours later, the patient’s hepatitis serologic test was positive for hepatitis B core IgM (HBcAb IgM) antibodies but negative for hepatitis B surface antigen (HBsAg) and antibody (HBsAb). Concerned that this represented the “window phase” and that he might have an acute hepatitis B infection, multiple members of the health care team asked him whether he had engaged in risky sexual activity or illicit drug use. The patient stated that he had not done so and became very anxious about having contracted hepatitis B and the potential long-term sequelae.

The following day, the local public health office became involved because hepatitis B is on the list of infectious diseases that must be reported to the local medical officer of health. As part of their contact tracing protocol, the public health office contacted the patient’s wife to let her know that she was at potential risk and that she should be tested too. Two days into the hospitalization, the team discovered that the actual diagnosis was an acute hepatitis A infection (hepatitis A IgM positive) and not an acetaminophen overdose or a subacute hepatitis B infection.

CLINICAL PEARL: Acute hepatocellular injury with aminotransferase >1000 can be commonly attributed to 5 etiologies: severe viral hepatitis, drugs, ischemia, Wilson’s or Autoimmune Hepatitis.

Acetaminophen and Elevated Bilirubin:

Acetaminophen toxicity is the most common cause of acute liver failure in the U.S. and quantification of plasma acetaminophen can be used to predict the severity of injury. Using 6 different acetaminophen quantitation systems on plasma obtained from patients with acute liver failure (unrelated to acetaminophen toxicity), a group found that the most commonly used acetaminophen assays were markedly affected by plasma from patients with liver injury and increased bilirubin concentrations. Hyperbilirubinemia changes the range of light that the blood emits, which the machine detects and falsely interprets as representing the presence of acetaminophen. Most hospitals use light chromatography to measure the concentration of acetaminophen.

IMPORTANT CAVEATS:

  1. Duke Laboratories does not use light chromatography for acetaminophen levels.
  2. Most patients with acute acetaminophen overdose are seen within 48 hours of ingestion when they will most likely have a mildly increased bilirubin concentration and therefore less likely to have a false positive result.

WINDOW PERIOD: Hepatitis B

Acute Hepatitis B can be diagnosed during the time when HBsAg has become undetectable and anti-HBs has not yet appeared. During this window period the diagnosis of acute HBV is made based on positive IgM anti-HBc titers, which will be the only clue to acute infection.

POTENTIAL CAUSES OF ISOLATED HEPATITIS B CORE ANTIBODY

  1. False Positives
  2. Window Period
  3. Resolved hepatitis B infection with waning titers of anti-HBs. The detection of anti-HBe would support the diagnosis of prior infection. HBV DNA will be negative.
  4. Remote infection with persistent “occult” infection. The diagnosis requires measurement of detectable HBV DNA and the infection is considered chronic, since HBV is actively produced and detectable in serum.

FALSE POSITIVE ANTI-HBc

False positive anti-HBc results may occur when nonspecific IgM binds to the HBcAg peptides used as a probe in the assay. Less than 3% of positive serological HBcAb IgM test results are false positive.

MANAGEMENT OF ISOLATED ANTI-HBc:

  1. If the patient has no risk factors for hepatitis B – Probable false positive/non-immune patient
  2. If the patient has risk factors for hepatitis B – Repeat
  3. If aminotransferases are significantly elevated in the setting of positive IgM anti-HBc, obtain HBV DNA in the acute setting and repeat serologic testing several weeks later should yield a positive anti-HBs result.

REFERENCES:

  1. Polson J, Wians FH Jr, Orsulak P, et al; Acute Liver Failure Study Group. False-positive acetaminophen concentrations in patients with liver injury. Clin Chim Acta. 2008;391(1-2):24-30
  2. Lok AS, McMahon BJ. Chronic hepatitis B: update 2009. Hepatology. 2009; 50(3):661
  3. http://depts.washington.edu/hepstudy/hepB/index.html

QI CORNER

Aaron Mitchell, MD

 

First this week, updates on the Choosing Wisely projects. We passed a milestone last Wednesday – as of then, the abbreviation “FFWU” was nowhere to be found on ANY of the gen med signouts! Way to go, guys! This project has been a huge success. Instead, the signouts are containing a lot MORE intelligent anticipatory guidance, to help cross-cover think about what kinds of studies actually might be high-yield for your patients. I’d like to give a shout-out in particular to Ryan Orgel, who had the most well-thought out and helpful guidance for the patients on his team.

Regarding the daily labs project, kudos this week go to Kirema Garcia-Reyes for her parsimonious ordering of routine lab studies. Since she started on gen med, her patients have gotten a daily CBC and BMP only 28.6% of the time! This is in comparison to an average of 59.5% on gen med before the project started, and of 43% during block 8. A great demonstration of how few labs you actually need to take good care of patients!

In terms of conference next week, we have an M&M coming up on Wednesday at noon conference. You may also be hearing more about the Choosing Wisely projects in the near future.

Finally, there is a new QI project opportunity for anyone who is interested. Dr Kipnes in hospital medicine is interested in describing and writing up our experience in the use of ketamine for sickle cell pain crisis. Sounds like this is a novel use of ketamine in the literature, so should be an area to make an impact it. Let me or Dr Kipnes know if you are potentially interested and would like to hear more.

CLINIC CORNER

New faces at Pickett

Jasmine Jenkins, LPN

Jeffrey Clough, MD

Audrey Metz, MD

We are saying farewell to Dr. Rookwood 4/15/15 and our PA Marie Evangelisa 6/1/15. They will be missed.  Make sure you say goodbye!

SARS are starting to say goodbye to their patients. Now is the time to start running your PCP list and writing what needs to be done for the patient when handed off to the Interns. You can watch this video or ask me when you are in clinic. Your last clinic session will be reserved for this.
https://vmw-msc.duhs.duke.edu/production/DUHS_Common/Epic_Ambulatory/rubin_tips_create_list_PCP/rubin_tips_create_list_PCP.html

Spring Cleaning: in April we will be collecting any items you may want to donate to the Durham Rescue Mission (a few blocks away). If you have old clothes, books, blenders please make a note to bring them in. We will have a truck pick up all these items!

Sincerely,

Sharon Rubin, MD, FACP

 

  From the Chief Residents Grand Rounds

Fri., March 20: General Medicine, Alex Cho

Noon Conference Date Topic Lecturer Time 3/16/15 MKSAP Mondays: Hypertension Steve Crowley/Chiefs  12:00 3/17/15 MED-PEDS Combined: SAR Talk  Greene/Mercer 12:00 3/18/15 Resident M&M  QI Team 12:00 3/19/15 QI Patient Safety Noon Conference 12:00/2001 3/20/15  Match Day Celebration  Chiefs  12:00                   From the Residency Office MiniCEX MADNESS!

MiniCEX Madness will run through the end of March!  Our goal is to have everyone complete at least two (2) MiniCEX’s (inpatient or outpatient) by the end of the month.  Each Friday, the MedRes office will do a drawing of everyone who has had a MiniCEX completed on them for the prior week and the lucky winner will win a special prize!

As a reminder, MiniCEX’s evaluations are assigned to GenMed attendings at the start of each block, and the program requires each trainee to complete a total of six (6) MiniCEX’s each year, 3-inpatient and 3-outpatient.  Please remind faculty that they can complete the evaluation online in MedHub as a faculty-initiated evaluation.  Please see this week’s Clinic Corner (above) for more information on the MiniCEX process in the ambulatory setting.

2015 Family Weekend

We are excited to announce Duke IM Residency’s FIRST ever FAMILY WEEKEND on May 28th- 30th!!!! It will be a great way to show our families what we do and let them meet some of the amazing people we work with every day!  It is sure to be a lot of fun and we really hope your families can attend!

Please fill out the following survey by Monday, March 16th with whomever you would like us to invite!https://duke.qualtrics.com/SE/?SID=SV_emrWRxuaHUWuimV

Next Book Club Event

When: March 25th, 7-9 pm

Where: Searle Center Faculty Lounge

What book: The Spirit Catches You and You Fall Down by Anne Fadiman. This book tackles the conflict of Eastern v Western medicine through the true story of Lia Lee and her family, Hmong refugees from a war-torn Laos who relocated to California in the 1980s.

Similar to last time, snacks and drinks (yes, still wine) will be provided so let us know if you’re planning on attending so we have enough to go around.  Additionally, we again have a limited supply of FREE BOOKS for the first residents to RSVP.  The books have already been ordered so get back to us ASAP to reserve your free copy, we’ll be sending an email to the whole program soon!

We’re looking forward to seeing you all there!​

Thank you!

Laura M. Caputo, MD

laura.caputo@va.gov

laura.caputo@duke.edu

Register for 10th Annual Duke Medicine Patient Safety and Quality Conference

We invite you to register for the 10th Annual Duke Medicine Patient Safety and Quality Conference.  The conference will be held Friday, March 20, 2015 at the Durham Convention Center, 301 West Morgan Street, in Downtown Durham NC.  Registration will begin at 7am with conference activities from 8am until 4:30pm. The conference agenda is attached.

Two plenary lectures will be presented:  “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age” by Robert Wachter, MD; Professor,  Associate  Chairman,  Department  of  Medicine,  and Chief of  the  Division  of  Hospital  Medicine, University  of  California,  San  Francisco and “The Changing Landscape of Patient Safety” by Tejal Gandhi, MD, MPH, CPPS; President and CEO of the National Patient Safety Foundation (NPSF).

One of the conference highlights is the poster session.  Come learn from the poster presentations and speaking with the abstract writers.

Afternoon breakout sessions include:

  • Creating a Psychologically Safe Environment: Behaviors that promote a culture of safety.
  • The Quality, Safety and Value Movements: A Conversation with Bob Wachter
  • Best Practices in Resiliency: Thriving versus Surviving during Times of Change (The Duke Resilience Mini-course)
  • Maximizing a Multi-Generational Workforce in Safety and Quality initiatives
  • The Challenges of How We Think…Cognitive Biases, Cognitive Errors, & Metacognition strategies
  • Topic: Learning from Defects: A Practical Tool for Resolving Threats to Safety at the Unit Level
  • Handoffs: The Evolving Story of Inpatient Handoffs: A “new” obstacle in the quest for quality patient care
  • Disruptive Violent Patient and Visitors: Perspectives from the clinical provider,  risk management and Duke Police. (PLEASE NOTE: this is a half day workshop. This session will begin at 1:15 and go until 4:30)

Register online today!

https://www.eventbrite.com/e/10th-annual-duke-medicine-patient-safety-and-quality-conference-tickets-15537471997

Back to Basics Curriculum

Dear Internal Medicine, Med-Peds and Med-Psych Residents,

We would like to invite you to participate in the creation of a core “Back to Basics” curriculum that contains foundational Internal Medicine subspecialty content for the Internist.

The objectives of this project are to:

1)- Build standard, core curriculum content for each subspecialty, geared towards the internist

2)- Generate teaching scripts for core topic that can be shared among residents, medical students, and teaching faculty (see the topics and slide set examples attached)

3)- Develop and amass supplemental teaching tools for each topic

4)- Engage subspecialty faculty (and fellows) to develop, share, maintain and deliver the teaching material during each rotation

5)- Create a valuable learning resource for residents by compiling the teaching scripts and supplemental tools in the form of a manual

www.SignUpGenius.com/go/20F0F44AEAA2AA4F85-back/23016617

Neph Madness!

I would like to invite you to play NephMadness. This initiative celebrates all things kidney during the entire month of March (National Kidney Month). NephMadness (brought to you by the AJKD blog, the official blog of the American Journal of Kidney Diseases) is an online game that invites everyone to predict the “winners” of competing medical concepts. Like in March Madness, where fans try to pick the winner of the NCAA Basketball Tournament, NephMadness provides brackets for participants to fill out and then compete with a worldwide community of peers.

The medical concepts—or “teams”—are divided into eight regions highlighting the intersection between nephrology and other specialties. They are: Obstetric Nephrology, Infectious Disease and Nephrology, The Heart and Kidney Connection, Nephrology and Nutrition, Genetic Nephrology, Critical Care Nephrology, Nephrology and Vascular Surgery, and Onconephrology. Detailed scouting reports with background information is all provided at the blog.

NephMadness begins March 1st and entries are collected until March 22nd when the game begins at roughly the same pace as the real NCAA tournament.

Winners of the concept matchups will be determined by a blue-ribbon panel of nephrologists and physicians. Those who guess the most correct matchups correctly will have a chance to win AJKD/NephMadness swag, textbooks, and fame!

Go to www.ajkdblog.org to review the scouting reports for each concept or go to the bracket submission site to place your pics.

Matthew A. Sparks, MD

 

Information/Opportunities

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

 

  Upcoming Dates and Events

March 20, 2015 – Match Day Celebration, West End Billiards

June 6th – SAR Dinner, Hope Valley Country Club

June 13 – Spring Picnic

  Useful links

Ambulatory Care Leadership Track residents visit N.C. General Assembly

Thu, 03/12/2015 - 14:26

ACLT residents with Dr. Robin Cummings, director of North Carolina Medicaid.

Daniella Zipkin, MD, associate professor of medicine (General Internal Medicine) shared this report about the Ambulatory Care Leadership Track residents’ recent trip to meet with legislators in the North Carolina General Assembly:

Residents in the Ambulatory Care Leadership Track traveled to Raleigh on March 4 for an advocacy day at the N.C. General Assembly. Trainees met with N.C. House and N.C. Senate health care leadership, including Dr. Robin Cummings, N.C. Medicaid Director; Rep. Nelson Dollar (R – Wake); Rep. Donny Lambeth (R – Forsyth); Rep. Marilyn Avila (R – Wake); Sen. Fletcher Hartsell (R – Cabarrus); and Sen. Mike Woodard (D – Durham).

Residents shared outcomes from the Duke Outpatient Clinic’s HomeBASE program, a collaborative, team-based care model between our patients, nurse case managers, physicians, mental health providers, and social workers.

The HomeBASE program, led by DOC’s medicine-psychiatry attending Natasha Cunningham, MD, nurse case manager Marigny Manson, Julia Gamble, NP, and Jan Dillard, MSW, targets patients with mental health comorbidities and excessive ED usage, successfully shifting the focus of care to the clinic setting.

The ACLT residents, including Matthew Atkins, MD; Jacob Feigal, MD; Ryan Jessee, MD; Claire Kappa, MD; Adrienne Klement, MD; Amy Jones, MD; James Lefler, MD; Dinushika Mohottige, MD; and Aaron Mitchell, MD, chief resident for quality improvement and patient safety at the Durham VA, showcased the effectiveness of this program and encouraged state lawmakers to pursue provider-led accountable care reform to help control health care costs and improve outcomes for patients.

Residents also shared patient’s stories in an effort to make their struggles come to life for legislators. Overall, the residents were very well received at the Capitol and found the experience both powerful and illuminating.

See the one-page “leave behind” that the ACLT created for legislators here.

The HomeBASE program is part of the overall DOC redesign implemented in July 2013. Led by Adia Ross, MD, MHA; Alex Cho, MD, MBA, assistant professor of medicine (General Internal Medicine); Lynn Bowlby, MD, associate professor of medicine (General Internal Medicine); David Zaas, MD, MBA, president of Duke Raleigh Hospital; Aimee Zaas, MD, MHS, associate professor of medicine (Infectious Diseases) and director, Internal Medicine Residency Program, and many others, the DOC redesign will be presented at Medicine Grand Rounds on March 20.

Internal Medicine Residency News, March 9, 2015

Mon, 03/09/2015 - 09:55
From the Director

It’s official…best night of the year to be on nights (aka “spring forward”) has passed.   Great representation as well (way to go, interns!) at Motorco for a great Duke-UNC game with an even better ending! Thanks Erin Payne for organizing.

Other big thanks to our recent ACRs Erin Boehm, Angela Lowenstern and Mike Woodworth.  Welcome to ACRs Nick Rohrhoff, Carli Lehr and Adrienne Belasco also!  We also enjoyed a fantastic grand rounds by Aaron Mitchell’s visiting professor Dr. Gilbert Welch from Dartmouth. Additional kudos to Linda Koshy from Jason Webb for great work on 9300.

Final totals are in for the Charity Auction…we are so happy to be donating over $10,000 to Senior PharmAssist and the DOC Patient Fund.  I’m looking forward to paying my dues and covering for Dr. Chris Hostler this week on GERM! We are also making plans to start our first SOCIAL ACTION COUNCIL for the residency program – we would love this group to be in charge of our current community service activities as well as plan new ways for us to get involved in helping our community.  Details to follow!  One of your upcoming opportunities to get involved is the 2nd Annual Spring for Support 5K benefitting the Duke Cancer Patient Support Program, on March 28.  Please see the information at the end of Med Res News for details – Dr. G. is a big supporter of this event so you will be sure to see him there!

Congrats to our MiniCEX Madness winner Tim Hinohara! Remember, if you get a minicex completed in the month of March, you are eligible for our weekly prize drawing.  Other eligible residents were Michael Dorry, William McManigle, Andy Mumm, Yi Qin, Iris Vance and Cecelia Zhang.

Looking forward to the networking event on Tuesday at Dr. Klotman’s – thank you JARs and faculty for your RSVP’s.  The fellowship directors will be organizing meet and greets in the coming months, so keep your eye out for those emails and announcements as well.

This week’s Pubmed from the Program goes to 2014 Grad (and new dad!) Hany Elmariah for his poster detailing the results of the resident burnout project that was accepted to the Duke Patient Safety Symposium (presenter Joel Boggan!)

 

Have a great week!

Aimee

What Did I Read This Week?

 

What Did I Read This Week

(submitted by Murat Arcasoy, MD)

“Feeding tube placement in patients with advanced cancer: a teachable moment” by Bowman and Widera, in JAMA Internal Medicine, January 2015 and “My own life” by Oliver Sacks, MD and author, Professor of Neurology, NYU, Op-Ed article NY Times February 19, 2015

Why these articles

End-of-life decisions can frequently present formidable challenges for us and our terminally ill patients and their families, during the process of shared decision making. “The teachable moment” series in JAMA, authored by trainees, are truly wonderful. Every day, I learn a great deal from the experiences of our residents, so I was particularly curious about this brief article authored by an Internal Medicine resident at another academic medical center.

In his newspaper article from last week, Dr. Oliver Sacks says: “ I am now face to face with dying. But I am not finished with living”, describing his confrontation with his own mortality after finding out he has metastatic cancer. Here, he teaches us not just as a physician, but also as a patient, sharing intimately, his marvelous outlook on life, even at this juncture.

What is the “Teachable Moment” article about

This article describes the case of a woman in her 70s, very ill with metastatic lung cancer, BMI of 16, who had a PEG tube placed in an effort to extend her life to allow for visiting family to arrive. She was re-admitted one week later with inability to tolerate enteral feeding and cellulitis at the tube site. She died 18 days after PEG tube placement. The family later expressed frustration that this invasive procedure was performed despite limited life expectancy and that, had they – as the patient’s surrogates- understood her prognosis, they would not have pursued a PEG. The resident and her co-authors then reflect on this case.

What did I learn

In a large cohort of all hospitalized patients, 1–year mortality after PEG placement was 60%, with in-hospital mortality of 20%. In hospital-mortality was highest for lung cancer patients, reaching 50%. In another community-based cohort of all patients with PEG, 70% had no improvement of functional, nutritional or general health status. In another study, it turns out that surrogates – not patients- consented for 92% of PEG placements, and that >90% of surrogates expected the patients would survive >1 year, highlighting a major discrepancy between surrogates’ expectations from artificial nutrition / hydration versus actual clinical outcomes.

Dr. Oliver Sacks – a doctor who can write – borrowed the title of his newspaper article “My own life” from the title of the autobiography by his favorite philosopher David Hume,- whose words from more than two centuries ago when facing his own mortality- provided Sacks with encouragement. Many of you may have read Sacks’ wonderful books “Awakenings” or “The man who mistook his wife for a hat”. I learned that he now as an autobiography coming out this spring, which I look forward to reading. The link for Sacks’ article:

http://www.nytimes.com/2015/02/19/opinion/oliver-sacks-on-learning-he-has-terminal-cancer.html?_r=0

“Teachable moments” and “Less is more” series in JAMA Internal Medicine

Teachable moments are wonderful articles authored by trainees, encouraging them to submit a clinical vignette (entitled “Story from the Front Lines”) that brings attention to the harms that can result from medical overuse and from underuse of needed medical interventions. Some of these are “Less Is More” articles that present patients’ and physicians’ perspectives on their health care experiences, with special emphasis on examples when more care is not always better, even to the point where it is perceived as harmful. The subject of the article is expected to highlight the value of improved patient-centered outcomes associated with lesser intensity or quantity of interventions.

Many of you – our residents – think of and encounter similar challenges every day, as you try to make this world a better place, one patient at a time. I encourage you to share your experiences with the medical community!

QI CORNER

Aaron Mitchell, MD

 

First this week, a quick reminder about the Patient Safety and Quality Council meeting on Wednesday. This will be at 5:30pm in the Med Res Library, and will focus on the Choosing Wisely projects; feel free to bring other patient safety or QI ideas you might have.

As for Choosing Wisely updates this week, we continue to do an AMAZING JOB in getting the “FFWU” phrase out of our signouts. More thoughtful advice has taken its place, and the number of low-yield studies getting ordered has come down as a result. However, our rates of lab ordering on Duke Gen Med have ticked back up since the start of block 9. One thing we are learning so far is that it is us residents who often want to order tests, rather than our supervisors. If you are undecided about whether you patient needs a particular lab tomorrow, consider asking your upper-levels and attendings – you may very well end up hearing that it isn’t necessary at all!

 

CLINIC CORNER

DOC Clinic Corner

March 9, 2015

The big news this week was that the ACLT residents traveled to Raleigh on March 4th for an advocacy day at the General Assembly. Trainees met with NC House and NC Senate health care leadership, including Dr. Robin Cummings, NC Medicaid Director, Rep. Nelson Dollar (R – Wake), Rep. Donny Lambeth (R – Forsyth), Rep. Marilyn Avila (R – Wake), Sen. Fletcher Hartsell (R – Cabarrus), and Sen. Mike Woodard (D – Durham).

Residents shared outcomes from the DOC’s HomeBASE program, a collaborative, team-based care model between our patients, nurse case managers, physicians, mental health providers, and social workers. The HomeBASE program, led by our medicine-psychiatry attending Natasha Cunningham, nurse case manager Marigny Manson, Julia Gamble NP, and Jan Dillard MSW, targets patients with mental health comorbidities and excessive ED usage, successfully shifting the focus of care to the clinic setting. The ACLT residents showcased the effectiveness of this program and encouraged state lawmakers to pursue provider-led accountable care reform to help control health care costs and improve outcomes for patients. Residents also shared patient’s stories in an effort to make their struggles come to life for legislators. Overall, the ACLT was very well received at the Capitol and found the experience both powerful and illuminating.

See the one-page “leave behind” that the ACLT created for legislators here

The HomeBASE program is part of the overall DOC redesign implemented in July of 2013. Led by Adia Ross (MLPR class of 2013), Alex Cho, Lynn Bowlby, David Zaas, Aimee Zaas and many others, the DOC redesign will be presented at Department of Medicine Grand Rounds on March 20th. We hope to see you all there!

See the March DOC Newsletter here!

 

Director of North Carolina Medicaid, Dr. Robin Cummings

 

Finishing a meeting with Rep. Donny Lambeth

 

Sen. Mike Woodard of Durham, Roxboro, and Caswell counties

 

  From the Chief Residents Grand Rounds

Fri., March 13: Geriatrics, Dr. Heidi White

Noon Conference Date Topic Lecturer Time Vendor 3/9/15 MKSAP Mondays: Glomerular Diseases Bonike Oloruntoba  12:00 3/10/15  PEAC Study Hall  Chiefs 12:00 – MedRes 3/11/15  Evidenced Based Management of HTN  Daniella Zipkin 12:00 3/12/15  Management & Evaluation of Renal Transplant Patients  Matthew Ellis 12:00/2001 3/13/15  Chair’s Conference  12:00                   From the Residency Office MiniCEX MADNESS!

MiniCEX Madness starts today and will run through the end of March!  Our goal is to have everyone complete at least two (2) MiniCEX’s (inpatient or outpatient) by the end of the month.  Each Friday, the MedRes office will do a drawing of everyone who has had a MiniCEX completed on them for the prior week and the lucky winner will win a special prize!

As a reminder, MiniCEX’s evaluations are assigned to GenMed attendings at the start of each block, and the program requires each trainee to complete a total of six (6) MiniCEX’s each year, 3-inpatient and 3-outpatient.  Please remind faculty that they can complete the evaluation online in MedHub as a faculty-initiated evaluation.  Please see this week’s Clinic Corner (above) for more information on the MiniCEX process in the ambulatory setting.

2015 Family Weekend

We are excited to announce Duke IM Residency’s FIRST ever FAMILY WEEKEND on May 28th- 30th!!!! It will be a great way to show our families what we do and let them meet some of the amazing people we work with every day!  It is sure to be a lot of fun and we really hope your families can attend!

Please fill out the following survey by Thursday, March 12th with whomever you would like us to invite!https://duke.qualtrics.com/SE/?SID=SV_emrWRxuaHUWuimV

Next Book Club Event

When: March 25th, 7-9 pm

Where: Searle Center Faculty Lounge

What book: The Spirit Catches You and You Fall Down by Anne Fadiman. This book tackles the conflict of Eastern v Western medicine through the true story of Lia Lee and her family, Hmong refugees from a war-torn Laos who relocated to California in the 1980s.

Similar to last time, snacks and drinks (yes, still wine) will be provided so let us know if you’re planning on attending so we have enough to go around.  Additionally, we again have a limited supply of FREE BOOKS for the first residents to RSVP.  The books have already been ordered so get back to us ASAP to reserve your free copy, we’ll be sending an email to the whole program soon!

We’re looking forward to seeing you all there!​

Thank you!

Laura M. Caputo, MD

laura.caputo@va.gov

laura.caputo@duke.edu

Register for 10th Annual Duke Medicine Patient Safety and Quality Conference

We invite you to register for the 10th Annual Duke Medicine Patient Safety and Quality Conference.  The conference will be held Friday, March 20, 2015 at the Durham Convention Center, 301 West Morgan Street, in Downtown Durham NC.  Registration will begin at 7am with conference activities from 8am until 4:30pm. The conference agenda is attached.

Two plenary lectures will be presented:  “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age” by Robert Wachter, MD; Professor,  Associate  Chairman,  Department  of  Medicine,  and Chief of  the  Division  of  Hospital  Medicine, University  of  California,  San  Francisco and “The Changing Landscape of Patient Safety” by Tejal Gandhi, MD, MPH, CPPS; President and CEO of the National Patient Safety Foundation (NPSF).

One of the conference highlights is the poster session.  Come learn from the poster presentations and speaking with the abstract writers.

Afternoon breakout sessions include:

  • Creating a Psychologically Safe Environment: Behaviors that promote a culture of safety.
  • The Quality, Safety and Value Movements: A Conversation with Bob Wachter
  • Best Practices in Resiliency: Thriving versus Surviving during Times of Change (The Duke Resilience Mini-course)
  • Maximizing a Multi-Generational Workforce in Safety and Quality initiatives
  • The Challenges of How We Think…Cognitive Biases, Cognitive Errors, & Metacognition strategies
  • Topic: Learning from Defects: A Practical Tool for Resolving Threats to Safety at the Unit Level
  • Handoffs: The Evolving Story of Inpatient Handoffs: A “new” obstacle in the quest for quality patient care
  • Disruptive Violent Patient and Visitors: Perspectives from the clinical provider,  risk management and Duke Police. (PLEASE NOTE: this is a half day workshop. This session will begin at 1:15 and go until 4:30)

Register online today!

https://www.eventbrite.com/e/10th-annual-duke-medicine-patient-safety-and-quality-conference-tickets-15537471997

Back to Basics Curriculum

Dear Internal Medicine, Med-Peds and Med-Psych Residents,

We would like to invite you to participate in the creation of a core “Back to Basics” curriculum that contains foundational Internal Medicine subspecialty content for the Internist.

The objectives of this project are to:

1)- Build standard, core curriculum content for each subspecialty, geared towards the internist

2)- Generate teaching scripts for core topic that can be shared among residents, medical students, and teaching faculty (see the topics and slide set examples attached)

3)- Develop and amass supplemental teaching tools for each topic

4)- Engage subspecialty faculty (and fellows) to develop, share, maintain and deliver the teaching material during each rotation

5)- Create a valuable learning resource for residents by compiling the teaching scripts and supplemental tools in the form of a manual

www.SignUpGenius.com/go/20F0F44AEAA2AA4F85-back/23016617

Neph Madness!

I would like to invite you to play NephMadness. This initiative celebrates all things kidney during the entire month of March (National Kidney Month). NephMadness (brought to you by the AJKD blog, the official blog of the American Journal of Kidney Diseases) is an online game that invites everyone to predict the “winners” of competing medical concepts. Like in March Madness, where fans try to pick the winner of the NCAA Basketball Tournament, NephMadness provides brackets for participants to fill out and then compete with a worldwide community of peers.

The medical concepts—or “teams”—are divided into eight regions highlighting the intersection between nephrology and other specialties. They are: Obstetric Nephrology, Infectious Disease and Nephrology, The Heart and Kidney Connection, Nephrology and Nutrition, Genetic Nephrology, Critical Care Nephrology, Nephrology and Vascular Surgery, and Onconephrology. Detailed scouting reports with background information is all provided at the blog.

NephMadness begins March 1st and entries are collected until March 22nd when the game begins at roughly the same pace as the real NCAA tournament.

Winners of the concept matchups will be determined by a blue-ribbon panel of nephrologists and physicians. Those who guess the most correct matchups correctly will have a chance to win AJKD/NephMadness swag, textbooks, and fame!

Go to www.ajkdblog.org to review the scouting reports for each concept or go to the bracket submission site to place your pics.

Matthew A. Sparks, MD

Personalized Medicine Workshop Series

Dr Susanne Haga and faculty from the Center for Applied Genomics and Precision Medicine have developed a 6-session workshop series on personalized medicine and interdisciplinary practice. The workshop series will take place this March 3 – May 5 and all clinicians are invited to register for the workshop series. Each session will include a lecture component as well as an interactive skills-based component. Following participation in the course, all participants should be able to identify patients with genetic predisposition to disease and/or disease associated with genetic causality, determine appropriateness of genomic testing including who should have testing and what test is most fitting, interpret genomic testing results and apply those results to treatment, provide information about genomics, disease risk, and testing tailored for each patient, and work together as a team to deliver these services. Attendees will be asked to complete surveys assessing knowledge and satisfaction in order to improve the course for future use. Interested providers can contact program coordinator Rachel Mills (r.mills@duke.edu) for more information and to register for the course.

 

Information/Opportunities

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

 

  Upcoming Dates and Events

March 10, 2015 – JAR Networking Event

March 20, 2015 – Match Day Celebration, West End Billiards

June 6th – SAR Dinner, Hope Valley Country Club

  Useful links

Internal Medicine Residency News, March 2, 2015

Mon, 03/02/2015 - 10:46
From the Director

What a great end to the week! Despite the snow and ice (and a big thank you to everyone who braved the elements to make it into work), our interns enjoyed a fantastic Friday leading up to an incredible 15th Annual Duke IM Residency Charity Auction.  Many many kudos and thanks to our auction co-chairs Adrienne Belasco and Allyson Pishko, and their amazing team of Andrea Sitlinger, Jenny Van Kirk, Azalea Kim, Christine Bestvina and Marc Samsky.  Thanks to Olinda Pineda, Maria Abril, Jessie Seidelman, and Aaron Mitchell for assisting with donations.  Also thank you to Lauren Dincher, Lynsey Michnowicz and Erin Payne for their amazing work on Friday night, as well as the incomparable Dr. G for emcee-ing.  Thank you also to Lynn Bowlby and Dani Zipkin for donating clinic time, to David Butterly, Nancy Allen, Jane Trinh, Tom Bashore, David Simel, Larry Greenblatt, Diana McNeill, Heather Whitson, Ken Lyles, Mary Klotman and Susanna Naggie for donating auction items,  as well as Myles Nickolich, Jesse Tucker, Brian Sullivan and Marc Samsky.

My kids hands are STILL green, but now a lifelong dream of being on DoubleDare has been fulfilled for the chiefs and me.  Great night for a great cause.  Thank you also to the great representation from our attendings and residents!

Other kudos this week go to Tony Lozano from Pooh Setji and Joanna Kipnes for great work on Duke Gen Med, to Jenny Van Kirk from the 7800 nurses, to John Wagener from his gen med interns Maggie Infeld and Sweta Sengupta (he ended a great month by giving them a ride home in the snow) and to Jon Buggey from Dani Zipkin for outstanding work at the DOC.  An enormous THANK YOU to all who covered for our interns on Friday – much appreciated by all.

Hard to believe it is MARCH!! Countdown to Match Day (yes, interns, people are literally lining up to take your job) begins! We have a few things on the books before Match Day, including MiniCex Madness — try to get 2 MiniCEX’s done this month, the Duke-Carolina game event (no snow this time, please), new PEAC modules, the Duke Patient Safety Symposium, the JAR networking event at Dr. Klotman’s and the annual SAR photo this Friday.  Keep an eye out on the calendar for dates and times of all the upcoming events.

Did you know that Ryan Schulteis created a rounding app that is being tried at the DVAMC? Talk to your VA Chief/ACR or Quality Chief to learn more!

This week’s pubmed from the program goes to Adrienne Belasco whose poster on the “G-Briefing” sessions was accepted to the Patient Safety Symposium.

Have a great week!

 

Aimee

 

Intern Day Off 2015!

 

Charity Auction 2015

What Did I Read This Week?

 

What Did I Read This Week (Again)

(submitted by Alex Cho, MD, MBA)

[Note: This is a lightly revised encore presentation of a prior WDIRTW, to commemorate the start of March mini-CEX Madness – and basketball.   Let’s Go Duke!]

Jenkins, L. “How ‘bout them apples.” Sports Illustrated. April 29, 2013. Available at: http://sportsillustrated.cnn.com/vault/article/magazine/MAG1207447/index.htm.

Gawande, A. “Personal Best: Top athletes and singers have coaches. Should you?” New Yorker. October 3, 2011. Available at: http://www.newyorker.com/reporting/2011/10/03/111003fa_fact_gawande.

Looking back, I’ve sometimes – almost wistfully – thought that I was at the peak of my (admittedly limited) powers as an all-around clinician (from primary care to hospital medicine and critical care, from central lines to communicating bad news; you get the drift) as I neared the end of residency.

And then it’s done – the mix of ICU and primary care and back again is over, and slowly but surely, skills fade. Perhaps more importantly, no one really ever directly observes (or asks to) any more how one practices medicine. And, until Lish Clark succeeds in beating Epic (nicely) into giving up its secrets, even the performance data we might get (admittedly not as easily reduced as shooting efficiency) has its limits as well.

So, to the SARs w/ little more than 100 days to go, I salute you.

And in your honor, submit two articles for your consideration in this week’s WDIRTW

Let’s start with the fun one first. This profile of Kevin Durant, whom many consider the second-best player in the NBA today (behind Lebron James), talks about how he is trying to overcome that label – and lead the Oklahoma Thunder to a championship in the bargain – by consulting a statistician who tells him like it is, and watching things like his shooting efficiency from different points on the floor, his impact on scoring by others, and of course, video. The result? The Thunder had a better season statistically than they did the year before, which makes no sense, because they traded key third man James Harden (not to be confused with Duke IM grad and current GI fellow Ivan Harnden), the fifth-highest scorer in the NBA, days before the season began. And Durant himself took the fewest shots of his career. But his efficiency was the highest it had ever been, and he increased his average APG (assists per game) by nearly two, versus a couple of years ago. That is, he was making his team better, and in the words of his coach Scott Brookes, scoring “smarter.”

(And the improvement continued into last season, where he shot an astounding 50.3% from the floor, 39.1% from 3-point range, and 87.3% from the foul line – while leading the Thunder to the Western Conference Finals, where they were bested by eventual NBA Champions the San Antonio Spurs, losing a close Game 6 in OT.)

So what does this have to do with anything? (Besides medicine also being a team sport.)

Atul Gawande opens his piece by speaking to the fact that he feels like his performance in the OR has plateaued. On the one hand, he says he’d like to think this is a good thing, that he’s arrived at his professional peak. But on the other, he confesses it also seems to him that he’s just stopped getting better.

To continue with the sports metaphor, he recounts how, during some downtime during a medical meeting, he goes to a local tennis club looking to get some whacks in. He ends up hitting with the club pro, who after playing some points, begins coaching Gawande, pointing out that he could get more power from his serve. Gawande reports being dubious, having been a fair player himself in high school, playing in national tournaments, and that his serve had always been the best part of his game.

But then with some tinkering at the direction of this impromptu coach, Gawande soon began serving harder than he ever had. Not long afterwards, he was watching Rafael Nadal play, and the camera panned to his coach – and what he admits as being completely obvious struck him: even Nadal had a coach; almost every elite athlete does.

“But doctors don’t.”

Gawande then describes how he enlists one of his former attendings, Robert Osteen, with whom he had done his first splenectomy, and who let him discover for himself during that operation – without prompting or anger – that he had made his initial incision too small to fully expose the spleen. Gawande asks Osteen now to observe him doing a thyroidectomy, a procedure Gawande had done about a thousand times before – secretly wondering if he would have anything to tell him that he didn’t already know.

Osteen comes up with a whole list of observations, from the fact that the patient was draped in a way that perfectly accommodated Gawande, but made it difficult for the surgical assistant to assist, that Gawande’s elbows were up in the air at times – suggesting that he was not in the right position or needed different instruments, etc. The piece then goes on to describe how, through the use of a mix of video and in-person observation, Gawande continues the coaching relationship with Osteen.

Gawande also doesn’t mince words when it comes to discussing the uncomfortable implications. When patients – and we, too – would rather think of physicians as fully trained, completely knowledgeable, and incapable of mistakes, it can be hard to advance the parallel idea that doctors might also benefit from continued coaching.

Here in the Duke IM residency, opportunity knocks in the form of the mini-CEX, both inpatient and in clinic. In clinic we’ve tried to create some perks to doing them: interns get to see patients without being followed, JARs can batch signout for two patients at a time (if the first is routine, you get that patient’s phone number, and there is a queue for signout), and SARs can do an abbreviated signout – that is, if one has three mini-CEXs in that year that are in line with expectations for year in training. Admittedly, the challenges to doing them are legion, from difficult (and late) patients to busy preceptors. One tactic is to start with the first patient of the session, and ask a preceptor to do a mini-CEX with you before clinic gets busy.

Like Kevin Durant, you are all stars. But you are also adults, who, absent hard certification requirements, have a great deal of latitude to determine what you are willing to do to become even better than you already are. Ultimately, it’s up to you.

 

 

QI CORNER

Aaron Mitchell, MD

 

This week, I wanted to give you all some updates on the other Choosing Wisely project that we have been working on – trying to replace the phrase “FFWU” in our signouts with more informed and thoughtful anticipatory guidance.

Overall, you guys on gen med have been going great! Since the rollout of this project we have seen the # fevering patients with “FFWU” on their signout drop from 23% to 0% (!!!!!), and also the # of fevering patients with anticipatory guidance on the signout increase from 18% to 52%. The number of studies ordered on each patient with a fever has started to decrease as well…more data on that to come. But this is a great start – thanks to everyone for participating, and keep up the good work! Special thanks to Matt Aktins for helping crunch the numbers for this week’s data.

CLINIC CORNER

Want to be more confident in clinic?

Thank you to all who have jumped in feet-first into the new online ambulatory curriculum from the Johns Hopkins Physician Education Assessment Center (PEAC), now entering its third month. Want to thank Bonike and especially Katie Broderick for getting the ball rolling on its introduction, which came about as a response to this very question, posed by residents past and present. I’d like to take this Clinic Corner, as March “mini-CEX Madness” kicks off, to highlight this other tool available to you all – direct observations (aka “mini-CEXs”) – which also responds to the same question; and of which the program requests (3) inpatient and (3) outpatient be done each year.

First, I should acknowledge the residents and attendings who have participated in the over 100 Ambulatory mini-CEXs completed thus far this year – residents, for inviting preceptors into your clinic rooms to observe what you do well, and offer pointers on how you can become even better; and attendings, for taking the time to provide feedback, and enter the mini-CEXs into MedHub.

Second, we also want to reward those residents who complete at least three (3) Ambulatory mini-CEXs – and who were rated to be at or above their expected level for their stage of training – with advancement in the level of autonomy with which they would be able to practice in clinic.  The idea for this came from Duke’s participation four years ago in a multi-center study of milestone-based “promotion” of interns to seeing patients independently in clinic, published in Academic Medicine (Acad Med. 2013 Aug;88(8):1142-8. doi: 10.1097/ACM.0b013e31829a3967). The milestone-based mini-CEX forms allow us to use a similar approach for JARs and SARs as well.

For your reference, then, are attached a .pdf of the Ambulatory mini-CEX form and a one-pager describing the three “precepting levels”; and courtesy of Larry Greenblatt, a brief summary of SNAPPS, one of the signout frameworks that promoted SARs can now use instead of the conventional narrative one – as well as a paper describing the “Aunt Minnie” signout framework, which is another. And each month, the clinic site directors are receiving a report updating their mini-CEX counts from the Residency Program Office. But I would hasten to add that the mini-CEX is not meant to be a value statement on individual residents, or a check-y box (or three), but a standing invitation for mentored improvement – a chance to be observed doing something specific that you want to work on – part of the exam, taking the history of a difficult patient, or counseling someone you’re not sure grasps what you are trying to tell him/her – in order to build your confidence further, faster.

In the words of the legendary UNC Coach Dean Smith: “Confidence must be earned. It takes time, work, dedication – on the part of the teacher and the pupil.” Speaking of which, the final thought I’ll leave you with relates to the concept of “managing up.” Your preceptors have a great deal of respect for each of you, and are thus loath to force anyone to go through a mCEX. (Plus, circumstances sometimes make them difficult to do without creating queues and constipating the clinic – which is why Sharon Rubin advises doing one with your first patient of the session.) Feedback is also not something that comes naturally to highly accomplished individual performers, either seeking it or giving it. And so it may take some coaxing to get your preceptor out of his/her chair to follow you into the room (I am of course being a little arch here, and possibly a bit self-referential), but s/he’ll be nonetheless happy – delighted even – to do so, if asked. : )

PEAC Ambulatory Curriculum

Congratulations! Duke IM was the top user group for the past week!

 

 

 

 

 

The assigned modules for the month of March are:

Chronic Kidney Disease and Hypertension.

We understand that your schedules are already pressed but it is our hope that completing these modules will be of benefit in improving your ambulatory educational experience.

If you haven’t already completed the previous assigned modules for February (Back Pain and Hip/Knee Pain) or January (Community Acquired Pneumonia and Upper Respiratory Tract Infections) please do so as soon as possible as these modules are required from the program leadership.

  From the Chief Residents Grand Rounds

Fri., March 6: Visiting Speaker, H. Gilbert Welch

Noon Conference Date Topic Lecturer Time Vendor 3/2/15  MKSAP Mondays: CKD  Susan Gurley/Chiefs  12:00 Mediterra 3/3/15  Resistant Hypertension/Debriefing  Bonike Oloruntoba 12:00 – MedRes/9242  Chick-Fil-A 3/4/15  Edema, Renal Syndromes and Clinical use of Diuretics  John K Roberts 12:00 Cosmic Cantina 3/5/15  IM-ED Combined Conference: Toxidromes 12:00/2001  Dominos 3/6/15  Chair’s Conference  12:00 Panera                   From the Residency Office MiniCEX MADNESS!

MiniCEX Madness starts today and will run through the end of March!  Our goal is to have everyone complete at least two (2) MiniCEX’s (inpatient or outpatient) by the end of the month.  Each Friday, the MedRes office will do a drawing of everyone who has had a MiniCEX completed on them for the prior week and the lucky winner will win a special prize!

As a reminder, MiniCEX’s evaluations are assigned to GenMed attendings at the start of each block, and the program requires each trainee to complete a total of six (6) MiniCEX’s each year, 3-inpatient and 3-outpatient.  Please remind faculty that they can complete the evaluation online in MedHub as a faculty-initiated evaluation.  Please see this week’s Clinic Corner (above) for more information on the MiniCEX process in the ambulatory setting.

SAR Group Photo Please mark your calendars for next Friday, March 6th immediately after Grand Rounds.  The group picture will be taken at 9:15am in the Duke Cancer Institute healing path (the lobby).

 

Register for 10th Annual Duke Medicine Patient Safety and Quality Conference

We invite you to register for the 10th Annual Duke Medicine Patient Safety and Quality Conference.  The conference will be held Friday, March 20, 2015 at the Durham Convention Center, 301 West Morgan Street, in Downtown Durham NC.  Registration will begin at 7am with conference activities from 8am until 4:30pm. The conference agenda is attached.

Two plenary lectures will be presented:  “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age” by Robert Wachter, MD; Professor,  Associate  Chairman,  Department  of  Medicine,  and Chief of  the  Division  of  Hospital  Medicine, University  of  California,  San  Francisco and “The Changing Landscape of Patient Safety” by Tejal Gandhi, MD, MPH, CPPS; President and CEO of the National Patient Safety Foundation (NPSF).

One of the conference highlights is the poster session.  Come learn from the poster presentations and speaking with the abstract writers.

Afternoon breakout sessions include:

  • Creating a Psychologically Safe Environment: Behaviors that promote a culture of safety.
  • The Quality, Safety and Value Movements: A Conversation with Bob Wachter
  • Best Practices in Resiliency: Thriving versus Surviving during Times of Change (The Duke Resilience Mini-course)
  • Maximizing a Multi-Generational Workforce in Safety and Quality initiatives
  • The Challenges of How We Think…Cognitive Biases, Cognitive Errors, & Metacognition strategies
  • Topic: Learning from Defects: A Practical Tool for Resolving Threats to Safety at the Unit Level
  • Handoffs: The Evolving Story of Inpatient Handoffs: A “new” obstacle in the quest for quality patient care
  • Disruptive Violent Patient and Visitors: Perspectives from the clinical provider,  risk management and Duke Police. (PLEASE NOTE: this is a half day workshop. This session will begin at 1:15 and go until 4:30)

Register online today!

https://www.eventbrite.com/e/10th-annual-duke-medicine-patient-safety-and-quality-conference-tickets-15537471997

Back to Basics Curriculum

Dear Internal Medicine, Med-Peds and Med-Psych Residents,

We would like to invite you to participate in the creation of a core “Back to Basics” curriculum that contains foundational Internal Medicine subspecialty content for the Internist.

The objectives of this project are to:

1)- Build standard, core curriculum content for each subspecialty, geared towards the internist

2)- Generate teaching scripts for core topic that can be shared among residents, medical students, and teaching faculty (see the topics and slide set examples attached)

3)- Develop and amass supplemental teaching tools for each topic

4)- Engage subspecialty faculty (and fellows) to develop, share, maintain and deliver the teaching material during each rotation

5)- Create a valuable learning resource for residents by compiling the teaching scripts and supplemental tools in the form of a manual

www.SignUpGenius.com/go/20F0F44AEAA2AA4F85-back/23016617

Register for the BLS Blitz

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.

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.

Personalized Medicine Workshop Series

Dr Susanne Haga and faculty from the Center for Applied Genomics and Precision Medicine have developed a 6-session workshop series on personalized medicine and interdisciplinary practice. The workshop series will take place this March 3 – May 5 and all clinicians are invited to register for the workshop series. Each session will include a lecture component as well as an interactive skills-based component. Following participation in the course, all participants should be able to identify patients with genetic predisposition to disease and/or disease associated with genetic causality, determine appropriateness of genomic testing including who should have testing and what test is most fitting, interpret genomic testing results and apply those results to treatment, provide information about genomics, disease risk, and testing tailored for each patient, and work together as a team to deliver these services. Attendees will be asked to complete surveys assessing knowledge and satisfaction in order to improve the course for future use. Interested providers can contact program coordinator Rachel Mills (r.mills@duke.edu) for more information and to register for the course.

 

Information/Opportunities

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

www.carleconnect.com

  Upcoming Dates and Events

March 7, 2015 – Duke vs UNC

March 20, 2015 – Match Day Celebration, West End Billiards

June 6th – SAR Dinner, Hope Valley Country Club

  Useful links

Training at Duke, living in Durham

Fri, 02/27/2015 - 15:39

Duke Internal Medicine residents joined students from the School of Medicine for a new video to explain why living in Durham is so enjoyable.

Internal Medicine Residency News, February 23, 2015

Mon, 02/23/2015 - 10:48
From the Director

We have survived snowmaggedon 2015, hoping for only warm and sunny days for awhile.  Thanks to everyone who went out of their way to brave the NC elements and make it into work.  We got to have some fun this week with our first annual distinguished alumnus lecture with Class of 2013 alum Jon Menachem giving noon conference on Friday.  Great class of 2013 representation with Sam Horr and Tara Weiselberg (Horr joining us from Cleveland), as well as Hassan Dakik, Sima Hodavance, Lisa Vann, Phil Lehman, Megan Diehl McNamara and John Stanifer in the audience.  Love seeing the Duke family reunion here in Durham!

Other kudos this week go to Coral and Bonike for “pulling” off the best use of the pull list and bringing Rajiv Agarwal and Azalea Kim off the pull list to Cameron Indoor to see Duke destroy Clemson! Additional kudos to Adva Eisenberg (our amazing GM 2 night float), Jason Zhu, Melanie Goebel and Julia Cupp for being stellar night JARs this week, to Taylor Bazemore and Pascale Khairallah from Mike Minder for great work as CCU interns last month and to Stephanie Giattino from Christine Bestvina for great work in the VA CCU.

We are so excited for the charity auction this Friday! Adrienne Belasco and Allyson Pishko have been working really hard with the auction team to plan and organize.  Check out the video preview for what’s to come – SEE YOU THERE ON FRIDAY NIGHT!

This week’s pubmed from the program goes to alumnus Jon Menachem and current SAR Aparna Swaminathan for their article “Initial Experience with Left Ventricular Assist Device Support in Adults with Transposition of the Great Vessels”

Have a great week

Aimee

What Did I Read This Week?

Sue Woods, MD

Use of Pneumococcal Vaccine in Adults

JAMA Feb 17, 2015; 313: 719-720

Authors:  Jennifer Pisano, MD and Adam S. Cifu, MD

Why did I read this clinical guideline synopsis: Vaccines are one of my favorite topics and we had a session on immunizations at DRH AM report in the recent past. Everyone needs to understand the current recommendations for adult immunizations including the ACIP guidelines and CDC immunization schedule in order to provide high value quality care for their patients.

Background:

  • Streptococcus pneumoniae: major cause of upper respiratory tract infection and community acquired pneumonia
  • Invasive disease includes bacteremia, meningitis, endocarditis, osteomyelitis
  • In 2012, estimated 31,600 cases of pneumococcal infection and 3,300 estimated deaths in the US.
  • Highest rates of infection are in children and adults >65yo
  • PPSV (polysaccharide) 23 licensed in US in 1983. Data shows this vaccine is associated with the prevention of invasive disease, but no consistent evidence that it is associated with reduced rates of all-cause pneumonia or all-cause mortality.
  • PCV7 (conjugate) vaccine added to pediatric schedule in 2000 and is associated with pediatric and adult decrease in invasive disease. In 2011 FDA approved PCV13 for adults > 50yrs old.
  • PCV13 recommended for all adults > 65 years old in Sept 2014. Conjugate vaccines are thought to elicit a more robust T cell-dependent immune response then polysaccharide vaccines. This recommendation is supported by data from the Community Acquired Pneumonia Immunization Trial in Adults (CAPITA) which is not yet published.
  • Harms: pain/swelling at injection site, fatigue, headache

Major Recommendations:

  • Pneumococcal vaccine-naïve adults aged 65 years or older (or adults >65 years whose pneumococcal vaccine history is unknown) should receive 1 dose of 13-valent pneumococcal vaccine (PCV13) followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) 6 to 12 months later (minimum duration between PCV13 and PPSV23) is EIGHT weeks.
  • Adults >65 years or older who have previously received one or more doses of PPSV23 should receive 1 dose of PCV13 one year or longer after the most recent PPSV23 dose.
  • Adults who have received PPSV23 before the age of 65 years, should receive PCV13 after age 65 years (and > 1 year after the PPSV23 was given). PPSV23 should then be repeated 6 to 12 months later (and >5 years since the initial PPSv23 injection).

QI CORNER

Aaron Mitchell, MD

 

First of all this week, I wanted to let everyone know to keep their eyes and ears open for round 2 of the Duke Internal Medicine chocolate chip cookie championship. Maybe we can crown the champion sometime during March Madness? Who is on top of YOUR bracket?

Second, I want to give another update on the Choosing Wisely – Daily Labs project. If you recall, at the end of last week, your co-residents on Duke gen med were already doing an AWESOME job. Thinking harder about which patients really warrant daily labs, they were able effect a significant decrease in the number of patients getting both a CBC and BMP drawn everyday. This week, the trend continued – since the beginning of the project, this number is down to 45% from 60% as the prior baseline. If my projections are correct, we have already saved our patients well over a liter of blood!

Thanks to Andrea, Sam Lindner, Emily Ray, Jenny Van Kirk, and our med students Madelyn and Adeola for all the hard work they’ve done on this. Check out the updated control chart with an additional week’s worth of data:

From the Chief Residents Grand Rounds

Fri., February 27th : Trivia Bowl, IM Chiefs

Noon Conference Date Topic Lecturer Time Vendor 2/23/15 Inpatient Pain and Opiate Management  Chris Jones  12:00  Nosh 2/24/15  SAR Talk: I’m an Elephant  Christine Bestvina 12:00  Subway 2/25/15  Approach to Osteomyelitis  Ted Hendershot 12:00/2001 Cosmic 2/26/15  Approach to Back Pain  Anand Joshi 12:00/2001  Dominos  2/27/15 Research Conference  12:00/2002 Panera                   From the Residency Office   Back to Basics Curriculum

Dear Internal Medicine, Med-Peds and Med-Psych Residents,

We would like to invite you to participate in the creation of a core “Back to Basics” curriculum that contains foundational Internal Medicine subspecialty content for the Internist.

The objectives of this project are to:

1)- Build standard, core curriculum content for each subspecialty, geared towards the internist

2)- Generate teaching scripts for core topic that can be shared among residents, medical students, and teaching faculty (see the topics and slide set examples attached)

3)- Develop and amass supplemental teaching tools for each topic

4)- Engage subspecialty faculty (and fellows) to develop, share, maintain and deliver the teaching material during each rotation

5)- Create a valuable learning resource for residents by compiling the teaching scripts and supplemental tools in the form of a manual

www.SignUpGenius.com/go/20F0F44AEAA2AA4F85-back/23016617

Register for the BLS Blitz

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.

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.

Personalized Medicine Workshop Series

Dr Susanne Haga and faculty from the Center for Applied Genomics and Precision Medicine have developed a 6-session workshop series on personalized medicine and interdisciplinary practice. The workshop series will take place this March 3 – May 5 and all clinicians are invited to register for the workshop series. Each session will include a lecture component as well as an interactive skills-based component. Following participation in the course, all participants should be able to identify patients with genetic predisposition to disease and/or disease associated with genetic causality, determine appropriateness of genomic testing including who should have testing and what test is most fitting, interpret genomic testing results and apply those results to treatment, provide information about genomics, disease risk, and testing tailored for each patient, and work together as a team to deliver these services. Attendees will be asked to complete surveys assessing knowledge and satisfaction in order to improve the course for future use. Interested providers can contact program coordinator Rachel Mills (r.mills@duke.edu) for more information and to register for the course.

Duke Pain Conference

Duke Pain presents “Pain Management for the Practicing Physician and HCP” February 28 &March 1, 2015 at the Mary Duke Biddle Trent Semans Center for Healthcare Education on the Duke Campus.  Register today by visiting www.carolinapain.org  - this is a great meeting to recommend to all of your internal medicine, family practice and primary care colleagues!   PSOC members enjoy a discounted fee to attend!

Please click here for more details!

Upcoming Events

Save the Date – Parents Weekend!!

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

 

AAMC 2015 IQ Call for Abstracts

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

 

Information/Opportunities

ExploreAfterResidency-CompHealth

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

www.carleconnect.com

 

  Upcoming Dates and Events

February 27, 2015 – Charity Auction

March 7, 2015 – Duke vs UNC

March 20, 2015 – Match Day Celebration, West End Billiards

June 6th – SAR Dinner, Hope Valley Country Club

  Useful links

Internal Medicine Residency News, February 16, 2015

Mon, 02/16/2015 - 11:54
From the Director

Hope you all are staying warm! We had an outstanding weekend at the NC ACP meeting.  Poster presentations were fantastic, with Gena Foster  bringing home 2nd place honors for her clinical vignette poster as well as our “Doctor’s Dilemma” Jeopardy team of Nick Turner, Paul St. Romain and Peter Hu taking first place in the Jeopardy competition against all other NC residencies.  I hope this is a preview of the Duke-Carolina game on Wednesday! Congratulations to all.  Nick, Paul and Peter get an expense-paid trip to the national ACP in Boston in May to compete at the internist equivalent of the big dance.  Also many thanks to the faculty who came out to support our residents (Sharon Rubin, Murat Arcasoy, Alicia Clark, Joel Boggan among others) and to Coral Giovacchini for representing in the Chief Residents portion of the program.

What’s on tap this week?  Well, we have the Duke Carolina game festivities on Wednesday, the chiefs are sequestered making your schedules and Dr. Arcasoy has opened up his office hours for mentorship and research discussions.  The announcement for Faculty Resident Research Grants went out last week, so now is a great time to discuss with your mentor, Dr. Arcasoy or me.

Get ready for the third annual MINI CEX MADNESS coming up in March! As you know, direct observation is critical to personal and professional development, and is a major component of milestone based evaluations.  Do you find MINI CEX’s not to be helpful? Then ASK your preceptors to observe you on something specific that you are wanting to improve upon (setting an agenda, counseling on a new med, neurologic exam, knee exam?) so that you get the most out of the encounter.  The goal for MINI CEX madness is TWO mini CEX’s per resident…can we do it?

Other kudos this week come from Pooh Setji to our entire inpatient teams – ALL THREE GEN MED UNITS have gone nearly ONE YEAR without a CLABSI (central line associated blood stream infection) and are at all time records for avoiding CAUTI (catheter associated UTI).  Way to go! Also kudos to Eric Black Maier from the night JARs for making a timely diagnosis that expedited patient care and to Myles Nickolich from Matt Sparks for representing at the first CIMIgro Journal Club.

Hope you are planning to come to the charity auction on FEB 27th! Adrienne Belasco and Allyson Pishko are leading an all-star planning team for what promises to be a fabulous evening of great prizes and fun.

If you didn’t see the email, we are thrilled to welcome Alyson McGhan, Adam Banks, and Aparna Swaminathan as our 2016-17 Chief Residents!

Please also join us in congratulating our 2015-16 Assistant Chief Residents

Duke: Rajiv Agarwal, Bassem Matta, Ashley Bock, Sarah Goldstein, Nick Turner and Andrea Sitlinger

DVAMC: Kristen Glisinski, Marc Samsky, Jesse Tucker, Emily Ray, Adva Eisenberg, and Alan Erdmann

DRH/Ambulatory: Paul St Romain, Ben Peterson, Matt Atkins, Ryan Jessee, Li-Wen Huang and Stephanie Giattino

This weeks PUBMED from the PROGRAM goes to our ACP presenters:

Matthew Atkins, Doran Bostwick, Yevgeniya Foster, Stephanie Giattino, Dr Li-Wen Huang, Kara Johnson,  David Kopin,  Samuel Lindner, Myles Nickolich, Benjamin Peterson, Daniel Pugmire, Kevin Shah , Bhavana Singh, Dr. Carli Lehr , Alyson McGhan, Aparna Swaminathan, Colby Feeney, Brian Wasserman

Have a great week,

Aimee

 

What Did I Read This Week?

David Butterly, MD

Patiromer in Patients with Kidney Disease and Hyperkalemia Receiving RAAS Inhibitors Matthew Weir, George L Bakris, et al New England Journal of Medicine 2015; 372: 211-21

 

This article appeared in last months’ NEJM. It was paired back to back with an article detailing results of a second trial using another potassium binding agent- Sodium Zirconium Cyclosilicate in Hyperkalemia Packham et al NEJM 2015; 372: 222-31. We discussed the results of each trial in Nephrology Journal Club. The Packham study included more patients but was shorter in duration. The Weir study utilizing Patiromer reports on longer term medication use in patients with CKD along with RAAS blockade and is similar to the patient population I see in clinic and on the consult service. The results of each trial were very positive and worth a read.

Background:

Hyperkalemia is a common electrolyte disturbance which can be associated with the presence of life threatening cardiac arrhythmias along with increased mortality. ACE-Inhibitors, Angiotensin Receptor Antagonists, and Aldosterone Receptor Blockers all have been shown to have mortality benefit in patients with CHF, but each impairs urinary potassium excretion. Hyperkalemia is an uncommon complication of these agents when used in patients without other risk factors and was, by and large, seen at low incidence in trials involving these agents. However, patients included in these trials were low risk and about one third of the patients we see with CHF have CKD, which markedly increases the risk of hyperkalemia. Additionally, the use of these drugs in patients likely to have a cardiac and mortality benefit can sometimes be limited by hyperkalemia. So a therapy that could potentially allow continued utilization in this group would be advantageous.

Medications that lower the potassium levels and not just shift potassium intra-cellularly have been limited to sodium polystyrene sulfonate (Kayexalate)) which exchanges K for Na and increases colonic K excretion.  This drug was approved by the FDA for use in hyperkalemia more than a half a century ago. RCT data showing efficacy are lacking and the presence of potential GI side effects makes long-term treatment problematic and lead to a black box warning issued by the FDA in 2009. Thus, newer and improved agents are needed.

Current Study:

The study was done at 14 centers across the US and another 45 across Europe. Patients with hyperkalemia ( K of 5.1-6.5) on RAAS- Inhibitors and with CKD were eligible for enrollment. In the first stage, patients were treated with Patiromer for four weeks. Primary endpoint was the normalization of serum K. In the second phase, those who achieved goal potassium of 3.8-5.0 with initial K > 5.5 were eligible for enrollment in the second phase and were randomized to continue treatment with Patiromer versus Placebo. In this phase patients were followed for the development of recurrent hyperkalemia as the primary endpoint.

Results:  

Baseline Demographics for the groups is given in Table 1:

The group had Stage III CKD with mean GFR of 35 to 40. 97% of patients had hypertension, 57% had Type II diabetes, 42% had CHF and 25% had prior history of MI. All patients were on at least one RAAS Inhibitor and 54% were on a non-RAAS diuretic. Roughly 70% were on and ACE-I. 31-44 % were on an ARB and 7-9% were on an Aldosterone Antagonist. 12-18% were on dual RAAS blockade and 40% were on maximal RAAS blockade.

Figure 1 on page 215 shows these results:

The change in K in patients with mild hyperkalemia was – 0.65 mmol per liter. The change in patients with moderate hyperkalemia was – 1.23 mmol/liter. Mean decrease in serum K was 1.1.  76% of patients reached the target endpoint of serum potassium below 5.1 at week 4.

Figure 2 shows results of Withdrawal phase

In this phase of the study, patients who had moderate hyperkalemia and achieved goal, were randomized to continue drug or were randomized to placebo. A total of 107 patients were included in this phase of the study and the primary endpoint was the development of K > 5.5. A total of 60% (47/74) versus 15% in the Patiromer group had at least one potassium value of 5.5 or greater. Additionally, 62% the patients in the Placebo group versus 16% of those in the treatment group required an intervention to control hyperkalemia and more than half in the Placebo group had their RAAS blockade discontinued compared to only 6% in the Patiromer group.

Conclusions:

The results of both studies are encouraging. In a group of patients at high risk for hyperkalemia and complications of RAAS blockade, the use of Patiromer reduced the incidence of hyperkalemia and allowed continued use of RAAS blockers. Obviously, longer term data is needed, but both agents hold promise.

 

QI CORNER

Aaron Mitchell, MD

 

First, just a reminder that Tuesday is the regular monthly meeting of the GME-wide Patient Safety and Quality Council. There is usually a presentation on patient safety issues and time to work in various task forces. If you would like to get involved (or like free breakfast – Einstein Brothers breakfast sandwiches…Mmmm), let me know. Tuesday, 6:30am, DMP 2W93 conference room (usually – sometimes the executive conference room in Duke South).

But mainly this week, I wanted to share with you some of the preliminary results from the Choosing Wisely projects. Just as a refresher, we have been asking the teams on Duke Gen Med to be as parsimonious as possible when ordering routine daily labs, and avoiding ordering them when they are expected to be unhelpful.

I have created the following control chart to show the data, up through Wednesday the 11th. The y-axis is the percent of patients on gen med getting BOTH a CBC and BMP ordered on a given day, and on the x-axis are individual days. Our pre-intervention period on the left includes days from November and December, and post-intervention is over the last few weeks after we announced the projects at noon conference.

Those 9 red dots in the post-intervention period are all below the long-term average (the blue line). The reason they are red is that the QI tool I am using to analyze the data has flagged them as statistically anomalous – an event that would be very unlikely to occur by random chance. In other words, we have a p of <0.05 that the daily labs project is making a difference!

To put the numbers in another way, so far we have draw 46 fewer BMPs, and 47 fewer CBCs than we would have otherwise. That’s half a liter of blood that is still in our patients.

 

 

CLINIC CORNER

Sharon Rubin, MD

Update from Pickett

Interns: welcome to night call on ambulatory. The second half of intern year we start putting you in the rotation for night call one night a week when you are on ambulatory. Pl

We have officially obtained 3 mini cex per resident! We need to get our attendings to enter all these. I have posted the mini cex in the resident room. Please remind your attendings to put the mini cex into the computer. You are still encouraged to request mini cex- maybe you want to see how your counseling skills are, agenda setting skills or physical exam skills. Please let your attending know.

Keep working on your PEAC modules. Last week we went over the Hip section, this week the knee and next week the lower back. I have posted the great summary tables. The videos really are good to watch.

Amelia Query, RN, BSN will be coming to us from Wake Forest Baptist where she has been a nurse in the Surgical ICU.

Marie Paul, LPN comes to us from NJ where she has worked in fast-paced outpatient settings as a float nurse.

Both candidates are scheduled to start in March!

The form bins have been moved to the front desk located next to printer #2 …per staff request.

Make sure you are parking in the lines. There is limited parking spaces in the upper lot and we are trying to squeeze all the cars in.

Medicare is covering the cost of Prevnar 13 even if a patient has had pneumonia 23 after the age of 65. Please consider ordering this vaccine on your > 65 year old patients.

Medicare announced last week that it would begin covering screening for lung cancer with low-dose CT, effective immediately.

Medicare will now cover the screens once per year for beneficiaries who meet all of the following criteria:

  • age 55 to 77,
  • current smokers or those who have quit smoking within the last 15 years,
  • a smoking history of at least 30 pack-years, and
  • a written order from a physician or qualified nonphysician practitioner that meets certain requirements.

A visit for counseling and shared decision-making on the benefits and risks of lung cancer screening will also be covered.

In December 2013, the U.S. Preventive Services Task Force recommended annual screening for adults age 55 to 80 who currently smoke or have quit within the past 15 years and have a 30 pack-year smoking history.

If you are available Saturday Feb 29- Sunday March 1, consider attending “Pain Management for the Practicing Physician and HCP” hosted by our pain clinic. key speakers: Dr. Collins on Headaches, Dr. Runyon on neck pain, Dr. Fraas on fibromyalgia.  I have some burning questions, like why do they send a very different Urine drug screen then we do? Should be be using their drug screen? I do hope they speak about Suboxone.

ACP Presenters!

Sincerely

Sharon Rubin, MD, FACP

 

From the Chief Residents Grand Rounds

Fri., February20th : Gastroenterology, Dr.Dawn Provenzale

Noon Conference Date Topic Lecturer Time Vendor 2/16/15 MKSAP Mondays: GIM  Aaron Mitchell  12:00  Picnic Basket 2/17/15  MED-PEDS Combined: SAR Talk  Han/Feeney 12:00/2001  Chick Fil A 2/18/15  HVCC Dani Zipkin  QI Team 12:00 China King 2/19/15  Resident M&M 12:00/2001  Sushi  2/20/15  Chair’s Conference  Chiefs  12:00  Mediterra                   From the Residency Office Duke-Carolina This Wednesday!

Residents are all invited to join local DukeMed alumni from the classes of 2005-14 as well as current and recent house staff to cheer the Blue Devils to victory over our Tar Heel neighbors!

RSVP & get details here: http://medalum.mc.duke.edu/events/regional/hoops-watch

Location: Tyler’s Taproom

Time: 8:30pm

  Back to Basics Curriculum

Dear Internal Medicine, Med-Peds and Med-Psych Residents,

We would like to invite you to participate in the creation of a core “Back to Basics” curriculum that contains foundational Internal Medicine subspecialty content for the Internist.

The objectives of this project are to:

1)- Build standard, core curriculum content for each subspecialty, geared towards the internist

2)- Generate teaching scripts for core topic that can be shared among residents, medical students, and teaching faculty (see the topics and slide set examples attached)

3)- Develop and amass supplemental teaching tools for each topic

4)- Engage subspecialty faculty (and fellows) to develop, share, maintain and deliver the teaching material during each rotation

5)- Create a valuable learning resource for residents by compiling the teaching scripts and supplemental tools in the form of a manual

www.SignUpGenius.com/go/20F0F44AEAA2AA4F85-back/23016617

Lactation Rooms – Duke Medical Center

Duke provides 18 lactation rooms for faculty and staff to support women balancing their return to work with their needs as mothers of young children. Each room offers a clean, secure, and user-friendly environment for women who need to express breast milk during their work shift.   Please click on the link for the specific locations for DN, DMP, Duke Clinics and Duke Cancer Center.

The two lactation rooms require Duke ID card access. Women interested in using the lactation facilities must submit a card reader access form to program their Duke ID card for access to the lactation rooms. Once the website is updated with the additional DMP lactation room information, women may also reserve room space by using an online lactation room calendar scheduler. Instructions for submitting the Duke ID card number for access, and additional policy and detailed information are referenced at the following Human Resources website: http://www.hr.duke.edu/benefits/family/newborn/lactation/

The sign up process is easy but access isn’t instantaneous. Once the form is faxed to the program coordinator asking for access, the user will receive a link to the Google calendar in an email. Right before staff are ready to pump, they should sign into the calendar from a NON DUKE email address ( so forward the link to your personal email or it won’t work), ensure one of the rooms is open and available, and sign yourself into the room to reserve it. You should check that your badge access is working for the rooms first to ensure you can get into the room.

If there are questions, please contact Regina McKoy, Program Coordinator at (919) 684-1942. Email: ramckoy@duke.edu

Register for the BLS Blitz

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.

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.

Duke Pain Conference

Duke Pain presents “Pain Management for the Practicing Physician and HCP” February 28 &March 1, 2015 at the Mary Duke Biddle Trent Semans Center for Healthcare Education on the Duke Campus.  Register today by visiting www.carolinapain.org  - this is a great meeting to recommend to all of your internal medicine, family practice and primary care colleagues!   PSOC members enjoy a discounted fee to attend!

Please click here for more details!

Schwartz Center Rounds

Medicine and Miracles: One Case on a Collision Course

Panelists: TBD

Tuesday, February 17, 2015  Noon – 1 p.m., Duke North 2002
Lunch available at 11:45 AM

About Schwartz Center Rounds:

Duke Medicine physicians, nurses and other providers of all disciplines are invited to attend an ongoing series of presentations and discussions, called the Schwartz Center Rounds, about the human side of patient care.

Schwartz Center Rounds is a monthly interdisciplinary conference that offers clinicians a regularly scheduled time during their fast-paced work lives to openly and honestly discuss social and emotional issues that arise in caring for patients. An initiative of the Schwartz Center for Compassionate Healthcare, the rounds take place at 250 sites in the U.S. and U.K. including many of Duke’s peer institutions (Massachusetts General Hospital, Brigham & Women’s, Vanderbilt, Mount Sinai, Emory, Cleveland Clinic and UNC-Chapel Hill). We are excited to be bringing this program to Duke and hope many of you will join us!

Please contact, Lynn Bowlby, MD (lynn.bowlby@duke.edu), Nathan Gray, MD (nathan.gray@dm.duke.edu) or Bill Taub (arthur.taub@dm.duke.edu) with questions. There is no need to RSVP, but we do recommend that you arrive early as food and seats are at a premium!

Upcoming Events

Save the Date – Parents Weekend!!

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

 

AAMC 2015 IQ Call for Abstracts

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

 

Information/Opportunities

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

RM Medical Search

 

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

March 20, 2015 – Match Day Celebration, West End Billiards

June 6th – SAR Dinner, Hope Valley Country Club

  Useful links

Chief Residents for 2016-2017 announced

Fri, 02/13/2015 - 15:30

Mary Klotman, MD, chair of the department, Aimee Zaas, MD, MHS, program director of the Internal Medicine Residency Program, and David Simel, MD, vice chair for Veterans Affairs, have announced the Chief Residents for the 2016-17 academic year.

It is with great pride that we announce the 2016-2017 Chief Residents for Internal Medicine:

Duke University Hospital

Alyson McGhan, MD
Alyson is a graduate of Rutgers University and received her MD degree from the Perelman School of Medicine at the University of Pennsylvania. She served as the Duke University Hospital Assistant Chief Resident this year and will be joining the Gastroenterology Fellowship at Duke in July.

Durham VA Medical Center

Adam Banks, MD
Adam is a graduate of Vanderbilt University and received his MD degree from The University of Texas Medical School at Houston. He served as the Durham VA Medical Center Assistant Chief Resident this year and will be joining the Cardiology Fellowship at Duke in July.

Ambulatory/Duke Regional Hospital

Aparna Swaminathan, MD
Aparna is a graduate of Princeton University and received her MD degree from Case Western Reserve University School of Medicine. Her outpatient clinic during residency was at the VA PRIME clinic, and she served as the Ambulatory/DRH Assistant Chief Resident this year. She will be joining the Pulmonary and Critical Care Medicine Fellowship at Duke in July.

The Chief Residency is one of the largest commitments to leadership development made by the Department, and our Chief Residents serve as mentors, teachers and guides for our residents during their year of chief residency and beyond.

Please join us in congratulating the 2016-2017 chiefs as they become part of the Duke legacy!

2/27/15: 15th annual Residency Charity Auction

Thu, 02/12/2015 - 12:01

UPDATE 2/27/2015: This event will take place as scheduled.

The Duke Internal Medicine Residency Program will host the 15th annual Duke Medicine Charity Auction at 7 p.m. Fri., Feb. 27.

The auction, which supports Senior PharmAssist and the Duke Outpatient Clinic patient fund, will be held at Full Frame Theater at the American Tobacco Campus, 320 Blackwell Street in Durham.

Tickets are $20 and include heavy appetizers and two drinks. Buy tickets in advance at Medicine Grand Rounds and in the Med Res Office (8th floor Duke North).

Internal Medicine Residency News, February 9, 2015

Mon, 02/09/2015 - 11:30
From the Director

Hi Everyone,

The first Stead-fast Breakfast was a huge hit at the VA! If you are rounding at Duke, look for your Stead Leaders to be bringing breakfast to the Med Res library on Thursday.  Thanks for helping everyone have a good start to the day.

This week we also have the NC ACP meeting on Friday – there are over 20 posters from Duke residents as well as medical students.  Come on out and support your friends! We are also hoping to maintain our title in NC ACP Trivia Bowl…if our team wins, they get to go to (no, not Disneyworld) but the national ACP meeting!

We also have our charity auction upcoming on Feb 27th. Where else can you get an attending to auction off a shift on Duke Night Float or a half day at the DOC? Plus great restaurant gift certificates, wine and more.  All for a good cause.  We are going to be sending out some trivia questions for free tickets to the auction, so pay attention. If you couldn’t make it to noon conference on Tuesday, you missed the introduction of “MedMessage” , the texting app created by Bill Hargett.  This week you will receive instructions on how to “opt in” for board style question texts.  Details to be found in the sign up instructions.

Kudos this week from Lish Clark to the night float team of Adva Eisenberg, Jason Zhu, Julia Cupp, Jonathan Buggey and Melanie Goebel for great work on some very busy nights.  Also this week Andy Mumm, Jessie Seidelman and Colleen Stack received GOLD STARS from Patient Visitor Relations.  You earn a gold star when a patient turns in your name as someone who made their hospital stay or clinic appointment better.  Nice work Andy, Jessie and Colleen. Also kudos to Stephanie Giattino from the ED for coming in early to help out with a shift.

This week’s pubmed from the program goes to Tim Mercer for his article (with Joanna Kipnes, Jon Bae and Pooh Setji) that was accepted to the Journal Of Hospital Medicine . “The highest utilizers of care: individualized care plans to coordinate care, improve health care service utilization, and reduce costs at an academic tertiary care center”.  Congrats to the whole team!

 

Have a great week!

Aimee

What Did I Read This Week?

Daniella Zipkin, MD

Last week I gave a noon conference with URI cases, to round out the first PEAC module for 2015. Residents broke into groups and answered questions about rhinitis, sinusitis, pharyngitis, bronchitis, and otitis. In the process, I re-reviewed the Rational Clinical Exam series on the value of the Centor criteria for diagnosing strep pharyngitis. Well, this stuff isn’t as straightforward as it seems, and I think it bears repeating – so, if you missed it, check this out:

The Rational Clinical Exam, edited by our very own David Simel, is a JAMA series of systematic reviews of elements of the history and physical as “diagnostic tests”. They compile Likelihood Ratios for certain findings or combinations of findings. (A likelihood ratio is a ratio of the proportion of patients WITH disease with a certain finding, over the proportion WITHOUT disease with that finding. The bigger the number, the more likely it is seen in those WITH disease. The smaller the number, the more likely it is seen in those WITHOUT disease. An LR of 1 is…. useless).

It turns out the original articles get UPDATED – and sometimes, the update changes the data significantly. Updates can be found in the physical Rational Clinical Exam book, or on the JAMA Evidence site, available as a link on our medical library clinical tools page.

Take for example the Centor criteria for predicting strep pharyngitis: (1) fever, (2) tonsillar exudates, (3) tender cervical lymphadenopathy, and (4) absence of cough. We used to consider 3-4 positive criteria a slam dunk for the diagnosis of strep. Not so anymore. Here’s the data from the UPDATE:

 

Centor Score for Adults Likelihood Ratio (LR) (95% CI) 4 1.2 (0.62-2.2) 2-3 1.3 (0.85-1.9) 0-1 0.26 (0.14-0.48)

 

BUT, look what happens when we add the results of rapid strep testing!!

Centor Score Rapid Strep Testing LR (95% CI) 2-4 Positive 179 (110-2861) 0-1 Positive 26 (1.4-465) 0-4 Negative 0.09 (0.03-0.24)

That is all. Don’t rely on the Centor criteria – for a score of 2-4, a rapid strep is needed. For a score of 0-1, you can likely stop there (unless your pre-test probability is super high, then get the rapid strep).

QI CORNER

Aaron Mitchell, MD

 

Thanks to everyone for help in getting the Choosing Wisely initiatives off to a great start last week!

As we had been doing throughout December, we are still collecting data to see what kind of improvements we all are capable of making. And we are already seeing changes! Here are the rates of daily lab ordering on gen med, compared to our averages in recent months:

Chance of patient having lab ordered on a given day:

Chemistry CBC Both chem and CBC November-December 74% 66% 60% Last Week 67% 60% 50%

 

As for the “Full Fever Workup,” this is already becoming an endangered species, hopefully well on its way to extinction. Looking through the gen med sign outs, I have found this phrase increasingly hard to come by! And, more importantly, in its place we have been really happy to see truly thoughtful guidance to help cross-coverage more effectively (and less wastefully) respond to fevers or other signs of infection.

Keep up the good work everyone! You are doing great – let’s try to do even better!

Next week we will be also having the monthly meeting of the Patient Safety and Quality Council. This will be on Wednesday, 5:30pm in the med res library.

CLINIC CORNER

Daniella Zipkin, MD

DOC Clinic Corner 2/9/15

We’d like to take this opportunity to welcome the newest members of the Ambulatory Care Leadership Track! The track involves expanded clinical opportunities in outpatient medicine, additional support for scholarship, training and experience in teaching, and leadership experiences including health policy advocacy. ACLT residents will spend three blocks per year together, including additional weekly didactics. We had a lot of interest this year, and we’re please to welcome four incoming JARs, two additional incoming SARs and one new med-psych resident to the program. The updated roster is:

Rising JARs:

Brian Andonian

Lauren Collins

CoCo Fraiche

Anne Weaver

Rising SARs:

Matt Atkins

Melanie Goebel

Ryan Jessee

Amy Jones

Dinushika Mohottige

Andrea Sitlinger

Med-Psych:

Jake Feigal

Jim Lefler

Sarah Nelson

Graduating 2015:

Adrienne Belasco

Claire Kappa

Brice Lefler

 

Congratulations everyone!

Dani, Alex, and Bonike

Please also see the DOC Newsletter, attached!

From the Chief Residents Grand Rounds

Fri., February 13th : Pulmonary, Dr. Loretta Que

Noon Conference Date Topic Lecturer Time Vendor 2/9/15 MKSAP Mondays: GIM  Bonike Oloruntoba  12:15  Nosh 2/10/15  MSK Exam Part 1  Lisa Criscione-Schreiber 12:15  Subway 2/11/15  Palliative Care Management of Chronic Medical Disease: COPD & CHF  Jason Webb 12:15/2001  Cosmic 2/12/15  MSK Exam Part 2   Lisa Criscione-Schreiber 12:15/2001  Dominos  2/13/15  Chair’s Conference  Chiefs  12:15  Rudinos                         From the Residency Office Congratulations!

Congratulations also to Eric Fountain and his wife on the birth of their daughter!

ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!   Lactation Rooms – Duke Medical Center

Duke provides 18 lactation rooms for faculty and staff to support women balancing their return to work with their needs as mothers of young children. Each room offers a clean, secure, and user-friendly environment for women who need to express breast milk during their work shift.   Please click on the link for the specific locations for DN, DMP, Duke Clinics and Duke Cancer Center.

The two lactation rooms require Duke ID card access. Women interested in using the lactation facilities must submit a card reader access form to program their Duke ID card for access to the lactation rooms. Once the website is updated with the additional DMP lactation room information, women may also reserve room space by using an online lactation room calendar scheduler. Instructions for submitting the Duke ID card number for access, and additional policy and detailed information are referenced at the following Human Resources website: http://www.hr.duke.edu/benefits/family/newborn/lactation/

The sign up process is easy but access isn’t instantaneous. Once the form is faxed to the program coordinator asking for access, the user will receive a link to the Google calendar in an email. Right before staff are ready to pump, they should sign into the calendar from a NON DUKE email address ( so forward the link to your personal email or it won’t work), ensure one of the rooms is open and available, and sign yourself into the room to reserve it. You should check that your badge access is working for the rooms first to ensure you can get into the room.

If there are questions, please contact Regina McKoy, Program Coordinator at (919) 684-1942. Email: ramckoy@duke.edu

Register for the BLS Blitz

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.

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.

Duke Pain Conference

Duke Pain presents “Pain Management for the Practicing Physician and HCP” February 28 &March 1, 2015 at the Mary Duke Biddle Trent Semans Center for Healthcare Education on the Duke Campus.  Register today by visiting www.carolinapain.org  - this is a great meeting to recommend to all of your internal medicine, family practice and primary care colleagues!   PSOC members enjoy a discounted fee to attend!

Please click here for more details!

Schwartz Center Rounds

Medicine and Miracles: One Case on a Collision Course

Panelists: TBD

Tuesday, February 17, 2015  Noon – 1 p.m., Duke North 2002
Lunch available at 11:45 AM

About Schwartz Center Rounds:

Duke Medicine physicians, nurses and other providers of all disciplines are invited to attend an ongoing series of presentations and discussions, called the Schwartz Center Rounds, about the human side of patient care.

Schwartz Center Rounds is a monthly interdisciplinary conference that offers clinicians a regularly scheduled time during their fast-paced work lives to openly and honestly discuss social and emotional issues that arise in caring for patients. An initiative of the Schwartz Center for Compassionate Healthcare, the rounds take place at 250 sites in the U.S. and U.K. including many of Duke’s peer institutions (Massachusetts General Hospital, Brigham & Women’s, Vanderbilt, Mount Sinai, Emory, Cleveland Clinic and UNC-Chapel Hill). We are excited to be bringing this program to Duke and hope many of you will join us!

Please contact, Lynn Bowlby, MD (lynn.bowlby@duke.edu), Nathan Gray, MD (nathan.gray@dm.duke.edu) or Bill Taub (arthur.taub@dm.duke.edu) with questions. There is no need to RSVP, but we do recommend that you arrive early as food and seats are at a premium!

Upcoming Events

Save the Date – Parents Weekend!!

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

NC ACP Meeting – Registration and Info

Registration and information available here.

AAMC 2015 IQ Call for Abstracts

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

 

Information/Opportunities

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

RM Medical Search

Opportunities in Chicago

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

March 20, 2015 – Match Day Celebration, West End Billiards

June 6th – SAR Dinner, Hope Valley Country Club

  Useful links

Internal Medicine Residency News, February 2, 2015

Mon, 02/02/2015 - 11:07
From the Director

Happy February! Thank you to everyone for your incredibly hard work – things are REALLY busy everywhere, and your hard work is much appreciated.  Special thanks to Erin Payne, Kim Evans, LaVerne Johnson-Pruden, Bonike Oloruntoba, Hal Boutte, Alyson McGhan, Brittany Dixon, Deng Madut, and the rest of the MRRC recruitment team for planning and hosting a fantastic second look weekend for some fabulous applicants.  We have found a new place to go for residency events (Kings Bowl!) and ended the weekend with SNMA’s spectacular Dr. Martin Luther King Jr banquet.  We appreciate everyone’s extra effort to meet with the second look applicants, take them on rounds, and generally keep showing off our great program.  Special thanks also to Angela Lowenstern and Mike Woodworth who helped us entertain people throughout the day.

Other kudos this week to Sam Lindner from Susan Spratt and the endocrinology team for great work in the clinic, to Alicia Clark and Laura Caputo for planning and hosting the first Internal Medicine Book Club – great attendance, great discussion and GREAT IDEA! Looking forward to the next one!  Kudos also to Stephanie Giattino for helping out in the ED!

Get ready for the upcoming charity auction! What will the chiefs auction off? Are pies in the face “so last year?”  Would Coral really let anyone shave her head? Join us and find out.

Your Stead Leaders want you to start the day off right! Get ready for the first “Steadfast Breakfast” delivered to the VA Conference Room on Thursday Feb 5th at 7 am, sponsored by Eileen Maziarz, Steve Crowley and Matt Crowley.  Steadfast breakfast comes to Duke on Feb 12th, sponsored by Manesh Patel and Heather Whitson.  Stop in and grab a bite to eat with your Stead Leaders to start the day off on a good note.

This week’s pubmed from the program goes to Jason Zhu for his paper that was recently accepted for publication..Comparison of Quality Oncology Practice Initiative (QOPI) Measure

Adherence Between Oncology Fellows, Advanced Practice Providers, and Attending Physicians; Journal of Cancer Education.  Jason’s co authors include Duke IM alum and Onc fellow Tian Zhang, as well as faculty Arif Kamal and Mike Kelley.

Don’t forget to register for the upcoming NC ACP meeting! Details at the bottom of the Med Res News!

Have a great week!

Aimee

What Did I Read This Week?

Lynn Bowlby, MD

New England Journal of Medicine  2014   371: 2218-2223  December 4, 2014.

Clinical Problem Solving: D is for Delay

Clinical and Basic science updates as found in NEJM and Annals of Internal Medicine are often key in remaining up to date as a general internist.

Equally important in these journals are features such as Clinical Problem Solving in NEJM, which reviewed medical decision making as you follow along clinical experts and see how they approached the case. As you read you ask yourself if you would approach the case in the same way.  I liked this recent Clinical Problem Solving case, and it reminded me to always think outside the box with many of our challenging patients.

In this case, a 47 year old homeless man presents with intermittent pain and pins/needles sensation in his legs. Common causes of polyneuropathy (DM, ETOH) were evaluated and in his case with rapid onset, vasculitis, paraneoplastic syndrome and heavy metal toxicity were also included in the ddx.

More history, including the presence of Hep C and HTN were revealed. Hep C related cryoglobulinemia  with vasculitis was considered, although no skin lesions were present. He was felt to have idiopathic peripheral neuropathy. 9 months later plaques developed. 8 months after that he developed diarrhea. Over the next 2 years he was admitted to the hospital x5, once with altered mental status, x4 with erythema, and occasional diarrhea. 5 years after presentation, he had been treated for multiple episodes of LE cellulitis. A niacin level was checked and was undetectable. After replacement with 500 mg po qd of niacin, all symptoms , except the neuropathy, resolved after 3 months.

Pellagra—the 4 D’s:

Diarrhea, dermatitis, dementia and death

The pathophysiology is not well understood.

Cognitive errors and system factors interfered with the correct diagnosis. Diagnostic momentum—reframing his illness with each new visit, is challenging.  Once cellulitis was felt to be the diagnosis, change was hard. In this vulnerable patients care in multiple places, by multiple MDs, interfered with the correct diagnosis being made. A simple empiric vitamin would have made a huge difference.

 

 

From the Chief Residents Grand Rounds

Fri., February 6th : Cardiology, Dr. James Daubert

Noon Conference Date Topic Lecturer Time Vendor 2/2/15 MKSAP Mondays: GIM  Nilesh Patel  12:15 Picnic Basket 2/3/15 How to Prepare for the Boards/Debriefing  Drs Zaas and Hargett 12:15/2003 and 9242 Chick Fil A 2/4/15  PEAC Study Hall Chiefs 12:15/2001  China King 2/5/15  IM-ED Combined Conference: Code Sepsis  Cara O’Brien 12:15/2001  Dominos  2/6/15  Chair’s Conference  Chiefs  12:15  Mediterra                     From the Residency Office Congratulations!

Congratulations for Jim and Brice Lefler on the birth of their daughter, Maren Grace!  Congratulations also to Eric Fountain and his wife on the birth of their child – picture to follow soon!  The Duke IM family keeps growing!

ABIM Summer 2015 Examination Dates  Please see the attached flyer for information on dates and registration!   PEAC Modules The assigned PEAC ambulatory modules for the month of February are Back Pain and Hip/Knee Pain. We understand that your schedules are already pressed but it is our hope that completing these modules will be of benefit in improving your ambulatory educational experience. If you haven’t already completed the first two modules for January (Community Acquired Pneumonia and Upper Respiratory Infections) please do so as soon as possible as these modules are required from the program leadership.How to Register:

  1. Go to www.peaconline.organd select the Internal Medicine curriculum.
  2. Click on the link to open a new account, and select Duke from the dropdown menu. It will ask you for a passcode. Please enter passcode “bc8”. The assigned modules for the month of February are Back Painand Hip/Knee Pain. 
Schwartz Center Rounds

Medicine and Miracles: One Case on a Collision Course

Panelists: TBD

Tuesday, February 17, 2015  Noon – 1 p.m., Duke North 2002
Lunch available at 11:45 AM

About Schwartz Center Rounds:

Duke Medicine physicians, nurses and other providers of all disciplines are invited to attend an ongoing series of presentations and discussions, called the Schwartz Center Rounds, about the human side of patient care.

Schwartz Center Rounds is a monthly interdisciplinary conference that offers clinicians a regularly scheduled time during their fast-paced work lives to openly and honestly discuss social and emotional issues that arise in caring for patients. An initiative of the Schwartz Center for Compassionate Healthcare, the rounds take place at 250 sites in the U.S. and U.K. including many of Duke’s peer institutions (Massachusetts General Hospital, Brigham & Women’s, Vanderbilt, Mount Sinai, Emory, Cleveland Clinic and UNC-Chapel Hill). We are excited to be bringing this program to Duke and hope many of you will join us!

Please contact, Lynn Bowlby, MD (lynn.bowlby@duke.edu), Nathan Gray, MD (nathan.gray@dm.duke.edu) or Bill Taub (arthur.taub@dm.duke.edu) with questions. There is no need to RSVP, but we do recommend that you arrive early as food and seats are at a premium!

Upcoming Events

Save the Date – Parents Weekend!!

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

Announcing GME Week 2015!

February 2 – 6, 2015 | GME Week Flyer

For several years the Office of GME has sponsored GME Week, a celebration of the GME community & its commitment to the pursuit of excellence in patient care and dedication to quality education.

Please join us for any of the several events that are scheduled.

For trainees – We will be raffling off 2 tickets to the Duke vs. Wake Forest game on March 4th. Your name will be entered into the drawing once for EACH GME Week  event you attend.

Schedule of Events: 

Monday, February 2nd

11am – 1pm Bunker Lunch for Trainees (free giveaways!)

Tuesday, February 3rd

4pm – 5pm Medical Education Grand Rounds (2W96 DMP)

“Reconciling Patient Safety, The EMR & Education” with Dr. Jane Gagliardi

Wednesday, February 4th

12noon – 1pm Medical Education Grand Rounds (2W96 DMP)

“Reconciling Patient Safety, The EMR & Education” with Dr. Jane Gagliardi

3pm – CLER Update

“DIO Perspective on Duke’s CLER Visit” with Dr. Catherine Kuhn

Thursday, February 5th

7am – 8am Medical Education Grand Rounds (2W96 DMP)

“Reconciling Patient Safety, The EMR & Education” with Dr. Jane Gagliardi

Friday, February 6th

7am – 9am Bunker Breakfast for Trainees (free giveaways!)

 

NC ACP Meeting – Registration and Info

Registration and information available here.

 

AAMC 2015 IQ Call for Abstracts

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

 

Information/Opportunities

Internal Medicine Opportunities GV Redding 1-2015

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

RM Medical Search

Opportunities in Chicago

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

March 20, 2015 – Match Day Celebration, West End Billiards

June 6th – SAR Dinner, Hope Valley Country Club

  Useful links