Internal Medicine Residency News, September 8, 2014

Monday, September 8, 2014

From the Director

DUKE.RESEARCH.NIGHT.03 (1)It's great to see the start of Turkey Bowl practices! And a 2-0 start for Duke football. Happy fall! Get ready for Doctoberfest coming up....details to follow. The ITE seems to be going well - thanks to everyone for being on time,and for covering your colleagues while they are testing. Kudos this week to our past two weeks of awesome SAR talks by Brice Lefler, Claire Kappa, Rachel Titerance, Fola Babatunde, Tony Lozano, Ben Lloyd and Chris Merrick.

Also kudos to our Med Res office for achieving Green Certification from Duke University!! We have met the many criteria to receive this designation - awesome job! Now keep recycling - there is a box for pager batteries in the office as well as a place for any plastic bottles in the med res library or outside the 8th floor elevators.

GET INVOLVED! Are you interested in helping with our curriculum project? Let me, Bill Hargett or Murat Arcasoy know. How about QI and patient safety? Let Lish Clark or Aaron Mitchell know. What about resident research and stats support? Talk to Murat Arcasoy! Community service? Talk to your Stead Leader or to Erin Payne and me.Looking forward to dinner with JARs this week.

Nick Rohrhoff has invited the SARs to the Zaas rental house for a SAR night, so stay tuned. It's almost in acceptable shape for guests and I think it will feel more like home once you join us on the (not as cool as the last one) back porch.

Congratulations to Paul and Katherine St Romain on the birth of Elizabeth Ann, arriving Sept 6 at 1:51 am! Everyone is doing well.

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This weeks pubmed from the program to Amit Bhaskar for his upcoming American College of Gastroenterology abstract with mentor Ziad Gellad…Title: Physician-Directed Bolus Sedation for Colonoscopy Improves Endoscopy Unit Efficiency Authors: Amit Bhaskar, MD, Ziad Gellad, MD, MPH, Duke University Medical Center, Durham, NC

Have a great week




What Did I Read This Week?

submitted by: Suzanne Woods , MD

Screening for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-analysis for the U.S. Preventive Service Task Force

Annals of Internal Medicine. 2014;161:336-346.

Author: Jonas et al.



Why did I read this article: On gen med I have been doing a lot of reading this week….notes, notes and more notes. Admission notes, daily progress notes and discharge summaries! But thanks to the efforts of Katrina Abril and Adam Barnett for getting these finished so expeditiously and thoroughly on a Saturday, I had time to look at the mail this week and this article caught my eye.

Background information:

Stoke is a leading cause of death and disability and affects an estimated 7% of US adults. Ischemic strokes are responsible for 90% of all strokes with carotid artery stenosis (CAS) causing ~10% of ischemic strokes in our country. Several studies have tried to estimate the rate of progression of asymptomatic CAS and predict subsequent neurologic events. The best available data revealed a 5-year risk for ipsilateral stroke of 5% for CAS of >70%. The goal of this review was to 1. evaluate the current evidence on whether screening asymptomatic adults for CAS reduces the risk for ipsilateral stroke

  1. evaluate harms associated with screening and interventions for CAS
  2. evaluate evidence on the incremental benefit of medical therapy and on risk-stratification tools


Identified and reviewed articles using analytic framework. Included studies of Asx adults with CAS, RCT’s of screening for CAS, RCT’s and systematic reviews of treatment ineffectiveness, multi-institution trials or cohort studies that reported harms, and studies that attempted to externally validate risk-stratification tools.

Results and Discussion:

The results came from 78 published articles that reported on 56 studies.

  1. No eligible studies provided evidence on whether screening reduced ipsilateral stroke.
  2. Duplex ultrasonography is widely available and non-invasive but reliability is questionable due to differences in accuracy and this can result in many false positive test results. If acted upon, this can result in many unnecessary confirmatory tests (angiography or MRA).
  3. Hard to obtain an accurate estimate of potential benefits for the primary care population. CEA c/w medical therapy in their review showed reduction in perioperative stroke or death or any subsequent stroke. Challenge: medical therapy is not all standardized but should include the use of statins, antihypertensives, glycemic control for DM patients and use of antiplatelet drugs for vascular disease and risk reduction. Also the trials used highly selected surgeons with low complication rates.
  4. The benefits of surgery depend on the risk of the Asx lesion eventually resulting in stroke and that risk appears to be decreasing in the last few decades.
  5. Medical interventions have been determined to be 3-8x more cost-effective.
  6. No externally validated, reliable risk-stratification tools are available that can distinguish between patients with Asx CAS who are at increased or decreased risk for stroke caused by CAS despite current medical therapy vs those patients who have increased or decreased risk for harm with surgery.
  7. May be lack of underreporting of harms postoperatively such as nonfatal MI, cranial nerve damage, PE, infections etc or even psychological harm. Most commonly on harms including stroke or death were noted.
  8. Need to look at life expectancy and timing of events. Potential for surgical benefit decreases with advancing age.

This review was accompanied by the Clinical Guideline and US Preventive Services Task Force Recommendation Statement (pgs 356 – 362) . This was an update to the 2007 recommendation on screening for CAS and concludes with the reaffirmation of its previous statement against screening for ASx CAS in the general adult population (D recommendation).

And the editorial was written by Dr. Larry Goldstein of our own Neurology department! Check out pages 370-371 for his thoughts.


Clinic Corner

zipkinDOC Clinic Corner, 2014 September

Hello Team DOC!

Last year, we implemented several key changes at the DOC as part of our overall DOC redesign effort, lead by Alex Cho. The changes included establishing Natasha Cunningham as our Med-Psych medical director and launching the HomeBase program for our Medicaid patients who over-utilize the ED, Marigny Manson became the HomeBase case manager, Julia Gamble became our NP practitioner who can create better bridges in patients’ clinical care, and the Stead or Firm groupings began,s led by Lynn Bowlby, Dani Zipkin, and Larry Greenblatt.

Recently, Drs. Cho, Bowlby, Cunningham, Brandie Johnson and Gina Green presented to Dr. Klotman, Dr. Sowers, Dr. Zaas, and Chris Samples on our progress. Please see the slide deck attached for details!

The September DOC Newsletter is attached here! Please read!

And now, last but definitely not least…

 Maestro Rules: We are expected to close encounters in 24 HOURS!! That means, please finish your notes and route to your attending by the end of the clinic day so that we can close the encounters.




From the Chief Residents

Grand Rounds

Fri., Sept.12, 2014: Dr. David D'Alessio, Endocrine

Noon Conference

Date Topic Lecturer Time Vendor
9/8/14 SAR Emergency Series: Pneumonia/Debriefing Borderick-Forsgren 12:15 Picnic basket
9/9/14 SAR Emergency Series: DVT/PE John Wagener 12:15 Domino's
9/10/14 Antibiotic Stewardship Clinical Pharnacist 12:15 China King
9/11/14 SAR Emergency Series: ABG Interpretation  Laura Musselwhite  12:15 Sushi
 9/12/14  No conference- lunch only  Mediterra

From the Residency Office


ITEs Are in Full Swing!

Friday, September 5th marked the first testing date for the ITEs!  House staff - please check your Amion to know what date you are scheduled to take the exam.  As a reminder, the exams are being administered electronically this year!  Please be sure to review the information below and contact Jen Averitt in the MedRes office if you have any questions.  Good luck!!

The following is important information – PLEASE REVIEW CAREFULLY BEFORE your test date!

  • Please take a few minutes to take a practice test at  Please try and practice BEFORE 9/2/14 as the test may become unavailable after the national testing window opens
  • The testing center is located at 406 Oregon St, Lab 101, Durham  There is free parking in front of the building
  • Please be at the testing center NO LATER THAN 8:00 am on test day!!
  • There is no food allowed inside the testing room, but a boxed lunch will be provided for you in the building.  You will be allowed a 30 minute lunch break.


ETHOS for Noon Conference Attendance Tracking!

AS of 9/8/14 we now ONLY use ETHOS for tracking attendance.  Most of you should already have an ETHOS account which you use for tracking your attendance at Grand Rounds, but EVERYONE should read the following instructions carefully, as it applies to new and current account holders.  You MUST have your Duke Unique ID entered in to you ETHOS account in order for the system to work properly!  Please make sure that you enter your Duke Unique ID and NOT your Net ID!  If your unique ID is entered incorrectly, you will not get credit for attending the conference!

How do I Set up an ETHOS account for the first time?

How to register with Ethos

  • Go to the Duke Continuing Medical Education home page.
  • In the upper right corner, click Join. The Account Information page opens.
  • Complete the fields on the screen. A field with an asterisk is required.
  • NOTE:  Please make sure you include your Duke Unique ID– even though it does not show as a required field.
  • Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
  • At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you provided.
  • Open the email (from and click the top link in the body of the message.
  • In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
  • In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
  • Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
  • Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.

To record your CME attendance via text message, follow these steps

  • The 6-character SMS code will be provided on a slide during your CME event.
  • Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
  • In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
  • In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
  • Press send.
  • If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”

To add your Duke Unique ID to your account

  • Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
  • Enter your username and password. Click My Account in the upper right corner.
  • Under My Profile, click Edit
  • Scroll down until you see Duke Unique ID filed.  make sure it is correct
  • Save the changes to you My Profile page

Flu Vaccination Season 2014

As you know, Duke University Health System (DUHS) requires all healthcare workers who perform their duties in a DUHS facility or a community home-based setting to be vaccinated annually against the flu. This is in alignment with our core value of “caring for our patients, their loved ones and each other.” Annual vaccination against influenza, or policy compliance through a granted medical or religious exemption, is a condition of employment for all DUHS employees. Annual vaccination or policy compliance is also a condition of access to Duke Medicine facilities for those holding clinical privileges in a Duke Medicine facility and learners who wish to train in our facilities.

With this in mind, please note these key dates for this flu vaccination season:

  • Start of Flu Vaccination Season: Thursday, September 18, 2014
  • Applications for Medical or Religious Exemption should be submitted before Friday, October 17, 2014.  This will allow sufficient time for review and for communication of the review decision. Please note: Due to the availability of an egg-free formulation of the flu vaccine, egg allergy will no longer be a valid reason for a medical exemption.
  • Policy compliance through vaccination or granted exemption by Monday, November 17, 2014

We will kick off our annual flu vaccination campaign with a 24-hour Duke Medicine Mass Flu Vaccination drill. The drill will begin on Thursday, September 18, 2014. Mass vaccination clinics will be available at each of the hospitals with peer vaccination available throughout DUHS. Following the drill, we will begin our annual flu vaccination program, during which time we will provide many additional opportunities for you to get vaccinated. 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.


Now Accepting Applications for Global Health Elective Rotations

The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2015 and March 2016.

Application is open to residents from the Departments of Medicine and Pediatrics: Internal Medicine (PGY 2); Med-Peds (PGY 3); Med-Psych (PGY 4); Pediatrics (PGY 2).

The application is attached and available at or submit online

(Application addendum is available by request –

Interviews will be held in October. For more information about this opportunity, contact Tara Pemble, Program Coordinator at or 668-8352.

Application Deadline: September 30, 2014


September 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer2

Carolinas HealthCare System Internal Medicine Opportunities 8-2014

Announcement Geriatrician Opportunity

Elkin Hospitalist

Montana Hospitalist

Summit Placement Service

Washington State Opportunities

Madison WI opportunities


Upcoming Dates and Events

September 2 - 18: Internal Medicine In-Service Training Exams Testing Window


Useful links