Cardiology Consult

Educational Purpose:  The educational purpose of this rotation is to provide first and second year fellows with the knowledge, experience, and skills necessary to fulfill the role of in-hospital cardiovascular consultant to non-cardiovascular physicians.  The rotation is structured for the fellow to gain experience and knowledge in the 3 roles of consultancy: (1) responding to requests for specific information or interpretation; (2) co-managing the care of the patient with a cardiovascular problem, concomitant with another medical or surgical problem; and (3) responding to the need to take over a primary role in management in a circumstance in which a cardiovascular problem dominates other medical problems. 
 
At the end of the rotation, the fellow is expected to know how to diagnose co-morbid or evolving cardiovascular conditions, and implement the patient care requirements at each of these three levels.  They will have acquired broad knowledge of the conditions that lead to cardiovascular consultations, learn about the role of the consultant through practice-base learning, and in the context of the system-based practice in hospital.  Finally, they will have acquired skills in interpreting and communicating findings professionally in dealing with requesting physicians, with a high level of professionalism. This will be achieved by a combination of daily rounds with the attending physician, supplementing the fellow’s medical knowledge base by appropriate reading of text and journals, and dealing on a regular basis with housestaff and attendings on other services. 
 
The fellow’s performance will be evaluated using direct observation by the attending physician on service with the fellow, as well as by peers and support staff in the hospital environment.  The mix of patients in each teaching environment will be different.  The methods of evaluation and goals, however, will be the same. 
 
Overall Goals:
·         Become competent in the provision of comprehensive guidance to physicians and care to patients with cardiac illnesses that co-exist with other conditions or evolve to dominate the clinical presentation. (COMPETENCIES: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, systems-based practice)
·         Learn how to apply evidence-based, cost conscious strategies to diagnose and manage hospitalized patients. (COMPETENCIES: patient care, medical knowledge, practice-based learning)
·         Learn to function as a member of a multidisciplinary team. (COMPETENCIES: patient care, professionalism, interpersonal and communication skills, systems-based practice)
·         Be able to participate in patient education in regard to their cardiovascular conditions, including prevention and therapy. (COMPETENCIES: interpersonal and communication skills, professionalism)
·         Effectively participate in discussions of patient care with providers in other medical disciplines and specialties. (COMPETENCIES: Patient care, interpersonal and communication skills, professionalism)
·         Have an understanding of utilization of resources and appropriate levels of care in patients with various cardiac diseases. (COMPETENCIES: medical knowledge, practice-based learning, systems-based practice)
 
Competency-Based Learning Objectives:
·         Demonstrate competency in advanced history taking and physical diagnosis as they relate to common and uncommon cardiac diseases and cardiovascular complications of non-cardiac diseases and procedures (COMPETENCIES: patient care, interpersonal and communication skills)
·         Formulate a differential diagnosis and outline a plan for evaluating and managing patients being seen in cardiovascular disease consultation (COMPETENCIES: patient care, medical knowledge).
·         Demonstrate organizational skills necessary to care for the patient with pre-existing  cardiovascular diseases or cardiovascular complications of medical, surgical, or obstetrical conditions, including development of a problem list and the use of information technology (COMPETENCIES: patient care, practice-based learning, system-based practice)
·         Demonstrate an open, analytical approach to the acquisition and application of knowledge to patient care by performing patient-specific literature review (COMPETENCIES: practice-based learning, medical knowledge.
·         Efficiently and effectively document in writing on initial consultation assessment, conclusions, and recommendations; and chart daily progress notes in the medical record (COMPETENCIES: patient care, practice-based learning)
·         Demonstrate effective communication with patients, families, consulting providers, other consultants, and staff (COMPETENCIES: communication and interpersonal skills, professionalism)
 
Goals & Objectives by PGY level:
PGY 4:
1.      Demonstrate competency in advanced history taking and physical diagnosis as they relate to common and uncommon cardiac diseases and cardiovascular complications of non-cardiac diseases and procedures
2.      Formulate a differential diagnosis and outline a plan for evaluating and managing patients as a member of a multidisciplinary team.
3.      Demonstrate organizational skills necessary to care for the patient with pre-existing  cardiovascular diseases or cardiovascular complications of medical, surgical, or obstetrical conditions, including development of a problem list and the use of information technology
4.      Demonstrate an open, analytical approach to the acquisition and application of knowledge to patient care by performing patient-specific literature review
5.      Efficiently and effectively document in writing on initial consultation assessment, conclusions, and recommendations; and chart daily progress notes in the medical record
6.      Demonstrate effective communication with patients, families, consulting providers, other consultants, and staff
7.      Learn how to apply evidence-based, cost conscious strategies to diagnose and manage hospitalized patients.
 
PGY 5:
1.      Continue to develop Goals & Objectives from the PGY 4 year.
 
Mix Of Diseases:  Fellows will be exposed to patients with a wide range of cardiovascular disorders and complications of other diseases or procedures at varying degrees of progression (from initial presentation and diagnosis to end-stage disease), as well as to patients referred to the Cardiology service for diagnostic or therapeutic procedures.  Patients seen by the Cardiology fellow will include a full range of adults and selected adolescent patients, from a comprehensive mix of ethnic and racial origins.  At JMH and UMH, the gender mix will be balanced.  Cardiac diseases encountered and managed typically include but are not limited to the following:  Coronary artery disease, ischemic and non-ischemic cardiomyopathies and congestive heart failure, arrhythmias, valvular disorders, pericardial disease, as well as congenital heart disease in the adult and peripheral vascular disease.  Furthermore, pregnant patients with cardiovascular disease may be encountered.
Teaching Methods:
·         Patient-Centered Teaching/Learning:   Case-based teaching will take place at the bedside, and/or during the presentation to the attending, with occasional visits to the pathology, Radiology and cardiac procedure laboratories.  Emphasis will be placed on the approach and evaluation of the patient complaint, application of evidence-based medicine, as well as the approach to efficiently searching for answers to clinical questions.  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 perform appropriately focused history and physical exams based on the clinical presentation.  They will both be supervised by, and have the opportunity to observe and assist, the Cardiology attendings in procedures used in the evaluation of cardiac disease, including: cardiac catherizations (with therapeutic interventions as indicated), echocardiography, stress testing, tilt table testing, and electrophysiologic testing.  The fellow will gain an understanding of the appropriate indications, contraindications, usefulness and interpretation of these diagnostic and therapeutic procedures.

Pathologic Material/Educational References:
·         The fellows will review EKGs, chest X-rays, cardiac catheterizations, CT scans, stress tests and echocardiograms as indicated by the patient’s cardiac condition. 
·         Up to Date: http://www.uptodate.com/home/index.html
·         PubMed: www.ncbi.nlm.nih.gov/pubmed/
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:
·          JMH and VAMC:

o   One Supervising Attending

o   One Fellow

o   One or two housestaff (from Internal Medicine or Anesthesiology)

o   Students/Observers

·         At UMH:

o   One Supervising Attending

o   One Fellow

o   2-4 ARNPs


Attending Responsibilities:
·         Supervises and assumes ultimate responsibility for the care of the patients on the service.
·         Conducts rounds with the team during which he/she reviews clinical information, formalizes management plan, and performs patient-centered teaching.
·         Responsible for providing verbal and written feedback to the fellow
 
Members of the full-time faculty are assigned to the Consult Service on a rotating basis.  The faculty rotations will consist of assignments, each 1-2 week blocks.  From Monday through Fridays, the fellows should immediately notify the faculty member on the Consult Service of any new cases or management problems on which he/she needs help.  During the period of time that a faculty member is on service, he/she will respond to private consults not designated for a specific individual.  All patients must be presented to a member of the full-time faculty, and a faculty note must be written on the consult sheets.  On nights, weekends, and holidays, the faculty member on-call for the Cardiology Service will cover the Consult Service along with the fellow(s) on-call
 
Fellow Responsibilities:
·         Respond to all Cardiology consults and present each consultation to the attending faculty member.
o   The consult beeper is carried by the fellow on the Consult Service during normal working hours and by the fellow on night/weekend/holiday call at other times
·         Initial consultation:
o   All consults must be seen on the day that the consultation is requested, and of course, immediately in the case of emergencies.  Emergency consults requiring cardiac intensive care are to be referred promptly to the fellow assigned to the CCU.
o   Obtain the initial history and physical examination of all new consultations including a thorough review of prior treatments, laboratory testing, imaging studies, etc.  Obtain outside records when available.
o   Formulate a plan of care that will be presented to the attending physician.  Communicate this plan of care to the primary/consulting physicians
o   Dictates initial reports as part of the patient’s medical record
o   In general, the fellow will assign some consults to the resident and evaluate others as the primary evaluator
·         Fellows will be responsible for the daily follow up of patients on the service and conducting rounds with the attending to formulate a plan of care.  The fellow will document the plan in a formal note (dictated or written in the electronic record preferred) and communicate the plan with the primary care team and other members of the multidisciplinary team when appropriate.
·         The fellow will guide, supervise, and teach medical housestaff (usually Internal Medicine and Anesthesiology) rotating through the consultation service.
·         Attends all divisional conferences
·         Attend assigned Cardiology clinics
·         Completes a written evaluation of the attending

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