Cardiology Curriculum Project

                                               Introduction


In an effort to provide a mea...
Cardiology Curriculum Project
                                     Core Competencies by Area

Knowledge Areas by Topic

Co...
Acute complications of cardiac therapy

Cardiac Pharmacology
        Anticoagulation, both short and long term
        Dru...
Housestaff Curriculum Project
                                    Cardiology - CCU Rotation

I. Goals of the Rotation

The...
Appropriately manage symptomatic           R1-R3     Daily rounds, didactic talk
       bradyarrhythmias, including use of...
The CCU rotation is a busy clinical service in a critical care setting. Patients admitted to the CCU have a
variety of acu...
Housestaff Curriculum Project
                                   Cardiology - A Service Rotation

I. Goals of the Rotation...
decompensation in chronic CHF
      Discuss results of large CHF             R2-R3     Reading list
      treatment trials...
Attitudinal / Lifelong Learning Behaviors

                     Objectives                                                ...
Housestaff Curriculum Project
                                    Cardiology - Arrhythmia Service

I. Goals of Rotation

T...
Objectives                                                Methods
                                               Learner
 ...
Housestaff Curriculum Project
                       Cardiology - General and Arrhythmia Consult Services

I. Goals of Rot...
Attitudes / Lifelong Learning Behavior

                 Objectives                                                     Me...
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  1. 1. Cardiology Curriculum Project Introduction In an effort to provide a meaningful and useful exposure to Cardiovascular Medicine, the Cardiology Section has developed the following curriculum for this rotation. Please note that this is an ongoing and evolving project and that your input and feedback are appreciated. Also please note that the implementation of this curriculum will take some time as certain aspects require resources which may not yet be in place. It is our intent that the knowledge covered by this curriculum be a floor of knowledge that every practicing internist should know. We encourage your reaching beyond the confines of this curriculum at every opportunity, and will be happy to assist you in that endeavor if possible. Your evaluation and performance on this rotation will, in part, be based on your acquisition of the knowledge and skills as listed here. Again, because this is a project in evolution, not all of the resources that we intend to provide to help you meet these goals are yet in place. Accordingly, those areas in italics are not yet implemented, and you should not expect the rotation to include those activities in a formal way, nor should you expect to be evaluated on those topics specifically. These areas are included, however, to illicit your feedback and suggestions for implementation. Thank you in advance and please pass any suggestions (in writing if possible) to your attending physician or Dr. Barry K. Rayburn, the curriculum project coordinator.
  2. 2. Cardiology Curriculum Project Core Competencies by Area Knowledge Areas by Topic Coronary Artery Disease Epidemiology of coronary artery disease Identify the risk factors for the development of coronary artery disease Appropriate management of modifiable risk factors Recognition, evaluation and management of angina and unstable angina Recognition, evaluation and management of acute myocardial infarction Recognition and management of post infarction complications Appropriate post infarction risk stratification Appropriate post infarction home care Basic understanding of indications and use of non-invasive and invasive diagnostic tests Basic understanding of use of interventional techniques Understanding of the indications for revascularization Congestive Heart Failure and Pericardial Diseases Epidemiology of CHF Causes of CHF Recognition, evaluation and management of chronic CHF Evaluation and management of acute decompensation Management of cardiogenic shock Management of hypertrophic cardiomyopathy Recognition, diagnosis and treatment of pericarditis Arrhythmias Application of ACLS Recognition, evaluation and management of atrial fibrillation Evaluation and management of common bradyarrhythmias Indications for temporary and permanent pacing Evaluation and management of common tachyarrhythmias Indications and utility of electrophysiolgic testing and intervention Basic understanding of use of antiarrhythmic therapy Cardiac evaluation of syncope Valvular Heart Disease Common causes / clinical settings of valvular heart disease in general population Physical diagnosis and diagnostic testing in valvular heart disease Natural history of aortic stenosis, mitral regurgitation, aortic regurgitation and mitral stenosis Appropriate use of antibiotic prophylaxis in valvular heart disease Indications for surgical intervention in valvular heart disease Recognition and management of endocarditis Congenital Heart Disease Recognition, evaluation and management of a natural survivorsa - bicuspid aortic valve, ASD and mitral valve prolapse Physical diagnosis and diagnostic testing for common congenital heart disease in the adult Preoperative Evaluation for Noncardiac Surgery Recognition and Management of Important Cardiovascular Emergencies Aortic dissection Acute pulmonary embolus Cardiac tamponade Hypertensive emergencies
  3. 3. Acute complications of cardiac therapy Cardiac Pharmacology Anticoagulation, both short and long term Drug interactions Practical Skills Physical diagnosis of common cardiac abnormalities Interpretation of ECG s and rhythm strips in common cardiac disease states Indications, performance and use of invasive hemodynamic monitoring Indications, performance and use of temporary pacing Running a code Attitudes and Behavioral Skills Use of consultation in cardiovascular medicine Application of preventive strategies for CAD in everyday practice
  4. 4. Housestaff Curriculum Project Cardiology - CCU Rotation I. Goals of the Rotation The CCU rotation provides houseofficers with exposure to the recognition, evaluation and management of acute cardiovascular disorders in a critical care setting. This is a clinically busy rotation where the patiente s care is directly supervised by a cardiology fellow as well as a member of the cardiology faculty in conjunction with the housestaff. By the end of the rotation, houseofficers at each level are expected to be able to demonstrate competence in the emergent management of common cardiovascular problems including coronary artery disease, decompensated heart failure and potentially dangerous arrhythmias. In addition, upper level house officers are expected to gain an understanding of the broader issues surrounding the long term management of these patients including risk factor modification, the subtleties of post infarction risk stratification and the use of various invasive and non-invasive diagnostic and therapeutic modalities. II. Specific Learning Objectives Knowledge Areas Objectives Methods Learner s Coronary Artery Disease Discuss the evaluation of chest pain R1 Daily rounds, didactic talk Recognize and begin appropriate R1-R3 Daily rounds, didactic talk, reading list therapy for acute MI, including indication and use of thrombolytic therapy and anticoagulation Discuss post infarct complications R1-R3 Didactic talk, possibly rounds and their management Understand and compare different R2-R3 Daily rounds, case conference, reading list strategies for post infarct risk stratification, including supporting data R2-R3 Day in cath lab, review of cine films and Demonstrate a basic understanding didactic talk of interventional techniques Congestive Heart Failure Perform acute management of R1-R3 Daily rounds, didactic talk decompensated CHF and cardiogenic shock, including use of hemodynamic monitoring and inotropic support Discuss choice and use of vasoactive R2-R3 Didactic talk, case conference agents Discuss use of mechanical support in R2-R3 Didactic talk, reading list CHF Arrhythmias Competently manage a code under R2-R3 Patient care and follow-up discussion direct supervision Differentiate wide complex R1-R3 Daily rounds, didactic talk tachycardias and demonstrate correct acute management Revised January 2, 1996
  5. 5. Appropriately manage symptomatic R1-R3 Daily rounds, didactic talk bradyarrhythmias, including use of temporary pacing Practical / Skills Areas Objectives Methods Learner s Residents will increase their ability to R1-R3 Daily rounds, case conferences with ECGo s interpret ECGl s and rhythm strips Discuss indications for invasive R1-R3 Patient care, case conference hemodynamic monitoring, perform insertion of Swan-Ganz catheter using proper technique and demonstrate correct interpretation of results Discuss indications for temporary R2-R3 Patient care, discussions with fellow, reading pacing with both external (Zoll) and list internal devices, show correct use of temporary pacing equipment Demonstrate a practical R2-R3 Patient care, discussion with fellow/attending understanding of ACLS principles by running a code under supervision Demonstrate knowledge and R1-R3 Patient care, demonstration by fellow recognition of physical findings of cardiovascular disease in this setting Attitudes / Lifelong Learning Behaviors Objectives Methods Learner s Demonstrate use of preventive R1-R3 Daily rounds strategies in routine practice (both secondary prevention in patients with CAD and primary in those without) III. Logistics of Rotation Revised January 2, 1996
  6. 6. The CCU rotation is a busy clinical service in a critical care setting. Patients admitted to the CCU have a variety of acute cardiovascular problems varying in severity from immediately life threatening to currently stable patients with a potential risk for serious morbidity. Patients cared for by the CCU team will be admitted directly to the CCU. The team may follow patients onto the floor as well, but no patients should be admitted to the floor directly. The cardiology fellow in the CCU is responsible for supervising the care of all patients on the service and for serving as a liaison between the housestaff and various attendings with patients in the CCU but who are not the CCU teaching attending. The CCU teaching attending will be a cardiology faculty member who will have a substantial number of patients during the month and will serve as a principal teacher and resource for both the fellow and the housestaff. Coordination of didactic talks and case conferences will be the responsibility of the CCU fellow. Housestaff are expected to participate in the educational programs provided during the month. The nature of a critical care unit necessitates some flexibility in scheduling, and therefore a rigid schedule of talks and conferences is unrealistic. During the month, time will be arranged for each upper level houseofficer to spend a day in the catheterization laboratory beginning after work rounds. Ideally, this will be a day on which patients from the CCU are having a procedure performed. IV. Required Educational Resources A series of didactic talks will be presented during the month addressing the points noted in the curriculum outline above. The topics to be covered will be standardized, but the actual presentations will be arranged by the fellow in the CCU. Additionally, education of housestaff in the CCU will continue with daily discussions focusing on individualization of pertinent medical issues involving patients currently in the unit. This may necessitate that work rounds be somewhat longer than may be customary on other services. A formal reading list will be established and copies of classic or important articles provided to each resident at the beginning of the rotation with the expectation that they will be read during the month. Time will be provided for the R2-R3 level residents to spend time in the catheterization laboratory to observe the diagnostic and therapeutic techniques available. Finally, case conferences, using clinical examples from the CCU will be held to highlight decision making subtleties in the areas outlined. Revised January 2, 1996
  7. 7. Housestaff Curriculum Project Cardiology - A Service Rotation I. Goals of the Rotation The Cardiology "A Service" is the flagship rotation for the section. It is an active clinical service with patients demonstrating a variety of cardiovascular problems. The goals of this rotation are to expose the houseofficer to a wide range of common cardiovascular diseases in a setting that allows for learning and discussion of the pathophysiology, evaluation and management of the various disorders. Additionally, this rotation should serve as an introduction for those houseofficers considering a career in cardiovascular medicine. As more patient care is moved into the clinics, a wide variety of routine management issues never appear in the inpatient setting. Accordingly, this rotation will give upper level residents an opportunity to work in continuity with one of the cardiology faculty by participating in a weekly WFUP Cardiology Outpatient Clinic during their month on the service. By the end of this rotation, it is expected that residents will be able to recognize, correctly evaluate and initiate management for common cardiovascular disorders seen in the practice of medicine. They should also gain some insight into the unique skills and services provided by subspecialists in cardiovascular medicine, thus enabling them to better utilize consultants. Finally, they should develop an understanding of the role of preventive cardiology strategies in everyday patient care and the means for keeping up to date in this rapidly changing field. II. Specific Learning Objectives Knowledge Areas Objectives Methods Learner s Coronary Artery Disease Discuss the epidemiology of CAD R1-R3 Reading list Perform appropriate evaluation of R1 Reading list, patient care, upper level chest pain in patients with known residents CAD as well as previously undiagnosed patients R1-R3 Appropriately identify and manage Patient care, reading list, cardiology clinics modifiable risk factors in all patients R1-R3 Recognize, evaluate and initiate Patient care, reading list, clinics, didactic talk therapy for angina and unstable angina, including use of noninvasive R1-R3 and invasive testing Didactic talk, reading list, clinics Understand and employ appropriate post infarct counseling for patients in activity restrictions, rehab goals, life style changes Congestive Heart Failure Discuss the causes and epidemiology R1-R3 Didactic talk, reading list of CHF Appropriately evaluate and initiate R1-R3 Didactic talk, reading list, clinics, patient care therapy for new onset CHF Appropriately evaluate and manage R1-R3 Didactic talk, reading list, clinics, patient care Revised January 2, 1996
  8. 8. decompensation in chronic CHF Discuss results of large CHF R2-R3 Reading list treatment trials and their practical application Arrhythmias Recognize, evaluate and R1-R3 Reading list, patient care, clinics, didactic talk appropriately treat atrial fibrillation alone and in conjunction with other cardiac diseases R1-R3 Reading list, patient care Discuss evaluation of bradyarrhythmias and indications for R1-R3 Reading list, patient care, didactic talk permanent pacing Appropriately evaluate the patient with syncope, emphasizing those of R2-R3 Reading list, discussions with faculty cardiovascular origin Discuss common antiarrhythmic agents and their appropriate use and precautions Valvular Heart Disease Identify common valvular R1-R3 Didactic talk, patient care abnormalities in clinical practice and their risk factors R1-R3 Didactic talk, patient care Recognize and evaluate patients with common valvular abnormalities R2-R3 Reading list Know the indications for and choice of antibiotic prophylaxis in valvular heart disease R1-R3 Didactic talk Understand the indications for surgical intervention for common valvular abnormalities Congenital Heart Disease Identify the common "natural R2-R3 Clinics, reading list survivors" to adulthood and discuss their presentation and therapy Preoperative Evaluation for Noncardiac Surg. R2-R3 Clinics, reading list Discuss the principles of "pre-op" evaluation Practical / Skill Areas Objectives Methods Learner s Physical diagnosis of common R1-R3 Patient care, clinics, faculty one-on-one cardiovascular conditions sessions Interpretation of ECG's / rhythm R1-R3 Didactic sessions, case conferences, ECG strips teaching file Revised January 2, 1996
  9. 9. Attitudinal / Lifelong Learning Behaviors Objectives Methods Learner s Apply principles of CAD prevention in R1-R3 Patient care, clinics routine practice Establish foundation for keeping up to R2-R3 Each upper level resident will be responsible date with changing standards of care for scanning the recent literature in an and applying new findings in practice assigned topic for the specific purpose of updating the reading list for the rotation III. Logistics of Rotation The "A Service" rotation is centered around the care of inpatients with cardiovascular diseases. The activities of daily care of the patients and discussion of patient care issues with attending physicians will provide a large amount of the educational material during the rotation. In order to extend and supplement this experience, there will be conferences given on a scheduled basis by the attendings covering certain topics and related to cases if possible. The housestaff are expected to attend and participate in these conferences. A reading list will be established by the section with copies of the articles on reserve in the library for reading or copying. Each upper level resident will be assigned a specific topic / area at the beginning of the month and will be expected to review the recent literature and update the reading list in that topic. These updates will be reviewed with a faculty member. Upper level residents will also be paired with one of the faculty at the beginning of the month and will participate in at least one half-day clinic session with that faculty member each week of the rotation. This continuity should allow the resident sufficient time to be able to be an active participant in the clinic rather than just an observer. IV. Required Educational Resources It is expected that the residents will read many or all of the references on the reading list during the month. In order to facilitate this, we will make copies of the articles available in the library. The residents can either read them there, or more likely make copies for their own files. Alternatively, these references could be provided for each houseofficer depending on the availability of funds for copying and collating into binders. The faculty members who will participate in having residents in one of their clinic sessions during the entire month will need to have adequate room space in the clinic to allow for teaching to occur without jeopardizing service to our patients by slowing the progress of the clinic. Revised January 2, 1996
  10. 10. Housestaff Curriculum Project Cardiology - Arrhythmia Service I. Goals of Rotation The arrhythmia service provides in depth exposure to a group of patients bound together by the common phenomenon of some electrical disturbance of the heart. Fortunately, such phenomena rarely happen in total isolation, and these patients usually have an additional underlying cardiac diagnosis such as coronary artery disease or congestive heart failure. In addition, some of the rhythm disturbances themselves are quite common in the general practice of internal medicine such as atrial fibrillation and bradyarrhythmias in the elderly. It is expected that residents on the arrhythmia service will learn a great deal about the management of common rhythm disturbances, but also will increase their foundation of knowledge in cardiovascular diseases overall. Residents should also be able to markedly improve their skills in the interpretation of ECGs s, particularly with regards to rhythm disturbances. II. Specific Learning Objectives Knowledge Areas Objectives Methods Learner s Recognize, evaluate and manage R1-R3 Patient care, didactic talks, reading list common supraventricular arrhythmias including atrial fibrillation and flutter Recognize, evaluate and manage R1-R3 Patient care, didactic talks, reading list complex ventricular ectopy and ventricular tachyarrhythmias Understand, identify and manage R1-R3 Patient care, didactic talks, reading list bradyarrhythmias and conduction blocks including indications for permanent and temporary pacing Recognize the role arrhythmias play R1-R3 Patient care, discussions with faculty in the natural history of other cardiovascular illnesses (esp. CAD and CHF) Discuss use of electrophysiologic R1-R3 Case discussions with faculty, didactic talk testing and interventions in the management of patients with arrhythmias Understand the uses, general R1-R3 Patient care, case discussions with faculty, properties, side effects, toxicities and reading list and didactic talks general precautions needed for the use of the Class I- IV antiarrhythmics. Skills Areas Revised January 2, 1996
  11. 11. Objectives Methods Learner s Interpretation of ECGM s and rhythm R1-R3 Daily review of strips with faculty / fellow strips Attitudes / Lifelong Learning Behaviors Objectives Methods Learner s Identify appropriate use of R1-R3 Discussion with faculty consultation with arrhythmia specialists Become comfortable with interactions R1-R3 Patient care, case reviews among drugs in overall care of the patient III. Logistics of Rotation The arrhythmia service is a standard inpatient service tied closely to an active clinic and consultation service. There is an attending physician responsible for the care of all the patients on the service at any one time which provides for a great deal of direct interaction between the housestaff and the faculty. Didactic talks and case driven discussions are held periodically throughout the rotation and are arranged by the attending with the houseofficers. IV. Required Educational Resources The section will develop a reading list of pertinent articles for the housestaff on the rotation. Clinical material for the review of ECGd s and rhythm strips is abundant on the service and can be supplemented as needed by studies from the attendingy s files. Ideally, a teaching file of select ECG s and rhythm strips would be available to ensure coverage of important topics regardless of clinical material. Revised January 2, 1996
  12. 12. Housestaff Curriculum Project Cardiology - General and Arrhythmia Consult Services I. Goals of Rotation The consultation services of the cardiology section provide residents with the opportunity to see the effective use of subspecialists as consultants to other physicians. It is expected that residents rotating on these services will gain insight into the effects of cardiovascular disorders on patients with a wide variety of other medical conditions. Additionally, the very important skills of preoperative assessment of the patient undergoing noncardiac surgery and management of cardiac complications following noncardiac surgery are emphasized. These rotations are particularly useful for residents considering a career in cardiovascular medicine who want more exposure to the subspecialty to help them with their decision and for residents planning a career in general internal medicine where preoperative evaluation is a common reason for consultation with an internist. II. Specific Learning Objectives Knowledge Areas Objectives Methods Learner s Understand and apply the principles R2-R3 Daily rounds with attending, reading list of preoperative assessment of patients for noncardiac surgery Apply risk factor modification R2-R3 Daily rounds with attending strategies for primary and secondary prevention Learn appropriate use of consultation R2-R3 Daily rounds with attending and appropriate response to request for consultation Skills Areas Objectives Methods Learner s Correctly interpret ECGd s in a R2-R3 Discussion with fellow / attending variety of clinical settings Gain a basic understanding of the R2-R3 Review of studies with fellow / attending on a interpretation of diagnostic testing of case specific basis the cardiovascular system including stress tests and echocardiograms Physical diagnosis of common R2-R3 Case review with fellow / attending cardiovascular conditions
  13. 13. Attitudes / Lifelong Learning Behavior Objectives Methods Learner s Apply principles of preventive R2-R3 Daily patient care cardiology in everyday practice Learn appropriate consultant R2-R3 Daily patient care behaviors and relationships with other services III. Logistics of Rotation The consult services operate via a central phone number. The call is then routed to the fellow on the appropriate service who in turn will distribute the consults among the members of the team. It is expected that each resident on the consult service will perform at least one new consult daily and provide follow-up information on existing consults that they saw primarily. Generally the small team size allows for daily one on one interaction between the resident and the attending and fellow. This direct interaction provides for an excellent opportunity for case driven in-depth discussions often unavailable on busy inpatient services. IV. Required Educational Resources The major resources required for these rotations are consults which are generally plentiful.

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