Internal Medicine Residency News: February 24, 2014

February 23, 2014

By admin3

From the Director

Hello everyone! What a great game last night, and great turnout at Tobacco Road! Krish is definately hoarse from cheering. We are gearing up for March Madness, which also brings us to the time of year for "MiniCex Madness!" As exciting as March Madness it is not, however direct observation and feedback from your inpatient and outpatient attendings is a critical component of your development as physicians, so we want to make an effort for everyone to have at least 2 (but hopefully more) minicex's completed during March. Each week we will check medhub, and whoever has had Minicex's completed will be eligible for prizes, including Starbucks cards, new cars and tickets to the Duke Carolina game (well....maybe not). SO...ask your inpatient and clinic attendings to do a MiniCex while you are working with them, or ask an APD or chief to come observe you if you are on a non-medicine service. In other big news, the "Doximity" survey rated us as one of the top residency programs in the US. They surveyed internists who are doximity members, and we did extremely well, and particularly well among program directors. Very cool to see. What they didn't publish is what program has the best residents....clearly we are #1 in that regard! Thank you again - we had 87% compliance on our ACGME survey! Results to come in June! This week we have kudos to Hal Boutte for coming in on his day off to talk to some second look applicants, to Tony Lozano for his care of a patient overnight on Gen Med (from Tom Holland), and to Bobby Aertker, Jim Gentry, Alex Clarke and Lauren Porras for the past two weeks of outstanding SAR talks. The NCACP meeting is Friday and Saturday in Greensboro! We are very proud of everyone who has posters to present! This week's pubmed from the program goes to all who are preseentingt at the ACP - 27 posters in all, a record number. Check out the following list: ACP Presentations 2014 Have a great week! Aimee

QI Corner (submitted by Joel Boggan)

Thank yous: To Lish Clark, Alistair Smith, Drs. Teiling and Ossman from the ED, and Yvonne Spurney and Miranda from Nursing as they helped lead our first new Resident M&M discussion on Wednesday. Our next date is Wednesday, March 19th, again in 2002. [caption id="attachment_12759" align="alignright" width="163"]

Joel Boggan, MD, MPH[/caption] Thanks also to Ryan Schulteis for accompanying me on High Value Screening and Prevention on Thursday - our next date is March 26th with Alex Cho. Hand Hygiene: Here are our totals through the end of January, by unit - help us make a strong, compliant push to the end!

Unit	Observations YTD	Compliance YTD	Non Compliance YTD	Hand Hygiene Rate YTD
7100	87	78	9	89%
7300	97	84	13	87%
7800	68	60	8	88%
8100	90	81	9	90%
8300	55	44	11	80%
9100	99	87	12	88%
9300	66	61	5	92%
COMBINED	553	487	38	88.1%

Submited by George Cheely, MD

Subject: “Health Care Costs and the Future of Big Medicine” What: Guest Health Policy Lecture: “Health Care Costs and the Future of Big Medicine: Perspective of the Commonwealth of Massachusetts Health Policy Commission” Who: Stuart H. Altman, Ph.D.; Sol C. Chaikin Professor of National Health Policy; The Irving Schneider and Family Institute for Health Policy; Heller School, Brandeis University Where: Room 3037, Duke Law School, (Across Science Dr from Cameron) When: 12:00pm on March 3^rd Why: Come on now. Health care? It’s expensive.

Clinic Corner - Ambulatory Care

submitted by Alex, Cho, MD

On behalf of Sonal, Sharon, Lynn, Dani, and Larry, I wanted to again thank all the residents and attendings who have participated in the over 200 Ambulatory Mini CEXs completed thus far this year.

As the email that went out earlier this month said, our desire was to reward residents who volunteered for at least three (3) Ambulatory Mini CEX observations -- and who were rated to be at or above their expected level in the clinic for their stage of training -- with advancement in the level of autonomy with which they would be able to practice in clinic. Eligible residents should hear soon, if you have not already; and if you have not we encourage you to be proactive in reaching out to the site directors/clinic Stead leaders re: what areas you might work at a little more, both in additional Mini CEXs and in general. And for those who still need more observations to qualify for consideration for advancement, the list of newly-eligible residents will be refreshed each month, for potential "promotion" the following month. Finally, for your reference below are some links to a few documents: the Ambulatory Mini CEX form, a one-pager describing the three “precepting levels,” and courtesy of Larry Greenblatt, a brief summary of SNAPPS, one of the signout frameworks that promoted SARs can now use instead of the conventional narrative one. In closing, I want to stress again that doing Mini CEXs is not meant to be a value statement on individual residents, but a standing invitation for mentored improvement. Or, as Sharon Rubin sez: "We still believe in performing CEXs on our residents in the second half of the year." Because she, as all of the attendings do, believe in all of you, too. Amb Milestone-Based Mini CEX (Sep 2013) Ambulatory Care Precepting Levels v3 SNAPPS Card [box]

What Did I Read This Week?

National Trends in Patient Safety for Four Common Conditions, 2005-2011

Yun Wang, Ph.D., Noel Eldridge, M.S., Mark L. Metersky, M.D., Nancy R. Verzier, M.S.N., Thomas P. Meehan, M.D., M.P.H., Michelle M. Pandolfi, M.S.W., M.B.A., JoAnne M. Foody, M.D., Shih-Yieh Ho, Ph.D., M.P.H., Deron Galusha, M.S., Rebecca E. Kliman, M.P.H., Nancy Sonnenfeld, Ph.D., Harlan M. Krumholz, M.D., and James Battles, Ph.D.

N Engl J Med 2014; 370:341-351, January 23, 2014

[/box] Why did I read this? This article provides an interesting overview on the impact of the many patient safety initiatives on in-hospital adverse events in the U.S. over the past

decade. It takes a pooled analysis approach of the multitude of safety campaigns, program, and initiatives and drills it down to specific adverse events with 4 DRGs. Specifically twenty one well defined clinical outcomes (CLABSI, CAUTI, falls, hosp. acquired C Diff., VAP, contrast nephropathy, hypoglycemic events and Anticoagulant complications, hosp. Acquired MRSA/VRE etc.) are evaluated instead of more surrogate markers of quality such as readmit rates, length of stay and ED throughput times. I think of it as a report a card on U.S. hospitals. On a more personal note, this article also hit home because I started as a hospitalist just prior to this database and Hospital Medicine has often played a significant role in patient safety and quality. Lastly I read this because being an AHRQ sponsored project I thought there may be some insight into the future direction CMS may take us. Methodology: Data was abstracted from the Medicare Safety Monitoring System for 21 adverse events in patients hospitalized in the U.S. from 2005-2011. The final sample size was 61,523 patients with 4 different conditions (AMI, PNA, CHF, and surgical conditions). Patients were from over 4000 U.S. hospitals representing a comprehensive view of care delivery in the U.S. Events were trended over the course of 6 years, cohorts were broken up into 2 year subsets (2005-6, 2007 and 2009, 2010-11). There was additional stratification by age, race, gender, and comorbidities were also assessed. In general, age and gender was generally consistent across the 3 cohorts, race was skewed with a predominantly white (85-90%) population. Patient comorbidities over time also showed mild increase as a general trends with increasing obesity (14 to 22%) being the most significant increase, there were also subtle increases in diabetes, cancer and renal disease. What they Found: Overall, adverse event rates declined substantially among patients hospitalized for CHF and AMI but not for PNA or conditions requiring surgery. For AMI the occurrence rate for adverse events decreased from 5 to 3.7 % and for CHF 3.7 to 2.7 % but for folks with pneumonia and surgical conditions the rates overall didn’t change. Most of the deceases seen in AMI and CHF were similar to a particular adverse event (see table S5). Looking at across different adverse events there were some trends regardless of the DRG. There was a decease with digoxin related events, hypoglycemic agents, and warfarin but increased with LMWH and Factor Xa Inhibitors. CAUTI, CLABSI, VAP and post op PNA decreased but C.Diff, MRSA, and VRE rates stayed about the same. What is next: This is a really fascinating article and I am really just scratching the surface here. The article does not extrapolate as to why there was such a difference between DRGs and it is difficult to hypothesize why the pneumonia and surgical populations didn’t see a change in total adverse events. Are these two DRGs different populations all together or are CHF and AMI patients “seeing” a different version of care in general? Furthermore many of these adverse events in and of themselves are worth further detailed investigation as to why they have changed over the years. Some may be explained simply by decrease usage (digoxin and IV heparin) or increased usage (LMWH and Factor Xa inhibitors) while others may be impacted by changes in the literature (hypoglycemia and the NICE-Sugar trial). My general impression is that there have been improvements in adverse events in specific DRGs as well as in specific events (CAUTI for instance), but we are still learning how to manage newer medications such as LMWH and Factor Xa inh. We also haven’t made great improvements in some of the common infection rates (Cdiff, MRSA and VRE) despite that being a focus in many hospitals. Maybe the fact that these infection rates are not increasing is a sign of improvement although it is worrisome regardless. Patient comorbidities and complexity also seem to be increasing in both medicine and surgery which also may pose future challenges. The jump in obesity was most alarming. However the fact that we are seeing more complex patients maybe means we are doing a better job at treating illness and prolonging survival. Its hard to say. I suspect that once CMS teases out this data we will see a call to action and more initiatives or metrics around improving some of these opportunities. However I feel that with this first round of initiatives we have made significant inroads in world of patient safety and we are making the hospital a safer place for our patients.

From the Chief Residents

SAR Talks

February 25, 2013: Drs Dolger and Mouser February 27: Drs Caputo and Elmariah

Grand Rounds

February 28, 2014: Dr. Lanasa

Noon Conference

Date	Topic	Lecturer	Time	Vendor
2/24	MKSAP Mondays - Pulmonary	Chiefs	12:00	Picnic Basket
2/25	MED PEDS SAR TALK (Dolgner/Mouser)		12:00	Chick-Fil-A
2/26	MSK Exam Part 2	Irene Whitt & Lisa Criscione	12:00	Cosmic Cantina
2/27	SAR TALKS	Laura Caputo / Hany Elmariah	12:00	Pita Pit
2/28	Research Conference		12:00	Panera

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From the Residency Office

I'm Clear, Your Clear, We're All Clear About This Consultation - with Dr. Chad Kessler (Deputy Chief of Staff, Durham VA Medical Center).

Wednesday, March 26th 12noon – 1pm (DN2003)

Registration link:

https://www.surveymonkey.com/s/MEGRregistration2013

Session Objectives: 1. Develop a conceptual framework for communicating with and understanding different colleagues in medicine. 2. Demonstrate the 5-C's of Consultation. 3. Integrate the clinical science of communication into daily practice. Also, please remember to join us for our regularly scheduled March session - "Risk Management Issues Involving Learners" with Barbara Hendrix (Director, DUHS Clinical Risk Management).

Monday, March 10th 4pm – 5pm
Tuesday, March 11th 7am – 8am
Wednesday, March 12th 12noon – 1pm

Please use the following link to register:

MedicalEducationGrandRoundsFlyer March14_June14

Stead Society Trivia Night!

The Warren Society is hosting a Trivia Night for all the Stead Societies this upcoming Wednesday, February 26, at 7PM at the Carolina Ale House (3911 Durham-Chapel Hill Blvd Durham, NC)! Dinner starts at 7PM and trivia starts at 8PM. We’ll donate $100 to a charity chosen by the Stead Society with the most trivia points! Hope you can make it! Thanks!! Steve Crowley

Hoops Watch invitation - Let's try this again...

Join local DukeMed alumni from the classes of 2004-13, current and recent house staff to cheer the Blue Devils on to victory over our Tar Heel neighbors!

Duke Blue Devils vs. UNC Tar Heels

Saturday, March 8 | 8:30 pm Tyler's Taproom 324 Blackwell St Durham, NC 27701 (919) 433-0345

Complimentary appetizers and one drink ticket per person provided.

See who's coming.

Duke-NUS Graduate Medical School Singapore: Longitudinal Integrated Clerkship (LIC) Pilot Call for LIC Teaching Fellow (Academic Year 2014-2015)

Requirements:

Completion of Internal Medicine residency program by July 1, 2014
Strong interest in medical education
Willingness to live in Singapore (for one year)

INTERESTED PERSONS SHOULD CONTACT PATRICIA JOSEPH, DIRECTOR, OFFICE OF DUKE-NUS AFFAIRS AT patricia.joseph@duke.edu Details can be found in the following attachment: teaching fellow

Income-Driven Repayment Plans and Loan Forgiveness Programs

Wednesday, February 26 7:00pm – 8:00pm The Learning Hall, Trent Semans Center for Health Education You will not want to miss this presentation by Paul Garrard, an independent student loan consultant and national expert on educational debt management, scheduled for Wednesday night, February 26, 7:00p in the Learning Hall at TSCHE. Mr. Garrard will be joined by Heather Jarvis (see www.askheatherjarvis.com), a national student loan expert and Duke University School of Law alumni, who does workshops nationwide on income-driven repayment and forgiveness programs. Ms. Jarvis and Mr. Garrard will provide details on Income Based Repayment (IBR) and the new Pay As You Earn (PAYE) repayment plans, and the forgiveness programs associated with each, including Public Service Loan Forgiveness (PSLF). This workshop is open to all residents, fellows, medical students, and health profession students at Duke. Please sign up using the following link: https://www.surveymonkey.com/s/6QWPH72 Should you have questions, please contact Amy Coppedge at amy.coppedge@duke.edu.

Assigning Your DOC In-Basket When You Are Away (submitted by Jessica Simo)

To assign your In Basket to another member of staff when you will be away from work for a while:

Go to In Basket. Click on the "Out" button.
Select New in the Out of Contact window
Enter begin and end date/time.
Enter delegates (the people who are going to cover for you).
Click Accept, then Close in the next screen.

MKSAP / Board Review

By popular demand board review sessions are scheduled on the following dates: March 13 and 27; April 10 and 24; May 15, 29; June 12 and 19. All sessions are held in the Med Res Library from 7-8 PM. Light dinner is served.

The Commonwealth Fund: Pursuing a High Performance Health System in the ACA era”

Dr. David Blumenthalm President February 26, 2014 4:30 - 6:00 pm Rhodes Conference Room Sanford Building, 2^nd Floor 201 Science Drive David Blumenthal, M.D., M.P.P., is president of The Commonwealth Fund, a national philanthropy engaged in independent research on health and social policy issues. He is formerly a Professor of Medicine at Harvard Medical School and Chief Health Information and Innovation Officer at Partners

Healthcare System in Boston. From 2009 to 2011, he served as the National Coordinator for Health Information Technology, with the charge to build an interoperable, private, and secure nationwide health information system and to support the widespread, meaningful use of health IT. He succeeded in putting in place one of the largest publicly funded infrastructure investments the nation has ever made in such a short time period, in health care or any other field. He is the author of more than 250 books and scholarly publications, including most recently, Heart of Power: Health and Politics in the Oval Office. He is a recipient of the Distinguished Investigator Award from AcademyHealth, an Honorary Doctor of Humane Letters from Rush University and an Honorary Doctor of Science from Claremont Graduate University and the State University of New York Downstate. RSVP mary.grimm@duke.edu