From the Desk of Dr. Sinha … | Duke Neurology Residency

Volume 1 Edition 4
February 2015
| Duke Neurology Residency Newsletter |
From the Desk of Dr.
Sinha …
Thanks to everyone who
participated in the CLER visit.
While we don’t have the final
feedback yet, the logistics of the
meeting itself went very
The RITE exam will be
administered on 2/26 and
2/27/15. MOPC clinic is
cancelled on 2/27/15. There will
be a brief practice exam on
neuroanatomical localization
(put together by Duke-NUS) on
2/3/15 at noon. Otherwise, it is
time to settle into the normal
routine for a while, until AAN
and graduation/chiefs leaving
cause upheaval.A couple of
things coming up: Writing
Assignments are due on 4/30/15,
please start thinking about them
now. AAN is coming up as well,
refer to chief’s corner for details.
Lastly, Dr. Lerner’s
performance improvement
project related to workflow for
inpatient admissions is
underway. Please look for
updates from him about changes
in our standard procedures. Until
then, our procedures should the
same as always: discuss case
with attending before agreeing
to admit a patient.
Chief’s Corner
By Corey White
While there are only 5 remaining blocks in the academic year, we have
multiple upcoming events including the RITE, AAN in Washington DC,
and graduation dinner.
All Neurology residents will be taking the AAN RITE (Resident In-service
Training Exam) on February 26th or 27th. For JARs who haven’t taken the
exam it consists of 425 questions (SARs and chiefs, this is 20 fewer
questions than in prior years). The exam day is broken up into two sections.
The first includes questions only and the second includes questions that
correlate to the supplied graphics manual. The exam will use DSM-5
terminology for the behavioral/psychiatry portion. The results will be
released to Dr. Sinha and the examinee approximately six weeks after the
examination. Dr. Peters has graciously offered to provide a RITE review
session which will occur on Monday, February 23rd at 6pm in the Cancer
Center. An additional RITE study resource includes NeuroSAE, which is a
collection of multiple choice questions, available for free (access to one
exam at a time) with an active AAN membership.
AAN is in Washington DC this year and the residents are split into the first
or second half of April 18 – 25th. Take a look at the resident work schedule
and reply to David ASAP regarding the Airbnb option for group lodging.
AAN is a chance to network, learn, and socialize with residents and
Lastly, with the graduation dinner date confirmed for May 30th at
Maggiano's Little Italy, be sure to save the date. This is an opportunity to
celebrate the completion of another academic year and to recognize
outgoing residents and fellows.
Volume 1 Edition 4
Meet Your Resident
Dr. Anastasie Dunn-Pirio
Gina’s Corner
February 2015
I was born in Los Angeles, CA and when I was very young I moved
with my family to the Washington DC area. I have three sisters and a
brother and come from a multicultural family. When I was a child I
danced for the Joffrey Ballet for a number of years. In high school my
interests changed to martial arts as I studied Tae Kwon Do.I attended
The George Washington University for college and Georgetown
University for a Master of Science degree. During that time I was first
introduced to neuroscience at the NINDS in Bethesda where I worked
in a neuro-virology lab. Pipetting HIV was a unique experience! I
attended the University of Virginia for Medical school and during the
first winter, met my husband while stranded on the ski slopes. We were
fortunate to couple’s match at Duke and were married at the Duke
Chapel during my Jar year.I am currently enjoying chief year and
recently had a great experience being a teaching assistant for the
medical school’s Brain and Behavior course, along with some of the
other residents. Also, I am ecstatic to begin a fellowship in NeuroOncology here at Duke.
In my free time, I enjoy vegetarian cooking, and currently trying to
learn how to play the piano. Last February, there was an exciting new
addition to my family. We adopted Buddy, our mischievous, but very
adorable, golden retriever. Lastly, I am thrilled to be fulfilling part of
my bucket list this year by traveling to Rome next month.
-Time-off: Please remember that if you are not at Duke, you must still log
hours. If you are out for any reason, this must be documented under the
“Schedule Management” section on your MedHub homepage. This includes,
but is not limited to time-off for illness, vacation, away conferences.
-ACLS/BLS: You must notify me of your certifications as this will be entered
into MedHub as an alternate activity and I have to put that in for you.
-Interviews: Also, let me know if you are away from Duke because of
interviewing. If you need any help with this or have questions please let me
Dates to Remember:
GME Week: February 2nd – 6th with free food on Monday & Friday. Chance
to win tickets to Duke vs. Wake Forest game which will be on March 4th
Graduation Banquet: May 30th
Volume 1 Edition 4
Meet your faculty
Dr. Richard Bedlack
February 2015
Current title: Associate Professor with Tenure
When you were a kid, what did you want to be when you grew up: Rock Star
What do you love about Duke and your position as faculty? I get up every
day and I am excited to go to work. I get to live in a beautiful part of the
country, study a disease that never ceases to amaze me, and work creatively
with inspirational patients and compassionate colleagues.
What one word best describes you? Hopeful
People don't know what about you? When I was 10, I was a huge fan of the
band "KISS." I had all their albums and posters. My friends and I even used
to dress up like them, make-up and all (I was always Gene Simmons) and
put on concerts in my basement for the neighborhood.
Most common misconception about you? People that do not know me do not
understand my clothes. These help me keep an energetic, positive, fun
attitude, and they give my patients something to look forward to when they
come to see me in ALS clinic. I have to have some tough conversations in
that clinic with patients and families; it is really nice to be able to start a visit
with all of us laughing about the crazy jacket or shoes I have on.
Hobbies? Shopping (see above), golf (I have 2 career hole-in-ones) and
poker (I played in the world series of poker in 2013, and won so much from
Dr. Rozear over the years that he had to un-retire).
Last book you read? Confederacy of Dunces
Last movie you saw at theatres? The Theory of Everything
Favorite place to eat? Lantern
What person, living or dead would you like to meet and what would you ask
them? I already met her, asked her the same question several times, and she
finally said "yes" (my wife Shelly).
One thing on your bucket list you would like to accomplish within the next
year? I want to find the cure for ALS.
Dr. Bedlack attending and walking the runway at Designer Paul Smith’s show at Paris Fashion
Week January 2015 (another bucket list item checked off)
Outfit: Paul Smith leather motorcycle pants, Paul Smith sweater patterned after the rug in Jim
Morrison’s Paris apartment where he died, and Saint Laurent motorcycle boots
Volume 1 Edition 4
Alumni Update
Dr. S. Mitchell
Class of 1976
Director’s Corner
Interview season is upon us. Your participation is crucial to the program’s success. This
includes participation in ICC the evening before interviews followed by dinner with the
candidates. During interview day, we will have lunch from 12:45 to 2:00, everybody is
encouraged to attend. Please try to interact with as many candidates as possible and
provide feedback to the chiefs about your impressions.
For JARs, if you have not already done so, please make sure that you register for
USMLE Step 3 as soon as possible. Due to the new format, there is likely to be a
substantial delay in reporting of scores (scores from 11/14 may not be released until
4/15). You must pass Step 3 to be promoted to SAR status.
Please make sure that you stay on top of clinic cancellations for vacations/meetings.
Also, make sure you are at clinic by 1pm on the days that you are scheduled. Even if
your patient is not there, there are usually unassigned patients that need to be seen. In
addition, if a patient that was supposed to be cancelled shows up, if it is not their fault,
we should still try to see them.
For JARs and SARs, if you have not completed the first phase of your self-assessment
project, please do so immediately. The Clinical Competency and Excellence Committee
month to review all residents — this is one
of the items we look at. Any missing items usually lead to
closer scrutiny of the entire record.
will be meeting next
Gina’s Corner
Reminder to log and submit du ty hours on time
Things a trainee sho uld tell me:
- Dates for an away conference (log in duty hours)
- Dates for takin g Board exams
- Dates for takin g ACL S/BL S
- Any changes in the schedule
February 2015
I did my internship at Duke in Medicine 1972-73 (probably before you
were born!!)……I was already leaning towards neurology at that point in my
career. As a medical student at the University of Pennsylvania, my neurology
attendings were Dr. Lewis Rowland, Dr. Stanley Fahn and many other
luminaries in neurology. One of my early rotations in my medical internship
was Neurology. After I did well in that rotation, Dr. Stanley Appel (then
chair of the division) offered me a slot as a neurology resident. My wife liked
the area (she was a medical librarian at Burroughs Wellcome, now GSK) so
she encouraged me to take the opportunity.
In those days, most residents did not go on to specialty fellowships. Some did
epilepsy and some did neuromuscular fellowship training but little else was
available in the mid 70’s. I completed my residency in 1976 and then spent
two years at Womack Army Hospital as a Major in the US Army.
Following that, I decided with my wife’s encouragement to go in to practice
in Raleigh. I joined another neurologist and at that time I was the second
neurologist in Raleigh. Keith Hull trained at Duke and he joined me. We
split off from the senior partner in 1983 and founded Raleigh Neurology. The
practice has grown over the years and is now one of the largest independently
owned private practices in the country. We have 27 neurologists including 6
child neurologists. I am not entirely sure I understand how this happened,
going from 2 neurologists to over 20 but the practice has flourished.
Neurology training in the 70’s (and I suspect even now) is substantially inpatient oriented so I don’t think the training really prepared me adequately for
the real world. Certainly no training was available about the economics of
running an office. Since most young doctors these days work for
organizations like universities or healthcare corporations, perhaps this training
is not as necessary as it once was.
The choice of neurology as a career was the correct one for me. As a
neurologist I came in contact with physicians in virtually every specialty and
subspecialty. Over the years I worked with and got to know internists, family
docs, gynecologists, cardiologists, psychiatrists, geriatricians,
ophthalmologists, radiologists, ENT docs, orthopedists, etc. Few fields in
medicine cross with so many fields as neurology does. This has been very
rewarding. If I have any dislikes these days it is with the healthcare system
and its complexities and not with neurology per se as a career choice.
In my spare time I read novels and poetry, I listen to classical music, I go to
the opera, I visit art museums, I travel with my wife, I visit my children and
Words of wisdom: Medicine can be the most wonderful profession in the
world. It is not a job, it is a profession and a calling. When you regard it as a
job, you lose your soul. Figure out who you are. If you are an artist or poet
or farmer or jock, don’t lose that part of you. Incorporate it into your world of
neurology. If you find joy in teaching, do so. If you find fulfillment in
community or church work, do that.
February 26 & 27, 2015 – No time off
should be requested for these two days
Survival Tips
AAN Membership
Deadline to pay membership fee is December 1, 2014 (SARs/Chiefs)
by Dmitry Tchapyjnikov
Membership fees for JARs will be paid by program (this year only) so if you haven’t submitted paperwork to me, I need it!!
If you need to look up how much volume you need for a CSF lab (or any
other urine or serum lab, including what container it goes in) check out the
Duke Lab Manual. Click on the Start Menu -> All Programs ->
Departmental Systems -> LAB -> DUHS Clin Lab ELM. Alternatively
here is the URL:
Volume 1 Edition 4
February 2015
Resident of the Month
Chosen by faculty
Jennifer Creed
“She tirelessly provided care to the >20 patients on the stroke team
over several days in a row during the holidays. She never
complained, and simply provided excellent care and kept the team
organized and efficient under this tough pressure. She also did it all
with a smile and was a pleasure to work with. Kudos to the whole
team, especially to Jen.”
Resident Accolades
from faculty
Joshua Leibner: “Josh has been a big help with the VA inpatients and
outpatients this month.”
Corey White: “Scheduling above and beyond the call of duty.”
Mariam Wasim: “Mariam continues to do a great job with the
newsletter. It’s obvious that a lot of hard work goes into it.”
David Lerner: “Did a great job in clinic working with some difficult
Quality Improvement
by David Lerner
NAsAA (Neurologic Admission without Attending Approval)
Introduction: Currently at Duke University Hospital, there is a campus wide
initiative to decrease the consultation time to disposition time in the emergency
department. The neurology service has one of the largest consult volumes as
well as one of the longest consultation times. The current workflow includes
telephone staffing of all consultations – regardless of admission or discharge.
There is a workflow change planned which will not require staffing of
consultations over the telephone with an attending if the patient is to be
admitted to a neurology service. The aim of this study is to evaluate
consultation to disposition time and attending approval of admission.
Methods: There will be two phases to the trial. First includes a run in phase,
where workflow will remain the same – ED consultations will be staffed
regardless of admission or discharge (This is currently underway). Each
admission overnight is cataloged and the appropriate attending, either stroke or
general, will receive a brief (4 question) survey reviewing workup,
appropriateness of admission, and concerns from the attending. These will be
used as a baseline. As part of Duke University Hospital’s QI project there is
ongoing consultation to disposition times currently being collected. The second
part of the trial will utilize the new workflow –admission to the general
neurology service without telephone staffing while stroke neurology will keep
the same workflow and will act as an internal control. Attending satisfaction
and disposition times will be compared pre and post workflow change.
Results: Pending. Currently, completing the run in phase of the trial. For those
attendings who have completed surveys, your assistance is greatly appreciated.
Volume 1 Edition 4
Case of the Month
by Damien Earl
February 2015
Patient is a 74 year-old African-American man with history of diabetes,
hypertension, peripheral vascular disease, and end-stage renal disease
status-post deceased-donor renal transplant on tacrolimus and prednisone
(previously also on mycophenolate) who presented to Duke as transfer
from outside hospital for a second episode of slowed cognition and
generalized weakness. During his first episode on 12/8/14, he was admitted
to general medicine service who obtained MRI brain and LP, which were
remarkable for chronic white matter ischemic disease and protein of 131,
respectively. There were no cells and normal glucose. HSV, VZV, and
cryptococcal antigen were all negative. He began to recover after a change
in his immunosuppression, and was discharged to SNF for rehab. He was
doing well, until 1/11/14 when he developed similar symptoms, and was
taken to outside hospital. Workup included head CT, carotid ultrasound,
and echocardiogram, which were unrevealing. He developed a fever and
was started empirically on antibiotics. LP again revealed elevated protein
to 120, but normal glucose and cell count. He was transferred to Duke for
further management. Neurology was consulted, who noted patient to
initially be alert and oriented, but with slowed responses, proximal muscle
weakness, relative atrophy in right arm proximal muscles, and brisk
reflexes throughout. MRI brain showed no abnormal enhancement. MRI
cervical spine revealed cervical spondylosis to explain hyperreflexia and
atrophy. Repeat LP showed protein >600, glucose 18, and lymphocytic
pleocytosis with 74 nucleated cells. On second day of admission, the CSF
cryptococcal antigen from outside hospital returned positive, and within
days the crypto antigen from our LP also returned positive at 1:120.
Multiple other infectious etiologies as well as flow cytometry and cytology
were all negative. He was started on amphotericin and flucytosine.
Unfortunately, became progressively more somnolent, and on day 6 of
admission he was transferred to MICU for decreased responsiveness and
intubated for airway protection. Repeat LP showed CSF pressure of 38
cmH2O. He remains in the MICU (day 6) with persistently elevated CSF
pressure in the 20s requiring every-other-day LPs. His mental status is
improving daily and he is on minimal ventilator support. Hopefully, he will
continue to recover under the excellent care of the MICU team.
Volume 1 Edition 4
February 2015
Social Calendar February 2015
Chief Grand
David Lerner
GME week:
Bunker Lunch
11 a- 1 p
Corey White
GME week
Breakfast 7-9
RITE exam
RITE exam
Duke vs UNC
Tyler’s Taproom
8:30 pm
RITE Review
w/Dr. Peters
Cancer Center
6 pm
Residents (and attendings) just wanna have fun!
fashion files
continued …
You know it’s special
when residents are
sitting in the front at
Grand Rounds!
Volume 1 Edition 4
February 2015
The Chronicles of Aaron …
Volume 1 Edition 4
February 2015
Fun Corner
by Anastasie Dunn-Pirio