From the Director
It’s official…best night of the year to be on nights (aka “spring forward”) has passed. Great representation as well (way to go, interns!) at Motorco for a great Duke-UNC game with an even better ending! Thanks Erin Payne for organizing.
Other big thanks to our recent ACRs Erin Boehm, Angela Lowenstern and Mike Woodworth. Welcome to ACRs Nick Rohrhoff, Carli Lehr and Adrienne Belasco also! We also enjoyed a fantastic grand rounds by Aaron Mitchell’s visiting professor Dr. Gilbert Welch from Dartmouth. Additional kudos to Linda Koshy from Jason Webb for great work on 9300.
Final totals are in for the Charity Auction…we are so happy to be donating over $10,000 to Senior PharmAssist and the DOC Patient Fund. I’m looking forward to paying my dues and covering for Dr. Chris Hostler this week on GERM! We are also making plans to start our first SOCIAL ACTION COUNCIL for the residency program – we would love this group to be in charge of our current community service activities as well as plan new ways for us to get involved in helping our community. Details to follow! One of your upcoming opportunities to get involved is the 2nd Annual Spring for Support 5K benefitting the Duke Cancer Patient Support Program, on March 28. Please see the information at the end of Med Res News for details – Dr. G. is a big supporter of this event so you will be sure to see him there!
Congrats to our MiniCEX Madness winner Tim Hinohara! Remember, if you get a minicex completed in the month of March, you are eligible for our weekly prize drawing. Other eligible residents were Michael Dorry, William McManigle, Andy Mumm, Yi Qin, Iris Vance and Cecelia Zhang.
Looking forward to the networking event on Tuesday at Dr. Klotman’s – thank you JARs and faculty for your RSVP’s. The fellowship directors will be organizing meet and greets in the coming months, so keep your eye out for those emails and announcements as well.
This week’s Pubmed from the Program goes to 2014 Grad (and new dad!) Hany Elmariah for his poster detailing the results of the resident burnout project that was accepted to the Duke Patient Safety Symposium (presenter Joel Boggan!) Have a great week! Aimee
What did I read this week?
(submitted by Murat Arcasoy, MD)
“Feeding tube placement in patients with advanced cancer: a teachable moment” by Bowman and Widera, in JAMA Internal Medicine, January 2015 and “My own life” by Oliver Sacks, MD and author, Professor of Neurology, NYU, Op-Ed article NY Times February 19, 2015
Why these articles
End-of-life decisions can frequently present formidable challenges for us and our terminally ill patients and their families, during the process of shared decision making. “The teachable moment” series in JAMA, authored by trainees, are truly wonderful. Every day, I learn a great deal from the experiences of our residents, so I was particularly curious about this brief article authored by an Internal Medicine resident at another academic medical center.
In his newspaper article from last week, Dr. Oliver Sacks says: “ I am now face to face with dying. But I am not finished with living”, describing his confrontation with his own mortality after finding out he has metastatic cancer. Here, he teaches us not just as a physician, but also as a patient, sharing intimately, his marvelous outlook on life, even at this juncture.
What is the “Teachable Moment” article about
This article describes the case of a woman in her 70s, very ill with metastatic lung cancer, BMI of 16, who had a PEG tube placed in an effort to extend her life to allow for visiting family to arrive. She was re-admitted one week later with inability to tolerate enteral feeding and cellulitis at the tube site. She died 18 days after PEG tube placement. The family later expressed frustration that this invasive procedure was performed despite limited life expectancy and that, had they - as the patient’s surrogates- understood her prognosis, they would not have pursued a PEG. The resident and her co-authors then reflect on this case.
What did I learn
In a large cohort of all hospitalized patients, 1–year mortality after PEG placement was 60%, with in-hospital mortality of 20%. In hospital-mortality was highest for lung cancer patients, reaching 50%. In another community-based cohort of all patients with PEG, 70% had no improvement of functional, nutritional or general health status. In another study, it turns out that surrogates - not patients- consented for 92% of PEG placements, and that >90% of surrogates expected the patients would survive >1 year, highlighting a major discrepancy between surrogates’ expectations from artificial nutrition / hydration versus actual clinical outcomes.
Dr. Oliver Sacks – a doctor who can write - borrowed the title of his newspaper article “My own life” from the title of the autobiography by his favorite philosopher David Hume,- whose words from more than two centuries ago when facing his own mortality- provided Sacks with encouragement. Many of you may have read Sacks’ wonderful books “Awakenings” or “The man who mistook his wife for a hat”. I learned that he now as an autobiography coming out this spring, which I look forward to reading. The link for Sacks’ article: http://www.nytimes.com/2015/02/19/opinion/oliver-sacks-on-learning-he-has-terminal-cancer.html?_r=0
“Teachable moments” and “Less is more” series in JAMA Internal Medicine
Teachable moments are wonderful articles authored by trainees, encouraging them to submit a clinical vignette (entitled “Story from the Front Lines”) that brings attention to the harms that can result from medical overuse and from underuse of needed medical interventions. Some of these are “Less Is More” articles that present patients’ and physicians’ perspectives on their health care experiences, with special emphasis on examples when more care is not always better, even to the point where it is perceived as harmful. The subject of the article is expected to highlight the value of improved patient-centered outcomes associated with lesser intensity or quantity of interventions.
Many of you - our residents - think of and encounter similar challenges every day, as you try to make this world a better place, one patient at a time. I encourage you to share your experiences with the medical community!
QI Corner
First this week, a quick reminder about the Patient Safety and Quality Council meeting on Wednesday. This will be at 5:30pm in the Med Res Library, and will focus on the Choosing Wisely projects; feel free to bring other patient safety or QI ideas you might have.
As for Choosing Wisely updates this week, we continue to do an AMAZING JOB in getting the “FFWU” phrase out of our signouts. More thoughtful advice has taken its place, and the number of low-yield studies getting ordered has come down as a result. However, our rates of lab ordering on Duke Gen Med have ticked back up since the start of block 9. One thing we are learning so far is that it is us residents who often want to order tests, rather than our supervisors. If you are undecided about whether you patient needs a particular lab tomorrow, consider asking your upper-levels and attendings – you may very well end up hearing that it isn’t necessary at all! [box]
Clinic Corner
The big news this week was that the ACLT residents traveled to Raleigh on March 4th for an advocacy day at the General Assembly. Trainees met with NC House and NC Senate health care leadership, including Dr. Robin Cummings, NC Medicaid Director, Rep. Nelson Dollar (R – Wake), Rep. Donny Lambeth (R – Forsyth), Rep. Marilyn Avila (R – Wake), Sen. Fletcher Hartsell (R – Cabarrus), and Sen. Mike Woodard (D – Durham).
Residents shared outcomes from the DOC’s HomeBASE program, a collaborative, team-based care model between our patients, nurse case managers, physicians, mental health providers, and social workers. The HomeBASE program, led by our medicine-psychiatry attending Natasha Cunningham, nurse case manager Marigny Manson, Julia Gamble NP, and Jan Dillard MSW, targets patients with mental health comorbidities and excessive ED usage, successfully shifting the focus of care to the clinic setting. The ACLT residents showcased the effectiveness of this program and encouraged state lawmakers to pursue provider-led accountable care reform to help control health care costs and improve outcomes for patients. Residents also shared patient’s stories in an effort to make their struggles come to life for legislators. Overall, the ACLT was very well received at the Capitol and found the experience both powerful and illuminating.
See the one-page “leave behind” that the ACLT created for legislators here
The HomeBASE program is part of the overall DOC redesign implemented in July of 2013. Led by Adia Ross (MLPR class of 2013), Alex Cho, Lynn Bowlby, David Zaas, Aimee Zaas and many others, the DOC redesign will be presented at Department of Medicine Grand Rounds on March 20th. We hope to see you all there!
See the March DOC Newsletter here!
Director of North Carolina Medicaid, Dr. Robin Cummings
Finishing a meeting with Rep. Donny Lambeth
Sen. Mike Woodard of Durham, Roxboro, and Caswell counties
From the Chief Residents
Grand Rounds
Fri., March 13: Geriatrics, Dr. Heidi White
Noon Conference
| Date | Topic | Lecturer | Time | Vendor | |
| 3/9/15 | MKSAP Mondays: Glomerular Diseases | Bonike Oloruntoba | 12:00 | ||
| 3/10/15 | PEAC Study Hall |
|
12:00 - MedRes | ||
| 3/11/15 | Evidenced Based Management of HTN |
|
12:00 | ||
| 3/12/15 | Management & Evaluation of Renal Transplant Patients | Matthew Ellis | 12:00/2001 | ||
| 3/13/15 | Chair's Conference | 12:00 |
From the Residency Office
MiniCEX MADNESS!
2015 Family Weekend
Next Book Club Event
Register for 10th Annual Duke Medicine Patient Safety and Quality Conference
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Creating a Psychologically Safe Environment: Behaviors that promote a culture of safety.
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The Quality, Safety and Value Movements: A Conversation with Bob Wachter
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Best Practices in Resiliency: Thriving versus Surviving during Times of Change (The Duke Resilience Mini-course)
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Maximizing a Multi-Generational Workforce in Safety and Quality initiatives
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The Challenges of How We Think…Cognitive Biases, Cognitive Errors, & Metacognition strategies
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Topic: Learning from Defects: A Practical Tool for Resolving Threats to Safety at the Unit Level
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Handoffs: The Evolving Story of Inpatient Handoffs: A “new” obstacle in the quest for quality patient care
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Disruptive Violent Patient and Visitors: Perspectives from the clinical provider, risk management and Duke Police. (PLEASE NOTE: this is a half day workshop. This session will begin at 1:15 and go until 4:30)
Back to Basics Curriculum
- Build standard, core curriculum content for each subspecialty, geared towards the internist
- Generate teaching scripts for core topic that can be shared among residents, medical students, and teaching faculty (see the topics and slide set examples attached)
- Develop and amass supplemental teaching tools for each topic
- Engage subspecialty faculty (and fellows) to develop, share, maintain and deliver the teaching material during each rotation
- Create a valuable learning resource for residents by compiling the teaching scripts and supplemental tools in the form of a manual www.SignUpGenius.com/go/20F0F44AEAA2AA4F85-back/23016617
Neph Madness!
Personalized Medicine Workshop Series
Dr Susanne Haga and faculty from the Center for Applied Genomics and Precision Medicine have developed a 6-session workshop series on personalized medicine and interdisciplinary practice. The workshop series will take place this March 3 – May 5 and all clinicians are invited to register for the workshop series. Each session will include a lecture component as well as an interactive skills-based component. Following participation in the course, all participants should be able to identify patients with genetic predisposition to disease and/or disease associated with genetic causality, determine appropriateness of genomic testing including who should have testing and what test is most fitting, interpret genomic testing results and apply those results to treatment, provide information about genomics, disease risk, and testing tailored for each patient, and work together as a team to deliver these services. Attendees will be asked to complete surveys assessing knowledge and satisfaction in order to improve the course for future use. Interested providers can contact program coordinator Rachel Mills (r.mills@duke.edu) for more information and to register for the course.
Information/Opportunities
ExploreAfterResidency-CompHealth
Internal Medicine Opportunities GV Redding 1-2015
Locum Tenens and Permanent Internal Medicine/Hospitalist Opportunities
Upcoming Dates and Events
March 10, 2015 - JAR Networking Event
March 20, 2015 - Match Day Celebration, West End Billiards
June 6th - SAR Dinner, Hope Valley Country Club
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