Weekly Updates: August 5, 2013

By admin3

From the Director

DUKE.RESEARCH.NIGHT.03 (1)Happy August! And the end of a long "Block 1" for our JARs and SARs.  I hope we say it enough, but thanks to you all for an incredibly fantastic start to the year.  The SARs, Krish and I enjoyed a celebratory lunch at Nosh and the JARs celebrated at the VA as well. We had our first JAR dinner, so thanks to Joe Brogan, Carli Lehr, Amera Rahmatullah, Sneha Vakamudi and Allyson Pishko for joining me at Pizzeria Toro. JARs, we'll be sending out the August date this week, so keep an eye out. This week we have kudos to Nina Beri for her grand rounds intro, to Howard Lee for great work on the hepatology consult service, to Liz Campbell for being extremely helpful to a colleague at the DOC, to Kevin Shah for filling in a coverage gap in the CCU, Hal Boutte for a great chair's conference, everyone for awesome chair's conference participation, and to Chris Hostler for organizing the First Annual White Coat Housestaff vs Faculty PAINTBALL extravaganza! Date is still in the planning stages, but check your emails and sign up! Please check your BLOCK FOUR schedule for your IN TRAINING EXAM DATE (categorical interns, JARs, SARs, Med Peds and Med Psych).  We have a limited window of time that we are allowed to offer the In Training Exam, so Lauren and the chiefs have worked hard to balance the coverage of teams and the ITE dates. Also, we had a great noon conference with the SARs regarding fellowship application interviews.  For more information, check Medhub --> resource documents --> fellowship. Its time to order your MKSAP 16 — instructions below.  Remember, we get you a MKSAP one time in your training (digital version), so please take advantage of this offer!  VA Gen Med THANKS to our JARs for a rockin 5 weeks at "Club VA Gen Med".  And also to our SARS for the 5 weeks of maestro filled greatness at Duke Gen Med. Also kudos to Sajal Tanna for winning the noon conference attendance prize (2 Durham bulls tix) for July! 19 conferences!!! This week's PUBMED FROM THE PROGRAM goes to Nina Beri for her upcoming oral presentation at the International CLL meeting in Germany! "Molecular and clinical associations between Vitamin D and Chronic Lymphocytic Leukemia".  This work was done under the mentorship of Mark Lanasa. Have a great week! Aime [box]

What Did I Read This Week

Submitted by Bill Hargett, MD

Eberlein M, Reed RM, Bolukbas S, Parekh KR, Arnaoutakis GJ, Orens JB, Brower RG, Shah AS, Hunsicker L, Merlo CA. Lung Size Mismatch and Survival After Single and Bilateral Lung Transplantation. Ann Thorac Surg. 2013 Jun 26. [Epub ahead of print]  PMID: 23809729. [/box] There was not specific clinical question or motivation for reading this article beyond general intellectual curiosity… I just recently ran into it while perusing the literature to stay up to date. Background: The Lung Transplant Program Duke is one of the largest and most successful in the world.  Despite working with the most challenging cases (e.g. complex patients turned down by other centers, multi-organ candidates), our post-transplant outcomes such as survival are significantly greater than national averages.  Our research efforts work in concert with our clinical care and we’re particularly adept at rapidly incorporating new findings directly into improved patient care. Methods: •              Design – cohort (prospective database) •              Patient Population – approximately 7000 adult first time lung transplant recipients in the UNOS registry between May 2005 and April 2010 (post-LAS era) •              Prognostic factors – pTLC-ratio (the ratio of donor:recipient lung size calculated from gender and height) •              Analysis – Kaplan-Meier survival and Cox proportional hazards models; cohorts were stratified (bilateral vs. unilateral) and subsequently grouped by pTLC-ratio quartiles •              Outcome – Risk of death at 1 year after transplantation •              Follow-up – Patients with missing information or aberrant values (suspected data entry error) were excluded Results: •              In bilateral lung transplants patients, each 0.1 increase in pTLC-ratio was associated with a 7% reduction in the risk of death at 1 year (HR 0.93, 95% CI 0.88 to 0.98, p = 0.01); multivariate model included diagnosis, comorbidities, acuity, donor, and transplant factors •              Stratification on propensity scoring (ordinal quintiles) supported the treatment effect •              The pTLC-ratio was not associated with 1-year survival in unilateral lung transplant patients Comments: This is one of those fun articles that produces a stampede of thoughts, ranging from the most basic (estimating validity) to much broader and more complex considerations (e.g. organ utilization, outcomes pathophysiology), so I’ll keep things brief and highlight a few things I found interesting. Face validity is pretty reasonable, though some of the details regarding patient accounting are not provided and both the heterogeneity of transplant protocols and changes in practice and experience over the study interval are important unmeasured variables. That a higher pTLC-ratio (suggesting an oversized allograft) may be associated with improved survival after bilateral lung transplant is a pretty cool thing to think about.  A good first question is whether the measurement of the treatment, in this case is the pTLC-ratio, is meaningful and appropriate?  As you may recall, prediction equations for PFTs consider age, gender, and height and were derived predominantly from nonsmoking Caucasians of northern European ancestry.  There are multiple equations and correction factors available but, in short, the methodology for determining pTLC is not standardized and the pTLC-ratio is not necessarily a reliable marker of size matching.  This is only further confounded in the context of changes in thoracic size in patients with end-stage lung disease.  In this study, it’s completely unsurprising to find a relative surgical (and survival) advantage in patients who were “very oversized” (and in whom there was a disproportionate percentage diagnosed with COPD). Among the amazing and complex care we provide for our pre- and post-transplant patients, how much does donor-recipient lung size discrepancy impact clinically important outcomes?  Smaller studies have produced more variable results and there is also some support for size-reduced allografts.  Oversized allografts implanted into a smaller thoracic cavity may physiologically contribute to post-operative complications due to atelectasis, bronchial anatomy distortion, and impaired airway clearance (variable data on the effect on pulmonary vascular resistance).  Presupposing that oversized allografts do indeed confer a survival advantage, what might be the mechanism?  This also remains uncertain but my favorite hypothesis would be the relative reduction of ventilator associated lung injury in allografts receiving relatively lower tidal volumes (i.e. less “hyperinflation” leads to improved allograft function and survival) though I’m sure some surgeons and pulmonologists might disagree. In the big picture, how the size of the donor lungs relative to the recipient impacts outcome remains uncertain but any area that might improve organ utilization and survival is an exciting opportunity for further research. [divider]

From the Chief Residents

Grand Rounds

Date:  August 9, 2013 Presenter:  Dr. Jennifer Green

Noon Conference

Date Topic Lecturer Vendor Room
8/5 Lung Transplants Laurie Snyder The Picnic Basket 2002
8/6 Hazards of   Hospitalizations Tony Galanos Jersey Mike's 2002
8/7 IM-ED Combined   Conference Tiffany Christensen Moe's 2002
8/8 EKG Interpretation Al Sun Dominos MEDRES
8/9 Chair's Conference Chiefs Chic-fil-A 2002

Chief Residents - Get to Know us Better!

It is a real challenge to find the opportunity to work with everyone in our program as closely as we would like.  Unfortunately this means we do not have the chance to get to know everyone well as we start off in the new year.  With this in mind, wboggan_1e thought it would be helpful if we shared a little more about ourselves, including our training background, interests, and our goals for this year as chief residents. First up - Joel Boggan, who is our Chief Resident for Quality and Patient Safety a the VA Medical Center. "Throughout residency, I became interested in projects related to quality improvement, even though I wasn't aware that's what they were at the time.  First, I worked on antibiotic resistance and how we report it in antibiograms, and then I helped out on a hypertension control audit and feedback project.  Around the time that second project was kicking off is when I realized these really were QI-related and I really enjoyed this type of work.  Second, I got involved with the GME Patient Safety and Quality Council, mainly by chance rather than purpose, but I developed a strong interest in handoffs and was able to continue some very important work that originated with a group of SARs within our program and has now become a set of precepts we shared with many other departments.  If you've had your handoffs assessment already this year, know that those evaluations came directly from your preceding peers!  Overall, I think our program offers lots of resources and experts to speak with you if you have a specific interest, or, if like me early on, friendly perspectives if you don't know exactly what you want to do.  And, you'll definitely get great clinical training to go with it!  Other things I love talking about are food and where to get it in Durham, backpacking, travel, and Duke basketball, when it's time . . ." Joel

VA Prime Policy Updates (submitted by Sonal Patel, MD)

"I wanted to spend a minute and review the late policy that we are going to start implementing in PRIME clinic.  Remember however that you should always use your discretion and there are always extenuating circumstances where it would be helpful to bend rather than have everything in black and white. Be mindful and understanding of patients that are elderly, ill, inclement weather, have traveled a great distance for the first time to PRIME clinic  and underestimated the time it took to get to the VA.  Please use your judgment and see how busy you are at that time and if other patients have checked in.  It is OK to see patients for abbreviated visits or reschedule if you are busy, use your judgment.
  1. “Late” is defined as checking in for an appointment 15  minutes after the scheduled appointment time.  Any patient who      arrives before this time will be considered “on time” and will be seen by the provider for which his appointment is scheduled.
  2. If a patient is over 15 minutes late, the Clerical Support Staff will alert the Resident Provider and ask if there is a possibility that the patient can be worked in or seen at the end of clinic
  • If the resident provider agrees, Clerical Support  Staff will let patient know that the visit will be abbreviated and patient might have to wait until a no show to be fit into clinic or wait until end of clinic
  • If the Resident Provider cannot see the patient in his/her own clinic that day, the RN will be notified to assess the patient’s needs-  if needed if there are any open time slots that day or in the next couple of days the patient will be rescheduled with another provider or the patient’s own provider depending on patient preference and provider availability
  • If there is no urgency and patient is rescheduled, RN will let resident provider know if any medications or orders need to be placed for patient before his rescheduled appointment
Also PRIME staff was requesting to please be aware of the time for patients that are seen later in the afternoon. For example for your 3:30 patient, if you do not finish seeing your patient and send him/her for checkout at 4:30 or later, the patient still needs to be seen by the nurse, seen by the clerk and often times then to EKG or Lab or Radiology or other clinics that might be closed. Please try to have patients out of your clinic room by 4:15p if possible so the nurse and clerk can finish up with the patient in a timely manner.  Of course the staff realizes that this might not always happen if a patient shows up late or if a patient is complicated but the staff politely requested that you try and have the patients out of the clinic room and to check out by 4:15 if possible.' [divider]

From the Residency Office

QI Corner

'High-Value, Cost-Conscious' Care QI Lecture Numero Uno Thank you to all who made it to our first Quality and Safety Noon Conference this week for an "Introduction to High-Value Cost Conscious Care".  We hope we highlighted some of the nuances within Cost-Conscious Care, how we might think about costs and benefits of specific tests, and illustrated how different strategies for diagnosis can lead to vastly different billing charges.  This is the first of a several-part lecture series we'll be doing throughout the year, complete with QI updates (as shown below)! If you missed it and would like to watch online, the link is below. https://meded-media.duhs.duke.edu/Mediasite/Login?ReturnUrl=%2fMediasite%2fCatalog%2fFull%2f80e6c8ac20b04a88bee5c9fec486c7c721%2f%3fstate%3dsX1EcDKPbaFbRH0M0waS The two articles (attached) complement the lecture.  The first provides a framework for how to think about the levels of benefit vs. cost for studies we order, while the second estimates the amount of waste within healthcare. Clinical Guidelines, ACP, HVCC     Eliminating Waste in US Healthcare Berwick Stay tuned for our next Quality and Safety Conferences: 8/21/2013: Dr. Luke Chen presents Hospital Infection Control/Hand Hygiene 9/25/2013: High Value Cost Conscious Care Series, Lecture 2: "Healthcare Waste, Costs, and Over-ordering of Tests" by Dr. Dan Kaplan Rotation Burnout Assessment The first batch of rotation burnout surveys have been distributed via email.  Please look for these in your inbox and fill them out promptly.  You will be receiving these are every rotation this year, and we plan to use these data to determine which rotations/schedule types are most prone to burnout.   For any questions, please contact Hany Elmariah <hany.elmariah@duke.edu>. GME Incentive Program/Hand Hygiene Beginning Thursday, our hand hygiene compliance went online for the Incentive Program.  This is our program-specific metric (along with the other three mentioned before Jon's lecture), and housestaff can earn a total of $600 EACH by the end of the year if we reach the goals. Data - HH Our target for hand hygiene will be >90% compliance (overall) for 8 of 10 months between August and May, meaning we're already being watched.  Here's the July run-in data, just to show where we stand.  As you can see, we have some work to do. . . If you are interested in learning more about the Incentives, please contact Joel Boggan <joel.boggan@dm.duke.edu> or Jennifer Rymer <jennifer.rymer@dm.duke.edu> QI Craigslist Update HELP WANTED: Patient Safety Case Reviews: Need 1-2 resident to help review approximately 25 cases for categorization of root causes Possible academic output = poster +/- publication Estimated 3-4 hours/work/month Contact Jon Bae <jon.bae@duke.edu> if interested. Bears Pulling Trash Cans If you know any amazing YouTube videos or funny links that need to be viewed, send them to Joel & Jon.  We may share them, but mostly we just like to laugh . . . Follow Us on Twitter - @DukeMarines - Duke Chief Resident Updates - @JonBae01 - QI and Patient Safety (general news and program updates) - @DukeDOMQuality - Duke DOM Quality Updates - @bcg4duke - Maestrocare and health informatics

Where Can I Find Lauren Dincher?

As you may have noticed, Lauren has a new "home", and has moved to the office that is right across from her old desk.  This move is not without a lot of planning, and also is in recognition of Lauren's growth in level of responsibilities.  Lauren is taking over ALL of the scheduling duties for the program, and in doing so has been recommended for promotion to Staff Specialist.  Yes, she still serves as our notary, but many of her other duties have been reassigned.   Lauren's goal in moving to the new office is to ensure an added level of privacy when needed and to find some "quite space" to allow her to focus on the complex tasks of managing the schedules for over 150 residents. So, if you come by the office - it's OK to stop by and congratulate her, and when it comes to scheduling questions - Lauren is your "go to" person. You will also see that Lauren's old desk is now occupied by Toni Nicholson. Toni has joined us from Duke Temps as we work though realignment of duties and work to fill the position that was vacated by Shawna Alkon. Lauren - CONGRATULATIONS, and thanks for all that you do!!

MKSAP

The program encourages residents to take advantage of the opportunity to obtain Medical Knowledge Self-Assessment (MKSAP) at a significantly discounted rate. How?  First, you need to become a member of the ACP. Associate membership costs $109/yr https://www.acponline.org/membership/dues/new_us.htm . Please make note to record your ACP # – you will need it to complete our online request form
  • Which MKSAP format do you want?
The cost for Digital MKSAP 16 is covered by the program – simply complete the order blank using the following link. https://www.surveymonkey.com/s/SBL8C7B If however you request MKSAP 16 Print (hard copy), or the complete set, you will need to cover the additional cost. MKSAP 16 Digital – $389 for members (paid for by the program) MKSAP 16 Print – $389 for members (your cost $50) MKSAP 16 Complete – $629 for members (your cost $290) includes Digital and Print copies Summary:
  • This offer is open to all      Categorical, Med Peds, and Med Psych trainees who have NOT previously      received a copy of MKSAP
  • We cover the cost of the MKSAP16 Digital release
  • You are required to be a current ACP member to participate
  • You have the option to request the printed version or complete set – but you will need to cover the      additional cost
  • We do not place orders randomly at different times in the year.  This offer is for a limited time only – ending on August 18, 2013.

Inservice Training Exams (ITE's)

Weeks of work to map out a schedule to ensure that everyone is slotted in to take the ITE's has come to a close. The schedule is now loaded in MedHub, and the complete schedule is also posted in MedHub as a resource document.  Our office will send out reminders, but please take special note of your assignment. Just in case you wonder why we put so much effort into ITE's, its not just that they are required.   As examples of how they are used, the reports (individual) may offer you insights as to what areas to focus on in preparation for the boards, are a tool referred to by your advisor,  and in the aggregate help us determine what changes and should be incorporated into the training program.

Learning Portfolio - Residents AND Core Faculty

In accordance with the ACGME’s Next Accreditation System(NAS), we are required to report on the scholarly activity for our residents and core faculty on an annual basis.  To assist us in the process, we are asking all Internal Medicine residents and core  faculty members to maintain a current list of their publications, presentations, awards, etc., in the Learning Portfolio area of MedHub.   You can find the tab to access this section on the header of our MedHub home page.   If you have any questions, please feel free to contact Jen Averitt in the MedRes  office (jen.averitt@duke.edu) As a reminder to all residents and core faculty, PLEASE complete and return the scholarly activity worksheet that you were sent via email no later than 8/15/13!

Now Accepting Applications for Global Health Elective Rotations

hyc_logo_med_trans 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. Global Health 8-5(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.     Contact Information/Opportunities 130729 - INTERNAL MEDICINE  

Upcoming Dates and Events

  • August 16th  Program Wide "Summerfest Party" at the Zaas's

Useful links

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