From the Director
Thanks to the VA Jets for keeping it real with the Turkey Bowl video. Please send a much needed pep talk video to our Blue Devil football team! The first week of recruitment went AMAZINGLY well, thanks so much to everyone for being such great ambassadors of our program and showing off the #dukefamily to the applicants. Your efforts are much appreciated!
Kudos and thanks this week to our “My Take” residents Annie Reihman, Div Patel, Kevin Friede, Jason Zhu, Zach Il’Giovine, Elieth Martinez and Jenny Van Kirk, and also to our tour guides Julia Cupp, Myles Nickolich, Eric Pollack, Nick Turner, Adva Eisenberg, Jess Tucker, Peter Hu, Ani Kumar, Jared Lowe and Kristen Glisinski. Also kudos to Coco Fraiche for an amazing chair’s conference, and to Sarah Goldstein for presenting a fantastic case at the first recruitment report. Other kudos to Ashley Spann from her 9100 SAR Cece Zhang for doing a spectacular job on nights and to Manisha Bhattacharya from Jan Dillard and the DOC team for some above and beyond work at the DOC.
Please don’t forget to vote for the We Care Wednesday charities of choice (see email from your residency council co-chair Dinushika) and also to attend the first Town Hall of the year on Wednesday at noon, run by the residency council.
Our other charitable events for the fall/winter are underway as well, with the thanksgiving food drive and the holiday toy drive. An easy way to donate (I.e. PAYPAL!) will be coming your way soon.
This week’s pubmed from the program goes to Duke residency grad and current cardiology fellow Alex Fanaroff, our current Duke Chief Jenn Rymer, and SAR Sarah Goldstein for their article in JAMA! Born from Alex’s SAR talk, they are now “Rational Clinical Exam” authors. Congratulations Alex and Jenn.
Does This Patient With Chest Pain Have Acute Coronary Syndrome? The Rational Clinical Examination Systematic Review
JAMA. 2015;314(18):1955-1965
Alexander C. Fanaroff, MD; Jennifer A. Rymer, MD, MBA; Sarah A. Goldstein, MD; David L. Simel, MD, MHS; L. Kristin Newby, MD, MHS
Have a great week
Aimee
What did I read this week?
Submitted by: Dr. Alicia Clark
Ashish K. Jha, MD, MPH “Seeking Rational Approaches to Fixing Hospital Readmissions” JAMA. 2015;314(16):1681-1682
You are likely familiar with the Medicare Hospital Readmission Reduction Program (HRRP) that initially targeted discharges with a primary diagnosis of CHF, MI and PNA. You may also know that COPD Exacerbations, Total Hip and Total Knee Replacements were added in FY 2015. The plan is to add more diagnoses to this program over the next 3 years. This program was created because 1 in 5 Medicare patients were being readmitted within 30 days of discharge. In theory, the program was supposed to improve the quality of care transitions by incentivizing hospitals to decrease the number of “preventable” readmissions. In practice, the program penalizes hospitals by withholding a percentage of their CMS payments if they have “adjusted” readmission rates worse than the national average. This program and the specifics of the “adjustment” for patient factors has prompted a great deal of debate but has also focused attention on readmissions as a quality outcome.
I may have already evoked your visceral response….but I chose this paper because Dr. Jha briefly discusses some of the strengths and weaknesses of the program then proposes a path to better quality measures through bundled payments. He quotes the national downtrend in readmission rates from 2008 to 2013 but then admits that it remains unclear if this represents a true improvement in quality or just a “gaming” of the numbers. Specifically, he describes the coding of readmissions as “observation” status which excludes them from the totals. This concept of “gaming” a quality measure a common phenomenon in the world of QI – and an important factor to consider when you target an improvement effort towards a particular outcome measure. You have to ask yourself, will a change in that specific outcome measure actually represent improvement in the quality of care? Or have you simply incentivized a work around?
He describes readmission rates as a “utilization measure” rather than a “quality measure” and that the lower utilization rates do not necessarily mean higher value care. Value and quality of care are much more complex than utilization alone. Finally, he proposes bundled payments as a means to engage providers across the continuum of care. Post discharge monitoring would occur for different lengths of time based on the natural history of the condition itself and the measures would incorporate patient centered quality factors like functional status and symptoms. Rainbows and unicorns, right? Well, we have to start somewhere and Dr. Bae would tell you that the HRRP program has brought incredible national attention to readmissions and has focused efforts on improving transitions of care. The measure itself is admittedly not perfect but the movement is has prompted feels like the right direction.
Now is any of this really relevant to you? Well, readmissions are actually part of the GME incentive program and we now have department specific data. So even you have skin in the game. Anyone interested in tackling readmissions with a QI project – we are happy to hear your ideas!
QI CORNER
Join us for the next meeting of the Patient Safety and Quality Committee this Thursday 11/12 at 5:30pm in Duke North 8262. We are very excited to be tackling PAGING CULTURE!
The good...A brief text page with patient, question, urgency, and direct call-back number.
The bad...681-xx41.
The ugly...Should you disregard that wrong-number numeric page? Nope, your patient's coding.
We are so excited to be doing a QI project that will touch each and every one of our lives every day (again...and again...and again...). We are also psyched that this project has Dept of Medicine level backing and support, which means we have LOTS of flexibility in what we can do to make change. Join us Thursday as we hash out details!
PSQC
Thursday 11/12 at 5:30pm
DN 8262
Food provided!
CLINIC CORNER
Hi DOC !
We are very fortunate to have wonderful staff…it takes a village to take care of our complex patients…see below the many ways they can help our patients…
From our fantastic Pharm D, Holly --
“Am I just a pharmacist that manages pain contracts and takes care of anticoagulation?”
Holly is a Clinical Pharmacist Practitioner (CPP) , a pharmacist with specialized training who can independently provide drug therapy management and implement pre-determined drug therapy through a collaborative practice agreement under the supervision of a licensed physician (in this case, Dr. Greenblatt, Dr. Bowlby, Dr. Zipkin, and Dr. Cunningham). Holly is also a Certified Diabetes Educator (CDE).
While I do manage INRs for patients taking warfarin, I also manage routine compliance/laboratory monitoring for patients taking Target Specific Oral Anticoagulants (TSOACs). I can also assist in managing diabetes, hypertension, and smoking cessation as well as complex medication reconciliation and medication compliance reinforcement. In addition, I ensure that patients who have active pain management agreements (aka contracts) at the DOC are adhering to our clinics procedures by evaluating the controlled substance database, obtaining urine drug screens and assessing their pain/functioning/adverse effects/potential for abuse when I meet with them monthly. I also help coordinate and lead the group diabetes visit as well as the group hypertension visit at the DOC. I also help oversee our transitions of care service and contact patients after hospital discharge to ensure that they have implemented any medication changes. To refer patients to me, simply include “one on one (1:1) visit with Holly or pharmacy in x-x days/weeks for ***” in the follow up section of your encounter.
And our fantastic MSW Jan---
More than bus passes and free meds?
Yes!!! Clinical social work services at the DOC are much, much more! Jan is a Licensed Clinical Social Worker, meaning she has an MSW, has obtained 3000 hours of post graduate paid supervised employment in a clinical setting in no less than two years nor more than six years, has received a minimum of 100 hours of clinical supervision, and has passed the ASWB Clinical level exam. She can provide psychotherapy to patients for a variety of issues, including anxiety, depression, trauma, adjustment to illness and grief. She completes psychosocial assessments as needed, looking in depth at the “whole person,” identifying strengths and barriers. She coordinates the DOC PAIN Group, filling in to lead occasionally, and co-leads the DOC DM Group. She does a monthly home visit to a patient with a resident and the chief. She can assist with legal issues, such as guardianship. And she can be the point person for safety issues, including SI/HI/DV/abuse/neglect. She will even provide a supportive listening ear if you are having a tough time. So don’t forget to peek behind the bus passes and free meds to see what Clinical Social Work can do for you (and your patients)!
Refer to Jan thru Amb Ref, .doc swreferral…and/or stop by and talk with Jan about the patient..
Lynn, and our great staff
From the Chief Residents
Grand Rounds
Friday, November 13 - Alumni/Stead Speaker - Dr. Mark McClellan
Noon Conference
| Date | Topic | Lecturer | Time | Vendor |
| 11/9/15 |
Recruitment-Lunch with Applicants |
N/A |
12:00 | Bull City |
| 11/10/15 | MPeds Recruitment-Lunch with Applicants | N/A | Saladelia | |
| 11/11/15 |
Residency Council Townhall |
Jessie Tucker and Dinushika Mohottige |
12:00 | Cosmic |
| 11/12/15 |
Inpatient Geriatric Medicine: Management and Pearls |
Heather Whitson |
12:00 | Chick Fil A |
| 11/13/15 |
Recruitment-Lunch with Applicants |
N/A | 12:00 | Panera |
From the Residency Office
Memorial Service for Dr. Amit Bhaskar
The memorial service for our beloved Dr. Amit Bhaskar is on Saturday, November 14, 2015, at 2:00 p.m. It will be held on the 6th floor of The Mary Duke Biddle Trent Semans Center, Duke University Medical Center. Public parking is available at the Duke South Clinics parking garage. Please note that there is a home football game that day, start time TBD, so please be prepared for additional traffic. In an effort to ensure that we have adequate space planned for the service, we respectfully request that you indicate, using the link below, if you will be able to attend.
https://duke.qualtrics.com/SE/?SID=SV_a36umcRzOkMf8SF
To honor Amit’s memory, we will be sponsoring a Stuffed Bear Toy Drive, with all donations going to the Durham Rescue Mission. As of today, through next Friday, 11/13/15, there will be a Toys for Tots donation located in the ACR office, Room 8241A on the 8th floor of Duke North where we will collect new stuffed toy bears. If you would like to make a monetary donation, you may do so using the PayPal link* https://www.paypal.me/amitmemorial
In addition, if anyone would like to send a donation, please use the following address for delivery:
DUMC
Medical Education Office
2301 Erwin Rd.,8th Flr.
Room 8254
Durham, NC 27710
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
BLS Blitz - November 9-13, 2015
Just a reminder that the bi-annual BLS Blitz is coming up in November. The flier posted at the end of this blog has the dates. REMEMBER - Duke only holds BLS classes during the November and March blitz each yer, so if your BLS is expiring before March, PLEASE sign up for one of the dates in November!!
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