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Internal Medicine Residency News: January 27, 2014

From the Director

DUKE.RESEARCH.NIGHT.03 (1)Hello everyone! First, a FINAL thank you to the entire program for an amazing recruitment effort! A special thanks to Erin Payne and Dave Butterly for their phenomenal work putting together fantastic recruitment days for our applicants, and to Lynsey Michnowicz, Lauren Dincher, Jen Averitt and Randy Heffelfinger for the on the scene and behind the scenes help.  Additional thanks to our fantastic chiefs and APDs for coming in early, talking with applicants and helping us show them that we are the best place to do residency!  Our ACRs (Jim Gentry, Lindsay Boole, Chris Hostler and Mandar Aras) were extremely helpful in hanging out with applicants as they waited for interviews and organizing reports and chairs conferences, taking applicants to rounds and stepping in to give tours. Thanks to our Gen Med SARs and interns for hosting applicants on rounds, and also to all those who did tours and resident share (including Jesse Tucker, Adrienne Belasco and Lindsay Boole for Friday’s share).  I know many of you have communicated with the applicants that you know from med school and that is much appreciated! Can’t wait to bring in a new outstanding intern class.

Kudos this week go to Chris Merrick from a family he cared for at the DVAMC (thanks Mike Cicale for sending this in!) and to Myles Nickolich from a 9300 family (thanks to Chris Jones for sending this in!).  Sneha Vakamudi gave an outstanding chair’s conference on Friday, and we had really great audience participation, with Audrey Metz leading the discussion.  Also to Marcus Ruopp and Jenn Rymer for working on the Discharge Rapid Improvement Project with Jon Bae and team.  Other kudos to Ryan Huey for helping DOC residents identify patient panels in Maestro, to Adrienne Belasco, Marcus Ruopp, Andy Mumm and Dinushika Mohogitte for spear-heading the PCP continuity subgroup of DOC Kempner Stead (B) and to Adrienne Belasco and Marcus Ruopp for creating a PCP “owner’s bill of rights” (thanks also to Dani Zipkin for letting us know about these great efforts)!

Do you want to know how the DOC redesign efforts of last year are working?  Word is they are PHENOMENAL! Talk to Alex Cho for more details, and great work on the parts of the entire DOC team! This ongoing effort really exemplifies the mission to care for our patients in the best possible way.

Stephen Bergin and I got the opportunity to visit PRIME clinic this week.  We are looking forward to having the DRH ACR visit PRIME to co-precept with the great attendings there, and to share best practices between the DOC and PRIME. Dr. Patel will be contacting many of the PRIME residents to meet and work together to enhance the PRIME experience for residents and patients.

Congratulations to Chris and Carol Hostler on the birth of Cameron Hostler, the newest VA Jet!  I don’t think they make Jets jerseys in newborn size, but I am sure he will have his share of American flag onesies!

Please take the time to fill out your ACGME survey!  We are inching towards the required 70% mark, and I appreciate all who have taken time to log in and do the survey.  We have until FEB 16th, so please check your email, log in and fill out the survey!

Pubmed from the program this week goes to Tim Mercer, who is one of several residents who will be presenting at the upcoming Society of Hospital Medicine meeting (others to follow in subsequent Med Res News!).  Tim’s poster is THE HIGHEST UTILIZERS OF CARE: INDIVIDUALIZED CARE PLANS TO COORDINATE CARE, IMPROVE HEALTH CARE SERVICE UTILIZATION AND REDUCE COSTS AT AN ACADEMIC TERTIARY CARE CENTER.

Have a great week, (Subliminal message: fill out your ACGME survey), and stay warm!


VA Jets Recruit Early!

HostlerChris Hostler shared the following picture of the newest addition to their family – and the VA Jets.  CONGRATULATIONS!

“Cameron David Hostler, born at 8:19 pm. Mom and baby are doing great!”



What Did I Read This Week?

“Submitted by Krish Patel, MD.”

Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA.2013;310(21):2262-2270. Dec 4 2013 

Why I read this: It’s been really amazing to reflect on the increasing awareness and focus on quality improvement that has taken place in the program since my intern year.  Through the tremendous efforts of our program leadership and Jon Bae’s undying enthusiasm (yes Jon I promise I did all my QI modules!!!) thinking about and finding opportunities for QI has really become an integral aspect of our day-to-day experiences.  Handoffs are a great example of such a QI opportunity.  As work hour changes have shaped changes in our care models, we have all been increasingly aware that the numbers of patient handoffs and potential adverse events related to handoffs have increased.  The AHRQ (Agency for Healthcare Research and Quality) and ACGME have both identified improving handoffs as an important national effort and the ACGME now requires residency programs to provide formal handoff instruction.  This issue of improving handoffs is not unique to our program and as we navigate the challenges posed by increasing numbers of handoffs I’ve been wondering what other institutions have been doing to meet the challenge.  To date, there have been a number of different strategies assessed in the literature to improve handoff processes but the data from prior studies have been mixed and ultimately the impact of these strategies on actual patient outcomes is at best unclear.  This study was recently published in JAMA and is a bit more robust in terms of study design and outcomes reported than some of the Krish Patel, MDprior studies.

Background:  This observational study out of Boston Children’s Hospital sought to bundle a number of previously studied strategies for improving handoffs into a single standardized intervention and assess outcomes in terms of adverse events and medical errors pre and post intervention. The study took place on two different pediatrics units.  Both units had a mix of high complexity and subspecialty patients.  It included PGY1 and PGY3 trainees rotating on the two units over a roughly 6-month period of time (July 2009 to Jan 2010). The handoff intervention (or bundle) that was implemented combined communication training, use of the SIGNOUT mnemonic, and modifications to handoff environment to minimize interruptions during handoffs (quiet dedicated space etc.).   Furthermore, one of the two units incorporated use of a partially EMR generated handoff tool (similar to our Maestro generated signoff reports) which included auto-imported variables such as vitals, meds, problem list, code status etc.  I won’t go into the nitty gritty details of how adverse events and medical errors were observed, collected, and reported, but suffice to say it was a fairly rigorous process that adhered to accepted standards used in the medical safety literature.  It even included independent blinded review of all adverse events and medical errors reported by the initial study personnel.  In addition to following patient safety outcomes, the study also assessed resident workflow patterns (i.e. time spent on various tasks) to determine whether the bundle might have a negative impact on typical resident workflow.



This table summarizes the major primary outcome: there was a statistically significant reduction in overall medical error rates from 33.8 per 100 admissions pre intervention to 18.3 per 100 admissions and a significant decrease in errors classified as adverse or potentially adverse events (clinically meaningful). As you would expect, errors classified as non-preventable did not differ pre and post intervention. Most of the errors reported in the study were related to medications (~77%).  Also, the intervention did not appear to adversely affect resident workflow.  There was no significant change in time spent on handoffs, time spent on documentation, or time in front of the computer post intervention.  Interestingly, resident time spent with patients and families did significantly increase (8.3% vs. 10.6%; p=0.03) in the post intervention group.  This was mostly driven by significant change on the unit using a computer generated handoff tool.

What does this mean for us?

Well this data shows that implementing a systematic handoff bundle can help reduce medical errors and specifically reduce clinically meaningful errors (adverse or potentially adverse events).  There are of course a few limitations of this study that are worth touching on.  This study was done on a pediatric unit, so its ultimate application to adult patient care units may vary.  But many of the types of errors that existed in this study (med related), exist in adult care settings with similar incidences.  Some might point out that the post intervention data collection also occurred during a later period in the resident’s academic year, so there is always the potential that some of the improvement in error reduction was a result of improved resident experience/emerging competency.  But that’s unlikely to explain all of the improvement, as there are numerous studies that show that medical error rates in teaching hospitals don’t seem to change as much from July to December as we often believe they might. Then there is always the matter of the Hawthorne Effect (changes in behavior related to being observed as opposed to due to intervention being studied) to consider. And finally, the study personnel reporting errors in real time were not blinded to the intervention and even though there was blinded review of the reported events, the physicians reviewing the events had only moderate interobserver agreement about the categorization and preventability of the reported errors.  While not always straightforward to implement, a randomized study, with blinded data collection might have mitigated some of these potential confounders.

I think, limitations aside, this study supports our continued efforts to standardize handoff training. We already employ several of the strategies used in this study (EMR handoff tool, SIGNOUT mnemonic).  As we prepare for new interns in July (crazy to think they’ll be here sooner than we realize), I think this study provides a good evidence-based framework for how to structure handoff training.

QI Corner (submitted by Joel Boggan)

Thanks to Dr. Peter Ubel for leading us in a great discussion at M&M last week.  More of his work can be found on Twitter or through Forbes magazine’s website.

QI Conference
Dr. George Cheely
will be giving our next QI noon conference on ‘Overcoming Barriers to High Value, Cost-Conscious Care’ on Wednesday, 1/29, in 2002.

From the Chief Residents

SAR Talks

SAR Talks: January 30, 2014

Tyler Black and Jodel Giraud

Grand Rounds

January 31, 2013:

Dr Craig Brater – Visiting Professor
Topic: Diuretic Resistance

Noon Conference

Date Topic Lecturer Time Vendor
1/27 MKSAP Mondays 12:00 Pita Pit
1/28 MED   PEDS SAR TALK (Balasubramanian/Sudan) 12:00 Chick-Fil-A
1/29 IM-EM   Combined QI Patient Safety Noon Conference Cheely 12:00 Cosmic Cantina
1/30 SAR talks Tyler Black / Jodel Giraud 12:00 Sushi
1/31 Research   Conference 12:00 Panera

From the Residency Office

SAR Class Pictures

Please mark your calendars for Friday, February 14th immediately after Grand Rounds.  The group picture will be taken at 9:15am in the Duke Cancer Institute healing path (the lobby).

Thankful to capture such a remarkable class!!  Erin

Attendance At DoM Grand Rounds

As you may have noticed, there are changes underway as to how we record attendance at DoM Grand Rounds.   For the past 4 yrs we have captured attendance with a bar code scanner.  The data that we capture is uploaded to MedHub, and for faculty who wish to have CME credit, is uploaded to the CME office database.  Effective February 1, 2014, this system is being replaced with a new record keeping system called Ethos.  Internal Medicine will be using this new system to track residents’ attendance at Medicine Grand Rounds.  In addition, other services will also be using Ethos to track conference attendance, so it is very important that you take the time to register, per the instructions below, ASAP.  We will continue to use the card scanning method for Noon Conferences for the immediate future.

Many thanks in advance for taking the time to register for this new system at your earliest convenience!

How to register with Ethos

  • Go to the Duke Continuing Medical      Education home page.
  • In the upper right corner, click Join. The Account Information page opens.
  • Complete the fields on the screen. A field with an asterisk is required.
  • NOTE:  Please make sure you include your Duke Unique ID –  even though it does not show as a required field.
  • Be sure to include your mobile phone number; you will use this number to send a text message with a code supplied at each event and get credit for CME events you attend.
  • At the bottom of the account information form, click Create New Account. A green feedback message near the top of the screen informs you that a confirmation has been sent to the email address you      provided.
  • Open the email (from and click the top link in the body of the message.
  • In your browser window, enter a password of your choice in both fields and note your user name. Click Save at the bottom of the page.
  • In the same window, click the Mobile settings tab in the gray menu bar at the top of the page. If you entered your mobile number when you registered, it should appear on this page. Click confirm      number. You will receive a text message to that mobile number with a confirmation code from DCRI CME.
  • Enter the confirmation code in the box in your browser window and click Confirm Number. A message will appear below your number saying “Your number has been confirmed.”
  • Now when you attend an event for CME credit you can use your registered mobile phone to text the provided event codes and earn CME credit.

To record your CME attendance via text message, follow these steps

  • The 6-character SMS code will be provided on a slide during your CME event.
  • Begin a new text message on your registered mobile phone. Note: The provided code is only good for eight hours. You must text the code the day you attend Medicine Grand Rounds.
  • In the To field, enter the Duke CME phone number: 919-213-8033. Tip: Add this number to your mobile phone contacts.
  • In the message area, type the 6-character SMS code that was provided during the session (note: this code is not case sensitive).
  • Press send.
  • If you have set up your Ethos account, you will receive the successful confirmation text message, “Your attendance has been recorded for “[Name of Session].”

To view your CME training history

  • Log into Ethos by visiting the Duke Continuing Education home page and click Log In at the top right of the page.
  • Enter your username and password. Click My Account in the upper right corner.
  • Navigate the gray toolbar and click My Activities.
  • Click Transcript to view and search completed activities.
  • Click the Courses (in progress) tab to view pending activities.
  • Medicine Grand Rounds are listed at  Consider bookmarking this link in your browser for quick access.

MKSAP – Mid Year Opportunity

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 . 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 either the hard copy or digital MKSAP set is covered by the program – simply complete the order blank using the following link.


  • This offer is open to all  Categorical, Med Peds, and Med Psych trainees who have NOT previously received a copy of MKSAP
  • You are required to be a current ACP member to participate
  • You have the option to request the printed or digital version.  Should you want the complete set you have 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 February 9, 2014.

Annual Faculty Resident Research Grant applications are due on April 11, 2014.

Please find attached the forms and the link to our website below where the application instructions, forms and NIH format biosketch example can also be downloaded.

Please note that each proposal must have a Human Subjects section that describes the protections of the patients and patient data, describe the consent Murat Arcasoyprocedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues related to your project. Upon approval of the grant at the end of this academic year, each awardee will be asked to please submit a CITI human subjects basic training certificate.

Please email for any questions and look out for the Open Office hours coming up in February to schedule an appointment.

Faculty Resident Research Grant Application Forms-2014

Faculty Resident Research Grant Instructions-2014

Human Subjects example

Wishing you continued success with your research projects !

Murat and Aimee

new Best Practice Advisory (BPA) has been activated in Maestro Care to help prevent anticoagulant administration in patients with an epidural or regional catheter in place.

The BPA will read:

“An anticoagulant and epidural have both been ordered on this patient. Check with Anesthesiology before proceeding.”  A screen is included below.


Purpose of the BPA: to warn providers, pharmacists and nurses of the dangerous combination of anticoagulant therapy in a patient with epidural or regional catheters.

The BPA will read “An anticoagulant and epidural have both been ordered on this patient.  Check with Anesthesiology before proceeding.”  This BPA will fire at these points:

  • When an ordering provider enters an order for an anticoagulant (see list of medications below) on a patient with an active order for epidural or deep regional catheter (sciatic or lumbar plexus).  The provider should select “I will discontinue order” and proceed to cancel the order with an acknowledgement reason of “Contraindicated”.
  • If the ordering provider opts to not remove the order, the BPA will fire again upon  order signature
  • The BPA will fire again when the order reaches Pharmacy for verification.  Pharmacy should verify Attending APS approval.
  • The BPA will fire one final time at the point of medication administration.  The nursing staff should again verify Attending APS approval.

Anticoagulants that trigger the BPA:

abciximab   (Reopro) alteplase (tPa,   Cathflo Activase) anagrelide   (Agrylin)
apixaban   (Eliquis) cilostazol   (Pletal) clopidogrel   (Plavix)
dabigratan   (Pradaxa) enoxaparin   (Lovenox) eptifibatide   (Integrilin)
fondaparinux   (Arixtra) prasugrel   (Effient) reteplase   (Retevase)
rivaroxaban   (Xarelto) tenecteplase   (TNKase) ticagrelor   (Brilinta)
ticlodipine   (Ticlid) tirofiban   (Aggrastat) warfarin   (Coumadin)

 Lisa Clark Pickett MD FACS


Resident/Fellow Survey Instructions Now Open

Program Scheduled: Duke University Hospital Program – 1403621320

Survey Timeframe: January 13, 2014 – February 16, 2014


Residents that started the program off-cycle (after Aug 31 of the current academic year) will not be asked to participate in this year’s implementation.

  • 1. Open a new window using your internet browser (Internet Explorer [8.0 or higher]; Firefox; Google Chrome; etc.)
  • 2. Click the following URL, or copy and paste it into your internet window’s address bar –
  • 3. Your username for this survey is the program’s 10-digit number – 1403621320
  • 4. Your password for this survey is unique to you. It will consist of your date of birth, followed by the LAST TWO letters of your LAST NAME.

For example, if we want the password for Mary Smith, born 01/01/1969 (or January 1, 1969):
The birth date with no slashes is 01011969 and the last two letters of Mary Smith’s entire name are ‘t’ and ‘h’, making her password in this example – 01011969th

Every username and password must be changed upon initial login. Please remember your new ID and password. You can use it to re-access the survey until your program’s deadline.

You will have until February 16, 2014 to complete the survey. Responses may be modified anytime during the reporting timeframe, using your CHOSEN username and password to log in. Contact your program coordinator if you encounter problems or have questions.

Jennifer L. Averitt


RESIDENTS, FELLOWS wanted to be “SUPER USERS” FOR MAESTRO CARE Go LIVE : at Duke Regional and Duke Raleigh Hospitals:  OPPORTUNITY FOR TSMA (“internal moonlighting”)

The Need:   To support providers going Live on Maestro Care at Duke Regional and Duke Raleigh.  We are again offering “moonlighting”  (TSMA)  shifts for the first two weeks of the Go Live.  These are nonclinical at- the-elbow support on the floor supporting other providers in the first two weeks of March, 2014.  Pay is $75/hour.   Most shifts are during the weekend and evening times with more limited opportunities for regular AM shifts.  We are looking for more coverage the first few days of the Go Live and the need tapers off from there.

Who’s eligible: Any resident/fellow (PGY2 to end of fellowship training is eligible)  if they have

1.  Approval from their Program or Fellowship Director, Chair, and DIO (as for any TSMA)

2:  Nonclinical time to spare to complete the additional training and support and remain duty hour compliant..

Any specialty is possible, but you will be asked to support your “Base” clinical activity.  For example, a radiology resident would support Radiology.  Moonlighters will need to be identified into their primary specialty.

What’s needed:  This position requires a can-do helpful attitude, approval of your Residency or Fellowship Director and a commitment to a minimum of two shifts of service.  Shifts range from 6 to 12 hours in duration

Shifts needed:  Check excel spreadsheet attached and let Mary Beth Magallanes  know of your interest

Necessary training:  Super users will need to have been clinically active for at least 6 months in Maestro Care.

Interested Residents/fellows should contact Mary Beth Magallanes. to “schedule” shifts.  Complete the TSMA approval process.  You will be notified by February 3rd of dates and times.

“TSMA” forms (for approval) are on MedHub.

Any other  questions?   Contact: for Duke Regional or for Duke Raleigh shifts.



 Frankfort IM Flyer (1-23-14)
Richmond IM Flyer (Mansilla) (1-21-2014)
SRMC – Internal Medicine (1-21-2014)
 SWVA IM Flyer (Updated January 2014)

Upcoming Dates and Events

  • January 31:  Medicine Research Conference at 12 noon in DUH 2002.
  • February 14:  SAR Class Pictures
  • April 18th:  Charity Auction

Useful links

by · Posted on January 26, 2014 in Chief Residents, Internal Medicine Residency, Medical Education, Research, Uncategorized, Weekly Update · Read full story · Comments { 0 }

Internal Medicine Residency News: January 20, 2014

From the Director

DUKE.RESEARCH.NIGHT.03 (1)It’s been a great week for the program! We are winding down an incredible recruitment season…next Friday is our last day.  Thank you all for your ongoing support and enthusiasm as we work to bring in an incredible intern class for 2014-15.  Thanks to our tour guides, to Lindsay Boole for helping us get applicants where they need to go on rounds, to our gen med SARs, MICU residents and 9300 interns (as well as the attendings on these services!) for taking applicants on rounds, to Brian Miller and Shrey Purohit for report and chair’s  and to our resident share participants…Brian Miller, Kevin Trulock,  Andrea Sitlinger, Meredith Clement, Ryan Huey and Rajiv Agarwal.

Humanities and Medicine was a phenomenal night! With RECORD BREAKING attendance, and spectacular performances, we had the opportunity to share in the many talents of our residents and faculty.  Thank you so much to Vaishali Patel, Anton Zuiker, Lynsey Michnowicz and Erin Payne for planning a wonderful evening, and to the following residents and faculty for sharing their performances with us – Ben Lloyd, Carling Ursem, Scott Evans, Aaron Mitchell, Dave Karol (alum!), Josh Briscoe, Amy Rosenthal (mentor emeritus!), Ben Peterson, Tony Galanos and Tiffany Christenson.  And a special recognition to event founder, residency and chief alum, and geriatrics faculty member Juliessa Pavon! 

Members of our residency community were also honored at the University and Health System level as well.  Shelia Gainey received a distinguished service award for her work administering the medical student clerkships — she received as book with the many letters written about her by students and former students.  Erin Payne was a nominee for the Dr. Martin Luther King, Jr. Community Service award for her work with the North Street Community.  Check out the medicine blog for more information about Erin’s award.   I am very proud of how many of you have brought your community service efforts into the program, and with the National Day of Service coming up on Dr. Martin Luther King Jr’s birthday, it is time to recognize you all as well.

Kudos to Ashley Bock who was recognized by the 8100 nurses for her outstanding communication and patient care skills! Dr. Setji tells me that this is the FIRST time the 8100 nurses have taken time to write him a note about the excellent work of our residents.  Excellent job, Ashley.  Both Liz Campbell and Mallika Dhawan gave fabulous SAR talks this week as well!

Congratulations to Lauren Porras on her match into UNC’s Sports Medicine fellowship.  This is a tremendous accomplishment!

Stephen Bergin and I had a great time visiting the Pickett Road Clinic this week for leadership rounds with Bruce Peyser and Sharon Rubin.  We got to see Kedar Kirtane and Audrey Metz working hard there as well and hear about all of the great work going on at Pickett Road.  We look forward to visiting PRIME and the DOC in the upcoming weeks.

In other news, we have a large number of residents who will be presenting at the upcoming Patient Safety Symposium and also the NC ACP meeting in Greensboro.  You will all get announcements in our Pubmed from the Program, but deserve special recognition for your outstanding academic efforts.

This week’s pubmed from the program goes to many of our residents who have a paper accepted to The American Heart Journal – congratulations Adrienne Belasco, Aparna Swaminathan, Alex Fanaroff and Med Peds Alum Ann Marie Navvar Boggan!   “The Impact of a Measurement and Feedback Intervention on Blood Pressure Control in Ambulatory Cardiology Practice.”  Navar-Boggan AM, Fanaroff A, Swamithan A, Belasco A, Stafford J, Zimmer L, Shah B, Peterson ED.  American Heart Journal 2014; in press.


And finally, it’s already time to think about those New Years resolutions that are not being kept! Join me in the first Raleigh Rock and Roll Half (or full if you are Carling, Brian Miller or Kristen Glisinski!) marathon. Let’s make the Duke IM residency a big presence at this fun event!

RR flyer 1

Have a great week!


What Did I Read This Week?

“Submitted by Saumil Chudgar, MD.”

Two brief perspective pieces:

Gurpreet Dhaliwal and Karen E. Hauer. “The Oral Patient Presentation in the Era of Night Float Admissions: Credit and Critiques.”  JAMA 2013; 310(21): 2247-48.

Kelley M. Skeff.  “Reassessing the HPI: The Chronology of Present Illness (CPI).”  J Gen Intern Med 2014; 29(1): 13-5. 

Why did I read these?

I was recently on service and thinking about how presentations are different on “overflow” patients admitted by night residents and patients that the day team admits.   Additionally, I was thinking about how we teac133410_saumil_chudgar_prdh medical students to write H&Ps and do presentations before they come onto the wards and the feedback we given them afterward.  We’re taught in medical school to write-up and present a detailed account of the patient from HPI to assessment and plan.  However, much data is now collected (and hopefully verified/confirmed) from other sources rather than the patient with problem lists, medications, social and family history, and allergies prepopulating into notes.  How does this change what we teach our students and residents.

What I learned from reading these/thoughts on the articles?

The perspective on oral presentations in the era of night floats is fascinating.  It brings up the point that attendings have often read the written H&P or learned about the patient through sign-out prior to rounds.  In this situation, simply regurgitating the written H&P is not a good for learning or for efficient patient care.  Rather, the authors suggest the presentation should focus on several things: a brief HPI followed by interval events and then a discussion of what was done, what new data has come in, and how that has shaped the initial thoughts and plan.  This should be done in a respectful way with discussions about reasoning and systems-based practice.  It allows for discussion of clinical reasoning and teaches those skills to the presenters and team.  Many of us are doing this informally when we round, but it begs the question of does this need to be formally taught to residents?  Do we take it one step further and teach this in the latter part of medical school—on the subinternship or in a Capstone course, for example)?

Dr. Skeff’s article was also quite interesting.  It proposes a change from the HPI being told as a detailed story in narrative style to a “chronology of present illness” that is written in tabular or bullet form with the dates in a column to the left side of the page and the history elements on the right.  He emphasizes the increased organization for the writer and the ease of reading for other people caring for the patient by allowing for a stepwise analysis.  He also emphasize that this method should not diminish taking a patient-centered history and using effective listening.  I am not sure if this method will be adopted moving forward.  I haven’t seen it much to date other than in a complex long-stay ICU transfer or hospitalization. It is a learned skill, and perhaps the narrative should be taught first with a CPI used by more advanced learners.  Regardless, a very interesting idea and one that may also begin to be taught in medical school or to residents.

Both articles taken together make me consider how medical education is changing – are some of the things we have been teaching because that is how they have always be done now still the right way to teach?  Or, do we continue to teach them and add some of these newer methods moving forward?

QI Corner (submitted by Joel Boggan)

Congrats to the following residents for having QI-related posters accepted at either the NC ACP meeting and/or the Duke Patient Safety and Quality Conference:  Lindsay Boole, Katie Broderick, Alexandra Clark, boggan_1Hany Elmariah, Jim Gentry, Steph Giattino, Jeremy Halbe, Ryan Huey, Phil Lehman, Tim Mercer, Aaron Mitchell, Emily Ray, Marcus Ruopp,  Jessie Seidelman, Kevin Shah, and Aparna Swaminathan!  Strong work, guys!

QI Conference
Our very own Dr. George Cheely will be giving our next QI noon conference on ‘Overcoming Barriers to High Value, Cost-Conscious Care’ on 1/29 in 2002.  Food TBD. . .

Hand Hygiene
The mid-month update shows us at 94% aggregate performance  on the 7 seven wards through Jan 16th.  Keep up the good work!

And, finally . . .
The Health System is sponsoring a session on ‘Understanding Quality Reporting’, led by Kevin Sowers, President of DUH, and Jennifer Rose, the Director of Performance Services for DUHS on Wed., 1/22, at 1-2 pm in 2002 and again on Thurs., 1/23, from 6:15-7:15 am, again in 2002.  Link here to learn more . . .

From the Chief Residents

SAR Talks

SAR Talks: January 21, 2014

Nancy Lentz / Wendy Chan

Grand Rounds

January 24, 2013:

Dr. Joel Boggan/Dr. Peter Ubel – M&M

Topic: Cost

Non Conference

Date Topic Lecturer Time Vendor Room
1/21 SAR talks OR Difficult Death Debrief Nancy Lentz /   Wendy Chan 12:00 Bullock’s BBQ 2002 OR DN9242
1/22 12:00 China   King 2002
1/23 12:00 Domino’s 2001

From the Residency Office


Death Certificates – New Requirements

Dear Duke Physicians:

As part of our effort to educate physicians about completing death certificates, we want to alert you about the new death certificate form required in North Carolina beginning January 1, 2014.  Like the previous form, the new form includes instructions for completion, but we believe it may be helpful to highlight some significant changes.  Attached is a “Note on the New Death Certificate,” which includes information about the state’s new online training.  Also attached is a PDF image of the new death certificate, and a “Quick Guide to Signing a North Carolina Death Certificate” that we have prepared.

Of note, physicians are now required to provide their NC medical license number in part 33b.  Note: Post-graduate trainees who only have a “Resident Training License” should put “RTL” in this space.

Please note that we have also prepared a detailed module on completing death certificates, produced through a Duke Graduate Medical Education Innovations grant.  Many of you will be soon be receiving an invitation to review this module, which comes with brief, case-based pre and post tests.

Mitch Heflin, MD and Michael Arges, PhD


Notes on New Death Certificate_January 2014



Clinical Care Memo:

The EKG Support has an ongoing problem with getting orders for ECGs.  They are performing the ECG but then it takes multiple calls to get the order placed and sometimes it is never ordered.    This is a huge problem for charging as well as taking a lot of time for the ECG techs that could be performing ECGs in a more timely manner.   As of yesterday, Dr. Freedman and Dr. Grant have put a policy in place that an order will be in Maestro PRIOR to the ECG being performed (Now that Epic has been in use throughout our Health System for more than 6 months, no ECG will be performed until the order for that ECG is placed in Epic.  This rule will be enforced by all ECG technicians to keep the EKG Support Unit in compliance with contemporary policies.) Exemptions are Code Blue and RRTs.  Because the ICUs have emergency situations they have decided to extend a temporary exemption and monitor over the next 2-4 weeks to look at compliance.  If  the orders are being placed, the exemption will become permanent.  If the orders are not being placed, the no order, no ECG policy will go into effect.


Cardiovascular Research Center Seminar Series 4pm 143 Jones

January 15, 2014
4:00pm; 143 Jones
Matthew Sparks, M.D., Medical Instructor, Department of Medicine, Duke University
“Role of Vascular Angiotensin Receptors in Blood Pressure Control”
Presenter Disclosure Information:  None.

January 29, 2014
4:00pm; 143 Jones
Charles E. Murry, M.D., Ph.D., Director, Center for Cardiovascular Biology, University of Washington
“Regenerating the Heart”
Presenter Disclosure Information:  TBA

February 1, 2014
CVRC Retreat – Mary Duke Biddle Trent Semans Center for Health Education – Great Hall
Keynote speaker will be David A. Kass, M.D., Abraham and Virginia Weiss Professor of Cardiology, Professor of Medicine, Professor of Biomedical Engineering, The Johns Hopkins University Medical Institute TRPing Up Heart Disease With PKG”.
Anyone who will be attending must RSVP no later than January 27, 2014 to
No CME credit offered for this event

Flyer Matthew Sparks

Flyer David Kass

Flyer Charles Murry



 teaching fellow
Cary Medical Group, MD position, 2014 flyer

Upcoming Dates and Events

  • January 31:  Medicine Research Conference at 12 noon in DUH 2002.
  • April 18th:  Charity Auction

Useful links

by · Posted on January 19, 2014 in Chief Residents, Internal Medicine Residency, Medical Education, Uncategorized, Weekly Update · Read full story · Comments { 0 }

Two DoM staff recognized for community service

Two Department of Medicine staff were honored by Duke University Health System this week as 2014 Dr. Martin Luther King Jr. Community Caregiver Award Nominees, which commemorates the life and legacy of Dr. Martin Luther King, Jr. and recognizes employees who demonstrate a commitment to supporting the community.

mlkaward_Page_1Erin Payne, program coordinator for the Internal Medicine Residency Program, was recognized for her work with the North Street Community Project in Durham, an intentional living community created for a diverse mix of families and individuals with and without developmental disabilities.

mlkaward_Page_2Joy Williams, staff assistant in the Chair’s Office, was recognized for her work as a volunteer event planner and founder of A Touch of Joy Outreach Ministries, through which she reaches out to community organizations, gospel artists and others, bringing them together to support causes such as the Ronald McDonald House and Autism Research.

Payne and Williams attended a luncheon and award ceremony for the eight nominees.

“I am extremely impressed by what Joy and Erin have accomplished and continue to do in order to support our community,” said Joe Doty, vice chair for administration. “It is clear that Joy and Erin work on their community focused activities because these projects are  close to their hearts and help maintain their passion to care for others.”

Read the stories of all eight nominees. Visit the award Web page on the intranet.

by · Posted on January 16, 2014 in All things Duke, Awards - honors, Internal Medicine Residency · Read full story · Comments { 0 }

Internal Medicine Residency News: January 12, 201

From the Director

DUKE.RESEARCH.NIGHT.03 (1)“Hi everyone. It’s been incredibly busy on all the services, so a big thank you for your ongoing excellent work.

Lots of kudos this week – to Adam Banks for his gold star, to Andrea Sitlinger from Dr. Wilson and the GI team, to Lauren Porras from Mitch Black for great work covering on gen med and to both Jay Mast and Ben Lloyd for fantastic presentations at report and chairs conference. Murat Arcasoy sends kudos to Lindsay Anderson for a great case (legionella!) at DRH report and to Wendy Chan for getting the diagnosis. Audrey Metz and Kim Bryan brought us excellent SAR talks as well.

Thanks to Lindsay Boole, Ryan Huey, Nick Rohrhoff, Joanne Wyrembak and Alan Erdmann for doing resident share and to all of our tour guides – I know Aaron Mitchell, Marcus Ruopp, Bobby Aertker, Sajal Tanna and Mandar Aras led tours, and that I am missing a thanks to several others!Malika - Madar Engagement

Congrats to Mandar Aras and Mallika Dhawan on their engagement! And also to Andy Mumm and Azalea Kim on their engagement as well!

Please be sure to join us at Humanities in medicine night on Wednesday. Whether you have talent or not ( I certainly don’t!) come out and support your friends and enjoy music, dance and poetry.”

PubMed of the week goes to Lindsay Anderson, MD for her poster presentation at the American Heart Association meeting, in November 2013.   Direct Cath Lab Access Reduced Reperfusion Delays and Mortality for Transferred-in STEMI Patients: Insights From Mission: Lifeline.  (Lindsay Anderson, William French, Andrew Peng, Amit Vora, Timothy Henry, Matthew Roe, Michael Kontos, Christopher Granger, Eric Bates, Tracy Wang)  Mentor: Tracy Wang, MD

Have a great week


What Did I Read This Week?

“Submitted by David Butterly, MD

Combined Angiotensin Inhibition for the Treatment of Diabetic NephropathyNEJM: 11/14/2013, 369: 1892-1903

This article appeared in the NEJM in November and reports from the NEPHRON-D study group on the effect and safety of combination ACE-inhibitor and Angiotensin receptor antagonist therapy when used in patients with Diabetic Nephropathy.

Diabetic Nephropathy is the single most common cause of ESRD in the US.  Roughly half of all patients entering 128907_butterly005the ESRD program have Diabetic Nephropathy with roughly 80% of these due to Type II Diabetes.  The mortality in those reaching ESRD remains high and the annual cost of caring for these patients exceeds $10 Billion in the US alone.  Once proteinuria is present, ESRD can be postponed but generally not prevented.  Obviously any therapy which could slow or prevent this progression to ESRD could have an enormous impact on quality of life and mortality for this group of patients.  Effective means which have been shown to slow progression in Diabetic Nephropathy have included: 1) Improved glycemic control (DCCT NEJM 1993), 2) ACE-Inhibitors (Lewis NEJM 1993) and 3) ARBs (Lewis NEJM 2001 and Brenner NEJM 2001).

Although combination therapy with ACE and ARB has been demonstrated to reduce proteinuria, the safety and efficacy of the drugs when used in combination is uncertain.  This study reports on the results from the VA NEPHRON-D investigators which evaluated the effect of combined therapy in patients with Diabetic Nephropathy and CKD.  This is a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of the combination of Losartan with Lisinopril as compared to standard treatment with Losartan alone in slowing the progression of diabetic kidney disease.

A total of 32 VA medical centers participated in the study.  Patients with Type 2 DM and Stage II or III CKD (GFR of 30-90 ml/min with protein excretion of greater than 300 mgs) were eligible to participate.  Patients entering the study were initiated on 50 mgs of Losartan which was titrated to 100mgs.  Once they were on this dose for 30 days, they were randomly assigned in 1:1 fashion to ARB plus ACE-I with versus ARB along with placebo.  Patients were seen every 2 weeks and lisinopril was titrated from 10 to 20 to a maximum of 40 mgs.  Once a patient was on maintenance dose, they were seen every 3 months throughout the remainder of the study.  BP meds were titrated for target SBP of 110-130 and DBP < 80 in both groups.

A total of 1648 were enrolled and 1448 patients were randomized.  Baseline characteristics are shown in Table 1.  Average age was approximately 65 and roughly 70% enrolled were white.  Glycemic control was similar with HgbA1C in the groups at 7.8%.  Average GFR in each group was 53 ml/min with equal distribution of patients at each CKD stage.  Urine albumin excretion in each group averaged about 850 mgs and baseline UPC ratios averaged 1.6 to 2.1.


Blood pressure control was similar between the groups (within 2 mm Hg).  The primary endpoints followed were 1) a decline in GFR (absolute decrease of > 30 mls or a relative decrease of > 50%), 2) ESRD, and 3) death.  Secondary endpoints included cardiovascular outcomes (MI, CHF, Stroke) and change in albuminuria.  Safety outcomes included all-cause mortality, hyperkalemia, and Acute Kidney Injury.

The study results are shown in Table 2.  There was no difference demonstrated in Primary or Secondary outcomes over the course of the study.  A total of 182 patients died or progressed to ESRD (60 patients in the monotherapy and 63 patients in the combination therapy died).  Progression to ESRD was lower in the combination group (27 vs 43) but did not reach statistical significance.  MI, CHF, and Stroke were similar between the groups.  Kaplan-Meier plots for the primary and secondary endpoints are shown on page 1899 and the curves are essentially superimposable.

Adverse Events and Safety:

Adverse events occurred at a much higher rate in the group assigned to combination therapy.  AKI occurred at nearly two-fold the rate (12.2 combination vs 6.7 ARB alone) RR of 1.7.  Hyperkalemia was more than twice as common 9.9% versus 4.4%, RR 2.8 in the combination group.  These data are shown in Table 3.  Figure 2 shows the Kaplan-Meier plots for AKI and hyperkalemia.

Due to these concerns along with the failure to demonstrate clear benefit, the data monitoring and safety committee recommended that the study be stopped in October of 2012 and the study was thus halted.  Average duration of follow up for the patients enrolled was 2.2 years.


Combination therapy with ACE-I and ARB in patients with Diabetic Kidney disease was associated with an increased risk of adverse events – AKI and Hyperkalemia.  Proteinuria did decrease however there was no demonstrable improvement in progression of CKD or Cardiovascular events and the study was therefore halted early.  These data are consistent with ONTARGET (NEJM 2008) and the ALTITUDE study (Parving NEJM 2012) which showed increased harm and no cardiovascular or renal benefit in combination therapy with drugs that block the renin-angiotensin system.


QI Corner (submitted by Joel Boggan)

We Follow-Up Sharepoint Group Project Update

For those of you who did not link to the file embedded last week, here’s a summary of the first half of the year in the lab follow-up residency-wide JAR/SAR QI project.  We look forward to tracking everyone’s progress in the second half of the year!

Overall reporting of lab results within 14 days:  77%
By clinic – DOC 71%
Pickett 89%


From the Chief Residents

SAR Talks

SAR Talks: January 14, 2014

Malika Dhawan and Elizabeth Campbell

Grand Rounds

January 17, 2013:  Dr. Ebony Boulware – MRRC/MLK

Noon Conference


Date Topic Lecturer Time Vendor Room
1/14 SAR talks Mallika Dhawan / Elizabeth Campbell 12:00 Cosmic Cantina 2002
1/15 Between the Ferns with Armando and Chris Residency Council 12:00 Pita Pit 2002
1/16 Echo for the Internist Joe Sivak 12:00 Rudino’s 2001


From the Residency Office

Death Certificates – New Requirements

As some of you have noted, NC death certificates now have a box asking for the certifying doctor’s license number, which presents a challenge for residents who have “RTL” during training. The recommendation at this time is to enter your RTL number in the required field.  If you do not know your training license number it can be found in MedHub on your demographics page under certifications.

Residents Take on the Disney Marathon (aka Cruella deVille and two of her Dalmatians:   Brian Miller, Carling Ursem, and Scott Evans)

Disney 2014

While most of us were staying inside to stay warm and avoid the cold – or simply doing all we could to ward off getting a cold – we had a few who were brave enough to head outside and stick to their training routines.  These three hardy residents were in Orlando this morning running the Disney World marathon.  This picture is from the start of the race, in the dark.  Times?  Three hours and 38 minutes for Brian and Carling, and a big thank you to Lauren Pouras from Brian for covering his gen med shift so that he could do the race.


 GME Research Training Series

This is a reminder of the GME Research Training Series for residents. The third series of workshop sessions will be offered in January & February of 2014. Learning objectives are attached. Trainees can register using the link below. Registration for this third series will close on Friday January 10th.

The tentative agenda and learning objectives for the Blitz is also attached.

We hope you will consider strongly encouraging (or requiring) your residents to participate. These sessions will help meet ACGME requirements, enhance resident QI and research experiences, and help ensure residents follow sound research principles and practices now and upon graduation.

Registration Link:

GME Fellow Blitz

Learning Objectives for GME Resident Education Series

DOCR/GME Research Training

Human Subjects Research at Duke/Research Data Collection and Security Plan
Date Time Location
Wednesday, January 15, 2014 12:00pm-2:00pm Duke South M224
Thursday, March 6, 2014 4:00pm-6:00pm Trent Semans Classroom 4
How to Ask and Answer Research Questions Using Library Resources/Ethics of Conducting Research
Date Time Location
Wednesday, January 22, 2014 12:00pm-2:00pm Duke South 3031
Thursday, March 13, 2014 4:00pm-6:00pm Trent Semans Classroom 4
IRB Overview, Informed Consent, Regulations and Best Practices
Date Time Location
Wednesday, January 29, 2014 12:00pm-2:00pm Duke South 3031
Thursday, March 20, 2014 4:00pm-6:00pm Trent Semans Classroom 4
Presentation and Dissemination of Data
Date Time Location
Wednesday, February 5, 2014 12:00pm-2:00pm Duke South 3031
Thursday, March 27, 2014 4:00pm-6:00pm Duke South 3031
BLITZ – Training in Advanced Research Principles and Practices
Date Time Location
Saturday, February 8, 2014 8:00am-12:30pm Duke South Amphitheatre
Saturday, April 26, 2014 8:00am-12:30pm Duke South Amphitheatre



Sutter Coast_W_Site Profile_FINAL
Sound Business Model
Path to Partnership overview (4-11)
MHC Internal Medicine Program Flyer

Upcoming Dates and Events

  • Humanism and Voices in Medicine 

    Wednesday, January 15th at 7:30 PM
    Intrepid Life Coffee & Spirits
    106 W. Parrish Street, Suite 1, Durham, NC

  • April 18th:  Charity Auction

Useful links

by · Posted on January 12, 2014 in Chief Residents, Internal Medicine Residency, Medical Education, Uncategorized, Weekly Update · Read full story · Comments { 0 }

Save the date 1/15/14: Humanities in Medicine/Voices of Medicine

share-your-story-posterDon’t forget: The Department of Medicine is hosting a combined Humanities in Medicine  and Voices of Medicine event at 7:30 p.m. on Wed., Jan. 15 at the Intrepid Life Coffee House in Durham. Get ready to gather with internal medicine residents and members of the faculty for a night of music, poetry and storytelling by Duke faculty, fellows, residents and medical students.

Listen to stories from past Voices of Medicine.

If you’re interested in telling a story, contact Anton Zuiker. Jeff Polish, executive director of The Monti, an organization that encourages members of the community to share their experiences, will work with you to build your story into a performance.


by · Posted on January 9, 2014 in Events, Fellowship programs, Internal Medicine Residency · Read full story · Comments { 0 }

Internal Medicine Residency News: January 5, 2014

From the Director

DUKE.RESEARCH.NIGHT.03 (1)“It’s the first Med Res News of 2014! Welcome back everyone – lots to do in the new year!

Recruitment continues in full force – look for applicants on rounds and at lunch. Erin will be reminding you about tours and resident share. You guys are the reason we will have an amazing class of new interns in July!

Kudos this week to Lindsay Anderson from Alex Cho for  fantastic work in a busy ACC, to Marcus Ruopp from Aaron Mitchell for some VA CCU heroics, to Aaron Loochtan and Emily Ray from the CAD nurses for outstanding work and to Amy Jones from Krish Patel for her gracious covering on the pull list.

This week’s pubmed from the program goes to Katie Broderick Fosgren who will be presenting her work on the photo business cards at ICGME on Wednesday!”

Happy new Year!


What Did I Read This Week?

“Submitted by Vaishali Patel, MD

2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines and The Obesity Society (TOS)

Why did I read it?  CNN reports that weight loss is once again the nation’s number one New Year resolution (it beat “spending time with family” and “spend less, save more” by a mile).  And yet, in spite of the promotions and deals offered by gyms every January, according to Time magazine, “60% of gym memberships go unused and attendance is usually back to normal by mid-February.”  I suppose you have to give some credit to America for realizing that much of the burVAISHALI_PATEL__1den of obesity (no pun intended) does, in fact, fall on the individual. The release of the guideline by the ACC/AHA/TOS Task Force in November 2013 is somewhat timely in helping physicians tackle the post-holiday overweight or obese patient who is ready to make some changes.

How are society guidelines created?  The National Heart, Lung, and Blood Institute (NHLBI) expert panels first develop critical questions (CQs).  Recommendations are devised for each CQ based on rigorous systematic review of randomized trials, meta-analyses, and observational studies.  Most existing guidelines have not considered evidence beyond 2011, and so many will be updated by the societies in 2014.  See below for a summary of levels of evidence and classifications of recommendations (I always have to remind myself of the details of these).  Data that are included in the review may or may not provide adequate information about the efficacy of a certain intervention in different subpopulations.   Level of Evidence B or C does not necessarily mean that the recommendation is weak – rather, you have to interpret the data available in the right clinical context.  Many pertinent clinical questions that are addressed by guidelines are not easy to investigate in a clinical trial; some may lend themselves to a clear clinical consensus without evidence from a randomized trial.

What do these guidelines cover?  The panel’s goal was to create recommendations to assist primary care clinicians for 5 CQs. These guidelines address the expected health benefits of weight loss (CQ1), the appropriateness of the current BMI cutoffs, CV-related risk, hypertension risk, impact on lipid profiles, risk of diabetes (CQ2), dietary composition and interventions (how to create reduced dietary energy intake and pattern of weight loss over time with dietary intervention, CQ3), physical activity and efficacy of lifestyle interventions (CQ4) and interventions for weight loss maintenance (a hot topic since many studies have shown high rates of recidivism and poor weight loss maintenance), and lastly the efficacy and complications of surgical weight loss interventions (CQ5).  They also propose a model or treatment algorithm for the management of obesity as a chronic disease.

What are the summary recommendations for overweight or obese adults that you can share with your patients?  Height, weight and BMI should be calculated at annual visits (Grade E).  The BMI cutoff for overweight is 25kg/m2 (these patients have an elevated CV risk), and for obesity it is 30kg/m2 (these adults have elevated risk of CV disease, diabetes and all-cause mortality) as it has been in the past (Grade A).  A larger waist circumference, is associated with a greater risk of CVD, diabetes and all-cause mortality (Grade E).  Sustained weight loss of 3-5% produces clinically meaningful health benefits in lipids, A1c, and risk of developing diabetes; greater weight loss reduces the risk of hypertension, diabetes, and all-cause mortality. The initial goal should be weight loss of 5-10% of baseline weight within 6 months (Grade A).  Prescribe a 1200-1500 kcal/day diet for women and 1500-1800 kcal/day for men as part of a comprehensive lifestyle intervention (participation in a high intensity activity program for >6 months).  An energy deficit of 500-750 kcal/day should be recommended to those who would benefit from weight loss (Grade A).  Weight loss maintenance requires participation in a comprehensive program for >1 year. Patients with BMI >=40 or >=35 with obesity-related comorbidities who have not responded to diet and exercise may be appropriate for bariatric surgery referral.

1)      Applying Classifications of Recommendation

  1. Class I – benefit outweighs risk (procedure/treatment should be done).
  2. Class IIa – benefit outweighs risk but additional studies needed, or there may be some conflicting evidence (it is reasonable to do procedure/treatment).
  3. Class IIb – benefit outweighs risk but additional studies with broad objectives are needed, or there is greater conflicting evidence from RCTs or meta-analyses.  Procedure/treatment may be considered.
  4. Class III – no benefit or harm.  Procedure/treatment may be harmful/not useful and should be avoided.

2)      Applying Level of Evidence

  1. Level A – multiple populations evaluated, multiple RCTs or meta-analyses.
  2. Level B – limited populations evaluated, single RCT or nonrandomized trial.
  3. Level C – very limited populations evaluated, only consensus opinion of experts, case studies, or “standard of care.”

3)      NHLBI Grades of the Strength of Recommendation

  1. Grade A – strong recommendation/high certainty based on evidence that net benefit is substantial.
  2. Grade B – moderate recommendation/moderate certainty that net benefit is moderate to substantial, or high certainty that the net benefit is moderate.
  3. Grade C – weak recommendation/moderate certainty based on evidence that there is a small net benefit.
  4. Grade D – recommendation against /moderate certainty based on evidence that it has no net benefit or that risks outweigh benefits.
  5. Grade E – expert opinion / net benefit unclear, insufficient evidence to determine balance of benefits and harms, but the panel thought it was important to provide clinical guidance and make a recommendation.
  6. Grade N – no recommendation for or against / net benefit is unclear and panel thought there was insufficient evidence to make a recommendation.  Further research is recommended in this area.

QI Corner (submitted by Joel Boggan)

Welcome back
Welcome back, everyone!  Thanks for all your hard work during a great first half of the year.

Updates on projects
Below you’ll see updates on our Hand Hygiene compliance and the results of the We Follow-Up Sharepoint campaign for our JARs/SARs.  Our hand hygiene performance seems to have plateaued, but we still have five months to bring the average up to our goal of > 90%.

Hand Hygiene

Ward Compliant Total Observations
7100 9 11
7300 7 8
7800 9 10
8100 19 20
8300 4 5
9100 16 20
9300 8 8
Overall 72 82

Overall rate of compliance for December:  87.8%
Rate of compliance Aug-Dec:  87.9%

Lab Follow-Up Rates (attached)   Follow up # 2


From the Chief Residents

SAR Talks

SAR talks:  January 9th, 2014

          Audrey Metz and Kim Bryan

Grand Rounds

Dr. Kim Huffman – Rheumatology

Noon Conference

Date Topic Lecturer Time Vendor Room
1/8 Schwartz Rounds Lynn O’Neill, Lynn Bowlby 12:00 Jersey Mike’s 2002
1/9 SAR talks Audrey Metz / Kim Bryan 12:00 Domino’s 2001

From the Residency Office

SAR Talk Survey (submittedy by Kim Bryan)

Please take a moment to complete a simple, quick, anonymous survey regarding physician and nurse communication.

Your help is greatly appreciated !

Kimberly Bryan, MD
Duke University
Internal Medicine, PGY 3

Ambulatory Care Leadership Track Event

When:  Wednesday, January 8th

Where:  Alivia’s, 900 West Main street Durham, NC 919-682-8978

The Ambulatory care leadership team would like to hold a Get to know the  Ambulatory Care Leadership Track (ACLT) on Wednesday January 8, 2014 7pm at Alivia’s. This event is for any resident who is interested in the ACLT and  who would like to speak to the current ACLT residents about the program. We hope the Med psyche residents will join the ACLT residents and discuss their experiences.

So far ACLT resident RSVP’s include: Alexandra Clark, Lauren Porras, Claire Kappa and Jennifer Chung

Please RSVP to Dr. Sharon Rubin by Wednesday January 8, 2014.

Rising JAR – SAR Preferences

FINAL REMINDER:  rising JAR / SAR schedule preferences for FY 15 are to be submitted no later than Wednesday, January 8, 2014.  Access to the survey monkey link locks down on January 9th.



Resp Fit Test – T-DAP-TB Skin Test schedule for January, 2014
       January 14 Resp Fit Testing-T-Dap-TB Skin Testing Flyer

Upcoming Dates and Events

  • January 8th:  ACLT Meet and Greet
  • January 15th:  “Voices in Medicine”
  • April 18th:  Charity Auction

Useful links

by · Posted on January 5, 2014 in Chief Residents, Internal Medicine Residency, Medical Education, Uncategorized, Voices of Medicine, Weekly Update · Read full story · Comments { 0 }

Internal Medicine Residency News: December 30, 2013

From the Director


“It’s the last Medicine Residents News (the blog formerly known as Weekly Updates) for 2013! To all that enjoyed the first part of the holiday block with their families, welcome back! To those who are now enjoying the holiday block vacation, thanks for your work over Christmas.  The first half of this year has gone incredibly quickly, and I want to thank you all once again for your hard work, and for making this the best residency program/residency family anywhere! A special thanks to your families and loved ones for supporting you during residency.  Here’s to an equally fantastic 2014!

Kudos this week goes to the VA crew from Vaishali for their hard work, to the Duke crew from Krish, Hany and I and to the DRH crew as well! Thanks to our ACRs Hany Elmariah, Meredith Clement and Chris Hostler! Welcome to our new ACRs Lindsay Boole, Mandar Aras and Carter Davis.  Thank you to Dr. Klotman for the outstanding Foster’s Xmas dinner and to Dr. Kussin for underwriting the Christmas Day Chinese extravaganza.  For the especially brave, there are still leftovers in the ACR refrigerator.

Please remember to send in your 2014-15 schedule requests to the chiefs.  Any questions, please let either the chiefs or I know.  Recruitment begins again in full force on Monday January 6th.  We look forward to seeing you all at the dinners and lunches with the applicants.  For SARs, please remember to register for the ABIM exam and avoid paying any more than it already costs by incurring a late registration fee.

Congratulations to Jonathan and Ashley Hansen on the birth of their beautiful baby girl! She has the special honor of being the first baby born to the intern class this year.

This week’s pubmed from the program goes to John Wagener and Marc Samsky. Their landmark article was published just yesterday in “Duke Outlook Email”.

Again, I wish you and your families a very merry Christmas and the happiest and healthiest of New Years.”


What Did I Read This Week?

“Submitted by Aimee Zaas, MD

The survival time of chocolates on hospital wards: covert observational study

BMJ 2013; 347 doi: (Published 14 December 2013) BMJ 2013;347:f7198

Why did I read this:  Have you seen the amount of food available on the wards in December? This is a highly relevant study, although, as the authors point out, the results might be very different if conducted after New Year’s when resolutions are in full effect.

What did the authors do: They were curious as to what the consumption pattern of chocolates was on a hospital ward, as observational data suggests that the survival time of a chocolate in a hospital setting is quite low.  They compared the survival of two brands of chocolates (Nestle and Roses) and also the variance of consumption between different types of healthcare providers (nurse, assistant, MD).  Once chocolates were placed on a ward, a covert observer recorded: 1)time to box opening and 2) survival time of chocolates (primary outcome variable) as well as type of provider eating the chocolate.  A literature search did not reveal any data on which to base a power calculation, so their expert opinion based on years of working over Christmas on a hospital ward provided the following calculations: No previous studies were available on which we could base power calculations. We estimated that a total of 210 chocolates would be needed to provide 80% power (P<0.05, two sided) to detect a 50% change in the hazard ratio between groups (Quality Street and Roses), assuming a median survival of 60 minutes for an individual chocolate, and follow-up of four hours maximum.2 Assuming a 350 g box of chocolates contained 30 chocolates (based on pilot data), we estimated that we would need eight boxes, totally around 240 chocolates. Chocolates left after the observation period were considered lost to follow up.

What did they find:  The mean time taken for a box of chocolates to be opened after being placed on the ward was 12 minutes (95% confidence interval 0 to 24). The time to opening of Quality Street and Roses boxes did not differ significantly (19 v 5 minutes, 95% confidence interval for difference -19 to 46 minutes, P=0.35). Quality Street chocolates survived longer than Roses chocolates (hazard ratio for survival of Rosesv Quality Street 0.70, 95% confidence interval 0.53 to 0.93, P=0.014, fig 1?). They also found that nurses and healthcare assistants ate more  chocolates than MDs, however this calculation is biased due to the larger total number of nurses and healthcare assistants involved in the study. 

How should I interpret the results? DO they apply to our wards?  These results are likely generalizable across the pond. While we do not have Roses candy generally available, it is likely that any box of quality chocolates would have a similarly short survival time on the wards here or in a US hospital.   In fact, this study could be easily repeated by Lauren or Lindsay, noting an extremely short survival time of any food put into the residency office food basket.  A priori, I predict that fruit snacks have a survival time on the order of minutes despite having a shelf life of likely > 1000 years.

Happy holidays!  Check out the remainder of the Xmas BMJ at for classics like “Was James Bond’s shaken martini due to alcohol induced DTs?”


From the Chief Residents

SAR Talks

SAR talks resume January 9th, 2014

Grand Rounds

Grand rounds resumes January 10th, 2014

Noon Conference

Noon conference resumes on January 8th with the first Schwartz Rounds of the new year

From the Residency Office

Rising JAR – SAR Preferences and Clinical Epidemiology

Reminder to submit your preference if you have not already done so, and watch for the separate email regarding the Clin Epi applications.


Med-Peds Hospitalist      Schneck Profile

Upcoming Dates and Events

  • January 15th:  “Voices in Medicine”
  • April 18th:  Charity Auction

Useful links

by · Posted on December 29, 2013 in Chief Residents, Internal Medicine Residency, Medical Education, Uncategorized, Weekly Update · Read full story · Comments { 0 }

Internal Medicine Residency News: December 23, 2013

From the Director


Hello everyone! Can’t believe we are closing out 2013. I hope you all enjoy a well deserved holiday with your family and friends – I also look forward to seeing half of you on the Xmas block! We will enjoy dinner from Dr Klotman on the 24th and the other tradition of Chinese food on the 25th with PSK and me.

Kudos this week to Liz Kotzen, Bobby Aertker and med student Tom Lefevre on their gold stars. Also to Marc Samsky from Allyson Pishko for his work at the VA and to the Duke NF crew  of Nick Rohrhoff, Iris Vance, Rachel Titerance and John Yeatts for handling the deluge with smiles. We heard great SAR talks from Mandar Aras and Jeremy Halbe as well.  Thanks also to Chris Hostler, Aparna Swaminathan, Jesse Tucker, Emily Ray, Jenn Rymer and Carli Lehr for resident share on Friday. And, finally, congrats to Dr Simel on receiving a congressional award for his longstanding achievements at the VA!

And – awesome job Steve Bergin, Meredith Clement and Mike Shafique for our first high value cost conscious morning report followed by a similar noon conference.  Team Klotman beat Team Zaas in the morning and team Lehman was victorious at noon. Overall, we all worked hard to bring stewardship into our work ups. More of these to come!

PubMed from the program: Carling Ursem, MD, PGY3, Poster presentations (two) at the San Antonio Breast Cancer Symposium December 2013  Mentor: Gretchen Kimmick, MD

“Does socioeconomic status influence receipt of guideline concordant care in older women with breast cancer: Findings from a Centers for Disease Control and Prevention National Program of Cancer Registries (NPCR) patterns of care study”

Have a great week and an even better Christmas/New Year!



2015-16 Chief Residents for the Internal Medicine Residency Program

chiefs15_16It is with great pride that we announce the 2015-16 Chief Residents for the Internal Medicine Residency Program.  We are proud to partner with the Durham VA Medical Center and Duke Regional Hospital in selecting these outstanding individuals who join in an important and longstanding tradition of leadership in medicine.

The Chief Residents are chosen for their leadership skills and clinical acumen and are the most representative faces of the Internal Medicine Residency program for the year. The Chief Residency represents the largest investment in leadership made by the Department of Medicine, however the return on this investment is several-fold.

We look forward to our 2015-16 Chief Residents serving as teachers, role models and colleagues to our residents:

Jennifer Rymer MD, MBA – Duke University Hospital
Dr. Rymer is a graduate of Vanderbilt University, Vanderbilt University School of Medicine and the Vanderbilt Owen Graduate School of Management. She will be a fellow in the Cardiovascular Medicine training program beginning in July 2014.

Christopher Hostler MD, MPH – Durham VA Medical Center
Dr. Hostler is a graduate of the United States Military Academy at West Point, the Duke University School of Medicine and the UNC Gillings School of Global Public Health. He will be a fellow in the Division of Infectious Diseases and International Health beginning in July 2014.

Armando Bedoya, MD – Duke Regional Hospital/Ambulatory Medicine
Dr. Bedoya is a graduate of Brown University and the Warren Alpert Medical School of Brown University. He will be a fellow in the Division of Pulmonary and Critical Care Medicine beginning in July 2014.


QI Corner (submitted by Joel Boggan, MD)

Online module for specimen collection/labeling training:

Here is the link to the course.

Specimen Labeling Error Process

 Please note the target start date is Monday 12/23/13.

What Did I Read This Week?

Submitted by Lynn Bowlby, MD

“Opioid Prescribing: A Systematic Review and Critical Appraisal of Guidelines for Chronic Pain”

Annals of Internal Medicine  12 November 2013 (online first)

As many of you know , chronic non cancer pain management is one of our major challenges at the DOC.  I had recently reviewed the literature for a noon conference presentation. This recent review reviews the current guidelines and assesses their use of the evidence. 1270 documents were found from Jan 2007 to July 2013, 1132 were screened, with 13 eligible for review. bowlbyphotoAnnual fatalities from opioids have increased from 4000 in 1999 to 14, 200 in 2006. Treating chronic pain during those years changed from little use of opioids to active encouragement of their use.  Long term use is defined as 3-6 mos or longer. Most of the studies of opioids are based on < 6 mos of use.AGREE II (Apprasial of Guidelines for Research and Evaluation ) and AMSTAR (A measurement tool to Assess Systematic Reviews) were used to evaluate the quality of the guidelines. Ratings were highest for the guidelines by the American Pain Society , the American Academy of Pain Medicine and the Canadian National Opioid User Guideline.  > 50% of the appraisers voted to use these guidelines without modification.  These guidelines linked evidence to recommendations to reduce the risk of opioids the most frequently.10 guidelines agree that benzodiazepine and opioids are a very high risk combination, especially the elderly. As the risks of opioids become more well understood, the dose recomendations have been put into effect.The conclusions?The guidelines agreed to avoid > 90-200 mg of morphine /day, advanced knowledge needed to prescribe methadone, knowledge needed of risks of fentyl patches, titrate cautiously, reduce dose 25-50 % when changing opioids, use opioid risk assessment tools, use written agreements and UDS to reduce the risks of opioids.  Much of these reccomendations are based on observational data or expert opinion.This guideline does not address the fundamental issue of using opioids for chronic non cancer pain. Studies are very limited, often < 6 mos of treatment, and greatly underestimate the risk of addiction and diversion.

From the Chief Residents

SAR Talks

SAR talks resume January 9th, 2014

Grand Rounds

Grand rounds resumes January 10th, 2014

Noon Conference

Noon conference resumes on January 8th with the first Schwartz Rounds of the new year

From the Residency Office

Rising JAR – SAR Preferences and Clinical Epidemiology

To those who have already submitted preferences – and there are a surprising number of early birds – please note that Lauren has made the following changes to allow you to update your selections even after hitting the “send button”.

The survey will now to allow you to use the same link that was emailed to you to go back in and edit the survey at any time up until the survey is closed on 1/8/14.

JARS — the Clin Epi applications will be sent out right after the new year.  Instructions for eligibility will be included with the application. If you apply, we assume that you are preferencing this over any other elective, so please don’t feel the need to put “points” towards Clin Epi.

Please address any questions you may have to Dr Zaas or the Chiefs.

MedHub Resource Documents

Reminder that all schedule resource documents are now located in a tab labeled “Schedule Resources” on your home page in MedHub, including details as to your current schedule and future block schedules as they are completed. 


Planning a future in the outpatient setting? Consider the ACLT

submitted by Lauren Porras, MD

“I applied to join the Ambulatory Care Leadership Tract in order to broaden my experiences and learning in ambulatory topics. During my JAR year, I was able to audit a course in the PorrasMaster’s of Clinical Leadership program which was a great way to learn how to adapt to various learning scenarios. The residents in ACLT also have a separate ambulatory curriculum together that is more streamlined throughout the experience. My favorite part about ACLT is the fact that your experiences can be very flexible, especially in the third year. This has been phenomenal option to help address the deficiencies I felt I had in ambulatory topics. I would encourage everyone to consider applying to ACLT and please let me know if you have questions!”

Four JAR spots and two SAR spots are now open for the 2014-15 academic year.  The track is designed not only for residents interested in primary care, but for those interested in ambulatory subspecialty careers, too.  And social events with like-minded residents and faculty are organized by Sharon Rubin and others.

If interested please contact Alex Cho, Stephen Bergin, or Daniella Zipkin.  A brief, one-page application will be due Monday, December 30.  You can also go to for more information.  Thanks!

ACLT application form


 Florida Internal Medicine
Corpus Christi Hospitalist
Pediatric Hospitalist-Houston Texas
BC_FlyerTemplate_Billings Internal Medicine 2013

Upcoming Dates and Events

  • January 15th:  “Voices in Medicine”
  • April 18th:  Charity Auction

Useful links

by · Posted on December 20, 2013 in Chief Residents, Internal Medicine Residency, Medical Education, Uncategorized, Weekly Update · Read full story · Comments { 0 }