Block ICardiology

INTERNAL MEDICINE RESIDENCY PROGRAM

 

Faculty: C.Kenneth Bodine, MD, Andrea Brasch, MD, Bala Govindarajan, MD, Sanjay Mehta, MD, Aung Min, MD, Batalautundu Lakshminarayanan, MD, Reinaldo Sanchez-Torres, MD, Joseph Sutton, MD, Kolala Vasudevamurthy, MD 

Sites: Provena Covenant Medical Center (PCMC), Carle Clinic Association (CCA), Carle Foundation Hospital (CFH), Veterans Administration Illiana Health Care System (VAIHCS)

Duration: Block Rotation

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DESCRIPTION

4 week block rotation under the supervision of Dr. C.Kenneth Bodine, and Drs. Andrea Brasch, MD, Farhad Farokhi, DO, Bala Govindarajan, MD, Sanjay Mehta, MD, Aung Min, MD, Batalautundu Lakshminarayanan, MD, Reinaldo Sanchez-Torres, MD, Joseph Sutton, MD, and Kolala Vasudevamurthy, MD  in the direct experience for patient treatment and competent care management of chronic coronary artery disease, acute coronary syndromes and valvular heart disease.  The resident will have opportunity to assume responsibility for acutely and chronically ill patients to learn the natural history of cardiac conditions.

Additional cardiology training takes place longitudinally throughout all 3 years, i.e., block rotations in PGYI, PGY II and PGY III. Other cardiology education occurs during Continuity Clinic, Core Conference, Grand Rounds, Quality Review, and Journal Club.

I. GOALS

Demonstrate competence in the ambulatory and hospital management of patients with acute and chronic cardiovascular disorders with emphasis on basic mechanisms, clinically relevant pathophysiology, clinical manifestations and evidence-based therapy.  Demonstrate consultative skills and recognition of principles, indications, utility, and interpretation of invasive and noninvasive cardiovascular diagnostics.

II. OBJECTIVES

A. PATIENT CARE

Objective 1: Demonstrate clinical skills of comprehensive cardiac interview, history and physical examination at the patient bedside, including functional assessment and mental status as needed.

  1. History: Obtain complete history, with special emphasis on cardiovascular findings
    1. Chest pain
    2. Palpitations
    3. Orthopnea
    4. Paroxysmal nocturnal dyspnea
    5. Dyspnea on exertion
    6. Pedal edema
    7. Syncope
    8. Hemoptysis
    9. Exercise capacity
    10. Identify modifiable and non-modifiable risk factors for artereosclerotic cardiovascular disease

Objective 2: Demonstrate clinical skills in the diagnosis and medical management of acute and chronic cardiac conditions.

  a. Perform physical examination with special emphasis on the following

  1. Jugular venous pulse, hepatojugular reflux
  2. Carotid pulse
  3. General vascular exam
  4. Chest palpation
    • Apical impulse
    • Parasternal heave
    • Thrills
  5. Auscultation

6. Bedside maneuvers

7. Chest x-ray

8. Electrocardiography

9. Conduction abnormalities

10. P-wave abnormalities

11. Ventribular hypertrophy

12. Q-wave myocardial infarction

13. ST-, T-, U-wave abnormalities

14. Pacemaker basics and recognition, use of magnet

Objective 3: Generate a differential diagnosis and problem list in accepted format

Objective 4: Perform pre-operative evaluation for cardiac risk

a.Identify risk factors for cardiac risk during non-cardiac surgery

b. Gain knowledge on ordering tests for risk stratification and interpretation

c. Identify high-risk patients for management perioperatively

Objective 5: Perform and record procedures

a. Procedure Skills: The resident is expected to perform and become adept at the following procedural skills during his/her residency training:

B. MEDICAL KNOWLEDGE

Objective 1: Demonstrate fundamental knowledge of recognition, treatment and management of coronary artery disease, valvular heart disease, hypertension, cardiomyopathy, congestive heart failure, arrhythmias, peripheral vascular disease, pericardial disease, cor pulmonale, pulmonary hypertension, sudden death syndrome, congenital heart disease, pacemakers, syncopea.

Coronary Artery Disease (CAD)

    1. Acute Care

    aa. Recognize and treat unstable angina and acute myocardial infarction in the Coronary (CCU) and Intermediate Care Unit (ICU) to include:

    bb. Manage myocardial infarction patient on medical ward post CCU discharge to include

     2. Ambulatory Care

3. Long-term Treatment

b. Valvular Heart Disease

                1. Acute Care

                 2. Ambulatory Care

c. Hypertension

d. Cardiomyopathy and Congestive Heart Failure (CHF)

1. Acute Care

aa. Differentiate systolic vs. diastolic abnormalities

bb. Recognize etiologies of cardiomyopathy, including induced and alcholic

cc. Treatment of arrhythmias, e.g. implantable cardiac defibrillator, surgery

dd. Management of heart failure as per ACC/AHA & Heart Failure Society of America (HFSA) guidelines and recommendations

e. Cardiac Arrhythmias

1. Acute Hospital Management

aa. Recognize tachyarrhythmias vs. bradyarrhythmias

bb. Differentiate supraventricular vs. centricular tachyarrthmias

cc. Understand indications for non-pharmacologic, e.g. Valsalva, CSM measures

dd. Electrical cardioversion and defibrillation

ee.Pacemakers

ff. Indications for Electrophysiological studies

        2. Ambulatory Care

aa. Differentiate treatment modes pharmacological vs. catheter ablation vs. surgical

bb. Understand atrial fibrillation

f. Peripheral Vascular Disease

1. Acute Care

aa. Arterial occlusion

bb. Acute vein thrombosis

cc. Aneurysm, including dissecting aneurysm

 

2. Ambulatory Care

aa. Arterial disease

g. Pericardial Disease

1. Acute Care

aa. Diagnosis of acute pericarditis and pericardial effusion
bb. Pericardial tamponade

h. Corpulmonale and Pulmonary Hypertension

    1. Acute Care
    2. Pulmonary embolism

i.  Sudden Death Syndrome

    1. Diagnosis of malignant ventricular arrhythmias (EPS)
    2. Invasive and non-invasive work up 
    3. Implantable defibrillator versus medical management and surgical treatment options

j. Congenital Heart Disease

k. Pacemakers and Defibrillators

    1. Indications acute transvenous
    2. Types of implanted devices and follow up

l. Syncope

    1. Evaluation per Holter, electrophysiology study (EPS), Tilt Table

C. PRACTICE-BASED LEARNING AND IMPROVEMENT

Objective 1: Evaluate patients with acute and chronic cardiac disease, and cardiac emergencies to formulate an appropriate, cost-effective diagnostic and therapeutic plan.

Objective 2:  Demonstrate ability in medical decision making, which incorporates assessment, and patient values and preferences

Objective 3:  Demonstrate evidence-based practice through appraisal and assimilation of scientific information, e.g. scientific journals, related to patient care

 D. INTERPERSONAL AND COMMUNICATION SKILLS

Objective 1:  Create an atmosphere of positive regard for the patient and family to promote the best medical outcome through accessibility, affability and assurance of care continuity

Objective 2:  Incorporate psychosocial and ethical concerns of the patient and family in the development of the care management plan

Objective 3:  Dictate timely, comprehensive patient care notes, including admission summaries, and write thorough, succinct progress notes in accepted format.

E.  PROFESSIONALISM

Objective 1:  Demonstrate humane and compassionate use of medical skills to include high-quality care and technology, and an awareness of the limits of medical intervention.

Objective 2:  Actively participate in the multidisciplinary approach to caring for patients, including appropriate recognition of other health professional and paraprofessionals’ roles and demonstrate competence in team interactions, i.e. catheterization laboratory personnel, pharmacists, physician’s assistants, advanced practice nurses, nurses, and social workers.

Objective 3:  Recognize the documentation and legal requirements of informed consent, and advanced directives with understanding of the patient’s perspective.

Objective 4:  Model appropriate professional attitudes and behaviors of time management and punctuality, reliability, ethical behavior, and medical student teaching and evaluation

F.  SYSTEM-BASED PRACTICE

Objective 1:  Evaluate patients with cardiac emergencies and formulate an appropriate, cost-effective diagnostic and therapeutic plan.

Objective 2: Facilitate continuity of care of patients admitted to the hospital, including communication and collaboration with patients’ families, attending and consulting physicians, catheterization laboratory personnel, pharmacists, physician’s assistants, advanced practice nurses, nurses, and social workers.

Objective 3: Recognize financial issues of health care, with consideration of cost containment and emphasis on understanding acute and chronic care, and medication coverage and the role of the Center for Medicare and Medicaid Services (CMS), and other third party payers.

III. METHODS

Training occurs at all 3 training sites, i.e. Carle Clinic Association (CCA)/Carle Foundation Hospital (CFH)

CARLE CLINIC ASSOCIATION (CCA)/CARLE FOUNDATION HOSPITAL (CFH)

The CCA/CFH cardiology rotation is primarily focused in the in-patient consultation service.

Residents report to the Subspecialty Education Coordinator on day one for a detailed rotation schedule and orientation to the service. Residents provide care for 8-10 inpatients, including both Intensive Care Unit (ICU) and non-ICU. Residents perform history, physical examination, outline treatment plan, and patient's care management with attending supervision. Residents are required to attend autopsy examinations of any patients followed.

    1. Daily inpatient work/management rounds are 0715 to 0­930 daily.
    2. Teaching rounds are conducted by the designated teaching attending. Conferences are organized around interesting patients seen in the hospital or clinic. Pathophysiology, diagnosis and therapy, basic science and new advances in medicine are discussed.
    3. Residents see Cardiology consultations requested at CFH averaging one per day. The resident performs a complete history and physical examination and makes recommendations for the consultant with references from the medical literature.
    4. Ambulatory experience includes including echocardiography, treadmill stress tests, and holter monitor.
    5. Reading time is assigned for electrocardiograms to review interpretation with the attending.
    6. Catheterization laboratory may offer opportunity to assist the invasive cardiologist.

VETERAN ADMINSTRATION ILLIANA HEALTH CARE SYSTEM (VAIHCS)

The VAIHCS cardiology rotation has two components: ½ month focused on in-patient cardiology and ½ month on out-patient cardiology.  If more than one resident is assigned to the cardiology rotation, the residents switch blocks half-way through the month. 

The out-patient experience allows the resident to see patients independently in the cardiology clinic, subsequently staffing them with the cardiology attending and discussing management and treatment plans.  Experience interpreting stress tests and ECG’s is emphasized. 

The in-patient experience allows the resident to perform in-patient cardiology consults, and staff with the attending cardiologist.  Daily rounds on the cardiology consult patients are performed by the attending cardiologist and resident.  Reviewing echocardiograms, stress tests, and ECG’s is a major component.  Both in-patient and out-patient residents attend daily morning report, and are assigned to present at morning report.  Feedback is provided to the residents at the half-month point.  Overnight call is not assigned during this rotation.         

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PROVENA COVENANT MEDICAL CENTER (PCMC)/CHRISTIE CLINIC

Daily morning inpatient work rounds are held with the attending cardiologist.  The cardiology resident sees in-patient consultations under the supervision of the attending cardiologist.  The resident has opportunities to observe invasive cardiology procedures in the catheterization laboratory.  The resident may be asked to cover evening consults and management issues that arise on service after hours with the attending cardiologist.  Topics addressed and reviewed by the cardiologist and the resident together include echocardiography, treadmill stress testing, holter monitor interpretation, electrocardiogram interpretation, among others may also be offered.  The cardiology resident attends Core Conferences and daily subspecialty rounds, including weekly cardiology rounds with residents on other subspecialty electives.

Objectives of the rotation are listed on the program website, and cover the following 6 general competencies:

  1. Medical Knowledge, including a fundamental knowledge of the following topics recognition, and management: coronary artery disease, valvular heart disease, hypertension, cardiomyopathy/congestive heart failure, arrhythmias, peripheral vascular disease, pericardial disease, cor pulmonale and pulmonary hypertension, sudden death syndrome, congenital heart disease, pacemakers, syncope
  2. Patient Care of the above conditions, including management and clinical judgment
  3. Communications and Interpersonal Skills
  4. Professionalism, including attitude and work ethic
  5. Practice-based Learning and Improvement, including appropriate use of medical literature, performance of necessary literature searches, and demonstration of desire to improve and expand knowledge base
  6. Systems-based Practice, including working with the patient care team, nursing staff, catheterization lab personnel, and other health care professionals.

Methods:
The above objectives are directly observed by the supervising cardiology attending working closely with the resident.

V. EVALUATION

ACGME Competencies

According to the Accreditation Council of Graduate Medical Education (ACGME), training and evaluation must include the following competencies: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice.

Patient Care will be evaluated by 1 Mini-CEX and by global assessment of the attending physician and additional information from nursing staff, patients and families.  Procedures performed must be documented electronically.

Medical Knowledge will be evaluated by 1 Mini-CEX and by global assessment of the attending physician.

Practice-Based Learning and Improvement will be evaluated by global assessment of the attending physician.

Interpersonal and Communication Skills will be evaluated by 1 Mini-CEX and by global assessment of the attending physician and additional information from nursing staff, patients and families.

Professionalism will be evaluated by assessment of the global attending physician and additional information from nursing staff, patients and families.

System-Based Practice will be evaluated by 1 Mini-CEX and by global assessment of the attending physician.

The evaluation method is primarily accomplished electronically.  Residents’ performance in Cardiology is evaluated by the attending physician.  Evaluations are reviewed with the residents for formal feedback.  In addition, ongoing feedback is provided related to residents’ patient care responsibilities and activities.Residents will document the Cardiology rotation in portfolios, e.g. procedures performed.  This tool will provide individual learning, reflection and assessment.  Additionally, residents evaluate the Cardiology rotation.

Residents provide input on the Cardiology core lecture series, which is used in scheduling future topics and speakers.  Topics include adult congenital heart disease, arrhythmia basics, atrial fibrillation, CHF, diastolic dysfunction, endocarditis, evaluation of athletes, hypertension, non-invasive testing, pericardial disease, preoperative assessment, primary cardiomyopathy, secondary coronary prevention, syncope, and valvular heart disease.  

V. REFERENCES

American College of Cardiology http://acc.org/qualityandscience/clinical/topic/topic.htm 

"Management of Congestive Heart Failure", Francis, Gary S; The Heart House Learning Center Highlighter, 8:3(1993)

"Heart Failure: Drug Therapy in the Nineties and Beyond", Conti, Richard C; Editorial Clinical Cardiology; 16, 459-460 (1993)

"Challenges of Thrombolytic Therapy", Swan, HJC; American Journal of Cardiology, Continuing Education Series UCLA Extension (1993)

Heart Disease. E. Braunwald, Saunders, 1992.

Cardiology. Volume I, II. K. Chaterjee, Lippincott, 1991.

Acute Myocardial Infarction. S. Rahimthola, B. Gersh, 1992.

ECG SAP, by ACC, 1995 edition.

MKSAP, ACP, Cardiology Section, (current ed.)

Rev 4/30/2003, 7/25/2006, 7/1/2007, 11/5/2007, 5/6/2009