Internal Medicine Residency News, March 28, 2016

Monday, March 28, 2016

From the Director

Hey everyone! We are closing out March this week, leading up to a number of events for April and into the "last quarter" of the year. We are working on the dates for the faculty-housestaff basketball game, so if you are a weekend warrior, get yourself in shape now that the days are getting a bit longer.  We learned in the Trivia Bowl that Jessica Morris has some connections to LeBron James, so watch out Faculty!

Bracket busted? Still in it to win it? Check with Chris Hostler for the latest standings on our NCAA bracket challenge!
SARs, please pay attention to your procedure logs and make plans to have these complete by June.  Questions, please contact me or the chiefs. 

JARs and Interns, the schedules for next year are nearing completion and should be out in early April.  If anyone remembers the great April Fool schedule email last year, don't underestimate the current chiefs. 

Kudos this week from Brian Andonian to his colleagues working in the ED - Lauren Collins for an outstanding ED note that really helped the NF and gen med teams (I picked up a patient on ID consults also seen by Lauren in the ED - agree, amazing work!) and to Kavisha Singh who made an ED diagnosis of SAPHO!  Also kudos all around from Gen Med 3 - to Myles Nickolich from Annie Reihman and Luke Cerbin for being an awesome SAR and to Annie and Luke from Myles for being JAR-like in their work, and teaching the med students as well!  Thank you to Emily Ray for organizing our Easter brunch in the med res library on Sunday (I did not realize David Beavers was an awesome chef!).

Congratulations to Saumil Chudgar for winning the medical students Golden Apple Award! What a great honor!
Looking forward to JAR dinner this week, as well as the upcoming JAR party from last year's auction at our home on April 3rd.  JARs, look for emails from Jenny Van Kirk regarding the party.

This week's pubmed from the program goes to Matt Atkins for his upcoming SGIM poster presentation "Adherence to USPSTF and ACIP Clinical Guidelines in Resident Clinics" as well as our DOC team including Natasha Cunningham and Marigny Bratcher and medical students Jerry Lee, Morgan Hardy and Julie Rivo for their SGIM presentation "Duke Hotspotting Initiative (DHSI): Integrating Medical Education with Community Based Care Coordination".

Have a great week


What Did I Read This Week?

Submitted by Lynn Bowlby, MD

Chest 2016; 149 (2): 315-352

Antithrombotic Therapy for VTE disease: CHEST guideline and Expert Panel Report

We manage a lot of anticoagulation at the DOC with our complex patients. In the era of mostly warfarin we thought adjusting the dose was complex, but now it has gotten even more complex! We could not manage it without Diana our lead RN or Holly Causey, our amazing Pharm D. Holly pointed me to this reference, which is an amazing, clear, but long resource! It is very well organized and easy to use.  With both inpatient and outpatient anti coag needs, this addresses almost every situation.

These medications, along with insulin and opioids, are among the most dangerous medications that we use.

From this guideline—AT 10—updated from AT 9 released in 2012.

1.      VTE and no cancer: choose non vit K antagonists (NOAC  non Vit K oral anticoagulants),dabigatran, rivaroxaban apixaban or edoraban    over VKA   over LMWH

2.      VTE and cancer: choose LMWH over VKA

3.      VTE treatment with anticoagulation: no inferior vena cava filter

4.      DVT: no compression sock to prevent PTS

5.      Subsegmental PE and no prox DVT: clinical surveillance with low risk of recurrent VTE, anti coag with high risk

6.      DVT or PE with therapy: don’t need to change therapy unless there is a reason to change

7.      Duration recommendations have NOT changed:

3 months for provoked or unprovoked LE DVT if treating.

1st VTE unprovoked prox DVT or PE with low to mod bleeding risk > 3 mos of treatment

2nd VTE extended treatment with no stop date

8.      ASA recc. for unprovoked DVT when /if stop anticoag

9.      Low risk PE can be treated at home or early DC

10.   Acute PE with hypotension and those who deteriorate after starting anticoag but haven’t developed hypotension yet should have systemically administered thrombolytics

11.   Recurrent VTE on oral therapy , switch to LMWH for at least a month.


There are 30 statements with 54 recommendations, 20 strong recc. , none based on high quality evidence. There are many details in the text.

The method of consensus was the modified Delfi technique to achieve consensus on each recommendation.


Long term-- first 3 months

Extended – no scheduled stop date

The most common and difficult decision is whether to stop anticoag after the 1st unprovoked prox DVT or PE without a high risk of bleeding.

This can help you decide—

Men have a 75% higher risk of recurrent clot than women.

A positive ddimer one month post diagnosis of clot doubles the risk of recurrence.




Over the next few weeks I'll highlight each of the four GME Incentive Program metrics. Each of these metrics is worth $200 on your paychecks at the end of the year. None of these are a walk in the park--get ready to work hard if you want that cash. Here are all four metrics, and we'll focus on the first one this week:


SRS reports

ED consult completion time

Physician communication score on the patient satisfaction survey

30-day readmissions

To cash in on this one, we need 2 SRS reports per trainee over the course of the year. Guys, this one should be by far the easiest! Here's how you're doing, illustrated by old-school thermometer charts. Take-home: You need to submit 1-2 more SRS reports EACH by June to get your $200.

Across the board, we need at least 1-2 more SRS reports per trainee.
I know you see adverse events, near misses, and unsafe conditions on the wards. Just open that SRS icon on your desktop and report them!

Our hospital leadership does not know what goes on unless YOU tell them! Your reports are reviewed at multiple levels, and several of them have led to real change already this year. If you all do this, you'll get an easy $200 while making the hospital safer for your patients.



Hello from Clinic Land!!

4+2 schedules

Next year’s schedules will follow a 4+2 format for both interns and JARs! Schedules are currently being built and tweaked and final versions should be available in the next few weeks, thanks to our fearless chiefs. The +2 block will usually be ambulatory, but other 2 week rotations will take that space from time to time, including night float and consults for JARs. Stay tuned for details.

Lincoln as a “sub-specialty” site

Rising JARs have the opportunity to choose a “sub-specialty” clinic site for continuity during ambulatory and consult weeks. Traditionally, this has served as a chance to work with faculty in your specialty of interest and help prepare for fellowship, but this can also be a valuable opportunity for those of you aiming for general medicine or looking to work with a particular population. A number of other clinical sites, including gen med sites outside of your own clinic, pain clinic, obesity medicine, and others are options. This year, Elieth Martinez, Juan Magana, and Julia Xu have requested to go to Lincoln for their extra site, and with the help of Armando, Howard Eisenson, and the rest of the leadership at Lincoln, we are officially building this! Please let us know if you have other thoughts or questions about what we can arrange for your added clinic site.

ACLT Updates

The current ACLT group is preparing for their DC advocacy trip May 17-18! They will be meeting a couple of times before then to hash out their message on their selected topic of opioid prescribing and tying it in to current legislation, in order to make the message relevant for law makers. As for incoming ACLT’ers, I know you’re chomping at the bit to get this show on the road and you will hear more introductory info in the next couple of months. For now, though, mark your calendars for May 27, 6:00 pm, for our year-end dinner at Dani’s house – all are welcome! Invite to follow.



From the Chief Residents


Grand Rounds 

Friday, April 1 - Morbidity & Mortality, Lindsay Boole

Noon Conference

Date Topic Lecturer Time Vendor



12:00 Chick Fil A





ACGME Survey


12:00 Hungry Leaf

Residency Council Townhall

Jessee and Dinushika



Chair's Conference

Chiefs 12:00 Subway


From the Residency Office


Office Hours for Dr. Zaas


Dr. Zaas will have the following office hours.  Please feel free to stop by during these times and of course always feel free to reach out to her office to set up a meeting outside of these times if needed!

Monday - 3:00 p.m. to 4:00 p.m.

Thursday 10:00 a.m. to 11:00 a.m.

Invitation to participate in Clinical Research Day of the School of Medicine

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

We would like to invite and encourage you to submit an abstract of your research project(s) for the Annual Clinical Research Day of Duke School of Medicine to take place on May 19, 2016.

All posters will be accepted, however,  please see attached link for research and poster criteria. Monetary awards will be presented to the first, second, and third place winners of the competition. Dean Nancy Andrews will be the honorary poster judge.

Please email me and Lynsey Michnowicz THIS WEEK with the title of your research project entry. 

We will submit our list of all the participants in one email by March 28th. You do not need to email separately.

You do not need to prepare anything at this time. Your poster must be ready by May 19th for display. The event and poster instructions are described in the links below.

Those of you who have presented posters at a national scientific meeting (previous or upcoming meeting) can display the same poster if research was completed in the last 18 months. You can display a poster of your recently published work as well. 

If you would like to prepare a new poster, our MedRes office can send you a template and will help you print your poster 

Agenda is at

Poster instructions:

There is a possibility that our Department's Annual Resident Research Night might also take place on May 19th in conjunction with this event, but more on that later once our plans have been finalized.

Wishing you success with your projects !

Murat and Aimee



"A Singular Intimacy: Connecting the Bridge Between Caregiver and Patient"

Thursday, April 7, 2016 5:45 p.m. Great Hall, Trent Semans Center

Please see the attachment below for more information.


Charity Auction 2016 -Save the Date!

The Internal Medicine Residency program Charity Auction, benefiting Senior PharmAssist will take place Friday, April 29th, 2016 @ 7:00 p.m. at Motorco in Durham!  Tickets will go on sale the first week in April. We look forward to seeing you there.


Teaching and Leading EBM: A Workshop for Educators and Champions of Evidence-Based-Medicine

Registration is now open!
Teaching and Leading EBM: A Workshop for Educators and Champions of Evidence-Based-Medicine
Duke Medicine, Durham NC
April 12-15, 2016
This workshop focuses not only on learning EBM skills, but also on teaching EBM. Previous participants have included rising chief residents, faculty charged with developing an EBM curriculum, librarians, and other clinicians and faculty passionate about applying the best evidence to patient care. The program includes large group sessions in the morning, then supportive, small group, learner-driven sessions for the rest of the day.
The workshop will take place on the Duke Medicine campus in the new Trent Semans Center for Health Education and the Duke Medicine Pavilion.
Workshop Objectives:

Train leaders in medicine to facilitate evidence-based clinical practice in their teaching and practice settings.
Practice the skills involved in evidence-based medicine including clinical question formation and acquisition of medical evidence from the literature.
Review and develop critical appraisal skills and application of available evidence to patient care and medical education.
Develop skills in teaching EBM in both large and small group settings.
Provide interactive experience with a variety of evidence-based resources guided by faculty with expertise in evidence-based practice.

Please contact Megan von Isenburg ( or Laura Huffman ( with any questions.


Book Club Survey

If you haven't been to one of our events yet, please support the Dept of Medicine book club project by taking a quick moment to fill out the survey below!  Your participation is totally voluntary and anonymous, and the questions only takes ~2 minutes.  You may remember filling this out before -- if you have, try to use the same identifier you used last time (if you can't find it, just make up a new one).  
Here's the link:
Feel free to email if you have any questions.  Thanks so much for your participation!


Opportunities for Wellness


Feeling down? Need to talk to someone? 
All trainees at Duke have FREE access to Personal Assistance Services (PAS), which is the faculty/employee assistance program of Duke University. The staff of licensed professionals offer confidential assessment, short-term counseling, and referrals to help resolve a range of personal, work, and family problems. PAS services are available free of charge to Duke faculty and staff, and their immediate family members. An appointment to meet with a PAS counselor may be arranged by calling the PAS office at 919-416-1PAS (919-416-1727), Monday through Friday between 8:00 A.M. and 5:00 P.M. For assistance after hours, residents and fellows can call the Blood and Body Fluid Hotline (115 inside DUH, 919-684-1115 outside) for referral to behavioral health resources. Another resource is Duke Outpatient Psychiatry Referrals at (919) 684-0100 or 1-888-ASK-DUKE.


Upcoming Dates and Events


April 29 -Charity Auction

May 19 - Resident Research Night

June 4 - SAR Dinner


Useful links

GME Mistreatment Reporting Site
Main Internal Medicine Residency website
Main Curriculum website
Department of Medicine
Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response