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University of Missouri-Kansas City School of Medicine ... Presentation Transcript

  • 1. University of Missouri-Kansas City School of Medicine Internal Medicine Residency Program Rotation Information Form Hospital: Saint Luke’s Hospital Rotation: Cardiology Responsible physician(s): Anthony Magalski, MD UMKC Appointment: Yes Other participating physicians: Cardiovascular Consultants Inc. Duration Standard design is 2 months: yes Is one month possible: yes Is three months possible: yes Any months rotation is not offered: no Maximum number of residents at one time: 5 Average number of inpatients: 70 (not all seen by residents) Average number of consults: 20 (not all seen by residents) Outpatient of office experience included: yes List of conferences that the resident may attend: Morning Report, Noon Conference
  • 2. Schedule for a typical day, including regular occurrences (other than conferences noted above) that may not occur on a daily basis, but occur during the week or month: 7:00 am Work Rounds, CV Grand Rounds - Thursdays 8:15 am Morning Report 9:00 am Teaching Rounds 10:00 am Teaching Rounds 11:00 am Didactic Session 12:00 noon Noon Conference 1:00 pm CV Core Curriculum Didactic Series (M/W/F) 2:00 pm Direct Patient Care 3:00 pm Direct Patient Care 4:00 pm Direct Patient Care 5:00 pm Direct Patient Care Procedures the resident will perform: Arterial Line Placement, Central Line Placement, Central Flotation Catheters, and Temporary Pacemakers Procedures the resident will assist: Echocardiograms, Pericardiocentesis Procedures the resident will observe: Diagnostic and Therapeutic Catheterization Procedures the resident will NOT be permitted to perform: Echocardiograms, Pericardiocentesis, and Heart Catheterization Will the resident have primary patient responsibility: yes Will the resident be permitted to perform the initial examination of the patient and initiate therapy: yes Approved: ____________________________ Title: _______________________________ Date: ____________________________________
  • 3. University of Missouri-Kansas City School of Medicine Internal Medicine Residency Program Rotation Information Form Hospital: Truman Medical Center Rotation: Cardiology Responsible physician(s): Annette Quick, MD, Mukesh Garg, MD UMKC Appointment: yes Other participating physicians: no Duration (2 months is required): yes Is one month possible: yes Is three months possible: yes Any months rotation is not offered: no Maximum number of residents per month: 2 Average number of inpatients: 0 Average number of consults: 12-20 Outpatient of office experience included: no
  • 4. List of conferences that the resident may attend: Morning Report, Noon Conference, Wednesday Cardiology Noon Conference Schedule for a typical day, including regular occurrences (other than conferences noted above) that may not occur on a daily basis, but occur during the week or month: 7:00 am Work Rounds, CV Grand Rounds - Thursdays 8:15 am Morning Report 9:00 am Teaching Rounds 10:00 am Teaching Rounds 11:00 am Didactic Session 12:00 noon Noon Conference 1:00 pm Didactic Series 2:00 pm Direct Patient Care 3:00 pm Direct Patient Care 4:00 pm Direct Patient Care 5:00 pm Direct Patient Care Procedures the resident will perform: EKG interpretation, Swan-Ganz Catheters Procedures the resident will assist: Echocardiograms, Temporary pacemaker, Stress testing Procedures the resident will observe: Diagnostic and Therapeutic Catheterization Procedures the resident will NOT be permitted to perform: Echocardiograms, Pericardiocentesis, and Heart Catheterization Will the resident have primary patient responsibility: yes Will the resident be permitted to perform the initial examination of the patient and initiate therapy: yes Additional Comments: Each resident is encouraged to develop and formal presentation for the team. This will be delivered at the end of the month. Brief presentations of specific patient directed reading assignments will be required throughout the rotation. Approved: ____________________________ Title: _______________________________ Date: ____________________________________ Updated: ___________________________
  • 5. CARDIOLOGY CURRICULUM Introduction This curriculum description for the categorical Internal Medicine Residency Program at the University of Missouri Kansas City is formatted to incorporate the six newly defined areas of competency as described by the Accreditation Council for Graduate Medical Education (ACGME), incorporated under Principal Education Objectives below. The objectives are described for each of the six competencies: Patient Care, Medical Knowledge (including Clinical Competencies), Practice Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice. The educational objectives are listed with the learning venues, methods for assessing residents' performance, and where applicable for knowledge areas, PGY designated for completion of the objective and a priority index. Priority 1 indicates relatively frequent and important conditions; Priority 2 indicates less frequent conditions than Priority 1, but equally important, and residents should at least see the patients in a group and participate in team discussions; and Priority 3 indicates even less frequent, or less important conditions than Priority 2 and residents can learn about this condition by reading or attending lectures. The curriculum for the core rotations have been organized under the following sections: (A) Overview (B) Principal Teaching /Learning Activities (C) Principal Educational Objectives (D) Recommended Resources (E) Evaluation Methods The curriculum will be reviewed at least on an annual basis.
  • 6. (A) Overview All PGY 1 residents will rotate for at least one month on the Cardiology service. One or two months are available to PGY 2 and 3 residents. The Cardiology rotation at St Luke's Hospital comprises both primary and consultative cardiology services. Residents will rotate with faculty in the Cardiovascular Consultants group. The Cardiology rotation at Truman Medical Center provides consultative services. (B) Principal Teaching/Learning Activities • Morning Report (MR) - Every Monday through Thursday, all residents meet with Internal Medicine faculty members and the Chief Resident to discuss a case selected by the presenting PGY2 or PGY3 with focus on the development of a systematic differential diagnosis, current review of the disease process, diagnostic and treatment strategies. Monthly attendance requirement is 70%. • Attending Rounds (AR) - Every day of the week the attending physician will meet with the team for work rounds and teaching rounds. Rounds should include demonstration and evaluation of physical examination techniques. Supervising residents will be required to give short focused presentations to the team on specific aspects of the patients' condition or care. • Didactic Session (DS) - included in attending rounds and conference schedule below (Angiography, Truman Noon Cardiology, Nuclear conferences, as well as Cardiovascular Grand Rounds. • Noon Conference (NC) - Every weekday reviews of core topics in inpatient and ambulatory Internal Medicine will be given. Monthly attendance requirement is 70%. • Angiography Conference - lecture series every other Wednesday 0730-0830 in the Crockett Room at St Luke's Hospital. • Noon Cardiology Conference (NCC) - Wednesday at Truman Medical Center -various topics in Cardiology presented by fellows, and faculty. • Nuclear Conference -didactic lectures (2-3), journal review (1), reading of studies (1) over the course of one month. Meeting held every Friday at noon in the Cardiovascular Consultants' conference room. • Journal Club (JC) - Monthly discussion and critical examination of selected articles in Internal Medicine. • Cardiovascular Grand Rounds (CVGR) - Thursday at 0730 @ St Luke's Hospital • Grand Rounds (GR) - every Friday at St Luke's Hospital and Truman Medical Hospital.
  • 7. • Morbidity and Mortality Conference (M&M) - monthly presentation of statistics with focused presentation of one disease process. • Direct Patient Care (DPC) • Mini CEX (CEX) – Interns need to be observed and assessed for history taking and physical examination skills. (C) Principal Educational Objectives (1) Patient Care: Provide compassionate, appropriate and effective care for the treatment of disease and at the end of life. Learning Objective Learning venue How we assess it Priority PGY Obtain a thorough, accurate cardiac history AR/DPC AR/Mini CEX 1 1 a. differentiate cardiac from noncardiac chest pain b. differentiate cardiac from noncardiac dyspnea Perform thorough, competent CV physical examinations AR/DS AR/Mini CEX 1 3 a. Jugular venous pressure: elevated or not? Detect prominent V waves of tricuspid regurgitation b. Carotid pulse: differentiate normal/increased/decreased volume, slow vs. normal/brisk upstroke; differentiate carotid bruits from referred heart murmur c. Precordial palpation: right vs. left ventricular lift; differentiate a lift from a palpable heart sound (e.g. accentuated first heart sound of mitral stenosis, and accentuated pulmonic closure sound of pulmonary hypertension); cardiac thrill. d. Auscultation: understand basic findings of the following: 1. aortic stenosis 2. aortic insufficiency 3. mitral stenosis 4. chronic mitral regurgitation
  • 8. 5. mid systolic click and late systolic murmur of mitral valve prolapse 6. accentuated aortic closure sound (RUSB): systemic HTN 7. accentuated pulmonic closure with normal splitting of S2 (LUSB): pulmonary HTN 8. wide split S2: ASD 9. early diastolic S3: CHF 10. late diastolic S4: noncompliant ventricle 11. effect of inspiration, valsalva, hand grip on different murmurs Define and prioritize patients' medical problems AR/MR/NC/DPC AR/MR/CR/Mini CEX Generate and prioritize differential diagnoses AR/MR/NC/DPC AR/MR/CR/Mini CEX Develop rational, evidence based management plan AR/MR/NC/DPC AR/MR/CR/Mini CEX Implement plans/perform essential procedures AR/DPC AR/Mini CEX Procedures: Recognize and understand elements of a 12 lead ECG AR/DS AR 1 3 a. 12 lead placement; recognize right-left arm reversal b. axis deviation c. RAE/LAE d. RVH/LVH e. Differentiate RBBB and LBBB f. Recognize preexcitation/WPW g. Recognize acute MI and its mimics h. Recognize common SVTs: PSVT, AFib, Aflutter, MAT, AT with block, accelerated junctional rhythm i. Ventricular arrhythmias 1. benign, potentially malignant, malignant 2. VT: non-sustained, sustained: monomorphic vs polymorphic or Torsades de Pointes 3. accelerated idioventricular rhythm 4. concept of SVT with aberrancy mimicking VT
  • 9. 5. AV Bock: first, second (Mobitz I & II), and third degree Understand the basic indications and application of echocardiography: AR/DS AR 1 3 a. when not to order: elderly, too obese, severe COPD, chest wall deformity b. Common indications for echocardiography: 1. LV function i. systolic vs diastolic dysfunction ii. global vs focal wall motion abnormality iii. measurement of EF iv. identify complications of acute MI 2. Pericardial effusion: identify and measure fluid amount 3. Valvular heart disease: i. type and severity ii. rule out vegetations 4. Systemic hypertension-severity of LVH and LV dysfunction 5. Pulmonary hypertension- identify and measure severity 6. Rule out aortic root dissection (Transesophageal echo better) 7. Congenital heart disease: type and severity Understand the fundamental indications and concepts of treadmill AR/DS AR 1 3 exercise testing a. contraindications b. reasonable indications c. Interpretation of abnormal response d. When nuclear imaging and/or exercise echocardiography should be added Understand legal issues pertaining to advanced AR/DPC AR 1 3 directives, decision making capacity, competence Develop effective communication skills for end of life AR/DPC AR 1 3 care including withholding or withdrawing life sustaining treatment including nutrition, and hospice care.
  • 10. (2) Medical Knowledge: Demonstrate and apply basic and clinical science knowledge to critical thinking, problem solving, decision making and patient education. Learning Objective Learning venue How we assess it Effectively articulate medical knowledge in care of medical inpatients AR/MR/SR/DPC AR/MR/CR Access and critically evaluate current medical information and evidence relevant to patient care AR/JC AR/MR/JC Clinical Competencies ORGAN SYSTEM Learning venue How we assess it Priority PGY Cardiovascular Illness Anatomy Coronary arteries AR AR 1 1 Conduction system AR AR 1 1 Physiology Normal intracardiac pressures AR/DS AR 1 1 LV pressure curve related to heart sounds/murmurs AR/DS AR 1 3 LV function curve relating LVEDP/PCW to CO/CI AR/DS AR 1 1 Determinants of myocardial oxygen demand AR/DS AR 1 3 Preload/afterload and drug interventions AR/DS AR 1 3 Arrhythmias Atrial AR/DPC AR 1 1 Conduction abnormalities AR/DPC AR 1 3 Ventricular AR/DPC AR 1 1 Congenital heart disease (adult) NC 2 1 Cardiomyopathies Differentiate dilated, hypertrophic, restrictive AR/DPC AR 2 3
  • 11. Congestive Heart Failure AR/DPC/DS AR 1 3 Systolic vs diastolic LV dysfunction Medical therapy AR/DS/NC AR 1 1 Correct specific etiology Preload reduction Afterload reduction beta blockers inotropic stimulation Biventricular pacemaker therapy AR/DS AR 2 3 Cardiac transplantation: indications AR/DPC/DS AR 3 3 Coronary Artery Disease Identify risk factors AR/DPC/DS AR 1 1 Understand pathophysiology and management principles in: Angina, chronic stable AR/DPC/DS AR 1 1 Angina pectoris, unstable AR/DS/NC AR 1 1 Myocardial infarction AR/DPC/DS AR 1 3 indications/contraindications for thrombolysis IV nitroglycerin beta blockers aspirin heparin: SQ, IV and LMWH role of primary PTCA post MI complications role of CABG Q wave vs non Q wave MI Risk stratification AR/DS AR 1 3
  • 12. Endocarditis AR/DS AR 1 3 Hypertension Chronic stable hypertension AR/DPC/NC AR 1 1 Hypertensive crisis AR/DPC/NC AR 1 1 Secondary hypertension AR/DPC/NC AR 1 1 Pericarditis AR/DPC/DS AR 1 3 Cardiac tamponade Role of echocardiography constrictive pericarditis Pulmonary hypertension Differentiate specific causes AR/DS AR 1 3 Shock AR/DPC AR 1 3 Differentiate different etiologies: cardiac, hypovolemic septic, anaphylactic, endocrine Indications/complications of Swan Ganz catheter Interpretation of hemodynamic values from Swan Valvular Heart Disease AR/DS/NC AR 1 3 When to refer for intervention/open heart surgery Endocarditis prophylaxis Vascular Disease Aneurysm (atherosclerotic, mycotic) AR/DPC AR 2 1 Aortic disease AR/DPC AR 1 1 Arterial insufficiency AR/DPC AR 1 1 Chronic venous stasis AR/DPC AR 1 1 Deep venous thrombosis AR/DPC AR 1 1 Dissecting aneurysm AR/DPC AR 2 3
  • 13. Pharmacology AR/DS AR 1 3 Antiarrhythmics IA-quinidine, pronestyl, disopyramide IB-lidocaine, mexilitene IC- flecanide, propafenone II-beta blockers III- amiodarone, sotalol, ibutilide, dofetilide IV-calcium channel blockers miscellaneous- digoxin, adenosine, magnesium Antianginal agents Beta blockers Calcium channel blockers Nitrates Inotropes digoxin: dose adjustment in the elderly and with renal dysfunction; signs and symptoms of toxicity indications for dopamine vs dobutamine Vasodilators ACE inhibitors Hydralazine and isordil angiotensin II receptor blockers Lipid lowering agents Antiplatelet agents: aspirin, clopidogrel, ticlopidine Anticoagulants: SQ, IV heparin, LMWH, warfarin
  • 14. (3) Practice Based Learning and Improvement: Use scientific methods to evaluate and improve patient care. Learning Objective Learning venue How we assess it Identify gaps in knowledge or experience in the care of hospitalized patients. AR AR/MR Demonstrate willingness to learn from errors and use errors to improve the processes of care. AR/M&M/DPC AR/MR (4) Interpersonal and Communication Skills: Demonstrate the skills to maintain professional relationships with patients, families and other members of the healthcare team. Learning Objective Learning venue How we assess it Effective communication with patients, families, all physician and non-physician colleagues. AR/DPC AR/CEX Effective teaching to colleagues AR/MR/M&M AR/MR Clear, concise and timely verbal communication and medical records. AR/MR/DPC AR/CR 5) Professionalism: Commitment to continuous professional development, ethical practice and understanding of diversity. Learning Objective Learning venue How we assess it Demonstrate respect and integrity in all professional relationships AR/DPC AR/CEX Adhere to principles of confidentiality and informed consent. AR/DPC AR Participate with the peer review process to include identification of deficiencies to appropriate persons AR/SR AR
  • 15. (6) System-Based Practice: Understand the systems in which healthcare is provided to improve/optimize patient care. Learning Objective Learning venue How we assess it Access and utilize appropriate resources to provide optimal, collaborative care. AR/DPC AR/CR Recognize limitations and opportunities of different systems. AR/DPC AR Apply evidence-based, cost effective strategies to prevention, diagnosis and disease management. AR/MR/DPC/JC AR/CR NC (C) Recommended Resources Braunwald E. Heart Disease. Sixth Edition. WB Saunders Co; 2001. Giuliana E. Mayo Clinic Practice of Cardiology. 1996 Heger JW. Cardiology. Lippincott Williams and Wilkins; 2004 (Preferred Primary Text) Wagner GS. Marriott’s Practical Electrocardiology. Lippincott Williams and Wilkins; 2001 Hillis DL. Manual of Clinical Problems in Cardiology: With Annotated Key References. Lippincott Williams and Wilkins; 2002 Core Curriculum Didactic Series – Specific Handouts and Reading Assignments Physical Examination of the Cardiovascular System Basic Electrocardiography Aortic Valve Stenosis Chronic Aortic Insufficiency Mitral Stenosis Mitral Regurgitation Mitral Valve Prolapse Syncope Peripheral Artery Disease Stress Testing Prosthetic Valves
  • 16. Outpatient Evaluation of Permanent Pacemakers Hypertrophic Cardiomyopathy Current Management of ventricular Arrhythmias Atrial Fibrillation Update Nitty Gritty of Cholesterol Lowering Management of CHF Office Evaluation and Treatment of Hypertension (D) Evaluation Methods Residents will receive a formal face-to-face and online evaluation by the attending at the end of each rotation. Attending staff and residents alike are encouraged to provide and seek feedback at each rotation's mid point particularly to address any opportunities for improvement. Residents will also receive anonymous peer evaluations. All evaluations are available to the Program Director. If unfavorable evaluations are identified, the resident will be asked to meet with the Program Director or his/her designee. Each resident will meet with his/her counselor at least twice yearly. Updated November 2004