From the Director
Happy (almost) Thanksgiving! We are gearing up for fantastic weather for this year’s Turkey Bowl. The most recent VA video was really excellent, and I suspect we have a few more bits of trash talk to get through this week before we have the big game. Jonah “Littlest Jet” and Jake “Zaas Vegas” are both psyched for a good game! Following the game, join your fellow residents for a Thanksgiving meal in the Med Res library. December is right around the corner, so there are a lot of things to do before we transition to the holidays.
If you haven’t met with your advisor this year - YOU NEED TO MEET BEFORE 2015 ends! Please get in touch with your advisor (they will be reaching out to you as well) and schedule a meeting before the holiday break. Register for ABIM exam (aka “the boards”) - for SARs, check out abim.org for instructions
Update your procedure log. Don’t let those blood draws, NG tubes, etc be forgotten. Get them logged so you can get credit for what you do. Sign up for tours and “My Take” with Madi. Don’t let a good opportunity to chat with your future colleagues pass you by! Fill out the curriculum survey! Your opinions are very helpful in shaping your education.
Kudos this week to Pascale Khairallah from Matt Sparks for helping out with the CIMIGro Journal Club. Also kudos to Ani Kumar for presenting an outstanding chair’s conference and to our "My Take" residents Adva Eisenberg, Div Patel, Megan Dupuis, Luke Cerbin, Anubha Agarwal and Jessie Seidelman and to our tour guides as well – Jess Tucker, Andrea Sitlinger, Kahli Zeitlow, Alana Lewis, Eric Pollak, Emily Ray, Ani Kumar, Div Patel, Coco Fraiche, Ay Jones and Kara Wegermann.
Thank you to everyone who donated to our Thanksgiving food drive! Jen was able to deliver gift cards today for families to the DOC - much appreciated by all!
This week’s pubmed from the program goes to our TWO American Association for the Study of Liver Diseases Emerging Liver Scholars! Congratulations to Bassem Matta (mentor Keyur Patel) and Kara Wegermann (mentor Cindy Moylan) for being chosen out of 109 applicants to represent Duke at the AASLD meeting.
Have a great week! Happy Thanksgiving to our entire Duke Family, and to your families all over the world.
Aimee
What did I read this week?
Submitted by Lynn Bowlby, MD
Does This Patient with Chest Pain Have Acute Coronary Syndrome?
The Rational Clinical Examination Systematic Review.
JAMA 2015: 314 (18): 1955-1965.
A.Fanaroff MD, J. Rymer MD, S. Goldstein MD, D. Simel MD, L. K. Newby MD.
It wasn’t just that 2 of DOC’s finest are authors..or that I love the Rational Clinical Exam series for the excellent review of the evidence for so many common conditions that led me to read this review of Chest pain. With our complex medically ill population management of chest pain is very challenging.
Our patients may show up to the DOC or the ED, or leave the ED AMA with their complaint.
How best to determine their risk? This excellent review helps to guide us.
While CP is a very common ED complaint, ultimately 10% or less will be diagnosed with ACS. There is no firm guidelines for the acceptable rate of missed ACS, but many EDs aim for < 1 % rate. Clinical impression is not enough to exclude ACS or CAD on presentation to the ED.
Clinical Classification:
MDs categorize patients into 3 groups—
STEMI, NSTE-ACS, and non cardiac CP
STEMI is straightforward—EKG changes.
The challenge is defining NSTE-ACS from non-cardiac CP. EKG within 10 min, followed by exam, labs, and monitoring over 8-23 hours.
MI is defined as at least one elevation in troponin above the 99%.
ACS has no consensus definition, and remains a clinical diagnosis. Both reference standards introduce verification bias (the screening test result influences if the reference standard test is done ) and incorporation bias (the result of the screening test is a component of the reference standard).
Methods:
Searched in Medline, 2x2 tables developed, included pts who presented to the ED with CP, testing, and outcome described.
Several Clinical prediction rules were used in the studies:
TIMI risk score—7 variables
HFA/CSANZ rule-Heart Foundation of Australia and Cardiac Society of Australia and New Zealand
AHCPR rule—Agency for Health Care Policy and Research
GRACE-Global Registry of Acute Coronary Events
Results:
Of the 2992 unique articles, 58 were included in the systematic review.
Data was extracted from 1-12 studies.
The between-clinician reliability was moderate to good for risk factors but for CP quality, location, radiation and associated symptoms, reliability was fair.
Rates of final ACS diagnosis ranted from 5-42%, median 14%, consistent with a recent CDC report of 13% of ED visits for CP with dx of ACS.
FH of CAD, tobacco use, and obesity were not strong predictors of ACS.
History of an abnormal EST and PAD had LR+>2, as did pain radiating to both UEs, and change in pain pattern over 24 hrs.
Response to NTG was unhelpful.
Only 2 studies evaluated PE in dx ACS. Hypotension was the strongest clinical sign.
Pain reproduced by palpation lowered the likelihood of ACS the most.
ECGs were interpreted by physicians, and an ischemic ECG was the most specific.
The TIMI clinical prediction rule with score of > 5 had a LR of 6.8. TIMI 0-1 had LR of 0.31.
AHCPR algorithm if less accurate.
The heterogeneity of the ACS diagnosis and therefore evaluation contributed to major challenges in the use of the this diagnosis.
Only a minority of the included studies contributed data for any given test.
The cardiac troponin and ECG in the context of the symptoms should be the focus of assessment, not the risk factors, signs and symptoms in isolation. The prediction tools should be used in the decision whether to do serial testing.
QI CORNER
Happy almost-Thanksgiving! One big QI event to put on your radar this week: Lish has a great M&M conference planned for tomorrow's noon conference. M&M is such a great opportunity to break down an interesting case, learn from the expert specialists that Lish has invited, and analyze how the system we work in can be improved to better support us. These conferences are super interesting and are always some of our most popular. Hope to see you there!
CLINIC CORNER
PRIME Residents,
I wanted to spend a minute and tell you how appreciative the nurses in PRIME are regarding all of the assistant you give to your fellow residents and interns. I also wanted to congratulate Div Patel on his WOW award. If you see Div Patel in the hallways please congratulate him for helping out his fellow residents and nurses in PRIME.
Just a few reminders:
1. The patient appointments are set at the 15 and 45 minute time intervals to assist with nurses completing vitals, we are still working with the nurses to help facilitate your clinics starting on time both in the morning and in the afternoon 2. the PRIME resident committee met this month, I am working on a couple of things for next year including having fewer attendings precept in PRIME more often, having a float attending assist on half-days that need more precepting support (ie on half days that there are more interns in clinic) and ways of improving continuity both with you and your patients and you and your attendings.
3. Our RN care manager hire has been delayed to February, Denna Kellum has still graciously agreed to cover until then.
4. Our 3rd LPN will be starting mid December.
5. Our PRIME Clinic coordinator (Renee's position) will be starting January 11th.
Looking forward to another great year. Please stop by with any ideas or comments. My door is always open.
Sonal Patel, MD
PRIME Clinic Director
From the Chief Residents
Grand Rounds
Friday, November 20 - Holiday, No Grand Rounds
Noon Conference
| Date | Topic | Lecturer | Time | Vendor |
| 11/23/15 |
Recruitment-Lunch with Applicants |
N/A |
12:00 | Jason's Deli |
| 11/24/15 | Resident M&M | Lish Clark | 12:00 | Domino's |
| 11/25/15 |
Fundamentals of Asthma |
Tim Sciallia |
12:00 | China King |
| 11/26/15 |
No Conference - Thanksgiving - Meal after Turkey Bowl in MedRes |
TBD |
1:45 | Bullocks |
| 11/27/15 |
Holiday-no conference |
From the Residency Office
Hematology Division Newsletter
Please note that we will now include a copy of the Hematology Division Newsletter, published monthly, at the end of this post - check it out!
ACLT Applications Now Being Accepted!
Ambulatory Care Leadership Track (ACLT) Applications Due December 31, 2015:
Calling all interns who may be interested in either general internal medicine or a subspecialty where your focus will be ambulatory medicine, please consider applying to the ACLT. It’s a foundation for careers in general medicine leadership, primary care, academic ambulatory subspecialties, research, or education. Program highlights:
- Three blocks of ambulatory medicine throughout JAR and SAR years, with dedicated didactic time following four key themes:
- Clinical: Expanded clinical options in fields inside and outside of medicine: sports medicine, ENT, ophtho, dermatology, obesity medicine, as well as all medicine subspecialties. Maximum 4 weeks in any one medicine subspecialty (plus subspecialty continuity clinic), minimum 4 weeks general medicine ambulatory, over a total of 24 weeks.
- Teaching: Curricula in teaching and opportunities to teach in small group as a SAR
- Scholarship: Support for preparing and presenting scholarship, ambulatory journal club
- Advocacy and health policy: seminars given by faculty in government relations and health policy throughout the year, and an advocacy trip in the spring to both Washington DC and Raleigh, NC, alternating year.
Please fill out the application linked at the end of this post and submit to Armando Bedoya and Dani Zipkin before the end of the year!
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
Attention Medicine Residents!
We're excited to announce our next Department of Medicine book club event will be held on Wednesday, Dec. 2nd from 5:30 - 7:30 pm in the Searle Center Faculty Lounge. This time we'll be reading Abraham Verghese's book, Cutting for Stone, an award-winning novel about the orphaned twin children of a surgeon and his assistant in a war-torn Ethiopia, and how love, medicine, and family impact their decisions and lives.
As always, we have a limited number of copies available to those who would like to attend the event. If you are interested in attending, please email Laura Caputo at laura.caputo@duke.edu to reserve your copy while supplies last. We're excited to see you there!
NC ACP Call for Poster Abstracts
The North Carolina Chapter is excited to announce the Call for Poster Abstracts for the 2016 Chapter Scientific Session, taking place February 26-27 at the Grandover Resort in Greensboro, NC. As always, registration fees for the Scientific Session are waived for all Residents, Fellows and Students.
The poster competition is open only to Resident/Fellow and Medical Student members of the ACP North Carolina Chapter. First authors must be Medical Students or Resident/Fellow-level members of ACP or have made official application for membership in order to enter this competition. There will be no exceptions to this requirement. If you have not joined ACP (medical students join for free; Residents/Fellows should contact their residency program directors), please visit ACP Online to find out more and apply.
Each abstract will undergo careful review and will be ranked for scientific merit, originality, proper presentation, and clinical application. To view ACP's guidelines and tips on preparing an abstract, click here.
We will accept as many posters for display and judging as time and space permit.
The deadline for submitting entries is Friday, December 11, 2015, at midnight.
Abstracts can only be submitted electronically online. To electronically submit an abstract, go to http://www.acponline.org/about_acp/chapters/nc/abstract15.htm.
Why Submit?
Educational opportunity to showcase your work.
Best Clinical or Basic Research, Clinical Vignette, Quality Improvement, High Value Care, and Student Poster will each receive a cash award of $300 and reimbursement of travel expenses to the 2016 ACP Internal Medicine Meeting to present their poster.
Best Overall Poster will receive an additional cash award and reimbursement of travel expenses to the 2016 ACP Internal Medicine Meeting to present the winning poster.
For questions concerning this poster competition or the Scientific Session, please contact Nancy Lowe, CMP, Associate Director of the North Carolina Chapter, at nlowe@ncmedsoc.org.
Thank you,
Peter Lichstein, MD, FACP
ACP Governor, North Carolina Chapter
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).
Annual Call for New Ideas
The Journal of Graduate Medical Education is seeking brief articles on novel ideas in curricula, teaching, assessment, quality and safety, program evaluation, or other topics relevant to graduate medical education. Selected papers will be published in the July 2016 issue.
Criteria
New Ideas must describe an intervention that is novel.
The intervention must have been implemented at least once; longer implementation is preferable. While outcomes data may be preliminary; feasibility (effort, costs) and acceptability (to subjects) must be discussed.
Preliminary evidence should suggest the intervention is successful.
The intervention can be replicated in other specialties.
New Ideas manuscripts must
Follow required manuscript format
No more than 650 words
Organized into 3 parts:
Setting and Problem
Intervention (the “New Idea”)
Outcomes to Date
May include 1 figure or table
Descriptions should not include a literature review or references
Be submitted via the online editorial management system by 8:00 am CT, Monday, November 16, 2015.
Acceptance decisions will be communicated by January 31, 2016.
NOTES:
Due to the brevity of these submissions, manuscripts that are not accepted will not receive editor comments.
Manuscripts not following the required submission format and/or submission deadline will not be considered.
If you have additional questions, please contact the Journal office.
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
November 26 - Turkey Bowl
December 2 - Fellowship Match Day!
December 12 - DOM Holiday Party
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