From the Director
Hi everyone! The year keeps flying by…hard to believe that
Friday is MATCH DAY! We are looking forward to welcoming the newest members of the med res family, and celebrating with everyone on Friday night!
A continued thanks to everyone for participating in MiniCEX madness…a special thanks to
Jon Bae for completing 6 Minicex's this week while on gen med (and helping
Brian Sullivan and Bassem Matta log 3 MiniCex's each!). How can you participate ---
ASK YOUR GEN MED, CLINIC or other ward service attending to record a MINICEX for a patient encounter they observe with you! It's that easy.
Speaking of
Jon Bae, he also led our program to an amazing showing at the Duke Patient Safety Conference. Presenters/poster authors included many from our hospital medicine group (
Drs. O'Brien, Jolly-Graham, Setji, Schulties, Clarke) as well as residents
Lindsay Boole, Jenn Rymer, Katie Broderick, Jessie Seidelman, Hany El Mariah, Phil Lehman, Jeremy Halbe, Kevin Shah, Bonike Olorontoba, and Tim Mercer, and medical student
Wynn Hunter. Our DOC team won the highest award (the Rebecca Kirkland Award) for their work "
Impact of transitions of care services on an IM clinic population" and Katie's work on the patient centered business cards received a runner up award for best poster! This is really amazing to see such strong IM representation at this symposium.
The mock CLER visit went well, and we should be receiving some feedback soon from GME. Many thanks to
Audrey Metz, Trevor Poseneau and Bobby Aertker who helped guide the CLER team through the hospital. Remember, we get 2 weeks notice for the real CLER visit, so all I can tell you is that it is not happening this week or next! More information as we receive it.
Bill Hargett and I held the second fellowship information meeting – thanks to the JARs who attended. Please look at the MedHub folder "Fellowship Information" for the roadmap to the application process. For those applying to fellowship for the 2015 cycle, please set up an appointment with me (email Erin) for late April to go over your CV, personal statement, choices of places to apply and potential letter writers.
The residency council and I had a great meeting on Thursday night – if you want to hear more about it, please contact your class rep or contact me directly.
It's coming….many of you have heard of the iCOMPARE study, which will compare 24+4 for interns versus 16 hour limits. (see
www.icomparestudy.com). We just received notice on Saturday that the ACGME is prepared to fund the study. Details to follow, but we have permission to participate, and hope to be part of the many programs who will be randomized to allowing 24+4 for interns in either 2015-16 or 2016-17, with a cross over to 16 hours in the other year. While this affects none of you directly right now, my feeling is that this will be the most impactful graduate medical education study ever performed. There is a similar study approved for general surgery as well.
Kudos this week go to
Fola Babatunde who received accolades from a patient (sent to us by Lisa Pickett), and to
Brian Sullivan, who was recognized by the 4300 nursing staff for great communication skills. Additional kudos to Matt Atkins for a fantastic chair's conference, and to
Jeremy Gillespie and Marcus Ruopp for their SAR talks.
This week's pubmed from the program goes to 2 residents and one of our graduates!
Bobby Aertker, Alex Clark and Dan Ong for their recently published paper
"Radiation Associated Valvular Heart Disease" published in the Journal of Heart Valvular Disease J Heart Valve Dis Vol. 22. No. 5 September 2013.
Have a great week!
GO DUKE, and keep counting down till
MATCH DAY!
Aimee
The "Clinic Corner - Pickett Road" (submitted by Sharon Rubin, MD)
We have sadly said goodbye to
Dr. Tara Obrien who left Pickett on 2/28/14 to work in Montana. She will be missed!
Dr. Jennifer Brown has started 3/3/14. She is a transfer from Durham Medical Center. She trained as a resident at John's Hopkins and will start precepting Tuesday mornings in Dr. Obrien's place in April.
Dr. Rubin will be filling in Tuesday mornings for the month of March to give Dr. Brown time to adjust to the
new clinic.
The door codes have been updated (ask the attendings for code- we cannot circulate on the Internal Medicine web site)
Do not however share this code information with non-Pickett Road staff.
PECOS: as per GME, residents will not be signed up (this is still in negotiation). SO any Durable Medical equipment or medical supplies for Medicare patients may have to sent by your attending. Only small pharmacies are asking for PECOS for residents. The best course of action is to prescribe as normal but if you get a message from a pharmacy NOT allowing you to send in supplies, contact your attending or Dr. Rubin.
Please make sure you are signing in under the Pickett Road with your assigned attending. If you are signed in from inpatient, ANY order, lab or radiology, will default to the Inpatient attending. Also for Tuesday and Thursday, if you are here all day, you need to CHANGE from the morning to afternoon attending (log in and then out to attach the correct attending). Make sure you are marked as reviewed for Problem List. If in annual visit, please enter the family history and update PMH, PSH, Social history. We are required to use EPIC Patient information to count as mark as review (under References).
Reminder as per DPC policy, providers are still required to call their patients for HIV results. We can result them in My chart but as per policy patient will still need a phone call of their results.
PPDs: from DPC administration: see Dr. Rubin smart phrase SRTBFORM and the letter SRTBLETTER
We will like to provide an update in regard to the PPD shortage. The manufacturer is able to fulfill orders for PPD derivative. If your site has an adequate supply of PPD, please follow the State’s guidelines for administration:
1.
Resume testing for the previously deferred group, which includes –
a.
Staff with direct inmate contact
b.
Inmates in the custody of the Department of Correction (tested upon incarceration and yearly)
c.
Staff working in licensed nursing care homes
d.
Residents upon admission to licensed nursing care or adult care homes
e.
Staff in adult day care center providing care to patients with HIV/AIDS
2.
After verifying PPD supply level, resume regular employee testing per CDC and facility guidelines
3. Continue adherence to the June 21,2013 memo regarding administrative PPD testing for low risk individuals (e.g., teachers, child care workers, etc.)
a.
Perform risk and symptom screen
i.
If the screen is negative; then no further testing is required
ii.
If the screen is positive; then perform a PPD test or an Interferon Gamma Release Assay
Thank you to
Wassim for the HUGE poster in the resident work room. We are doing great with sending our patients new results. We can improve, especially with alert values. Always confirm with the patient when you are ordering any lab or radiology their phone number and encourage them to use my chart (use .mychart in patient instructions). You can addendum your note (you do not need a whole new telephone number for your conversation).
Thanks!
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What Did I Read This Week?
Submitted by Vaishali Patel, MD
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Why Did I Read It? Skin abscesses are common, and are mostly managed by internists in clinic/urgent care, and ED physicians. Knowing how to manage small, simple skin abscesses yourself, and knowing when to consult a surgeon for larger, complex cases is important. Not surprisingly, the incidence of skin abscesses has increased with the incidence of community-acquired MRSA (caMRSA) – this has prompted reconsideration of the importance of adjunctive antibiotics with drainage. This review is largely based on randomized trials, and some small, observational studies.
What Did I Learn?
- In addition to increasing your ability to detect an abscess, bedside ultrasound can help you determine the need for further imaging, the need for incision and drainage (I&D), or for surgical consultation. In a prospective study of 126 adults with a clinical diagnosis of cellulitis, ultrasonography resulted in a change in management for 56% of patients.
- Distinguish skin abscesses, furuncles, and carbuncles from folliculitis, hidradenitis suppurativa, and sporotrichosis. In immunocompromised hosts, consider skin lesions due to Cryptococcus and Nocardia.
- Needle aspiration can make the diagnosis, but an absence of pus on aspiration does not rule out an abscess (staphylococcal abscesses have a lot of fibrin and have high viscosity, making it difficult to aspirate). Needle aspiration is inferior to I&D for adequate drainage.
- Individuals at risk for endocarditis should receive antimicrobial prophylaxis prior to I&D (IV vancomycin, or single dose of oral anti-MRSA agent is also acceptable).
- Refer the following to a surgical specialist for I&D: large (>5cm), deep, complex/multiple collections, or recurrent abscesses, abscesses in certain areas, such as the hands, neck, face, breast, or genitourinary or perirectal area, areas with critical structures such as major vessels and nerves.
- The primary treatment is I&D (use 1% lidocaine and a scalpel). The single incision should be long and deep enough to allow drainage; a small study suggested that a small incision is adequate (median length, 1cm). Check out NEJM’s Videos in Clinical Medicine (
http://www.nejm.org/doi/full/10.1056/NEJMvcm071319). Small skin abscesses that you manage without surgical consultation do not need packing (associated with more pain but similar healing rates).
- Wound culture is not routinely needed for healthy patients who will not receive antibiotics, but should be done in patients with severe infection, sepsis, history of recurrent abscess, failure of initial antibiotic treatment, extremes of age, and immunocompromised states.
- Cure rates with I&D alone (without antibiotics) are high (>85%), however larger studies are needed to show smaller differences in response rates, especially in the era of ca-MRSA. Some observational studies show I&D is sufficient for immunocompetent hosts with MRSA abscesses; other retrospective data suggests that antibiotics may help prevent recurrent infection. Two large NIH RCTs are ongoing to investigate whether larger abscesses (>5cm) or surrounding cellulitis benefit from adjunctive antibiotics.
- IDSA recommends antibiotics with I&D for patients with severe disease (rapid progression, signs of systemic illness or sepsis), extensive disease, abscess>5cm, multiple sites of infection, immunosuppression, very young or very advanced age, associated septic phlebitis, or an abscess in an area that is difficult to drain (face, hands, genitalia). Otherwise, avoid over-treatment (risk of increased resistance).
- Antibiotic therapy should cover ca-MRSA (TMP-SMX, clindamycin, and doxycycline are good choices -- be aware of local resistance patterns for clindamycin and tetracyclines!). For patients with systemic illness or extensive involvement, your options include vancomycin, linezolid, daptomycin, and ceftaroline. 5-7 days of therapy is usually sufficient; severe disease may need a longer duration (tailor to clinical response). For early abscess that cannot be distinguished from cellulitis, use agents with activity against MRSA and streptococci, such as TMP-SMX and a beta-lactam (like cephalexin).
QI Corner (submitted by Joel Boggan, MD)
Congrats to Patient Safety and Quality Conference Presenters
To our residents who had posters at the Duke Patient Safety and Quality Conference on Thursday. 'Check out a couple of our presenters! Congrats as well
Katie Broderick-Forsgren, who won a Runner-Up award for her poster on the business card initiative on Gen Med!
Hand Hygiene Update
We did really well with hand hygiene in February, with almost 92% compliance overall and 100% compliance on 8300 with > 20 observations. Our aggregate rate since August is inching closer and closer to the goal of 90% for the year . . .
From the Chief Residents
SAR Talks
March 20: Anne Mathews / Ashley Lane
Grand Rounds
Dr. Kimberly Blackwell – Breast Cancer
Noon Conference
| Date |
Topic |
Lecturer |
Time |
Vendor |
Room |
| 3/17 |
MKSAP Mondays |
Chiefs |
12:00 |
Subway |
2002 |
| 3/18 |
MED-PEDS Combined: Transitions of Care to Adulthood OR Difficult Death Debrief |
Carl Cooley / Galanos |
12:00 |
Saladelia |
2002 OR DN9242 |
| 3/19 |
M and M |
Boggan |
12:00 |
Cosmic Cantina |
2002 |
| 3/20 |
SAR TALKS |
Anne Mathews / Ashley Lane |
12:00 |
Sushi |
2001 |
| 3/21 |
Chair's Conference |
Chiefs |
12:00 |
Rudino's |
Med Res Library |
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From the Residency Office
Mini CEX Madness
Week 2 of Mini CEX Madness saw a total of 14 CEXs completed! Our winner for week # 2 is
Alexandra Clark - congratulations! A special shout-out to
Basem Matta and Brian Sullivan who each completed THREE CEXs in week #2! As a reminder, everyone who has a CEX done during the month of March will be entered to win a $50 dinner at the restaurant of their choice (alcohol not included.) Great job everyone!
SAR's - Licensing and Credentialing
SARS — If you would, please give all forms you have for licensing and credentialing to Lynsey Michnowicz. She will make sure that Dr. Zaas fills them out and sends them in. No need to email Dr. Zaas directly! Actually if you do there be greater risk that they may be lost in the volume of email received.
Grand Rounds - Recording Attendance
Department of Medicine Grand Rounds is just one of the many learning opportunities that residents are strongly encouraged to attend. It is also one of the events that for which we track and record attendance in Med Hub. We understand that the changeover to ETHos in February may have caught a few residents off guard, which is probably why the conference attendance that we see in the data base has dropped, even though many residents can be seen sitting in the gallery. For reference, click on the following link for the directions to set up an account in ETHos, and YES - you do need log in each time to record your attendance at Grand Rounds.
How to register with Ethos
Financial Planning Seminar
We are sponsoring a brief financial planning seminar sponsored by The Benefit Planning Group (
www.myBPGinc.com). BPG is the exclusive provider of disability and life insurance for residents and fellows at Duke. The firm works nationally with clients in every state and 600 cities. The seminar will be conversational in order to best address your topics of interest and focus particularly on the specific needs of physicians transitioning from training to practice.
Topics will include:
- Debt Reduction for Home and School Loans
- Investment Strategy for Current Career Stages
- Risk Management through Insurance Solutions
Key Take-Aways:
- Through BPG and this seminar, disability insurance is currently available at up to a 45% discount
- This discount is only available while you are still in training at Duke.
- Guaranteed issue options are available for departing trainees – no medical or financial underwriting
- The insurance marketplace is continually training and these opportunities may not exist in the future
Details:
April 17 @ 5:00 in the Med Res Library
Marc C. Flur, CFP
Vice President, The Benefit Planning Group, Inc.
3400 Croasdaile Drive Suite 206
Durham, NC 27705
919-489-1720
800-225-7174
Information/Opportunities
Frankfort IM Hospitalist Flyer (3-6-2014)LGMC & Pulaski IM Hospitalist Flyer (3-5-2014)SRMC - IM Hospitalist (3-6-2014)Reston - IM Hospitalist (3-6-2014)CJW - IM Hospitalist (3-6-2014)
Upcoming Dates and Events
- BLS Blitz 3-2014: March 17 - 20
-
March 21: Match Day CELEBRATION !!
- March 22: Gastrointestinal Cancers Program 1st Annual 5K Run/Walk DukeCRC5K.org
- April 11: Final Faculty Resident Research Grant applications
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- March 31: GI Interest Meeting (contact Jill Rimmer, GI PC)
- April 17: Financial Planning Seminar
- April 18: Charity Auction
- April 18: SAR Class Picture (rescheduled)
- April 22: CPC Event, 7 PM @ The Pit
- May 3: the Stead Tread 5K www.steadtread.org
- May 30: Program pictures @ Duke Chapel 9:15
- June 3: Annual Resident Reseach Conference
- May 31: SAR Dinner, Hope Valley CC
Useful links
