From the Director
"Hey everyone! I continue to be impressed with how smoothly the year is starting off. The SARs on Duke Gen Med are handling busy services and teaching constantly, Intern Iris Vance did an awesome first intern report of the year (and a case of Wegener's, or granulomatosis with polyangiitis). How did she know that was Dr. Klotman's favorite diagnosis? Also nice job from SAR Jason Watts at Chair's Conference, presenting a case of syphilitic uveitis, and reviewing for all of us the important aspects of a good eye exam. I've also received several compliments from the night hospitalists regarding the great work and fantastic attitudes of our night JARs...thanks Brian Miller, Carling Ursem, Meredith Edwards, Scharles Konadu and Laura Caputo!
We have a landmark week for the medical center coming up this week, with the official start of Maestro Care in the primary care clinics (that means DOC and Pickett for us!). A ton of behind the scenes work has been happening, and we are excited to get started. The tallies are in from MAESTROPALOOZA last week at the DOC and Pickett….over 2000 patient problem lists were entered, which will make workflow easier when patients come through the clinics. Many many thanks to the following residents for participating in the palooza! And, most impressive, was the residents working side by side with clinic staff and attendings to accomplish this amazing project:
Nirjhor Bhowmik, Aparna Swaminathan, Ashley Whyte, Jodel Giraud, Denise Duan-Porter, Jennifer Rymer, Jennifer Chen, Ravi Vakani , Bertrand Tseng, Adia Ross, Adam Banks, Santoshi Billakota, Allyson Pishko, Nick Rohrhoff , Wendy Zhang, Josh Thade, Jeremy Halbe, Ben Heyman, Matt Summers, Mandy George, Ben Lloyd
Personalization Lab: Also, it is going to be extremely important that you take advantage of the personalization lab so that you can become proficient in Maestro Care. The 8 hours of training you did so far are a start, but to really get the most out of system, you need to PRACTICE and to use the resources available to make you efficient and effective in using the system. Many thanks to JARs Kaley Tash, and Jodel Giraud and SARs Denise Duan-Porter and Steven Sumner for logging some time in the lab to learn and practice. Bring a jump drive with you, and you can download your personalization work to bring to clinic.
For everyone else…..we will continue to publicize times that the labs are open. So far, you can also go to the Duke South Lab from 12-1 on the following dates: July 16, 24, 25, 31 or on Monday, July 16th from 4 – 8 pm at Raleigh Training Center, Haydn Room at 3025 Navaho Drive, 4th floor, or Tuesday, July 17th from 7 a.m. – 11 a.m. at Golden Drive. I suspect there will be more offerings, but things will slow down a bit in the two weeks after go-live because the trainers will be onsite in clinics. IF YOU ARE ON AMBULATORY AND HAVE QI MODULE/SHAREPOINT TIME OR ADMIN TIME DURING THE Monday AFTERNOON OR Tuesday MORNING SESSION, please talk to your clinic preceptor and get permission to go to the personalization lab. This is a great way to use the time. For JARs and SARs, we will be continuing the intern emergency lecture series during noon conference, so you can go to the personalization lab on the dates it is offered from 12-1. Just grab a lunch and head to Duke South. Maps are available at lunch.
Admin Time and Quality Improvement: We have launched the admin/QI time during ambulatory. We are really excited about this, as it should give you time to do appropriate patient follow up, to practice Maestro, to help your practice partnership, to do clinic-based QI (look out for a fantastic peer review program that is being championed by Amy Rosenthal!), and also complete your QI modules and personal share point data. QI Chief Ryan Schulties, QI Scholar George Cheely and QI APD Jon Bae will also be doing interactive QI teaching sessions during this time (first one happened on Friday…looking forward to hearing about it). Please see the "QI CORNER" below for some instructions on how to use this time.
Thanks to the following residents for making the first QI/Admin week a success and fully completing the assignments!
QI modules: Jen Chen, Ben Lloyd, Shereen Katrak, Dustin Norton, Allyson Pishko, Krishn Sharma, Bert Tseng, Adam Banks, Leah Rosenberg, Mandy George
Sharepoint: Krishn Sharma, Dustin Norton, Mandy George.
Have a great week,
Aimee!!
Pub Med: Another accepted abstract for ID Week is this week's Pubmed from the Program…congratulations to Intern Carli Lehr on her abstract "Multi-Pronged Interventions to Reduce Clostridium difficile Infections", which she will present at a poster session in San Diego this fall.
And this is a reminder to all interns, JARs and SARs to send me your abstracts, presentations and papers as they are accepted or published so that we can recognize your outstanding work in Weekly Updates!"
QI Corner (by Jon Bae, MD)
Thank you to all who have participated in our new QI experiences during ambulatory. We appreciate your patience as we refine our process and appreciate the feedback as well. Here are a couple troubleshooting tips for our most frequently asked questions Sharepoint: I cannot log-in! Help!- Please ensure that you are using either a pinstation or virtual pin
- Please ensure you are using adding “DHE\” prior to your username in the log-in window
- I cannot advance the slides! Answer - You cannot advance the slides until the narration completes. This is intentional.
- I have already taken these modules. Do I need to repeat them? Answer - No, Please let the house staff office aware.
- How long do the modules take? Answer - There is a pretest, 8 modules (each 15-25 min), and a post test. All told, it should take 3-4 hour to complete required elements. Fortunately, you are scheduled for a half day to complete this assignment.
What Did I Read This Week (by Dave Butterlry, MD)
[box] Survival with Three-Times Weekly In-Center Nocturnal Versus Conventional Hemodialysis, Lacson, Lazarus, Hakim et al, HakimJASN-Nocturnal[/box] The mortality of patients on hemodialysis in the US remains high at roughly 20% per year. Some of this excess mortality is obviously due to the significant comorbidities of our patient population (DM, HTN, CHF, CAD, etc) but the question remains if there are things inherent in the dialysis process itself which might impact this. This article appeared in the May issue of JASN and reports on the outcomes in Nocturnal Hemodialysis in the largest cohort reported to date. I was interested in the study because we run a Nocturnal shift (roughly 8 hour treatments) at our Durham West facility. I have been impressed with how well our own patients do with this modality and this provided confirmation of my own positive clinical impression. The majority of patients in the US receive thrice weekly in center Hemodialysis treatments. Treatment times vary between 3-5 hours and are adjusted based on urea clearance (Kt/V) which is checked monthly. This study is done from the Fresenius Database and reports on 746 patients who received nocturnal in-center treatments in FMC units. Treatment times averaged 7.85 hours versus 3.75 hours in the conventional group. The control group is comprised of 2062 propensity score matched patients undergoing thrice weekly 3-5 hour sessions. The propensity score is based on age, sex, race, dialysis vintage, DM, BMI, and vascular access. Baseline characteristics of the cohort is shown in Table 1. The group is younger (53 and 54 years) than the average patient commencing dialysis. The group is comprised of roughly 50% of the patients with ESRD due to DM and a much higher catheter rate at 46% than we see(the Duke units have a CVC rate all below 20% and several now are less than 10%). Survival data is shown in Figure 2. The 1 year mortality in the Nocturnal group was 9% compared to 15% in controls. The 2 year mortality was 19% in the Nocturnal group compared to 27% in controls. Both these outcomes are better than the USRDS average of about 20% at 1 year. The improved clinical features seen with longer duration dialysis are shown in Figures 4 and 5 and show better PO4 control along with lower achieved “Dry Weight” and BP in the nocturnal group. In summary, patients who opted for 3 times weekly nocturnal dialysis exhibited a 25-30% improvement in mortality. There is obviously some degree of selection bias seen in the type of patients willing to participate in this more intensive therapy, but given these encouraging outcomes I think you will see increasing utilization of this modality.
[hr]
From the Chief Residents
Grand Rounds
| Date | Division | Speaker | Title |
| 20-Jul-12 | General Medicine | Dr. Edelman | Complex Management |
Noon Conference
| Date | Topic | Lecturer | Time | Vendor | Room |
| 7/16 | EKG interpretation | Al Sun | 12:00 | Saladelia | MedRes |
| 7/17 | Surprise fun talk- come & see it, you'll love it if you are a Dookie! | Surprise | 12:00 | Bullock's BBQ | 2002 |
| 7/18 | QI/Patient Safety | Jonathan Bae | 12:00 | The Picnic Basket | 2002 |
| 7/19 | Hazards of Hospitalization | Tony Galanos | 12:00 | Papa John's | 2002 |
| 7/20 | Chair's Conference | Chiefs | 12:00 | The Pita Pit | 2002 |
VA General Internal Medicine Rotation Director (submitted by Dr. Simel)
Cindy Johnson, MD has agreed to become our first VA General Internal Medicine Rotation Director. This will fill an important gap that should lead to improvements on the General Medicine Inpatient Service. In this role, Dr. Johnson will have responsibility with me for oversight of Attending Physicians on the Service. She will plan an orientation, give them feedback on their performance, provide educational opportunities to improve teaching competence, and she will serve as a resource to the Residency Program Director and Clinical Clerkship Director. The VA Chief Resident will still have responsibility for the performance and day-to-day activities of our housestaff and students. The VA Chief Resident in Quality and Patient Safety will work with our housestaff and Dr. Johnson to evaluate their performance, and implement quality improvements. Dr. Johnson will review housestaff and student programmatic policies with the Chief Residents, Residency Program Director, and Clinical Clerkship Director to make sure that the roles of our VA attending physicians are considered and factored into process improvements. I will continue working on a daily basis, with both Drs. Webb and Johnson, though my focus will be on serving as the interface between the Medicine Service and Hospital. In that role, my responsibility will be to evaluate programmatic changes to insure that they are feasible, pragmatic, and have a positive impact on quality and patient safety throughout the hospital.[divider]
From the Residency Office
Maestro Countdown! 4 days to go live!! July 18 (from Drs Bowlby and Phelps!!)
Countdown to Maestro! 4 days to go!! Wednesday is the day—no more encounter forms! No more (or at least less) paper!! Tips for Maestro—- Practice in the lab and in the playground….
- You should only go into the real system to abstract (move info) from Problem list in Browser to Maestro—encounter type should be abstract
- We are ready! Time to change!
Moonlighting Residents (logging duty hours)
Remineder that the GME office links duty hours with hours submitted for TSMA payment. Please be sure to LOG your moonlighting hours as "internal moonlighting", and to also abide by duty hours rules (24+4 maximum, 80 hours per week maximum, 8 hours minimum off between shifts, 1 day off in 7), or they can't pay you for moonlighting. This policy was announced late last year by the GME office and is now in effect.HELP Recruit the Next Class of Duke Interns
Remember how great it was to find out that one of our current residents was from your home town, or that you went to the same medical school as the SAR who was giving you a tour of the MICU? Wouldn't it have been helpful to know why others chose Duke, or what makes the "Triangle" so awesome? We want this year's applicants to know these answers - and more. If you have not all ready completed the survey that was sent to you by Anton last week - please take time this week to do so. We are updating our website and need your content to complete the picture (http://news.medicine.duke.edu/life-of-the-internal-medicine-resident/)The 2012.2013 Health Policy: Just in Time Lecture Series
Duke GME Program Directors, Residents and Fellows are invited to participate in a Health Policy Lecture Series, presented by Fuqua faculty and national experts. This opportunity was made possible by the Duke GME Innovation Fund.
Sessions will be held one weeknight per month (6pm – 7:30pm) in Duke North from September 2012 to May 2013.
Session Topics include:
- Overview of ACA
- Discussion of political views of presidential candidates
- Physician Payment
- Medicare/Medicaid
- Quality & Performance
- Conflicts of Interest
- Comparative Health Systems
- Law & Medicine
- Employment & Contract Law
- Opening/Running a Private Practice
To Participate -Visit the Health Policy WordPress Site (sign-in using your NetID and password) and complete the “Participant Agreement” via the link found under the “Lecture Series Application” tab. http://sites.duke.edu/healthpolicy/
Russell E Blunt East Coast Invitational Track Meet
Opportunity to volunteer at the Russell E Blunt East Coast Invitational Track Meet….outstanding youth track meet bringing talent from all over NC! We are supervised by Duke attending physicians and would be manning first aid stations. Please report to the President's Box which is located at the flagpole on the EAST side of the stadium to pick up a shirt, credentials, and directions to either the concourse first aid support or the support for the track which will be located in the tunnel. If there are any questions, please feel free to page me at 970-2052. We anticipate house staff, and attendings from both UNC and Duke to help with first aid/sports medicine etc." Please contact Brenda Armstrong (brenda.armstrong@dm.duke.edu) for details!Dates to Add to Your Calendars
July 27 Residency Program Summer Celebration at the Zaas's Useful links- http://duke.exitcareoncall.com/.
- 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