From the Director
And here it is….the much awaited first Med Res News of 2016. Always remember, you read it here first!
Happy new year to all – whether you had the Christmas week or the New Year’s week as time to recharge, I hope you all had a fantastic time with family, friends and loved ones. It’s always hard to believe how fast the year goes by – congrats to interns on being halfway done with intern year, to JARs on hitting the halfway point of residency and to SARs on being very close to the next steps! The shortest calendar day of the year has passed, and there is a lot to look forward to in 2016.
Kudos came over the holidays from Matt Sparks to Tanya Aylward who "was able to arrange for a VA patient to get a cholecystostomy tube by IR on a SATURDAY morning! Also, she perfectly timed an INR drop from 2.4à1.4 to allow for this to happen.” I am sure there are many more, so send your kudos my way!
Schedule requests are due TONIGHT! Please go ahead and get these to the chiefs so we can get started on the 2016-17 block schedule. Clin epi applications are linked to the request as are the ACR nominations. ACLT applications are on a separate form – please ask Dani Zipkin if you are searching for this and cannot find the link!
What do we have coming up in January? Recruitment begins again on Friday, so we need people for tours and ‘My Take’ - please check in with Madi for details. And, as always, dinners are on Thursday and Sunday nights. We have 5 more recruitment days to go, so let’s keep up our enthusiasm to meet our future colleagues. New med students start on gen med tomorrow as well.
Lish and Lindsay will be announcing the results of the HVC competition soon – thanks to all who applied – there are some really fantastic ideas submitted.
If you are interested in the LINCOLN CLINIC VOLUNTEER OPPORTUNITY, our orientation is Wednesday NIGHT! Please see me, Madi or Lauren Collins for details.
We will be holding several meetings, get togethers and conferences for career planning, and also specifically for fellowship planning and primary care or hospital medicine career planning. Please be on the lookout for emails about upcoming dates and times. Bill and I try to do the “fellowship timeline” meeting twice to make sure that you are able to attend.
This week’s pubmed from the program goes to Dinushika Mohottige and current renal fellow/former resident John Stanifer for their article “CKD of Uncertain Etiology: A Systematic Review” published Dec 28, 2015 in the Clinical Journal of the American Society of Nephrology.
Please keep sending me your abstracts and publications!
We have a very special “WDIRTW” from our pre-holiday MICU crew .. Speical thanks to Peter Kussin for curating this important contribution to our learning.
Here’s to a great 2016!
Aimee
What We Are Reading in the MICU
Introduction by the Section Editor:
This is the first installment of what we hope will be a continuing series of curated reviews of major contributions in critical care. As section editor, I will try to bring the bleeding edge of critical care research and guidelines to the reader. Contributions from our colleagues are welcomed by the editorial board.
Title: Critical illness, Quiet time and Sleep: a Multi-Center, Randomized-Controlled Lullaby
Authors: Krueger, F (1); Hypnos (2), Somnus (2); N. Dorphin (3)
(1): Elm Street Medical Center (2): College of the Dieties (3): CNS University
Summary: Multi-variate analysis reveals bedtime stories with, but not without, warm blanket administration trends toward improved sleep (p<10). In mechanically ventilated patients, use of white noise machine during quiet time trends toward decreased agitation (p<50). Counting of sheep >3 times upper limit of normal, based on sheep per SIRS criteria nomogram, was an independent risk factor for reversal of sleep-wake cycle. High frequency oscillation of above-bed mobile, but not height of mobile (as measured from xyphoid process), is associated with increased incidence of visual hallucinations.
Contributed by William McManigle, MD and Anne Mathews, MD
Title: Rotisserie Mechanical Ventilation: Beyond Pronation
Authors: Sanders, C (1); Flay, B (2); Mixon, M (3)
(1): Kentucky Fried Medical Center (2): Iron Chef Institute of Medicine (3): Pitmasters' University
Summary: Risk of vertiginous symptoms (p<.000001) and falls while intubated (FWI) (p<.000002) are significantly increased in patients undergoing 14-day course of Frequent Alveolar Rotation with Calculated Equilibrium (FARCE) therapy. Patient visitors' episodes of nausea and emesis were significantly increased (p<.0000000000001) in patients actively rotating (PAR).
Contributed by William McManigle, MD and Anne Mathews, MD
Title: Interim Analysis of the iCOMPARE Study: You are What You Eat
Chang, Jian H.1, Cathy, Dan T2, Monaghan, Tom3, Travis, Nigel4
1Owner, China King, 2CEO, Chick-fil-A, 3Founder, Domino's Pizza, 4CEO, Dunkin Donuts
Summary: iCOMPARE is a systematic, large-scale cluster randomized trial comparing the effectiveness of duty hour rules among ACGME-accredited Internal Medicine training programs from July 2015 to June 2016. An interim analysis was performed at 6 months and showed no difference in patient outcomes or resident education between programs that were randomized to the current duty-hour regimen and the new flexible regimen. However, in subgroup analyses, resident satisfaction was dramatically increased by the availability of complimentary food (i.e. food provided at educational conferences and teaching sessions), and a positive linear correlation was noted between resident satisfaction and grams of carbohydrates consumed (p=0.003; r=0.91). Additionally, there was a positive association between the incidence of acute renal failure among residents and the distance from the nearest restroom to the resident workstation (p=0.045). The insights provided by this interim analysis argue for the adoption by residency programs of the universal provision of carbohydrate-heavy free food and the use of "workstation-side" commodes to promote resident satisfaction and health.
Contributed by Julia Xu, MD
Title: "There's a scream in my heart: ECMO and noise pollution in critical care"
Authors: Vee, V., Eh, V., Whir, W.
Avalon University School of Audiology
Summary: The authors compared the noise (measured in decibels, using a standardized decibel meter) generated by extra-corporeal membrane oxygenation (ECMO) to high frequency oscillators (HFO) and conventional mechanical ventilators (CMV) in the critical care units of 4 tertiary medical centers, and found that ECMO produced a 20 dB increase (p<0.05) in ambient noise, with the highest dB being located in the room with ECMO itself. Subgroup analysis revealed that V-V ECMO and V-A ECMO produce similar dB levels, however the V-A subgroup was incompletely studied due to limited measurement opportunity. A questionnaire was also administered to personnel (nurses, respiratory therapists, advanced practice providers, and physicians), and 78% of survey responders listed ECMO as the number one cause of increased ambient noise in the ICU. One responder wrote, "The 1973 Led Zeppelin tour was (slightly) louder."
Contributed by Lakshmi Krishnan, MD
Title: The Pain, Agitation, and Delirium Protocol - The Three Fold Path to Nirvana in the ICU
Authors: Hesse, Hermann; Siddhartha, Gautama; Tzu, Lao
Jefferson Starship College of Cosmology
Summary: 300 patients in a single medical intensive care unit were randomized to one of three arms - P (pain), A (agitation), and D (delirium) in contrast to another 300 patients who received standard ICU sedation and analgesia. The P arm received daily readings of Buddhist teachings on dukkha (pain); the A arm were given 250mL of antioxidant green tea via tube or per os daily, and the D arm listened to 30 minute recordings of the Tao Te Ching daily. Outcomes measured were pain, delirium, and respiratory rate. The D arm fared the best with a 30% decrease in all outcomes measured. The A arm had an increase in delirium as well as aspiration events (p<0.2). The P arm had a 5% improvement in outcomes, however had an increased requirement for standard fentanyl and midazolam infusions once off the protocol.
Contributed by Lakshmi Krishnan, MD
Title: PCC: a novel approach to end of life care.
Authors: Sartre. JP, Kierkegaard S. , Camus A
Journal of Existential Pain and Suffering
Summary: End-of-life can be a difficult time for families and relatives. Studies have shown that symptom management including use of narcotic medications and anxiolytics can help both the patient and family feel comfortable during this process and improves patient satisfaction scores. To date, there are no studies comparing usual practice of comfort care versus admission to an intensive care unit (ICU), initiation of ventilator and vasopressor support at the end-of-life. To that end, we instituted a new protocol, Palliative Critical Care (PCC), in which patients at end-of-life would be admitted to an ICU, intubated and placed on ventilatory support, started on vasoactive medications, with maximal diagnostic testing performed. The PCC protocol was implemented for 12 months and family satisfaction scores (PCC group) were retrospectively compared to the 12 months prior to implementation of the protocol (control). We found that satisfaction scores significantly improved after implementation of the protocol [92 (5) vs 77 (8), p=0.003]. Multivariate analysis of satisfaction scores showed the most significant increase was due to family’s desire for patients to be in a scenic environment at the end-of-life instead of their home, thus maximizing their exposure to strangers prior to withdrawal of care. The PCC paradigm has limitations. The PCC paradigm may not be as effective if the physician and nursing staff are unpleasant, the hospital is not a scenic environment, or if the patient is not intubated. A multi-center randomized control trial (RCT) will need to be performed to evaluate the effects of these factors. Until then, we recommend to families to adopt PCC.
Contributed by Sharon McCartney, MD
Title: Acute on Chronic Septic Shock (Or, How I Learned to Stop Worrying and Become Multidrug Resistant)
Authors: E.S.B. Lactamase; K.P. Carbapenemase; M.R.S. Aureus; V.R. Enterococcus
Journal of Acute on Chronic Medicine
Summary: In this study the authors compare continuous administration of multiple broad spectrum antibiotic agents with "standard of care," characterized by defined antibiotic durations, in an ICU setting. Primary outcomes included episodes of septic shock, number of days on vasopressors, and patient outcome (as defined by mortality). Patients in the study had antibiotic durations ranging from 7 to 130 days. Interestingly, while "standard of care" antibiotic administration was associated with more overall episodes of septic shock (p<0.0004), there was no difference in number of days on vasopressors or patient mortality (p=1). They also found that discrete episodes of septic shock resulted in an increased number of blood, urine and sputum cultures, from which nothing ever grew. The authors conclude that broad spectrum antibiotics should be administered to all patients for the duration of their ICU stay, regardless of apparent resolution of an infectious syndrome, since there was no difference in outcome and since the "standard of care" approach yielded many more useless cultures.
Contributed by Christine Bates, MD
Title: Discontinuation of Life Support, an Electrician's Guide
Authors: Alec Tron, Electra Cadia Graham, Ven Tilata
Duke Power Journal of Electricity in Medicine
Summary: The authors performed a randomized control trial of whole room vs. selected outlet electrical interruption for discontinuation of life support with primary outcomes of family, and provider satisfaction. Families and providers had a 97% response rate. Providers were significantly more satisfied with single outlet electrical interruption (p<0.002). On the contrary, family satisfaction was much higher with whole room electrical interruption (p<0.3). The sample size was insufficient to determine the exact cause of these differences, however authors postulate that providers preferred to stare at cardiac monitoring, which was only available with selected outlet electrical interruption. On the contrary families preferred the quiet of the whole room power interruption to all the incessant beeping that occurred with selected interruption.
Contributed by Christine A. Bates, MD
Title: The Snark Scale, Delta Snark, and Delta Delta Snark: Evaluation of Mood, Delirium, and Morale in the post-call ICU resident
Authors: Grumpie, Gus. (1), Ineda, Nap (2), Bag, E.L.
(1): Seven Dwarves University (2): American Center for Disordered Sleep (3): US Center for Resiliency Training
Summary: The Snark Scale was distributed to post call ICU residents at multiple teaching hospitals throughout the country. The Snark Scale includes evaluation of resident irritability, punchiness, mood, amount of sleep deprivation, nutritional status, kidney function, and also difficulty of the prior night on call (number of family meetings, number of calls from ED, number of failed procedures, number of patients threatening to leave AMA, etc.). Multi-variant analysis revealed two values with decided with resident mood (delta snark) and morale over the course of their ICU rotation (delta delta snark) correlation (r2 = 0.99989 and 0.97656 respectively). Acute changes in delta snark at levels > 15 correlated with significant post-call delirium and increased conflicts with nursing staff. Delta snark values were improved with poetry on rounds, pre-round jazz, doughnuts, and post-call breakfasts with peers, and nights with fewer admissions. Lower delta delta snark values correlated with residents’ subjective positive evaluation of their ICU resident teams, attendings, fellows, and multi-disciplinary staff.
Contributed by Ashley Hanlon, MD
Title: Empiric antibiosis in OSH transfers: the Duke Miracle discovered
Authors: Sanchez JS, Trump DJ, Spears B, and Squarepants S.
Six Pack Journal of Spiraling Empiricism
Summary: Each year, countless patients are transferred from outside hospitals to the Duke MICU in search of the elusive Duke miracle. For decades, billions of dollars have been spent searching for this miracle. Our group has finally solved the mystery. From 2010 to 2014, all OSH transfers to the Duke MICU were randomized to two groups: 500 Group A patients received empiric Vancomycin/Pip-Tazo (Aztreonam for penicillin-allergic patients) versus 500 placebo Group B patients (no ABX). Disease spectrum was variable, including (but not limited to) alcohol withdrawal, gastrointestinal bleeding, toxidromes, morbid obesity with consequent respiratory failure requiring intubation, and cardiogenic shock 2/2 STEMI (not admitted elsewhere due to bed availability). Exclusion criteria included T >100.4, HR >90, RR >22, WBC >12,000, or decompensated cirrhosis with an ascitic fluid cell count >250. All patients in Group A were discharged from the MICU in a mean of 3 days, regardless of disease presentation, compared to mean 48 days for Group B. 72% of Group A patients were even stable for discharge to home. Group A patients who were admitted for alcohol withdrawal never drank again. Similarly, patients with GIB never experienced bleeding recurrence. 94% of Group A patients admitted with large STEMI had preserved EF at 7 days. Unfortunately, after discharge, 92% of Group B patients were re-admitted with the same problem.
Conclusion: The Duke Miracle has been discovered.
Contributed by Juan Sanchez, MD
Title: How I Treat Hemophagocytic Lymphohistiocytosis: An Update for the 21st Century
Authors: NK (Natural born Killer)Lim Pho Cyte, Mac Rophage, Cy Topenia, Hy Ferritin
Acta Acronymica Haematologica Hallucinogenica
Summary: As someone who doesn’t know the difference between CD-25 and C-3PO, I got lost quickly in this review. However, I did manage to remember the one acronym I need in hematology: WWMAD – What Would Murat Arcasoy Do?
Contributed by Peter Kussin, MD
What Did I Read This Week?
Submitted by Lynn Bowlby, MD
Maintenance Intravenous Fluids in Acutely Ill Patients
Michael L Moritz MD and Juan C. Ayus MD
N Engl J Med 2015; 373: 1350-1360 October 1, 2015
While the majority of the faculty at the DOC do only ambulatory medicine, I am one of the few that still rounds!
After I rounded in September at DRH, I found this article which intrigued me…IVF is one of the most basic things that we do, yet do we really know the risks and what the correct choices are?
In preparation for rounding again I took another look at the article.
IVF is of course meant to maintain extracellular volume while keeping electrolytes normal. There is little consensus on which fluids to use and practice patterns vary widely. Acutely ill patients often have conditions that impair normal water and electrolyte homeostasis.
IVF can be classified as isotonic, or hypotonic (Na < 130). Dextrose has no effect on tonicity since it is rapidly metabolized, some are hyperosmolar to plasma but won’t impact tonicity.
A common practice has been to use hypotonic fluids, which have now been associated with a high rate of hospital acquired hyponatremia, and > 100 reports of death or permanent neuro disability. Data with both children and adults is available.
Recent data has shown that rapid volume expansion with 0.9% saline can cause complications.
Sodium and water homeostasis is affected by AVP, renin-angio tension system and natriuretic peptides. There are many hemodynamic and non-hemodynamic stimuli for AVP stimulation, putting almost all hospitalized pts at risk for hyponatremia.
SIADH is the most common cause of euvolemic hyponatremia.
A Na of < 135 , hyponatremia, affects 15-30 % of children and adults who are hospitalized. Most hyponatremia in these pts is hosp. acquired, and related to administration of hypotonic solutions with elevated AVP levels.
The most serious complication of this is hypnatremic encephalopathy, which is a medical emergency and can cause death or irreversible brain injury.
This can develop abruptly, symptoms are non-specific—headache, N/V, and weakness—and can start abruptly and not always correlate with the level of serum Na.
Children, women in reproductive years, and pts with hypoxemia or underlying CNS disease are particularly affected.
More data is showing that even chronic hyponatremia, developing over > 48 hrs, can be harmful with increased falls from subtle neurological deficits.
Hyponatremia is an independent risk factor for death in the hospital setting.
Hypotonic solutions are often used, based on theoretical calculations in the 1950’s.
Isotonic solutions are now felt to be more appropriate. There are no formal guidelines in the US, the UK has developed some.
Normal saline , Na 154, has same sodium as the plasma, but a high Cl concentration. A Low Ph with NS is felt to be from the bags currently used, as not true with the glass containers.
There is currently no perfect solution to use, an individualized approach is needed.
QI CORNER
Happy new year and welcome back! We're excited for the first M&M noon conference of 2016, which will be this Thursday. We hope you'll join us as Lish leads another interesting case discussion.
Please mark your calendars for the next meeting of the PSQC NEXT Thursday at 5:30pm. We're continuing to work on our paging culture project. It's off to a great start, with a standard paging template being piloted this month on 4300! If you are on gen med, you'll hear details about both the template and YOUR role in making this work at orientation today.
For those of you who submitted High Value Cost-Conscious Care proposals to the competition, you should expect to hear news of your funding status early this month. We are working to get all the pieces in place, including checks, mentorship plans, and proposal feedback, so that when you hear your results you can also hit the ground running!
CLINIC CORNER
Happy New Year from all at the DOC!!
A few updates—
1. Flu shots—continue to encourage patients to get!
If they refuse due to concerns of illness with the shot, do exlpain that if they felt ill with their last flu shot, that was due to the immune system reaction, not actually getting the flu, which would be much worse!
From Dr Greenblatt below--
It is that time of year again…. Time for trying to sort out if the viral illness your patient (or mother!) has is a bad cold or is it the flu? Here is some help-Check out the CDC’s weekly Influenza Activity Update: http://www.cdc.gov/flu/weekly/fluactivitysurv.htm. It’s good to know how much flu is going around and what types are being identified. FYI, we are Region 3. Need to make a clinical diagnosis in clinic or on the phone? During flu season, the combination of cough and fever has an LR of 5.0 while adding acute onset of symptoms gets you and LR of 5.4. Sneezing reduces the LR and is more often seen in viral URI’s. Patients with these symptoms have about a 70-75% likelihood of influenza, in season. LG
2. Say hello to Heather Hoecker, PA, sharing my office, our new PA. Like with Julia our NP, she will share pts with you and provide Mental health care.
3. Gina Green RN, sadly , moved on…we will be interviewing a replacement, and you will see Candy Penda, RN, in her office half days, to help with the Nurse Manager Role.
4. Need to get pts in quickly? Email Daniel Conners, our new ‘Brandie’, sitting in office near the front desk staff.
5. More mental health support from Alliance Behavior Health! You will hear more and see a new counselor here in early Feb.
6. Gina Callahan, front desk staff, is leaving the end of this week! She has a promotion, and will be working with Brandie!
Thanks all!!
LB and Team!
From the Chief Residents
Grand Rounds
Friday, January 8 - Infectious Disease, Gregory Gray
Noon Conference
| Date | Topic | Lecturer | Time | Vendor |
| 1/4/16 |
Outpatient Lipid Management |
Ann Marie Navar |
12:00 | Subway |
| 1/5/16 | MedPeds Recruitment-Lunch with Applicants/G-Briefing | 9242/Dr. G | 12:00 | Saladelia |
| 1/6/16 |
Hypertension: 2016 Updates |
Dani Zipkin |
12:00 | Domino's |
| 1/7/16 |
Resident M & M |
12:00 |
Chick Fil-A | |
| 1/8/16 |
Chair's 11:30 a.m., Recruitment lunch with Applicants |
12:15 | Jason's Deli |
From the Residency Office
Schwartz Rounds
Schwartz Center Rounds
Title: “TBD”
“TBD”
Panelists:
Aimee Zaas, MD, Dept. of Medicine Program Director and Family Member
Tony Galanos, MD
Tom Holland, MD
Wednesday, January 13, 2016, Noon - 1 p.m., TBD
About Schwartz Center Rounds:
All members of the Duke Medicine community are invited to attend an ongoing series of discussions called the Schwartz Center Rounds about the human side of patient care. Schwartz Center Rounds is a monthly interdisciplinary conference that offers all of us from no matter which discipline as well as non-clinicians who work closely with our patients a regularly scheduled time.... We are excited to have brought this program here to Duke and hope many of you will be able to join us on a regular basis.
Please contact, Lynn Bowlby, MD (lynn.bowlby@duke.edu), Nathan Gray, MD (nathan.gray@dm.duke.edu) or Bill Taub (arthur.taub@dm.duke.edu) with questions. There is no need to RSVP, but we do recommend that you arrive early as food and seats are at a premium!
Duke Narrative Writing Project
Dear Medical Trainees,
We invite you to participate in the inaugural Duke Narrative Medicine Project.
This initiative includes a special Medicine Grand Rounds by invited speaker Anna Reisman, MD from Yale School of Medicine (Director of Yale Internal Medicine Residency Writers' Workshop) as well as a one-day workshop focused on honing the craft of writing.
Duke medical students, residents, and fellows across all departments are invited to submit narrative or reflective writing samples in advance of a one-day workshop in which participants will engage in critical and constructive feedback of each other's writing.
The writing workshop will be moderated by Dr. Anna Reisman as well as Duke faculty members who will work with you to prepare your narrative writing pieces for publication.
Please see the attached flyer as well as the application link below for additional details.
Duke Narrative Medicine Project: Writing Workshop
Saturday, February 6th 2016
Duke Medicine Pavilion
Pre-workshop dinner February 5th, 2016
Application details:
https://duke.qualtrics.com/SE/?SID=SV_2fUx5jKrPKf9ZhH
Application deadline:
Rolling submissions until January 15th 2016
Please contact DukeNarrativeMedicine@duke.edu with any questions!
Sincerely,
Duke Narrative Medicine Project Team
Amy L Jones, Dinushika Mohottige, Lakshmi Krishnan, Anubha Agarwal
General Medicine Health Services Research Fellowship at Duke (Attention SARS!)
Health services research (HSR) is multi-disciplinary and focuses on the impact of systems of care, access, cost, quality, behavior and other factors on health care outcomes. We have a very robust network of support and outstanding faculty in HSR at Duke. Here is an introduction to our fellowship, courtesy of David Edelman. The application cycle begins in January!
The Division of General Internal Medicine collaborates with the Center for Health Services Research in Primary Care in the Durham VA Medical Center to offer fellowships for MD and PhD scholars with an interest in training in clinical or health services research. The fellowship is ordinarily a two year program, though three year fellowships may be available to certain candidates. Training grants are funded by the VA Office of Academic Affairs (OAA). We have trained more than 100 fellows in our 30-year history, including many leaders in Health Services Research and many of our core faculty in General Internal Medicine.
The primary goal of the post-doctoral fellowships is for fellows to perform high-quality, mentored clinical or health services research working closely with a mentor from the Division of General Internal Medicine. MD fellows ordinarily obtain a Masters in Clinical Research from Duke’s CRTP program, with tuition paid by the fellowship. All fellows also participate in a Faculty/Fellow Development Seminar Series, a set of weekly, one-hour discussions addressing a variety of career development topics. Stipend is at the appropriate PGY level.
Senior Residents wishing to apply for July 2016 should contact Dr. David Edelman, Fellowship Director (David.Edelman@duke.edu) no later than Friday, January 9 to express interest. Written application will be due February 1 with interviews competed by the 3rd week in February and applicants notified of their status by March 1.
Click the link for more info:
http://www.durham.hsrd.research.va.gov/MD_fellowship.asp.
Or, contact David Edelman, MD, Fellowship Director (david.edelman@duke.edu).
Book Club Event
Please join us for a special book club event on February 3rd from 5:30 - 7:30 pm in the Faculty Lounge. We'll be reading Black Man in a White Coat by our own Duke author, Dr. Damon Tweedy, who has graciously agreed to join us for the event. If you only make it to one book club event this year, make this the one!
If you would like to attend, please email laura.caputo@duke.edu. As always, a limited number of FREE COPIES of the book are available so RSVP early to reserve your copy. We look forward to seeing you there!
Thank you!
Laura M. Caputo, MD
Hospital Medicine, Durham VA Medical Center
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
March 2 - JAR Networking Event
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