Weekly Updates July 15, 2013

By residency1

From the Director

DUKE.RESEARCH.NIGHT.03 (1) Hi everyone! Hope you are all settling in to a nice routine. We've got all the fellowship letters uploaded, and Bill Hargett and I will be hosting a noon meeting for all who are applying this year to talk about interview preparation in the med res library on 7/30. Regular noon conference for JARs and interns. Kudos this week for all - Duke and VA services are at near record high numbers and you are all providing outstanding care to your patients. Please take the time to fill out your self eval in medhub. We also sent you the video that we made (kudos to Bill Hargett!) to train attendings to use the new evaluations. It's about 5 min long, and definitely worth watching. We will begin our minicex campaign this week, so please also remind your attendings to fill out a minicex as they work with you on rounds. Upcoming events include intern party at Dr Klotman's on Thursday and physical exam week starting July 22. For those of you interested, we have a great volunteer opportunity - physician volunteers needed at the Russel E Blount Track Meet.  See details below. Have a great week! Aimee  The Durham Striders Track Club will once again host the Russell E Blunt East Coast Invitational Track Meet which celebrates the legacy of the late Coach Russell E Blunt, Durham's most honored athletic coach and member of the NC Hall of Fame. The meet which will be held July 19-21 at Durham County Memorial Stadium, now in its 22nd year attracts the country's most talented track and field athletes to what has become the country's premiere summer developmental track competition for youth. The meet occurs strategically JUST BEFORE the USATF and AAU Junior Olympic National Championships and is therefore highly sought after as a "preparation" for these final championships of the summer track season. The meet this year is being held at Durham County Memorial Stadium,  which was recently completely renovated with a state of the art track and field venue. Thanks to the generous support of the County of Durham and its stadium authority,  we are able to put on what is considered the "class" of track and field competition in the country. The meet is free and open to the public.  I am writing to request your help with potential volunteers from your housestaff and faculty who might be willing to help staff one of the shifts for First Aid/Sports Medicine or volunteer for one of the many tasks necessary for the meet to run efficiently. We can only offer to feed, provide parking and volunteers meet shirts for their efforts. But they will see and meet some of the most talented young athletes from around the US as well as from Bermuda, Trinidad/Tobago, Mexico, the US Virgin Island, Jamaica, and the Bahamas.  We are anticipating almost 2000 athletes for the meet, plus their coaches, parents, as well as many local spectators, college scouts and coaches. There will be two large teams arriving to Durham from Bermuda and Mexico earlier in the week of the meet, and this year we are also anticipating teams from Trinidad/Tobago, the US Virgin Islands, the Bahamas and potentially a very strong team from Jamaica. We anticipate more than 100 teams from across the country to also send their very best athletes from 7-18 years old to participate in the 3 day meet.  We have broken the 3 days into shifts for first aid and sports medicine. Those wishing to volunteer should contact me, and plan to register at the Stadium at the President's Box on the East Side of the Stadium to pick up credentials, etc.  July 19 10AM-2PM 2PM-6PM July 20 8:30AM-12:30 12:30-4:30 4:30-7:30PM July 21 9:00AM-1:00PM 1:00PM-5:30PM Please contact Brenda Armstrong (Brenda.armstrong@dm.duke.edu) if interested This week's Pubmed from the Program goes to recent graduate (and current Penn Cardiology Fellow) Jon Menachem.. Recurrent Cerebral Abscess Secondary to a Persistent Left Superior Vena Cava Congenital Heart Disease; epub before print May 28, 2013  Jonathan N. Menachem, Senthil N. Sundaram, and  John F. Rhodes [box]

What Did I Read This Week

by Nick Rohrhoff, MD [/box] Making Residency Work Hour Rules Work Journal of Law, Medicine and Ethics, Vol. 41, No. 1, 2013 Why did I read this article: We have to log our duty hours every week and sometimes I forget to do it.  A red message pops up on MedHub, a “friendly reminder” email from the program office hits the inbox and if I’m really delinquent, there’s the dreaded text page.  People seem to care a whole lot about how much I’m working and well, I’m working a whole lot.  To this day, whenever I’m asked to do something, the 7-year old boy in me always asks, with varying volume and intonation, “…and what If I don’t?!”  Having recently become eligible to work up to 30 hours consecutively (longer than the intern 16, a day on Earth, a day on Mars and a Law & Order SVU marathon) and having deep interest in how we educate ourselves and learn from each other, I thought I’d look into it. Since a quasi-national conversation has erupted about graduate medical education, work hours, health care quality and patient safety, it wasn’t surprising to me that there’s very little known about what could happen…but plenty of opinions about what should. Summary: In this paper, Harvard sleep scientist Christopher Landrigan and colleagues outline the problem of resident duty hour non-compliance and present three possible enforcement alternatives to the mechanism currently in place.  Most of their discussion of the problem relies on data from after the 80-hour work week was implemented in 2003 and acknowledges the limited data available after the 2011 updates that included 16-hour intern work limits.  Right now, the only duty hour compliance enforcement mechanism in place is removal of a program’s accreditation by the ACGME.  That is a huge punishment.  So huge that it’s never really been doled out…to anyone.  So the authors suggest that other mechanisms would not only increase compliance but are necessary to do so. The first mechanism they suggest is what I call the “How to make Tom Owens show up at my apartment” whereby the Center for Medicare and Medicaid services would make Duke Hospital’s compliance with ACGME regulations a “condition of participation” and therefore required for reimbursement – in part or in whole.  The hospital would have a huge interest in compliance on the front end because if we were found to be non-compliant on the back end while receiving money from the federal health insurance programs, we’d be liable under the False Claims Act…which is the federal health regulatory version of backing into a parked car at  105 mph. Secondly, Congress could withhold funding for GME (derived mostly from the Medicare budget to the tune of nearly $10 billion per year) under the Taxing and Spending clause of the US Constitution to enforce compliance.  I call this the “Congress gets to do whatever it wants” - because it usually does.  And if there’s something bad out there, in this case duty hour reporting, there are 535 elected representatives ready to make it worse.  This mechanism was used most famously in 1984 when Congress withheld federal highway funding from states like Wisconsin where it was legal to buy alcohol under the age of 21 (then 18 in WI.)  And that explains Philip Lehman. Finally, individual states could make laws that make failing to comply with duty hour restrictions equivalent to “negligence per se” in a medical malpractice case.  This is the “Judge Judy” rule because in this case, the plaintiff would only have to prove that you worked more hours than you should have, NOT that you provided any less than the expected standard of medical care in order to find you medically negligent and thus guiltier than anyone who has ever been on Nancy Grace, Dr. Phil or Maury Povich. Conclusion: There is an interest by legislators, regulators and bureaucrats to control the practice of medicine broadly and specifically the education and training of the next generation of physicians.  As a profession, we need to bring moral accountability, scientific validity and community responsibility to this issue before we lose the opportunity to do it.  We need to push the ACGME for the freedom within the 80-hour workweek framework to experiment with alternative call schedules that don’t limit interns to 16 arbitrary hours.  Then we could compare similar programs in resident size, patient acuity and volume to see if less really is more.  We could add patient satisfaction data to quantify how much more patients like knowing exactly who their doctor is and what they look like (even at 3am in 8109 when the corner light is out and you feel like you’re walking into Narnia.)  And maybe we’d be wrong.  But the only thing worse than being wrong is knowing that we don’t know and refusing to do anything about it. Doing anything to physicians in the name of “patient safety” will always be a political winner regardless of how good an idea it is.  “We need more data” does not afford us a similar appeal.  We have to get the data first, and then make the argument.  Maybe the way to get it is to offer stricter compliance with ACGME rules and corresponding appropriate penalties, less severe than loss of accreditation, in exchange for the freedom to experiment.  Then maybe this national conversation would become something to talk about. [divider]

From the Chief Residents

Grand Rounds

Date:  July 19, 2013
Date Topic Lecturer  
7/19 Kidney Disease/Public Health Dr. Himmelfarb  
 

Noon Conference

Date Topic Lecturer Vendor
7/15 GI Bleeding Dan Wild Picnic Basket
7/16 Library Overview Megan Vonisenberg Bullock's
7/17 Cirrhosis Andrew Muir Saladelia-sandwiches
7/18 Stroke  Larry Goldstein  Sushi
7/19 Chair's Conference Chiefs Rudino's

 

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From the Residency Office

QI Corner  Med Res Patient Safety and Quality Council The Med Res PSQC (Patient Safety and Quality Council) had its first meeting this past week.  We had a great turnout, especially from our new intern class.  We reviewed last year’s successes (DOC Discharge Clinic project, Outside Hospital Transfers project), shared some of our interests, and began thinking about how to focus efforts this coming year.  If you’re interested in any particular topic but forgot to send me an email, now’s the time!  Also, look for the minutes coming out program-wide in an email early this week.  We’re going to be consolidating everyone’s interests over the next 1-2 weeks and then hopefully start connecting people with particular interests to start planning some projects for this year.  Potential areas for project focus: 1.     ‘We Follow-Up’ project for 2nd and 3rd years 2.     Hand hygiene and improvement 3.     EM-IM communications 4.     High-value, cost conscious care Let me know if you have any other specific interests at bogga002@mc.duke.edu (or joel.boggan@duke.edu) or Jon at jon.bae@dm.duke.edu. And join us for our next meeting Wednesday August 14th, 5PM in Med Res (2nd Wednesday of Each Month) Medicine Residency Rotation Burnout Assessment Be on the lookout for a program wide rotation burnout assessment led by Dr. Hany Elmariah. In order to better understand the impact of different rotations and work structures on resident fatigue and burnout, you will soon be seeing surveys (5 questions, < 1 min to complete) to assess your perceptions at rotation end. More details coming soon but for those seeking more info or who wish to get involved, please contact Hany.  Follow Us on Twitter!  For program specific and general patient safety and QI news, follow us @JonBae01 Contact Information/Opportunities Spartanburg Regional   hyc_logo_lrg       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 2014 and March 2015. 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. (Application addendum is available by request – tara.pemble@duke.edu) Application deadline is September 17, 2013. Interviews will be held in late September/early October. We encourage you to speak with past participants to get a better idea of what daily life is like on the wards of your top sites. For more information, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352. Newton_1                   Now recruiting eligible candidates for Duke’s Global Health-Internal Medicine Residency Program Duke Global Health Residents from the Department of Medicine extend the duration of their residency training by 12 months to gain specific global health core competencies. This extended residency includes nine months of course work which will lead to a Master of Science in Global Health and a total of nine months providing clinical care and conducting mentored research at a Duke University international partner site. Please visit our website for an in-depth description of the core curriculum including rotations, global health competencies, and program requirements as well as application instructions: www.dukeglobalhealth.org   Watch:  Current Global Health Resident, John Stanifer, discusses his decision to pursue global health training at Duke.  Internal Medicine Residents who have successfully completed PGY1 are eligible to apply.  Send all application materials electronically to cecelia.pezdek@duke.edu.   Applications accepted on a rolling basis until October 1, 2013.  Offers will be made November 1, 2013.   Duke University's Human Simulation and Patient Safety Center is recruiting residents for an Army sponsored study of our sedation training software, PDAATS.  We would like to reach the broadest possible set of non-anesthesia residents and fellows for our 60 person study. Participants who are selected will be compensated $500. Interested residents and fellows, can take a pretest by clicking on the link in this document.  If they are selected, then participants attend a training session at our lab on Duke Campus and take a post test. There is a long term post test that will be held at our center in Sep. It is critical that study participants commit to coming back for the long term post.    

 

Ambulatory Updates

Picket Road Information and Updates 1.  Please speak up if a computer is NOT working. I know the one computer in the dog house (close to the window) has not been printing letters. If computer or printer not working, start to trouble shoot, REBOOT or turn off/on the printer, check the connections. IF that fails, inform your attending and GLENN. This is a work stoppage and we want to keep you productive and working. 2. UGG Labs have not consistently going to residents. With the 6/22/13 upgrade we have been unhappy with this new feature, all the resident labs go to the attendings. The attendings need to forward the labs to the residents. Residents now have to check their patients labs the next day. One feature from maestro is create a patient list and put pt in there to keep tract of labs, studies. This is not ideal and a ticket has been placed but I doubt this is going to change soon or ever:(  The residents need to be VIGILANT for any lab drawn and to look in EPIC OUTPATIENT at least ONCE a week. The attendings will forward labs to the residents.  How to annotate when labs are NOT in new results folder If non portal patient, then go to chart, letters, new letter blank (I recommend making this a favorite). then you can put in .lastlabs or copy labs into letter. You can place your comments If portal patient, go to chart, go to More activities My Chart Utilities My chart Results Release (I would recommend starring this then this can stay on the left hand side at all times). Then annotate and accept.   3. Interns: remember first and second session 2 patients, third session 3 patients, fourth session 4 patients. This is the time to learn budgeting time. Use the computer, budget your time with your patient 20 minutes (further divide into history/PE/wrap up before sign out) and sign out about 5-10 minutes. That will keep you on 30 minutes. The attending can be busy signing out other patients, going in with other residents.  a. Make sure they attach to EVERYONE in the clinic (use the codes, faster than typing in names;the list is in the Pickett road handbook but Ila Mangum is wrong code) b. complete the quest around Pickett c. work their sign out list from the outgoing SARS. Create new message to Pickett Road PCP Front desk to bring the patients in for visit (if indicated). As you are going through their list, Change PCP (Snap shot, care teams communication, new PCP)
Takeover list  
Chung a-m Zhu
Chumg n-z Ng'eno
Day a-m Cupp
Day n-z Verma
George a-m Ray
George n-z Eisenberg
Goodwin a-m Matta
Goodwin n-z Nichloich
Westphal all Erdmann
4. Resident lists: I would LOVE for each resident to run a report listing them as PCP in EPIC. :( Residents are unable to use Dashboard. Dashboard is NOT activated for the residents. Shira is aware. The only work around I can think of is to create a Patient LIST to start keeping tract of Patients YOU ARE PCP until Dashboard eventually gets activated. Your attending and other residents are your EPIC superusers. ASK LOTS OF QUESTIONS: about inbox, messaging,  building a template, how to do things faster, orders, stealing smart phrases... Sharon Rubin, MD, FACP Assistant Professor, Duke University Medical Center Residency Director at Pickett Road

 

Ordering White Coats/Uniforms All continuing trainees will be able to order uniforms online through the Medical Center Bookstore beginning July, 1, 2013.  Orders must be placed by December 31, 2013.   Each individual department and/or program selects the style and quantities available to you and is provided to you at no cost. This is a one time opportunity to order GME provided uniforms for the current academic year. Go to https://shopgmeuniforms.dukestores.duke.edu to place your order. You will need to use the email address that is in MedHub to be able to log into the dukestores web site.

 

Upcoming Dates and Events

  • July 18th        Intern Welcome Party at Dr. Klotman's
  • July 22-26     Physical Exam Series Week (Noon Conference)
  • August 16th  Program Wide "Summerfest Party" at the Zaas's

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