Curriculum on Inpatient Cardiology Internal Medicine Residency Program Ochsner Clinic Foundation Authors: Bijesh Maroo MD David Elizardi MD, FACC Hector Ventura MD, FACC This document was created with considerable content drawn from the Michigan State Cardiology Department Cardiology Curriculum, as well as the Ochsner Clinic Foundation Internal Medical Hospital Service curriculum. I. Educational Purpose and Goals Cardiovascular diseases are not only the leading cause of death in the United States but also represent a significant proportion of the admitting diagnoses to the internal medicine in-patient service. Accordingly, understanding the principles of diagnosis and management of the most common cardiovascular diseases is an essential part of the training of the general internist. The mission of the in-patient cardiology rotation is to give the internal medicine residents the opportunity to develop advanced skills in clinical interviewing, physical exam and differential diagnosis of patients with cardiovascular disease symptoms, strengthen their medical knowledge in the basic and clinical science of cardiovascular disease and apply this knowledge to the care of patients. The critical evaluation of current medical information and scientific evidence is crucial to the understanding and appropriate use of diagnostic strategies and treatments in cardiology and will be emphasized. II. Principal Teaching Methods A. Supervised Direct Patient Care Activities Inpatient: Residents will participate in the evaluation and management of cardiology patients at the Ochsner Clinic Foundation Main Campus that are cared for by physicians of the Department of Cardiology. The patients will include those admitted to the Hospital A service from the emergency room, and those transferred from outside institution to the Hospital A service for further cardiac evaluation. Each patient evaluated by the internal medicine resident and interns will be seen with the cardiology attending and fellow 1
during daily management rounds. The management plan will be formulated by the resident and intern and discussed with the rounding team. The rounding team will consist of the attending cardiologist, a cardiology fellow, internal medicine resident, internal medicine intern, clinical nurse specialists and social worker. B. Educational Activities: Residents will have the opportunity to attend the following conferences which are regularly held in the Cardiology auditorium. 1. EKG conference: At this weekly conference (Thursday at 12 noon), IM residents will have the opportunity to participate in the interpretation of EKG s, in concert with the Ochsner Clinic Foundation cardiology fellows and representative Cardiology staff. Key elements of interpretation of EKG s will be provided to the IM residents. 2. Catheterization Conference: At this weekly conference (Friday at 7am), angiograms and hemodynamic data are discussed along with relevant literature review. 3. Cardiology Core Curriculum Lecture: At this weekly conference (Monday at Noon), a cardiology provides a 45 minutes lecture on a relevant topic in cardiology, along with a discussion session at the conclusion of the lecture. 4. Echocardiography Core Curriculum Lectures: This biweekly conference (Wednesdays at Noon) provides exposure to echocardiography in the form of both case based presentations and didactic lectures given the the Cardiology Fellows. 5. Board Review: This weekly conference (Fridays at Noon) is conducted by the senior cardiology fellows. It provides a multiple choice question and answer session covering a wide array of general cardiology topics. 6. Additional conferences occur as part of the Department of Cardiology conference schedule that include renovascular disease, peripheral arterial disease, cardiac computed tomography, electrophysiology topics, nuclear cardiology and cardiac magnetic resonance. III. Educational Content A. Mix of Diseases: The Hospital A service contains a diverse variety of acute and chronic cardiac and vascular conditions. Possible diseases that may be encountered on the Hospital A service include: 1. Coronary Artery Disease 2. Acute Myocardial Infarction and complications of MI 2
3. Congestive Heart Failure including systolic and diastolic dysfunction 4. Valvular heart disease: aortic stenosis, aortic regurgitation, mitral regurgitation, mitral stenosis 5. Cardiac arrhythmias: tachycardia, bradycardia, ventricular and supraventricular arrhythmias. 6. Pacemakers and ICD malfunction 7. Cardiomyopathies 8. Pericardial disease: cardiac tamponade, constrictive pericarditis, pericarditis 9. Peripheral Vascular Disease 10. Acute Stroke B. Patient Characteristics: As a tertiary care center, Ochsner Clinic Foundation draws from a very large patient population that includes the entire state of Louisiana, the Gulf South, and even Mexico and Central America. Patients encountered reflect the diverse nature of pathology of the patients from these areas. Residents will have ample exposure to patients of genders, multiple ethnicities, nationalities and socioeconomic backgrounds. C. Learning Venue: Resident clinical activity will take primarily at the main campus of the Ochsner Clinic Foundation in New Orleans, Louisiana. OCF main campus is a 478 bed hospital and is a major tertiary referral center for the Gulf South. Resident will work with OCF department of Cardiology Staff attendings and cardiology fellows. Residents will perform rounds on both the cardiac floors as well as the cardiac ICU (CCU), where they admit patients. They will gain experience interpreting EKG s, stress tests and echocardiograms with the supervision of the cardiology attending and cardiology fellows. Residents will gain insight into the indications, contraindications and performance of commonly ordered cardiac tests. Cost-effective health issues are regularly addressed in the hospital setting. Residents will also have the opportunity to observe diagnostic and interventional cardiac catherizations, echocardiograms (both transthoracic and transesophageal), and stress testing of patients on the Hospital A service. D. Structure of the Rotation 1. Cardiology is a mandatory rotation for the PGY 2 and PGY1 internal medicine resident. Additional rotations may be scheduled for the PGY3 resident who would function as the senior resident on the service. 2. Residents should be ready for floor duties by 7:00am on weekdays. Resident duties may extend before 7:30am or after 5pm at the discretion of the cardiology attending or cardiology fellow when necessary for patient care. At no time will a resident work more than 30 hours consecutively, and resident duties may not exceed 80 hours/week over the 3
4 week rotation. In addition residents will be given one day off per week in accordance with ACGME regulations. 3. Residents will be on call an average of every fourth day. The cardiology fellow will supervise the resident and intern directly during the rotation. Senior residents may perform admissions independently for later review by fellows and faculty. Interns will be supervised by the senior resident, or preferably the cardiology fellow. The Cardiology fellow will organize the team work schedule with a template to ensure that all work hour limits are enforced strictly during the rotation. Admission caps for the intern are 5 patients per call, and each intern may not be providing direct care for more than 10 patients. Senior residents (PGY2 or 3) may not supervise more than 10 patients per call period. In the event of patient volumes exceeding these limits, the cardiology fellow will cover the excess patient care directly. 4. Residents will have the opportunity to attend Department of Cardiology conferences; attendance is encouraged and only in the event of patient care emergencies or violation of work hours restrictions will attendance be curtailed. 5. During times when the resident is not involved in other activities, he or she will have the opportunity to participate in non-invasive cardiology labs, catheterization labs or ecg. 6. Minimum duty expectations account for expected time for resident/intern histories and physicals, review of clinical data including EKG s, labs and radiology/echo/cath data, supervision of the patient encounter by the cardiology attending, of suggested materials, documentation and appropriate interaction with OCF for follow-up of the patient care plan. 7. Residents/interns are expected to evaluate a minimum of 2 admissions daily during the weekday. 8. A generic sample schedule for the cardiology rotation follows: Monday Tuesday Wednes day Thursday Friday Sat/Sun 7-8am Prerounds Prerounds Prerounds Prerounds Cath Conference 8-12pm Inpatient Inpatient rounds, Inpatient Inpatient rounds, Inpatient rounds, Admissions, rounds, Admissions, rounds, Admissions, patient care, Admissions patient care, Admissions patient care,, patient, patient care, care, 12-1pm Fellow Lecture Echo Conference Misc Lecture ECG Conference Board Review Prerounds Inpatient rounds, Admissions, patient care, 4
1-5pm Inpatient rounds, Admissions, patient care, Inpatient rounds, Admissions, patient care, Inpatient rounds, Admissions, patient care, Inpatient rounds, Admissions, patient care, Inpatient rounds, Admissions, patient care, Housestaff will have on average at least one day off per week IV. Principal Ancillary Educational Materials A. Braunwald s Textbook of Cardiology B. Online access to standard cardiology texts and journals through Ochsner Medical Library C. Recommended list: 1. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. J Am Coll Cardiol, 2008; 51:210-247 2. 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina. J Am Coll Cardiol, 2007; 50:2264-2274 3. Lipoprotein Management in Patients With Cardiometabolic Risk (J Am Coll Cardiol 2008;51:1512-24) 4. Valvular Heart Disease: 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With (J Am Coll Cardiol;52:e1 e142) 5. Atrial Fibrillation: ACC/AHA/Physician Consortium 2008 Performance Measures for Management of Patients With Nonvalvular Atrial Fibrillation or Atrial Flutter (J Am Coll Cardiol 2008;51:865-906) 6. Unstable Angina/Non ST-Elevation Myocardial Infarction: ACC/AHA 2007 Guidelines for the Management of Patients With. J Am Coll Cardiol 2007;50:652 726 7. Chronic Heart Failure in the Adult: ACC/AHA 2005 Guideline Update for the Diagnosis and Management of (J Am Coll Cardiol 2005; 46:1116-43) 8. JNC 7 guidelines for management of hypertension: available at www.nhlbi.nih.gov/guidelines/hypertension/ 9. Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: ACC/AHA 2007 Guidelines on: J Am Coll Cardiol 2007;50:1707-32 10. ATP-NCEP III Lipid guidelines available at: www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf 11. Framingham risk calculator: hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof V. Methods of Evaluation: 5
A. Resident Performance: Residents are oriented to the rotation expectations at the start of the block and then will receive mid-rotation feedback from the Cardiology staff and Cardiology fellow. At the end of the rotation the resident will receive formal written evaluations by the staff cardiology attending, in a web based electronic format (Myevaluations.com). The supervising physician will provide feedback on performance from direct observation, and from collecting information from the cardiology fellow and other members of the inpatient service team. The evaluation will be competency based, fully assessing core-competency performance. The evaluation is available for review by the resident on-line, and is sent to the residency office for review. The evaluation is part of the resident file and is incorporated their semi-annual/annual evaluation. B. Program and faculty performance Upon completion of the rotation, residents complete a service evaluation form commenting on the faculty, facilities and service experience. These evaluations are sent to the residency office for review and the cardiology division chief receives anonymous periodic copies of completed evaluation forms. VI. Rotation Specific Competency Objectives A. Patient Care 1. History Taking: Residents at all levels of training will obtain a thorough history by collecting patient information and by consulting other sources of primary data in a logical and organized fashion. Interviewing will adapt to the time available, use appropriate non-verbal techniques and demonstrate consideration for the patient. Interviewing will be tailored to the the nature of diseases commonly encountered on the Cardiology service. 2. Physical Exam: Residents at all levels will perform a comprehensive exam for new admissions. Their exam will reflect particular attention to the cardiovascular system, including a full auscultatory exam, vascular exam and pulmonary exam. A more limited exam will be required for follow-up on the hospital service. 3. Charting: Residents at all levels will record data in a timely 4. Procedures: a. PGY I: Will demonstrate knowledge of procedural indications, contraindications, necessary equipment, specimen handling, patient after care and risk and discomfort management. They will participate in informed consent and assist patient with decision making. PGY I will initially observe and if 6
appropriate will be able to perform procedures under supervision of Cardiology Fellow. b. PGY II/III: Will demonstrate increased knowledge and facility in the performance of procedures while minimizing risk and discomfort to patients. They will assist their junior peers in skill acquisition. These residents will have opportunity for performance of central lines and swan ganz catheters under the supervision of the Cardiology Fellows. 5. Clinical Assessment and Management Plans: All residents will demonstrate improving skills in assimilating information they have gathered from the history, physical examination and laboratory interpretation. a. PGY I: Will identify patient s problems and develop a prioritized differential diagnosis. Abnormal findings will be interrelated with altered physiology. They will understand their limitation of knowledge and seek the advice of more advanced clinicians. PGY I residents will begin to develop therapeutic plans that are evidence based or guideline based. Residents will establish an orderly succession of testing on their history and exam findings. Residents will understand the correct administration of drugs, describe drug-drug interactions and be familiar outcomes. Residents will learn to incorporate cardiac procedures and testing information into their clinical decision planning. They will also learn to interpret the results of these various procedures and diagnostic tests while on the rotation. b. PGY II/III: Will regularly integrate medical facts and clinical data while weighing alternatives and keep in mind patient preferences. They will incorporate consideration of risks and benefits when considering cardiac testing and therapies. They will present up-to date scientific evidence to support their hypotheses. They will consistently monitor and follow-up patients appropriately. They will develop plans to avoid or delay known patient complications and be able to identify when illness has reached a point when treatment no longer contributes to improved quality of life. As the resident gains more experience, they will show appropriate reasoning in ambiguous situations. 7
They will continue revise assessments in the face of new data. 6. Patient Counseling: a. PGY I: Will be able to describe the rationale for a chosen therapy and medication side effects in lay terms. They will be able to describe treatment rationale and plans with the patient in lay terms. They will assess the patient s understanding and provide more information when necessary. Residents at this level will demonstrate the ability to be a patient advocate. b. PGY II/III: Will demonstrate, in addition to above, the ability to explain the benefits and risks of completing all therapeutic interventions. They will be expected to counsel their patients regarding adverse lifestyle habits and educate them and families for medication and lifestyle habits. As more experience is obtained the resident will gain skill in communicating with critically ill patients and their families. B. Medical Knowledge: 1. PGY I: Will consistently apply current concepts in the basic sciences to clinical problem solving. They will use information from the literature and other sources including electronic databases. PGY I residents will demonstrate satisfactory knowledge of common cardiac conditions, sufficient to manage situations with supervision. Residents will exhibit sufficient cardiac content knowledge by the end of the rotation to provide minimal cardiac care without supervision. 2. PGY II/III: Will demonstrate progression in knowledge and analytical thinking to develop a medical management plan for patients with cardiac problems. They will integrate socio-behavioral knowledge to the medical plans. They will utilize clinical and guidelines based therapy to the creation of such medical plans. C. Practice Based Learning and Improvement 1. PGY I: Will use hospital and library resources to critically appraise medical literature and apply evidence to patient care. They may use PDA s, desktop PC s and internet electronic references to support patient care and self education. They will model these behaviors and facilitate the learning of medical students and other healthcare professionals. 2. PGY II/II: In addition to the above, they will demonstrate the ability to investigate and evaluate their own cardiac 8
care practices and identify areas for improvement. They will regularly demonstrate knowledge of the impact of study design on validity or applicability to individual patients. D. Interpersonal Skills and Communication 1. PGY I: Will develop and refine their individual style when communicating with patients. They will strive to create ethically sound relationships with patients, the care providing team and supporting hospital personnel. They will create effective written communications through timely and accurate notes. They will exhibit listening skills appropriate to patient-centered interviewing and communication. Residents will recognize verbal and nonverbal cues from patients. 2. PGY II/III: Will exhibit team leadership skills through effective communication as manager of team. PGY 2 residents are expected to assist junior peers, medical students and other hospital personnel to form professional relationships with support staff. Residents will respond to feedback in an appropriate manner and make necessary behavior changes. They will need to communicate with patients and families extensively about end of life decisions. By the conclusion of the rotation, senior residents will have the ability to negotiate nearly all difficult patient encounters with staff/fellow supervision if necessary. E. Professionalism: 1. PGY I/II/III: All residents will demonstrate integrity, accountability, respect, compassion, patient advocacy and dedication to patient care that super cedes self interest. Residents will demonstrate a commitment to excellence and continuous professional development. They will be punctual and prepared for teaching sessions. Residents will demonstrate commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information and informed consent. Residents are expected to show sensitivity and responsiveness to patients culture, age, gender, religion, disability or sexual preference. F. Systems Based Practice: 1. PGY I: Will be sensitive to health care costs while striving to provide the best quality care. They will begin to effectively coordinate care with other health care professionals as required for patient needs. They will comply with hospital documentation requirements. 9
2. PGY II/III: In addition to the above, senior residents will incorporate clinical based guidelines and recognize the limitations of these guidelines. They will work with patient care managers, discharge coordinators and social workers to effectively coordinate and improve patient care outcomes. Finally, senior residents will enlist social and other out of hospital resources to assist patients with therapeutic plans and know how these activities can affect the hospital system performance. Senior residents are expected to model cost effective therapy. 10