SCHOOL OF MEDICINE • DEPARTMENT OF MEDICINE

Introduction/Overview

The rotation in the CICU is meant to enable fellows to achieve the knowledge, skills and attitudes of competent cardiologists in the care of patients with acute coronary syndromes and other complicated cardiovascular conditions. Fellows are expected to gain proficiency in the diagnosis and management of critical cardiac conditions. Learning occurs through hands on, supervised clinical experiences, bedside teaching, attending rounds, and divisional and departmental conferences. Attending physicians are expected to reinforce the understanding of the etiology, pathogenesis, clinical presentation and natural history of cardiovascular diseases treated by internists and cardiologists. Trainees are expected to develop their skills in clinical problem solving, diagnosis, therapy, interviewing, communication and interpersonal skills, and in navigating system issues impacting inpatient care. The rotation should enhance fellows understanding of the pathogenesis and management of acute cardiac conditions.

The fellow will play an integral role in the education of the house staff. The fellow is expected to contribute to rounds both by bringing in the appropriate literature for the house staff as well as providing his/her prospective on clinical management. Senior fellows are expected to demonstrate increased clinical leadership and are provided with autonomy commensurate with their training level. The fellow is expected to be intimately involved in patient care and be familiar with the results of diagnostic and therapeutic procedures, and review the actual tests as appropriate.

Appropriate utilization of the health system resources is particularly important in the CICU. The fellow is expected, when feasible, to come in early, prior to daily walk rounds, to evaluate new admissions and acutely unstable patients, in order to fully participate in decisions regarding additional testing, care, and triage. Fellows are expected to communicate effectively with house staff, nursing staff, referring physicians, other cardiologists, and other members of the health care team.

All fellows are expected to progress in the six ACGME Competencies. The CICU is particularly well suited for practice based learning and improvement and understanding a systems-based perspective. Senior fellows, in conjunction with attending staff, are expected to chose one relevant focused area of CICU function and endeavor to evaluate and/or improve the overall quality in that area.

 

Principle Teaching Methods

Direct Supervision of Patient Care
The attending physician provides supervision to all members of the team via direct patient care; the team includes PGY2 and 3 residents and a cardiovascular medicine fellow. The CICU fellow provides additional supervision to the resident team.

Case-Based Learning
Daily attending walk rounds: Attending physicians are expected to teach during team rounds in addition to discussing routine patient management; teaching time should average 4.5 hours per week. The fellow is expected to take a leadership and teaching role on rounds commensurate with his/her experience and knowledge. The expectation is that fellow leadership and teaching will progress during the training period.

 

Clinical Content

Patient Characteristics
The mix of patients is typical for a CICU in a tertiary/quaternary hospital and includes patients with myocardial infarction, unstable angina, ADHF, cardiogenic shock, severe valvular disease, aortic dissection, hypertensive emergencies and acute pericardial conditions.

Procedures
Fellows have the opportunity to learn procedures under the direct supervision of attendings and qualified fellows (fellows who have documented satisfactory competency in these procedure), including central venous lines, arterial lines, balloon pumps, transvenous pacemakers and swan-ganz catheters.

 

Principle Educational Material Used

Fellows have access to the libraries located in both hospitals. Computer access to literature searching, on line journals, Up-to-Date, and textbooks is available on all wards. Fellows are expected to be proficient in obtaining requisite information on pathophysiology from standard textbooks and the medical literature. Current therapeutics should be guided by the medical literature with particular weight given to clinical guidelines and consensus statements issued by the American College of Cardiology, the American Heart Association, the Heart Failure Society of America, the Society for Coronary Angiography and Intervention, the Heart Rhythm Society and similar professional bodies.

 

Methods used in Evaluation and Performance

A competency-based evaluation matrix for written evaluations is to be completed at the end of the CICU rotation by the attending using the www.myevaluations.com system. Attendings evaluations are sent electronically to the fellow upon completion and are available for review by the fellows on-line and at the time of their semi-annual evaluation/counseling meetings. In addition to a written evaluation, the attending physician is to give verbal feedback. Fellows complete written evaluations of the attending, which are anonymous. Fellows complete a written rotation evaluation with specific attention to the learning objectives. 360 degree feedback is accomplished via written feedback from social work and nursing personnel. Duty hour compliance is monitored by the Program Director.

 

Objectives by PGY Year

The first year fellows are expected to discuss the differential diagnosis and management plan in detail on every patient they see in the unit with the supervising attending. As they progress, they are expected to master the subject content necessary to care for patients with cardiovascular diseases. In addition, senior fellows will develop maturity and sophistication of clinical judgment; this demonstrated by their ability to understand the nuances of an individual patient’s health, particularly when multiple active disease processes are present. Senior fellows are expected to demonstrate their experience by tailoring generally recommended therapy to individual patients. They are expected to be aware of cutting edge and experimental therapies that may be utilized for an individual patient. In addition, they are expected to take a prominent role in being advocates for their patients with complex issues when collaborating care across multiple disciplines.

Residents take call every 4th night and are responsible for all patients assigned to their service and when on call assume full responsibility for the evaluation and management of all the patients seen on this service. With the assistance of the Attending and fellow, they are responsible for formulating a diagnostic and therapeutic plan on all patients admitted. In order to ensure optimal patient care, residents are provided with 24-hour access to their supervising fellow, attending physician, and consultants. Senior residents, and surgical specialties are always in hospital and available for emergent consultation. The attending physician is immediately available through paging, and speaks regularly with the senior resident during on-call periods. Fellows and attending physicians are available, usually within 30 minutes, for assistance with patient evaluation and for performance of procedures. Attending physicians must document their involvement in the evaluation and management of patients daily.