CHF

1. Overview

Trainees are involved intensively in the daily management of all patients on the Heart Failure (HF) service. They become familiar with patients with heart failure, both systolic and diastolic. Patients are very diverse ethnically and socioeconomically, representing the communities neighboring Montefiore Medical Center. The HF elective consists of one block of four weeks with 24/7 coverage by the cardiology fellows. Internal medicine residents rotate on the service 5 days per week without weekend or call responsibilities for the HF service. The HF elective is available to all Internal Medicine residents. Residents work under the supervision of the HF fellow and attending. The attending physician is responsible for supervision of all patient care.

2. Goals and Objectives

I. Goals: The HF elective is designed to provide the house officer with the knowledge and skills required to diagnose and treat HF

II. Level-based rotation objectives – at the end of the rotation, residents are able to:

a. PGY 1:

i. Patient Care:

1. Recognize the daily patient workload

2. Differentiate the acuity level of illness

3. Practice patient-focused care

PGY 1 level trainees are expected to provide patient care that is compassionate, appropriate, and effective for the promotion of health, prevention of illness, treatment of disease, and care at the end of life.

PGY 1 level trainees gather accurate, essential information from all sources, including medical interview, physical examination, medical records, and diagnostic procedures. They make informed recommendations about preventative, diagnostic, and therapeutic options. Any interventions are based on clinical judgment, scientific evidence, and patient preferences. They interact appropriately with patients, patient families, and consultants to determine the most appropriate course of action tailored to the individual patient, and then implement that plan.

PGY 1 level trainees are expected to formulate and initial assessment incorporating the patient’s history, physical examination, and their understanding of the patient’s underlying pathophysiology

ii. Medical Knowledge:

1. Use literature and reference sources to increase knowledge base

2. Apply society guidelines for patient management

3. Acquire basic knowledge in the areas of underlying pathophysiology and the clinical aspects of HF

4. Demonstrate knowledge base obtained during daily rounds

PGY 1 level trainees are expected to acquire basic knowledge of the medical conditions managed on the HF service and to demonstrate good clinical judgment in the application of their knowledge base to the care of patients.

Diagnosis and management of the following conditions is considered an essential foundation for the management of patients on the HF service by a PGY 1 level trainee:

1. Chronic HF

2. Acute decompensated HF

3. Systolic versus diastolic HF

4. Ischemic versus non-ischemic HF

5. Cardiorenal syndrome.

Essential to the understanding of these disorders is a comprehension of the appropriate selection and timing of diagnostic procedures such as electrocardiography, x-ray radiography, echocardiography, non-invasive stress testing, invasive hemodynamic assessment, coronary angiography, endomyocardial biopsy, and other radiologic techniques such as computed tomography and magnetic resonance imaging.

iii. Professionalism:

1. Establish trust with HF patients and family

2. Participate in teamwork

3. Exhibit honesty, reliability, and responsibility in patient care

4. Demonstrate respect for patients and Staff

5. Attend conferences

iv. Interpersonal Skills:

1. Write understandable and legible notes

2. Listen to and communicate with patients and staff

3. Work effectively as a member of the health care team

v. Practice-Based Learning and Improvement:

1. Recognize limitations of knowledge

2. Use literature to improve practice patterns

3. Accept feedback and change behavior

4. Ask for help when needed

5. Use outcomes of current patients to improve outcomes in the future

vi. System-Based Practice:

1. Be an advocate for HF patients

2. Learn and apply necessary society guidelines

3. Describe the health care systems/structure and how it relates to patients requiring cardiac procedures

b. PGY 2:

i. Patient Care:

1. Prioritize daily work

2. Recognize the relative significance of a HF patient’s list of cardiac conditions

3. Recognize acuity levels of illness

4. List indications, contraindications, and risks of cardiac procedures

5. Work with all providers to provide patient-focused care

PGY 2 level trainees are expected to formulate an assessment and initial plan incorporating the patient’s history, physical examination, the trainee’s understanding of the underlying pathophysilogy

ii. Medical Knowledge:

1. Use literature and reference sources to increase knowledge base in HF

2. Demonstrate basic knowledge in the areas of underlying pathophysiology and the clinical aspects of HF

3. Apply knowledge base in the treatment of patients

In addition to the above, diagnosis and management of the following additional conditions are considered an essential foundation for the management of patients on the HF service for the PGY 2 trainee:

4. Acute decompensated heart failure requiring intravenous medications

5. All forms of cardiomyopathy, including dilated, ischemic, and restrictive

6. All forms of valvular disease or pericardial disease that can cause HF

Essential to the understanding of these disorders is a comprehension of the appropriate selection and timing of diagnostic procedures such as electrocardiography, x-ray radiography, echocardiography, non-invasive stress testing, invasive hemodynamic assessment, coronary angiography, endomyocardial biopsy, and other radiologic techniques such as computed tomography and magnetic resonance imaging.

iii. Professionalism:

1. Establish trust with HF patients and family

2. Participate in teamwork

3. Exhibit honesty, reliability, and responsibility in patient care

4. Demonstrate respect for patients and Staff

5. Attend conferences

iv. Interpersonal Skills:

1. Write understandable and legible progress notes and consultation reports

2. Listen to and communicate with patients and staff

3. Work effectively as a member of the health care team

v. Practice-Based Learning and Improvement:

1. Recognize limitations of knowledge

2. Use literature to improve practice patterns

3. Accept feedback and change behavior

4. Ask for help when needed

5. Recognize limits of responsibilities

6. Use outcomes of current patients to improve outcomes in the future

vi. System-Based Practice:

1. Be an advocate for HF patients

2. Learn and apply necessary society guidelines

3. Describe the health care systems/structure and how it relates to patients requiring cardiac procedures

c. PGY 3:

i. Patient Care:

1. Prioritize daily work

2. Supervise junior house officers

3. Recognize the relative significance of a HF patient’s list of cardiac conditions

4. Recognize acuity levels of illness

5. List indications, contraindications, and risks of cardiac procedures

6. Work with all providers to provide patient-focused care

7. Discuss risks and benefits of procedures with patient and specialists

PGY 3 level trainees are expected to formulate an assessment and initial plan incorporating the patient’s history, physical examination, the trainee’s understanding of the underlying pathophysiology

ii. Medical Knowledge:

1. Use literature and reference sources to increase knowledge base in HF

2. Demonstrate sophisticated knowledge in the areas of underlying pathophysiology and the clinical aspects of HF

3. Apply knowledge base in the treatment of patients

4. Share knowledge base with junior house officers

In addition to the above, diagnosis and management of the following additional conditions are considered an essential foundation for the management of patients on the HF service for the PGY 3 trainee:

1. Pulmonary hypertension

2. Arrhythmias

3. A basic understanding of common adult congenital heart disease diagnoses that can lead to HF

4. A basic understanding of the evaluation of an end-stage HF patient that requires potential heart transplantation or mechanical circulatory support (MCS)

5. A basic understanding of post-transplant or post-MCS complications

6. Timing of palliative care for end-of-life HF patient

Essential to the understanding of these disorders is a comprehension of the appropriate selection and timing of diagnostic procedures such as electrocardiography, x-ray radiography, echocardiography, non-invasive stress testing, invasive hemodynamic assessment, coronary angiography, endomyocardial biopsy, and other radiologic techniques such as computed tomography and magnetic resonance imaging.

iii. Professionalism:

1. Establish trust with HF patients and family

2. Participate in teamwork

3. Exhibit honesty, reliability, and responsibility in patient care

4. Demonstrate respect for patients, staff, and junior house officers on the team

5. Attend conferences

iv. Interpersonal Skills:

1. Write understandable and legible progress notes and consultation reports

2. Listen to and communicate with patients and staff

3. Work effectively as a member of the health care team

v. Practice-Based Learning and Improvement:

1. Recognize limitations of knowledge

2. Use literature to improve practice patterns

3. Accept feedback and change behavior

4. Ask for help when needed

5. Recognize limits of responsibilities

6. Use outcomes of current patients to improve outcomes in the future

vi. System-Based Practice:

1. Be an advocate for HF patients

2. Learn and apply necessary society guidelines

3. Describe the health care systems/structure and how it relates to patients requiring cardiac procedures

3. Areas covered during HF elective rotation

I. Principles, physiology and basic sciences: Systolic and diastolic heart failure, hemodynamics, valvular heart disease, neurohormonal influence and modulation, myocardial strain and wall stress

II. Practical skills unique to HF: Detailed HF cardiac history and physical exam, detailed reading and interpretation of ECG’s, review of echocardiograms, hemodynamic data, coronary angiograms, endomyocardial biopsies, cardiac CT, and cardiac MRI

III. Specific diagnoses in HF:

a. Chronic HF

b. Acute decompensated HF

c. Systolic versus diastolic HF

d. All forms of cardiomyopathy, including dilated, ischemic, and restrictive

e. All forms of pericardial disease and valvular heart disease that can lead to HF

f. Pulmonary hypertension

g. Arrhythmias

h. Common types of adult congenital heart disease that can lead to HF

i. Heart transplantation

j. Mechanical circulatory support

4. Technical skills

- Include arterial blood gas, pulmonary artery catheterization

5. Emergencies

- To be seen in conjunction with the cardiology fellow and may include acute myocardial infarction, acute pulmonary embolus, hypertensive urgency, and cardiogenic shock

6. Schedule of activities

I. Morning or afternoon rounds with HF attending, daily

II. Division Grand Rounds, weekly

III. Cardiology lectures, daily

IV. Medical Grand Rounds, weekly

7. Methods of teaching competency assessment

The trainees are evaluated continuously during their four weeks of service on the HF rotation. There is continuous feedback to the trainees. The final evaluation is completed through New Innovations and the results are discussed in a meeting with the trainee. The trainees are evaluated in terms of their overall clinical competence with the following categories: clinical judgment, medical knowledge, clinical skills, humanistic qualities, professionalism, medical care, and continuing scholarship

8. References

References are distributed at the start of the rotation in electronic format on CD