From the Director
USA! USA! USA! Lots of national pride as we celebrate the 4th and the USWNT victory in the World Cup! Lots more to celebrate as we finish our first week of the new year. Many kudos to all of the interns, JARs, SARs and attendings as they worked through the week…great job to all. We had outstanding SAR talks to continue through the week by Sarah Goldstein, Marc Samsky and Matt Atkins — with a couple of days delay, you can find the powerpoint slides housed in Medhub under a folder called “Noon Conference”.
Other shout outs go to Marc Samsky from Lisa Vann who received a nice email from a family that Marc and Lisa took care of during the end of last year, a belated thanks to Angela Lowenstern from Maggie Infeld for ending her SAR year as an awesome VA dayfloat, to Sarah Nelson for starting of the year with an excellent CAT at VA report, and to the Duke gen med interns from Jenn, Sarah and I for a really great discussion at the first intern report. Kudos also from Dr. Bill Hargett to all of the interns on his team and Alan Erdmann for his extra help on sign-outs. A big thanks to Jenny Tucker for bringing in snacks for the snack basket as well.
Many thanks to the teams who are getting their interns to noon conference! Jenn and Chris will be holding pagers, and many interns told us that their fellows on cards and onc were holding pagers! Great start to the year – we had to move downstairs because of the amazing attendance.
We will be having some upcoming events, including JAR dinner … JARS, keep an eye out for an email from Madi about dinner with me (and Dave this month!)..first five to sign up can head out to dinner with us to Pizzeria Toro, As well as the upcoming Kirby Durham Bulls game. Tyler’s remains the place to be on any given Wednesday as well.
This week’s pubmed from the program goes to Paul St. Romain … St Romain P, Desai S, Bean S, Jiang X, Burbridge RA. Extramedullary plasmacytoma of the gallbladder diagnosed by endoscopic ultrasound fine needle aspiration (EUS-FNA). J Gastrointest Oncol 2015 Apr; 6(2): E7-E9.
Have a great week!
Aimee
What did I read this week?
THIS FEATURE WILL RETURN ON JULY 13TH WITH NEW CONTENT. PLEASE ENJOY THE FOLLOWING WHICH FIRST APPEARED JULY 7, 2014, FROM DR. SHARON RUBIN:
Bloomfield, Olson, Greer et al. “Screening Pelvic Examinations in Asymptomatic, Average Age Risk Adult Women: An Evidence Report for a Clinical Practice from the American College of Physicians.” Annals of Internal Medicine 2014; 161 (1):46-53.
When I was a medical student I could not believe a British patient who told me in England they do pelvic/pap smears every 5 years. Fast forward 10 years there is no supporting evidence to perform pelvic exam and due to improvements with technology and detection of HPV, pap smears interval can be increased to 5 years for women > 30 -65 with normal pap smear and negative HPV testing.
This was a systematic review article via Medline and Cochrane to evaluate the benefits and harms of routine screening pelvic exam and that focused the positive predictive value of pelvic exam to detect nonce rvical cancer, PID, other GYN conditions. They wanted to answer; does a pelvic exam reduce mortality and morbidity from any condition? What are the harms and benefits of a routine pelvic exam?
Results: Diagnostic Accuracy of Screening Pelvic exam: (only from 3 studies) only for ovarian cancer PPV was 1.2 to 3.6%. There were no studies that looked at morbidity or mortality benefits for detection of cancer or nonmalignant conditions. Harms: limited evidence suggested that women associate pelvic exam with pain, discomfort, fear, anxiety, embarrassment and 1 study showed indirect harm: screening pelvic exam led to unnecessary surgery in 1.5% of women. Importantly victims of sexual violence are more likely to avoid pelvic and Pap smear and would experience harm from a routine pelvic screening exam.
Split in recommendation: ACOG recommends annual routing pelvic exams but this is based on expert opinion. USPTSF recommend against pelvic exam for screen for ovarian cancer (Grade D recommendation). Many providers still perform pelvic exam: for screen for ovarian cancer, before prescribing hormonal contraception, to dx STDs or part of well woman visit.
High value care: Balancing clinical benefit with cost and harms with the goal of improving patient outcomes. From Medicare 2013 Pelvic exam #38.11 and pap $45.93. The estimated cost of preventative GYN exams + lab + radiology $2.6 billion. 1/3 = $850 billion spent on unnecessary cervical cancer screening in women < 21 years old; indeterminate % on other pelvic exams.
Conclusions: continue the Cervical cancer screening, there is evidence but consider stopping pelvic exam in asymptomatic women not at increased risk of gynecological cancer.
Clinic Corner
Hello from all at the DOC!
Welcome to the new interns!!
Our first group of 4 plus 1! Robert, Rachel, Carolyn and Megan…wonderful to have you at the DOC!
A few items..
Please remember to cc your note to your attending during the clinic visit..and to finish your note by 24 hours..important!
Our beloved front desk supervisor Brandie Johnson is leaving on July 24 for the Cancer Center and more responsibility..a wonderful move for her but a loss for us..Lashonda Whitfield, CMA, is also leaving then for a position at Duke that will allow her to complete nursing school. She has been a fantastic partner with all of us..We have a new RN, Amber Walters, so welcome her when you see her!
Check your inbasket at least several times a week! If decline refills state why, if ok, refill for 6-12 months. Most meds are refilled on protocol, and please refill during visits, even if pts don’t ask. We get hundreds of refill requests/day by fax, and have a 72 business hour turnaround time…
No opioids unless reviewed with attending, and we use a limited # (30) of short acting opioids and very limited use of short acting benzodiazapines.
Plan on your schedule being full! Appointments can change quite a bit, so even if there is an empty slot, it is very likely to be full. Know your Stead/clinic team! There is a nurse with your care team that you can Maestro message with simple tasks..
Wash/ gel your hands so that patients see it! They are asked, and we are monitored for it!
Communicate all labs to pt! letters or MyChart! Ask pts to sign up for my chart thru their phone if they don’t have a computer! Letters go to Carolyn Lawrence (our HIS, Med Records staff) who will mail them. Mychart even easier!
Thanks for all you do for our patients!
Lynn, Dani, Larry, Natasha, Gina, Brandie, and all of the DOC staff!
QI CORNER
Dr. Lindsay Boole, VA QI Chief Resident
Welcome to the first QI Corner of the year! This is where you will find weekly updates on all things quality and safety.
Lish and I are thrilled by the amount of interest in quality improvement we’ve already seen from all of our residents, and especially the new intern class. We are looking forward to a productive year, with lots of opportunities for residents to get involved and even take ownership of QI projects.
Here is an overview of QI curriculum and activities you can expect to see this academic year:
The IM Residency Patient Safety & Quality Council (PSQC):
This is a resident-driven committee with resident-driven goals and projects. It’s YOUR chance to get involved! We will meet monthly, usually luring you with food. As a group, we’ll select projects at the beginning of the year, and then work together to follow them through.
**Please join us for the first PSQC meeting**
Wednesday July 16th 7:00pm
Six Plates Wine Bar
We’ll ask your input on the best time for a standing monthly meeting. So if you want to be involved but you can’t make it to the Six Plates kick-off, email lindsay.boole@duke.edu or alicia.clark@duke.edu with your scheduling preferences.
Morbidity & Mortality (M&M) Conferences
Several Grand Rounds and noon conferences are dedicated to M&M. These are always multidisciplinary and are fantastic learning opportunities. The first is a Grand Rounds on August 21st.
QI Noon Conference Curriculum
Selected noon conferences will have a QI theme; this will be your source for a didactic curriculum on all things QI. The first one is also coming right up in August.
High Value Care Curriculum
A series of conferences are dedicated specifically to helping you understand and deliver high value cost-conscious care.
QI Sharepoint
This is your opportunity to perform QI on your own ambulatory clinic activities. You’ll have dedicated time in an ambulatory block to analyze your own clinic performance, and then you’ll have a chance to apply what you’ve learned and improve! Find this year’s metric, selected by the residents in the Ambulatory Care Leadership Track, in an upcoming Weekly Update.
QI Half-Day Curriculum
New this year! Interns will all have a half-day dedicated to patient safety and QI while on an ambulatory block.
QI Critically Appraised Topics (CATs)
JARs on VA gen med will take place in a unique conference, where they generate a clinical question that has to do with QI or patient safety, find an article that answers their question, and then critically appraise that article with an eye toward methodology and generalizability.
Duke SAR Patient Safety Conference
SARs on Duke gen med have a weekly resident report that is QI-themed. Every week, a SAR presents a case from their experience on the wards that they think represents a quality of safety issue. Together, the SAR group analyzes the root causes and comes up with potential solutions. Often, these have resulted in real change within the program or the hospital.
GME Incentive Program
Every year, GME selects four metrics and ties an end-of-year financial reward to them. When this year’s metrics are announced, we’ll let you know here.
From the Chief Residents
Grand Rounds
Friday, July 10th- No Grand Rounds (July 4th Holiday)
Noon Conference
Date Topic Lecturer Time Vendor
7/6/15 SAR Emergency Series: Acute Hypoxic Respiratory Failure
Kristen Glisiinski
12:00/2002 Nosh
7/7/15 SAR Emergency Series: Hospital Acquired Delirium: Recognition & Management
Julia Cupp
12:00/2002 Domino's
7/8/15 SAR Emergency Series: Undifferentiated Shock - Initial Mgmt
Jesse Tucker
12:00/2002 Cosmic Cantina
7/9/15 SAR Emergency Series: Oncologic Emergencies: TLS/Spinal Cord Compression
Jason Zhu
12:00/2001 Subway
7/10/15 Chair's Conference Chiefs 12:00/2002 Saladelia
From the Residency Office
Get Involved 2015!
As we start another academic year, we remind you of all of the opportunities the program and Duke Medicine offer for you to get involved and give back to to our community. Please see the brochure linked at the end of this post for more information!
Duke Partners Club
We are a group of significant others (spouses/fiancés/partners, etc) of residents and fellows in the many different specialties at Duke. Our group offers several monthly activities such as book club, dinners, movies, playgroup, and most simply, a community for those sharing similar experiences during this exciting time in our partners' careers.
This year, GME invited us to participate in orientation with a info-table allowing us to share details about our group. Knowing that information received at orientation doesn't always make it home, please see the information available for download at the end of this post!
Certification in Language Translation Services
If you speak a language other than English fluently and would like to be certified as a medical translator in order to inform/consent patients, please contact The Duke International Patient Center (919) 681-3007
First Annual Summerfest
The Duke Medical Alumni Association is delighted to host this year’s First Annual Summerfest, an event for all Duke residents and their families. We want to welcome Duke’s newest house staff and celebrate with all residents that they are part of the Duke medical alumni family.
SARs
Please know there is an excellent opportunity to hone your interviewing skills. Dr. Kathryn Pollak who is a communication coach and faculty member in the SoM will provide 4 1-hour sessions from which you can choose. In the session, Dr. Pollak will cover tips to finesse interviewing skills as well and give some a chance to role play. She also will be available for practice for their interviews in September and October.
The four sessions will be held the following dates and times:
Monday, August 17th: 12:00 noon to 1:00pm
Tuesday, August 18th: 4:00 to 5:00pm
Wednesday, August 26th: 12:00 to 12:00pm
Thursday, August 27th: 4:00 to 5:00pm
Each session will be 10 people or less, that way it’s more personalized. Please let me know as soon as possible which session you would like to sign up for. This is a very valuable tool being offered!
Upcoming Dates and Events
August 21 - Housestaff Welcome Event
Useful links
https://intranet.dm.duke.edu/influenza/SitePages/Home.aspx
http://duke.exitcareoncall.com/.
Main Internal Medicine Residency website
Main Curriculum website
Ambulatory curriculum wiki
Department of Medicine
Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response
Opportunities
http://www.ad001.info/blasts/CKS/CKS15_05431/CKS15_05431.html
CAH Primary Care Bulletin 2014.pdf
Decatur Primary Care CHIC Bulletin.pdf
PC Beardstown Bulletin.pdf