From the Director
Welcome to April! Up and coming this month we will have class meetings with Dr. Klotman, ongoing fellowship prep meetings for JARs, someone winning the residency March Madness bracket and the Mummkim baby naming challenge, the faculty-resident basketball game and THE CHARITY AUCTION! Jessie Seidelman and Andrea Sitlinger have been hard at work as this year’s co-chairs, and have planned a fantastic night of fun for a good cause. If you are interested in helping out with the final details, please contact Jessie or Andrea. We are going to need co-chairs next year, so this is a great time to get involved. Plus, when else will you have a chance to throw a pie in a chief’s face or bid on coverage for a shift or many of the great items from around the Triangle? We had a great time last night for the JAR party at our house (which was one of the items up for bids at the auction) with Azalea Kim, Bill ‘Alligator’ McManigle and Christine Bates! Looking forward to next month at M Sushi!
Kudos this week go to David Sermer for preparing an outstanding chair’s conference, to Rajiv Agarwal, Katrina Abril and Shai Posner from Matt Sparks for stopping at nothing to get their patient the treatment he needed while on VA Gen Med, and to the following residents and faculty who were nominated by the medical students for the Golden Apple Teaching Award, which was won by our very own Dr. Saumil Chudgar! Also had a fun JAR dinner
Faculty:
Dr. Aimee Chung (runner up this year)
Dr. Allison Clay
Dr. Aubrey Jolly Graham
Dr. Mitchell Black
Dr. Annalisa Crowley
Dr. Larry Greenblatt
Dr. Han Kim
Dr. Micah McClain
Dr. David Ming
Dr. Christopher Newgard
Dr. Snehal Patel
Dr. John Perfect
Dr. John Roberts
Dr. Timothy Scialla
Dr. Jane Trinh
Dr. Aimee Zaas
Residents:
Dr. Vedran Oruc
Dr. Andrea Sitlinger
Dr. Andrew Strand
Dr. Anne (Doran) Bostwick
Dr. Anubha Agarwal
Dr. Bassem Matta
Dr. Ben Peterson
Dr. Dan Maselli
Dr. Dana Clifton
Dr. David Kopin
Dr. Elizabeth Kotzen
Dr. Emily Ray
Dr. Greg Brown
Dr. Jason Zhu
Dr. Lakshmi Krishnan
Dr. Landon Brown
Dr. Maggie Infeld
Dr. Matt Atkins
Dr. Meg Steiner
Dr. Nick Turner
Dr. Peter Hu
DR. Taylor Bazemore
This week’s pubmed from the program goes to our residents who are representing at the ACC in Chicago (see pic). Not pictured is Div Patel, who was en route when the picture was taken. Congrats to Adam Barnett, Div Patel, Taylor Bazemore, Tim Hinohara, and Eric Black-Maier!
Have a great week
Aimee
What Did I Read This Week?
Submitted by Daniella Zipkin, MD
Next week is Duke’s Teaching and Leading Evidence-Based Medicine Workshop, a national course we offer here annually. I’ll be teaching the session on Harm and Causation, so I’ve been trolling for good examples. Turns out, all I had to do was go for a haircut… EBM is everywhere!!
My hairdresser said, “hey, can I ask you a doctor question?”. He’s in his late thirties and tells me he takes Protonix for GERD. He just heard about the connection with kidney problems, so he stopped it. But ever since, he’s been having a horrible time with his GERD symptoms which recurred. He wants to know if he should really be worried about the kidney disease. I ask him a few more questions – he does not have hypertension or diabetes and he takes no other medications.
I hadn’t heard about this study yet, so I Googled it while getting my hair cut and checked out the abstract (and later the paper):
Lazarus et al. Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease. JAMA Intern Med. 2016;176(2):238-246
Here’s the quick and dirty:
- ARIC (Atherosclerosis Risk in Communities Study); population-based cohort between 1987 and 1999 from four communities in the US. 11,656 of the participants who attended the 12 year follow up (of a total of 15,792 enrolled). Median f/u was 13.9 years. Primary outcome incident CKD at a hospital discharge, or incident ESRD. (inpatient Dx!)
- Results were validated in another, separate cohort – Geisinger Health System, 248,751 patients with normal renal function, median f/u 6.2 years. Primary outcome was first incidence of eGFR below 60 or ESRD. (outpatient Dx!)
- PPI use at baseline associated with higher BMI; taking BP meds, statin, aspirin.
- RESULTS: ARIC cohort had 56 CKD events in the 322 PPI users, and 1382 CKD events in the 10,160 PPI non users. Adjusted HR 1.50 (95% CI 1.14-1.96).
- RESULTS: Geisinger cohort had 1921 CKD events in 16,900 PPI users, and 28,226 CKD events in 231,851 PPI non users. Adjusted HR 1.20 (95% CI 1.15-1.26).
- Validity? These very large cohorts measured the exposure well, but both are subject to the risk that exposed (PPI) users may have been more likely to have the outcome detected, since they’re interacting with health care more. Also, the ARIC study used hospital discharge codes which are less sensitive than direct outpatient measurement in the Geisinger study.
- Bottom line: PPI use may increase the risk of CKD 20-50%. The truth is probably closer to 20%. So, your next question is, what’s the baseline risk by which we increase this much?
- Back to the patient (my hairdresser): As a young man with no hypertension or diabetes, his risk of CKD is very low, 1-2% at worst according to Up to Date. If his current risk is 1%, his PPI use may increase that to 1.2 or 1.5%. Not a big deal. And because he is symptomatic without the PPI with a lower quality of life, so he should definitely take it!!
- We should try to avoid long term PPI use in people at higher risk of CKD. Still, the increased risk is very modest and should be balanced by the harms of removing the PPI.
QI CORNER
First, please mark your calendars for the next meeting of the PSQC NEXT Thursday, 4/14 at 5:30pm in the Med Res Library.
This week's GME Incentive metric of the week is: ED consult completion time. Again, you will get $200 on your July paycheck for each metric that we meet by the end of the year.
To cash in on this one, we need to hit a median ED consult completion time of 26.5 min EITHER over the course of the whole year, or for 3 out of the last 4 months. Here's how we've done so far:
It's going to be very tough but definitely possible to meet this one; we'll need stellar performance for April, May, and June. This one lies largely in the hands of our ACRs and night JARs. Remember, it's MEDIAN time, so as long as they close out consults in 26.5 minutes or less for HALF of the consults they get, we'll cash in. Give them a pat on the back for how hard they're working so that you can all get some extra $$!
The other GME Incentive Metrics, at a price of $200 each, are:
SRS reports: 2 per resident
Physician communication score on the patient satisfaction survey: >80% "always"
30-day readmissions: <20%
CLINIC CORNER
This month from the DOC,
Photo and info courtesy of Jan and Holly, our fabulous MSW and Pharm D. Prize for best caption!
We are lucky to have a fabulous team at the DOC!
Lynn, Holly, and Jan
Heard of our Redesign work? Holly and her students summarized Redesign 1, began July 2013 after a year of planning, and the current work on Redesign 2 with much support from the hospital—
Redesign 1
- Cost Savings
Reduced ED visits from low acuity (Level IV/V) and “nuisance admits”
616 à 458 admits from ED
$1.7M direct cost saving
Net margin loss decreased 50%
- HomeBASE
Management of high-need patients’ psychosocial issues
Same-day walk-in access
Change in Practice Culture
Post-discharge transitions
Redirecting care to DRH
Community partners: ABH collaborations, Hillman foundation grant for RN-led Durham homeless health initiative
Redesign 2
- Tackling a “new frontier”
Replacing higher-acuity ED visits during the day
Spillover benefits by creating next-day capacity and through direct communication between DOC and ED providers
- Cost Savings
$454k in direct cost savings
- Expanded HomeBASE
Targeting high-need patients with Epic-based stratification tool(s)
Active panel management with active care coordination
Prepared acute illness care by substituting the DOC for the ED
- Cementing the Practice Culture
Making the practice culture from redesign 1 permanent
Establish consistent environment to enable new residents and practitioners to integrate seamlessly
From Jan—
EXPANDED BEHAVIORAL HEALTH SERVICES AT DOC
Have you heard??? Joy Long and Ashley Cyr, Behavioral Health Consultants (BHCs), have joined the behavioral health team at DOC!
Ashley Cyr 919-316-0154 Joy Long 984-227-9459
WHAT DO WE DO?
- Provide consultation to PCP for patients whose problems are related to behavior (for both physical health and mental health)
- BHC ≠ traditional therapy
- Brief visits (20-30 minutes)
- Develop treatment plans
- Teach self-improvement techniques
- Schedule follow up if needed
- Refer to specialty mental health as needed
- Document in Maestro
WHY DO WE DO IT?
- Typical psych complaints (e.g., mood disorders, ADHD, substance abuse, psychosis)
- Socio-emotional problems (e.g., bereavement, marital problems)
- Chronic disease management (e.g., hypertension, diabetes, headaches, chronic pain)
- Dementia, cognitive impairments, I/DD
- Fatigue without medical etiology
- Wellness (e.g., sleep, healthy eating, smoking cessation)
- Parenting and behavioral problems in kids
- Adjustments to new diagnoses (e.g., STIs, cancer)
- And much, much more!
WHAT DO YOU DO?
- Identify patient behavior issue
- Warm handoff
- Monitor and support patient progress with tx plan
- Continue to refer to Jan for psychosocial assessments and safety issues (DV, abuse/neglect)
- Can’t figure out whether to refer to Ashley, Jan or Joy? Refer anyway, and we’ll sort it out!
Lynn, Holly, Jan and the DOC!
From the Chief Residents
Grand Rounds
Friday, April 8 - George Phillips Speaker, Dr. Deidra Crews
Noon Conference
| Date | Topic | Lecturer | Time | Vendor |
| 4/4/16 |
MKSAP Pulm |
2002 |
12:00 | Domino's |
| 4/5/16 |
Non-Invasive Positive Pressure Ventilation - Dr. Hargett |
2002/12:00 |
Bullocks |
|
| 4/6/16 |
Uritcaria |
Ankoor Shah |
12:00 | China King |
| 4/7/16 |
IM-ED Combined Conference: Pulmonary Hypertension |
Talal Dahhan |
12:00/2002 |
Picnic Basket |
| 4/8/16 |
Chair's Conference |
Chiefs | 12:00 | Jason's Deli |
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.
General Internal Medicine Career Night
General Internal Medicine Career Night
Interested in a career in General Internal Medicine?
Thinking about primary care medicine, Gen Med fellowship or hospitalist medicine?
Envision working in academics, research, Quality Improvement
or a combination?
Come to Gen Med Career Night
Tuesday May 3, 2016
6:30-8:30pm
Gen Med Resident Library
Dinner from Nosh
Come ask questions for our panelists about their path and journey:
Kevin Shah, Claire Kappa, Sharon Rubin, David Edelman, Sonal Patel, Lance Teagen, David Gallagher and Daniella Zipkin
Please RSVP to Sharon.rubin@dm.duke.edu by May 2, 2016
Please see flyer at the end of this post
Charity Auction 2016
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 in early April. We look forward to seeing you there. Please see the flyer at the end of this post!
LiveSafe Mobile App
Duke is introducing a new mobile app called LiveSafe to put a powerful safety tool in the hands of the Duke community.
The app, available as a free download from Apple and Android app stores, enables smartphone users to submit real-time tips to Duke Police, virtually “SafeWalk” friends and family while traveling, place emergency calls, and access important resources for support.
You can find more information, including instructions on how to download the free app, on the DukeALERT website: http://emergency.duke.edu/notified/livesafe.
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: https://duke.qualtrics.com/SE/?SID=SV_bfJqGFkA6HScRq5
Feel free to email Laura.Caputo@duke.edu 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.
https://www.hr.duke.edu/pas/
Upcoming Dates and Events
April 29 -Charity Auction
May 20 - Resident Research Grand Rounds
June 4 - SAR Dinner
Useful links
GME Mistreatment Reporting Site
https://intranet.dm.duke.edu/influenza/SitePages/Home.aspx
http://duke.exitcareoncall.com/
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
Opportunities
www.bidmc.org/CentersandDepartments/Departments/BIDHC
http://www.careermd.com/employers/latestbulletins.aspx