Internal Medicine Residency

Program Director/Division Chief: Alan Yeung, MD, Ronald Witteles, MD, John Schroeder, MD
Duration: 1 Month Block Rotation PGYI and PGYII

The rotation is a month long block of time with one PGYII as the lead together with 2 to 3 PGYI. The team admits and manages all inpatients cardiology patients with close coordination with the CCU/heart failure service.

Goals

General cardiology rotation remains part of the “bread and butter” core of internal medicine inpatient rotations. Together with the CCU/heart failure (PGY II) and the cardiology consult service (VA and Stanford), these rotations form the foundation of the cardiology knowledge base of the internal medicine trainees. Advances in diagnostic imaging, rapid bedside testing and evidence based clinical trials have allowed us to deliver coordinated complex care to our patients with ample opportunities for teaching and learning for the internal medicine residents.

The development of the skills and knowledge required for the practice of cardiac vascular medicine is an essential part of the educational process of internal medicine training. Cardiovascular diseases affect millions of Americans and now we have tools and drugs to treat and/or prevent this problem. It is an essential large component of a daily internal medicine practice.

Objectives

System-based Practice

Patient Care

Objective 1: Demonstrate clinical skills of medical history and physical examination, with specific attention acute and chronic cardiovascular diseases.

Objective 2: Demonstrate clinical skill in the diagnosis and management of acute coronary syndrome/chest pain.

Objective 3: Demonstrate clinical skill in medical management of patients admitted with congestive heart failure. Interpreting an echocardiogram and evaluating imaging studies such as chest x-rays and diagnostic reports of echocardiograms, coronary arteriograms and nuclear studies.

Objective 4: Evaluate the cost-effective care of above patient subsets.

Professionalism

Medical Knowledge

Objective 1: Describe the current understanding of the atherosclerotic vascular process.

Objective 2: Describe the general basis and performance of cardiac catherization, coronary arteriography, angioplasty, coronary stenting.

Objective 3: Describe the general diagnostic evaluation and workup of the following patients:

ACS
Hypertension
Angina
Atrial fibrillation
Ventricular arrhythmias
Congestive Heart Failure
Aortic dissection

Interpersonal and Communication Skills

Practice-based Learning and Improvement

Objective 1: As with other clinical rotations, residents will have the opportunity to apply medical literature, research and statistical methods, and data management technology for self-evaluation and improvement on this rotation. Clinical questions will be formulated and researched through clinical databases pertinent to patient care as they arise.

Objective 2: Cases may be selected for in depth research and discussion and presentation at the New Patient conferences or cardiomyopathy conference.

Practice-based Learning and Improvement

Interpersonal and Communication Skills

Objective 1: The resident will develop and demonstrate competence in effective and efficient communication with patients and their families.

Objective 2: The resident will develop and demonstrate competence in effective and efficient communication with physician colleagues on Cardiology service, physicians from other services, nursing and support staff. Since the Cardiology involves interactions with multiple ancillary services including social work, dietary, physical therapy, blood bank, nurse coordinators as well as Nurse Practitioners/Physician Assistants, communication is essential for the successful treatment of these patients.

Medical Knowledge

Professionalism

Objective 1: Demonstrate respect and compassionate use of medical skills for cardiac patients. This includes the treatment of patients and families dealing with life-threatening illnesses.

Objective 2: Demonstrate respect and compassionate use of medical skills severely-ill patients.

Objective 3: Residents will have the opportunity to develop and demonstrate an increasing commitment to carrying out professional responsibilities and adherence to ethical principles. An effective therapeutic relationship with patients and families will be demonstrated through listening, narrative and nonverbal skills; education and counseling of patients and families.

Patient Care

System-based Practice

Objective 1: Recognize the high cost of cardiovascular disease not only to the patient and family but to society.

Objective 2: Actively participate in the multidisciplinary approach to caring for Cardiology patients including appropriate recognition of other health professional and paraprofessional’s roles and demonstrate competence in team interactions, including nutritionist, pharmacist, physician’s assistant, nurse practitioner, physical therapist, social worker, nurse coordinator.

Methods

Inpatient

PGY I residents receive Cardiology training primarily in the inpatient setting on the Cardiology ECG monitored wards including D-1, D-2, B-2, B-3. The residents are part of a physician team including the Attending physician, a total of two PGYI residents, 1-2 medical students. They are assisted not only by nursing staff, but patient care managers in order to facilitate scheduling of tests, obtaining outside records and developing appropriate discharge planning.

Curriculum

The educational content is provided in the following ways:

Individual responsibility for assigned patients and their 24 hour progress for review with the attending of daily AM rounds, usually 8 or 9 am.
Teaching sessions on the Inpatient Unit before and during inpatient rounds by the Attending physician and ancillary staff.
New Patient presentations daily at 9:00 am to the attending
Medical Grand Rounds on Wednesdays at 8:00 am,
Reading Materials (see References below)
Review of all imaging studies related to the patient. This may include participation of radiologist, echocardiographers and interventional cardiologists.
Student and/or resident presentations on clinical a issues (e.g. Pericarditis or anticoagulants, etc.)
Bedside rounds of every patient on a daily basis with the attendings and general cardiology team.

Evaluation

ACGME Competencies

According to Accreditation Council of Graduate Medical Education (ACGME), training and evaluation must include the following competencies: Patient Care, Medical Knowledge, Practice – Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice.

Patient Care will be evaluated by global assessment of the attending physician and additional information from nursing staff. Procedures performed will be documented.
Medical Knowledge will be evaluated by global assessment of the attending physicians, and peer-reviewed chart audit.
Practice-Based Learning and Improvement will be evaluated by peer-reviewed chart audit.
Interpersonal and Communication Skills will be evaluated by global assessment of the attending physicians and additional information from nursing staff, other ancillary staff, patients and families.
Professionalism will be evaluated by global assessment of the attending physicians and additional information from nursing staff, other ancillary staff, patients and families
System-Based Practice will be evaluated by global assessment of attending physicians, and peer-reviewed chart audit.

Evaluations are reviewed with the residents for formal feedback. Face to face interaction between the attending physician and the resident is the required method. At the midway point of the rotation, the resident is encouraged to approach the attending to assess and discuss performance. In addition, ongoing feedback is provided related to residents’ patient care responsibilities and activities.

In addition, residents provide feedback to the Attending Physicians and Program Director regarding the rotation to add input on deficiencies in the experience.