Internal Medicine Residency News - August 25, 2014

By residency1

From the Director

DUKE.RESEARCH.NIGHT.03 (1)Hello everyone! It's intern block 3!!!! Hang in there JARs and SARs, block 3 for you is in a week. Thanks to all for making the first two blocks run so smoothly. It was great to see so many JARs and SARs at our JAR/SAR liver rounds. Also saw some great pics from the Kerby Society baseball game. This week, hope to see everyone at the Warren Society trivia night. Don't forget there is Duke employee appreciation day at the Duke football game. Come see honorary captain Tony Galanos and enjoy the slightly injured but vastly improved Duke football team. Kudos this week to Tony Lozano from Jess Morris and Aly Shogan for being an amazing VA dayfloat and to Jay Mast from Peter Hu and Linda Koshy for his leadership as a Gen Med SAR. Also to Aparna Swaminathan for an awesome chairs conference and to Mike Woodworth and Paul St. Romain for pushing us to the answer. Congrats to alumni Mandar and Mallika (Dhawan) Aras on their wedding. Check out the beautiful picture sent by Sajal Tanna.   IMG959003 While it is great to celebrate all the good things, this job can be very stressful. Please remember all the resources available - the chiefs, the APDs, me, other residents and the FREE confidential Personal Assistance Service (PAS)  (919) 416-1PAS who are always available to listen and help out. This weeks pubmed from the program goes to our DOC attending and ambulatory curriculum leader Daniella Zipkin: http://annals.org/article.aspx?articleid=1897104&atab=1 Have a great week Aimee [divider] [box]

What Did I Read This Week?

submitted by: Omobonike Oloruntoba, MD

Reference: N Engl J Med. 2014 Apr 3;370(14):1287-97. doi: 10.1056/NEJMoa1311194.

PREFERRED_Oloruntoba_Omobonike_5909-200x300

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What I Read (Last) Week: FDA Approves Cologuard for Colorectal Cancer Screening Although colorectal cancer screening with FOBT, sigmoidoscopy and colonoscopy has reduced the number of deaths from CRC, a substantial proportion of the US population is not up to date with screening. It is thought that a simple, non-invasive test with high sensitivity for CRC and advanced adenomas may increase adherence and improve clinical outcomes. On Aug. 12, FDA approved Cologuard, a multitarget stool DNA test for the screening of colorectal cancer (CRC). What are stool tests are available for CRC screening?
Method Advantage Disadvantage
Fecal Occult Blood Test (FOBT) Identifies hemoglobin by the presence of a peroxidase reaction that turns guaiac-impregnated paper blue. - Noninvasive- Cheap - High False Positives- Multiple Samples (3)- Not the best for polyp detection (which do not usually bleed)
Fecal Immunochemistry (FIT) Detects hemoglobin with an antibody specific to undegraded human hemoglobin (more specific for bleeding from the lower GI tract) - Noninvasive- Fewer samples (1-2)- Fewer false positives More expensiveSensitivity declines with delay in mailing or processing after sampling
So What Is Cologuard? Multitarget stool DNA test that analyzes stool specimens to detect hemoglobin, multiple DNA methylation and mutational markers, and the total amount of human DNA contained in cells that are shed by CRC or advanced adenomas into the colon. In essence, this stool DNA test detects the presence of colorectal cancer associated DNA and presence of occult blood which, when positive, may indicated the presence of CRC or an advanced adenoma. How does it compare? A cross sectional study published in the NEJM in April (and funded by Exact Sciences, makers of Cologuard) found that Cologuard was more sensitive than the fecal immunochemical test in detecting CRC (92% vs 74%; P = .002) and advanced precancerous lesions (adenomas and sessile serrated polyps) (42% vs 24%; P < .001). However the specificities with Cologuard and FIT were 86.6% and 94.9%, respectively, among participants with nonadvanced or negative findings (P<0.001) and 89.8% and 96.4%, respectively, among those with negative results on colonoscopy (P<0.001). In the clinic:
  1. Fecal DNA is NOT currently recommended as a method to screen CRC by the United States Preventative Services Task Force
  2. Cologuard is only indicated in patients aged 50 to 85 to screen patients of AVERAGE risk (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn's disease and ulcerative colitis; no family history of colorectal cancers or an adenomatous polyp, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer) and a positive test warrants a diagnostic colonoscopy.
  3. CMS proposes to cover theCologuard test once every three years for Medicare beneficiaries who meet all of the following criteria:
    1. Age 50 to 85 years,
    2. Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and
    3. Average risk of developing colorectal cancer (no personal history of adenomatous polyps, of colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or an adenomatous polyp, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).
  4. COSTS:
    1. FOBT: ~$5
    2. FIT: ~$30
    3. Cologuard: $300-600
Reference: N Engl J Med. 2014 Apr 3;370(14):1287-97. doi: 10.1056/NEJMoa1311194. [divider]

Clinic Corner

chophoto_thumbnailWant to know what’s on The Test? The American Board of Internal Medicine (ABIM) Certification Exam (aka the Boards), that is. You can! Not to say that anyone reading this was one of those gunners the rest of us were secretly grateful to have in class, who was bold enough to ask what was going to be on the next test. But perhaps someone at the ABIM was. The ABIM actually publishes a “blueprint” of the content breakdown on the Boards, listing the percentage of exam questions that are supposed to fall in different medical content categories – which, conveniently enough, correlate in the main with the major MKSAP topics. There is even a more detailed breakdown of the number of questions by specific subtopic one might expect on a typical exam. (This Excel spreadsheet lists all subtopics said to have at least one question on said exam.) The written explanation accompanying the blueprint goes on to say that “the setting of the encounters reflect current medical practice, so most take place in an outpatient or emergency department setting (roughly 75 percent); the remainder occur in inpatient settings, ranging from the intensive care unit to the nursing home.” Finally, through a herculean scheduling effort on the part of the chiefs and the Residency Program Office, each year every resident is given the opportunity to diagnose one’s own medical knowledge strengths and weaknesses, on the Internal Medicine In-Training Exam (ITE). These results provide both the percentage of questions answered correctly by content area, as well as how this stacks up relative to one’s peers nationally – which again can be diagnostic of areas warranting further study. Be sure to use them – and happy reading and MKSAPing! Alex Cho, MD [divider]

From the Chief Residents

Grand Rounds

Fri., Aug. 29, 2014 at 8 a.m. Great Hall, Mary Duke Biddle Trent Semans Center for Health Education Robert A. McDonald U.S. Secretary of Veterans Affairs

Noon Conference

Date Topic Lecturer Time Vendor
8/25/14 SAR Emergency Series: Rheumatologic Emergencies Fola Babatunde 12:15 Picnic Basket
8/26/14 SAR Emergency Series: Sickle Cell Crises Tony Lozano 12:15 Dominos
8/27/14 SAR Emergency Series: Hyponatremia and Hypernatremia Benjamin Lloyd 12:15 China King
8/28/14 SAR Emergency Series: Acute Pain Management Chris Merrick 12:15 Sushi
8/29/14 Chair's Conference Chiefs 12:00 Mediterra
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From the Residency Office

 

ETHOS for Noon Conference Attendance Tracking!

After much work with the wonderful folks in the ETHOS offices, as of September 2, 2014 we will be able to track Internal Medicine Noon Conference attendance using the ETHOS system.  From September 2-5, we will continue to use the old badge swipe system in addition to ETHOS so everybody can get used to the process, but as of 9/8/14 we will 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! 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 dcri.cme@dm.duke.edu) 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
 

Mini CEXs Assigned to Gen Med Attendings

As of today, the Med Res office will be assigning Mini CEXs to the attendings on Gen Med rotations at Duke, the VA and DRH at the beginning of each block.  Our hope is that this will increase the number of inpatient Mini CEXs done (we require 3 Inpatient and 3 Outpatient per training year) and simplify the process for all.  If faculty or house staff have any questions, please feel free to contact Jen Averitt in the Med Res office.  

Recycle Your Old Batteries

In an effort to further our “Go Green” initiative, we are now recycling batteries! We have a dead batteries collection box in the Med Res office (Duke North, Room 8254) so please feel free to bring in your dead batteries and we are happy to recycle them for you.  

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities ! The applications due on September 1, 2014 for a funding start date on October 1, 2014. Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application. Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor. http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues. Wishing you continued success with your research projects ! Murat Arcasoy and Aimee Zaas  

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 https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  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 duke.edu/flu, 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.

What is the GME Incentive Program?

The GME Incentive program was started July 2012 as a collaboration between hospital, GME, and Internal Medicine program leadership in order to:
  • Engage trainees in hospital-based quality improvement
  • Provide exposure to models of pay for performance
  • Educate trainees in quality improvement
  • Provide a focus for ACGME program requirements and CLER visits
Each year, residents and hospital leadership select 3-4 measures at the hospital level. These typically mirror the priorities of the overall health system, with the targets for each specific measure based on prior performance data and also aligned with hospital targets (top quartile performance meets and top decile performance exceeds target). For each target met, trainees are paid $200, for a maximum payout of $600. Who is eligible? All GME ACGME or ICGME trainees who have worked for at least 3 months leading up to June 2015. What are the measures for this year (2014-2015)? This year, with resident and leadership input, the following 4 measures have been selected:
  1. HCAHPS Patient Experience Measurement
  2. 30-day same hospital readmissions
  3. Emergency Department Median Consult Time (NEW)
  4. RL-6 Safety Event Reporting (NEW)
What is the reasoning behind these measures? What are the targets?
  1. HCAHPS: As all hospital systems continue to improve, the standards for patient satisfaction will continue to rise as well. Target: Meet the National Median of 87.5% (7 out of 8 dimensions).
  2. 30-day hospital readmissions: Trainees will have an additional opportunity to demonstrate improvement. Target: 13.05% (median of comparable health care systems on the UHC US News Honor Roll).
  3. Emergency Department Median Consult Time: Extended consult times in the ED contribute to increased Left Without Being Seen rate and decreased patient satisfaction and care. Target: Overall decrease in consult time by 10%.
  4. Safety Event Reporting in RL Solutions: Increasing trainee input and awareness for adverse outcomes or near-misses. Trainees only submitted 0.5 (74) of overall reports last year. Target: Increase trainee submitted reports for an average of 2 submissions per trainee.
What were our measures last year (2013-2014)? Last year, we had 3 program measures encompassing the domains of patient satisfaction and quality and patient safety:
  1. HCAHPS (Hospital Consumer Assessment of Healthcare Providers & Systems) surveys: publicly reported data from patient surveys on hospital performance
  2. Duke Hospital 30-day hospital readmission rate
  3. Influenza vaccinations
Additionally, several programs chose program-specific measures:
  • Hand Hygiene: Internal Medicine, Pediatrics, General Surgery, Anesthesia, Neurology, Orthopedics
  • Left Without Being Seen Rate: Emergency Medicine
  • OB Trauma: Vaginal with Instrument: OB/GYN
How was our performance last year?
  1. HCAHPS: Target of 87.5% met
  2. 30-day hospital readmissions: data unavailable through much of the year
  3. Influenza vaccinations: data unavailable through much of the year
  4. Program specific measures: Pediatrics met their target with hand washing.
Trainees received the full pay-out of $600. How will we be updated on our progress? Performance Services will create monthly reports with up-to-date performance metrics that will be distributed to trainees and program directors. Program representatives are also willing to present the program structure to your trainees; contact information is below. What can we do with this information? You can work with your program or peers to create a QI project or initiative to specifically address improving upon these measures. How can I get involved? To get involved or for more information, please contact one of the program co-chairs: Anjni Patel (anjni.patel@dm.duke.edu) or Sarah Dotson (sarah.dotson@dm.duke.edu). Attachments:    

Stead Society Trivia Night

The Warren Society would like to invite house staff and Stead preceptors from all the Stead groups to Stead Trivia Night, held starting at 7:30PM (dinner at 7:30, trivia at 9) on Wednesday, August 27, at Bull McCabes (427 West Main St., Durham).  If you come, we will feed you dinner and provide you with tasty beverages of your choice.  The trivia is really just an excuse to gather the residency class, so there is no need to be a trivia buff to participate.  Please come and chat with your resident colleagues in a relaxed atmosphere.  Also, please feel free to bring your families and significant others. Sincerely, Steven Crowley on behalf of the Warren Society  

Information/Opportunities

Hospitalists Practice Opportunity in PA 7-2014 Announcement Geriatrician Opportunity Elkin Hospitalist Montana Hospitalist Summit Placement Service Washington State Opportunities Madison WI opportunities www.mercydesmoines.org Optional Survey from UC San Diego Please complete a 2-minute survey about smartphone and tablet use in hospitals. Link HERE.   All data is anonymous and results will be publicly available. Thank you for your help, Orrin Franko, MD Resident Physician, Post-Graduate Year 6 University of California, San Diego Once again:  SURVEY LINK HERE Survey: https://docs.google.com/spreadsheet/viewform?usp=drive_web&formkey=dElCcmh0dFhyNE9HNjJNNHBERU9WZGc6MA#gid=0  

Upcoming Dates and Events

August 27th - Drs. Schuyler Jones and Manesh Patel at Alivia's  - Careers in Cardiology August 27th - Stead Society Trivia Night, Bull McCabes (427 West Main St., Durham)  

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