Weekly Updates: July 22, 2013

By admin3

From the Director

DUKE.RESEARCH.NIGHT.03 (1)Hi everyone! We've continued to be quite busy in the hospitals and in the clinics. Many thanks for your hard work. Upcoming this week is "physical exam week" at noon conference - Dr. Arcasoy has put together a great series of demonstrations/lectures so we hope to see you there. This reminds me that we need our first trivia question of the year... Which Duke resident diagnosed RBBB by physical exam ... While in clinic? Bonus if you can tell me how to make that diagnosis. Email me with your answers. Kudos this week come from Scharles Konadu to Myles Nickolich for his stellar work on 9100 nights, and to Jim Lefler from his colleagues at the VA for his exemplary patient care. And a very belated thank you to Chris MERRICK and his team of Aparna Swaminathan, DeAnna Baker, and Kedar Kirtane for planning and running intern practicum. And a final thank you goes to Dr Klotman for hosting a fantastic intern welcome party, with great representation from our faculty, residency council and ACRs as well. Pubmed from the program goes to Marc Samsky for his recent article with mentor Adrian Hernandez:  Cardiohepatic interactions in heart failure: an overview and clinical implications, Samsky MD, Patel CB, Dewald TA, Smith AD, Felker GM, Rogers JG, Hernandez AF.

J Am Coll Cardiol. 2013 Jun 18;61(24):2397-405. doi: 10.1016/j.jacc.2013.03.042. Epub 2013 Apr 17.

Please fill out your info for Erin for the website- she sent you an email survey. Venu Reddy is helping us shape things up for recruitment (yes, the year just started). Not surprisingly, our prospective Duke residents want to know about you! As you may have heard, both Laura and Shawna will be taking new positions at Duke. We will truly miss them and all the contributions they have made to our residency family. Please stop by the office this week and wish them well. Have a great week Aimee [box]

What Did I Read This Week

Submitted by Jon Bae, MD

Sheehy,A, et al. “Hospitalized but Not Admitted: Characteristics of Patients With “Observation Status” at an Academic Medical Center.” JAMA Intern Med, July 2013;

[/box] To admit or not to admit?  That is the age-old question plaguing gen med residents, particularly those with the privilege of covering 1010.  At its core, the question is really asking, “Is there something that can be offered to patient, therapeutically or diagnostically, that cannot be offered safely and timely in an outpatient setting?”  That this question is oftentimes very difficult to answer should come as no surprise.  What may be a surprise is how little standardization and training exists to help docs make these decisions.  Despite my tours of duty as a gen med house officer, and now after 4 years of hospital medicine, I still struggle with this determination.  Yet, even this is an over simplification as it does not account for “observation” or outpatient status.  Getting an admission consult from the ED becomes minefield of confusing terminology as we decide to admit, observe, or place in outpatient status.  How do we make sense of this?  Perhaps CMS will enlighten us with their definition of observation care: Observation care is a well-defined set of specific, clinically appropriate services, which include... treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital...(and) in the majority of cases, the decision...can be made in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases do… outpatient observation services span more than 48 hours. Clear as mud.  Perhaps we can define observation care by what it is not – an inpatient admission.  Medicare uses a number of screening tools to determine if a hospital admission is medically necessary (i.e. does a patient meet any “admission criteria”).  The principal tool used is the McKesson InterQual criteria, a large tome of algorithms and scenarios that attempt to use “intensity of service” and “severity of illness” to determine medical necessity.  There has been an increasing role for hospitals to employ Utilization Management to help sort this out, but ultimately it comes down to physician judgment.  Reflecting on this, it makes me cringe thinking of the times when I may have made the claim “this patient doesn’t meet any inpatient criteria”.  Did I even know what that meant? This decision, made by providers of highly variable experience, can have profound impact on patient care downstream that is often underappreciated.  For example, many of our patients have complicated medical needs post-hospitalization (e.g. nursing, wound care, IV antibiotics, physical therapy, or occupational therapy) that may be best provided in skilled care centers.  Yet, as a pre-requisite to qualify for this level of care, they must have three inpatient days (as opposed to three observation days).  What kind of unconscious (or conscious) incentivization does this promote?  For these patients, do we upcode to help those patients who don’t meet inpatient criteria to get them those precious 3 inpatient days?  More importantly, placement in observation may mean a greater degree of cost is placed on the patient.  For Medicare Part A patients who do not meet admission criteria, observation care is not covered.  Medicare Part B patients will cover some observation services although with higher deductibles, additional copays, and uncovered inpatient pharmacy charges.   And what about the patient’s experience in all of this?  For patients who are observed in the hospital, they go to the same patient rooms, interact with the same nurses/physicians, and receive the same therapies as the admitted patients.  How do you explain to them that “well, yes, technically you are a patient IN the hospital, but we are just observing you so you are not admitted”?  Confused yet? So, that brings me to the article in question in which the authors purport to describe the characteristics of patients admitted under observation status.  The study took place at University of Wisconsin Hospital and involved the review of 43,000 hospital stays (inpatient and observation).  Approximately 10% of the stays were for observation and encompassed 1,141 distinct diagnosis codes.  The mean LOS for observed patients was 33.3 hours with 16.5% lasting longer then 48 hours; for general medicine patients, 26.4% stayed >48 hours.  General medicine patients compromised the bulk of these observation stays (52.5%) with ¼ of medicine stays classified as observation.   Most interestingly, the authors found that there was a net loss of $331 per encounter for each observation case compared with a net gain of $2163 per encounter for an inpatient stay.  This was particularly exacerbated on medicine services where the net loss was $1378 per encounter.  As observation care has increased (from 3% of all inpatient stays in 2006 to 11% in 2011), it has resulted in financial losses for hospitals, which subsequently affects their capabilities for caring for populations of patients and a transfer of costs to patients.  All told, the authors concluded that observation status is not well defined.  Furthermore, the high proportion of observation patients with LOS >48 hours were not “rare and exceptional cases”, but rather quite common, particularly on general medicine services.  This is unlikely what CMS had intended when they originally proposed the definition of observation care. In an accompanying editorial (“Observation Status for Hospitalized Patients: A Maddening Policy Begging for Revision”), Bob Wachter (recent chair of the ABIM) highlights the inconsistencies in the CMS policy and discusses proposed changes.  These changes are needed and are clearly a step in the right direction. But in the meantime, we are still left with the lingering question of whether to admit (or obs) or not to admit?  And in the evolving, cost conscious world of healthcare, this makes sense.  Much of the focus on admission versus observation does come down to costs - to the payers, to the hospitals, and to the patients themselves.  And while I do believe that cost recognition has a role in our delivery of patient care, this focus highlights for me the potential pitfalls in cost conscious care delivery.  Specifically, how powerful are the drivers of cost consciousness (read “reduction”) in influencing the decision making of caregivers (especially trainees) when making determinations for whether patients should be admitted to the hospital?  What are the unintended (unforeseen?) consequences?  And why should the question be anything but “can we help this patient with our hospital care?”  That, my friends, is the real question.   [divider]

From the Chief Residents

Grand Rounds

Date:  July 26, 2013 Presenter:  Dr. Todd Kiefer Topic:  Adult Congenital Heart Disease

Noon Conference

This week is dedicated to enhancing physical examination skills.
Date Topic Lecturer Vendor
7/22 PE Week - Intro and CV Exam Arcasoy/Chetan Patel Pita Pit
7/23 PE Week - Daily inpt and new outpt exams Zaas/Arcasoy Jersey Mike's
7/24 PE Week - Abdominal and MSK exams Alastair Smith/Irene   Whitt Moe's burrito
7/25 PE Week - HEENT and Respiratory exams Simel/Hargett Domino's pizza
7/26 PE Week - Neurologic Exam Morgenlander Chick-Fil-A

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From the Residency Office

QI Corner

Updates from GME Patient Safety and Quality Council  (Jenn Rymer, GME PSQC representative) The first meeting of the academic year got off to a great start this past Tuesday, July 16th. Residents, fellows, and attendings from all departments were in attendance. We would like to have increasing involvement from our medicine residents in the five task forces created by this council. Each of these task forces will take on several projects throughout the year, and you have the opportunity to help with the selection of these projects. One exciting new task force is the Incentive Plan task force, led by Jon Bae and George Cheely. The GME targets for this year will be patient satisfaction, 30-day readmission rates, housestaff immunizations, and hand ashing with the potential for an extra $600 dollars at the end of new year. Other task forces are listed below: 1)    Handoff Task Force – Aaron Mitchell and Deana Miller plus Joel Boggan. This task force will look at issues surrounding housestaff handoffs. In particular, they will be reviewing how handoffs affect RRTs. 2)   Supervision Task Force- Tian Zhang. This task force primarily focuses on whether housestaff have appropriate supervision during their training. A focus is on issues of compliance with ACGME regulations. 3)   Resiliency Task Force- Sarah Dotters-Katz. Exciting work has been done at Duke in this area, particularly by Dr. Sexton and Dr. Bae. You may remember the 3 Good Things Initiative as a part of efforts to improve resiliency and decrease burnout among the housestaff. This task force will focus on ways to improve resiliency and decrease burnout among housestaff. 4)   Education Task Force- Sarah Dotters-Katz. Several initiatives have come from the efforts of this task force, including increased roll-out of the TeamSTEPPS program to housestaff, as well as the creation of badge cards which discuss components of SBAR and how to reach translation services. There are opportunities within each of these areas to initiate your own project ideas. If you have any questions or are interested in any of the above areas, please contact Jon Bae, George Cheely, Jenn Rymer, or Nick Rohrhoff. QI Craigslist: We are beginning to assemble a list of QI projects and resident interests.  From time to time, you may see postings here in weekly updates about project opportunities.  If interested in getting involved or if you have project ideas/interests, please contact Joel Boggan or Jon Bae Help Wanted Project: DOC Discharge Clinic Needed: 1-2 DOC residents Roles:
  • -participate in chart reviews/data extraction
  • -participate on Discharge clinic committee
  • -assist with project academic work (posters, abstracts)
Time commitment: 2-3 hours/month Follow Us on Twitter
  • @DukeMarines - Duke Chief Resident Updates
  • @JonBae01 - QI and patient safety (general news and program updates)
  • @bcg4duke - maestrocare and health informatics.
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

hyc_logo_med_trans       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. Shiprock Farewell 027(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.

How to Prepare for Professional Job Interview

What questions interviewee should ask and get answered? What questions should interviewee be prepared to answer? InterviewSponsor: American College of Physicians North Carolina chapter
  • When: Friday August 2, 2013
  • Where: Duke Medicine Resident Library 8th floor
  • Time: 7pm (Dinner provided)
This is a great opportunity to find out first hand what works - and what doesn't. The panelists include:
  • Dr. David Gallagher Hospitalist Medicine Duke
  • Dr. Lalit Verma Hospitalist Duke Regional Hospital
  • Dr. Saumil Chadgar Hospitalist Medicine/Academics
  • Dr. Jonathan Bae Hospitalist Medicine/Academics/Quality Improvement
  • Dr. Amy Rosenthal (Federal government/VA/Private Practice)
  • Dr. Sharon Rubin Primary Care/Outpatient
Please RSVP to Dr. Sharon Rubin sharon.rubin@dm.duke.edu by Friday July 26, 2013 The following attachment provides a list of some of the discussion topics: Thinks to know about a job and questions to ask  

Invitation to the Chapel Hill CareerMD Career Fair for Residents & Fellows

Physicians-in-training are invited to attend the Chapel Hill CareerMD Career Fair for residents and fellows on the evening of Thursday, September 12, 2013. Those who would like to attend are asked to RSVP online at www.CareerMD.com/ChapelHill or by emailing me at lesley.forsythe@CareerMD.com. Representatives from leading hospitals, practices, and healthcare organizations from around the country will attend the Chapel Hill CareerMD Career Fair to meet residents and fellows in all specialties and in all years of training. Residents and fellows who are nearing completion of their program will find the event instrumental to their job search, and those who are in earlier years of training can network with prospective employers and learn about stipend opportunities that may be available to them as they complete their training. Date & Time Thursday, September 12, 2013 Residents and fellows may attend any time between 5:00 PM to 9:00 PM Spouses and significant others are also welcome to attend Location Sheraton Chapel Hill Hotel One Europa Drive Chapel Hill, NC 27517 Cost Free-of-charge for all residents and fellows RSVP & Additional Information RSVP online at www.CareerMD.com/ChapelHill or by email to lesley.forsythe@CareerMD.com   Contact Information/Opportunities Internal Medicine OP Opportunities Carolinas HealthCare System 7-13-2013 MHC Internal Medicine Program Flyer  

Upcoming Dates and Events

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

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