Med 304A: General Cardiology Inpatient Services
Program Director/Division Chief: John Schroeder, MD and Alan Yeung, MD
Duration: 1 Month Block Rotation
The rotation is a month long block of time with one PGYII as the lead together with (2-3)
PGYI and (1-2) 4th year students. The team admits and manages all general cardiology inpatients with close coordination with the CCU/heart failure service.
General cardiology rotation remains part of the “bread and butter” core of internal medicine inpatient rotations. Together with the CCU/heart failure (PGY II) and the cardiology consult service (VA and Stanford), these rotations form the foundation of the cardiology knowledge base for students in their 4th year. Advances in diagnostic imaging, rapid bedside testing and evidence based clinical trials have allowed us to deliver coordinated complex care to our patients with ample opportunities for teaching and learning.
The development of the skills and knowledge required for the practice of cardio vascular medicine is an essential part of the educational process of internal medicine training. Cardiovascular diseases affect millions of Americans and now we have tools and drugs to treat and/or prevent this problem. It is an essential large component of a daily internal medicine practice.
A. PATIENT CARE:
Objective 1: Demonstrate clinical skills of medical history and physical examination, with specific attention to acute and chronic cardiovascular diseases.
Objective 2: Demonstrate clinical skill in the diagnosis and management of the Non-ACS chest pain patients.
Objective 3: Demonstrate clinical skill in medical management of patients admitted with cardiovascular disease.
Objective 4: Discuss the issues of lost effectiveness on the care of cardiovascular patients.
B. MEDICAL KNOWLEDGE:
Objective 1: Describe the current understanding of the atherosclerotic vascular process.
Objective 2: Describe the general basis and performance of cardiac catherization, coronary arteriography, angioplasty, coronary stenting.
Objective 3: Describe the general diagnostic evaluation and workup of the following patients:
- Atrial fibrillation
- Ventricular arrhythmias
- Congestive Heart Failure
- Aortic dissection
The primary objectives of the rotation are the following:
- Understand the basic pathophysiology and etiology of the following clinical syndromes.
- Arteriosclerosis/coronary artery disease
- Valvular heart disease
- Acute coronary syndrome
- Cardiac Arrhythmias
- Congestive Heart Failure, heart transplantation and ventricular assist devices.
- Cardiac risk factors and contribution of racial difference and lifestyles to the development of cardiovascular disease.
Objective 4: Discuss the general concept and role of imaging techniques for the problems listed in Objective 3
Objective 5: Discuss the general pharmacology and use of the following classes of cardiovascular drugs:
- Antianginal agents, Beta blockers, Vasodilators/nitrates, Calcium channel blockers, Anticoagulants including anti platelet drugs
- Antiarrthymic agents including Betablockers, nondihydropyridines blockers, Amiodarone, class C agents
- Lipid lowering agents
- Be knowledgeable with primary side effects and drug interactions of these agents
Objective 5: Discuss the Risk/Benefit of cardiovascular medicines and procedures.
Objective 6: Be familiar with the concept of false positive/negative testing in cardiology.
Objective 7: Discuss the general epidemiology of cardiovascular disease in the world and be able to comment on racial and geographic differences. Objective 8: Discuss immediate therapy for the following in the emergency department setting:
- Atrial fibrillation with RVR
- Ventricular tachycardia
- Pulmonary Edema
- Chest pain
- Pulmonary embolus
- Aortic dissection
C. PRACTICE-BASED LEARNING AND IMPROVEMENT
Objective 1: As with other clinical rotations, students will have the opportunity to apply medical literature, research and statistical methods, and data management technology for self-evaluation and improvement on this rotation. Clinical questions will be formulated and researched through clinical databases pertinent to patient care as they arise.
Objective 2: Cases may be selected for in depth research and discussion and presentation at work or teaching rounds with your attending.
D. INTERPERSONAL AND COMMUNICATION SKILLS
Objective 1: The student will develop and demonstrate competence in effective and efficient communication with patients and their families.
Objective 2: The student will develop and demonstrate competence in effective and efficient communication with physician colleagues on Cardiology service, physicians from other services, nursing and support staff. Since Cardiology involves interactions with multiple ancillary services including social work, dietary, physical therapy, blood bank, nurse coordinators as well as Nurse Practitioners/Physician Assistants, communication is essential for the successful treatment of these patients.
Objective 1: Demonstrate respect and compassionate use of medical skills for cardiac patients. This includes the treatment of patients and families dealing with life-threatening illnesses.
Objective 2: Demonstrate respect and compassionate use of medical skills severely-ill patients.
Objective 3: Students will have the opportunity to develop and demonstrate an increasing commitment to carrying out professional responsibilities and adherence to ethical principles. An effective therapeutic relationship with patients and families will be demonstrated through listening, narrative and nonverbal skills; education and counseling of patients and families.
F. SYSTEM-BASED PRACTICE
Objective 1: Recognize the high cost of cardiovascular disease not only to the patient and family but to society.
Objective 2: Actively participate in the multidisciplinary approach to caring for Cardiology patients including appropriate recognition of other health professional and paraprofessional’s roles and demonstrate competence in team interactions, including nutritionist, pharmacist, physician’s assistant, nurse practitioner, physical therapist, social worker, nurse coordinator.
Med 304A students will receive Cardiology training in the inpatient setting on the Cardiology ECG monitored wards including D-1, D-2, B-2, B-3. They are part of a physician team including the Attending physician, a total of two PGYI residents, 1-2 medical students.
They are assisted not only by nursing staff, but patient care managers in order to facilitate scheduling of tests, obtaining outside records and developing appropriate discharge planning.
The General Cardiology team admits 7 days a week with admission responsibility until 7 pm and patient care responsibility until 9 pm 7 days a week.
Oversight patient and admission coverage is provided by separate PGYII residents who are then responsible for patient care transfer of responsibility around 7 am daily back to the General Cardiology team.
Currently General Cardiology students will have the opportunity to be exposed to three separate cardiology attendings during the 4 week period.
The educational content is provided in the following ways:
- Individual responsibility for assigned patients under the supervision of the general cardiology PGYI and II residents and their 24 hour progress for review with the attending of daily AM rounds, usually 8 or 9 am.
- Teaching sessions on the Inpatient Unit before and during inpatient rounds by the Attending physician and ancillary staff.
- New Patient presentations daily at 8:30 am - 9:00 am to the attending
- Medical Grand Rounds on Wednesdays at 8:00 am,
- Reading Materials (see References below)
- Review of all imaging studies related to the patient. This may include participation of radiologist, echocardiographers and interventional cardiologists.
- Student and/or resident presentations on clinical a issues (e.g. Pericarditis or anticoagulants, etc.)
- Bedside rounds of every patient on a daily basis with the attendings and general cardiology team.
According to 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 global assessment of the attending physician and additional information from nursing staff. Procedures performed will be documented.
Medical Knowledge will be evaluated by global assessment of the attending physicians, and peer-reviewed chart audit.
Practice-Based Learning and Improvement will be evaluated by peer-reviewed chart audit.
Interpersonal and Communication Skills will be evaluated by global assessment of the attending physicians and additional information from nursing staff, other ancillary staff, patients and families.
Professionalism will be evaluated by global assessment of the attending physicians and additional information from nursing staff, other ancillary staff, patients and families.
System-Based Practice will be evaluated by global assessment of attending physicians, and peer-reviewed chart audit.
Evaluations are reviewed with the residents for formal feedback. Face to face interaction between the attending physician and the resident is the required method. At the midway point of the rotation, the resident is encouraged to approach the attending to assess and discuss performance. In addition, ongoing feedback is provided related to residents’ patient care responsibilities and activities.
In addition, residents provide feedback to the Attending Physicians and Program Director regarding the rotation to add input on deficiencies in the experience.