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News from the Duke Department of Medicine
Updated: 18 hours 44 min ago

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

New internal medicine book club starting Jan. 28

Mon, 01/26/2015 - 11:45

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

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

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

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

Internal Medicine Residency News, January 26, 2015

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

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

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

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

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

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

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

 

Have a great week

Aimee

What Did I Read This Week?

Reference:

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

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

Background:

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

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

Why did I read it?

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

Results:

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

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

occurring in the setting of a major transient risk factor.

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

without an appropriate clinical indication.

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

 

Discussion:

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

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

 

QI Corner

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

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

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

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

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

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

 

Clinic Corner

Chronic Pain/Opioid Safety

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

Treating The Common Cold

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

Larry Greenblatt, MD

 

From the Chief Residents Grand Rounds

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

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

First Medicine Book Club Event

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

Save the Date – Parents Weekend!!

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

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

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

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

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

http://oit.duke.edu/mfa

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

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

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

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

AAMC 2015 IQ Call for Abstracts

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

 

Information/Opportunities

Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities

Marshfield Clinic GIM

RM Medical Search

Opportunities in Chicago

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

  Useful links

Internal Medicine Residency News, January 20, 2015

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

Hi everyone!

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

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

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

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

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

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

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

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

Have a great week

Aimee

What Did I Read This Week?

Nilesh Patel, MD, MS

Lactic Acidosis

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

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

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

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

Cardiogenic shock

Hypovolemic shock

Trauma

PaO2<30

Hb<5

CO poisoning

Cocaine

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

Sepsis

Severe Asthma

Trauma, cardiogenic shock, hypovolemic shock

Pheo

Cocaine

Beta agonists

  1. Drugs that impair oxidative phosphorylation

Antiretrovirals

Propofol

Metformin (also suppresses hepatic gluconeogenesis)

Salicylates

Cyanide

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

Diabetes can contribute for unknown reasons

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

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

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

Bicarbonate infusions are unproven.

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

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

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

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

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

All in all, more investigation is needed.

QI Corner

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

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

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

Clinic Corner

Sonal Patel, MD – VA PRIME

PRIME residents,

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

Enter Sticky Note 2.0

You can now “color” coordinate your reminders to yourself

STICKY NOTE RED

STICKY NOTE YELLOW

STICKY NOTE GREEN

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

Sticky Note Business Rules:

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

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

Sonal Patel

From the Chief Residents Grand Rounds

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

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

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

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

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

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

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

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

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

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

Professionalism
Faculty engagement in training on professionalism

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

Welcome Theodore Greene!

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

 

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

Combined Stead Society/PWIM and Office of Faculty Development Event

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

First Medicine Book Club Event

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

AAMC 2015 IQ Call for Abstracts

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

 

Information/Opportunities

RM Medical Search

Opportunities in Chicago

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

  Useful links

Internal Medicine Residency News, January 12, 2015

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

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

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

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

Have a great week!

Aimee

HAPPY BIRTHDAY CORAL!!!

What Did I Read This Week?

 

Coming Soon!

 

 

QI Corner

Hey Guys!

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

Clinic Corner

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

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

There will be a shift of attendings starting March 1:

Tuesday morning Dr. Boinapally

Wednesday morning Dr. Metz

Thursday afternoon Dr. Brown

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

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

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

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

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

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

Epic

Tool

Patient care tools

Inbasket Class

Choose Pickett Road Primary Care Residents

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

Sincerely,

Sharon Rubin, MD, FACP

 The Ambulatory Care Leadership Track:

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

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

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

ACLT application form – 2014-15

 

From the Chief Residents Grand Rounds

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

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

Combined Stead Society/PWIM and Office of Faculty Development Event

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

First Medicine Book Club Event

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

AAMC 2015 IQ Call for Abstracts

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

 

Welcome Jack Feeney!

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

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

Sue Woods

 

Information/Opportunities

RM Medical Search

Opportunities in Chicago

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

  Useful links

Internal Medicine Residency News, January 5, 2015

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

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

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

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

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

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

Choosing Wisely – get involved by attending the PSQC meetings!

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

Here’s to a GREAT year!

Aimee

What Did I Read This Week?

Aaron Mitchell, MD

Submitted by: Aaron Mitchell, MD

Reference:

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

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

Why did I read this:

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

Background:

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

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

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

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

Results:

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

Discussion:

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

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

Clinic Corner

DOC Clinic Corner 1/5/15

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

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

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

 

 The Ambulatory Care Leadership Track:

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

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

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

ACLT application form – 2014-15

 

From the Chief Residents Grand Rounds

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

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

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

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

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

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

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

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

Thank you,

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

 

Evidence-Based Medicine: A Cross-GME Course

Open to all Duke residents and fellows

January 7 – February 11

Wednesdays 5:30 – 7:00 PM

(Duke Medicine Pavilion Conference Rooms)

Dinner Served

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

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

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

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

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

 

Information/Opportunities

Primary Care Baptist Medical Group Pensacola

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

  Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

  Useful links

Internal Medicine Residency News, December 19, 2014

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

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

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

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

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

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

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

We’re back on the blog in 2016!

Aimee

Toys for Tots Donation!

What Did I Read This Week?

Submitted by: Aimee Zaas, MD

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

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

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

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

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

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

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

 

Cheers!

 

 

From the Residency Office

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

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

 

Uniforms Ordering Closes December 31

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

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

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

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

Do No Harm Project

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

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

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

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

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

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

Thank you,

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

 

 

Evidence-Based Medicine: A Cross-GME Course

Open to all Duke residents and fellows

January 7 – February 11

Wednesdays 5:30 – 7:00 PM

(Duke Medicine Pavilion Conference Rooms)

Dinner Served

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

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

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

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

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

 

 

Information/Opportunities

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

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, December 15, 2014

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

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

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

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

 

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

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

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

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

Have a great week

Aimee

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

What Did I Read This Week?

Submitted by: Aimee Zaas, MD

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

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

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

What information did they learn from the literature?

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

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

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

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

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

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

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

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

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

Novel/Molecular Adverse Prognostic Factors

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

What about therapy?

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

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

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

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

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

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

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

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

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

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

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

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

 

Clinic Corner

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

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

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

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

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

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

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

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

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

Have a safe and happy holiday and new year!

Sincerely,

Sharon Rubin, MD, FACP

 

 

What? The Ambulatory Care Leadership Track:

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

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

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

ACLT application form – 2014-15

 

QI Corner

 

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

 

 

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

 

 

From the Chief Residents Grand Rounds

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

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

2014 Internal Medicine Residency Council Holiday Toy Drive

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

Details:

– Unwrapped

– New/Unused

– No guns

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

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

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

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

Best regards to all,

Murat and Aimee

 

Annual GME Holiday Celebration

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

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

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

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

 

Uniforms Ordering Closes December 31

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

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

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

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

Do No Harm Project

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

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

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

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

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

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

Thank you,

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

 

Evidence-Based Medicine: A Cross-GME Course

Open to all Duke residents and fellows

January 7 – February 11

Wednesdays 5:30 – 7:00 PM

(Duke Medicine Pavilion Conference Rooms)

Dinner Served

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

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

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

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

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

 

Information/Opportunities

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

Hospitalist Opportunity

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, December 8, 2014

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

Hi Everyone!

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

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

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

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

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

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

Have a great week

Aimee

MATCH DAY!

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

 

What Did I Read This Week?

Submitted by: Sue Woods, MD

Clinic-Community Linkages for High-Value Care

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

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

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

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

The strategy that the authors outline has the following components:

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

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

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

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

Challenges identified by the authors include:

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

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

Clinic Corner

DOC Clinic Corner 12/8/14

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

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

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

 

What? The Ambulatory Care Leadership Track:

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

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

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

ACLT application form – 2014-15

 

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

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

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

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

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

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

 

QI Corner

 

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

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

 

From the Chief Residents Grand Rounds

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

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

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

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

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

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

Best regards to all,

Murat and Aimee

ACP Abstracts Due!

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

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

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

Murat and Aimee

 

Annual GME Holiday Celebration

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

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

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

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

 

Uniforms Ordering Closes December 31

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

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

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

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

Do No Harm Project

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

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

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

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

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

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

Thank you,

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

 

AAMC-CDC Public Health Policy Fellowship

Public health policy experiential learning opportunities for early-career physicians

 

Information/Opportunities

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

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

December 13, 2014 – DoM Holiday Party

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Duke Heart Center launches new mobile app for cardiovascular education

Fri, 12/05/2014 - 11:19

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

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

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

 

Results posted for 2014-2015 fellowship match

Wed, 12/03/2014 - 16:15

The 2014-15 national fellowship match was announced today.

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

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

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

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

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

Internal Medicine Residency News, December 1, 2014

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

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

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

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

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

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

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

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

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

Have a great week

Aimee

What Did I Read This Week?

Submitted by: David Butterly, MD

ANCA-RituxNEJMNov2014

Rituximab versus Azathioprine for Maintenance in ANCA-Associated Vasculitis

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

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

Background:

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

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

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

Current Study:

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

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

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

Findings:

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

Conclusions:

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

Clinic Corner

 

Ambulatory Clinic Corner

Want more autonomy in the clinic?

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

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

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

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

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

 

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

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

 

Wanted: Future leaders in Ambulatory Care

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

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

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

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

ACLT application form – 2014-15

QI Corner

 

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

Aaron Mitchell

 

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

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

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

Thanks so much !

Lish Clark

 

From the Chief Residents Grand Rounds

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

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

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

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

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

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

Best regards to all,

Murat and Aimee

ACP Abstracts Due!

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

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

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

Murat and Aimee

Information/Opportunities

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

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

Upcoming Dates and Events

December 3, 2014 – SAR Match Party

December 13, 2014 – DoM Holiday Party

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links

Internal Medicine Residency News, November 24, 2014

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

Hello Everyone,

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

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

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

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

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

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

Aimee

What Did I Read This Week?

Submitted by: Omobonike Oloruntoba, MD

Early versus On-Demand Nasoenteric Tube Feeding in Acute Pancreatitis

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

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

BACKGROUND:

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

METHODS:

Study Participants:

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

Study Design:

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

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

RESULTS:

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

CONCLUSION:

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

 

Clinic Corner

 

Hi everyone

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

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

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

Dr. Bhaskar- PRIME D great.

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

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

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

Dr. Palsson- follow-up of emergency room visit

 

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

Best,

Sonal Patel

VA PRIME

From the Chief Residents Grand Rounds

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

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

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

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

Best regards to all,

Murat and Aimee

ACP Abstracts Due!

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

American College of Physicians NC Chapter Meeting

Date: Feb 13,14 2015

Where: Sheraton RTP

Submissions for abstracts due 12/12/14

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

Murat and Aimee

 

Partners In Health and BWH Hospitalist Program

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

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

Partners In Health and BWH Hospitalist Program

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

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

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

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

Qualifications:

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

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

Information/Opportunities

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

Internal Medicine Opportunities

Physician Recruiting Services – Beck & Field

 

 

Upcoming Dates and Events

November 27, 2014 – Turkey Bowl

December 3, 2014 – SAR Match Party

December 13, 2014 – DoM Holiday Party

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

February 27, 2015 – Charity Auction

March 3, 2015 – Duke vs UNC

Useful links