UC San Diego Hillcrest Cardiovascular Medicine
The Hillcrest cardiology service includes cardiology and vascular medicine inpatients on:
- The Cardiac Care Unit (CCU)
- The 10E telemetry unit
- Occasional patients on other units.
In addition, this team will be responsible for all in-house cardiology consults from other services.
The CCU is located on 10 West. It is a combined unit with the Medical Intensive Care Unit (MICU), and together is termed the 10th floor Critical Care Unit. The Cardiology team takes care of all patients on the Cardiology services that are in the CCU and on the telemetry floors.
Educational purpose and learning objectives
The educational purpose of this rotation is to give the fellow the experience and varied responsibilities of a practicing clinical cardiologist. Specific learning objectives include gaining expertise in the following areas:
- Consultative inpatient cardiology
- Emergency room evaluation of patients with cardiac and vascular disease
- Cardiac catheterization
- Cost-effective management of hospitalized patients with cardiac disease
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The team assigned to the Hillcrest Cardiology Service is comprised of:
- An inpatient/consult cardiology attending,
- 1-2 physician’s assistants, and
- One cardiology fellow (from 7 a.m. - 7 p.m.). A second fellow covers from 7 p.m. - 7 a.m. in-house (a call room is provided).
- It is expected that a cardiology fellow will be in house at any given time.
- For approximately five months of the year, an intern from the Emergency Medicine department will be a team member. Fellows will have access to a call room.
These include teaching rounds with attending staff and direct faculty supervision of procedures such as cardiac catheterization, stress echocardiography and transesophageal echocardiography. The fellows will also attend regularly scheduled didactic sessions.
Disease mix/patient characteristics
The patient population on this service is quite varied. Both male and female genders are well-represented. The majority of patients are over 60 years of age, but there is a significant minority of younger patients with CAD, non-ischemic cardiomyopathy, endocarditis, and valvular heart disease. This is a busy emergency room where a high volume of acute cardiovascular disease patients and STEMI patients are evaluated.
Admissions, ER evaluations, and cardiology consultations are generally seen first by the fellow or PA and then together with the faculty attending. Fellows are strongly encouraged to assist with cardiac catheterizations, transesophageal echos, elective cardioversions, and percutaneous coronary interventions. Fellows are expected to interpret echocardiograms while on the Hillcrest rotation.
The fellows and PA will evaluate and admit patients to the cardiology service. Consultative cardiology services will be provided to other services by the same team.
Independent analysis of patient information by the fellow is encouraged, but all inpatients and consultations are seen by the faculty and reviewed with the fellow. All major clinical decisions are discussed by the fellow and faculty. In addition, faculty directly supervise transesophageal echocardiograms and procedures performed in the PACU or CCU. Daily rounds on the inpatient service and consultation service are performed by the attending physician, fellow and PA.
- Braunwald's "Heart Disease"
- Hurst's "The Heart"
- Feigenbaum's "Echocardiography"
Teaching files of interesting echocardiograms, angiograms, and stress tests are available on-line on the hospital's digital cardiac imaging system.
ACGME core competencies are evaluated monthly by the attending faculty. These evaluations are discussed with the fellows and forwarded to the program director. First-year fellows are expected to have a mean evaluation score of 5 or greater on the standard 1-9 scale of the 6 ACGME core competencies. Second-year fellows are expected to have a mean score of 6 or above; third-year fellows are expected to have a mean score of 7 or above. Expectations of fellow performance vary by year of training.
First-year fellows are expected to be able to perform an adequate history and physical examination, and to understand the basic concepts of consultative cardiology, including (but not limited to) preoperative assessment and “cardiac clearance,” as well as evaluation for heart failure, coronary disease, arrhythmia, and valvular heart disease. First-year fellows are also expected to hone their skills in inpatient management of acute coronary syndromes, acute CHF, and valvular disease. They should perform right heart catheterizations independently and left heart catheterizations with attending input and supervision. Finally, fellows are expected to show empathy with patients and their families, and to communicate well with patients, their families, and ancillary staff.
Second-year fellows are expected to show continued clinical maturation: they should act with increased levels of independence in patient care activities, and should act as the leader of the inpatient service. They should also serve as primary operators for cardiac catheterization and TEE procedures, with less attending input.
Specific activities during this rotation that will enhance the fellows’ skills in the 6 core competencies:
- Patient Care: Fellows will encounter a large group of patients a wide variety of acute and chronic cardiovascular illnesses. They will direct the care of these patients and assist in procedures performed.
- Medical Knowledge: Fellows will learn from the attending faculty during patient rounds and teaching rounds, and also from self-directed review of the literature.
- Interpersonal and Communication Skills: Fellows will interact with medical staff, nurses, pharmacists, and other ancillary personnel. They will communicate with patients’ families. There are no internal medicine residents working with the fellow during this rotation, so fellows are the main contact person for family members, discharge planners, ancillary personnel, etc. Fellows are expected to keep accurate, timely-signed medical records.
- Professionalism: Fellows will gain experience in the respectful treatment of all the above-mentioned groups, and will also maintain accurate procedure reports and logs.
- Practice-Based Learning: Fellows are expected to gain knowledge from self-directed literature review. Fellows will present cases from the Jacobs Medical Center during weekly catheterization conference and discuss pertinent literature.
- Systems-Based Practice: Fellows will work within a team of health care professionals and participate in inpatient management, facilitation of transfers, and discharge planning. They will be exposed to patient concerns such as cost of medication, ambulatory follow-up, and end-of-life issues.