Internal Medicine Residency News: April 28, 2014

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From the Director

DUKE.RESEARCH.NIGHT.03 (1)Hey everyone! Get ready for the Stead Tread on May 3 - it's not too late to sign up! Www.steadtread.org! Run, walk, rance (if you don't know what that is, ask Erin Payne!) a fantastic 5k.   Thanks so much to our ACRs Marcus Ruopp, Ashley Lane and Bronwen Garner as well as our pinch hit ACR Kevin shah.  Also kudos this week to Matt Summers and Sarah Wingfield for great SA talks, to Damien Earl for his gold star and to Bronwen Garner from Lynn Bowlby for making a great diagnosis at DRH. #pishkorocks!! Allyson Pishko had an amazing presentation at our CPC. Great case, great speaker, great attendance from residents and faculty! Special thanks to Krish and Erin for planning and to our guest pathologist Paulie Papavissalou! The new VA gen med schedule starts Monday.  We really appreciate the hard work of Vaishali and the VA attendings, ACRs, and residents who helped plan it and also who are going to try it out. Your dedication to patient care and education is what makes us the best. Looking forward to the basketball game at Cameron on Friday night! Housestaff hoping to keep the trophy! On a more serious note, we will be sending out a survey in the next week to drill down on what rotations cause the  most issues with duty hours and patient caps. Your honest reports will help is improve. This weeks pubmed from the program goes to the 26 residents who submitted faculty resident research grants!!!! Way to go. Have a great week! Aimee SAR Selfie [box]

What Did I Read This Week?

DuPont HL. Acute Infectious Diarrhea in Immunocompetent Adults. N Engl J Med 2014; 370(16): 1532-40.

Submitted by Saumil Chudgar, MD

[/box] Why did I read this? I was recently on service and had several patients admitted with diarrhea or developed diarrhea while hospitalized. Common causes of diarrhea are great pimp questions for students and interns. Though this is a review article, I found it to be a great recap of some general principles of management. I sent it to my students to read and wanted to read it myself as well.210_ChudgarSaumil2010 What I learned from reading this article? Causes: I think all of us remember making flash cards or listing off the common causes of diarrhea when studying. Many of us remember the noroviruses as a common cause with outbreaks on cruise ships and in hospitals/nursing homes. Common bacterial causes include Salmonella, Shigella, E. coli, Campylobacter, Vibrio, and Yersinia. I think all of us have seen several cases of C. diff in patients with risk factors. Evaluation: We see more severe cases of diarrhea since many are self-limited and do not seek medical care. As with many diseases, starting with a good history including exposures, travel, duration, and quality is all very important. This may be much of the battle in the evaluation of patients with diarrhea. Figure 1 is a great flowchart of evaluation, with more extensive workup needed in cases of colitis, fever, exposure to hospital or antibiotics, and persistent diarrhea > 14 days. Diagnostic testing including stool examination for culture and C. diff PCR is indicated if one of those is present. Management: Evaluation of stability and fluid and electrolyte balance is an appropriate place to start. Table 1 is a great review of methods of diagnosis and treatment of common causes of bacterial, viral, and parasitic causes of diarrhea. Recommendations for empiric antibiotics therapy are included. Additional information: The article concludes with future areas for study including research priorities. Suggestions for strain identification, duration of therapy (especially C. diff), associated medications such as PPIs, more targeted therapy, and new vaccinations are all discussed in the article.  

The "Clinic Corner" - Duke Outpatient Clinic

(submitted by Larry Greenblatt, MD )

Hello to all department of medicine residents and faculty from the ambulatory side of things! 3 DOC-relevant topics for your reading pleasure: Procedure Clinic, The Joy of Observation and Feedback, and Medicaid Happenings. Procedure Clinic Beginning next month the Duke of patient clinic will begin a trial of Procedure Clinic which will be scheduled each Monday afternoon. Supervision of the treating residents will be provided by the not-yet-famous proceduralist, Dr. Greenblatt. Please consider scheduling patients who need any of the following:
  • Injections in the knee, shoulder, trochanteric bursa, trigger finger, or carpal tunnel.GreenblattLarry08
  • Cryotherapy for actinic keratoses, warts, skin tags, or other benign and treatable lesions.
  • Punch biopsy for diagnosis of a skin lesion or rash of unclear etiology.
  • Other procedures that you know are straightforward and safe for a primary care setting (check with me first, please).
The Joy of Observation and Feedback The vast majority of the residents now have three or more documented mini-CEX evaluations. Experienced clinical educator faculty are convinced that this is a powerful tool to help you to improve in the way that you care for patients. We want to remind you that a mini – CEX is available most any day if you just ask for it. We are happy to come in and observe you performing some part of the history, examination, or patient education. We will be happy to give you feedback and coaching about any aspect of clinical medicine that you think would be helpful. Please don’t let the minimum of three serve as the maximum that you will allow. Medicaid Happenings You may know that North Carolina is one of 24 states that have chosen not to expand Medicaid which would be funded for the first three years entirely by federal dollars. For now, North Carolina taxpayers can be pleased to know that their money is being sent to states that have expanded Medicaid and are providing services to low income individuals there. You probably don’t know that North Carolina has a sophisticated primary care-based care management program for Medicaid recipients that is a model for the nation. Services are provided by a statewide nonprofit called Community Care North Carolina or CCNC (www.communitycarenc.com). This organization is composed of 14 networks and ours, Northern Piedmont Community Care or NPCC is owned and operated by Duke Medical Center and serves Durham and 5 neighboring counties. Our state is known for having extremely high quality metrics for Medicaid recipients and the lowest rate of growth of per person Medicaid costs, near zero over the last five years. You will notice that there are care management notes which are now being posted in Maestro. At DOC, we have 2 care managers –Marigny Manson and Jennifer Williams-Salifou who can provide an array of services supporting your role particularly for high complexity, high cost individuals. In addition, I have attached 2 pharmacy newsletters published by NPCC which can help you be a smarter prescriber. Rx Bites I            Rx Bites II

QI Corner (submitted by Joel Boggan, MD)

Resident M&M Many thanks to the stellar Drs. Stephen Bergin and Lars Grimm for leading us through our M&M discussion this past week. Our next case will be on 5/29. Next PSQC meeting Our next PSQC meeting will be 5/14 in the Med Res Library at 5:30 pm. Hand Hygiene Next week we'll have our April data ready for your consumption - only 6 more weeks are left to bring the total rate up above 90%. Keep up the foaming and washing on all our wards (and at the VA, as well) . . . Joel [divider]

From the Chief Residents

Grand Rounds

Dr. Susanna Naggie – Infectious Diseases Topic: HIV/HCV Coinfection

Noon Conference

Date Topic Lecturer Time Vendor Room
4/28 MKSAP Mondays Chiefs 12:00 Picnic Basket Med Res Library / 2003
4/29 A Rheum Approach for the Internist Adam Gelber 12:00 Chick-Fil-A 2002
4/30 QI Patient Safety Noon Conference 12:00 Cosmic Cantina
5/1 Medical Problems of Pregnancy Lynn Bowlby 12:00 Saladelia 2001
5/2 Chair's Conference Chiefs 12:00 Rudinos Med Res Library
[divider]

From the Residency Office

STEAD TREAD

DON'T MISS THIS EVENT !! For those of you who haven't already registered, we are extending an open invitation to support the Stead Tread, Kempner Society's annual charity event. It was a blast last year, and since we're due for some good weather this year, I'm sure it will be even better this time around. Some additional information:
  • Please access the Stead Tread 2014 website (http://www.steadtread.org) for additional details, to securely register ($25), or make a donation
  • Race date/time: Saturday, May 3rd, 2014 at 10AM
  • Race location: Al Beuhler Trail (on our USATF-certified course around the Washington Duke Inn and Golf Course)
  • Race beneficiary: Lincoln Community Health Center
  • Your registration fee includes an official Stead Tread 2014 T-shirt – register ASAP to reserve your size, they are going fast!
  • Participants are welcome to run or walk, and strollers are permitted - kids under 12 can run/walk for free, so bring your families!
  • In case you cannot make the race this year, individual and corporate donations can be made securely through our website
Thank you for considering supporting the Stead Tread – we really hope to see you there this year. For any questions, please contact us through our website (http://www.steadtread.org), via e-mail at steadtread5K@gmail.com, or by replying directly to me. Thanks, Matt

LPS Snapshot

Congrats to the Kerby (A) Stead Society for posting the highest response rate for the Clinic Learner Perception Survey (LPS) Snapshot!  They will receive $250 for the charity of their choice, which is Senior PharmAssist and the Duke Outpatient Clinic fund. Thanks to Drs Mary Klotman and Gene Oddone for their generous contributions to make this possible. The LPS Snapshot was co-developed by recent IM graduate and Current GIM fellow Denise Duan-Porter.  The results are being analyzed and will be presented at the upcoming Ambulatory Town Hall meetings scheduled for Tuesday May 27 LPS - final  

Duke GME Concentration

We are excited to begin accepting applications from residents and fellows for the 2014 cohort of Duke GME Concentration participants. Please consider sharing this information with trainees or nominating those who you believe would benefit from this opportunity. GME Concentrations were developed, with support from the GME Innovation Fund, in response to resident/fellow and program feedback to provide critical content to better prepare physicians for practice in the current & future health care system. Four Concentrations are being offered as an optional  "minor" for residents and fellows (PGY level 2 and above) across specialties at Duke. Residents/fellows will participate in a number of educational opportunities related to their concentration and develop a personal project with a identified mentor. Participation will span over the course of their training and last a minimum of one year (some exceptions may apply) resulting in the awarding of a Certificate of Completion. GME Program Directors must approve resident/fellow participation in order to ensure this commitment will supplement training and benefit the program overall. Expert champions have been identified to serve as part of an Advisory Committee for each concentration identifying and developing educational objectives, opportunities/assignments, and assessment strategies. Committees will guide and assess the work of residents/fellows participating in each concentration and determine individuals' successful completion. Concentrations include:
  • Resident as Teacher
  • Patient Safety & Quality Improvement
  • Law, Ethics & Health Policy
  • Leaders in Medicine
Detailed information can be found on the GME Concentrations website at: http://sites.duke.edu/gmeconcentrations/ Applications can be found under the "How to Apply" tab on the Concentrations website above (netID log in required). The first round of applications are due by Friday May 30th. If you have questions, please contact: Alisa Nagler  or  Mariah Rudd

Housing Updates

The GME office is once again posting homes for sale/rent on their website.  Take a look if you are trying to find that perfect spot.  And, if you are hoping to sell/rent, posting information is as follows:

submit a one page portrait orientation PDF or Word document to dukegme@mc.duke.edu.

Listings may be submitted by those working at Duke University Hospital.

Grand Rounds Attendance

Reminder that our office does track and report resident attendance at Grand Rounds.  How? Residents need to log in using ETHos to start from which we get a weekly report which is loaded into MedHub.  If you are not currently recording your attendance at Grand Rounds, please start doing so. How?  Create an account here to get started: go to the Duke Continuing Medical Education home page  

Information/Opportunities

CARDIOLOGY FELLOWSHIPS AND T32 TRAINING FOR INTERNAL MEDICINE GRADUATES  

Upcoming Dates and Events

  • May 2: Faculty/Resident BB Game on Coach K Court
  • May 3: the Stead Tread 5K www.steadtread.org
  • May 30: Program pictures, Trent Semans West Steps, 9:15
  • May 31: SAR Dinner, Hope Valley CC
  • June 3: Annual Resident Research Conference
  • June 6: Serve dinner at the Ronald McDonald House

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