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.
From the Director
The first annual Physical Exam Week was a success! Huge thanks to Murat Arcasoy, the chiefs and ACR Tian Zhang for organizing these unique and valuable noon conferences.
To start the week, David Simel taught tips and tricks for the head and neck exam, including reminding us what the red filter does on an opthalmoscope (if you don’t know the answer, check out this website from ophthalmologist Timothy Bennett in Hershey PA (
http://www.opsweb.org/?Monochromatic). Dr. Simel also astutely noted that Altoids are a necessary addition to a good eye exam, and showed us the paper he wrote as AN INTERN describing afferent pupillary defects (the Marcus Gunn pupil). Dr. Joe Govert then detailed the daily ICU physical exam, with observation as a key element, and reminded us that the exam is a tactile reminder of why we are physicians. We enjoyed an hour with Dr. Cary Ward teaching the cardiovascular exam, starting with “Name that Tune” (did you know that Cheney’s LVAD is in an Eminem song?), a few facts about shark hearts (one ventricle!) and that practice is the only way to get good at recognizing heart sounds. All this was accomplished using YouTube, an iPod and Scott Tolan in a fat suit.
On Wednesday, Dr. Joel Morgenlander simplified the neuro exam for us into “localization, onset, pathophyisiology and ‘spells’”, and taught us what nerve root controls flipping the bird (C7) and kicking someones … (L4). Dr. Bruce Peyser gave a most enthusiastic review of the abdominal exam, including using Mandy George (JAR) to demonstrate a fluid wave on Mike Durheim, acting as our patient with cirrhosis. Dr. David Zaas, with the help of Leon Cannizzaro (SAR) and Eileen Maziarz, showed us how to use the pulmonary exam to diagnose shortness of breath, and that if you listen only to someone’s back, you are just examining the lower lobes of the lung. Dr. Russ Rice walked us through the musculoskeletal exam (with additional thanks again to Leon “The Owl” Cannizzaro), reminding us to keep one hand firmly placed on the top of the shoulder to isolate the joint to test mobility. We capped off the week on Friday with my review of the inpatient exam, Dr. Sharon Rubin’s review of the new patient in clinic exam (thanks John Stanifer for serving as the patient) and Murat Arcasoy’s review of the lymphatic exam. While posing as the patient, John Stanifer taught us how Osler would check out his daughter’s suitors with the double handshake/epitrochlear adenopathy screening. Now, test your eyes by clicking on the following link to view how last week's events have changed this famous picture
Master Clinician - 2011 (thanks Jon Bae!).
Keep up your exam skills on the wards and in the clinic. Special thanks to Vaishali Patel for taking a group of students and sub-I’s to the bedside to examine a patient with goiter. Other notables from this week were an outstanding intern report by Lindsay Boole on Conn’s syndrome, a “case to be used later” from Anne Mathews at VA morning report, and Talal Dahhan diagnosing dermatomyositis with jo-negative antisynthetase syndrome after Dan Fox said one or two sentences of his PM report case. Nice to see the SARs so engaged in Duke PM report! Thanks to our Stead attendings Heather Whitson and Claude Piantadosi. Coming up soon will be James Tulsky and Mike Felker.
And finally, thanks to everyone who was able to come to my home for the first Liver Rounds of the year. The rains held off, the deck was almost complete, and it seems that good times were had by all. Looking forward to having you back soon.
Aimee
What I Read This Week “WIRTW” (submitted by Saumil Chudgar)
[box]Lindenauer PK, et al. “Association of Corticosteroid Dose
and Route of Administration With Risk
of Treatment Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease” JAMA 2010; 303:2359[/box]
Why did I read this?
We were recently doing bedside rounds on a new admission – a patient with COPD with acute exacerbation. He looked well, and we discussed that he could likely go home soon with a prednisone taper. Our medical student asked us why do some patients get IV methylprednisolone 125 mg q6h while others get 60 mg oral prednisone? I tried to find some data to support our practice patterns.
What I learned from reading this?
This is an observational, cohort study with nearly 80,000 patients with COPD exacerbation admitted to a non-ICU bed. Low-dose was defined as 20-80 mg prednisone daily. High-dose was defined as 120-800 mg of prednisone-equivalents daily. 92% of patients received high-dose steroids. Primary outcome was composite treatment failure (defined as need for mechanical ventilation, inpatient mortality, or readmission for COOD in 30 days) while secondary outcomes were length of stay and total hospital costs.
Results after propensity matching and covariate-adjustment:
Treatment failure OR = 0.93 (95%CI 0.84-1.02)
Length of stay OR = 0.92 (95%CI 0.91-0.94)
Total hospital cost OR = 0.93 (95%CI 0.91-0.94)
The authors conclude that low-dose steroids are not less effective than high dose in treatment of COPD exacerbation and may reduce length of stay and total hospital costs.
Anything controversial?
The authors discuss that this is an observational study and physician decision on IV vs oral therapy may have been influenced by perceived severity of illness. They suggest a clinical trial comparing the two. I did find the results interesting as it does lend some support to using lower doses of steroids given the potential complications with high dose IV steroids.
Global Health Residency:
Developing the next generation of globally educated, socially responsible healthcare professionals dedicated to improving the health of disadvantaged populations.
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
Priya Gopwani, 2011 Med-Peds graduate, completed her elective rotation at a public hospital in Bangkok, Thailand. She is pictured here with some of the people she worked with at the hospital. “I was not sure what to expect given that I do not speak Thai. The people on the infectious disease team were wonderful. They always made sure that someone was there to translate for me, and even helped me learn a bit of Thai myself! I learned a great deal about infectious diseases, HIV and tropical medicine from them. I really couldn’t have asked for a better team to work with.”
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.
Judge Edwin Cameron: “Stigma and AIDS – The personal and the political”
Please find attached the poster announcing Judge Edwin Cameron’s talk “Stigma and AIDS – The personal and the political” on September 7 at 4pm in the John Hope Franklin Center.
Edwin Cameron Lores Poster - Annoucement
Judge Cameron is sure to give an inspiring talk – as a South African Constitutional Court judge, an activist, and an individual living with HIV. Anyone who attended the International AIDS Conference in Durban in 2000 will remember his keynote address, in which he provided a searing indictment of global neglect for HIV and made a passionate appeal for access to antiretroviral therapy.
Documentary Program – Open to Medical Residents
This year Duke will select up to 15 Medical Residents to pair with documentarians at the Center for Documentary Studies at Duke to produce works exploring medical stories. Projects can take the form of a photography exhibit, website, documentary writing, audio or multimedia.
If interested, please review the following video:
http://vimeo.com/27464627. Applications are due August 25, 2011, and Residents will be notified by September 1.
[divider]
From the Chief Residents
Grand Rounds - Friday, August 19, 2011
| Date |
Speaker |
Topic |
| 8/19/11 |
Michael Valdez, Bruce Capehart |
Returning from battle: OIF/OEF Issues in Primary Care |
Noon Conference
| Day |
Date |
Topic |
Lecturer |
Time |
Vendor |
| Monday |
8/15 |
COPD management |
Peter Kussin |
12:00 |
Simply Delicious |
| Tuesday |
8/16 |
Town Hall Meeting |
The Chiefs! |
12:00 |
Dominos |
| Wednesday |
8/17 |
Transfusion Medicine |
Nick Bandarenko |
12:00 |
Saladelia |
| Thursday |
8/18 |
Global Health |
Tara Pemble |
12:00 |
Bullock's BBQ |
Procedural Tutorials
Thanks to everyone who participated in the 8/8 tutorial. Reminder that we are holding the second Procedure Tutorial Sessions on 8/15 for any of the interns who did not make it to the first session. This will be held in the Med Res Library. Your attendance is strongly encouraged. If you were scheduled for 8/8 and couldn't make it, that's okay! You are more than welcome at this week's session. We have asked your residents to assist you and to help with pager coverage so as to make your attendance possible.
The second session will be held from 430P-600P in the MedRes library on 8/15
430-500PM Paracentesis with Dr Jazwinski
500-530PM LPs with Dr Morgenlander
530-600pm Thoracentesis with Dr Momen Wahidi
* We will have Safe-T-centesis and lumbar puncture kits available for you as well so that you can become familiar with these!
In-Training Exam
All Categorical, Med Peds and Med Psych Interns and residents are scheduled to take the Medicine ITE. Thank you for contacting us with schedule changes. The attached schedule is the final schedule that we will be submitting for registration purposes (
ITE final 8 12 2011). 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. The exam is approximately 8hrs long and begins at 7am. Any further changes will need to be reviewed by the Chiefs and Program Directors before they are approved. More details to follow closer to the dates of the exam. ITE schedule will be posted in Med Hub under Resources/Documents
Town Hall Meeting -- Aug 16 Noon Conference
Please make every effort to attend the first Town Hall meeting of the year. This conference will be held in DN2002 and is for house staff only.
No students please.
Diagnostician of the Week
Coming off the heels of our first annual "Physical Exam week," this week's honor goes to Vaishali Patel (SAR) who was seen with a group of students and interns this Friday afternoon demonstrating the thyroid exam on a patient with a large substernal multi-nodular goiter that caused compressive symptoms. Please let the ACRs know of great physical exam findings on the wards and (if your patients are agreeable), we will arrange for a group of students and residents to learn from your patients and hone their skills in the art of bedside examination. Many thanks to Dr Arcasoy and Dr Aimee Zaas, all of the master clinician and faculty lecturers for Physical Exam week (Dr Simel, Dr Govert, Dr Ward, Dr Morgenlander, Dr Peyser, Dr Rice, Dr Dave Zaas, and Dr Rubin) as well as our simulated patients (Scott Tolan, John Stanifer, Mike Durheim and Leon Cannizzaro) for their contributions to this successful program. Thank you in advance for your efforts in making 2011-2012 the "Year of the Physical Exam!"
GME Patient Safety and Quality Council
The GME Patient Safety and Qualtiy Council is having a monthly meeting on Tuesday, 7am on August 16th, in the Medical Center Board Room, 1170B Duke Clinics Yellow Zone. We will be discussing recent innovations in transitions of responsibility/handoffs including the evaluation tool that's now available on MedHub. Please join us if interested or email
tian.zhang2@duke.edu. Thanks!
Award Winners - MedPeds:
We received the announcement that 3 Med Peds residents received Honorable Mention for their responses to the 2010-2011 CME Question of the Week. The Office of Pediatric Education emails 2 CME questions/week, with the opportunity to send in answers. They compile the number of correct responses and identify the winner and runners up for the 2010-2011 year.
Congratulations to our 3 MedPeds residents who received Honorable Mentions: Apara Dave, Carolyn Avery, and Joel Boggan
[divider]
From the Residency Office
MKSAP – 2011 Order
This is the time of year when the Program places an order with the American College of Physicians for MKSAP. The order this year will be for the most recent version of the Digital/CD-ROM only.
Who: JAR or above who has not received a set of MKSAP training materials. You are also required to be a current member of the ACP (verified by providing your ACP #).
When/How: We will collect requests for MKSAP on line for the next two weeks (ending on Sunday, August 28). Please use the following link and complete all fields.
MKSAP ORDER FORM or
(https://www.surveymonkey.com/s/MKSAP_2011_Order)
Postings in MedHub: Block 3 Schedules / Noon Conference Recordings
Schedules for block 3 will be posted to MedHub this coming week as attachments under "Resources/Documents".
As you may have noted last week, we are now recording/posting the noon conference series for viewing. Links to the recorded sessions are uploaded each day to MedHub in the 'Resource/Document" section. Each session will be titled with the date, topic, and speaker to help make your search as easy as possible.
Employee Health and Wellness
All residents and interns - please review your training logs and follow-up on any notices that you receive regarding training modules / tests that need to be renewed. You can do so using the following link
http://www.safety.duke.edu/. 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. 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 2011
Career Opportunities
We will continue to post opportunities that are received by our office as attachments/links.
NC Opportunities - Career MD - Thursday, August 18
Internal Medicine position near Charlotte
Useful links
The first annual Physical Exam Week was a success! Huge thanks to Murat Arcasoy, the chiefs and ACR Tian Zhang for organizing these unique and valuable noon conferences.
To start the week, David Simel taught tips and tricks for the head and neck exam, including reminding us what the red filter does on an opthalmoscope (if you don’t know the answer, check out this website from ophthalmologist Timothy Bennett in Hershey PA (http://www.opsweb.org/?Monochromatic). Dr. Simel also astutely noted that Altoids are a necessary addition to a good eye exam, and showed us the paper he wrote as AN INTERN describing afferent pupillary defects (the Marcus Gunn pupil). Dr. Joe Govert then detailed the daily ICU physical exam, with observation as a key element, and reminded us that the exam is a tactile reminder of why we are physicians. We enjoyed an hour with Dr. Cary Ward teaching the cardiovascular exam, starting with “Name that Tune” (did you know that Cheney’s LVAD is in an Eminem song?), a few facts about shark hearts (one ventricle!) and that practice is the only way to get good at recognizing heart sounds. All this was accomplished using YouTube, an iPod and Scott Tolan in a fat suit.
On Wednesday, Dr. Joel Morgenlander simplified the neuro exam for us into “localization, onset, pathophyisiology and ‘spells’”, and taught us what nerve root controls flipping the bird (C7) and kicking someones … (L4). Dr. Bruce Peyser gave a most enthusiastic review of the abdominal exam, including using Mandy George (JAR) to demonstrate a fluid wave on Mike Durheim, acting as our patient with cirrhosis. Dr. David Zaas, with the help of Leon Cannizzaro (SAR) and Eileen Maziarz, showed us how to use the pulmonary exam to diagnose shortness of breath, and that if you listen only to someone’s back, you are just examining the lower lobes of the lung. Dr. Russ Rice walked us through the musculoskeletal exam (with additional thanks again to Leon “The Owl” Cannizzaro), reminding us to keep one hand firmly placed on the top of the shoulder to isolate the joint to test mobility. We capped off the week on Friday with my review of the inpatient exam, Dr. Sharon Rubin’s review of the new patient in clinic exam (thanks John Stanifer for serving as the patient) and Murat Arcasoy’s review of the lymphatic exam. While posing as the patient, John Stanifer taught us how Osler would check out his daughter’s suitors with the double handshake/epitrochlear adenopathy screening. Now, test your eyes by clicking on the following link to view how last week's events have changed this famous picture Master Clinician - 2011 (thanks Jon Bae!).
Keep up your exam skills on the wards and in the clinic. Special thanks to Vaishali Patel for taking a group of students and sub-I’s to the bedside to examine a patient with goiter. Other notables from this week were an outstanding intern report by Lindsay Boole on Conn’s syndrome, a “case to be used later” from Anne Mathews at VA morning report, and Talal Dahhan diagnosing dermatomyositis with jo-negative antisynthetase syndrome after Dan Fox said one or two sentences of his PM report case. Nice to see the SARs so engaged in Duke PM report! Thanks to our Stead attendings Heather Whitson and Claude Piantadosi. Coming up soon will be James Tulsky and Mike Felker.
And finally, thanks to everyone who was able to come to my home for the first Liver Rounds of the year. The rains held off, the deck was almost complete, and it seems that good times were had by all. Looking forward to having you back soon.
Aimee
Priya Gopwani, 2011 Med-Peds graduate, completed her elective rotation at a public hospital in Bangkok, Thailand. She is pictured here with some of the people she worked with at the hospital. “I was not sure what to expect given that I do not speak Thai. The people on the infectious disease team were wonderful. They always made sure that someone was there to translate for me, and even helped me learn a bit of Thai myself! I learned a great deal about infectious diseases, HIV and tropical medicine from them. I really couldn’t have asked for a better team to work with.”