From the Director
Hi everyone!
Two months left of the year! Let's keep up our great work. We are at 58% on the ACGME survey - fill it out if you haven't so I don't have to page you this week!
Got some shout outs for intern
Lindsay Boole for going above and beyond on geriatrics as well as to SARs
Jason Lappe and Tiffany Randolph on their SAR talks.
This week, I was at the program directors meeting in Atlanta with great Duke representation -
Saumil Chudgar, Jane Gagliardi, Sue Woods, Diana McNeill, Mitch Heflin, Larry Greenblatt, SAR
Andrea Archibald and
Eileen Maziarz! I learned a lot about how we will need to evaluate residents in the future and got some great ideas for new ways to teach.
Pubmed from the program goes to all mentioned above - we presented 4 seminars at the meeting. Nice job!!!
Have a great week and see you in
Cameron Indoor on Tuesday for our annual basketball game! And at
Humanism in Medicine night on Friday!
Aimee
What Did I Read This Week (by Jon Bae, MD )
[box] Qaseem, A., et al. “Appropriate use of Screening and Diagnostic Tests to Foster High-Value, Cost Conscious Care.”
Annals of Int Med. 2012; 156 (2): 147-49. [/box]
Why Did I Read This?
In my daily practice of unceasing effort to improve health care quality, I stumbled upon this short but sweet article in the Annals. The title alone hits a sweet spot by using words like “value” and “cost-conscious care” – How could I resist? I’m only human although, admittedly, one interested in QI. This issue of cost-conscious care will continue to be one that will get a lot of press in the foreseeable future. For example, raise your hand if, in the last year, you have seen a presentation where there was at least one slide showing the unstoppable march that is rising health care costs that will surely be the crucible of our children’s children’s children. Everyone should have their hand up (and I hope that you are reading this in a very public place). I would argue much of the research that we read really deals with what more things we can do to patients – tests, procedures, medications – rather than how to judiciously use these tools. What’s more, we have created systems of care that have made it easy to order these tests. Think about CPOE for example. What stopgap exists to prevent a provider from clicking a button to order an unnecessary basic metabolic panel? Or a CT scan? You don’t even need to be near the patient to do this! You could do this from another country if you wanted (seriously, don’t do this). It’s like iTunes for tests. This type of ease of ordering is efficient but is it cost conscious? Absolutely not. But it certainly is effective and it’s the reason I have spent thousands of dollars on music. Add to this a culture of defensive medicine where we order tests to make sure we “CYA” or because we don’t want to miss something. This is all with a workforce that has a substantial percentage of workers still in training and may not even know what that “something” could be. For all these reasons, the Institute of Medicine has made “Efficiency” one of their Six Aims. (I will assume that, of course, you know the Six Aims of Quality Improvement according to the IOM. But in case your memory needs jogging: Safe, Effective, Patient-Centered, Timely, Efficient, Equitable). And it’s a good reason for you to read this primer on the development of a list of tests that have low value for our patients.
What Did I Learn?
This article is principally a thought piece but it does describe the development of a workgroup within the American College of Physicians to identify common clinical situations in which certain screening or diagnostic tests are of little value. Value is an indirect measurement of quality with costs (including charges, but also risks to patient) incorporated (Value = Quality/Cost). Tests may be of high cost but of low value and vice versa. We as physicians need to take this into account and this workgroup provides a list of scenarios/tests they have identified that are of low value (See Table (there is only) 1). This list is a veritable hot bed of potential QI projects. The authors go on to list simple principles for the appropriate use of diagnostic tests, which I have found to be helpful (below).
- Diagnostic tests usually should not be performed if the results will not change management
- When the pretest probability of disease is low, the likelihood of a false-positive test result is higher than the likelihood of a true-positive result
- The true cost of a test includes the cost for the test itself but also the downstream costs incurred because the test was performed.
These recommendations are now finding their way into national initiatives as part of the “Choosing Wisely” Campaign (
www.choosingwisely.org). This is essentially a collection of lists from nine specialty societies of “Five Things Physicians and Patients Should Question” with the goal being to eliminate unnecessary tests/procedures and thereby improve care. Please check out the referenced New York Times article (below) for a little more discussion.
In conclusion, I found this article to encourage reflection on my personal practice. Moreover, it also gives some great kindling for idea formation about how we can use ideas like these to redesign our system to provide higher value, efficient, and cost-conscious care. (Maestro-care, anyone?)
Five Things Physicians and Patients Should Question Appropriate Use of Screening Tests
Until next time, loyal readers…
“Doctor Panels Recommend Fewer Lab Tests”, New York Times, April 4, 2012 (
http://www.nytimes.com/2012/04/04/health/doctor-panels-urge-fewer-routine-tests.html?_r=3&adxnnl=1&ref=health&adxnnlx=1333758805-HGqES1zRlR7713WVFu0jYg)
[hr]
From the Chief Residents
Grand Rounds
| Date |
Speaker |
Division |
Topic |
| 5/4/12 |
Deepak Bhatt |
Cardiology |
Greenfield Guest Speaker |
| 5/11/12 |
Joel Morgenlander |
Neurology |
Spinal Cord Disease for the Internist |
| 5/18/12 |
Dr. Powe |
MLK Visiting Professor |
George Phillips Memorial Visiting Professor |
Noon Conference
| Day |
Date |
Topic |
Lecturer |
Time |
Vendor |
| Monday |
4/30 |
Stead Society Conference |
Stead Leaders |
12:00 |
Meelos |
| Tuesday |
5/1 |
SAR TALK |
Cheryl Roberston/Kristen Dicks |
12:00 |
Domino's |
| Wednesday |
5/2 |
Patient Perspectives |
Tony Galanos |
12:00 |
Moe's |
| Thursday |
5/3 |
SAR TALK |
George Cheely/Miriam Naveed |
12:00 |
The Picnic Basket |
SAR Fellowship Advice Session #2:
Session #2 of the Residency Council's SAR driven fellowship advice sessions will be subspecialty specific advice and
opinions regarding the application process and various programs. These will be led by SARs who have matched in the respective field. There will be 4 sessions to reflect the 4 subspecialties that are expected to be most applied to by the current class. Dates and times are as listed below. If you have any questions, please don't hesitate to email
Leon.C@duke.edu.
All sessions will be in the medres library.
Cardiology: Thur, April 26th 5:30-6:30PM
Pulmonology: Wed, May 2nd 6:00-7:00PM
GI: Thur, May 3rd 5:30-6:30PM
[divider]
From the Residency Office
ACGME Survey Completion Rates by Stead Group
We are well on our way to completing the survey, but if you are wondering how the Stead Groups are doing - her are the results thus far:
Opportunities
TSMA (work done inside Duke for extra compensation)
The program fully supports Duke's policies regarding moonlighting as delineated in the Trainee Manual and Benefit Guide found on the GME website.
At no time may the hours allocated for TSMA activities negatively impact training or violate duty hour policies.
Residents who would like to be considered for Temporary Special Medical Activity (TSMA) on the Oncology or Student Health must meet the following:
1. Program level - either JAR or SAR
2. Successful completion of rotations on MICU and Gen Med
3. Be in good standing and without any active corrective action
4. Provide written support from their advisor supporting the trainee's request. The advisor may send an email to the attention of the Program Director, copy to the Program Coordinator, confirming their approval (to be completed prior to initiating the online TSMA form).
5. Initiate the online TSMA form found on MedHub.
On notification of approval by GME, the trainee may contact the service Director and request approval to participate in the TSMA service.
Please Note: TSMA is approved only for each academic year. If you are currently participating in TSMA and plan to continue after July 1, you will need to resubmit the required forms for approval.
Rwanda Human Resources for Health
The following webpage has been established to help answer questions and direct inquiries regarding opportunities for physicians and other health care professionals in Rwanda.
http://hrhconsortium.moh.gov.rw/
Open Oncology Fellow Position at Hopkins--July 2012
Hopkins is announcing that they have an unanticipated opening in our Oncology Fellowship beginning July 2012. For more information please contact:
Sanjay V. Desai, MD FACPDirector, Osler Medicine Training ProgramJohns Hopkins School of Medicine, Room 90291830 East Monument StreetBaltimore MD 21205410-955-7910 (phone)
Dates to Add to Your Calendars /Contact Information
May 1 - Annual Duke Residents vs Faculty Basketball Game (6:00 @ Cameron Indoor Stadium)May 4 - Humanism in MedicineMay 19 - Annual Resident Picnic (Dr Burton's Farm)
June 2 - Annual SAR Dinner
(invitations only)
June 13 –Resident Research Event, 5-7pm
Useful links
