VA Outpatient Cardiology

Purpose:

This rotation provides exposure to general cardiology in an outpatient setting.
The purpose of this rotation is to acquire expertise and proficiency in the management of outpatient cardiovascular issues in a patient population with common cardiovascular diseases like coronary artery disease, valvular heart disease, peripheral vascular disease, heart failure, arrhythmias and preoperative evaluation. Fellows will gain experience in ECG interpretation, performance and interpretation of exercise and pharmacologic stress testing, and performance and interpretation of transthoracic echocardiograms. Fellows will also perform transesophageal echocardiograms and elective cardioversions.

Responsibility / Specific Duties:

The fellow has primary responsibility for all patients referred to the service, under the supervision of one faculty member dedicated to this rotation. This rotation also provides the opportunity and time to acquire expertise in nuclear cardiology (half day every afternoon on all weekdays) on studies performed at the VA and basic training in cardiac CT.

When responding to a request for consultation, the trainee is expected to provide comprehensive evaluation of the patient’s cardiovascular illness in a prompt and concise manner, formulate a prioritized differential diagnosis, and outline the evaluation. The trainee is expected to document the evaluation and management plan in the patient’s electronic medical record. The trainee should communicate the evaluation in a clear and concise manner to the requesting physician and provide adequate follow up. Interactions with colleagues and allied personnel should be conscientious, respectful, responsible, punctual and appropriate. The trainee must exhibit humanistic qualities when interacting with patients and their families and demonstrate integrity, respect and compassion.

Outpatient consultations for patients referred from other services and other VA hospitals are provided week day mornings each week. Patients are scheduled by the physician assistant’s and are seen in the 8E office area. Patients are seen separately by the PA’s and the outpatient fellow. The fellow is responsible for personally reviewing all cardiology studies for the patients evaluated in clinic.

The VA outpatient fellow is expected in the VA clinic on 8E at 8am except on those days where there is a morning conference (e.g. Thursday 8-9am echo conference and Wednesday 7:30 to 8:30 am cardiology grand rounds/clinical conference). Fellows are expected to evaluate no more than 5 patients (typically no more than 3 new patients) until 1pm. After 1pm, the VA outpatient rotation is dedicated to non-invasive cardiology. Fellows are expected to participate in the performance and interpretation of nuclear cardiology studies (typically from 2:00pm – 3:30pm), CT coronary angiograms and also review echo studies done in the VA echo lab. Fellows are required to maintain a detailed procedure log. The fellow will perform and interpret GXTs at the VA and follow up the abnormal results as appropriate. The VA outpatient fellow is responsible for interpretation of all Holter monitor studies and will read half of all ECGs for the day. The other half of the ECG reading is to be shared with the VA inpatient fellow.

Supervision:

The fellow is expected to discuss all cases with the supervising VA cardiology staff. However, complex cath cases and EP cases maybe directly discussed with cath lab and EP staff. All discussed cases must be documented in the VA electronic chart (CPRS) with the name of the attending physician.

Learning Objectives:

  1. Obtain training in the concepts and practice of effective outpatient cardiac consultation. This includes:
    1. Improving skills for acquiring a detailed and accurate history and physical examination. (A, B)
    2. Improving skills for insightful review of laboratory data. (A, B)
    3. Obtain training in review of noninvasive and invasive cardiac tests and incorporation of the test results into the context of the patient’s cardiac presentation. (A, B)
    4. Obtain training in placing the cardiac findings in the patient’s overall medical context. (A, B)
    5. Obtain training in formulation of a broad differential diagnosis with focus on the most likely diagnosis. (A, B)
    6. Obtain training in formulation of an effective treatment plan. (A, B)
    7. Gain experience in providing support of the proposed diagnosis and treatment plan by citation of relevant clinical studies and guidelines. (B, C)
    8. Gain experience in effective communication and interaction with referring physicians. (D, E)
     
  2. Gain exposure to a broad range of cardiac conditions through individual outpatient consultations and supplemental reading. (A, B)
  3. Gain training in guideline-based preoperative cardiac risk assessment and effective preoperative risk reduction. (B, C)
  4. Obtain training in ECG interpretation. (B)
  5. Obtain training in exercise and pharmacologic stress testing performance and interpretation. (B)
  6. Obtain training in performing elective cardioversions and in understanding the indications, contraindications, and risks of the procedure. (B)
  7. Gain an appreciation for the role of the staff members in the non-invasive labs, including the technicians, nurses, and administrative staff. (D, E, F)

Level Specific Goals and Objectives:

Junior Fellows (first year fellows)

Every patient will be staffed with the faculty in a timely fashion. The faculty will then review the history and physical findings with the fellow as well as any pertinent laboratory studies. The fellow will then formulate a plan and generate a note in the medical record. These findings will then be communicated with the patient and health care team.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

Patient Characteristics / Mix of Diseases / Types of Clinical Encounters:

At the VAMC, most patients presenting to the non-invasive labs for cardiac procedures and those presenting to the outpatient consult clinic are adult males from a variety of ethnic backgrounds. Fellows will evaluate patients in the outpatient clinic setting and will perform exercise treadmills, and elective cardioversions. Fellows will also evaluate patients pre and post procedure. Cardiac conditions encountered will include chronic coronary disease, congestive heart failure, valvular heart disease, and dysrhythmias.

Teaching Methods:

Teaching occurs by a variety of methods on this rotation.

  1. Direct teaching related to technical skills occurs during the performance of elective cardioversions.
  2. The supervising physician will overread fellow interpretation of stress ECGs, and TTEs and offer constructive criticism and further instruction. Attendings will read echos directly with the fellow and provide didactic teaching during the reading sessions.
  3. The supervising physician will review the detailed consult notes written by the fellow on all patients seen in clinic. The attending cardiologist provides constructive suggestions for acquisition of additional relevant clinical information, alternate interpretations of the data presented, recommendations for additional diagnostic considerations, and additional treatment considerations. The attending cardiologist reviews the noninvasive and invasive study results performed on the consult patients with the fellow.

Evaluation:

  1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
  2. The fellow’s progress will be reviewed verbally at mid-rotation.
  3. A standard fellow evaluation form will be completed by the VAMC attending cardiologists who worked with the fellow during the course of the month at the end of the rotation.
  4. The final evaluation will be based on the fulfillment of the rotation objectives as determined by
    1. Personal observation during interaction with the fellow.
    2. Evidence of literature review related to individual patients seen in the consult clinic or related to the various procedures performed during the month.
    3. Evidence of a thorough and accurate patient history and physical examination for each consult patient seen in clinic and evidence of an appropriate directed history and physical examination for each patient referred for procedures requiring pre-procedure evaluation.
    4. Accuracy in interpretation of invasive and non-invasive tests for the consult patient, with good insight into the role of those test results in arriving at an appropriate differential diagnosis and treatment plan.
    5. Performance of the fellow in arriving at a broad, appropriate differential diagnosis, with focus on a most likely diagnosis.
    6. Use of literature and guidelines to develop appropriate treatment plans.
    7. Improved accuracy in interpretation of ECGs, stress ECGs, and TTEs.
    8. Progression of technical skills in performing TTEs and TEEs.
    9. Feedback from the support staff in the non-invasive, ECG lab and nurse managers.
     

Resources:

  • University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
  • Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, Editor
  • www.cardiosource.com
  • Chou’s Electrocardiography in Clinical Practice (6th edition) Surawicz B and Knilans T
  • Otto’s Textbook of Clinical Echocardiography (4th edition)
  • Feigenbaum’s Echocardiography (7th edition)
  • The Echo Manual by Oh et al (3rd edition)
  • ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery. Eagle KA et al. Circulation. 2006 (recent update)
  • ACCH/AHA guideline update for perioperative atrial fibrillation Circulation 2006 (recent update)
  • www.acc.org (Scientific statements and Practice Guidelines)

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