SCHOOL OF MEDICINE • DEPARTMENT OF MEDICINE

Introduction/Overview

Fellows alternately rotate each week between the clinics at the VAMC and the University Hospital throughout their 3 year period. This enhances the diversity of exposure to patients, mentors, and systems and enriches the learning experience.

The outpatient clinics provide a unique opportunity for understanding longitudinal health care issues relevant to the individual patient as well as larger system issues. The clinics are well suited for fellows to participate and understand prevention, risk factor management, and early detection of disease; management ranging from the simple to the complex, chronic health maintenance; and support for those with advanced disease. This is feasible due to fellow’s participation in the continuity care clinics where they are expected to follow their patients throughout their training period.

The rotation in the clinics is meant to enable fellows to achieve the knowledge, skills and attitudes of competent cardiologists in the care of patients with chronic cardiovascular illnesses, preventive aspects of cardiovascular conditions, management of risk factors for cardiovascular diseases and outpatient consultative cardiology. Fellows are expected to gain proficiency in the diagnosis and management of cardiac conditions and the triage of patients to appropriate patterns of care – e.g. inpatient vs. outpatient. Learning occurs through hands-on, supervised clinical experiences, bedside teaching, and focused discussions with faculty. Attending physicians are expected to reinforce the understanding of the etiology, pathogenesis, clinical presentation and natural history of cardiovascular diseases relevant to the patient in the clinic. Trainees are expected to develop their skills in, interviewing, communication and interpersonal skills, cultural sensitivity, clinical problem solving, diagnosis, therapy and in navigating system issues impacting outpatient care. The rotation should enhance the fellows understanding of the pathogenesis and management of cardiac conditions and risk factors.

The fellow will play an integral role in the management of these patients and the coordination of care among other specialists as needed. All fellows are expected to contribute to clinics by reading and applying the appropriate literature; responsibilities are based in part on their seniority. Senior fellows are expected to demonstrate increased clinical independence and the more junior fellows will require more supervision with the attending seeing each of their patients. The number of patients will vary according to PGY level, but will not exceed eight.

Fellows are expected to be intimately involved in patient care and be familiar with the results of diagnostic and therapeutic procedures; the fellows are expected to review the actual source data rather than relying on reports of diagnostic/therapeutic imaging studies.

Appropriate utilization of the health system resources is particularly important. The fellows are expected to be cognizant of the impact of available resources on clinical decision making. The fellow is expected, when feasible, to review the charts of scheduled patients prior to the clinic in order to facilitate timely management of patients in the clinic. Preparation in this manner will reduce the likelihood of missing relevant information during their outpatient clinic. The fellows are expected to fully participate in decisions regarding additional testing, care, drug therapy, addressing lifestyle changes, providing access to educational resources as well as means for following up on decisions made.

Fellows are expected to communicate effectively with house staff, nursing staff, referring physicians, other cardiologists, and other members of the health care team.

Thus, fellows are expected to progress in the six ACGME Competencies. The clinics are particularly well-suited for practice based learning and improvement and understanding on a longitudinal basis. In conjunction with attending staff, fellows are expected to chose one relevant focused area of Clinic 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 fellows via direct patient care.

Case-Based Learning
Attending physicians are expected to do focused teaching during fellow’s presentation in addition to discussing routine patient management; teaching time should average 3 to 4 hours per week. The fellow is expected to demonstrate their decision making commensurate with his/her experience and knowledge. The expectation is that fellow’s clinical independence and learning will progress during the training period.

Clinical Content

Patient Characteristics
The mix of patients is typical for a clinic in a tertiary hospital and includes patients with coronary artery disease, valvular heart disease, hypertensive vascular disease, dyslipidemia, chronic systolic and diastolic heart failure, peripheral vascular diseases, pulmonary hypertension, arrhythmias, consultative evaluations for peri-op management, pre and post chemotherapy, peripartum management and adult congenital heart diseases.
Fellows will have the opportunity to interact with subspecialty attendings with expertise in electrophysiology, heart failure and interventional cardiology in the outpatient clinics.

Principal Educational Material Used

Fellows have 24-hour access to the core library located in the hospital. 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 from standard textbooks and the current 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, and similar professional bodies.

Methods used in Evaluation and Performance

The attending physician is to give written and verbal feedback to the fellows. Fellows complete written evaluations of the attending, which are anonymous. A competency based evaluation matrix is to be completed on a quarterly basis by the attending using the www.myevaluations.com system. The evaluations are sent electronically to the fellow and are available online by the fellows for review.

Level of Supervision by Faculty
All residents are supervised by the attending of record according to the institutional policy on attending supervision that is included in our departmental policies.

Objectives by PGY Year

Fellows are responsible for all patients assigned to their clinic and assume full responsibility for the evaluation and management of all the patients seen in the clinic. With the assistance of the Attending, they are responsible for formulating a diagnostic and therapeutic plan on all patients seen. In order to ensure optimal patient care, fellows are provided with 24-hour access to their attending physician and consultants. They have Nurse Practitioners, Advanced Nurse Practitioners, Physician Assistants and other extenders to assist in providing optimal care and follow up of patients. Attendings and surgical specialties are always in hospital and available for emergent consultation. The attending physician is immediately available through paging. Attending physicians must document their involvement in the evaluation and management of patients.

The first year fellows are expected to discuss every patient they see in the clinic, with the supervising attending. As they progress, they are expected to master the subject content necessary to care for patients with cardiovascular diseases. Senior fellows will develop maturity and sophistication of clinical judgment. This is 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.In the clinic, they are expected to participate in guiding education and patient care with medical students.