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
Lots of great stuff to report this week…first of all, if you think you have worked hard this week, you’ve got nothing on Carling Ursem (PGY-1), her "husband" Scott Evan (PGY-1 Emergency Medicine), and Senior Administrator Randy Heffelfinger (and his wife Mindy) who rode the MS150 this weekend! Take special note of the quotations around husband. Carling and Scott were married last weekend in California, but still made in back to ride 100 miles on both Saturday and Sunday.
I understand they were part of over 2,400 cyclists who were in New Bern to take part in this event - all to raise funds to support MS research. Way to put us all to shame when we take the elevator between 8100 and 9100. Here is a picture of the newlyweds at the starting line.
Congratulations are also in order for Blair Irwin (PGY-3) and Andre Bautista (prelim '09 and Radiology PGY 2), who are also celebrating their wedding. What a great opportunity to extend our congratulations to the new couples!
On the wards and in the clinics, there are a lot of kudos to go around as well. One of the perks of being Program Director is hearing about the great care from the residents! This week, Audrey Metz (PGY-1) was noted by a patient to have provided superb care in the clinic, and the team of George Cheely (PGY-3), Kelly Han (MedPeds PGY-1) and Jon Bae (MedPeds grad, former chief and now APD for Quality Improvement and Hospital Med faculty) received a gold star for care provided on Duke Gen Med in July. Carly Kelley (PGY-3) gets special mention for going above and beyond the call of duty to facilitate safe transfer of a patient from DRH to Duke AND coming over to Duke in person to discuss the patient with the Duke MICU team! That is a true “transition of responsibility”!
Much teaching continues on the wards, with PGY-1 Sarah Wingfield spotted countless times teaching MS II Kevin Huang, and PGY-3 Mike Durheim teaching MS IV Sub-I Nicole Joy (rumor has it that they spun urine on at least 3 admits with acute renal failure). Ryan Schulteis (PGY-3) stepped up and covered for a teammate who needed to be away which was also much appreciated. We’d give him the Duke Marine award, but I think he is a VA JET at heart. Alex Fanaroff (PGY-1) taught his fellow interns about causes of acute hepatitis with a stellar intern report presentation (quick – what are the causes of AST and ALT > 1000?). Richard Wu (PGY-3) and Newton Wiggins (PGY-2) are our Diagnosticians of the Week, with a chair’s conference worthy diagnosis to be named later. Richard and Newton have been spotted in an intense “Rock, Scissors, Paper” competition to see who is lucky enough to present. Much thanks also to Dr. Rambi Cordones (Derm) for an outstanding Grand Rounds.
We celebrated the MSII’s halfway point on the medicine clerkship with pizza on Thursday – great job, everyone! Lucky for us, this group gets to stay on medicine for another 4 weeks.
ERAS applications continue in full force – we are tipping the scales at > 2000 applications at last count. The candidates are very impressive and we are excited to have strong faculty participation in the interview process. Look for emails from Emily Strollo with program FAQ’s, interview dates, etc. Our website is under major overhaul as well – much has been updated due to great efforts from Emily, Anton Zuiker, and others. We’ll be sure to announce the official “unveiling” soon so that you can take a look.
Pubmed from the program: This week’s pubmed goes to current Palliative Medicine/Medical Oncology fellow (and former VA Chief Resident) Tom LeBlanc .
Autopsy and Grief: A Case of Transformative Postmortem Examination.
[box] Leblanc TW, Tulsky JA, Simel DL.; J Palliat Med.
2011 Aug 4. [Epub ahead of print]; PMID:21815752 [/box]
Other Presentations: Kevin Parrott presented a “doggone great case” this week at Chair’s Conference, with MSIV Nicholas Turner getting the answer of Capnocytophagus canimorsus sepsis in a vet (-eran, not –ernarian) with a dog bite. We also learned the mouth flora of bears includes S. aureus and that if you are a pig in the Netherlands, you better watch out for Staph as well. Dr. Corey piqued our interest in the animal kingdom’s oral flora, and a quick literature search reveals that alligators often carry Aeromonas, Tasmanian devil bites also have Pasturella, similar to our more typical dog/cat bites with this bacteria, and rats in America carry Streptobacillus moniliformis (“rat bite fever”), whereas Asian rats carry Spirillum minus. In order to test who might actually be READING weekly updates, I will offer a prize to the housestaff member or med student who is first to tell me what is the most common isolate from Komodo dragon bites. The article where I found all this great medical trivia will be seen in a “What I Read This Week” sometime soon.
QI CORNER:
Question: what is an “
omelos”?
A. One of those sandwiches wrapped in foil that comes with a side of SnakPak pudding, served at noon conference
B. A rare type of fungus, only treated by itraconazole
C. A quality metric important to improving how we care for patients at the DVAMC
D. The new term for the SAR/extender team on VA Gen Med, since VATS didn’t really catch on like wildfire
If you guessed “A”, almost…the sandwiches are from MEELOs.
The answer is “C” – OMELOS is the Observed Minus Expected Length of Stay, and the resident led/chief Tom LeBlanc inspired QI project on VA Gen Med has knocked it out of the park! See below for details…
"Over the last several years the Durham VA Medical Center was noted to have an unexpectedly long length of stay as compared to statistical predictions and other surrounding VA hospitals. Paradoxically, many community VA hospitals in the southeast also appeared to have sicker patients, despite the fact that they transfer their most complicated cases to our tertiary facility. During the 2010-11 academic year we explored this discrepancy. As it turns out, the predictive models used to calculate expected length-of-stay and complexity/mortality are largely based on information derived from coding, which in turn is based on our documentation. We thus undertook a QI project to assess the accuracy of our discharge summary documentation on the medical service. Quite quickly we found that our summaries were often missing important information, such as secondary diagnoses, and that we often used words that underrepresented the acuity of illness and complexity of care that we provide. The QI project thus evolved to include education efforts by our hospitalists, to teach us how to better describe acuity and complexity in our documentation, and to thus get credit for the hard work that we do. We learned that albumin is a key part of these predictive models, and found that we were rarely obtaining albumin values at the time of admission. In its absence the predictive model imputes a normal value of 4.0, thus making our patients look more healthy. With a push to obtain albumin values on admission, in conjunction with ongoing QA/QI attention to documentation in our daily practice, the Durham VA has seen significant improvements in our data over the last few quarters, especially with regards to the observed vs. predicted length-of-stay.
The data below shows the following:
For each patient, the VA calculates an expected length of stay based as follows:
“The predicted length of stay is determined by a linear regression model that uses age, diagnosis or procedure, comorbid disease burden, and the worst of 11 laboratory values in the 24 hours surrounding admission (sodium, blood urea nitrogen, creatinine, glucose, albumin, bilirubin, white blood cell count, hematocrit, and 3 arterial blood gas values - pH, PACO2, and PAO2) to predict ICU length of stay.”
In 2010, our OMELOS shows us at 0.81 which means that after adjusting for the predicted length of stay our patients stay in the hospital 0.81 days longer than similar patients in the VA. For the first three quarters in 2011, we now show a value of 0.32 days which means that the patients are getting out much closer to when they should. We think this is mostly attributable to housestaff efforts in appropriately doing discharge summaries that reflect the burden of disease. This is not gamesmanship, because what we’ve seen (empirically) is that the quality of the discharge summaries has improved.
There has also been improvement in the standardized mortality ratio (now 24% lower, SMR), which is attributable to the same effort to fully explain in our discharge summaries the burden of disease experienced by the patient.
| |
2010 |
2011 YTD |
| |
N |
LOS |
OMELOS |
N |
LOS |
OMELOS |
| Durham |
5,035 |
5.69 |
0.81 |
4,201 |
5.64 |
0.32 |
| Medical |
3,673 |
5.86 |
0.94 |
2,964 |
5.76 |
0.3 |
| Surgical |
1,362 |
5.24 |
0.47 |
1,237 |
5.35 |
0.36 |
| |
2010 |
Rolling 12 months |
|
Rolling 6 months |
| |
N |
ND |
SMR |
N |
ND |
SMR |
N |
ND |
SMR |
| Durham |
5,445 |
281 |
1.23 |
5,946 |
277 |
1.02 |
3,177 |
153 |
0.98 |
| Medical |
3,803 |
243 |
1.24 |
4,101 |
255 |
1.07 |
2,190 |
139 |
1.01 |
| Surgical |
1,642 |
38 |
1.17 |
1,845 |
22 |
0.64 |
987 |
14 |
X |
| |
|
|
|
|
|
|
|
|
|
| |
2011 YTD |
2011 Q3 |
|
|
|
| |
N |
ND |
SMR |
N |
ND |
SMR |
|
|
|
| Durham |
4,540 |
208 |
0.96 |
1,595 |
64 |
0.86 |
|
|
|
| Medical |
3,156 |
191 |
1 |
1,068 |
56 |
0.86 |
|
|
|
| Surgical |
1,384 |
17 |
0.65 |
527 |
8 |
X |
|
|
|
Our next task is to use this data to also figure out the best time to bring our patients back for a visit after discharge.
Don’t forget to mark your calendars for the CPC, Leader’s Board with Dr. Dzau and Evening Rounds with Ann Lore! Dates and times are listed in the "Residency Office" section.
Have a great week,
Aimee
Duke Medicine wide effort to vaccinate all health care works September 27.
Please add this to your calendar and plan to parcticipate in the Mass Vaccination planned for September 27, 2011
The goal is to get 100% of all health care workers vaccinated in 24 hour period. This exercise will test DUHS mass vaccination/drug distribution plans which would be used during an epidemic, pandemic, or emergency event such as an explosion at Sharon Harris Nuclear Plant. Residents/fellows can receive at Duke Hospital, DRH and Duke South clinics (as they're working in clinical areas) Residents, at VA can come to cafeteria or Employee Occupational Health and Wellness Duke South Clinics.
What I Read This Week “WIRTW” (by Jon Bae 9-12-11)
[box]“Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents” West, C., Shanafelt, T, et al; JAMA, 2011, 306 (9): 952-960 [/box]
After a long day of ‘improving quality’ around the residency program, the last thing that I want to do is to pick up a journal and start diving into the world of clinical trials. But as part of my own personal self (quality) improvement project, I’ve tried to make it a goal to read for at least 20-30 minutes each evening. My success rate is only around 30%, but I have a proposal submitted to IRB for an intervention that may improve my rates. I can’t divulge what the intervention is, but I can tell you that I call it “The Corey.” Pending that, self-motivation must suffice. And on one of those 1 out of 3 nights this week, while sitting in my leather-bound armchair, sipping chamomile tea, dreaming of diabetic foot exams, I happened to pick up that sensationalistic rag, JAMA, and stumbled upon the article listed above.
Being the educational visionary that I am, I could not help but think an article entitled “Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents” would be relevant to our internal medicine residency program. I was confused, however, because I was under the impression that burnout was eliminated and quality of life and medical knowledge were improved in the era of the 80-hour workweek. Already, things were not adding up. I was also struck by this concept of “burnout”. Back in the glory days of 1992, when I was in high school, a “burnout” was someone who wore dirty baseball caps turned backwards, wore a lot of flannel, and debated the virtues of Nirvana vs. Pearl Jam in the back of Mr. Robertson’s Biology 2 class. I haven’t seen a lot flannel in the program, so I assumed our burnout burden was low until I saw that the authors were defining burnout through assessments of “emotional exhaustion” and “depersonalization”. In this case, burnout was assessed by asking questions derived from the Maslach Burnout Inventory – a validated tool to assess, you got it, burnout. (I don’t know who Maslach is or why he is so burned out, but that is a discussion for another time.) The questions used in this particular study were “How often do you feel burned out from work” (emotional exhaustion) and “How often do you feel more callous toward people since starting residency” (depersonalization). Respondents then provided answers based on a 7-point Likert scale (ranging from “never” to “daily”). As a quick commentary, the addition of an emotional component to the definition of “burnout” is hugely important to distinguish it from simple fatigue. I have 2 kids and I am writing this at 11:15 PM; I’m fatigued all the time but I’m not burned out. It’s an important distinction. But perhaps I am getting ahead of myself.
First of all, why is this relevant? The authors contend that increasing levels of stress and burnout have been associated with negative effects on patient care, particularly medical errors, poor patient satisfaction, and suboptimal care practices. Thus, unhappy, burned out residents equals more mistakes and subsequently more harm to patients. So, it makes inherent sense that we should evaluate physician well being among our medicine housestaff. The authors of this study also looked at a number of different relationships related to quality of life and burnout, specifically associations with educational debt and medical knowledge (as evaluated by the medicine in-service training exam). The authors hypothesized that worse quality of life and burnout would be associated with higher debt and decreased improvement in medical knowledge. Certainly not revolutionary concepts, but interesting nonetheless.
How did they do this? The authors incorporated a survey into the medicine ITE exam in 2008 (wait, I was a resident then!) and in doing so, captured 74% of medical residents in the United States. Of that sample, 14.8% indicated that their quality of life (QOL) was “somewhat bad” (13.5%) or “as bad as it can be” (1.5%). Similarly, 51% of respondents demonstrated some degree of burnout and there were high rates of emotional exhaustion and depersonalization as well. They also found associations between higher degrees of burnout and lower quality of life with increasing educational debt and worse performance on ITE exams. This makes me worried that based on my own ITE performance intern (and JAR!) year, my advisor thought I was the most burned out resident around. I should have bought some flannel! Interestingly, the authors also found that US medical grads had lower QOL and were more burned out then international medical grads. And they found that you became less burned out and had improved QOL the further you advanced in training. I guess that’s why Associate Program Directors are so happy.
Are there problems with all of this? Well, such is life, yes. First of all, there may be some bias introduced in that 26% of residents did not complete the survey. Perhaps they were too happy to do so? Second, their assessment of medical knowledge included only performance on the ITE exam. As we all know by now, there is more to medicine then book learnin’. Lastly, they asked them to complete the survey after an 8-hour test! For a survey reliant on subjective responses, context is everything. That would be comparable to me administering an Epworth Sleepiness Scale (a validated tool to assess sleepiness) after a 24-hour shift! (Wait? Do we have 24-hour shifts anymore?) However, while there are limitations to the study, it raises interesting questions about our work culture and how it could potentially impact patient care.
What do I take away from all of this? Well, we cannot assess burnout by fatigue or flannel alone. More importantly, burnout and decreased quality of life are probably more prevalent then we generally think. Unfortunately, nothing in this study suggests modifiable areas where we can improve upon resident quality of life or decrease burnout, except maybe allowing our residents to advance to the next year of training. And I hate to break it to everyone, duty hours in and of themselves will not be the answer. (Are you listening, Institute of Medicine?) In all seriousness, burnout, and to a lesser extent, quality of life have little to do with fatigue or how hard you work. It is very much tied up in the satisfaction you derive from your work, the perceived value you feel you provide to patients and to each other, and in the network of support that surrounds you. Being aware of burnout is the first and best strategy to prevent it. And when you start finding yourself “feeling burned out from work,” stop and take stock the important work you do and why we are doing it. Taking care of people, especially the unsavory ones, is hard work. But you already knew that or you wouldn’t be here. But it is easy to forget after your third admission in 1 hour or after another patient yells at you for discontinuing their pain contract. In those times, having colleagues and faculty to support you, to laugh with you, and to learn with you makes all the difference in burnout prevention. And I like to think we have some of that here in Duke Medicine, where we have no flannel. And FYI, to all of you burnouts who are out there: Nirvana clearly was the king of the grunge era.
[divider]
From the Chief Residents
Grand Rounds
| Date of Lecture: |
September 16, 2011 |
Learning Objectives: |
| Title of Lecture: |
"Management of asthma: from inhalers to bronchoscopic thermoplasty" |
Following this activity series, learners should be able to: 1. Discuss the pathophysiology of asthma 2. Learn about the current treatment approach to asthma 3. Discuss the challenges of severe and persistent asthma 4. Learn about a novel bronchoscopic treatment in asthma: bronchial thermoplasty |
| Speaker(s): |
Momen M. Wahidi, MD, MBAMonica Kraft, MD |
|
Noon Conference
| Day |
Date |
Topic |
Lecturer |
Time |
Vendor |
| Monday |
9/12 |
EKGs |
Joe Greenfield |
12:00 |
The Picnic Basket |
| Tuesday |
9/13 |
Business of Medicine |
Sabrina Olsen |
12:00 |
Dominos |
| Wednesday |
9/14 |
Teaching Feedback |
Chudgar/Gagliardi |
12:00 |
Moe's |
| Thursday |
9/15 |
Respiratory Failure |
Joseph Govert |
12:00 |
Papa John's |
Turkey Bowl Practice
Reminder that preparations for the annual event have begun! Watch your inbox for "personal" annoucements submitted by the Jets and Duke Marine!
Week 2 Turkeybowl Practice
Sunday 9/11/11 @ 3:30pm
Forest Hills Park
Residency Program Slide Show
Carly Kelley is helping lead the charge to create an awesome slide show for the recruiting events this year. Please Help ! There is a folder under PC Commons titled "Internal Medicine Recruitment" with a "2011-2012" folder and subheadings with things we need pictures for: intern orientation, working in the hospital, hanging outside the hospital, SAR picnic, international rotations, turkey bowl, etc.
For those who do not have access to PC Commons, please feel free to email pictures to Carly's attention (email address:
carly.kelley@duke.edu )
New Resident Dermatology Clinic (From Dr. Atwater)
Dermatology is announcing the opening of a resident continuity clinic in the department of dermatology. Residents will see patients on Friday afternoons at the Duke South Clinic, 3K, and the clinic starts on 9/16/11. If you have any patients you want to place in the clinic, please contact our schedulers at (919) 684-3432 and tell them that you would like the patient to be seen in the resident continuity clinic. Each patient will also be (briefly) seen by an attending but the primary dermatologist will be the resident
General Medicine Grand Rounds on Tuesday, September 12, 2011
Thyroid Nodules, Masses, and Overactive states
Presented by: Jennifer Perkins, MD
7:30am to 8:15am
3024 Pickett road, 2nd
From the Residency Office
Cardiology Interest Group
The Cardiology program would like to offer the opportunity to meet with representatives to learn more about the fellowship program and address any questions that you may have. The meeting will be held on Wednesday, October 5, from 5-6 in the Med Res Library.
https://www.surveymonkey.com/s/Cardiology_Interest_Group
Dates to Add to Your Calendars
Looking ahead, dates to keep in mind:
Sept 20 – CPC @ 604 W Morgan (RSVP to follow)
Sept 27 - Leader Board @ 5:30 PM in the Faculty Lounge
Sept 27 - Duke Mass Vaccination Exercise
Oct 5 - Cardiology Interest Group, 5-6, in the Med Res Library
Dec 10 – DOM Holiday Party
Feb 24 – Charity Auction (Contact Tian or Ann Marie to participate)
June 13 –Resident Research Event, 5-7pm
The Learners' Perceptions Survey is Open
The VA Learners' Perceptions Survey is a valuable tool that is used to help improve training opportunities. Please take the time this week to log in and provide your feedback using the following link:
http://www.va.gov/oaa/surveys/
Your responses will be kept confidential. If you have trouble logging in, call 1- 888-877-9869
or e-mail OAA Help Desk.
Employee Heath - September Services
Fit Testing/ T-Dap Vaccination/ TB Skin Testing will be again be available for your employees in September. We do not have many days scheduled at North due to Staffing the Flu Program.
Resp Fit Testing-T-Dap-TB Skin Testing Flyer Sept 2011
Also available: Color Vision, Flu Shots, TB Skin Testing
(T-Dap) vaccine (Diphtheria, Tetanus, Pertussis) Required for all employees working with Children 18 months of age or younger.
Location - 4th floor room 4000C. This Room is beside the private patient elevator behind the main circle elevators on the 4th floor). Feel free to call us in room 4000C- at 681-7185 or at Employee Health at 684-3136 Option 2 or Rita Oakes 681-0513, if you have questions.
Useful links
Lots of great stuff to report this week…first of all, if you think you have worked hard this week, you’ve got nothing on Carling Ursem (PGY-1), her "husband" Scott Evan (PGY-1 Emergency Medicine), and Senior Administrator Randy Heffelfinger (and his wife Mindy) who rode the MS150 this weekend! Take special note of the quotations around husband. Carling and Scott were married last weekend in California, but still made in back to ride 100 miles on both Saturday and Sunday. 
I understand they were part of over 2,400 cyclists who were in New Bern to take part in this event - all to raise funds to support MS research. Way to put us all to shame when we take the elevator between 8100 and 9100. Here is a picture of the newlyweds at the starting line.
Congratulations are also in order for Blair Irwin (PGY-3) and Andre Bautista (prelim '09 and Radiology PGY 2), who are also celebrating their wedding. What a great opportunity to extend our congratulations to the new couples!
On the wards and in the clinics, there are a lot of kudos to go around as well. One of the perks of being Program Director is hearing about the great care from the residents! This week, Audrey Metz (PGY-1) was noted by a patient to have provided superb care in the clinic, and the team of George Cheely (PGY-3), Kelly Han (MedPeds PGY-1) and Jon Bae (MedPeds grad, former chief and now APD for Quality Improvement and Hospital Med faculty) received a gold star for care provided on Duke Gen Med in July. Carly Kelley (PGY-3) gets special mention for going above and beyond the call of duty to facilitate safe transfer of a patient from DRH to Duke AND coming over to Duke in person to discuss the patient with the Duke MICU team! That is a true “transition of responsibility”!
Much teaching continues on the wards, with PGY-1 Sarah Wingfield spotted countless times teaching MS II Kevin Huang, and PGY-3 Mike Durheim teaching MS IV Sub-I Nicole Joy (rumor has it that they spun urine on at least 3 admits with acute renal failure). Ryan Schulteis (PGY-3) stepped up and covered for a teammate who needed to be away which was also much appreciated. We’d give him the Duke Marine award, but I think he is a VA JET at heart. Alex Fanaroff (PGY-1) taught his fellow interns about causes of acute hepatitis with a stellar intern report presentation (quick – what are the causes of AST and ALT > 1000?). Richard Wu (PGY-3) and Newton Wiggins (PGY-2) are our Diagnosticians of the Week, with a chair’s conference worthy diagnosis to be named later. Richard and Newton have been spotted in an intense “Rock, Scissors, Paper” competition to see who is lucky enough to present. Much thanks also to Dr. Rambi Cordones (Derm) for an outstanding Grand Rounds.
We celebrated the MSII’s halfway point on the medicine clerkship with pizza on Thursday – great job, everyone! Lucky for us, this group gets to stay on medicine for another 4 weeks.
ERAS applications continue in full force – we are tipping the scales at > 2000 applications at last count. The candidates are very impressive and we are excited to have strong faculty participation in the interview process. Look for emails from Emily Strollo with program FAQ’s, interview dates, etc. Our website is under major overhaul as well – much has been updated due to great efforts from Emily, Anton Zuiker, and others. We’ll be sure to announce the official “unveiling” soon so that you can take a look.
Pubmed from the program: This week’s pubmed goes to current Palliative Medicine/Medical Oncology fellow (and former VA Chief Resident) Tom LeBlanc .
Autopsy and Grief: A Case of Transformative Postmortem Examination.
[box] Leblanc TW, Tulsky JA, Simel DL.; J Palliat Med. 2011 Aug 4. [Epub ahead of print]; PMID:21815752 [/box]
Other Presentations: Kevin Parrott presented a “doggone great case” this week at Chair’s Conference, with MSIV Nicholas Turner getting the answer of Capnocytophagus canimorsus sepsis in a vet (-eran, not –ernarian) with a dog bite. We also learned the mouth flora of bears includes S. aureus and that if you are a pig in the Netherlands, you better watch out for Staph as well. Dr. Corey piqued our interest in the animal kingdom’s oral flora, and a quick literature search reveals that alligators often carry Aeromonas, Tasmanian devil bites also have Pasturella, similar to our more typical dog/cat bites with this bacteria, and rats in America carry Streptobacillus moniliformis (“rat bite fever”), whereas Asian rats carry Spirillum minus. In order to test who might actually be READING weekly updates, I will offer a prize to the housestaff member or med student who is first to tell me what is the most common isolate from Komodo dragon bites. The article where I found all this great medical trivia will be seen in a “What I Read This Week” sometime soon.