UIHC Cardiology Consults

Purpose:

This rotation provides broad exposure to a wide variety of clinical disorders in cardiology. The purpose of this rotation is to expose the fellow to cardiology problems encountered in a tertiary care hospital, which includes complex cardiology problems on the medical services, as well as exposure to the cardiology problems which may arise in surgical, gynecologic, psychiatric, neurologic patients and cardiac illnesses in pregnancy as well as patients presenting to the emergency room. The fellow is expected to develop expertise in preoperative evaluation and perioperative cardiac management. Consultative services are provided for all clinical services at UIHC with the exception of pediatrics. The fellow has primary responsibility for all patients referred to the service, under the supervision of the faculty. When a medical resident or residents are assigned to this service, the resident assists the fellow and will be primarily responsible for a subgroup of patients on the service. The fellow will supervise the medical resident in this capacity and report directly to the attending. The attending will make rounds daily with all members of the consult team (fellow, medical residents, and students). Thus, during this rotation, the cardiology fellow is expected to acquire skills related to the clinical management of complex cardiology problems, as well as develop supervisory and teaching skills in the context of working with medical residents or students. It is further expected that the fellow’s skills will progress over time and during subsequent rotations on this service.

Responsibilities/Specific Duties:

The fellow is expected to be involved with all patients on the UIHC Inpatient Consult Service and chest pain center patients admitted by the ER physicians. The fellow will see consults with the residents and medical students on the team and discuss patients with the consult attending physician. For non-urgent consultations, the fellow assigns the initial consult workup to a resident or student on the UIHC Consult Service. Relative to the resident, the fellow then reviews the initial consultation workup with the resident, takes a focused history and physical examination, reviews all diagnostic tests, laboratory data, and progress notes, and assists, if needed, in the presentation of the consult patient to the attending cardiologist on daily rounds. For the student, the complete history and physical examination are completed either by the fellow or by the resident with review as above by the fellow. The fellow performs the evaluation of patients for whom the consult is urgent. This includes a history and physical examination, review of diagnostic test results, laboratory data, and progress notes. The fellow formulates a differential diagnosis and treatment plan. The fellow presents the urgent consultation to the attending cardiologist as soon as possible, or if appropriate, on daily consultation rounds. The fellow assists with teaching for residents and students on the UIHC Consult Service. This typically consists of providing information related to individual consult patients and participation in teaching on daily attending rounds. In addition, the fellow participates in the presentation of didactic core cardiology topics that are required for the residents and students on the UIHC Consult Service. In general, the fellow will alternate with the resident in terms of initial evaluation of all consults. When the resident is unavailable (e.g. in clinic), the fellow will evaluate all consults patients. In general, all consults will be seen and staffed on the same day the consult is called. The fellow is expected to evaluate all on the patients seen by the consult team. UIHC consult fellow and staff physician provide consultation for Emergency Room chest pain unit. These patients are staffed with the UIHC consult staff. Usually, patients admitted to the CP unit need not be examined the same night if you are called after 10pm unless the ER physicians specifically request a consultation. These patients are to be seen early the next morning. Weekend CP patients treadmill coverage is provided by CHAMPS (cardiac rehabilitation service). The Consult Fellow must communicate with the F1 fellow on call the previous night to determine if there are any pending consults or patients requiring immediate follow-up. Similarly, the Consult Fellow must call the F1 fellow taking call after 5pm and review any critically ill patients that may require follow up consultation over night. Weekend cardiology consult coverage is provided by the on-call cardiology fellow. The staff physician coverage for the UIHC consult service on the weekend is provided by the cardiology staff on the attending directed service.

Supervision:

  1. All cardiac consultations are reviewed in detail with the attending cardiologist with attention to patient and diagnosis based teaching of the fellow.
  2. In addition to clinical review, the attending cardiologist reviews the progress of the fellow in providing appropriate communication and collaboration with the requesting service.
  3. The attending cardiologist provides teaching of electrocardiographic interpretation.
  4. The fellow’s teaching and learning skills are reviewed on rounds and constructive suggestions are made.
  5. The attending cardiologist reviews cardiac invasive and non-invasive tests on cardiac consult patients with the fellow and other team members on attending rounds.

Learning Objectives:

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

Training occurs at the University Hospital. The patient population includes men and women of all adult ages and of varied ethnic and socioeconomic background. The population includes patients from a primary care base and tertiary referral patients and emergency room patients. Special populations include patients with transplanted organs, acute and chronic neurologic disease, surgical patients, and patients in intensive care units. Clinical encounters consist of inpatient cardiac consultations. Consultations often are for diagnosis and management of chest pain, unexplained dyspnea, dysrhythmias or syncope, and for preoperative cardiac risk evaluation or perioperative cardiac management. Initial consultation and inpatient follow-up are included.

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, as well as the presentations by residents or students that have been directed 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. The attending physician reviews electrocardiograms interpreted by the fellow and provides appropriate feedback for the accurate interpretation of ECG. The attending cardiologist provides bedside teaching of clinical history and cardiac examination skills. In addition to didactic teaching on rounds, the attending cardiologist may assign didactic talks and literature review to the house staff and students to assure that a broad range of cardiac topics are reviewed during the course of the rotation.

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 teaching of residents and students.
    10. Evidence of effective patient follow-up following initial consultation.
    11. 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)
  • Chou’s Electrocardiography in Clinical Practice (6th edition) Surawicz B and Knilans T
  • Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
  • ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation - Executive Summary (Circulation. 2006; 114:700-752.)
  • ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy; JACC Vol. 47, 2006
  • Perioperative Practice: Time to Throttle Back; Annals of Internal Medicine 152:47-51, January 5, 2010.
  • www.cardiosource.com

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