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Cardiovascular Course Anita Soni MD FRCPC Cardiology June 10, 2013 UGME CV Course Committee Course Leader: Anita Soni Administrative Assistant: Kathy van der Vis Basic Sciences: Anatomy: Sabine Hombach-Klonisch Embryology: Mark Torchia Physiology: Ian Dixon Pharmacology: Don Smyth Cardiology: Heart Failure/nuclear: Francisco Cordova IHD/hemodynamics: John Ducas Arrhythmia: Kevin Wolfe Valvular Heart Disease/other: Anita Soni ECG/Imaging- Davinder Jassal Preventative/Rehab- Thang Nyugen Related Medical Disciplines: Intensive Care: Alan Schaffer Vascular Surgery: April Boyd Cardiac Surgery: Ed Pascoe Longitudinal Themes Generalism: Travis Minish Pathology: Gabor Fischer Infectious Diseases: George Zhanel Genetics: Sandra Marles Pediatrics: Reeni Soni Radiology: Iain Kirkpatrick Geriatrics: Colette Seifer Longitudinal Courses: Community Health: Sharon MacDonald Clinical Skills: Karen Klym Indigenous Health: Barry Lavallee Resident: Robin Ducas (PGY 5 Cardiology) Student: William Liang (CV course rep) CuRe Preclerkship M0, 1/2: Human Biology , Health and Disease Y1 Human Biology and Health wks.days ( w. 2 days eval ) M0 • FOUNDATION of MEDICINE M1 1. Blood & Immunology I (+ Skin I) 2. CV I & Resp (+ ET) I 3. Neurobiology I(Psych, Neuro + Opth) 4. Musculoskeletal I 5. Endocrine I & OBS/Gyn I 6. GI/ Nutrition I & Urinary system I TOTAL CuReX DRAFT 3 March 11, 2013 Approximate dates 4 ---- 2014 Aug 25 - Sept 19 3------------ Sept 22 - Oct 10 5 ------------ Oct 13 - Nov 14 4.6 --------- Nov 17 - Dec 17… Dec break 2------2015 Jan 5 - Jan 16 4------------- Jan 19 - Feb 13 4------------- Feb 17 - Mar 13 26.6 ……………….Mar 16 - 20………Reading week M2 Health and Disease 1. Intro to ID/Intro Oncology 2. Blood & Immunology (+ autoimmune diseases) 2 3. CV 2 Y2 4. 5. 6. 7. 8. 9. 10. Resp + ET 2 Endocrine 2 OBS/Gyn 2 GI & Nutrition 2 Urinary system 2 Neurobiology 2 (Psych, Neuro, Opth) Musculoskeletal 2 (+Skin 2) M3 Consolidation 2-------------Mar 23 - April 3 5 3-------------Apri 6 - April 24 4-------------Apri 27 - May 22 -----------May 25- 29 …………. Rural week 4--------------Aug 24 - Sept 18 3--------------Sept 21 - Oct 9 3--------------Oct 12 - Oct 30 3 -------------Nov 2 - Nov 20 3 +3d------- -Nov 23 - Dec 17…… Dec break 6 -----2016- Jan 4 - Feb 12 4--------------Feb 18 - Mar11 ----------------Mar 14 - 18 ……. Reading week 10-------------Mar 21 - May 27 3 Goals: ①Create Outline for the CV course: Specific topics objectives content format Review current course IDENTIFY GAPS & OVERLAP (RELEVENT VS REDUNDANT) - compare to other medical schools/review MCC objectives Ensure related medical disciplines and longitudinal themes are represented Goals: ② Organization and Integration: Dividing into Module 1 & Module 2 - Integration of longitudinal courses to optimize learning - Integration of longitudinal themes- where they fit in Consolidation Clerkship (academic ½ day) Goals: ①Create Outline for the CV course: Specific topics objectives content format Review current course IDENTIFY GAPS & OVERLAP (RELEVENT VS REDUNDANT) compare to other medical schools/review MCC objectives Ensure related medical disciplines and longitudinal themes are represented Current CV Course Objective (OPAL) CV.1 Describe the scope and burden of illness of cardiovascular disease in our community. CV.2 Explain normal anatomy, physiology, and pathology of the cardiovascular system. CV.3 Explain the abnormal anatomy, physiology, and pathology in cardiovascular disease: including ischemic heart disease, heart failure, rhythm disorders, valvular heart diseases, pericardial/myocardial disorders, shock, peripheral vascular diseases, thoracic aortic disease, hypertension, endocarditis and congenital heart disease. CV.4 Perform a cardiovascular history and physical examination in patients with cardiovascular disease. CV.5 Evaluate the clinical presentations of cardiovascular diseases, including the workup of chest pain syndromes, shortness of breath, palpitations and syncope. CV.6 Describe primary prevention, risk factors and risk factor modification for cardiovascular diseases. CV.7 Discuss and implement the clinical tools and investigations available for the evaluation of cardiac patients. Have an approach to ECG interpretation. CV.8 Describe the treatment options of cardiovascular diseases, both acute and chronic Current Cardiovascular Course Intro, Reviews & Community Health Aorta & PVD Instructional Embryology tests Anatomy Physiology Infections Shock /Vascular and Autonomic Drugs EKG Cardiovascular Course Genetics/ Molecular Arrhythmia HTN Pericardial and Cardiomyopathy Congenital & Pediatrics Heart Failure Lipids Imaging Ischemic Heart Valvular Disease Heart Disease Current Cardiovascular Course Intro, Reviews & Community Health Aorta & PVD Instructional Embryology tests Anatomy Physiology Infections Shock /Vascular and Autonomic Drugs EKG Cardiovascular Course Genetics/ Molecular Arrhythmia HTN Pericardial and Cardiomyopathy Congenital & Pediatrics Heart Failure Lipids Imaging Ischemic Heart Valvular Disease Heart Disease Current Cardiovascular Course Intro, Reviews & Community Health Aorta & PVD Instructional Embryology tests Anatomy Physiology Infections Shock /Vascular and Autonomic Drugs EKG Cardiovascular Course Genetics/ Molecular Arrhythmia HTN Pericardial and Cardiomyopathy Congenital & Pediatrics Heart Failure Lipids Imaging Ischemic Heart Valvular Disease Heart Disease Course ID CV001 CV059 CV041 CV002 CV003 CV008 CV041 CV044 CV048 CV014 CV004 CV010 CV011 CV013 CV015 CV017 CV025 CV027 CV029 CV030 CV019 CV020 CV058 CV045 CV023 CV022 CV024 CV026 CV059 CV033 CV034 CV037 CV038 CV016 CV078 CV079 CV080 Topic Introduction to Cardiovascular Mid Term Review Cardiovascular Review Anatomy of the Heart I Anatomy of the Heart & Mediastinum and Thorax 1 Anatomy of the Heart II CV Anatomy Review - Combined with RS 80 Development of the Heart Development of the Heart and Lung Autonomic Nervous System Cardiovascular Physiology Blood Pressure Regulation Regulation of Cardiac Output and Venous Return Hemodynamics 1 Hemodynamics 2 Cardiac Pathology: Consequences of Abnormal Hemodynamics Cardiac Cycle Cardiac Indices Cardiac Performance Abnormalities in Cardiac Performance Excitation - Contraction Coupling Cardiac Electrical Properties Exercise Physiology and Stress Testing Cardiovascular Physiology of Aging Introduction to ECG 1 Introduction to ECG 2 ECG Interpretation 1 ECG Interpretation 2 ECG in IHD Arrhythmias I Arrhythmias II Arrhythmias III Arrhythmias IV Hypertension I Hypertension II Hypertension III Hypertension IV Type ID Duration L IT T L GLP GLP GLP L A/GLP L L L L A T A L L L L L L L T L L T T T L L L T L L L A 1 1 2 1 1 2 1 2 2 2 2 1 2 2 2 1 2 1 2 1 2 2 2 1 2 1 2 2 1 2 1 2 2 1 1 1 1 Dept ID IN-CV IN-CV IN-CV AN AN AN AN AN AN PC IN-CV IN-CV IN-CV IN-CV IN-CV PA IN-CV IN-CV PC PC IN-CV IN-CV IN-CV IN-CV IN-CV IN-CV IN-CV IN-CV IN-CV IN-CV PC PC IN-CV IN-CV IN-CV IN-CV IN-CV Session Leader Anita Soni Anita Soni Anita Soni Sabine Hombach-Klonisch Sabine Hombach-Klonisch Sabine Hombach-Klonisch Sabine Hombach-Klonisch Mark Torchia Mark Torchia Don Smyth Rohit Singal Bojan Paunovic Bojan Paunovic Bojan Paunovic Bojan Paunovic Gabor Fischer Andrew Morris Malek Kass Ian Dixon Ian Dixon Larry Hryshko Ali Khadem Ivan Barac Colette Seifer Nasir Shaikh Davinder Jassal Nasir Shaikh Nasir Shaikh Nasir Shaikh Kevin Wolfe Kevin Wolfe Kevin Wolfe Kevin Wolfe Brian Penner Brian Penner Brian Penner Brian Penner Introduction, Reviews, Instrucitonal Tests Anatomy Embryology Physiology ECG Arrhythmias Hypertension CV057 CV064 CV063 CV005 CV061 CV058 CV051 CV052 CV056 CV066 CV059 CV059 CV059 CV062 CV062 CV062 CV062 CV062 CV062 CV081 CV053 CV040 CV040 CV040 CV040 CV042 CV040 CV CV046 CV043 CV021 CV028 CV031 CV041 CV045 CV032 CV039 CV041 CV059 CV041 Lipid Metabolism and IHD I Lipid Metabolism and IHD II Lipid Metabolism and IHD III Cardiac Pathology: Atherosclerosis Cardiac Pathology: IHD Exercise Physiology and Stress Testing Acute Coronary Syndromes Chronic IHD Revascularization in IHD IHD I ECG in IHD IHD II Cardiac Pathology: Valvular Heart Disease Valvular Heart Disease I Valvular Heart Disease II Valvular Heart Disease III Cardiac Pathology: Pulmonary Vascular Disease and Cor Pulmonale Cardiac Pathology: Heart Failure Heart Failure & Therapy I Heart Failure & Therapy II Heart Failure & Therapy III Heart Failure & Therapy IV Congenital Heart Disease I Acquired Conditions in Pediatric Heart Disease Congenital Heart Disease II Congenital Heart Disease III Pericarditis & Cardiomyopathies Genetic Aspects of Cardiomyopathy Molecular Aspects of Cardiac Disease Shock I Shock II Vascular and Autonomic Drugs I Vascular and Autonomic Drugs II Vascular and Autonomic Drugs III Cardiac Infections Diseases of the Thoracic Aorta Vascular Disease I Vascular Disease II Prevention of Vascular Disease Appl yi ng Communi ty Hea l th Concepts to Res p a nd Ca rdi ova s cul a r Di s ea s e 1 L L T L LP L L L L A T T T A T T L L L L L T A L L T L L L L T L L T L L L T L A 1 1 2 2 1 2 2 2 1 1 1 2 1 1 3 2 1 1 2 1 1 2 1 1 2 2 1 1 1 1 2 1 1 2 1 1 2 1 1 0 IN-CV David Mymin IN-CV David Mymin IN-CV David Mymin PA Gabor Fischer PA Gabor Fischer IN-CV Ivan Barac IN-CV Kunal Minhas IN-CV John Ducas SG Kunal Minhas IN-CV Kunal Minhas IN-CV Nasir Shaikh IN-CV Kunal Minhas PA Gabor Fischer IN-CV Anita Soni IN-CV, SGAnita Soni/Rizwan Manji IN-CV Anita Soni PA Gabor Fischer PA Gabor Fischer IN-CV Shelley Zieroth PC Anita Soni PC Anita Soni IN-CV Shelley Zieroth PD Reeni Soni PD Reeni Soni PD Reeni Soni PD Reeni Soni IN-CV John Ducas BC GN-GNAb Chudley IN-CV Davinder Jassal IN-CV Rizwan Manji IN-CV Rizwan Manji PC Don Smyth PC Don Smyth PC Don Smyth MM Fred Aoki SG Ed Pascoe SG Josh Koulack SG April Boyd CH Sharon Macdonald CH Sharon Macdonald Lipids Ischemic Heart Disease Valvular Heart Disease Heart Failure Congenital & Pediatric Heart Disease Pericardial Disese & Cardiomyopathies Genetics-Cardiomyopathies Molecular Aspects Shock/Vasclar & Autonomic Drugs Infections Aorta/Peripheral Vascular Disease (Surgery) Community Health Clinical Skills 1. Intro session- 2 hours of demonstration with 5 groups- rotating through 5 stations: 1. 2. 3. 4. 5. History JVP BP Heart Sounds Peripheral exam 2. Three 2 hour small group sessions (5-6 students) with a cardiologist using real patients on ward Gaps • Preventative medicine- primary prevention – cover HTN and Lipids directly, but no specific lecture formally dedicated to smoking, diet, DM, obesity (from a clinical perspective) • Diet and nutrition (ie. Mediterranean diet). • Cardiac rehabilitation • Presyncope / syncope • Pericardial disease and cardiomyopathies should be separated • Indigenous health • Interprofessionalism/ multidisciplinary care Overlap- relevant vs redundant • Physiology section- combination of lecturers from different fields leading to some redundancy. Also, some ICU oriented sessions with question of relevancy • IHD- some redundancy; review content relevancy • Autonomic nervous system- how much to cover with new curriculum (no longer being taught prior to course) • Lipids- also covered in Endocrine ?combine • pulmonary HTN/cor pulmonale- one pathology lecture (combined with resp), not covered in CV otherwise • Pathology- ?some redundancy based on student evaluations • Anticoagulants/antiplatelet drugs- overlap with heme? • Shock- cover all types of shock ?relevant / ensure not redundant Goals: ② Organization and Integration: Dividing into Module 1 & Module 2 - Integration of longitudinal courses to optimize learning - Integration of longitudinal themes- where they fit in Consolidation Clerkship (academic ½ day) Module 1 Positive Aspects: Combined with Resp- ideal! Integrate anatomy, embyrology, and some imaging (ie. CXR). Number of lecturers can be limited: Course leader: intro, mid and final test/review, diagnostic testing/imaging, ECG (may need one more cardiologist). 1 for Anatomy 1 for Embryology 2-3 for physiology 1 for pharmacology (also some physiology) 1 radiologist Module 1 Challenges: Ensuring enough baseline knowledge to understand pharmacology/drugs (ie. autonomic nervous system, heme / nephro background) Challenge to teach diagnostic testing/imaging, ECG and drugs without clinical context, but will be spiraling with M2. Integration into longitudinal courses (?what topics to cover) Timing of M1 is during 2 of the most popular Cardiology Conferences Module 1 Consider? Pathology: in CV, pathology lectures presently go though pathological processes (ie. atherosclerosis, or LV systolic dysfunction), from a cellular level. Introduces disease states at a very basic level (ie. IHD, CHF). It may be okay to demonstrate some of these abnormal processes (also taught in physiology section as it differs form normal processes) in M1. This would serve to introduce disease states that will be unavoidably discussed in diagnostic testing, imaging, pharmacology and clinical skills. Can shock/vascular & autonomic drugs be taught in M1- also serves as an intro into disease states as above Module 2 Positive Aspects: Excellent opportunity for optimal integration with longitudinal courses- would like CV to be involved with these sessions- (see later slide) though also need to consider resources with tutors ‘Spiral’ curriculum- review diagnostic tests/imaging/ECG/drug treatment -now under each disease entity after being taught in M1 first. Module 2 Challenges: A lot of material to cover, only appropriate in M2 (not M1) Difficult to go only theme based (ie. approach to dyspnea) without background of disease first, and without being paired with respirology Some topics better to be theme based (ie. syncope)where to fit in? No time for integration/unknown patient case (except at final review session)- unless move pathology/shock to M1 Very tight timing with 19 teaching days, and new material on week of exam (more ideal to combine with Respirology also for resource allocation) Module 2 Challenges: Clinical skills- do not want to compromise this section at all, as it is the strongest part of the current course: very very challenging in this format of 4 weeks. Initially allotted 4 hours 2x/ week. This is impossible. Intro session (one lecture, one rotating stations), then leaves 3 weeks (one session per week per student). To keep status quo: even if given flexibility (2 hour time slots, once per day), would mean 4 groups (5-6 students per group) per day, 5 days per week (each group gets a 2 hour session), and repeat next 2 weeks. Timing/location- 8am best; predominantly at SBGHneed to consider travel time. Patient fatigue- Cardio ward Resources- same tutor per group; and also with teaching in the am hours Module 2 Challenges: There will be more lecturers than what is perceived as ideal: Course leader: intro, mid and final test/review ECG review Arrhythmia HTN Dyslipidemia IHD HF Valvular heart disease Pericardial disease Cardiomyopathies Genetic Molecular aspects ID Shock Autonomic Drugs Vascular Pediatrics/Congenital **Cardiologist-based topics Longitudinal Courses: Considerations: Clinical skills- extreme challenge want to maintain current format Incorporating ‘theme-based’ approach into clinical reasoning. Ideal to have CV involvement: ie- go through case from H & P, to ECG, to diagnostic imaging (include angiographic & echo images or reports) and treatment. Expand community health Professionalism: can we incorporate a multidisciplinary session into professionalism: include clinical psychology, rehab, etc.. ?transplant case-ethical issues Incorporate indigenous health topics specific to CV Longitudinal Themes Considerations: - Most themes well integrated into M1 and M2 - consider interprofessional care case- ?into professionalism course - many are not specific to CV- fit into TTC/JC/SC/TTR portions Composite Clinical Presentations CP4* UGME Sept 2012 SYMPTOMS & SIGNS DRAFTV6 ABNORMAL LABS HEALTH CONDITIONS 1 abdominal mass 2 abd pain: acute & chronic 3 allergic reactions 4 anxiety 34 hemoptysis 35 hirsutism 36 hoarse voice 37 impotence 38 incontinence 66 acidosis 67 alkalosis 68 hemoglobin disorders 69 calcium/phopshate/magnesium 99 ADHD spectrum 100 adrenal disorders 101 arthritis 102 CVD 103 cirrhosis 5 ascites 6 blunt trauma 7 burns 39 jaundice 40 joint pain-acute & chronic 41 low back pain 70 71 coagulation abnormalities 72 creatinine:acute & chronic 8 bleeding 42 lymphadenopathy 73 107 eating disorders 9 43 neck mass/thyroid CXR abnormalities 74 lipid abnormality 104 CNS infections 105 diabetes 106 Drug OD 44 pain syndrome 75 leukocyte disorders 109 HIV/AIDS 11 constipation 12 cough- acute & chronic 45 46 pruritus 76 liver enzymes/function 77 potassium abnormalities 110 111 infertiltiy 13 14 delirium 15 dementia 16 diarrhea- acute & chronic 47 red eye 48 paralysis 49 pelvic pain/mass 50 seizures 78 platelet disorders 79 pulmonary function tests 80 sodium abnormalities 81 urinalysis abnormalities 112 kidney disease-chronic 113 lung disease-chronic 114 malnutrition 115 menses/menopause 17 diplopia 51 skin growths 18 dysphagia 52 skin rashes 82 117 multiple sclerosis 53 sleep disorders 54 somnolence 55 sore throat 84 Contraception 85 Culture 118 osteoprosis 119 pediatric emergencies 120 palliative care 86 WHO Determinants of Health 121 pituitary disorders 57 tendon rupture 58 testicular swelling/pain/mass 59 tinnitus 60 vomiting 61 vision loss acute&chronic 62 weakness 87 developmental pediatric delay 88 Disabilities 89 neglect/abusive relationship or behavior 90 educational level 91 elderly/frail 92 environmental health 122 pregnancy/complications 123 psychosis 124 suicidal behavior 125 shock/resuscitation 126 sports injuries 127 STI 63 wheezing- acute & chronic 93 infectious epidemic/prevention 128 98 133 cardiac murmurs 10 chest pain cyanosis dyspnea-acute & chronic 19 20 dysuria/UTI 21 ear pain 22 edema 23 extremity pain 24 eye trauma 25 fever 26 fatigue 27 foot ulcers 28 fracture/dislocation 29 GI bleed palpitations 56 syncope cardiac markers/EKG FACTORS EFFECTING HEALTH adverse drug reactions 83 chronic disease smoking 108 fungal infections hypertension 116 mood disorders 26 Venous thrombosis Clerkship • Internal Medicine Selective or Elective • Academic ½ day: – Internal medicine- ½ day CV topics (CP, CHF, ECG, HTN) – Surgical ½ day – request to consider cardiac surgery topic(s)- ie. post CABG or post valve replacement care (at the level of a generalist). This topic would be better after some clinical exposure (ie. not in M1 or M2). Overall- Positive Aspects • Excellent opportunity to scrutinize the course, find gaps/redundancies, improve course in terms of objectives, content, organization, sequencing and teaching methods. • Dividing into M1 and M2 is logical; M2 will be far better understood after learning the basic sciences of all the systems first. • Large course, crosses over many other related disciplines and longitudinal themes • Current course- minimal gaps (but still some); have identified areas to decrease redundancy • Excellent opportunity to enhance learning with optimal integration of the longitudinal courses Overall- Challenges • Very condensed timing for M2- would have been ideal to combine with Respirology for obvious reasons • Division of M1 & M2 and sequencing • Number of lecturers will be more than ‘ideal’-- even just for the core Cardiology lectures (I can’t do them all), and adding the other related disciplines (ICU/vascular surgery, cardiac surgery) and longitudinal themes (geriatrics, peds, genetics, ID, pathology, radiology, etc…) • There are a lot of GFT cardiologists (25) – trying to be fair in distributing the teaching ‘duties’ while at the same time, focusing on student needs to have the best teachers. Agenda of CuRE is fewer teachers- but if only 4-6 teachers, huge amount of hours for them (difficult to sell this model to these 4-6 teachers when majority not participating). Also, some want to teach, but may not get ‘picked’- may be ‘hard feelings’. • Clinical skills Next Steps • Committee to be subdivided to ‘clean up’ gaps/redundancies in their area (ie. physiology, IHD sections), develop objectives, then develop content. • Teaching format to be determined- direction from CuRE. Challenges with being such a large course- difficult to reduce lectures to <25%; ideal to use on-line module teaching methods, but development will be a lot of work up front. May need to gradually make changes. • Consider role for purchasing material- ie. ECG tutorials etc… for student self study.