Cardiac Rehab

Educational Purpose:  The educational purpose of this rotation is to provide third year fellows with the knowledge and experience necessary to perform cardiac rehabilitation.  The rotation is structured for the fellow to evaluate patients who are referred for rehabilitation, perform a screening stress test, write an exercise prescription and supervise the rehabilitation exercise. All these activities will be under the under the supervision of an attending physician.  By the end of this rotation, the fellow is expected to be knowledgeable about the indications and contraindications for cardiac rehabilitation, the application of exercise physiology principles, use of stress testing to prescribe rehabilitation exercise, and the supervision of patients undergoing rehabilitation exercise programs.  The individual should also become facile at communicating information, verbally when necessary, to the physician requesting the rehabilitation program, and deal with him/her on a professional level.  The competencies involved include medical knowledge, system-based practice, practice-based learning, and interpersonal and communication skills.  The fellow will be performing rehabilitation with the attending on service and will be evaluated as part of the comprehensive evaluations system by peers in the institutional community.  

Overall Goals:
To become competent in the performance of cardiac rehabilitation.  (COMPETENCIES: medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, systems-based practice)
To learn how to use stress testing procedures to prescribe exercise for patients with heart disease.   (COMPETENCIES: patient care, medical knowledge, practice-based learning, systems-based practice)
To have an understanding of the potential complications of exercise in the presence of heart disease and how to manage such complications (COMPETENCIES: patient care, medical knowledge, practice-based learning, systems-based practice)
To learn to function as a member of a multidisciplinary team  within the cardiac rehabilitation program (COMPETENCIES: patient care, professionalism, interpersonal and communication skills, systems-based practice)
To be able to participate in education of patients in the use and limitations of exercise (COMPETENCIES: interpersonal and communication skills, professionalism)
To effectively communicate the progress of the patient during rehabilitation to providers in other medical disciplines and specialties (COMPETENCIES: Patient care, interpersonal and communication skills, professionalism)
To have an understanding of appropriate utilization of resources used in cardiac rehabilitation (COMPETENCIES: practice-based learning, systems-based practice)



Competency-Based Learning Objectives: 
Demonstrate competency in the evaluation of patient for rehabilitation and performance of rehabilitation  (COMPETENCIES: patient care, interpersonal and communication skills)
Demonstrate the knowledge of indications and contraindications for cardiac rehabilitation and prescribe the appropriate exercise for given patient (COMPETENCIES: patient care, medical knowledge).
Demonstrate knowledge of  the potential complications of exercise rehabilitation and how to manage such complications (COMPETENCIES: patient care, medical knowledge, practice-based learning, systems-based practice)
Formulate an exercise prescription based upon the stress test findings (COMPETENCIES: patient care, medical knowledge).
Demonstrate organizational skills necessary to integrate the findings into the systems available to give access of other physicians to the interpretations (COMPETENCIES: practice-based learning, system-based practice)
Demonstrate the ability to identify and distinguish artifacts from clinically important variations on graphic recordings (COMPETENCIES: practice-based learning, medical knowledge)
Efficiently and effectively document in writing the observations, measurements, and conclusions, that will be entered into the medical record (COMPETENCIES: medical knowledge, system-based practice, practice-based learning, interpersonal and communication skills)
Demonstrate effective communication with consulting providers, and other physicians and supporting staff (COMPETENCIES:  interpersonal skills and communication, professionalism)

Goals & Objectives by PGY Level:
PGY 6:
1. Demonstrate competency in the evaluation of patient for rehabilitation and performance of rehabilitation  
2. Demonstrate the knowledge of indications and contraindications for cardiac rehabilitation and prescribe the appropriate exercise for given patient
3. Demonstrate knowledge of  the potential complications of exercise rehabilitation and how to manage such complications
4. Formulate an exercise prescription based upon the stress test findings
5. Demonstrate organizational skills necessary to integrate the findings into the systems available to give access of other physicians to the interpretations
6. Demonstrate the ability to identify and distinguish artifacts from clinically important variations on graphic recordings
7. Efficiently and effectively document in writing the observations, measurements, and conclusions, that will be entered into the medical record
8. Demonstrate effective communication with consulting providers, and other physicians and supporting staff

Mix of Diseases:  Fellows will be exposed a wide range of patients with varying severity of cardiovascular disease and other co-morbidities that may alter the type of rehabilitation needed.   

Teaching Methods:
Patient-Centered Teaching/Learning: Teaching will take place in the stress test laboratory and in the rehabilitation service gym during the presentation to the attending, with additional discussions during conferences.  Fellows are expected to identify knowledge gaps and search for answers to their questions on a routine basis.   
Conferences/Didactic Learning:  Fellows are expected to attend the Division of Cardiology Fellows’ Core Curriculum Lectures given throughout the academic year in addition to the departmental Grand Rounds.  
       
Procedures:  Fellows will participate in procedures necessary to evaluate patients’ candidacy for cardiac rehabilitation including treadmill and stress testing.  They will be trained in the operation of treadmills and stress test recording systems, as well as the detection of erroneous lead placements and causes of equipment failure. 

Pathologic Material/Educational References: 
The fellow will review echocardiograms, nuclear imaging and coronary angiogram films when indicated, to correlate findings of stress ECG to these modalities.
References available : www.acc.org (Practice guidelines on stress testing) 
Text books:  American College of Sports Medicine: Guidelines for Exercise Testing and Prescription - available in Rehabilitation Service and  VAMC library
Text books:  Cardiology textbooks are available in the Hospital Library and the Calder Medical Library.
Institutional access for http://www.cardiosource.org and CardiosourcePlus with ACCSAP7.

Evaluations: Fellows will be evaluated by their supervising attending physician(s) using a competency-based system on New Innovation.  Feedback will be provided during and at the end of the rotation.

Supervision Policy: Direct/Indirect with direct supervision immediately available.

Team Structure:
Supervising Attending 
Cardiology Fellow
Various support staff including physical therapist, exercise therapists, and physicians and technicians from Physical Medicine and Rehabilitation Service


Attending Responsibilities:
Supervises and assumes ultimate responsibility for the rehabilitation program
Responsible for providing verbal and written feedback to the fellow

Fellow Responsibilities:
Initial evaluation of patient
o In general, the fellow will perform stress test and then review them with the attending
o Fellows should review any related tests and co-morbidities that may alter the decision to begin cardiac rehabilitation
Fellow will monitor patients undergoing rehabilitation exercises
Enter preliminary note before review and finalizing with attending supervision
Communicate with the referring/consulting physicians regarding patient candidacy and progress
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