Internal Medicine Residency News, October 27, 2014

Monday, October 27, 2014


From the Director

DUKE.RESEARCH.NIGHT.03 (1)Hi everyone!

Thank you all for the great birthday celebration, and especially for the photo book.  I love it, and am glad to have a chance to celebrate with you all.  Happy birthday also to Lynsey Michnowicz! We had a lot happening this week, with a great SAR talk by Deng Madut, an awesome chair’s by Sneha Vakamudi, the CIMIGRO med student event at Tyler’s (Chris Hostler gets to go to Tyler’s twice in ONE week!), a really fun lunch in the courtyard on Tuesday (thanks, chiefs, for planning it!), teaching by Joe Brogan captured on film, a farewell to our fantastic ACRs Claire Kappa, Adam Banks and Kevin Trulock, and ongoing Doctoberfest trivia.   Other kudos to Jay Mast from Jan Dillard, LCSW at the DOC for great patient-centered care.

In other big news this week…Marc Samsky and Sarah Goldstein got engaged! Erin and I were pretty psyched to have the first ever ring sent to the program office for pre-proposal safekeeping.  Also belated engagement congratulations to Bassem Matta, and also to Adam Banks.  And a belated wedding congratulations to Rachel Titerance Hughes and Daniel Hughes.

Recruitment officially kicks off this week! We have our Monday night party, and then prelim interview day on Friday, with the first categorical day on Monday Nov 3.  Thanks to all who have signed up for dinners, tours, resident share, etc.  It’s going to be a great season, and you all are the most important part!  The end of the week is the Residency Council’s annual Halloween Party, so get your costumes ready.

Welcome to our new ACRs John Wagener, Iris Vance and Christine Bestvina.  We need some Turkey Bowl trash talk to get started before the big game.

In other program news, the ITE scores will be sent to your advisors this week and also to each of you individually.  As a program, we did really well this year (great work!), and we will be doing some more analysis to see what areas we can improve on as a group.  With thanks to Katie Broderick-Forsgren and GME Concentration mentor Dr. Sue Woods, as well as the ambulatory team, we are looking to improve our ambulatory curriculum.  Please pay attention to the upcoming ambulatory evaluations and surveys, and get ready for the introduction of the Ambulatory Online PACE curriculum!

There are two opportunities this week to meet the editor of JAMA! Dr. Howard Bauchner will be speaking Monday at 11:45 in the Trent Siemans Center (med school) on cardiovascular guidelines and then at noon conference on Tuesday about careers in medicine.  Please take advantage of these great talks!

This week’s Pubmed from the Program goes to Mike Woodworth for his presentation at ID Week detailing the history and epidemiology of nocardia infections at Duke, as well as his outstanding ID grand rounds “Lung in the time of Nocardia”.  Great job, Mike.


Have a great week!




What Did I Read This Week?

Submitted by: Saumil Chudgar, MD


Haubitz S, Hitz F, Graedael L, Batschwaroff M, et al. “Ruling Out Legionella in Community-Acquired Pneumonia.” Am J Med 2014; 127: 1010e11-1010e19.

Legionella Score in CAP




What I read:

Haubitz S, Hitz F, Graedael L, Batschwaroff M, et al. “Ruling Out Legionella in Community-Acquired Pneumonia.” Am J Med 2014; 127: 1010e11-1010e19.

Legionella Score in CAP

Why did I read this?

I was recently on the Duke GM wards, and we had several patients with CAP. As per IDSA guidelines, we treated them either Ceftriaxone + Azithro/Doxy or with a respiratory FQ like Moxi or Levo. The causes of CAP (typicals versus atypicals) and therapy for CAP is one of my favorite questions to ask medical students. We always check people for Legionella even without risk factors and end up including therapy for it with the Azithro or the respiratory FQ. I saw this article so read it to see if it provides an easy method to exclude Legionella.

What I learned from reading this/thoughts on the article?

The authors sought to validate a predictive score proposed in 2009 that used 6 dichotomous risk factors: Temp > 39.4C, CRP > 189 mg/L, LDH > 225 mmol/L, Platelet count < 171, Na < 133, and “dry cough.” They used a preexisting database and had 1939 eligible patients who had at least 5 of the 6 variables available/recorded. Thirty-seven of these patients were diagnosed with Legionella (1.9%). 34/37 was diagnosed by positive urine Ag, 2 by positive respiratory culture, and 1 by blood culture. Univariate analysis was done with calculated AUC – 5 of the 6 variables had a strong association with Legionella (all but dry cough). Having a score of < 2 (none or only one factor present) had a sensitivity of 94.4% to rule out Legionella in CAP (NPV of 99.6%). The urinary antigen test has a sensitivity of 64 to 88%.

The authors suggest that in patients with a score < 2, further testing and coverage for Legionella only be used if the patient is felt to be high-risk for mortality or has a contributory history. I started the article very excited at the idea of a predictive score, but I do not think I am yet ready to use this in clinical practice. I only routinely obtain 4 of these 6 parameters in most patients with CAP whom I take care of – specifically, I rarely get an LDH or CRP unless there is another clinical indication to do so. I am not sure if it is worth adding those on versus getting a urinary Legionella antigen. One could argue the model has a higher sensitivity, but in practice, we do not tend to stop the macrolide if the patient is Legionella negative. So, does “ruling out” Legionella change our practice? The authors appropriately acknowledge studies that have shown potential anti-inflammatory benefits of macrolides even without atypical pneumonia present. I am interested to see how this score is applied further and what impact it may have on clinical practice.


Clinic Corner

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Clinic Corner

Wanted to take this opportunity to share some results from last year’s Ambulatory QI project: “We Follow Up,” regarding the documented follow-up of laboratory and other testing ordered by y’all in your continuity clinics. This project was led, organized, and conducted by Jon Bae and Joel Boggan, with help from George Cheely as well as the Residency Program Office. And made possible, of course, by the JARs and SARs who did the SharePoint self-assessments. Aparna Swaminathan is currently working on writing these results up with Jon and Joel.

The objectives of the SharePoint individual performance Improvement modules in general are to give residents an opportunity their performance around a quality measure; encourage creative thinking about how to improve one’s own performance; to meet ACGME requirements of Practice-Based Learning and Improvement and Systems Based Practice; to provide skill-based training in quality improvement; and to improve the quality of the care we deliver to our patients.

This particular project was spurred in part in response to prodding from David Simel at the VA and others, and developed with the input of the Ambulatory Care Leadership Track (ACLT) residents and continuity clinic site directors at PRIME, Pickett Rd, and DOC.

METHODS: For the project, JARs and SARs were asked to review 20 clinic patient encounters during or after which they ordered any tests (excluding point-of-care), 10 of which had “significant” (i.e., abnormal, see table below) results; and to look for documentation or other charted evidence (e.g., web portal annotations) of communication with patients regarding these results in line with the following expectations:



All eligible test results should be followed-up, communicated to patient, and documented at a maximum of within 14 days of result.

All eligible test results with significant/abnormal results should be communicated to patient and documented within no more then 72 hours of test result

RESULTS: 68 second- and third-year residents completed both initial and follow-up self-assessments. A total of 3222 patient encounters with tests ordered by these residents in their own continuity clinics were reviewed; 1713 initially, 1509 in follow-up. Nearly a third (32%) of patients had “significant” results. All three clinics showed improvement; two of three with gains that were statistically significant.








*p-value <0.05

DISCUSSION: The failure to review and follow up on outpatient test results in a timely manner represents a patient safety and malpractice concern. Failures to document follow-up abnormal test results are also common in ambulatory care, averaging 7.1% in one review of 5400 primary care patients, ranging from 1-62% across studies included in a systematic review published in JGIM.

Surveys have found widespread dissatisfaction by primary care providers with their current systems to manage abnormal test results. Physicians who actively tracked their test orders to completion were also more likely to report being satisfied.

The good news is that when confronted with these facts in their own practice, however, residents responded by working to improve that practice – and succeeding!

(Sources: Int J Med Inform. 2003;71(2-3):137-49. Arch Intern Med. 2009;169(12):1123. J Gen Intern Med. 2011;27(10):1334.)

A cross-sectional survey of 216 primary care physicians (PCPs) that utilize a single electronic medical record (EMR) without computer-based clinical decision support.

The overall response rate was 65% (140/216Therefore, we sought to identify problems in current test result management systems and possible ways to improve these systems.


We surveyed 262 physicians working in 15 internal medicine practices affiliated with 2 large urban teaching hospitals (response rate, 64%). We asked physicians about systems they used and the amount of time they spent managing test results. We asked them to report delays in reviewing test results and their overall satisfaction with their management of test results. We also asked physicians to rate features they would find useful in a new test result management system.




From the Chief Residents

Grand Rounds

Fri., Oct. 31: General Medicine, Dr. David Edelman

Noon Conference

Date Topic Lecturer Time Vendor
10/27/14  Ebola  Cameron Wolfe 12:15/Room 2002 Rudinos
10/28/14  JAMA Editor In Chief  Howard Bauchner 12:00/Room 2002 Dominos
10/29/14  Inpatient Geriatric Medicine: Management & Pearls  H. Whitson 12:15/Room 2002 We Care Wednesday
10/30/14  Library Overview  Megan Von Isenburg  12:00/Room 2001  Subway
 10/31/14  Research Conference  12:00/Room 2002  Panera

From the Residency Office

Recruitment Kick-Off!

October 27th- Recruitment Kick Off Tonight! Join us at City Beverage at 7pm for appetizers, drinks, and a fun start to this season. We hope you can make it!

Pin Station Re-located

The pin station is the MedRes library has been re-configured so that images can be projected on the large screen for report.  If you need an individual pin station for work, please feel free to use the one in the front cubicle of the MedRes office, suite 8254.


Open Enrollment for Benefits Begins 10/27/14!

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

Open Enrollment

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

Housestaff Healthcare, Dental and Vision Premiums 2015

Open Enrollment Information

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

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

Qualifying events include, but are not limited to:

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

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


New Badge-Backers Required by GME

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


CLER Visit Information

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


Doctoberfest is Coming to an End!

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

Thank you to everyone who has planned for an participated in our annual Doctoberfest celebration!  Look for some special treats on Halloween as we mark the end of Doctoberfest and the beginning of Recruitment!

[caption id="attachment_16994" align="aligncenter" width="300"]Fun Lunch Day -Taco Tuesday Fun Lunch Day -Taco Tuesday[/caption]

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


Flu Vaccination Update

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

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

A schedule of vaccination clinics is posted on the employee intranet at  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.

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

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


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

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

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

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



Trent Center Colloquium Series

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

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

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

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



Career Fair-Chapel Hill

Biomedical Informatics Research Training Opportunity

Des Moines IM Opportunities



Internal Medicine opportunities



Upcoming Dates and Events

October 27, 2014 - Recruitment Kick-Off Event

December 13, 2014 - DoM Holiday Party

November 27, 2014 - Turkey Bowl

Useful links