Rotation: Cardiology Firm
Physician directors for the rotation:
Alan C. Braverman, MD., 362-1291, abraverm@im.wustl.edu
Gregory A. Ewald, MD., 454-7009, gewald@im.wustl.edu
Administrative secretary: Linda Gallo, 454-7009, lgallo@im.wustl.edu
Educational goal and description of the rotation: Cardiovascular
disease is the leading cause of death in the United States. Disorders of
the cardiovascular system also represent a large proportion of the
admitting diagnoses to the internal medicine inpatient service. Therefore,
understanding of the principles of diagnosis and management of the most
common cardiovascular diseases is an essential part of the training of the
general internist. The purpose and goals of the Inpatient Cardiology Firm
is to provide the internal medicine interns and residents the opportunity to
develop advanced skills in the clinical evaluation (including interviews
and physical examination) and differential diagnosis of patients with
cardiovascular disease, enhance their medical knowledge in
cardiovascular disease and apply this knowledge to the care of patients
in the inpatient setting. The critical evaluation of current medical
information and scientific evidence is paramount to the understanding
and appropriate use of diagnostic strategies and treatments in cardiology
and will be emphasized. Evidence-based medicine and review of the
current literature will be emphasized throughout the rotation.
The Inpatient Cardiology Firm is a four-week long rotation during which
internal medicine housestaff will care for inpatients with high risk and
general cardiology disorders. The Cardiology Firm is concentrated on
9100-9200 Nursing units in Barnes-Jewish Hospital South. Patients are
also housed on 8100 and 5200 as necessary. Each of 4 teams consist of
an Attending cardiologist, 1 medicine resident, 2 medicine interns and 1
or 2 third or fourth year students.
Logistics:
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When, where, and to whom to report on the first day:
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Orientation: 8:30 am. 9100 Conference Room. 1st Day of new
rotation. Includes review of the rotation and refresher course on
how to use the defibrillator (AED) and Zoll pacemaker.
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Rounds and conferences:
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The Cardiology Firm rotation is a 4-week rotation. Interns and
Residents must be ready for floor duties at 7:30 a.m. on weekdays.
The call schedule is on a cycle of: long—off--short—off. House
officer hours may not exceed the ACGME duty limits.
Each of 4 teams on the Cardiology Firm consists of one resident
and two interns. One or 2 medical students also participate on the
rotation. Each team is supervised by an Attending cardiologist.
Interns and residents continue to attend mandatory Internal
Medicine Grand Rounds and continue to see patients in their
Internal Medicine Continuity Clinic. During this Clinic, they are
excused from cardiology patient care duties.
Interns and residents are expected to use the time during this
rotation for resident H & P, review of clinical data including EKGs,
labs, radiology, echocardiography, catheterization data,
reading/research, documentation, and supervision of the medical
students as well as discussion/rounding with the attending
physician.
Residents may experience educational interactions with the
supervising attending physician beyond the functional time
required for usual patient care. The teaching interaction will be
integrated into the daily work schedule and will total a minimum of
4.5 hours weekly.
A sample schedule for the rotation follows
Monday
Tuesday
Wednesday
Thursday
House Staff
House Staff
Cardiology
Patient
Management
Conference
House Staff
Work Rounds
Work Rounds
7:00
7:30 House Staff
8:00
8:30
9:00
Work
Rounds
Attending
Rounds
Work Rounds
Attending
Rounds
Weiss
Rounds
10:00 Resident's
Report
10:30 10-11am
9:30
EKG Review
(Fellow/Interns/
Students)
Cardiology
12:00 Cardiology
Attending
Rounds
Resident's Report
Medicine
Grand
Rounds
Attending
Rounds
House Staff
Work Rounds
10-11am
Chief
Resident's
Rounds
Core
Cardiology
Imaging
Conference
Core
11:00
11:30
Friday
CT
Surgery/Card
Conference
(1st
Friday)
Cardiology
Resident
Report
CPC
12:30 Core Conf
Diagnosis/
Treatment
Curriculum
Curriculum
(Echo
Conference)
Physical DX
(Students)
Firm Admin
Mtg
13:00
13:30
14:00
14:30
15:00
Professor's
Rounds
(Students)
15:30
16:00
16:30
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ACES
Core
Curriculum
(Students)
Hours,Call:
See monthly team assignment sheet and call schedule
Call is on a 4 day cycle: Long—Off—Short—Off schedule.
On call interns/residents must leave by 9:30 pm and may not
return before 7:30 am post-call
On call interns/residents must leave by 9:30 pm and may not
return before 7:30 am post-call
Educational purpose (curriculum): All of the Competency Milestones
are pertinent to this rotation. Areas of special focus are noted below.
Interns should be able to be able to develop a basic level of
competence in the skills listed. JARs should be able to perform the
skills with less supervision, at a higher level (eg, elicit subtle physical
findings), in multiple patients and in more complex patients. SARs
should be almost independent in these skills, and able to deal with
unexpected events and ambiguous situations.
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Patient care
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By the conclusion of the rotation, PGY1 residents will
demonstrate ability to perform an appropriate cardiac history
and physical, documenting their findings in an appropriate
summary, with appropriate generation of a differential
diagnosis list.
By the conclusion of the rotation, PGY2 and 3 residents will
perform the above skills, and will also evidence appropriate
ability to independently generate an appropriate management
plan.
While on the cardiology rotation, the resident will be able to
demonstrate proficiency in the physical exam features of
common types of valvular heart disease and congestive heart
failure and to recognize symptoms of coronary artery disease.
During the cardiology rotation, the resident will enhance his or
her skills in obtaining and presenting a hypothesis driven
history and problem-based assessment and plan of common
cardiovascular disease presentations including acute chest
pain syndromes, CHF exacerbations, syncope and
arrhythmias.
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Medical knowledge
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Demonstrate an appropriate analytic approach to cardiac
conditions, and a satisfactory basic and clinical knowledge of
cardiac function and pathophysiology.
Understand current evidence-based practices in primary and
secondary prevention of cardiovascular disease, especially
atherosclerotic coronary artery disease.
Understand the pathophysiology and prognosis of common
cardiovascular diseases and their medical and non-medical
management. These may include:
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Acute myocardial infarction and its complications
Congestive heart failure (systolic and diastolic)
Cardiomyopathies (ischemic, non-ischemic, dilated,
hypertrophic, infiltrative)
Infective endocarditis
Myocarditis
Pericardial disease
Valvular heart disease
Arrhythmias (SVT, atrial fibrillation, atrial flutter, ventricular
tachycardia, bradyarrhythmias, sick sinus syndrome,
conduction abnormalities)
Pacemakers and Implantable defibrillators and their
complications
Hypertension/hypertensive crisis
Syncope
Hyperlipidemia
Pulmonary hypertension and cor pulmonale
Pulmonary embolism
Congenital heart diseases
Aortic diseases (aortic aneurysm, aortic dissection)
Practice-based learning and improvement
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Acute and chronic coronary artery disease
All interns and residents should understand their limitations of
knowledge and judgment; ask for help when needed; and be
self motivated to acquire knowledge
Accept feedback, learn from own errors and develop selfimprovement plans
Residents will demonstrate self-initiative in the use of
information technology to access and retrieve materials for
self-education regarding cardiac cases.
Residents will be expected to show progressive learning
throughout the rotation, with emphasis on learning from any
cognitive or procedural errors.
They are also expected to facilitate any quality improvement
initiatives in place.
Interpersonal and communication skills
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Demonstrate caring and respectful behaviors with patients,
families, including those who are angry and frustrated; and all
members of the health care team
Counsel and educate patients and their families
Conduct supportive and respectful discussions of code status
and advance directives
Facilitate the learning of students and other health care
professionals
Demonstrate ability to convey clinical information accurately
and concisely in oral presentations and in chart notes
Residents are expected to demonstrate professional
communication skills throughout their interactions with
cardiology patients. In addition, residents will be assessed for
appropriate communication with the WUSM Cardiology
attending, including setting clear expectations for duty hours
and inpatient duties. Residents are expected to act as a
constructive and proactive member of the Cardiology Firm
team
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Professionalism
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Demonstrate respect, compassion, and integrity
Demonstrate a commitment to excellence and on-going
professional development
Demonstrate a commitment to ethical principles pertaining to
provision or withholding of clinical care, confidentiality of
patient information, informed consent, and other aspects of
clinical care
Develop an appreciation for the ethical, cultural and
socioeconomic dimensions of illness, demonstrating sensitivity
and responsiveness to patients’ culture, age, gender, and
disabilities
Residents should display initiative and leadership; be able to
delegate responsibility appropriately
Throughout the Cardiology Firm rotation, residents are
expected to exhibit reliability in their clinical duties, as well as
integrity and respect in their interactio
Systems-based practice
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Work effectively with others (such as nurses, secretaries,
social workers, nutritionist, interpreters, physical and
occupational therapists, technicians) as a member of a health
care team
Advocate for quality patient care and assist patients in dealing
with system complexities
Understand and appreciate the importance or contacting the
patient’s primary care provider at the time of admission of
soon thereafter
Residents should develop proficiency in leading the health
care team, organizing and managing medical care
Learn the cost-effective use of diagnostic and therapeutic
technology
Teaching Methods:
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Progressive, graduated responsibility for performance of the
admission history and physical examination, formulation of
diagnostic and therapeutic plans, writing of orders, continued
inpatient care, and performance of bedside procedures, all under
the supervision of attending physicians
Inpatient: Residents will participate in the evaluation and
management of cardiology patients at BJH cared for by
physician of the BJH and WUSM faculty and Cardiovascular
Division, Department of Medicine.
Outpatient: Interns and Residents and medical students may
arrange to spend time in the outpatient cardiology clinics of any
of the attending cardiologists in the Center for Advanced
Medicine, 8th floor, Heart and Vascular Section. This should be
arranged with the attending physician and resident physician.
Teaching rounds are held up to 6 times/week at the discretion of
the attending physician. These consist of presentations by the
medical students, interns and residents to the attending
physician as well as physical diagnosis rounds at the bedside
and didactic presentations by the house officers and attending
physician. Review of echocardiograms, chest x-rays, CT scans,
cardiac catheterization films and stress tests are emphasized in
these sessions.
Electrocardiograms are to be read daily on rounds with the
attending physician. Interns and Residents are expected to
review a series of electrocardiograms and demonstrate
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proficiency and competency in ECG interpretation appropriate
for the level of training.
Required Presentations: Interns and Residents present cases at
teaching rounds and are expected to research and Residents
are to present at a weekly Resident’s report held each Friday.
Didactic Lectures: Interns and Residents are expected to attend
the following didactic lectures during the Inpatient Cardiology
Firm
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Cardiology Core Curriculum Conference. Mondays at 12 noon.
4300 Conference Room.
Cardiology Diagnosis/Treatment Conference. Tuesdays at 12
noon. 4300 Conference Room (includes echo mini-course
July-Sept).
Cardiology Grand Rounds. Every other Wednesday, 7:30 am,
East Pavilion Auditorium. September-June Schedule.
Combined Cardiology/CT surgery Conference. 1st Friday of
the month. 7:00 am. 17th floor Queeny Tower Board Room
The mix of diseases, patient characteristics, and types of
clinical encounters, procedures, and servicesPatients come
from the admissions through the emergency room; from transfers
from outside hospitals and from direct admissions from the CAM
clinic and referring cardiologists’ offices. Patients encountered
reflect the diverse nature of pathology present in the local urban
area as well as that of St. Louis County and the greater
metropolitan area. Patients also reflect the disease states present
in rural Missouri and Illinois. There is equal exposure to men and
women of diverse ethnic and socioeconomic backgrounds.
Reading lists, pathological material, and other educational
resources to be used:
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Braunwald’s Heart Disease: A Textbook of Cardiovascular
Medicine
Cardiology Firm Reading Curriculum: A series of journal articles
and reviews on current topics in cardiovascular medicine
Online access to standard cardiovascular texts, journals, Up-toDate and medical literature through the Becker Library and
internet access.
Interns and residents are encouraged to read extensively during
their cardiology rotation.Click here for reading list.
EKG interpretation:
 Interns and residents on the Cardiology Firm are expected to
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become proficient in recognition and interpretation of common
EKG patterns.
Web-based EKG sessions to be utilized for learning.
Method of evaluation of resident performance:
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Resident Performance – Residents are oriented to the rotation
expectations at the beginning of the rotation and then receive a
formative midpoint feedback evaluation, followed by a formal
summative written evaluation at the conclusion of the rotation. The
designated clinical faculty (Cardiology attending) completes a
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web-based electronic resident evaluation form provided by the
Internal Medicine Residency office. The attending physician who
evaluates the resident will elicit feedback from the team members,
students, and other professionals regarding the resident’s
competency performance. The evaluation is competency-based,
fully assessing core competency performance. The evaluation is
shared with the resident, is available for on-line review by the
resident and is sent to the residency office for internal review. The
evaluation is part of the resident file and is incorporated into
routine performance review for directed feedback.
Program and Faculty Performance – Upon completion of the
rotation, residents complete a service evaluation form commenting
on the faculty and service experience. These evaluations are sent
to the residency office for review and the cardiology firm Director
and Co-Director receive periodic copies of completed evaluation
forms.
Resident supervision:
Level of residents' supervision by faculty members in patient care
activities:
Residents will participate in the evaluation and management of
cardiology patients at BJH cared for by physician of the BJH and WUSM
faculty and Cardiovascular Division, Department of Medicine. Each
patient evaluated by the internal medicine resident will be seen with the
cardiology attending during daily rounds. The management plan will be
formulated by the intern and resident and discussed with the attending
physician and the medical students.
Updated: : 1/8/07