Cardiology

Cardiology Competency-Based Curriculum

Educational Rationale

Cardiovascular disease (CVD) is still by far the leading cause of mortality in the United States among women and men. Although women fear breast cancer the most, heart disease kills more women in the United States than the next 16 causes of death combined. Nearly one in two women will eventually die of CVD, whereas about one in nine will develop breast cancer and far fewer will die of breast cancer. The economic cost of CVD exceeds an estimated $250 billion per year.

This emphasizes the importance of internists' need to recognize, diagnose and manage common cardiologic conditions. Internists must have the cornerstone of excellent interviewing and physical examining skills to guide the management of patients with cardiac symptoms. Data has also shown that a combined team of an internist and cardiologist can provide better care than any one individual in patients suffering from CVD. So we strongly encourage our residents to gain this experience during their residency.

Goals

The goals of the cardiology experience will be for the residents to gain experience in the evaluation and management of patients with a broad spectrum of cardiac diseases including:

  1. primary prevention of cardiovascular disorders
  2. assessment of risk
  3. evaluation and management
  4. secondary and tertiary prevention

A. Knowledge:

Upon completion of training, we expect our residents to:

1. Understand the basic mechanisms of normal cardiac function, and understand the etiology and pathogenesis of common CV disorders.

2. Master the clinical presentation, natural history, diagnosis and management strategies of common CV diseases including coronary artery disease (CAD), cardiomyopathies, valvular disorders, pericardial diseases, diseases of the aorta, arrhythmias, and conduction disorders.

3. Properly and effectively use the laboratory, electrocardiographic, radiologic, and physiologic (stress testing) diagnostic studies in CV disease, and correctly interpret the results.

4. Manage patients with common CV complaints: angina, CAD, pericarditis, congestive heart failure, valvular disease, and tachy/bradyarrhythmias.

5. Manage CV emergencies: acute coronary syndromes, cardiogenic shock, and aortic dissection.

6. Identify situations where appropriate referral for invasive procedures, device implantation, cardiac surgery, and cardiac transplant.

7. Be familiar with the indications and contraindications of CV procedures (stress tests, cardiac catheterization, electrophysicologic testing), and be familiar with the complications of these procedures and their management

B. Skills

Upon completion of the Cardiology elective, the resident will be able to:

1. Develop the ability to accurately assess clinical situations, obtain a problem focused comprehensive CV history and perform a complete gastrointestinal physical examination, including rectal examination and fecal occult blood testing.

2. Synthesize a thorough assessment for a specific CV illness and create a rational plan of clinical management.

3. Be able to function as part of a team providing care for a patient with CV problem(s).

4. Observe and assist in CV procedures.

5. Be able to correctly interpret diagnostic imaging and laboratory studies.

C. Attitudes:

Upon completion of training, we expect our residents to appreciate those attitudes valued and nurtured by cardiologists, including:

1. Viewing medicine as humane science.

2. Balancing art with science.

3. Recognizing the limitations of technology and the value of clinical insight.

4. Making difficult judgments when certainty is elusive.

5. Understanding that testing, no matter how advanced or sophisticated, rarely substitutes for thorough, thoughtful evaluation by an informed clinician.

6. Balancing intervention with patience.

7. Recognizing limitations of our interventions.

8. Appreciating the unique circumstances of caring for patients with chronic, usually incurable diseases.

9. Learning the importance of functional considerations.

Experiences

The resident / intern will be assigned for a whole month for a cardiology elective. They will be assigned to one of our cardiology attending physicians on our staff at the institution with a desire and ability to teach the residents in both inpatient and outpatient settings. The selection of these cardiology attending physicians is made by the residents. The residents can do more than one month if they wish to do so.

The residents will round with the attending assigned on a daily basis. They will first evaluate the patients on their service and suggest their assessment and plan to the attending cardiologist. The residents also will be the first to evaluate any patients seen on the consult service as far as possible. The residents will follow the cardiologist on their daily rounds. This may involve going to the outpatient clinics, cardiac catheterization lab, EP lab, EKGs, Echo, TEE, stress lab, CCU and CT ICU etc. It is strongly encouraged that residents get to go to as many of these places as possible during their rotation.

Teaching rounds, under the supervision an attending physician, must occur daily. These rounds will be both didactic in nature and focused on management. They must include presentation and discussion of each patient, at least in part, at the bedside. While it is appropriate to review certain academic topics in the conference room, rounds cannot neglect bedside medicine. Indeed they are best conducted solely at the bedside.
In order to achieve the goals and objectives for the residency program the following experiences have been established for the purpose of teaching Gastroenterology to residents.

1. The Inpatient Experience (IP)

The residents assigned to this rotation will be responsible for supervising evaluation of inpatient consultations and patients admitted to the cardiology service as well as the continued follow up of these patients during their hospitalization. Essential in this role is the development and refinement of clinical evaluation skills of patients with CV diseases. These skills include the development of appropriate differential diagnosis, assessing the
need for hospitalization, diagnostic evaluation strategies and treatment plans. Essential in this rotation will be developing skills in providing consultation services, to include communicating with the referring physicians and ensuring support for continuing care of the patients' CV condition. A resident will be called upon to perform literature research on topics appropriate to the case at hand. They will participate actively in the teaching activities of the consultation team. Through this experience the resident will also develop a comprehensive understanding of the indications, contraindications, techniques, complication of CV procedures as well as the interpretation of results from these procedures. The resident will acquire the knowledge of and skill in educating patients about the procedure and in obtaining informed consent. Faculty supervision is required in developing these skills.

2. The Ambulatory Experience (AM)

All residents will participate in cardiology outpatient activities appropriately supervised by dedicated attending faculty members. The goals of this experience will be for the residents to gain expertise in the outpatient evaluation and management of digestive problems. The experience provides an opportunity to develop an understanding for the natural history of these conditions over an extended period of time.

3. Didactic Conferences (DC)

Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties

Evaluations

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

  • Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
  • Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
  • Self-evaluation by In-service training examination scores
  • MKSAP study plan (MKSAP)
  • Participation and presentations at didactic conferences (DC)
  • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge

Goals and Objectives-PGY1 Learning Activities* Assessment
Describe the epidemiology, genetics, natural history, clinical expression of the CV illness encountered in the inpatient setting. IP, AM, DC AE, DC, MKSAP
Summarize an approach to the evaluation of the common presentations of CV diseases (CAD, ACS, CHF, valvular diseases, pericardial diseases, aortic diseases, arrhythmias, conduction disorders) IP, AM, DC AE, DC, MKSAP
Describe structure and function of heart (myocardium, calves, coronaries, conduction system), pericardium, aorta. IP, AM, DC AE, DC, MKSAP
Generate and prioritize differential diagnoses for patients with CV disease IP, AM, DC AE, DC, MKSAP
Develop rational, evidence-based management strategies for patients with CV disease IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Summarize an approach to the evaluation of common CV presentations IP, AM, DC AE, DC, MKSAP
Distinguish patients with functional chest pain syndromes from those with organic heart disease IP, AM, DC AE, DC, MKSAP
Interpret diagnostic tests used in the evaluation of outpatients with suspected CV Illness IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of outpatients and inpatients with CV disorders. IP, AM, DC AE, DC, MKSAP

2) Patient Care

Goals and Objectives-PGY1 Learning Activities* Assessment
Effectively perform a comprehensive history and complete physical examination in patients with CV symptoms IP, AM, DC AE, DC, MKSAP
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of CV disorders IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Construct a comprehensive treatment plan and assess response to therapy. IP, AM, DC AE, DC, MKSAP
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies. IP, AM, DC AE, DC, MKSAP
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy. IP, AM, DC AE, DC, MKSAP

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1 Learning Activities* Assessment

Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases
IP, AM, DC AE, DC, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills of patients related diseases IP, AM, DC AE, DC, MKSAP
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education. IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Set and assess individualized learning goals IP, AM, DC AE, DC, MKSAP
Analyze clinical experience and employ a systematic methodology for improvement IP, AM, DC AE, DC, MKSAP
Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care IP, AM, DC AE, DC, MKSAP

4) Interpersonal Skills and Communication

Goals and Objectives-PGY1 Learning Activities* Assessment
Apply empathy in all patient encounters IP, AM, DC AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team IP, AM, DC AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing IP, AM, DC AE, DC, MKSAP
Goals and Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending IP, AM, DC AE, DC, MKSAP
Compose clear and timely admission and progress notes and consultations IP, AM, DC AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate IP, AM, DC AE, DC, MKSAP
Teach colleagues effectively IP, AM, DC AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1 Learning Activities* Assessment
Be prompt and prepared for all clinical duties IP, AM, DC AE, DC, MKSAP
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all IP, AM, DC AE, DC, MKSAP
Respect patients and their families, staff and colleagues IP, AM, DC AE, DC, MKSAP
Goals and Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings IP, AM, DC AE, DC, MKSAP
Demonstrate integrity IP, AM, DC AE, DC, MKSAP
Respond to phone calls and pages promptly IP, AM, DC AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1 Learning Activities* Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty. IP, AM, DC AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information. IP, AM, DC AE, DC, MKSAP
Goals and Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Discuss how the health care system affects the management of inpatients with related diseases. IP, AM, DC AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions. IP, AM, DC AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices IP, AM, DC AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized IP, AM, DC AE, DC, MKSAP

Teaching Methods

All residents participate in patient care duties, didactic conferences and independent reading. They will learn at the bedside from attendings, nurses and physician extenders, pharmacists, social workers, case managers, peers, and patients.

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY-2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

Educational Resources

  1. Supervising clinicians-didactic and bedside rounds and concurrent patient care
  2. Medical literature including assessment of knowledge using the MKSAP
  3. Bedside rounds with team and faculty.
  4. Medical Grand Rounds weekly.
  5. Scheduled didactic conferences including: medicine morning report, journal club, ambulatory care conference, EBM conference
  6. Saint Barnabas Medical Center library, librarians, and online references/resources.

REFERENCES

  1. Cardiology Section from the MKSAP Series.
  2. Braunwald Heart Disease ( most current)
    a. Chapter 10, pp. 153-185, Exercise Stress Testing
    b. Chapter 13, pp. 300-306, Assessment of Myocardial Blood Flow by Radionuclide Imagery.
    c. Chapter 13, pp. 311-319, Disease Detection, Risk Stratification and Clinical Decision-Making
  3. Current guidelines from the American College of Cardiology: congestive heart failure, acute coronary syndromes, atrial fibrillation, syncope.
    (www.acc.org/index)
  4. The AFFIRM Trial. A comparison of rate control and rhythm control in patients with atrial fibrillation (AFFIRM). NEJM. 2003;347:1825-1832.
  5. Review of Congenital Heart Disease in Adults NEJM 2000;342:256-263,334-342.
  6. Valsartan, captopril or both in MI complicated by heart failure, LV dysfunction or both. (The VALIANT TRIAL) NEJM 2003;349:893-906.
  7. CHARM Trials. Effects of candesartan in patients with chronic heart failure and preserved left ventricular ejection fraction: the CHARM-Preserved Trial. Lancet 2003;362:777-781.
  8. Current Literature as assigned by the faculty supervisor.

FACULTY

Rogal, Gary, M.D., Educational Coordinator
Hawthorne, Keith, M.D., CCU Director
Ciccone, John, M.D.
Demidowich, George, M.D.
Dobesh, David, M.D.
Fabrizio, Lawrence, D.O.
Gandhi, Davang, M.D.
Goldberg, Mark, M.D.
Gressianu, Monica, M.D.
Haik, Bruce, M.D.
Harback, Edward, M.D.
Khoobiar, Sargir, M.D.
Modi, Kaushik, M.D.
Pamidi, Madhavi, M.D.
Schwanwede, Jacqueline, M.D.
Torre, Sabino, M.D.
Tullo, Nicholas, M.D.
Wangenheim, Paul, M.D.