Cardiology
I. Rationale
As cardiovascular disease is the most common disease state encountered in medicine, residents will understand the psycho-social implications of cardiovascular disease on the patient and the family. Residents will understand the need for an integrated approach to prevention and rehabilitation including nutritionists, behavioral scientists, exercise, physiologists, educators, cardiologists, and family physicians.
II. Competencies
Patient Care
Goal: Provide Evidence Based Care to patients with Cardiovascular Conditions
Objectives:
A. Learn incorporation of health promotion and disease prevention into patient care.
1. Know risk factors for cardiovascular disease and counsel patients regarding risk factors.
2. Understand how to implement programs to modify cardiovascular disease risk factors: smoking cessation, weight management, lipid management including dietary intake and exercise. Be able to use for primary and secondary prevention of cardiovascular disease.
3. Understand indications and proper techniques for screening for HTN / Lipid abnormalities and CAD.
B. Develop knowledge of the diagnosis and initial management of additional problems anticipated to require cardiologist assistance.
1. Acute coronary syndromes ( Unstable Angina / Acute Myocardial Infarction)
2. Hypertensive emergency
3. Cardiac trauma
4. Acute severe congestive heart failure
5. Unstable tachy or brady arrhythmias
6. Pericardial tamponade
C. Learn a set of procedural skills essential to the practice of family medicine and select advanced procedural skills appropriate to anticipated future practice needs.
1. EKG mechanics and interpretation
2. Routine treadmill stress testing
3. Exercise prescription for the cardiac and non-cardiac patient
4. Basic and advanced cardiac life support
5. Interpretation of results from stress and non-stress nuclear imaging, pharmacologic stress testing, echocardiography.
6. Types and indications for internal and external pacing devises.
7. Interpretation of results from arterial and venous doppler studies.
8. Elective and emergency cardioversion.
Learning ActivitiesX / Attending Rounds / Research Conference / X / Outpatient Clinics
X / Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
X / Grand Rounds / X / Specialty Conference / Resident Seminar
Sub-Specialty Conference / X / Noon Conference / Journal Club
X / Morning Report / X / Faculty Supervision / Readings
Didactics / X / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / X / Morning Report
X / Program Dir
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
X / 360 ᵒ evaluation / Videotape Review / Quarterly Review
Other
Medical Knowledge
Goal: Develop a broad knowledge base of symptoms, physical exam, diagnoses and interventions
Objectives:
A. Attain mastery of the following knowledge areas:
1. Normal anatomy and physiology
2. Common variants of growth and development
3. Detailed history and physical
4. Evaluation of the pre-operative patient for cardiovascular disease and management of the cardiac patient pre-operatively.
5. Coronary artery disease- stable and unstable angina, myocardial infarction, and sudden death
6. Hypertension- mild, moderate, severe, urgent, and emergency
7. Congestive heart failure-systolic and diastolic
8. Common cardiac murmurs
9. Cardiac risk stratification
10. Indications for non-invasive and invasive cardiac evaluation
11. Indications for SBE prophylaxis
12. Common arrhythmia's/palpitations
13. Stable cardiomyopathy
14. Understand issues in selection and risks of performing PTCA and bypass grafting
15. Thromboembolic disease
16. Peripheral vascular disease
17. Cardiovascular changes in the athlete
18. Pericarditis
19. Endocarditis
Learning ActivitiesX / Attending Rounds / X / Research Conference / X / Outpatient Clinics
X / Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
X / Grand Rounds / X / Specialty Conference / Resident Seminar
Sub-Specialty Conference / X / Noon Conference / Journal Club
X / Morning Report / X / Faculty Supervision / X / Readings
X / Didactics / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / X / Morning Report
X / Program Dir
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other
Practice Based Learning and Improvement
Goal: The resident should develop skills in evaluating their own patient care, appraising and assimilation of scientific evidence to improve patient care.
Objectives:
A. Identify resources for personal education.
B. Develops a plan for ongoing education.
C. Identify Point of Care learning resources.
D. Utilize Electronic Medical Records Decision aid tools and templates for patient care.
E. Recognizes strengths and weaknesses of knowledge and skills in self and others.
Learning ActivitiesX / Attending Rounds / Research Conference / Outpatient Clinics
X / Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
X / Grand Rounds / X / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / Journal Club
Morning Report / Faculty Supervision / Readings
X / Didactics / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / X / Morning Report
X / Program Dir
Review / In-Training Exam / X / Faculty Supervision and Feedback
X / 360 ᵒ evaluation / Videotape Review / Quarterly Review
Other
Interpersonal and Communication Skills
Goal: Residents will develop and demonstrate effective information exchange and teaming with patients, their families, and other health professionals.
Objectives:
A. Develop skills for interviewing that allow accurate, complete collection of information regarding symptoms, family, and community environment that affect the patient's cardiovascular health.
B. Develop skills in communicating results, educating patients and their families, dealing with sensitive issues for patients and families, and negotiating a plan of treatment with the patient and family.
C. Residents will understand the need for an integrated approach to prevention and rehabilitation including nutritionists, behavioral scientists, exercise, physiologists, educators, cardiologists, and family physicians.
Learning ActivitiesX / Attending Rounds / Research Conference / Outpatient Clinics
X / Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / Journal Club
X / Morning Report / X / Faculty Supervision / Readings
Didactics / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / X / Morning Report
X / Program Dir
Review / In-Training Exam / X / Faculty Supervision and Feedback
X / 360 ᵒ evaluation / X / Videotape Review / X / Quarterly Review
Other
Professionalism
Goal: Residents will demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
Objectives:
A. Demonstrate integrity, honesty, respect and a commitment to excellence in all activities.
B. Demonstrate sensitivity, respect and adapt appropriately to the social and cultural issues of each patient.
C. Display initiative and resourcefulness in patient care and in solving problems.
D. Be timely in attendance of activities and completion of tasks.
Learning ActivitiesX / Attending Rounds / Research Conference / X / Outpatient Clinics
X / Multidisciplinary Rounds / X / Ethics/Comm Conference / X / Direct Patient care
X / Grand Rounds / X / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / Journal Club
X / Morning Report / Faculty Supervision / Readings
Didactics / Procedures
Other:
Evaluation Methods
X / Attending Evaluation / Directly Supervised Procedures / X / Morning Report
X / Program Dir
Review / In-Training Exam / X / Faculty Supervision and Feedback
X / 360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other
Systems Based Practice
Goal: demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value
Objectives:
A. Utilize and understand the importance of appropriate referral or consultation with cardiologists or cardiothoracic surgeons.
B. Support of the individual and family through consultation, evaluation, treatment, and rehabilitation.
C. Understand the psychosocial and economic impact of cardiovascular disease on the individual and family and use of the health care system to assist as needed.
D. Learns most cost effective ways to manage cardiovascular patients.
Learning ActivitiesX / Attending Rounds / Research Conference / X / Outpatient Clinics
X / Multidisciplinary Rounds / X / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / X / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / Journal Club
Morning Report / Faculty Supervision / X / Readings
Didactics / Procedures
Other
Evaluation Methods
X / Attending Evaluation / Directly Supervised Procedures / Morning Report
X / Program Dir
Review / In-Training Exam / X / Faculty Supervision and Feedback
X / 360 ᵒ evaluation / Videotape Review / Quarterly Review
Other
III. Instructional Strategies (see above)
A. Direct patient care of cardiology service patients
B. Direct patient care of continuity clinic patients
C. Teaching during patient rounds
D. Cardiology lectures / conferences
E. Independent reading
F. Procedural learning (see above list)
IV. Evaluation Strategies (see above)
A. Observation by Attending, fellow and residents
B. End of rotation evaluation from the inpatient cardiology service at CLH.
C. Procedure documentation by the resident
D. Conference attendance
E. In-training exam profiles
F. Resident evaluation of rotation and faculty
H. Completion of required readings and scoring >90% on open book Monograph quizzes
V. Implementation Strategies
Interns rotate on the inpatient cardiology service at Crawford Long Hospital for a four week
block.
Location: Crawford Long Hospital
Internal Medicine Morning Report is located in Classroom 5 of the Medical Office Tower.
Report at 8:00 on first day of rotation.
Refer to intern survival guide for specific instructions to finding the classroom
(Resident link under www.fpm.emory.edu)
Contact: Crawford Long Internal Medicine Chief Resident
Family Practice Center: Continuity clinic is ½ day week
Call: There is no call responsibility at CLH
Call responsibility is with the Emory Dunwoody Hospital on the Family Medicine Service, typically 2 weekend calls in the block. No weekday call
Supervision: CLH Cardiology Service Attending / Fellow / Resident
Responsible Party:
Jerre Lutz, MDContact: Michelle (assistant)
Medical Director
The Emory Clinic 404-778-2165 ofc #
1365 Clifton Road
Emory Campus
(404) 778-4351 ofc
(404) 778-3417 fax
Conferences: Morning report on M-F @ CLH
Grand Rounds on Tuesday @ EUH
Thursday AM didactics @ Emory Dunwoody Hospital
Noon conferences at CLH
VI. Bibliography
Reading list: AAFP Monographs Update on Heart Failure (#298), Hypertension (#305),
Perioperative Care (#263), CAD/MI (#270), Valvular Heart Disease (#397), Arrythmias (#391)
Dubin D. Rapid Interpretation of EKG's: An Interactive Course: Cover Pub.; 2000.
American Family Physician Collection of Articles on Coronary Artery Disease/Coronary Heart Disease available at http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=4 Accessed on December 3, 2012. Last Update: 11/29/2012
Screening and Diagnosis
1. The Use of Coronary Computed Tomography Angiography to Rule Out CAD in the ED [AFP Journal Club] (11/15/2012)
2. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment [Putting Prevention into Practice] (02/15/2011)
3. Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment: Recommendation Statement [U.S. Preventive Services Task Force] (02/15/2011)
4. Can ECG Rule Out ACS if Performed While the Patient Is Having Chest Pain? [AFP Journal Club] (11/15/2010)
5. Global Risk of Coronary Heart Disease: Assessment and Application (08/01/2010)
6. AHA Guidelines on Cardiac CT for Assessing Coronary Artery Disease [Practice Guidelines] (03/01/2008)
7. Cardiomyopathy: An Overview (05/01/2009)
8. Diagnosis of Acute Coronary Syndrome (07/01/2005)
9. Noninvasive Cardiac Imaging (04/15/2007)
10. Update on Exercise Stress Testing (11/15/2006)
11. Radiologic Evaluation of Acute Chest Pain—Suspected Myocardial Ischemia (08/15/2007)
12. Contemporary Management of Angina: Part I. Risk Assessment (12/01/1999)
Prevention
1. AHA Updates Guidelines on CVD Prevention in Women [Practice Guidelines] (01/01/2012)
2. Aspirin for the Prevention of Cardiovascular Disease: Recommendation Statement [U.S. Preventive Services Task Force] (06/15/2011)
3. Aspirin for the Prevention of Cardiovascular Disease [Putting Prevention into Practice] (06/15/2011)
4. Primary Prevention of CVD: Physical Activity [Clinical Evidence Handbook] (07/15/2010)
5. Diets for Cardiovascular Disease Prevention: What Is the Evidence? (04/01/2009)
6. Preventing Cardiovascular Disease in Women (10/15/2006)
7. Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal Women [Putting Prevention into Practice] (12/15/2005)
8. Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal Women [U.S. Preventive Services Task Force] (07/15/2005)
9. Should We Use Multiple Risk Factor Interventions for the Primary Prevention of Coronary Heart Disease? [Cochrane for Clinicians] (07/15/2002)
Treatment
Acute
1. Drug-Eluting Coronary Artery Stents (12/01/2009)
2. ACC/AHA Guideline Update for the Management of ST-Segment Elevation Myocardial Infarction (06/15/2009)
3. Acute Coronary Syndrome (Unstable Angina and non-ST Elevation Myocardial Infarction) [Clinical Evidence Handbook] (08/15/2009)
4. Unstable Angina and Non-ST- Segment Elevation Myocardial Infarction: Part I. Initial Evaluation and Management, and Hospital Care (08/01/2004)
5. Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: Part II. Coronary Revascularization, Hospital Discharge, and Post-Hospital Care (08/01/2004)
6. Heparins for Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction [Cochrane for Clinicians] (04/01/2009)
7. Early Invasive Therapy or Conservative Management for Unstable Angina or NSTEMI? [Cochrane for Clinicians] (01/01/2007)
8. Aspirin Combined with Clopidogrel (Plavix) Decreases Cardiovascular Events in Patients with Acute Coronary Syndrome [Cochrane for Clinicians] (12/01/2007)
Chronic
1. Adding ACE Inhibitors or ARBs to Standard Therapy for Stable Ischemic Heart Disease [Implementing AHRQ Effective Health Care Reviews] (07/01/2012)
2. Medical Management of Stable Coronary Artery Disease (04/01/2011)
3. AHA Releases Guidelines for Hypertension Management in Adults with or at Risk of CAD [Practice Guidelines] (07/15/2008)