From the Director
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
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:
- Define community and establish a sound infrastructure for data analysis.
- 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.
- “Target positive outliers” in these specific communities.
- They look for patients who have attained favorable outcomes, especially those with historically poor outcomes who have had recent improvements in health care issues.
- Obesity, hypertension, diabetes, readmission to hospital are examples
- Once the outliers are identified, the goal is to identify strategies for achieving success
- The goal is to “create an operational toolkit specific to a given community.”
- 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:
- 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.
DOC Clinic Corner 12/8/14
- Check out this month’s DOC Newsletter for new info!
- 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.
- 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
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.
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
Fri., Dec. 12: Pulmonary, Dr. Claude Piantadosi
|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
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 DatesPlease 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
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
T-401 Duke North (Bunker)
Thursday, December 18
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.
Vikas Saini, MD Shannon Brownlee, MSc
President Senior Vice President
Lown Institute Lown Institute
AAMC-CDC Public Health Policy Fellowship
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.
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
- Main Internal Medicine Residency website
- Main Curriculum website
- Ambulatory curriculum wiki
- Department of Medicine
- Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response