Internal Medicine Residency News, July 27, 2015
Monday, July 27, 2015
From the Director
Hi Everyone!
Block 1 is in the books for the interns this week - hard to believe it is almost August. I am continuing to get compliments from many attendings throughout the hospitals about how well everyone is doing!
For those applying to fellowship, please take a minute to read the interview email from the chiefs and me that went out on Friday. If you have any questions, please let us know. As always, all complaints go to Armando. If you are planning to apply in hospital medicine or primary care, please take advantage of the mock interview sessions by Dr. Kat Pollack, the DOM communciations specialist (see below). The chiefs are working on some informal fellowship planning sessions for each of the specialties as well.
Thank you to the interns for your patience as we work out hte kinks in the "4+1"...it's our first year trying this, and we are learning as we go with you. We are very hopeful that the regularly scheduled ambulatory time (better understanding of clinic PLUS a lighter week) every 5th week is a benefit that outweighs the puzzle pieces of the schedule. Now that we are through to Week 5, things can get smoother in the transitions.
Kudos this week to Maggie Moses and Zach Il'Giovine from Dr. Mike Sketch for earlier work on CAD, to John Musgrove for an outstanding Chair's Conference, and to our SAR talk speakers Jon Hansen, Katie Qin, Brittany Dixon, and Melanie Goebel. Great job everyone. The Gen Med SARs send kudos to their interns and night residents as well (thank you Paul St. Romain for sending!)
We also are welcoming ANOTHER future Duke resident...Madison Diana (Clark) Cubre, daughter of amazing QI APD Alicia Clark and Alan Cubre. We can't wait to meet her! Just because Lish is out on maternity leave doesn't mean you can leave your Sharepoint and QI Modules until she returns though! Keep an eye out for the assignments when you are on Ambulatory.
August is a busy month for social events, with the upcoming Kerby Night at the Durham Bulls as well as the Warren night at Bull McCabe's trivia. Hope to see many of you at the Summer Celebration for the program at the end of August as well!
This week's Pubmed from the program goes to our very own UME Director, Saumil Chudgar for his recent paper in Academic Medicine!
Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools are Preparing Students for Internship.
Elnicki, D. Michael MD; Gallagher, Susan MD; Willett, Laura MD; Kane, Gregory MD; Muntz, Martin MD; Henry, Daniel MD; Cannarozzi, Maria MD; Stewart, Emily MD; Harrell, Heather MD; Aiyer, Meenakshy MD; Salvit, Cori MD; Chudgar, Saumil MD, MS; Vu, Robert MD; for the Clerkship Directors in Internal MedicineAssociation of Program Directors in Internal Medicine Committee on Transition to Internship
Have a great week,
Aimee
What did I read this week?
Submitted by Lindsay Boole, MD
We can’t let July come to a close without talking about the July Effect! Every July this topic manages to come up in the popular media. This month, one lovely news piece from Philadelphia’s NPR station started like this: Imagine it’s the final game of the season. The stakes are high and suddenly, a quarter of your team is subbed out and replaced with – rookies. If you haven’t heard of it before, July Effect refers to the supposed rise in bad hospital outcomes each July, when interns, residents, fellows, and even attendings are all newly minted.
This July, an article published in the Journal of Hospital Medicine gives that negative media some legitimacy.
Wen T, Attenello FJ, Wu B, Ng A, Cen SY, Mack WJ. The July effect: An analysis of never events in the nationwide inpatient sample. Hosp Med. 2015 Jul;10(7):432-8.
METHODS: This study was novel because it assessed outcomes on a national level, using the Nationwide Inpatient Sample (NIS). The NIS is a database that contains information on more than 8 million hospital admissions each year from more than 40 states and 1000 hospitals. This study analyzed all inpatient admissions in the NIS from 2008 to 2011: over 143 million admissions in total.
The outcome of interest was probability of a hospital-acquired complication (HAC). HACs are those preventable complications that result in withholding of Medicare reimbursement, ranging from wrong-site surgery to hospital-acquired pressure ulcers, catheter-associated UTIs (CAUTIs), central line-associated infections (CLABSIs), poor glycemic control, and falls. The authors controlled for a multitude of possible confounders, including patient factors like demographics and comorbidities, and hospital characteristics.
RESULTS: The most prevalent HACs were falls, pressure ulcers, CLABSIs, and CAUTIs. Adjusting for confounders, the July Effect was significant, with a 6% higher likelihood of HACs in July compared to all other months (p<0.0001). They went a step further and looked at whether there’s a July-August Effect, and did find that July + August admissions had a 7% higher likelihood of HACs compared to all other months (p<0.0001). The higher rate of HACs was also associated with significantly higher inpatient charges and longer length of stay.
Conclusions: Interns aren’t the only new faces in the hospital in July! Senior residents find themselves in a new role, attending physicians are new hires, and importantly, lots of nurses also finish nursing school in June and start jobs this month. This article supports the hypothesis that this collective inexperience results in an uptick in complications. In an optimistic interview with The Hospitalist, the first author was hopeful that the July Effect can be blunted if interns and residents focus on effective communication, especially with ancillary staff, and if experienced physicians and nurses provide a layer of extra attention in July.
I’ll go so far as to suggest that, because Duke residents and hospitalists are so on top of quality and safety, we can kick the July Effect to the curb around here. Senior residents and attendings, talk to your interns this week about CAUTI, pressure ulcer, and fall prevention. Pull those foleys! Mobilize your patients! Prevent delirium! Let’s show ‘em that the Duke July Effect is defined by diligent new doctors championing patient safety.
Clinic Corner
The year is off to a great start! Our fifth group of interns is starting their ambulatory week today, making this the first July ever where every intern got to their continuity clinic!!
Ambulatory updates:
- Intern 4+1 schedules are going well, and each clinic is using one admin half day per week to go over clinic logistics, other topics in health care, and PEAC modules. This will continue and evolve over the course of the year. Please send any thoughts or feedback to Armando or Dani Zipkin!
- Ambulatory scheduling is incredibly complicated. It’s complicated every year, and 4+1 has added a few new things to work in. Please bear with us if you end up having changes to your schedule, and continue to send any questions to Armando and Lauren Dincher. We are working on getting schedules put in further into the future to give you all a better chance of continuity with your own patients.
- CEX – Please ask your attendings to do a brief observation of you in clinic, called a CEX, as soon as possible! The goal is 6 total per year (3 in clinic, and 3 in hospital) for all residents.
- Evaluations – the ambulatory form has been revised this year, look for a more streamlined eval! Please continue to identify the attendings you’ve worked with in clinic each block. Also, your attendings want more feedback, so be sure to fill out evals for them too!!
- Agile MD is an app which is full of information to help navigate clinic and other topics, if you haven’t yet started to use it, ask Dani or Armando for help.
- PEAC Modules – please keep up with these very well designed educational modules, no matter what rotation you’re on in a given month. We’re watching the numbers and aiming for 100% completion! Armando will announce each month’s modules, this month is Immunizations (see Armando’s email from July 8)
See you all in the clinic!
Dani
QI Corner
This week’s QI Corner comes from Lish Clark:
We recently went live with our 2015-2016 Sharepoint project (JARs/SARs) and wanted to share the background for this year’s project with you. In early 2015, the Ambulatory Care Leadership Track (ACLT) group met to brainstorm about clinic performance improvement projects. There was particular interest in conversations about goals of care, health care power of attorneys and advanced directives with continuity clinic patients. We thought it would be interesting to find out how often these conversations were happening and how comfortable you were having them with your continuity clinic patients. This project aligns well with Duke Health System goals of better understanding, documenting and adhering to patient preferences. Meanwhile, the recent Institute of Medicine Report “Dying in America” further underscored the importance of addressing patient preferences regarding end of life care. There has been increased national attention to this issue and on July 8th, 2015 Medicare proposed to provide reimbursement starting Jan 1st, 2016 for advanced care planning discussions in addition to that covered at the time of enrollment.
For the first phase of Sharepoint 2015-16 (July to Dec), we will gather some baseline data about your comfort level in having these conversations in clinic with a survey that will be assigned to you in Medhub. In your assigned Sharepoint time in an ambulatory block, you will perform a panel review for 15 of your continuity patients focusing on the elderly and those patients with many comorbidities. You will compare your results to those of your peers, and then you’ll devise a project statement about how you might want to improve in the second half of the year. We will have a few different educational sessions in the fall to learn about NC HCPOA forms, VA forms, the “CODE” tab in Epic, and to review some best practices with Dr. Trig Brown who has a new role in helping align Duke’s primary care and palliative care teams. The second phase of Sharepoint 2015-2016 (Jan to June) will provide another opportunity for panel review and a follow up survey regarding your comfort level. Please let Jennifer Averitt or Lish Clark know if you are having technical difficulties with the survey or sharepoint website. Ask Lauren Dincher if you have questions about the timing of sharepoint during your ambulatory block.
IOM report “Dying in America”: http://iom.nationalacademies.org/Reports/2014/Dying-In-America-Improvin…
If you are interested in borrowing a copy of Atul Gawande’s “Being Mortal”, we have a few extra from this year’s IM book club and would be happy to share.
Interns, we have something for you too! In the second half of the year, you will each get a half day during your ambulatory block for interactive small group learning about quality improvement and patient safety. You’ll be well-prepared for your first Sharepoint assignment when you are JARs.
From the Chief Residents
Grand Rounds
Friday, July 31st- Dr. Lisa Pickett/Dr. Lou Diehl - RELATE Training
Noon Conference
| Mon. 7/27 | 12:00 | PE Week: Cardiovascular Exam | Chet Patel | Mediterra |
| Tues. 7/28 | 12:00 | PE Week: Musculoskeletal Exam | Lisa Criscione-Schreiber | Domino's |
| Wed. 7/29 | 12:00 | PE Week: Chest/Thorax Exam | Bill Hargett | China King |
| Thurs. 7/30 | 12:00 | PE Week: Neurologic Exam | Joel Morgenlander | Chick-Fil-A |
| Fri. 7/31 | 12:00 | PE Week: Inpatient Daily Exam &New Patient in the Clinic Exam | Aimee Zaas & Murat Arcasoy | Saladelia |
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
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
September 12 - Stead Tread
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