VA Inpatient Cardiology

Purpose:

The purpose of this rotation is to provide broad exposure to the cardiology fellow to a wide variety of common and rare cardiovascular disorders in the inpatient setting. The fellow has primary responsibility for all patients referred to the service, under the supervision of one faculty member dedicated to this rotation.

The goals and objectives of this rotation are:

  1. to gain experience in providing cardiology consultation on inpatients, including providing prompt response, assessment of all clinical data (especially ECG monitoring), differential diagnosis, outlined evaluation and interpretation of evaluations, and follow-up of prescribed therapies.
  2. to work closely with the assigned cardiology staff, which provides opportunity for detailed discussion of treatment plans and demonstration of characteristics and qualities to deliver quality care.
  3. to develop proficiency in inpatient consultative cardiology including pre-operative and peri-operative evaluation.
  4. to develop proficiency in intensive care consultation on critically ill cardiac patients utilizing invasive and non-invasive tests and interventions.
  5. to encourage and develop humanistic care of inpatients.

The structure and purpose of the consult service is similar to the UIHC consult service except that medical students may pursue a cardiology elective rotation and may occasionally participate as members of the cardiology consult team. The VA inpatient fellow is responsible for reviewing all cardiac tests requested on the patients including ECG, Holter monitor studies, nuclear and echo studies, interrogating pacemakers and reviewing invasive studies such as cardiac catheterization. The cardiology fellow on this rotation serves as a cardiology consultant to patients admitted to the intensive care unit and to other medical and surgical services. The critical care staff physician serves as the primary physician for patients in the intensive care unit at the VA medical center. However, all cardiology consultations are reviewed with the assigned cardiology staff physician whose has the final authority for all recommendations made by the cardiology consult service.

Responsibility / Specific Duties:

The VA inpatient fellow is responsible for all inpatient and Urgent Care Clinic cardiology consults between 8:00 am and 5:00 PM Monday through Fridays. If there is an ICU patient on the service or floor patients with active cardiac problems, the fellow should come in on one of the weekend days to round on that patient. Usually, it suffices for the VA inpatient fellow to come in on one of the weekend days after deciding with the VA staff. The VA fellow is required to take at least one day of the weekend off every week. The VA inpatient fellow is expected to evaluate any urgent consult as soon as possible. This includes performing a history and physical examination and reviewing all diagnostic test results, laboratory data, and progress notes. The fellow then formulates a differential diagnosis and treatment plan and offers any urgent recommendations immediately. The fellow presents the urgent consultation to the attending cardiologist as soon as is necessary for optimal patient care.

All consultations on patients in the Intensive Care Unit or wards must be reviewed with a staff cardiologist. This interaction should be documented by entering the staff physician’s name as the supervising physician and naming the staff as a cosigner on the note. In most cases, patients should be discussed with the designated consultation cardiology staff, but may, at the discretion of the fellow/general cardiology staff physician be discussed with the cardiac catheterization staff, electrophysiology service staff or other cardiology staff with particular expertise depending on the nature of the problem. Daily follow up of inpatients should continue as long as the patient’s cardiology problem is active. Daily review of Consult Service patients with the designated staff is expected. Night (5:00 PM to 8:00 AM) hours and weekend coverage of the inpatient service will be provided by the F1 call fellow. Patients that require follow up on the weekend or are unstable should be indicated to the fellow on F1 call. Cardiology consultation for VA patients on other services will also be provided by the Fellow (F1) on call after 5pm. The fellow is encouraged to participate in the VA daily ICU rounds (at 8am) conducted by a critical care MICU staff physician. The fellow is expected to be available for all ICU procedures for cardiology patients and those on the neurology team, internal medicine team and, if requested, the surgical team. The fellow may participate in the procedure (including insertion of temporary pacemakers and Swan-Ganz catheters, electrical cardioversions, etc.).The fellow is expected to read half of all VA EKG’s daily. Holter monitor studies are to be read by the VA outpatient fellow. The fellow is expected to meet with the Cardiology staff daily for review of patients and clinical teaching. Requests for inter-hospital patient transfers may be evaluated by the fellow, but acceptance of a patient in transfer must be done only by the Medical Officer of the Day (MOD). Eligibility for VA care should be verified through the admitting MOD and AOD before elective patient transfer. The inpatient fellow maybe requested to assist the outpatient fellow as needed. Concerns regarding VA Cardiology services should be discussed with the chief of cardiology service at the VA and the fellowship program director.

Supervision:

All cardiac consultations are reviewed in detail with the supervising cardiologist with attention to patient and diagnosis-based teaching of the fellow. In addition to clinical review, the attending cardiologist reviews the progress of the fellow in providing appropriate communication and collaboration with the requesting service. This most importantly includes review of the written consultation documented in the chart. The fellow’s teaching and learning skills are reviewed on rounds and constructive suggestions are made. The attending cardiologist reviews cardiac invasive and non-invasive tests on cardiac consult patients with the fellow on attending rounds.

Learning Objectives:

  1. Obtain training in the concepts and practice of effective inpatient 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)
    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. Obtain training in organizing a consultative service, including effective prioritization based on acuity of patients’ clinical problems. (A)
  3. Gain exposure to a broad range of cardiac conditions through individual patient consultations, supplemental reading, and formal didactic presentations on rounds. (A, B)
  4. Gain training in guideline-based preoperative cardiac risk assessment and effective preoperative risk reduction. (A, B, C)
  5. Learn to assist physicians on other services in the management of cardiac emergencies. (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:

On this rotation, fellows will perform inpatient cardiology consultations. Most inpatients at the VAMC are adult males of a variety of ages and ethnicity. A variety of cardiac disorders will be encountered, including coronary artery disease, heart failure, arrhythmias, and valvular heart disease, preoperative and peri-operative consultation.

Teaching Methods:

Teaching by the attending cardiologist occurs daily on attending rounds and is supplemented as needed for urgent consultations. The attending physician reviews the detailed consult presentations prepared by the fellow. 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 noninvasive and invasive studies with the fellow, including ECGs. The attending cardiologist provides bedside teaching of clinical history and cardiac examination skills.

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 electronic fellow evaluation form will be completed by the attending cardiologist at the end of the rotation.
  4. The attending cardiologist’s 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 the individual consult patient.
    3. Evidence of a thorough and accurate patient history and physical examination for each consult.
    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 arrival 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 electrocardiograms.
    8. Evidence of effective written and oral communication with referring physicians.
    9. Evidence of effective patient follow-up following initial consultation.
    10. Feedback from other consult team members and referring physicians.
     

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)
  • www.cardiosource.com
  • Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor

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