From the Director
Hi everyone!
Vacation was great, but it is also good to be back. I feel a bit of pressure to be as funny as
Dr. Hargett writing for updates…thanks again Bill for doing an amazing job filling in. I also got to spend a few days at the Program Director's meeting in Nashville with
Drs. Woods, Trinh and Rivelli. We learned a lot about the milestone based evaluations and residency accreditation, as well as some exciting new curriculum that we hope to bring to you in the next few months. Be sure to talk with me or your advisor about the summative "reporting" milestone evaluations we complete for each of you…its a good opportunity to set goals for your upcoming rotations.
The first How to Be A JAR was a great success…many thanks to
Vaishali and Krish for putting together fantastic sessions on Leadership and Dealing with Uncertainty, as well as to
Cory Miller and Rob Harrison for running the Code Blue Simulation. Thanks also to
Bobby Aertker, Aparna Swaminathan, Adrienne Belasco and Kevin Shah for providing JAR/SAR input and to all the participating interns for asking questions and allowing for excellent discussion. Next session is Monday, so remember to check Medhub to see if you are scheduled.
Lots of kudos to be given this week. First to
Lindsay Boole who was left off (sorry!!) the ACP announcement last week. Lindsay had a platform presentation of the QI Afternoon Report data..great work Lindsay.
Ashley Bock and Amanda Verma both received gold stars based on excellent patient comments. Many of our residents were mentioned by name by the medical students in the July-January clerkship evaluations….congratulations to the following residents for your recognition by the second year med students!
Bobby Aertker, Mandar Aras, Shailesh Balasubramaniam, Armando Bedoya, Adrienne Belasco, Amit Bhaskar, Hal Boutte, Schell Bressler, Kimberly Bryan, Laura Caputo, Meredith Clements, Mallika Dhawan, Alex Fanaroff, Sarah Goldstein, Jonathan Hansen, Chris Hostler, Scharles Konadu, Ashley Lane, Howard Lee, Jim Lefler, Philip Lehman, Carli Lehr, Angela Lowenstern, Jay Mast, Alyson McGhan, Brian Miller, Aaron Mitchell, Laura Musselwhite, , Ragnar Palsson, Rebecca Sadun, Paul St. Romain, John Stanifer, Matt Summers
Aparna Swaminathan, Sajal Tanna, Carling Ursem, Jonathan Yates, Jason Zhu
Also kudos to
Howard Lee and Chris Hostler for fantastic SAR talks (although I missed them being at APDIM, I hear the
Brian Miller especially loved Chris's talk). More kudos as well to
Brian Sullivan for his Chair's Conference presentation, and to
Lauren Porras for her noon conference on shoulder exams.
Cary Ward sends kudos to
Amy Lee, Jonathan Hansen, Sarah Goldstein, and Yvonne Baker for their outstanding work on CAD. Congratulations to
Armando and Jennifer Bedoya on their marriage — we all had a fantastic time celebrating with you on Saturday! Congratulations as well to
Tyler Black on the birth of Davis Black! Mom, Dad and baby are all doing well!
Can't wait for the
AUCTION this Friday!!! Hope to see you all there!!! While you are at it, go ahead and sign up for the
STEAD TREAD as well.
This weeks Pubmed from the PRogram goes to Amy Newhouse for her work with Dr. Wei Jiang.
Newhouse Jiang - Heart Failure and Depression
Have a great week
Aimee
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What Did I Read This Week?
Submitted by Bill Hargett, MD
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If you missed our interdisciplinary discussion at the joint IM/EM Conference on Wednesday, this is an important article that every one of our residents should read: The ProCESS Investigators.
A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med. 2014 Mar 18. [Epub ahead of print] PubMed PMID:24635773.
There’s a lot of information in this trial (you can also read the
Supplementary Appendix) so I’ll try to reduce the burden and simplify a few things.
Background and Question:
Sepsis is among the most common reasons for ICU admission and a top-10 cause of death in the United States. The
Surviving Sepsis Campaign (SSC) Guidelines have successfully called attention to the delay in the recognition of and initiation of appropriate therapy for sepsis and septic shock. Furthermore, the Guidelines are endorsed by multiple professional and regulatory organizations, achieving de facto “standard-of-care” status. However, the evidence base for major components of the SSC is poor, and there remains significant controversy surrounding the initial hemodynamic resuscitation “bundle” (based upon early goal directed therapy (EGDT)).
The ProCESS Trial is the first published of three major trials assessing EGDT in sepsis. So what did they find? What is the efficacy of early, protocol-based, targeted resuscitation in patients with septic shock?
Methods:
Investigators randomized 1341 patients with septic shock at emergency departments in 31 U.S. academic, tertiary care hospitals to one of three 6-hour resuscitation arms:
- EGDT a la Rivers (n=439)
- Standard therapy (protocol-based, IVF until clinical euvolemia, transfusion threshold Hgb < 7.5 g/dl, and CVC/inotropes/ScVO2 not mandatory, n=446)
- Usual care (no protocol or directed intervention, n=456)
The primary outcome was 60-day mortality. Regarding validity, groups were similar at baseline (e.g. APACHE II ~ 21) and there was no evidence of contamination.
Results:
There were no differences between groups in 60-day mortality (19-21%), 90-day or 1-year mortality. Protocol adherence was very good (89.1% in EGDT, 95.6% in standard therapy).
Table 2 (Article) further details the outcomes and Table S4 (Supplement) nicely delineates the resuscitation and overall care from enrollment to 72 hours.
Take-Home:
The results of this trial are unsurprising to many emergency or critical care providers and I could go on and on regarding the shortcoming of the SSC resuscitation bundle and the “one size fits all approach” for the treatment of severe sepsis and septic shock (e.g. transfusion threshold in critically ill patients, ScVO2 as a physiologic surrogate, inotrope selection, etc.). However, I think it’s important to emphasize a couple of major take-home points:
- There was no clear superior resuscitative approach for septic shock (i.e. “more” is not always “better”)
This may be, in part, explained by the underlying “pre-randomization protocol,” whereby most study participants, by virtue of the enrollment process, received early recognition of sepsis and antibiotic administration, which are likely the most important components of care.
- Overall, sepsis outcomes have improved over recent years (mortality is much lower than reported in Rivers, 2001)
Indeed, this earlier identification of septic patients and aggressive treatment may be the greatest product of the Rivers trial and the SSC… “knowing is half the battle,” as they say. Increased awareness and early treatment clearly saves lives.
For future studies, how about some more data to look more closely at individual bundle elements? Well, that may be coming – keep an eye out for the ProMISe trial in the UK and the ARISE trial in Australasia, both of which are also examining EGDT and which have been designed collaboratively to allow the results to be pooled for all three RCTs on EGDT.
The "Clinic Corner - DOC"
(submitted by Dr Sharon Rubin )
Hello from sunny Orlando. Attached is a picture of Sam and Jake at Hollywood Studios (he is dressed as a Star Wars padawan with a Jake doll!)
This is a reminder for the SARs. make sure you are letting your patients know you are leaving in June and that a great new doctor will be assuming their care. As soon as I have names I will give to each SAR. We will have 6 new interns to replace the 6 SARS. Then you can put their name on the AVS. Please RSVP for the Pickett Senior Dinner in June on the Doodle pool (let me know if you need the link).
Running your panel is possible. When you are on Administration time or as a SAR for your last clinic session will be Admin and will run your own panel. I have made instructional videos where you can
1. Run your own panel
2. Run your panel for Diabetics or hypertensives
3. Run another resident's panel
Due to HIPPA, Sharee has access to these videos and will release them to you if you are on ADMIN or if you want to run your panel.
Please pay attention to Marie Evangelista's emails for Maestro updates as she is our superuser.
Good news the Rapid flu works! Bad news this is a little late coming.
I had a patient, in APRIL, who had classic Flu symptoms. The NURSES run the flu (order POC FLU), this takes 10 minutes but better than 2 days. At least we will be ready for next flu season.
I am proud to see the Duke residents and medical students posters at ACP. Attached are
Julia and Wassim's posters from the North Carolina ACP.
See you when I get back!
QI Corner (submitted by Joel Boggan, MD)
The Importance of Coding
Many thanks to Dr. Momen Wahidi, who led us through a discussion (and some examples) of how our documentation affects overall patient care and safety. You will be hearing more about this topic as we move into the next academic year.
We Follow-Up project
The first look at the Sharepoint project during Phase 2 is done, and it appears we are improving our rates of notifying patients about lab results. We have picked up about 6% in absolute notifications at the DOC, 5% at Pickett, and 8% at PRIME. Overall, PRIME and Pickett are neck-and-neck reporting >90% of results back within two weeks, while the DOC is lagging a little behind. Keep up the good work!
From the Chief Residents
SAR Talks
April 17: Brian Miller / Marianna Papademetriou
Grand Rounds
Dr. Frank Neelon --- Obesity
Noon Conference
| Date |
Topic |
Lecturer |
Time |
Vendor |
Room |
| 4/14 |
MKSAP Mondays - Cardiology |
K Patel / Chiefs |
12:00 |
Picnic Basket |
Med Res Library / 8262 |
| 4/15 |
MED-PEDS Combined: HPV Screening and Vaccination OR Difficult Death Debrief |
Chip Walter / Galanos |
12:00 |
Saladelia Wraps |
2002 OR DN9242 |
| 4/16 |
Nephrology Board Review |
K Patel / Butterly |
12:00 |
Cosmic Cantina |
Med Res Library |
| 4/17 |
SAR TALKS |
Brian Miller / Marianna Papademetriou |
12:00 |
Sushi |
2001 |
| 4/18 |
Chair's Conference |
Chiefs |
12:00 |
Rudino's |
2002 |
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From the Residency Office
Califf Medicine Resident Research Award
Internal Medicine Residency Program and the Department of Medicine would like to invite you to submit an abstract of your research project for: The
Califf Medicine Resident Research Award competition. Abstracts are due on May 5, 2014
Please see attached request for applications and abstract preparation instructions, also included within our Resident Research website link:
http://residency.medicine.duke.edu/duke-program/resident-research/research-events-and-awards
All abstracts submitted for competition will also be presented as posters during Resident Research Night on June 3, 2014 at the TRENT SEMANS Center 5 pm - 7 pm.
The top 3 abstracts will be selected by a faculty committee for the Califf Research Awards and these research projects will be presented as 15 minute talks.
The best poster will be selected by the Chief Residents during the poster viewing session.
In addition, we invite all of you to present your scholarly activities during Resident Research Night as posters :
- Basic, clinical and translational research projects
- ase studi
- QI projects
To discuss any issues related to the application process or once you have decided to submit an abstract, please e-mail
murat.arcasoy@mc.duke.edu to declare your intention to submit, your research mentor's name and the title of your poster. Please contact the MedRes office staff (Ms. Lynsey Michnowicz) for assistance with the poster preparation process.
LPS Snapshot (submitted by Dr. Wei Duan-Porter)
Please provide feedback about your continuity clinic experiences, and help earn $$ for the charity supported by your Stead Society! Only 10 more responses per Stead will get you $150 for each of your great causes!
Thank you to all those who have already responded!
Medical Education Grand Rounds: "MAKING THE MOST OF MILESTONES"
Presented by Dr. Aimee Zaas (Program Director, Internal Medicine)
- Monday, April 14th 4pm – 5pm
- Tuesday, April 15th 7am – 8am
- Wednesday, April 16th 12noon – 1pm
Registration for can be completed using the follwoing link:
https://www.surveymonkey.com/s/MEGRregistration2013
Upcoming Sessions:
"Due Process or Don't Process: Medical Education & The IRB" with Dr. Mitch Heflin
- Monday, May 12th 4pm – 5pm
- Tuesday, May 13th 7am – 8am & 12noon – 1pm
"Longitudinal Curricula" with Dr. Barbara Sheline
- Monday, June 2 4pm – 5pm
- Tuesday, June 3 7am – 8am
- Wednesday, June 4 12noon – 1pm
Financial Planning Seminar at Duke for Residents and Fellows April 22 - Register Now
Financial Planning Seminar for Residents and Fellows
Gerald A. Townsend, a nationally recognized financial advisor, will be at Duke on April 22
nd to talk with Duke’s residents and fellows about the fundamentals of building a successful financial plan. He will cover topics such as budgeting, investing, protecting assets, retirement, and estate planning. The objective of the seminar is to provide attendees with an overview of the essential considerations necessary for creating a comprehensive financial plan and to provide a level of comfort for taking the next steps towards creating a secure financial future.
Time/Location: April 22nd at 6:30 PM in North Duke Lecture Room 2002
Register:
https://duke.qualtrics.com/SE/?SID=SV_aibTo7E8crQSmMd
Changes in USMLE Step 3 for 2014-14
Please note the changes to the Step 3 test for next year. As a reminder, you cannot advance to PGY3 until you pass Step 3. We STRONGLY ENCOURAGE you to register as soon as possible and take the test as soon as possible. Please remember to clear your dates with the Chiefs and send them to me when you have them!
Changes in the USMLE Step 3 Examinations
- Registration for the current Step 3 examination will end July 18, 2014.
- Registration for the restructured Step 3 examination will begin August 2014.
- No Step 3 examinations will be administered during most or all of October 2014.
- There will be a substantial score delay following introduction of the restructured Step 3 examination in November 2014. The duration of the score delay will be determined by examinee volume during the early months of exam administration. Based on historic trends, we estimate that the first scores for Step 3 exams taken on or after November 1, 2014 will be released during the first week of April 2015.
For more information, please review the
Changes to USMLE 2014-2015 document on the USMLE website.
You may contact us with any questions at
http://www.usmle.org/contact/
The link containing this info:
https://gme.duke.edu/?q=node/2893&gme-shib-auth-deny=1
Information/Opportunities
Florida Internal Medicine
Idaho Hospitalist
South Texas Internal Medicine Outpatient
Alabama Physician Needs
Upcoming Dates and Events
- April 17: Financial Planning Seminar
- April 18: Charity Auction
- April 18: SAR Class Picture (rescheduled)
- April 22: CPC Event, 7 PM @ The Pit
- May 2: Faculty/Resident BB Game on Coach K Court
- May 3: the Stead Tread 5K www.steadtread.org
- May 30: Program pictures @ Duke Chapel 9:15
- May 31: SAR Dinner, Hope Valley CC
- June 3: Annual Resident Research Conference
- June 6: Serve dinner at the Ronald McDonald House
Useful links
