September 2016 | Vol. 9 | No. 3

From the Desk of the Associate Dean

It is September and hopefully the hot temperatures are waning. It is pleasant in the mornings but it is also now dark. Interns and new fellows have had the opportunity to become immersed in their new positions and everyone has had the time to adjust to new roles. The word on the street is, in general, everyone is performing well which makes me very happy.

As a testament to the expansion of GME over the past 10 years, an assistant dean for graduate medical education has been appointed—David Carlson, MD, MS. Dr. Carlson is currently the program director of the Reno psychiatry program and has had a 20 plus year career in academic medicine. He is the ideal person to join me in GME and ultimately take over as DIO when the splitting of the schools takes place in July 2017. As many of you know, I will be staying in Las Vegas with those programs. In addition to managing the seven programs in Reno, Dr. Carlson has been tasked with developing new programs in to meet the needs of the community and of northern Nevada.

Speaking of expansion, since academic year 2006-07, graduate medical education has grown 80%. As an institution, we have gone from 219 to 395 residents and fellows statewide. The number of ACGME accredited programs has increased from 15 to 24 including the addition of three core residencies (Las Vegas) and six fellowships (statewide). In the next several years GME will expand further with the funds from the governor's first round funding initiative. Internal medicine and both psychiatry programs received approval for their planned expansions—16 for Las Vegas psychiatry and 8 for Reno psychiatry and 15 for Reno internal medicine. A couple of days ago the second round of grants were awarded and the school received grants to expand family medicine in a rural direction with 6 additional positions and geriatrics with 1.5 positions. In total, the school received $6.3 of the allocated $10 million. The goal of public medical education is to meet the needs of the state and mitigate the extreme physician shortage we face.

Above, I mentioned the splitting of the schools. The split will be able to occur—hopefully in a seamless manner for trainees—as scheduled. On August 12, 2016 the UNLV School of Medicine was accredited by the ACGME as a sponsoring institution. This means that the institution will be able to sponsor the Las Vegas residency programs. The details of making this happen are complicated and are in process. Because the institutions are both part of the Nevada System of Higher Education, I am hoping that this will simplify the process, but it is anyone's guess if that will prove to be true.

Recruitment for fellowships has started and moving forward rapidly. Last year, we did really well in our fellowship matches and anticipate that happening again. The word is getting out that the new fellowships are strong, fellows are learning a lot and publishing. UNSOM, now UNR Med students are returning to participate in the fellowships, making the commitment to train and hopefully remain in Nevada. Last June we saw the first Las Vegas child psychiatry fellows complete their training—both remaining as faculty in the program and increasing the number of child psychiatrists in the area by 25%. This coming June we will have the first graduates of the Las Vegas based cardiology and gastroenterology fellowships.

In a similar manner, the programs are preparing for the opening of the NRMP on September 15, 2016. At that time, the 2017 recruitment season will formally begin. Interview invitations will be forthcoming and the process of bringing in the next group of interns commences. Good luck to all of the programs who will be recruiting!!

Programs are also completing their annual updates for the ACGME and their APEs for me. During this process, program directors are asked to reflect on the past academic year and identify strengths and areas needing improvement. The areas needing improvement come in the form of action items that will be worked on during the current academic year. All of the associated activities to develop action items are focused on the self-studies that will be starting in the next few years, part of the ACGME's Next Accreditation System or NAS. The ACGME moved from site visits with cycle lengths to annual accreditation and a continuous quality improvement system.

With that said, it doesn't mean that the ACGME is not visiting our programs. We have had a significant number of site visits with variable outcomes over the past six months. Just a few weeks ago, child psychiatry and cardiology had initial site visits with the anticipated outcomes of leaving the initial accreditation status and receiving continued accreditation. Other programs will have repeat visits this coming academic year to review progress made since the last visit.

Residents and fellows who will be completing their training in June 2017 have all been invited to Graduating Resident Seminars either in Las Vegas or in Reno. The Las Vegas seminar was accompanied by a job fair organized by the Clark County Medical Society as part of their initiative "Keep Our Doctors in Nevada". It was anticipated that this event would be replicated in Reno by the Washoe County Medical Society, but that did not occur. The Reno residents and fellows will have their seminar on September 14 at Renown. The speakers for these events donate their time and address important topics like interviewing for fellowships, interviewing for jobs, legal issues (applying for an unrestricted license and contract review), CV building and finances 101. We have been holding these seminars for the last nine graduating classes statewide.



Miriam Bar-on, MD
Associate Dean for Graduate Medical Education and DIO

The Resident Voice

How to Call a Consultant

By Zachary David Skaggs MD
PGY-2 Emergency Medicine Resident
University of Nevada School of Medicine - Las Vegas

Fall is here and with it come a fresh class of interns. Last year at this time I wrote a rather lengthy guide to surviving intern year. This year, I want to focus on one specific issue that often vexes new interns: the appropriate way to speak to a consultant.

As medicine grows ever more complex, patient care requires the attentions of multiple specialists. As a medical resident at a tertiary medical center, one of your key roles will be coordinating this care. Having a good approach to speaking with consultants that is pertinent, concise, and confident will significantly aid in the care of your patients. Here are some lessons that I have learned during my medical training as to how to speak to the attending on the other end of the line:

  1. Be prepared. You put out the page to the neurosurgeon. It's up to you to have the patient's information and history ready to go when you get your call back! That means the patient's name, medical record number, pertinent labs, and, often most critically, the pertinent verbiage of the patient's radiology report. It is often a good idea to have the patient's CT brain printed out in your hand awaiting the neurosurgeon's call. If you are about to talk to Renal, have the patient's Renal Function Test laboratory values at the ready.
  2. Be succinct. Now is not the time to tell the entirety of the patient's past medical history nor the manifold complaints that brought them into your department. Instead, lead with your name, your level of training, whether the patient is stable or not, and what the diagnosis is with a brief synopsis of your ongoing management.
  3. Be pertinent but thorough. Knowing what to say and what not to say about a given patient presentation will take you the longest time to master. For now I will just say, never willfully omit information because you think it will affect how promptly the consultant will see your patient. For instance, if you patient is with anticoagulated with a supratherapeautic INR, you will need to let your consulting surgeon know this information.
  4. Be firm but civil. Your relationship with your consultant needs to be maintained throughout your residency. Acknowledge that they have a difficult job, often making management decisions based solely on your phone report, and remember to be firm but civil for patients that you know need immediate attention.
  5. Ask. Your relationship with your consultant is a two-way street. Ask your consultant if they have any further questions or would like you to put in any studies as they prepare to see your patient. Small things such as this will help you earn the trust of your consultants as you go forward in your training.

Here is a sample transcript of a conversation with a consultant as I would recommend doing it:

Hello, my name is Dr. Skaggs, I'm a PGY-2 Emergency Medicine Resident calling you out of the UMC ED about a critical patient. This is a 65M with a history of uncontrolled hypertension who presented with chest pain and was found to have a Type A aortic dissection. He is hemodynamically stable at this time, mentating well, BPs 110s/70s on an esmolol drip. I am calling you because this patient requires evaluation here in the emergency department for endovascular versus open thoracic surgical approach for correction of his aortic dissection. Do you have any questions for me? Are there any studies that you would like me to order now while I await your arrival here? Thank you.

Questions? Feedback? Stories of interactions with consultants that have made you a better clinician? As always, you can email me with your comments. Thanks!

From the ACGME

Early Impressions of the CLER Program: A Survey of the Designated Institutional Official Community

Nancy J. Koh, PhD, Robin Wagner, RN, MHSA, Hongling Son, PhD, Robin Newton, MD, FACP, Baretta R. Casey, MD, MPH, FAAFP, Kevin B. Weiss, MD, MPH.
Accreditation Council for Graduate Medical Education

This article presents the results of a survey to all of the Designated Institutional Officials (DIOs) from accredited sponsoring institutions after the first cycle of CLER or clinical learning environment review visits. The ACGME was in a learning process with the first round of visits and noted that improvements in learning and education for residents/fellows was occurring. Further, it was determined that there needed to be improvements in the structure of the visits to meet the need of institutions. The process is dynamic and continual changes are being implemented as the ACGME moves forward… continue reading Early Impressions of the CLER Program: A Survey of the Designated Institutional Official Community.

Best Practice

Podcasts: Assessing, Choosing, Creating, and Disseminating Content

James Ahn, MD, FACEP; P. Charles Inboriboon, MD, MPH, FACEP; Michael C. Bond, MD, FACEP

This article is featured as a Rip-Out in the July Journal of Graduate Medical Education. It poses the creative solution of podcasts as a way to help deal with the challenge of a constantly growing knowledge base combined with multiple, competing information sources. Further, today's learners are faced with increased work intensity related to a variety of components, including the EMR and duty hours. Read the article Assessing, Choosing, Creating, and Disseminating Content.

In the spotlight

Congratulations to former and current internal medicine residents Mohanad Hasan, Pannaga Malalur, Manas Agastya, Ali Malik, Yaser Dawod and Mohammad Jaradat for having their paper A high-value cost conscious approach to minimize heparin induced thrombocytopenia antibody (HITAb) testing using the 4T score published in the Journal of Thrombosis and Thrombolysis October 2016. Their faculty supervisors were associate program director Ranjit Makar and Ji-Won Yoo.

Congratulations to Las Vegas child psychiatry program director Lisa Durette who presented A demonstration of a public and private partnership to achieve improved outcomes at the Foster Family Treatment Association meeting in New Orleans in July 2016.

A second congratulations to Lisa Durette, the 2016 recipient of the Rieger Service Program Award for leadership in the development and/or implementation of an innovative community-based child and adolescent mental health program that addresses prevention, screening, evaluation and/or treatment of mental illness. The award is supported by the Norbert and Charlotte Rieger Foundation.

Congratulations to obstetrics and gynecology residents Patricia Kennel and Hillary Allen who will be attending the ACOG District VII annual meeting in Hawaii in September 2016.

Congratulations to obstetrics and gynecology resident Linda Tran who received a fully paid scholarship to attend Family Planning Forum in Denver Colorado in November 2016.

Congratulations to former obstetrics and gynecology resident Megumi Akiyama and program director Vani Dandolu who published their research Mesh complications and failure rates after transvaginal mesh repair compared with abdominal or laparoscopic sacrocopopexy to native tissue repair in treating apical prolapse in International Urogynecology Journal.

Las Vegas Emergency Medicine residents continue to lead the way in Event Medicine. Residents manned several medical tents as well as the Carrison Care Center at the Las Vegas Motor Speedway June 17-19 for the Las Vegas Electronic Daily Carnival. Over 130,000 attendees were present. Common presentations included various pharmacological toxidromes as well as several critical cases of heat stroke that were transferred to University Medical Center hospital for further care. Lending a helping hand were Las Vegas EM residents Bailey Zhao (PGY-3), Ben Smith (PGY-3), Lauren Pellman (PGY-2), Clayton Wu (PGY-2), and Zachary Skaggs (PGY-2). Participating faculty included Ron Scheer and Dale Carrison, Chairman of the Department of Emergency Medicine at University Medical Center of Southern Nevada.

Meanwhile, Burning Man has just concluded and with it return Rampart Medical Tent staffers emergency medicine residents Ben Smith (PGY-3), Elizabeth Busby (PGY-3), Bailey Zhao (PGY-3), Omar Ahmed (PGY-2), Liz Chen (PGY-2) and Eliot Welder (PGY-1). Residents provided care ranging from splinting to managing STEMI transfers.

GME Residents at Burning Man

Congratulations to former resident and current faculty member Tony Zitek for being named Academic Faculty of the year in our annual award ceremony held in June. Joe Sontgerath was named MOFMC faculty of the year, and David Nelson again won Pediatric Emergency Medicine Faculty of the Year. Resident winners included former residents Joshua Pascoe as resident of the year, Leon Edeylman for outstanding contribution in research, and Josh Pascoe and Jaime Bailey for winning Pediatric Emergency Medicine Resident of the Year.

Former resident and incoming attending Jaime Bailey won second place in the resident research symposium in May for his case report entitled "Catecholaminergic Polymorphic Ventricular Tachycardia as the Etiology of Presumed Traumatic Arrest." The case report has been accepted for publication in the journal Pediatric Emergency Care. The paper was coauthored with Las Vegas Emergency Medicine Program Director Ross Berkeley.

Congratulations to the pediatrics residents who had poster presentations at the Nevada Chapter of the American Academy of Pediatrics annual meeting in August 2016 in Las Vegas:

  • Unique cause of congenital muscle weakness
    Senthil Bhoopalan (PGY-2), Renu Jain (Faculty)
  • Painful wrist swelling in early infancy
    Senthil Bhoopalan (PGY-2), Alan Ikeda (Faculty)
  • Improving oral health in underserved communities
    Irene Murema (PGY-3), Dodds Simangan (Faculty)
  • Severe diarrhea and weight loss in a cardiac transplant patient
    Bhuvaneshwari Jagadesan (PGY-2), Erin Caliri DO (Faculty)

Congratulations to Ambika Chidambaram (PGY-2) in pediatrics who got her abstract titled An unusual case of prolonged site bleeding after lumbar puncture in an infant accepted for poster presentation for 2016 AAP National conference October 22-25, San Francisco, Rani Kharrubi and Mark Dugan (faculty in pediatrics) are co-authors.

Congratulations to Irene Murema (PGY-3) in pediatrics who had her abstract titled "Importance of School Based Health with a focus on Dental Hygiene" accepted for poster presentation for 2016 AAP National conference October 22-25, San Francisco, CA. Dodds Simangam (faculty in Pediatrics) is co-author.

Congratulations to Uche U Nwokidu-Aderibigbe (PGY-3), Andrea Buenostro (PGY-3) who had their manuscript titled "7 Month Old with Desquamating Rash and Facial Swelling," published in Consultant for Pediatricians August 2016 edition. Rita Shah (faculty) is co-author.

Congratulations to the following internal medicine residents who presented their scholarship at a variety of professional society meetings:

  • Ammar Yousif: Drug Induced Hemolytic Anemia From Ceftazidime/Avibactam, A New Old Antimicrobial: A Case Report. IDSA Conference.
  • Muthena Maklad: Sister Mary Joseph Nodule: A rare route of metastasis from colonic adenocarcinoma. Society of General Internal Medicine Mountain West.
  • Muthena Maklad: Cannabinoid Hyperemesis Syndrome: Systematic Review. ACG Conference, Las Vegas.
  • Eyas Chafkeh: Pneumomediastinum with pneumopericardium in a young healthy male methamphetamine use: a case report. Society of General Internal Medicine Mountain West.
  • Eyas Chafkeh: A deviated tongue from neck stretching: a case report. Society of General Internal Medicine Mountain West.
  • Mohamed Azab: Hospital-acquired Clostridium difficile infection risk comparison, proton pump inhibitor vs histamine-2 receptor antagonist, for prophylaxis and treatment of stress ulcers: A systematic review and meta-analysis. ACG, Las Vegas.
  • Ali Malik: Access to PPCI is a determinant of survival of patients with ST segment elevation myocardial infarction in the State of Nevada. World Congress of Cardiology.

Congratulations to the following internal medicine residents who published their scholarship in a variety of professional journals:

  • Phil Ribeiro: Desirable characteristics of consulting cardiologists for sustained referrals by primary care physicians.International Cardiovascular Forum Journal.
  • Phil Ribeiro: Case Report: Unilateral conduction hearing loss due to central venous occlusion. Journal of Vascular Access.
  • Phil Riberio: Management of a partially dislodged embolization coil in an arteriovenous fistula for dialysis access. Journal of Clinical Nephrology and Research.
  • Matthew Prekupec: Ultrasound guided central venous catheterization: a review of the relevant anatomy, technique, complications and anatomical variations. Clinical Anatomy.
  • Mohammed Jaradat: Beta-blockers do not provide survival benefit in a population with angiographic coronary artery disease without myocardial infarction or reduced ejection fraction: A meta-analysis. International Journal of Cardiology.
  • Ali Malik: Dabigatran increases platelet reactivity study - DIPS study. Cardiology.
  • Ali Malik: Geographical determinants of treatment and outcomes of ST segment elevation myocardial infarction in the State of Nevada. Journal of American College of Cardiology.
  • Ali Malik: Interpretation of Inferior Wall ischemia on Single Photon Computed Tomography, Myocardial Perfusion Imaging in Non-Dominant Right Coronary Anatomy: A hypothesis generating study. American Journal of Nuclear Cardiology.
  • Ali Malik: Management of Symptomatic Severe Aortic Stenosis in Patient with very Severe Chronic Obstructive Pulmonary Disease. Seminars in Thoracic and Cardiovascular Surgery.
  • Ali Malik: Comparison of Irrigation versus No Irrigation during Burr Hole Evacuation of Chronic Subdural Hematoma. Journal of Neurological Surgery Part A: Central European Neurosurgery.
  • Ali Malik: Resource utilization for transfemoral transcatheter aortic valve replacement: an international comparison. Catheterization and Cardiovascular Interventions.

Congratulations to Reno psychiatry resident Faraaz Merchant who was elected as the Nevada Psychiatric Association Member in Training (MIT) Representative and sits on the Nevada NPA Executive Council.

Congratulations to Reno psychiatry resident Trent Suggs who was elected as President of the Northern Nevada Chapter of the NPA and to Sunny Shaw who was elected as Secretary/Treasurer. Both also serve as members of the NPA Executive Council.

Congratulations to the entire Reno psychiatry program as it was selected as a member of the APA 100% Club by virtue of all residents in the program having become members of the APA (American Psychiatric Association).

GMEmail is a service of the Office of Communication, University of Nevada, Reno School of Medicine. Miriam Bar-on, M.D., Editor, Office of Graduate Medical Education. Copyright © 2016 University of Nevada, Reno School of Medicine.