From the Director
Interns are starting block 2 this week! Once again, congrats on an outstanding start to the new year. This weekend, a big thanks to our MICU team, including Allyson Pishko, Mike Woodworth, Nick Rohrhoff, Veronica Jarido, and Talal Dahhan, as well as Drs Govert and Hollingsworth and the entire MICU staff for a smooth transition to the new (amazing) MICU. It was nice to see them settling in to the new place!
Kudos this week also to Kristen Glisinski from the ICU team for her work on 9300, and to Scott Tolan, Chris Hostler and Adrienne Belasco for helping us out during Physical Exam Week. A big thanks to Dr. Arcasoy for planning a fantastic week of noon conferences!
Please fill out your website information for Erin if you haven’t already done so…it is the most important part of our website…prospective Duke residents want to know you!
Coming up this week is the fellowship interview discussion with Bill Hargett and me at noon on Tuesday in the med res library. Regular noon conference will take place in 2002 for interns, JARs and those not applying to fellowship this year. For those looking at attending jobs next year, please try to attend the job interview panel hosted by Sharon Rubin and the NC ACP (details below!)
This weeks pubmed from the program goes to Chris Hostler! We found his article while doing a lit search in afternoon report: Hostler CW and Chen L., Fidaxomicin for treatment of clostridium difficile-associated diarrhea and its potential role for prophylaxis, Expert Opin Pharmacother. 2013 Aug;14(11):1529-36. doi: 10.1517/14656566.2013.802307. Epub 2013 May 17.
Have a great week!
What Did I Read This Week
Submitted by Lynn Bowlby, MD
This has been an exciting time at the Duke Outpateint Clinic with the roll out of the year long DOC Redesign work. Among many new initiatives, we now are organzied into 3 large Stead Groups, with a Lead Stead Attending, and are hiring a second care manager and an advanced practice provider. In the analysis of our data over the past year during this redesign work, we saw the high number of patients with a mental health diagnosis, and the high utilization of expensive venues such as the ED. One of the most important metrics we will be following over the next year is the rate of ED utlization. Not only is the ED an expensive location of care, but due to the social and psychiatric complexitiy many of our patients are admitted from the ED. Handling the need for those acute unscheduled visits is a complex matter. This recent article in the Annals of Internal Medicine showed that we are not the only ones with this challenge.
In the US there are 2 general locations for these acute unscheduled visits, the ED and primary care. Acute unscheduled care is about 30% of the outpatient visits in the US. There is not a system in place to help patients determine where to go and when, they can be caught in the middle with financial and emotional punishment for the wrong choice.
Continuity of care plays into the mix as well, with low acuity acute needs not impacted by the lack of continuity, but acute exacerbations of chronic disease benefiting from continuity of care with the PCP. One popular solution is expanding the primary care workforce. Now only 42% of acute visits are with the PCP.
Much of health care reform is focused on reducing ED visits due to cost issues. The fixed costs of the ED are high, so the marginal cost of one extra patient may not be that much more than going to the PCP. The ED facility charges are the driver for the high cost.
Innovative solutions? a new business model for the ED with a different service line, similar to urgent care is one. The barriers for this is the profit from these visits is high, especially with commercial insurance.
Can the delivery model be changed in primary care? incentivize the primary care work force, after hours care, virtual care, alternative care prividers, health coaches are all ideas that are begin explored.
As we all plan ideas and solutions for our local challenges, good to know the national perspecitve as well.
From the Chief Residents
Date: August 8, 2013
Presenter: Dr. Mark Lanasa
|7/30||JAR/SAR Fellowship Prep AND Shock (Interns in MedRes)||Zaas/Hargett and Bergin||12:00||Bullock’s||2002 AND MEDRES|
|7/31||DVT/PE||Vic Tapson||12:00||Saladelia sandwich||2002|
|8/1||QI & Patient Safety Noon Conference: High Value Cost Conscious Care||Bae/Boggan||12:00||Sushi||2002|
On Tuesday, 7/30 Dr. Zaas, Hargett and chiefs will lead noon conference in the Med Res Library which will cover interview scheduling and advice for securing a great match. SARS currently applying for fellowship are strongly encouraged to attend. JARS planning to apply for fellowship are also welcome to attend.
The interns and medical students should report to the DN 2002 conference room. We’ll continue the emergency lecture series with “Shock”. Though not required, those attending the shock lecture should bring smartphones, tablets or any device with a web browser, as the session will be interactive.
Traditionally, Preclinic conference (PCC) has been held at each clinic site once the Intern Emergency Lecture series concludes. PCC was designed to deliver a core ambulatory curriculum but has been complicated by a number of logistical issues over the years. As we work to prioritize Academic Half Day and revitalize our core conferences, this important curriculum will be delivered in a different venue. As a result, we will no longer have a mandatory PCC. Each clinic site may still host events occasionally during what would have been PCC time as an additional opportunity to be involved in clinic improvements or other educational opportunities. More details to come soon!
From the Residency Office
Quality Improvement & Patient Safety Noon Conference
Join us for the first QI and Patient Safety noon conference of the year this Thursday, August 1. We will be kicking off our series of QI lectures on High Value Cost Conscious Care (one per month).
When: Thursday, August 1, 2013; Noon Conference
Who: Jonathan Bae - Introduction to High Value Cost Conscious Care.
Special Guest: Joel Boggan with QI Updates and the key to capturing bearded individuals and Hany Elmariah discussing his rotation burnout assessment study.
Come for the QI, stay for the AUDIENCE RESPONSE SYSTEM
Rotation Burnout Assessment (submitted by Hany Elmariah
- New 1-2 minute optional burnout survey Q2 weeks
- Fill it out to Stomp Out Burnout
- For more details, email Hany or see below
I wanted to let you all know about a new QI project we are starting that will make our residency program even better! Basically, we are trying to stomp out burnout among the residents in our program…essentially turning our residency program into a year-round vacation. But, we need your help!
The goal of the project is to identify factors in our program, like especially taxing rotations or the newish shift-work system, that seem to cause more burnout among the residents…a first step in eliminating or improving these factors.
So, what can you do to help, you ask? Basically, you just have to respond to our email survey to evaluate your level of burnout throughout the year. I know, I know, no one wants to do more surveys. The good news is, this survey takes LITERALLY 1-2 minutes, even if you read on a fourth grade level like all of the VA ACRs.
The surveys will go out every 2 weeks. We will follow your responses over time to see how each resident’s level of burnout changes over the course of the year. We won’t know what your responses are, but we will be able to follow your responses anonymously using a unique identifier (mother’s maiden name and birthday). Because the survey is intended to identify your level of burnout on the day it is sent to you, we ask that you please fill out the surveys within a few days of receiving it. If you forget to respond to one of the surveys, that’s okay…you can just start back up with the next one.
We will also be tracking survey completion rates by class year as well and hope to be able to reward the class with the highest return rate.
Of course, you don’t HAVE to participate in this survey, but we are really excited about this opportunity to make our program better, and hopefully you will be as well. The first cycle goes out to interns this Friday (tomorrow) for the end of block 1.
If you have any questions, please contact Hany Elmariah (firstname.lastname@example.org).Thank you all very much for participating!
QI Craigslist – HELP WANTED
Patient Safety Small Group Debrief - Help teach and debrief patient safety topics with rising MS2′s from 10:30-12:00 on Wednesday 7/31! You will be paired with a faculty member to lead 10 students in a discussion of PS topics, and to reflect upon the video, panelist testimonial, and lecture they receive that morning. Discussion questions and materials will be provided for your review beforehand. It should be a fun and engaging session! Sessions will be held in the new medical school building.
Handoffs Workshop - On Wednesday, 8/7, from 1-4PM, Rising MS2′s will receive a 1 hour introductory lecture on inpatient handoffs and then be broken up into small groups for hands-on case-based practice. Please join our faculty members in teaching and supervising these students as they take on handoffs, likely a brand new concept to them! Resident input and anecdotes will be invaluable to this session! You would be needed from 2-4 to help facilitate the small groups, and would be sent the materials and overview beforehand. Sessions will be held in the new medical school building.
If interested, please contact Aubrey Jolly Graham (email@example.com) ASAP! We are excited to get the students exposure to a variety of clinicians and residents during these sessions, and to give residents invaluable teaching experience!
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
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 – firstname.lastname@example.org)
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 email@example.com or 668-8352.
Picture from Kenya
Lindsay Boole share the following picture of from her experiences in Kenya with Anne and Dr. Kussin
TSMA (work done inside Duke for extra compensation)
The following policies apply to the moonlighting opportunities that are available to trainees:
At no time may the hours allocated for TSMA activities negatively impact training or violate duty hour policies. Residents who would like to be considered for Temporary Special Medical Activity (TSMA) in Oncology, Emergency Medicine, Cardiology, or Student Health must meet the following:
- Program level – either JAR or SAR
- Successful completion of rotations on MICU and Gen Med
- Be in good standing and without any active corrective action
- Provide written support from their advisor supporting the trainee’s request. The advisor may send an email to the attention of the Program Director, copy to the Program Coordinator, confirming their approval (to be completed prior to initiating the online TSMA form).
- Initiate the online TSMA form found on MedHub.
- Meet any additional training requirements as specified by the sponsoring department.
On notification of approval by GME, the trainee may contact the service Director and request approval to participate in the TSMA service.
Please Note: TSMA is approved only for each academic year. If you are currently participating in TSMA and plan to continue after July 1, you will need to resubmit the required forms for approval.
Cardiology (submitted by Dr. Matt Sherwood/contact for additional information)
“Our chief of service (and other attendings) have asked me to encourage the medicine residents to sign up for the weekend morning PAC and HFS rounding positions. They run from 7AM to ~12-1PM and pay $420. Light work, rounding on several patients and possibly discharging 1-2 of them”
Student Health (submitted by Dr. David Mellinger / contact for additional information)
“I am in the process of recruiting residents/fellows who are interested in working at Duke Student Health in a moonlighting capacity this academic year. We will be open only on Saturdays this year from 9am-1 pm, not on Sundays as we have done in the past. You can also let fellows know that with approval of their division they can participate as well. The residents/fellows will be staffed by an on-site attending and will be compensated at $75 an hour. Please announce this and pass on the information and have residents email me directly ASAP with questions and to express their interest.”
Upcoming Dates and Events
- August 16th Program Wide “Summerfest Party” at the Zaas’s