The Internal Medicine Residency newsletter is posted each week to share important news, announcements and updates about the residency program. Please contact Randy Heffelfinger or Emily Strollo with corrections, contributions and suggestions.
It has been another busy week in the residency program! The hospital and clinics are busy, and we are continuing with great cases at resident report (kudos to Sahar Koubar for a flawless presentation on enterococcal endocarditis to Dr. Corey!), outstanding noon conferences and we capped off the week with a tour de force Chair’s Conference presentation by Johanna Chan (PGY-3). Most impressive was Johanna’s integration of disease pathogenesis and drug development into her discussion of Gastrointestinal Stromal Tumors and treatment with imatinib (including a discussion of the Science paper that described the KIT mutation responsible for most GISTs). Way to set the bar high, Johanna! I have also been pleased to get a series of pages from attendings who are extremely impressed with the outstanding work of our residents here at Duke, at the VA and DRH, as well as in the clinics.
QUALITY IMPROVEMENT IN ACTION…..In preparation for our annual report to the RRC, we have also reviewed the year end data from our ambulatory clinics. One measure that we pay close attention to is our “continuity index”, a measure of how often patients are able to see their primary provider. Ensuring continuity is an active process, requiring the residents to look at the schedule and notify the scheduling team of an appropriate window of time for the patient to return. Data for >1000 visits to the DOC is shown below. Pro-active residents are able to get THEIR patients back to see them more regularly, or to see residents who are in their “group practice” (practice partnership). Congratulations to PRACTICE PARTNERSHIPS 14 and 6 for having the best continuity at the DOC for academic year 2010-11.
Practice partnership 14 (Ivan Harnden, Andrea Archibald, Steve Sumner and Sahar Naderi): Over 129 tracked visits, 50% with primary provider, 31% with a practice partner and 19% with another resident physician.
Practice Partnership 6 (Kathleen Kiernan, Dan Fox, Matt Rein and Sarah Sandberg): Over 111 tracked visits, 59% were with the primary provider, 15% with a practice partner and 26% with another resident physician.
We will use the ideas developed by these partnerships to help those groups with less robust continuity numbers.
We are looking forward to physical exam week, as well as a new group of Stead Attendings on the wards (Heather Whitson and Claude Piantadosi). Thanks again to Tom Owens and Steve Crowley for joining us for the past two weeks.
Hope to see everyone on Friday at our house for “Extreme Makeover: Home Improvement Liver Rounds"
Aimee
Darrell Gray, 2010 Internal Medicine graduate, completed his elective rotation at a small mission hospital in Kenya. He is pictured at left teaching ward rounds. For many residents the Global Health Rotation provides an opportunity to get back in touch with the basic principles of medicine and patient care as well as appreciate the importance of cultural awareness. “It’s an amazing feeling to know that my daily work, prayers, and time are making a difference in people’s lives and to be able to see the fruits of my labor. The sense of fulfillment that I’m leaving with cannot be compared to any other work experience I’ve had.”
Read more about day to day life serving patients at Tenwek Hospital in Darrell’s blog.
From the Director
It has been another busy week in the residency program! The hospital and clinics are busy, and we are continuing with great cases at resident report (kudos to Sahar Koubar for a flawless presentation on enterococcal endocarditis to Dr. Corey!), outstanding noon conferences and we capped off the week with a tour de force Chair’s Conference presentation by Johanna Chan (PGY-3). Most impressive was Johanna’s integration of disease pathogenesis and drug development into her discussion of Gastrointestinal Stromal Tumors and treatment with imatinib (including a discussion of the Science paper that described the KIT mutation responsible for most GISTs). Way to set the bar high, Johanna! I have also been pleased to get a series of pages from attendings who are extremely impressed with the outstanding work of our residents here at Duke, at the VA and DRH, as well as in the clinics.
QUALITY IMPROVEMENT IN ACTION…..In preparation for our annual report to the RRC, we have also reviewed the year end data from our ambulatory clinics. One measure that we pay close attention to is our “continuity index”, a measure of how often patients are able to see their primary provider. Ensuring continuity is an active process, requiring the residents to look at the schedule and notify the scheduling team of an appropriate window of time for the patient to return. Data for >1000 visits to the DOC is shown below. Pro-active residents are able to get THEIR patients back to see them more regularly, or to see residents who are in their “group practice” (practice partnership). Congratulations to PRACTICE PARTNERSHIPS 14 and 6 for having the best continuity at the DOC for academic year 2010-11.
Practice partnership 14 (Ivan Harnden, Andrea Archibald, Steve Sumner and Sahar Naderi): Over 129 tracked visits, 50% with primary provider, 31% with a practice partner and 19% with another resident physician.
Practice Partnership 6 (Kathleen Kiernan, Dan Fox, Matt Rein and Sarah Sandberg): Over 111 tracked visits, 59% were with the primary provider, 15% with a practice partner and 26% with another resident physician.
We will use the ideas developed by these partnerships to help those groups with less robust continuity numbers.
| Practice Partnership - DOC - FY 11 Data | ||||||||||
|
Comparative % by PP |
|
|||||||||
|
PP Team |
Sum of My Pt |
Sum of PP Pt |
Sum of Neither |
Total |
PP Team |
My Pt |
PP Pt |
Neither |
My Pt + PP Pt |
|
|
1 |
39 |
27 |
17 |
83 |
1 |
47% |
33% |
20% |
80% |
|
|
2 |
4 |
36 |
11 |
51 |
2 |
8% |
71% |
22% |
78% |
|
|
3 |
21 |
28 |
50 |
99 |
3 |
21% |
28% |
51% |
49% |
|
|
4 |
36 |
26 |
14 |
76 |
4 |
47% |
34% |
18% |
82% |
|
|
5 |
13 |
15 |
11 |
39 |
5 |
33% |
38% |
28% |
72% |
|
|
6 |
65 |
17 |
29 |
111 |
6 |
59% |
15% |
26% |
74% |
|
|
7 |
12 |
1 |
11 |
24 |
7 |
50% |
4% |
46% |
54% |
|
|
8 |
5 |
9 |
7 |
21 |
8 |
24% |
43% |
33% |
67% |
|
|
9 |
52 |
35 |
39 |
126 |
9 |
41% |
28% |
31% |
69% |
|
|
10 |
7 |
5 |
8 |
20 |
10 |
35% |
25% |
40% |
60% |
|
|
11 |
6 |
13 |
16 |
35 |
11 |
17% |
37% |
46% |
54% |
|
|
12 |
23 |
13 |
8 |
44 |
12 |
52% |
30% |
18% |
82% |
|
|
14 |
64 |
40 |
25 |
129 |
14 |
50% |
31% |
19% |
81% |
|
|
15 |
28 |
15 |
9 |
52 |
15 |
54% |
29% |
17% |
83% |
|
|
16 |
7 |
1 |
2 |
10 |
16 |
70% |
10% |
20% |
80% |
|
|
17 |
11 |
12 |
16 |
39 |
17 |
28% |
31% |
41% |
59% |
|
|
18 |
8 |
13 |
5 |
26 |
18 |
31% |
50% |
19% |
81% |
|
|
19 |
8 |
2 |
7 |
17 |
19 |
47% |
12% |
41% |
59% |
|
|
20 |
1 |
4 |
2 |
7 |
20 |
14% |
57% |
29% |
71% |
|
|
Total |
410 |
312 |
287 |
1,009 |
What I Read This Week “WIRTW” (submitted by Daniella Zipkin, August 5th, 2011)
Like Larry, I stay current by signing up for the free email alerts through BMJ Evidence Updates. I highly recommend signing up as a way to scan recent high impact papers. I caution, though, that the commentary for each abstract is unfiltered and of variable quality. Some respondents are well versed in EBM, others aren’t – so you should read for yourself and draw your own conclusions. Google BMJ Evidence Updates to sign up in any discipline. My favorite recent highlights are: [box] 1. Outpatient vs. inpatient treatment for patients with acute PE. [Aujesky et al., Lancet 2011; 378:41-48]. This was a randomized, non-inferiority trial of sending patients home within 24 hours of PE Dx vs. stay in the hospital for 5 days. Subjects had a low risk of death (PE severity index class I or II). Primary outcome was recurrent VTE in 90 days.[/box] a. Study had 80% power (i.e. 20% of being wrong if no difference found) using an absolute difference between groups of up to 4% as the threshold for non-inferiority. When a study is trying to find no difference, power calculation is critical. b. 344 patients were randomized (they needed at least 320) c. RESULTS: 1 outpatient had recurrent VTE, 3 had major bleeds (no VTEs or bleeds for inpatients.) Absolute risk increase in VTE with outpatient Rx, 0.6%. NON-INFERIORITY WAS MET. Absolute risk increase in major bleed with outpatient Rx, 1.8%. d. Many of our lowest risk acute PE patients can likely safely be sent home to f/u with primary care. [box] 2. Reduced Lung Cancer Mortality with Low-Dose CT Screening. [NEJM 2011; 365:395-409]. Now in print, this landmark trial randomized 53,454 people at high risk of lung cancer to annual chest CT vs. PA chest x-ray for three years. Primary outcome was death from lung cancer. Outcome assessors were blind to group assignment. Patients were followed for six years.[/box] a. Methodologic concerns – (1) Comparing to CXR instead of no screening may have diminished the difference between groups. (2) Is six years enough time to adequately assess lung cancer death? Both of these concerns would make groups look more similar. b. PRIMARY RESULT: Death from lung cancer: 247 per 100,000 person yrs in CT; 309 per 100,000 person years in CXR. The authors report a number-needed-to-screen (NNS) of 320. (Numbers to calculate NNS are not in the text, but a figure with actual event rates in both groups led me to an absolute risk reduction of roughly 0.3%). c. 96% of positives in CT group, 94% of positives in CXR group were FALSE POSITIVES. d. This is a small but clinically important absolute benefit. We should wait for cost-effectiveness analysis data before implementing this, and we need more data on harms, but I suspect that lung cancer screening will become the standard of care. [box] 3. Stretching to prevent or reduce muscle soreness after exercise [Cochrane review; 2011, issue 7]. For all you gym rats out there, a Cochrane meta-analysis on the critical topic of stretching has been updated. Driven by one large study of 2377 participants, results show that stretching before, after, or before and after exercise reduces soreness at one day and one week by a tiny, clinically irrelevant benefit (1 to 4 points out of 100 scale.) So if folks are bugging you about not stretching, slap them with this! [/box]
Global Health Residency:
Developing the next generation of globally educated, socially responsible healthcare professionals dedicated to improving the health of disadvantaged populations.
The Department of Medicine has a long history of supporting Global Health Education in residency training. In fact, many residents credit global health opportunities as an important reason why they chose to train at Duke. This month, the Hubert-Yeargan Center is excited to announce open recruitment for two such programs, our Global Health Elective Rotations and the Global Health Residency Program. Check in with our special Weekly Update Global Health section for news from residents in the field, event and application announcements. For more information about Global Health education and training, visit www.dukeglobalhealth.org. Now Accepting Applications for Global Health Elective Rotations The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2012 and March 2013. Application is open to residents from Departments of Medicine: Internal Medicine (PGY 2); Med-Peds (PGY 3) and Med-Psych (PGY 4). Access the application form and FAQ at http://dukeglobalhealth.org/education-and-training/global-health-elective-rotation. News from the Field
Darrell Gray, 2010 Internal Medicine graduate, completed his elective rotation at a small mission hospital in Kenya. He is pictured at left teaching ward rounds. For many residents the Global Health Rotation provides an opportunity to get back in touch with the basic principles of medicine and patient care as well as appreciate the importance of cultural awareness. “It’s an amazing feeling to know that my daily work, prayers, and time are making a difference in people’s lives and to be able to see the fruits of my labor. The sense of fulfillment that I’m leaving with cannot be compared to any other work experience I’ve had.”
Read more about day to day life serving patients at Tenwek Hospital in Darrell’s blog.
Mark Your Calendar: Global Health Noon Conference
Joint Session with Medicine and Pediatrics Thursday, August 18 12:00 to 1:00PM in Duke North 2002 The HYC, in conjunction with the departments of Medicine and Pediatrics, will hold a joint information session open to all Medicine, Pediatrics, Med/Peds and Med/Psych residents during noon conference. Join us to learn more about Global Health Opportunities available during residency training including global health sites, the application process and personal experiences from a panel of past participants. [divider]From the Chief Residents
Grand Rounds - Friday, August 12, 2011
Date of Lecture: |
August 12, 2011 |
Learning Objectives: |
| Title of Lecture: | "Global Health at Duke 2011" | Following this activity series, learners should be able to:1) To define global health and differentiate it as a field of study.2) To understand the evolving global burden of disease.3) To become aware of Duke's activities in global health.4) To identify opportunities to become involved in global health. |
| Speaker(s): | John A. Bartlett, MD |
Noon Conference
Noon conference this week is devoted to an in-depth review of physical examinations, including the topics listed below. Please make every effort to arrive BEFORE 12:00 to minimize any potential interuptions. Conference wil start promptly at noon.| Day | Date | Topic | Lecturer |
| Monday | 8/8 | Physical Exam Week/ Head and Neck, inpt MICU | Arcasoy/Simel/Govert |
| Tuesday | 8/9 | Physical Exam Week/Cardiovascular | Arcasoy/Ward |
| Wednesday | 8/10 | Physical Exam Week/Neuro/Abdominal | Arcasoy/Morganlander/Peyser |
| Thursday | 8/11 | Physical Exam Week/MSK/Thoracic | Arcasoy/Rice/Zaas |
| Friday | 8/12 | Physical Exam Week/Inpatient/lymphatics/new patient | Arcasoy/Zaas/Rubin |
Procedural Tutorials
Reminder that we are holding Procedure Tutorial Sessions on 8/8 and 8/15 for all of the interns in the Med Res Library. Your attendance is strongly encouraged. We've created the schedule (Intern Procedure Training schedule) such that you should be able to make it and we will ask your residents to assist you so as to make your attendance possible. The sessions will be held from 430P-600P in the MedRes library on 8/8 and 8/15. 4:30-5:00PM Paracentesis with Dr Choi/Jazwinski 5:00-5:30PM LPs with Dr Morgenlander 5:30-6:00PM Thoracentesis with Dr Momen Wahidi * We will have Safe-T-centesis kits available for you as well so that you can become familiar with these! **** Please make every effort to attend (Med/Peds interns on Peds rotations and Prelim interns are welcome but we understand that you may have other service obligations.) If you are having difficulty with the date you are scheduled, please let Eileen know.In-Training Exam
All Categorical, Med Peds and Med Psych Interns and residents should have received the ITE schedule (ITE final 8.1.2011) this week by email. We are holding the exam six days this year (Oct 7,8,14,15, 17 and 18) and have made the following schedule to allow coverage for essential services at all times. Please understand that coordinating this schedule such that we still have coverage on the necessary services is no small task and there are limited options for changing the schedule as is. Please review and if you identify a conflict, let the chiefs know ASAP (conflicts/requests will be reviewed on a case by case basis. The exam is approximately 8hrs long and begins at 7am. More details to follow closer to the dates of the exam. Please review and if there are conflicts, notify me, Tony or Juliessa no later than 8/15 as we need to register everyone for the exam and the exam schedule will be posted to Med Hub at that time.She's a Doctor, and a Writer! Congrats, Leah!!!!
Congratulations to Leah Rosenberg (JAR) whose letter to the New Yorker was published last week! Leah wrote a very poignant response to Aleksandar Hemon's piece called "The Aquarium," a personal narrative of a father's experience at the end of his daughter's life. For Leah's response, and a link to the original piece: http://www.newyorker.com/magazine/letters/2011/07/25/110725mama_mail5General Medicine Grand Rounds on Tuesday, August 9, 2011
Common Compliance Quandaries: How to follow the rules and stay out of trouble! Presented by: Colleen Shannon, JD, DUHS Chief Compliance and Privacy Officer 7:30am to 8:15am; 3024 Pickett Road, 2nd floor; Durham, NC 27705 Learning Objective:- Review common compliance issues as they face teaching clinicians within the Dept of Medicine
- Learn the rules of what learners can do to help write notes (answer=not much)
- Review common billing and documentation guidelines for attending physicians
- Become aware of the common papers that are required of young individuals who shadow teachers in the clinic.
Upcoming Dates
- August 12 - Liver Rounds at the Zaas' home
Motivational Interviewing (by Larry Greenblatt)
Interested in improving your Motivational Interviewing skills? Come out on 8/9 to the MI Club for a chance to practice under the supervision of 2 true experts. We'll meet 4:30-6:00 (ok to be late) in the nursing school, room 1011. Hope to see you there! [divider]From the Residency Office
Secure Systems – Your Responsibilities
Key points to remember to remain in compliance and to protect confidential information.- Help us stay in compliance for encryption of every Duke-owned laptop. Our IT staff can assist with configuring your new purchases.
- Mobile devices, flash drives, external hard drives need to be kept secure, too. Please ask our IT staff if you have questions.
- E-mail with sensitive information really requires use of secure messaging. Both Lotus Notes and Outlook have this option.
- Remember to use the HIPAA privacy statement for fax management (the text is in the attached memo)
- Data storage off-site, for example, "DropBox" is not secure.
- Options for Survey tools used in research: Duke endorses RedCap or survey development via Steve Wilfong in DHTS
Employee Health and Wellness
This is frequently the time of year - July/August - when it is time to update compliance modules and complete required Employee Health and Wellness tests. If compliance is not kept up to date you (AND your Chief Residents) will be notified that you will be required to be removed from service. Please review the status of your current compliance on the OESO website using the following link. http://www.safety.duke.edu/. You can also contact EOHW directly should you have questions (919) 668-3201. The list of times when Health and Wellness services are available at Duke North during the month of August are attached for reference.Resp Fit Testing-T-Dap-TB Skin Testing Flyer August 2011Useful links
- Main Internal Medicine Residency website
- Main Curriculum website
- Ambulatory curriculum wiki
- Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response.
- Department of Medicine website