Download U O M

UNIVERSITY OF
MANITOBA
Adult Cardiology Residency
Training Manual
2015/2016
TABLE OF CONTENTS
Introduction
.............................................................................................
4
Rounds, Meetings and Courses ...................................................................
7
University of Manitoba Cardiology Teaching Faculty ................................
17
Cardiology RPC Terms of Reference ..........................................................
18
Career and Stress Reduction Counselling/ Harassment and Intimidation ...
20
Resident Safety Policy for Adult Cardiology Residents…………………..
23
Assessment and Evaluation of Adult Cardiology Residents………………
26
Remediation and Probation Process for Adult Cardiology Residents……..
28
Industry Relations and Quality Assurance/ Improvement ...........................
31
Chief Cardiology Resident Duties…………………………………………
32
Educational Aims and Objectives (Rotation specific) .................................
Ambulatory Care .............................................................................
38
Cardiac Catheterization ...................................................................
41
Coronary Care Unit (CCU)..............................................................
47
Clinical Training Unit (CTU) ..........................................................
53
Consults/Coronary Care (CCU) at HSC ..........................................
57
Echocardiography ............................................................................
65
Advanced Multimodality Cardiac Imaging: Cardiac CT/MRI .......
73
Nuclear Cardiology/ Stress Testing .................................................
77
Research...........................................................................................
84
Electrophysiology (ECG and Ambulatory ECG Monitoring) .........
89
Adult Congenital Cardiology...........................................................
98
Heart Failure/Transplant .................................................................
103
Cardiovascular Prevention and Rehabilitation ……………………
110
Log Sheets
.............................................................................................
113
2
Appendices:
1. RCPSC Objectives of Training in the Subspecialty of Adult Cardiology (2010 Version 1.0)
2. RCPSC Subspecialty Training Requirements in Adult Cardiology (2010 Version 1.0)
3. RCPSC Specific Standards of Accreditation for Residency Programs in Adult Cardiology
(2010)
4. RCPSC Standard Assessment of a Clinical Encounter Report (STACER)
5. RCPSC Final In-Training Evaluation Report (FITER)
6. Department of Medicine Resident Travel Guidelines and Travel Policy
7. Faculty of Medicine Policy on Interactions with Industry
8. Department of Medicine Professional Attire policy
9. Faculty of Medicine PGME Resident Safety Policy
10. Senior/Junior Resident Roll Description
11. Section of Cardiology Resident Request to Travel Form
3
INTRODUCTION
Overall Goals of Adult Cardiology Residency Training
The core training program in Adult Cardiology at the University of Manitoba lasts for three years.
Entry requires completion of at least three years of training in Internal Medicine in an accredited
program. It is anticipated that at the end of this three year period of training, the trainees will
become competent clinical Cardiologists who will be able to adapt to the many changes in the
specialty which will occur in their professional lifetime. Upon satisfactory completion of the
training, trainees will be qualified to take the Cardiology Subspecialty examination of the Royal
College of Physicians and Surgeons of Canada. The four months of elective time allows trainees
to develop substantial skill in a subspecialty within Cardiology. Full training in a subspecialty
within Cardiology may require additional time beyond the three year program. Those wishing to
pursue an academic career may elect to carry out several years of research training. Elective time
can be spent in research as well.
The three year training program in Adult Cardiology comprises eight compulsory rotations with
six months of elective/research of which two months must be spent in research. The rotations are:
•
Clinical Cardiology (6 periods); including cardiology CTU and consultations
•
Echocardiography (6 periods)
•
Research (2 periods)
•
Elective (4 periods)
•
Coronary Care (4 periods)
•
Cardiac Catheterization (3 periods)
•
Advanced Cardiac Imaging (include cardiac CT/MRI) (1 period)
•
Ambulatory Cardiology (3 periods)
•
Electrophysiology (including ECG and ambulatory ECG monitoring) (3 periods)
•
Nuclear / Stress Testing (2 periods)
•
Adult Congenital Cardiology (2 periods)
General objectives of the Cardiology Residency Program and specific objectives for each
rotation are included in this training manual. It is vital that you read the appropriate specific
objectives carefully before starting each rotation. Assessments are all web-based and are sent
out to staff and residents at the end of each rotation. Cardiology is a technical specialty and for
many rotations it is important to complete a log of procedures carried out. Appropriate forms
are provided for these rotations.
4
Format of the Comprehensive RCPSC Objective Examination in Adult Cardiology
Comprehensive objective examinations make it possible to obtain a more complete evaluation of
the candidate's strengths and weaknesses. The important feature of comprehensive objective
examinations is that candidates do not need to pass the written component in order to take the oral
component. Success or failure is based on consideration of all components of the examination.
The comprehensive objective examinations are considered a "whole" and cannot be fragmented.
Candidates who are unsuccessful at this examination must, if within their period of eligibility,
repeat all components of the examination.
a. Written Component The written component consists of one three-hour paper. The paper
consists of short-answer questions that combine the clinical and basic science aspects of
cardiology.
b. Practical (Graphics) Component The practical (graphics) component lasts 2 hours. Each
candidate is provided with a quiet room equipped with a desktop computer, flat LCD
screen, keyboard, and mouse. The examination consists of a Microsoft PowerPoint
presentation that includes bilingual information and question slides, still images and short
movie clips. The candidate is expected to interpret a series of ECG's, CXR's, ambulatory
(Holter) recording rhythm strips, exercise stress tests, transthoracic Doppler
echocardiograms, SPECT MIBI studies, hemodynamic tracings and angiograms, and
record the answers in a booklet. Candidates may progress through the different
components of the practical examination at their own pace and utilize the allotted time to
their best advantage.
c. OSCE Component There will be an OSCE component of approximately 2 and a half hours in
duration. It will consist of 8-10 stations each of approximately 15 minutes duration.
Candidates will be required to demonstrate elements of the cardiovascular history and
physical examination and answer questions based on case scenarios (structured orals). The
OSCE component may also include some graphics material (e.g., ECG interpretation) and
material designed to assess competence in CanMEDS roles other than the Medical Expert
role. Standardized real patients may be used in this component.
See appendices for:
1. RCPSC Objectives of Training in the Subspecialty of Adult Cardiology (2010 Version 1.0)
2. RCPSC Subspecialty Training Requirements in Adult Cardiology (2010 Version 1.0)
3. RCPSC Specific Standards of Accreditation for Residency Programs in Adult Cardiology
(2010)
4. RCPSC Standard Assessment of a Clinical Encounter Report (STACER)
5. RCPSC Final In-Training Evaluation Report (FITER)
5
Cardiology Monthly Rounds Schedule
Monday
Tuesday
Wednesday
1
Grand Rounds
0800-0900
All CanMEDS Pillars
2
8
Journal Club
1200-1300
Scholar/ Communicator
Complex Patient
Care Rounds
1600-1700
Medical Expert/
Communicator/
Collaborator
9
15
Grand Rounds
0800-0900
Medical Expert/
Communicator/
Collaborator
10
22
17
18
Complex Patient
Care Rounds
1600-1700
Medical Expert/
Communicator/
Collaborator
23
Senior Resident Rounds
(With Jr. Res. only)
0800-0900
Medical Expert/ Scholar
Academic Half Day
(Sr. Only)
1300-1700
Y3011
All CanMEDS Pillars
24
25
EKG Rounds
0800-0900
Medical Expert
RCPSC Practice
Written Exam
1200-1300
All CanMEDS
Pillars
19
Service Rounds
1200-1300
All CanMEDS Pillars
Grand Rounds
0800-0900
All CanMEDS Pillars
Discovery Rounds
1200-1300
Scholar
Senior Resident Rounds
(With Jr. Res. only)
0800-0900
Medical Expert/ Scholar
EKG Rounds
0800-0900
Medical Expert
Physical Exam Rounds
1200-1300
Medical Expert/
Communicator
12
Service Rounds
1200-1300
All CanMEDS Pillars
Complex Patient
Care Rounds
Medical Expert/
Communicator/
Collaborator
Echo Rounds
1200-1300
Medical Expert/
Collaborator/
Manager/
Communicator
Senior Resident Rounds
(With Jr. Res. only)
0800-0900
Medical Expert/ Scholar
11
EKG Rounds
0800-0900
Medical Expert
Device Rounds
1200-1300
Medical Expert/
Collaborator/
Manager/ Health
Advocate
16
5
Academic Half Day
(Sr. Only)
1300-1700
Y3011
All CanMEDS Pillars
Combined Cardiac
Sciences Seminar
(Sr. Only)
0900-1200
All CanMEDS Pillars
Grand Rounds
0800-0900
All CanMEDS Pillars
Cath Potpourri Rounds
1200-1300
Y3003
Medical Expert
Friday
4
EKG Rounds
0800-0900
Medical Expert
Case of the
Week/Royal
College Rounds
1200-1300
Medical Expert/
Communicator/
Health Advocate
Cath Potpourri Rounds
1200-1300
Y3003
Medical Expert
Thursday
3
Complex Patient
Care Rounds
1600-1700
Medical Expert/
Communicator
Academic Half Day
(Sr. Only)
1300-1700
Y3011
All CanMEDS Pillars
26
Senior Resident Rounds
(With Jr. Res. only)
0800-0900
Medical Expert/ Scholar
6
ROUNDS, MEETINGS & COURSES
Mandatory Rounds:
Monday: 0800 – 0900
Y3 Auditorium
Cardiology Grand Rounds will begin in September: Each resident will present at least once
during the academic year. Topics should be extensively researched. The resident is expected
to attend throughout the year.
Monday: 1200 - 1300
Y3 Auditorium
Physical examination rounds /Discovery research rounds/ Cath Potpourri rounds will
begin in September: Four times a month, at noon, the resident will be exposed to either
Physical Examination rounds, Discovery research rounds, or Cath Potpourri rounds. These
rounds are lead by a Staff attending on a topic of his/her choice. The resident is expected to
attend throughout the year. Discovery research rounds occur once a month and are lead by
Dr. Davinder Jassal, Postgraduate Research Director (please see research section of the
Adult Cardiology residency training manual).
Tuesday: 1200 – 1300
Y3 Auditorium
Case of the week/ Cardiology EP rounds / Echo rounds/ RCPSC Written style practice
exam. Case-based presentation by resident on the first Tuesday of each month. The
resident on call for the preceding Saturday will present the case on Tuesday. Each resident
is expected to attend throughout the year. The second Tuesday of each month, the resident
will attend EP rounds which are lead by a Staff Cardiologist. The third Tuesday of each
month, echo rounds are leads by a Staff Echocardiologist on a topic of his/her choice. The
resident is expected to attend throughout the year. On the last Tuesday of each month, from
1200-1300 pm, a RCPSC practice style written exam will be administered to the Cardiology
residents on a number of topics, by the Program Director and/or his designate.
Wednesday:
0900 - 1200
Y3 Auditorium
Cardiac Sciences Academic Half Day. The Cardiac Sciences academic half days includes
participation from the residents in Adult Cardiology, Cardiac Surgery, Cardiac Anesthesia
and Critical Care. These rounds are lead by dedicated staff attendings. Cardiology residents
are expected to attend these rounds throughout the year. Ten sessions occur annually. See
separate schedule for this. During this week, there will be no Academic Half Day on
Thursday.
Wednesday:
1600 – 1700
Y3 Auditorium
Complex patient care rounds. The resident is expected to attend when on cath rotation,
CCU, CTU or consult service. These rounds start in September.
Thursday:
0800 – 0900
Y3 Conference room
EKG rounds. The resident is expected to attend these rounds. Once a month, EKG rounds
will be replaced by either Holter/ICD interrogation or Hemodynamic interpretation.
Thursday:
1200 - 1300
Y3 Auditorium
Resident rounds. Presentation by one of the junior residents rotating through Cardiology.
The Cardiology resident should attend if on CCU, CTU or Consult service. Once a month,
the Cardiology resident will be assigned to either morbidity and mortality rounds or journal
club rounds for presentation.
7
Thursday:
1300 - 1700
Y3 Conference room
Academic Educational Half Day. Cardiology residents are expected to attend these rounds
throughout the year.
Friday: 8:00 – 9:00
Y3 conference room
Senior Cardiology Resident Rounds will begin in July: These rounds are lead by the Chief
Cardiology resident and/or his designate, focused on dedicated teaching to the junior
residents rotating through Cardiology.
Friday: 1200 – 1300
Y3 conference room
Resident teaching rounds. A didactic session presented by an attending on service and
directed towards the junior residents rotating through Cardiology. The Cardiology residents
on CCU, CTU or consult service should attend.
In addition to the core rounds in Adult Cardiology, a number of additional mandatory sessions are
provided by the University of Manitoba PGME department.
Conferences/Out of Province Elective:
1. Each trainee is allowed up to 5 consecutive days of conference leave (including travel) per
academic year. Trainees in the Adult Cardiology Residency program at the University of
Manitoba who are presenting at a national or international conference should apply for external
funding support through the following means in descending order:
i)
ii)
iii)
Department of Internal Medicine, Faculty of Medicine education fund: $2000.00
per conference when presenting
Supervisor funding when presenting.
Section of Cardiology funds up to $1000.00 per academic year when presenting.
2. Trainees in the Adult Cardiology Residency Program at the University of Manitoba who are not
presenting at a national or international conference (simply attending the meeting) will not be
provided with external funding support.
3. Trainees in the Adult Cardiology Residency program at the University of Manitoba attending
WECREEP should apply for external funding support through the Section of Cardiology.
4. Financial support for one exam prep course in the third year of training will be no longer
provided.
All conference and course requests must be submitted, in writing (or email), to the Program
Director (with a copy to the Program Assistant) a minimum of 2 months prior to the
conference. The request must include name of conference, departure date, and return date.
All requests for out of province electives must be in writing (or email) to the Program
Director (with a copy to the Program Assistant), and must include name of institution,
supervisor at institution, date of departure, and date of return. You must complete a
Request to Travel form prior to traveling. For reimbursement, you must submit original
receipts including flight boarding passes or you will not be reimbursed.
Conference leave will not be granted during rotations in CCU, CTU or consult service unless the
resident is able to find appropriate coverage (ie another resident).
8
It is the responsibility of the resident to inform the appropriate attending of their absence at the
beginning of the rotation.
Once conference leave is granted, the resident must inform the chief resident so the call schedule
can be reconciled. If a resident has an oral or poster presentation at a conference, the section will
fund them to attend a second conference, as per the above terms. See appendix 6.
Cardiology conference dates for 2015/2016
Canadian Cardiovascular Conference (CCC)
Toronto, Ontario October 24 -27, 2015
American Heart Association (AHA)
Orlando, Florida, November 7 – 11, 2015
American College of Cardiology (ACC)
Chicago, Illinois April 2 – 5, 2016
WECREEP 2016
February 12 – 14, 2016 Calgary
Vacation:
You will be allowed to take vacation in either 2 week or 4 week blocks. No 1 week vacation
blocks will be allowed.
Sick Calls:
When away sick, you are required to call your attending directly to advise you will be absent and
you should also leave a message with the Administrative Assistant to the Program, Kathy van der
Vis 258-1290 or [email protected] and the Program Director.
Exam Preparation Courses:
This will not be funded through the Section.
Call Schedules and Responsibilities:
2014-2015 academic year:
We have an in-house call requirement based on a graduated call program with decreasing
requirements from PGY-4 to PGY-6. Junior residents are first on-call for the service. Cardiology
residents should review all new consults to the service with the junior residents and determine an
appropriate management plan. The resident should confirm with the attending on service (CCU,
CTU, or Consult) whether they want to be telephoned with all routine night-time consults or
admissions of stable patients. Any critically ill patient or any patient in whom there is a significant
change in status should be discussed with the attending. If you have any concerns regarding a
patient, you should not hesitate to contact your attending. The on-call resident is responsible for
ensuring adequate sign-over rounds in CCU.
9
It is expected that the R6 (C3) residents will take on a more senior mentoring role for the R4 and
R5 residents, particularly during teaching sessions and rounds.
PARIM rules mandate a maximum of 7 calls/block with at most 2 weekends affected and
post call days off 2 hours after sign-over (maximum time at hospital ~26h involved with
mandatory pt care). (some conditions/exceptions can apply for coverage during vacation/exams
etc)
HMO Calls:
HMO call is restricted to HSC and SBGH MICU/CCU units until such time as the Adult
Cardiology RPC accepted training rotations are provided at alternate ICU sites (at which time the
matter can be reviewed at the RPC for expansion).
HMO call can occur at the aforementioned sites, provided it does not exceed the maximum of 7
calls per month and the 2 weekend per month restriction (PARIM appropriate resident workload)
HMO call cannot occur during a clinical rotation (CCU/CTU/Consults) during the week which
involves direct patient care/procedures. Friday/Saturday call is acceptable if on
CCU/CTU/Consults rotations, as long as a total of 7 calls occur per month (PARIM rules).
No changes will be made by the Chief Resident to accommodate HMO call. HMO call should not
be organized prior to the Cardiology Schedule being completed to ensure no conflicts can occur.
If there is concern regarding performance or attendance of Residency requirements, HMO call can
be restricted by the Residency Program Committee until such time as said concern is appropriately
addressed.
Research
Dr. Davinder S. Jassal is the Cardiology research co-ordinator. He will meet with each resident
early in the academic year to discuss your research interest(s) and to let you know what projects
are available in the section through the Discovery Course which will occur on a monthly basis.
The aim is that all residents will be ready to submit an abstract to the Canadian Cardiovascular
Society meeting which occurs on a yearly basis. The Cardiac Sciences program has a research
day in May of each year. Projects from the basic science research centre, Cardiac anaesthesia,
Cardiac surgery and Cardiology are presented. It is expected that the R5 and R6 residents
present at this research day as well as the Internal Medicine Research Day. During the 3 year
Cardiology residency, it is expected that the Cardiology resident must present on at least 2
separate occasions, of which one must be an oral presentation, at either Cardiac Sciences
and/or Internal Medicine Research Days.
Rotations
Please read the objectives before each rotation. It is the resident’s responsibility to meet with
the Cardiologist responsible for the rotation before starting, and again before completion to
discuss the assessment.
10
Cardiology Grand Rounds
Educational Aims and Objectives
Objectives:
Cardiology Grand Rounds are a weekly lecture series that takes place every Monday morning
(0800-0900 am) from September through June of the academic training year. It is designed to
address basic and clinical topics that are intended to improve the participant’s knowledge base in
the evolving field of Cardiology. These rounds are given by a member of the teaching faculty,
invited speakers, and/or residents in the Adult Cardiology training program. Attendance at
Cardiology Grand Rounds is mandatory for the senior Cardiology resident.
Process:
• Cardiology Residents will present grand rounds once a year as scheduled by the Chief
Cardiology Resident or a designate.
• In general, PGY4 trainees will be scheduled between December through February so as to
have observed several grand rounds prior to performing one, and also not to interfere with
their RCPSC Internal Medicine exam.
• Residents will be required to submit the title of the presentation to the Program Director
and PD Administrative Coordinator 2 weeks prior to the presentation date.
• Residents are expected to collaborate on the presentation with a faculty mentor of their
choice prior to the presentation so as to ensure completeness and accuracy of the
presentation.
• Presentations are expected to be structured and include a thorough review of the literature
surrounding the topic.
• The presentations should be approximately 35-40 minutes in length allowing for time for
questions. The presenter will be expected to be able to field all questions asked from the
audience.
• It is strongly recommended that an audiovisual presentation software such as
PowerPoint™ or KeyNote™ be used. Slides should be clear and concise with adequate
visuals to illustrate points being made.
• Residents should coordinate with senior residents/staff to avoid topics recently presented.
Medical Expert
• Understand the risk factors, clinical presentation, natural history, pathophysiology and
prognosis of disease process to be discussed
• Know the indications, contraindications, technical aspects and limitations for cardiac
diagnostic tests to be discussed including diagnostic utility (sensitivity, specificity, etc)
• Know the rational for a variety of therapeutic options pertaining to the topic presented and
the appropriate timing for the interventions.
• Be prepared to discuss all potential complications of testing or treatment advocated during
the presentation.
• Understand evidence based medicine and ensure clinical evidence is referenced for any
statements made during the presentation
Communicator
• Be able to present topic in a highly structured format including introduction and a closing
summary of discussion. Invite questions at the end of the presentation.
• Be aware of presentation length and aim for a 35-40 minute presentation
• Use audiovisual tools (slide show presentation) to enhance the presentation
• Speak with clear and concise language, keeping aware of presentation tempo
11
•
Be able to answer all questions that may arise from the presentation.
Collaborator
• Be conscious of multidisciplinary nature of audience, coordinate with allied health in
preparing presentation
Manager
• Organize time effectively so as to prepare presentation while maintaining other service,
educational, and call duties.
• Understand the financial aspects of delivering health care and address any financial
considerations for any testing and therapies advocated during the presentation
Health Advocate
• Understand epidemiology of disease process and local prevalence, risk factors for the
disease process in question and detriments of health if applicable
• Understand local practice patterns and local availability of test discussed and procedures
discussed to include in all presentations
• Recognize and respond to those issues where advocacy is appropriate
Scholar
• Recognize gaps in knowledge base and use appropriate reference materials (ie textbooks,
journals, web-based systems, Medline, etc.) to fill in knowledge base
• Be able to research a topic and conduct a thorough literature search
• Critically appraise sources of medical information and apply this appropriately any
positions taken in the medical literature
• Be able to synthesize literature review into a concise presentation
• Understand a topic at the level where presenter is able to facilitate learning of all members
of the audience (staff, trainees and other health professionals)
Professional
• Understand the legal and ethical constraints of physicians
• Be able to discuss any conflicts of interest that the resident may have in presenting the
topic and disclose at the beginning of the presentation
• Be prepared for constructive criticism
• Exhibit appropriate personal attire and grooming for presentation (see PGME policy)
12
Cardiology Journal Club
Educational Aims and Objectives
During the course of training in the Adult Cardiology residency program at the University of
Manitoba, each senior cardiology resident will be responsible for presenting Cardiology journal
club presentations on a frequency of 1-2 times per year. The schedule for the Cardiology journal
club, which take place on the first Thursday of each rotation from 12-1 pm, will be the
responsibility of the Chief Cardiology Resident and/or a designate.
The Cardiology journal club presentation should focus on a current journal article, published
within the previous 2 years in a peer-reviewed journal, which is relevant to the practice of
Cardiology.
The Cardiology senior resident is expected to:
1) Conduct a structured critical appraisal. (Medical Expert)
2) Identify the fundamental study design and clearly explain the research methods and results.
(Medical Expert, Scholar, Communicator)
3) Understand and explain the types of statistical analysis performed, its meaning, and
limitations. Be able to critique the statistical methods used if appropriate. (Medical Expert,
Scholar, Communicator, Health Advocate)
4) Understand and explain the limitations and application of the research evidence provided.
(Scholar, Communicator)
5) To clearly and concisely communicate the information in the study, its interpretation, and
any further questions left by the research findings. (Medical Expert, Communicator)
6) To effectively identify if the research study presented is applicable and appropriate for our
patient population (Health Advocate)
The journal article should be selected at least 1 week in advance of the presentation date, and sent
to the Program Director (PD) and the PD Administrative Coordinator, in order for it to be
distributed to the participants of the Cardiology journal club for review. The presentation is
expected to use clear visual materials and should be done in a PowerPoint or KeyNote format. The
presentation should be approximately 30-35 minutes long allowing for discussion time at the end.
The Cardiology resident is expected to identify, interpret, and communicate the following when
presenting a journal club article*: (Medical Expert, Scholar, Communicator, Health advocate,
Professional)
1) What is the research question? Why does it matter? What do we already know about this
topic?
2) What is the study design? Is the design appropriate for the study question?
3) What are the study methods?
a. Population selection (inclusion/exclusion criteria)
b. Primary and secondary outcomes? How where they measured?
c. Confounding variables?
d. Statistical tests used? Were they interpreted appropriately?
4) Main findings? Do these findings advance current knowledge?
5) Generalizability: Are these findings relevant to our population and community?
6) Implications of this research?
7) Questions remaining from this research and future research required.
8) Summarize in one slide: main study findings, conclusions, limitations and implications.
13
*Resources for Journal Club Critical Appraisal:
1) Critical Appraisal Worksheets
http://ktclearinghouse.ca/cebm/teaching/worksheets
2) The Revised CONSORT Statement for Reporting Randomized Trials: Explanation and
Elaboration. Ann Intern Med, Apr 2001; 134: 663 - 694.
3) The CONSORT statement: revised recommendations for improving the quality of reports
of parallel group randomized trials. BMC Medical Research Methodology 2001, 1:2
http://www.biomedcentral.com/1471-2288/1/2
4) The Cochrane Handbook for Systematic Reviews of Interventions
http://handbook.cochrane.org
5) How to assess epidemiological studies. Postgrad. Med. J. 2004;80;140-147
http://pmj.bmj.com/content/80/941/140.full.pdf
6) How to Read a Paper, BMJ 1997;315:305:
http://www.bmj.com/content/315/7103/305
7) A RADICAL Approach: Annals of Family Medicine 4:196-197 (2006)
14
Cardiology Case Of The Week
Educational Aims and Objectives
Objectives:
Case of the week is presented once per month on Tuesdays (1200-1300) from September through
June of the academic training year and weekly on Tuesdays (1200-1300) from July to August. It
is aimed at the level of the cardiology residents and designed to showcase an interesting case
which represents Royal College of Physicians and Surgeons of Canada style of questioning. These
rounds are given by one of the cardiology residents in PGY 4-6. Attendance at these rounds are
mandatory for the cardiology residents.
Process:
1) Case of the week will be presented by a cardiology trainee and the presenter will be
assigned by the associate chief and/or designate in advance.
2) Cases presented should be relevant to the field of cardiology and have an
educational impact for the cardiology trainees.
3) Presentations should be in case/question format and engage the cardiology trainees.
4) The presentations should be approximately 30-40 minutes in length allowing for
time to review the pertinent information and answer any questions.
5) Presentations should preferably be stored on the resident room computer, accessible
to all cardiology residents.
Medical Expert
• Be able to systematically approach a clinical problem, generate a reasonable
differential diagnosis and perform a comprehensive focused physical exam.
• Understand utility of imaging techniques (i.e. echo, MRI, CT, ECG), invasive
procedures (i.e. right and left heart cath), and be able to interpret them in the clinical
setting presented.
• Know the therapeutic options pertaining to the clinical topic presented, their
benefits and side effects.
Communicator
1) Be able to present a clinical topic in an interactive format.
2) Speak with clear and concise language, keeping aware of presentation timing
3) Effectively teach other fellow trainees.
Manager
§ Organize time effectively so as to prepare presentation while maintaining other
service, educational, and call duties.
Health Advocate
§ Review cases and understand practical points to enhance future patient care.
§ Understand local practice patterns and local availability of test discussed and
procedures discussed to include in all presentations.
§ Recognize and respond to those issues where advocacy is appropriate.
Scholar
§ Be able to research a topic and conduct a thorough literature search
§ Critically appraise sources of medical information and apply this appropriately any
positions taken in the medical literature
15
§ Be able to synthesize literature review into a concise presentation
§ Understand a topic at the level where presenter is able to facilitate learning of all
members of the audience (staff, trainees and other health professionals)
Professional
Ø Be on time
Ø Effectively teach without criticizing fellow residents
Ø Be prepared for constructive criticism
Ø Exhibit appropriate personal attire and grooming for presentation (see PGME
policy)
16
UNIVERSITY OF MANITOBA
CARDIOLOGY TEACHING FACULTY
Echocardiography
Dr. J. Tam (Section Head of Cardiology, Site Coordinator
HSC), Dr. D. Jassal (Program Director of Adult Cardiology,
resident education for research, resident education for
cardiac CT/MRI), Dr. K. Wolfe, Dr. N. Shaikh, Dr. S.
MacKenzie (Cardiac Anaesthesia), Dr. A. Morris, Dr A. Soni
(resident education for CTU/Consults, undergraduate
coordinator), Dr I Barac, Dr. A. Malik (resident education for
echo).
Nuclear Cardiology
Dr. I Barac (resident education for nuclear medicine)
EP/Devices
Dr. K. Wolfe, Dr C. Seifer (Site Coordinator SBGH), Dr A.
Khadem (resident education for EP), Dr. Clarence Khoo, Dr. A.
Tischenko
Interventional Cardiology
Dr. B. Elbarouni, Dr. J. Ducas (Cath Lab Director), Dr. M.
Kass (Assistant Program Director of Adult Cardiology,
resident education for ambulatory care/ postgraduate
coordinator for residents rotation through Cardiology), Dr.
K. Minhas (resident education for CCU SBH/HSC), Dr. M.
Vo (resident education for cath), Dr. A. Ravandi, Dr. O. Toleva
Adult Congenital Cardiology Dr. R. Soni (Director, resident education for pediatric
cardiology)
Heart Failure/Transplant:
Dr. A. Schaffer
HF/Transplant)
(Director,
resident
education
for
Other
Dr P. Garber (General Cardiology)
Dr S. Zieroth (Heart Failure/Transplant)
Dr. F. Cordova (Heart Failure)
Dr W. Czarnecki (Community cardiology)
Dr. T. Nguyen (General Cardiology, lipid clinic, cardiac rehab)
Dr. Lyle Stronger (resident education for Community
Cardiology)
Members listed in bold above form the Residency Program Committee for the Adult
Cardiology Residency training program at the University of Manitoba.
17
CARDIOLOGY RESIDENCY PROGRAM COMMITTEE
TERMS OF REFERENCE
INTRODUCTION
The Cardiology RPC is responsible for planning, supervising, and evaluating the Adult
Cardiology Residency Training at the University of Manitoba.
COMMITTEE MEMBERSHIP
Faculty Representatives
§ Program Director
§ Assistant Program Director
§ Chief of Cardiology
§ Undergraduate coordinator
§ Postgraduate coordinator for residents rotating through Cardiology
§ Education Director of Research
§ Education Director of CTU/Consults
§ Education Director of Ambulatory Care
§ Education Director of Echocardiography
§ Education Director of Nuclear Medicine
§ Education Director of Electrophysiology
§ Education Director of CCU
§ Education Director of Cardiac Catheterization
§ Education Director of Adult Congenital Cardiology
§ Education Director of Community Cardiology
§ Education Director of Advanced Cardiac Imaging
Resident Representative(s)
• Chief resident (Dr. Mehrdad Golian)
• Assistant Chief resident (Dr. William McIntyre)
• Elected resident (TBA)
MAJOR DUTIES AND RESPONSIBILITIES
The committee meets on a quarterly basis or more frequently if required and reports to the
Section Head of Cardiology at the University of Manitoba and through him/her to the
Chairman, Department of Medicine. The Program Director also sits on the Postgraduate
Medical Education Committee of the Department of Medicine, University of Manitoba. The
major duties and responsibilities for the Cardiology RPC include:
PROGRAM DEVELOPMENT
The Committee is responsible for reviewing the Training Program in Cardiology on an ongoing
basis and at least every two years to ensure:
Ø that the educational goals and objectives of the Program are clearly defined and kept up to
date. It must ensure that the accreditation guidelines of the Royal College of Physicians and
Surgeons are met satisfactorily.
Ø that the Training Program has adequate facilities, personnel and support services to function
adequately.
18
Ø that the resources for patient care and for medical education within the three teaching
facilities are being effectively utilized by the Teaching Program.
Ø that the Training Program is being administered effectively, efficiently, and fairly.
RESIDENT SELECTION
The Committee is responsible for supervising selection of all residents entering the Cardiology
Training Program whether MATH funded or not. This is carried out within the guidelines of the
Faculty Postgraduate Education Committee.
RESIDENT EVALUATION
The Committee has the responsibility of ensuring that:
Ø residents are effectively and fairly evaluated mid way through and at the completion of each
of the rotations.
Ø the In-training Evaluation Reports are completed promptly at the completion of each
rotation, at the end of each year and at the termination of their programs. The final Intraining Evaluation Reports must be completed at the end of the Training Program.
Ø residents have a clearly defined mechanism for appealing evaluations which they feel to be
inaccurate or unfair.
Ø to review all ITERS where residents performances are rated as unsatisfactory or those
rejected by the residents as being inaccurate. Should the residents feel that the decision of
the RTC is unfair, they may appeal to the Postgraduate Medical Education Committee of
the Department of Medicine.
Ø identify early these trainees where clinical competence is deficient, verify and document
these observations and monitor the trainee's progress. Appropriate counselling must be
provided to the trainee and a plan for remediation and management developed.
FACULTY EVALUATION
The committee is responsible for establishing ongoing evaluation procedure to assess how
effectively faculty members are carrying out their teaching and administrative functions within
the various programs.
COMMITTEE ORGANIZATION AND OPERATION
The Committee meets quarterly throughout the year on the third Wednesday of the appropriate
month. Minutes are kept and distributed to the members of the Committee, Section Head in
Cardiology and Director of Graduate Education in the Department of Medicine. The Program
Director has the authority to call meetings of the Committee at any time during the academic
year, when the need arises.
19
CAREER AND STRESS REDUCTION COUNSELING/
HARASSMENT AND INTIMIDATION ISSUES
Career Development Counseling
Early in the recruitment process, career plans are discussed with the Cardiology trainees. Once the
residents begin their training, more formal discussions with respect to their long-term career goals
take place during regularly convened meetings. Career planning is discussed at quarterly meetings
between the Cardiology resident and the program director/ associate program director during the
academic year. These discussions guide the career development planning for the Adult Cardiology
residents. Trainees pursuing a subspecialty within Cardiology including cardiac catheterization,
multimodality cardiac imaging, heart failure or electrophysiology must undergo further training
(usually one or two years). Trainees pursuing an academic career are encouraged to do further
training in one of the aforementioned subspecialties of Cardiology. Trainees pursuing a career in
community cardiology are encouraged to spend clinic time with the local community cardiologists
(of note, Dr. Lyle Stronger, as a community cardiologist is a RPC member to facilitate exposure to
this field).
As part of the core Cardiology academic half day curriculum, dedicated career development
sessions are arranged focused on: i) Community Cardiology: staffing, booking patients, billing,
accounts payable/ receivable; current and anticipated job market ii) Academic Cardiology: how to
create a professional CV, interviewing for fellowship and Staff Cardiology positions, how to
negotiate a contract, billing practices; current and anticipated job market.
Additional resources available for career counselling are offered at the following Faculty of
Medicine websites for the trainees:
(http://umanitoba.ca/faculties/medicine/student_affairs/careerplanningsteps.html).
(http://umanitoba.ca/faculties/medicine/education/pgme/core_curriculum.html)
Additional venues of career counselling include core PGME sessions hosted by MD Management,
educational sessions and networking opportunities for Cardiology trainees at the Canadian
Cardiovascular Congress (national meeting for Cardiology trainees), and one-on-one discussions
with the University of Manitoba Staff Cardiology attendings and Program Director.
The Canadian Cardiovascular Society has a direct members-in-training weblink
(http://ccs.ca/members_training/index_e.aspx) which provides opportunities for fellowship
training/ staff Cardiology positions following the completion of their core Cardiology training.
Stress Reduction Counselling
The Cardiology residents generally approach the Program Director with issues of personal stress
and concern. In addition, other members of the Section of Cardiology are in frequent contact with
the trainees, and may act on their behalf. We anticipate that through frequent direct contact with
the Cardiology trainees, stress related issues can be detected early and an appropriate action
pursued. When an issue with personal stress and distress are identified, avenues to overcome this
are discussed between the program director/ or designate and the resident in strict confidentiality.
The resident may be provided with a leave of absence and is encouraged to receive appropriate
counselling. Formal teaching sessions on stress reduction counselling is provided by Dr. Samia
Barakat (Associate Dean of Professionalism; Department of Psychiatry) within the Core Academic
20
Half day for the Cardiology trainees and the combined Cardiac Sciences teaching sessions on an
annual basis.
Outside the Section of Cardiology, for stress reduction counseling, the Cardiology trainees have
access to venues of wellbeing resources including the annual PARIM Resident Wellness Day in
June of each year and the Faculty Counseling Services (204-789-3328) and MDCARE (204-4801310) under the supervision of Dr. Mark Prober and Dr. Jack Perlov, Psychiatry Department at the
University of Manitoba. Finally, Dr. Bruce Martin, Associate Dean Students, is available to
provide stress counseling (204-272-3186).
Finally, the following websites are additional venues for stress reduction counseling:
(http://www.cair.ca/en/wellbeing/resources/)
(http://www.umanitoba.ca/faculties/medicine/units/faces_places/counselling/index.html)
Department of Internal Medicine: Statement on Resident Harassment and Intimidation
The Department of Internal Medicine strives to create a teaching environment that is open and
responsive to trainee concerns. This includes timely identification of a concern about intimidation
or harassment. Ideally the teaching environment in each program is such that the trainee is
comfortable approaching the Program Director, Section Head or any other member of the Section.
However, out of recognition that this may not be case for all programs, especially where there are
small numbers of trainees, the Department of Internal Medicine has appointed Dr. X as the
Resident Ombudsman. Dr X has a unique role within the Department. The role combines being
an advocate and resource at an individual level for trainees as well as having a proactive role in
terms of addressing issues of resident wellness and equity throughout the Department. The
Ombudsman reports to the Director of Postgraduate Medical Education (PGME) for the
Department of Internal Medicine and is a member of the Postgraduate Medical Education (PGME)
Committee. The Ombudsman is not an active Program Director.
Management of Concerns:
Issues arising within an individual training program should first be addressed by the Program
Director and the Residency Program Committee (RPC). Ideally the trainee should be able to bring
the issues up to the Program Director. Concerns will be investigated in a timely manner and if
they cannot be resolved at an individual level referred to the RPC. In a situation where the trainee
is concerned about raising these issues directly, the Ombudsman is there to be a resource and
advocate. The Ombudsman could, if necessary meet directly with the Program Director or RPC.
Issues that reflect broader Department policies or conduct are more appropriately referred to the
Ombudsman. The Ombudsman in turn would bring the issue to the Director of PGME or the
PGME Committee.
Leave of Absence:
Residents must successfully complete all training requirements of their program, including
duration of training, normally in sequence, and competence as assessed by the university. The
university will set policy for the circumstances that would qualify residents for leaves of absence.
Acting on university policy, the Postgraduate Dean, on the recommendation of the residents’
Postgraduate Program Director, may grant interruptions in training. It is anticipated that the time
21
lost or rotations missed would be made up with equivalent time in the residency program upon the
resident’s return.
RCPSC and CMQ Maximum Allowable Times for Waivers:
It is the responsibility of the Royal College of Physicians and Surgeons of Canada (RCPSC) and
the Collège des médecins du Québec (CMQ) to set maximum allowable times for waivers of
training that would maintain eligibility for certification.
Maximum Allowable times for waivers:
1. Family Medicine – 4 weeks
2. One year program – no waiver allowed
3. Less than one year for remediation or enhanced skills – no waiver allowed
4. Two year program (excluding Family Medicine) – 6 weeks
5. Three year program – 6 weeks
6. Four year program – three months
7. Five year program – three months
8. Six year program – three months
9. For residents taking subspecialty training in the final year of a specialty program in all
provinces (e.g. Internal Medicine and Pediatrics), up to three months is allowable during PGY1-4
only if both the Program Director in the specialty and subspecialty programs agree that a waiver
can be recommended.
22
RESIDENT SAFETY POLICY FOR ADULT CARDIOLOGY
RESIDENTS
This policy applies only during the execution of duties of Adult Cardiology residency training.
Preamble
The Adult Cardiology PGME Training Program (The “Education Committee”) recognizes that
Cardiology residents have the right to a safe working/educational environment during their
residency training. This safe environment includes the domains of physical, emotional and
professional security. The responsibility for the safety of the Cardiology residents is held jointly
by the faculty of Medicine at University of Manitoba, WRHA and other regional Health
Authorities, Clinical Departments, the Cardiology Residency Program, and the residents
themselves. This policy will function in conjunction with any additional policy which is
established by the Faculty of Medicine PGME office.
Key Responsibilities
For Residents: To recognize they have a responsibility for their own safety by being
knowledgeable and compliant with the Residency safety policy, and communicating safety
concerns to the Adult Cardiology Education Committee.
Adult Cardiology Residency Program: To maintain a current Safety Policy and act promptly as
new safety concerns are identified.
1. Physical Safety
•
When traveling by private vehicle for clinical or academic activities, the Cardiology
resident is responsible for ensuring this vehicle is in an appropriate state of repair, their itinerary is
known to others if driving long distances and they are informed of adverse road/ weather
conditions.
•
They must be compliant with Provincial laws pertaining to use of cell phones while driving
private vehicles.
•
Residents should ensure they are well rested before driving distances longer than 1 hour
for clinical or academic activities. The resident is responsible for any call requests to avoid the
potential for excess fatigue. If unavoidable, a travel day may be considered at the start if an out of
city rotation is scheduled. This is at the discretion of the PGME office. In the event of severe
weather or road conditions, residents are expected to use caution for short distance travel and
avoid long distance travel. In this situation, the residents should be in communication with the
Educational Assistant or Cardiology Chief Resident for guidance. If conditions are uncertain, it
would be appropriate for the resident to contact the Adult Cardiology Program Director for
guidance. In addition, the resident should communicate any potential delays to their Attending
physician in order to adjust their daily schedule.
•
Residents should not work alone after hours without the support of Security Services.
•
Residents should not make home visits unaccompanied.
•
Residents should use telephone communication with telephone sets with caller ID
blockers.
•
Residents are encouraged to contact Security Services for any walking outdoors in the
areas of Health Care Facilities and parking lots at night.
•
If a resident is anticipating an interaction with a potentially violent or aggressive patient or
parent, Security Services should be present during the interaction. The resident should also be
23
aware of safe positioning in an examination or interview room to allow for an unobstructed exit in
case of urgent need.
•
Residents will be provided with safe call rooms as per the PARIM contract. Any
deficiencies in regards to fire alarms, smoke detectors, adequate lighting and phone services
should be brought to the attention of the PGME office.
•
Access to these areas will be with coded door access.
•
Residents are responsible for complying with all isolation, and infection control
precautions during patient care.
•
Residents are responsible for being up to date with WRHA and other Regional Health
Authority policies and procedures pertaining to infection control, protocols after exposure to
contaminated body fluids, needle stick injuries and reportable infectious contacts.
•
Residents are responsible for maintaining appropriate immunizations status as per
Occupational Health. This includes flu shots.
•
Residents should be aware of radiation policies within the Regional Health Authority.
•
Residents who are pregnant should be aware of added risk prevention for themselves and
their foetus. Further consultation with Occupational Health may be advised.
2. Psychological Safety
•
All work and learning environments must be free from intimidation, harassment and
discrimination, as per the Policy at the Faculty of Medicine at the University of Manitoba. (see
the guidelines for Conduct in Teacher-Learner Relationship, and Professionalism at the Faculty of
Medicine: University of Manitoba)
•
Residents are encouraged to come forward with any concerns regarding their psychological
safety, or well being. Support services are available as per the Faculty of Medicine, Student
Mental Health Services, the Cardiology Mentorship Program, Doctors Manitoba Physician at Risk
Help Line, and the Cardiology Program Director. Residents should be advised of the availability
of leaves of absence as per University of Manitoba Policy.
3. Psychological Safety
•
All residents are entitled to a culture of safety and respect, as per the WRHA Respectful
Workplace Policy. Any act of discrimination based on religion, gender, race, age, color, physical
or health condition, (not limited to this list), should be reported to the PGME Office and Program
Director . Residents are encouraged to be familiar with this policy and procedures if situations
arise which fall under this provision. They can expect prompt attention with any matter which
arises.
•
The Cardiology Residency Program will follow all allowances for Religious Holiday as
per the PARIM contract.
•
The residents shall be encouraged to participate in any debriefing of Critical Incidents
which occur, without fear of negative consequence.
•
Residents shall be guaranteed confidentiality for any critical incidents in which they are
involved. Th e exceptions to this would include any severe incident where their or others safety is
compromised and is reportable to Associate Dean of Postgraduate Medicine, WRHA, or the
CPSM.
•
Residents shall be guaranteed confidentiality of all Personal Information within their
Personal Files within the PGME Office, as per PHIA.
•
Residents will be guaranteed any feedback they provide regarding their teachers, rotations,
or clinical experiences, will be anonymous, as per the guidelines set out by the RCPSC.
•
Residents must be members of CMPA.
•
Residents must have current educational licenses from the College of Physicians and
24
Surgeons of Manitoba
4. Additional Resident Safety Policies
(http://umanitoba.ca/admin/governance/governing_documents/community/669.htm).
(http://www.wrha.mb.ca/professionals/safety/index.php)
(http://www.wrha.mb.ca/professionals/students/index.php)
WRHA Policy and Procedures
Section 2- Occupational Health
•
Immunization and Tuberculin Testing
•
Sharps, Safe handling, use and disposal
•
Bed Bug Protocol
•
Blood and Body Fluid- Exposure Protocol
•
Biological Hazards Prevention and Control
•
Infection Prevention and Control Manual
•
Emergency Eye Wash
•
Respiratory Protection- Personal Protective Equipment (N95 Respirator)
•
Working Alone or in Isolation
•
Respectful Workplace Program
•
X-ray Safety
University Of Manitoba:
•
Respectful Work and Learning Environment
•
Health and Safety- Students
•
Faculty of Medicine Guidelines for Conduct in Teacher – Learner Relationships
•
Violent or Threatening Behaviours- Policy and Procedures
25
ASSESSMENT AND EVALUATION OF ADULT CARDIOLOGY
RESIDENTS
Evaluation strategies are critical in the implementation of any educational initiative. While
resident evaluation permits the assessment of competency, it also plays an essential role in
motivating and directing the learning process, and in providing feedback to program directors for
program evaluation. The development of new roles, educational electives, or objectives must be
accompanied by effective evaluation strategies. The evaluation system must demonstrate
accountability to the Royal College directly, and indirectly to the community within which future
specialists will practice.
These evaluation strategies are judged in terms of accountability, validity, reliability and
feasibility. Testing methods must be accountable to those involved, and decisions must be
defensible. A valid assessment tool measures competency that it is designed to test. Reliability
is a measure of reproducibility that is achieved through the reduction of testing error. Finally, an
accountable, reliable and valid testing must be feasible in terms of its cost in human and physical
resources. There is no single assessment strategy that meets all of these criteria; multiple
assessment strategies and compromises in terms of strengths and weaknesses are therefore
necessary. There are numerous methods for the testing of Cardiology resident clinical
competency. Depending upon the circumstance, they vary in terms of their psychometric qualities
and utility.
Cardiology residents in all years of training will be subject to the evaluation process. Using the
above principles of evaluation, the evaluation techniques are used to assess Cardiology Resident
performance at the University of Manitoba includes:
1. ITERS
Cardiology residents are effectively and fairly evaluated mid way through and at the completion of
each of the rotations by the Staff Cardiology attendings and allied health care personnel using
standardized ITERS. The in-training evaluation system utilizes the standard ITER from the PGME
office, which is organized in the CanMEDS format. The Program Assistant aligns the residents’
rotation schedule with the faculty clinical schedule and ensures that the appropriate faculty
member/ allied health care personnel has the ITER(s) that will be required for that rotation. The
faculty member/ allied health care personnel receives the ITER approximately one week before
the end of his/her time with that resident. The faculty member/ allied health care personnel is then
responsible for completing the ITER and discussing the evaluation with the resident. The ITER is
also used for evaluation during elective rotations. The Program Director reviews ITERs as they are
received from faculty members to ensure that no problems have arisen and not discussed fully
with the resident. If such a situation becomes evident, then the Program Director speaks directly
with the appropriate faculty member to ensure that such a discussion does take place. In some
instances, problem evaluations may also be discussed by the RPC faculty in order to arrive at a
satisfactory resolution.
The Program Director and RPC will identify trainees where clinical competence is deficient,
verify and document these observations and monitor the trainee's progress. Appropriate
counselling will be provided to the trainee and a plan for remediation and management developed.
Residents have a clearly defined mechanism for appealing evaluations which they feel to be
inaccurate or unfair. The RPC review all ITERS where residents’ performances are rated as
unsatisfactory or those rejected by the residents as being inaccurate. Should the residents feel that
26
the decision of the RPC is unfair, they may appeal to the Postgraduate Medical Education
Committee of the Department of Medicine.
2. Monthly written, biannual graphics examination, and biannual oral examinations
Cardiology residents successfully complete a RCPSC style written examination on a monthly
basis. The trainees also participate in graphics and OSCE style examinations twice a year
covering the CANMEDS pillars. The exams are set by the Program Director and members of the
RPC in the Section of Cardiology at the University of Manitoba. Additionally, the Cardiology
residents at the University of Manitoba participate in the annual WECREEP examination which
assesses all of the Cardiology trainees in Western Canada.
The Cardiology Resident will be expected to perform at an appropriate level on all exams.
Failure to perform at an appropriate level will result in remediation (see remediation guidelines).
Consistent comments about difficulties in clinical areas or with communication issues will also
require remediation. If the identified problems are not successfully remediated, the program
director will not be able to issue a final ITER at the completion of training. The program may
also begin the process to place the resident on probation (see document on probation process).
Other activities during the training program which are subject to evaluation:
1.
Presentation at Cardiology Grand Rounds, Echo Rounds, Device Rounds, Complex Patient
Care rounds, Junior resident teaching rounds, Journal Club and other teaching rounds.
2.
Teaching activities (undergraduate and junior house staff).
3.
Regular attendance at various teaching sessions.
4.
Research projects
5.
Communication skills.
6.
Procedural skills.
3. Summary Evaluation
Bi-annually, all Cardiology residents receive a Summary Evaluation following a one-on-one
meeting with the Program Director. This will entail data collection from all available resources
including ITERS, allied health care staff, secretaries, transcriptionists, 360 assessment, and written
evaluations of various presentations. This will be constructed by the Program Director and
reviewed within a formal meeting with the resident.
27
REMEDIATION AND PROBATION PROCESS FOR
CARDIOLOGY RESIDENTS AT THE UNIVERSITY OF
MANITOBA
The Adult Cardiology Residency Training Program has established educational goals and
objectives for its trainees. The expectations of the program regarding objectives for intellectual,
technical and attitudinal areas are clearly set out in the University of Manitoba Adult Cardiology
Residency Training Manual.
The program expects that attending physicians will provide an evaluation to Cardiology residents
if they are exposed to the resident on a rotation. The attending physician must communicate these
evaluations verbally and in writing to the resident. The evaluation form must be electronically
signed by the evaluator and by the resident to indicate that the resident has received the evaluation.
The resident’s signature does not indicate agreement with the evaluation; it only acknowledges
that the resident has seen the evaluation.
Bi-annually, all Cardiology residents receive a Summary Evaluation following a one-on-one
meeting with the Program Director. This will entail data collection from all available resources
including ITERS, allied health care staff, secretaries, transcriptionists, 360 assessment, and written
evaluations of various presentations. This will be constructed by the Program Director and
reviewed within a formal meeting with the resident.
Remediation
If deficiencies in a Cardiology resident progress are noted during the evaluation process, these
must be discussed with the Cardiology resident and the Program Director. The Program Director
and RPC should embark on a remediation process with the resident.
1.
Specific remediation activities must be proscribed to address the deficiencies noted in the
resident’s progress.
2.
These remediation activities must be designed to help the resident enhance their
performance.
3.
The assigned remedial period shall be no longer than the rotation on which performance
was deemed unsatisfactory, and no shorter than half a rotation.
4.
The specific remediation prescription must be documented in writing, and there must be
written evidence the resident has agreed to the remedial plan.
5.
The program director and the resident will both receive written copies of the remedial plan.
6.
If remediation results in satisfactory improvement, this must be documented with copies
provided to the resident and to the program director.
7.
If the deficiency remains at the end of a period of remediation, there are two options:
a) A further period of remediation following the same process as outlined above with the
same requirements for documentation.
b) The program may decide to proceed with Probation as outline in the section on
Probation (see below).
28
Probation
The Program Director and RPC need to approve the establishment of a committee to decide if
grounds exist to place a resident on probation in the following circumstances:
1. After one or more periods of remediation there still exists a significant deficiency in
resident performance (i.e. remediation has been unsuccessful).
2. If the Program Director believes that there is a very serious concern about a resident’s
performance for reasons of impairment of function, ethical or legal violations, or
unprofessional conduct.
The resident will be notified that this process has been initiated. If there is reason to believe the
resident’s deficient performance results from mental or other illness, the program and supervisors
have a responsibility to recommend that the resident seek appropriate professional care. Time off
due to illness will be negotiated among the Program Director, Associate Dean, and the
Cardiology resident. The provisions of the PARIM contract and the guidelines of the Royal
College of Physicians and Surgeon’s must be considered.
Composition of the committee to consider probation:
1
Minimum of three members.
2
Faculty regulations suggest that two should be “impartial” staffs that have not supervised
the resident in question. In most cases, this will mean involving physicians from outside the
Section of Cardiology to sit on this committee.
3
There should be at least one resident member on the committee. The resident could be
from outside of the Cardiology training program as well.
4
The Faculty of Medicine should be asked to provide a chair for this committee who will be
a “consultant on due process” with expertise in the application of the probation policies.
Mandate of the committee:
1. Review relevant documentation (evaluations, remediation plans, remediation evaluations,
written submissions from the resident, program director and supervisors)
2. May decide to hear oral submissions from the resident, program director and supervisors.
3. Decide if the resident should be placed on probation. The resident and program director
must be informed in writing of the decision of the committee.
4. If the committee decides upon probation it must establish the probationary time period,
and must develop a specified and detailed remediation plan.
5. The remediation plan should outline specific educational tasks in the areas of knowledge,
practice of skills, and supervision arrangements. The plan may circumscribe, limit, or set
conditions on the amount and type of patient contact the resident will have during the
probation and remediation period.
6. The committee must establish a mechanism to evaluate the remediation plan and the
improvement agreed to before embarking upon remediation.
If the committee does not recommend probation the resident and the program director must be
informed and the resident will proceed normally. If the committee does recommend probation the
process outlined above will be followed.
29
If a resident is placed on probation and performs satisfactorily the committee can recommend that
the probation be terminated. If the resident is placed on probation and is still performing
unsatisfactorily after the remediation period the committee has the following options:
1
2
Recommend a further period of remediation
Recommend that the resident be terminated from the program.
Termination from the Adult Cardiology Residency Program
If the probation committee concludes that the probationary remediation attempt(s) have been
unsuccessful in addressing the deficiencies in knowledge, skills, or professional conduct the
committee may advise the program director that the resident should be terminated from the
program. The program director must inform the resident of this decision.
Termination from the program may be appealed by the resident to the Faculty Postgraduate
Medical Education Committee as outlined in the section on appeals.
30
INDUSTRY RELATIONS AND QUALITY ASSURANCE/
IMPROVEMENT
Industry Relations
The Section of Cardiology strictly follows the University of Manitoba and Canadian Medical
Association guidelines on physician interaction with pharmaceutical companies (see Appendix 7).
Direct approaches by pharmaceutical representatives to Cardiology trainees are strongly
discouraged. Any teaching activity planned by pharmaceutical companies must be approved by the
Program Director and the Section Head of Cardiology at the University of Manitoba.
Quality Assurance and Improvement
On an annual basis, the Cardiology residents have formalized teaching on the topic of quality
assurance and improvement. With the support of the Winnipeg Regional Health Quality Assurance
and Improvement department, educators are invited to the Combined Cardiac Sciences Academic
Half day to provide lectures on QA/QI in three continuous modules. It is mandatory for the
Cardiology trainees to attend these lectures.
Additionally, each Cardiology resident is involved in a number of ongoing QA/QI projects within
the Section of Cardiology at SBGH. Recent projects in 2012-2013 have included: i) Audit of
venous thromboembolism prophylaxis in Cardiology patients admitted to the ward and CCU; ii)
“Time Out” program for the effective transfer of cardiac patients from the cath lab to the intensive
care unit; iii) Code Blue in the cath lab; iv) 2P program for understanding patient flow for the
development of the new acute cardiac care unit at SBGH; v) EPR (electronic patient record) order
sets for admitted Cardiology patients; vi) Code STEMI program.
Finally, on a monthly basis, section members from Cardiology, Cardiac Surgery, Cardiac
Anesthesia and allied health care meet at the Cardiac Sciences Quality Assurance/Improvement
rounds to discuss morbidity and mortality cases within the program. As of September 1, 2011, the
Cardiology trainees formally attend these monthly rounds. In addition, the 2013-2014 core
curriculum from the University of Manitoba Faculty of Medicine PGME department provides a
number of courses that address quality assurance/improvement including the teach development
program, conflict management in medicine, residents and the learning environment, and conflict
management in medicine.
31
CARDIOLOGY CHIEF RESIDENT DUTIES
The Chief Resident for the Cardiology residency-training program is responsible for
administrative duties, teaching duties, as well as resident advocacy and representation at the
postgraduate level.
1.0)
Administrative Responsibilities
1.1) Call schedule
• The Chief Resident is responsible for creating the monthly cardiology resident call
schedules for both the cardiology fellows and junior residents. See “Call rules” document
for instructions on call schedule creation to maintain call schedules in accordance with
PARIM contract specifications.
• The Chief Resident is responsible for setting a date to collect call requests prior to the call
schedule creation. Call request dates can be set at the discretion of the Chief Resident but
should allow at least 2 weeks time for residents to submit call requests prior to schedule
creation.
• Call schedules should ideally be created in 3-month blocks and sent out to the residents at
least one month prior to the start of their rotations.
• The Chief Resident is responsible for making last minute changes to the call schedule
should there be any unforeseen circumstances that require re-assigning or re-creating the
call schedule.
• The Chief Resident is responsible for maintain a running tally of all the call assignments
each resident has had in an academic year. This includes: the total number of calls, number
of weekend calls (Friday, Saturday, Sunday) as well as number of holiday/STAT day calls.
• The Chief Resident is responsible for equally distributing calls amongst the residents. This
is to ensure that, within reason, no one resident is assigned to more call days including
weekend calls or holiday calls then the others.
1.2) Resident Assignment
• When requested by the program director or RPC committee, the Chief Resident is
responsible for assigning the cardiology fellow to present Cardiology Journal Club,
Cardiology Grand Rounds.
• When assigning the Cardiology Fellows to prepare presentations the Chief Resident must
be mindful of the first year cardiology fellows who will be writing their Royal College
exam for Internal Medicine in the spring. Ideally the first year cardiology fellows should
prepare presentations in late fall or early winter (October-January) to avoid overlapping
presentation preparation with exam studying/writing.
• When requested by the program director or RPC committee, the Chief Resident is
responsible for assigning the cardiology fellows to attending the Standards Committee
meetings.
1.3) Resident Organization
• The Chief Resident may be asked to help ensure appropriate attendance and participation
of the other cardiology fellows at teaching rounds. Including but not limited to Case of the
Week, Grand Rounds and Journal Club.
2.0) Teaching Responsibilities
32
2.1) Junior Resident Teaching
• The Chief Resident is responsible for creating a teaching schedule, assigning the third year
cardiology fellows (C3) as well as the Associate Chief Resident (usually C2) to Friday
morning teaching sessions with junior residents.
• The Chief Resident is responsible for ensuring the content of each teaching session is
appropriate to the level of the junior residents as well as maintain a list of topics covered,
(A fib, CHF, post MI care, STEMI, etc.)
• The Chief Resident is also encouraged to perform impromptu teaching sessions for the
junior residents on duty, as long as it does not interfere with the junior resident clinical and
academic duties.
2.2) ECG Rounds Teaching
• The Chief Cardiology Resident is responsible for running ECG rounds, Thursday mornings
8:00-9:00. Should the Chief Resident be unavailable they must appoint another resident to
direct ECG Round. This may be the Associate Chief Resident or another senior cardiology
fellow.
• The Chief Resident should prepare/have available at least 5 ECG teaching cases for rounds
and ensure that the group read, interpret and discuss several ECGs each session.
3.0) Resident Advocacy and Representation
3.1) Resident Representation on RPC and Section Meetings
• The Chief Resident is responsible for attending all RPC meetings and Cardiology Section
meetings to voice resident issues and concerns.
• When requested, the Chief Resident is responsible for informing the other Cardiology
fellows of changes or issues brought up by the aforementioned committees, as it pertains to
the training program.
• The Chief Resident may be requested to sit on other committees to endure appropriate
resident representation.
3.2) Liaison with the Cardiology Program Directors and Staff
• On an ongoing basis, the Chief Resident will liaise with the cardiology program director(s)
and cardiology fellows regarding issues with the training program.
o Issues with call
o Issues with running CTU, CCU, Consults
o Concerns regarding the educational content of the program
o Concerns with resident behavior/treatment
• When required the Chief Resident may act as an intermediary between the staff
cardiologist and trainees to address concerns from either party. This will be done with the
council and knowledge of the cardiology program director.
33
CARDIOLOGY CALL RULES FOR THE
CHIEF CARDIOLOGY RESIDENT
The following rules apply to scheduling 24-hour in-house call for the cardiology service at the St.
Boniface Hospital, Winnipeg Manitoba. These rules have been developed to up-hold the PARIM
contract working requirements while providing the best possible patient care.
Call Rules:
1) Residents are not to be on call more then 2 weekends a month
a. Per PARIM contract all residents must be given 2 weekends off per month
b. Weekend days include: Friday, Saturday, Sunday
c. This means a resident can work Friday, and Sunday of the same weekend and
Friday or Saturday or Sunday of another weekend, as they would still have 2 full
weekends off
2) Maximum 7 calls per month
a. In Emergency cases residents may do up to 8 or 9 calls a month
b. Residents cannot be post call the first day of their vacation. If a resident is post call
the first day of their vacation, they are entitled to a statutory holiday day at the
discretion of the program director.
3) Cardiology fellows and Juniors cannot be on call together if they are both on CCU, CTU or
Consults (leaving the service underserviced the post call day)
a. Exceptions of Friday and Saturday call or the day preceding a Statutory holiday
4) Typical call assignments for Fellows: (Assuming 3 cardiology fellows/year)
a. C1 = 5 to 7 per month
b. C2 = 3 to 4 per month
c. C3 = 1 per month (No call on pseudo-attending)
Call over the years for Fellows: (Assuming 3 cardiology fellows/year)
a. C1 typically do 65 to 70 calls in a year with 21-25 of those call being weekend days
b. C2 typically do 40 to 45 calls in a year with 20 to 25 weekend days
c. C3 typically do 10 to 12 calls in a year with 3-5 weekend days
5) The Fellow on CCU cannot be on call Monday – This would put him/her post call on
Tuesday when the IM residents are on half day.
6) Do not put a resident on call 1 in 2 if avoidable
a. Example: Do not put a resident on call Monday and Wednesday of the same week.
7) If the junior resident has an academic full day (or academic half day) the other junior
resident on service with them (CCU, CTU or Consults) cannot be post call the day of the
first junior resident’s academic full day/half day
a. Example: If there are 2 residents on consult service and one is on academic full day
Wednesday, the other resident cannot be on call Tuesday (Post call Wednesday)
leaving the service understaffed Wednesday.
8) During the time period of the Royal College exam for Internal Medicine, (Typically April,
May-June) the C1 residents should only be placed on call 4 times in the month leading up
34
to the exams to allow them study time. The C2 and C3 residents will cover the remaining
call.
Call Suggestions:
1) Avoid putting residents on call the night before their academic half day more then once per
rotation
2) Avoid putting residents on consecutive weekends
3) Avoid putting very new junior residents (R1 in first 3 months of residency) on call the first
day of a rotation
4) Avoid putting residents on call 2 Saturdays in the same rotation
35
CARDIOLOGY CHIEF RESIDENT: HOLIDAY COVERAGE
Holiday Periods:
The cardiology fellows and junior residents will have 5 consecutive days off service during period
7 for either the “Christmas” or “New Years holidays”. The “holiday period” typically consists of
3 statutory holiday days attached to a 2-day weekend where a resident is not placed on call and not
required to attend work. This results in 5 consecutive days off. The fellows and junior residents off
for one of the “holiday periods” will be working on the core cardiology services during the other
“holiday period”.
There are typically 2 days between the “Christmas holidays” or “New Years holidays” and these
days fall outside the “holiday period”. Both cardiology fellows and junior residents will be
expected to attend their regularly scheduled rotation for period 7 on those days. (e.g. Echo, Cath,
electrophysiology etc.)
A resident can volunteer to work both “holiday periods” and may then bank the 3 statutory holiday
days for use at a later date providing the program director and chief resident approve.
Fellow Coverage:
Fellows will be assigned to services (either CCU, consults or wards) for each holiday day and will
not be on their scheduled rotation for period 7 during the “holiday period”. All fellows are
expected to arrive in CCU at 8 AM to receive sign over from the fellow on call the preceding
night. Once sign over is completed the remaining work is to be divided up between the fellows
and each fellow will return to their assigned service for the day (Ward, CCU or Consults).
If more then one fellow is assigned to a service both fellows will work on that service until all the
patient care and related work is completed. Once all work on a service is completed (e.g. rounding
on all ward patients, performing all new admission and completing all notes and orders), then the
fellows assigned to that service will check in with the other services (Ward, CCU, Consults) to
help out with any outstanding work, patient care or procedures.
Daily service hours are from 8:00AM to 5:00 PM, however after 2PM, and only once all the work
on each service is complete the fellows may check in with the “ON CALL” fellow for that evening
and sign over.
Junior Coverage:
Junior residents will be assigned to services for each holiday day. All junior residents are expected
to arrive in CCU at 8 AM to receive sign over from the cardiology fellow and junior resident on
call the preceding night. Once sign over is completed the remaining work is to be divided up
between the junior residents and each will return to their assigned service for the day (Ward, CCU
or Consults).
CCU coverage is the priority and junior residents will be assigned so there is always a resident in
the CCU, (junior residents from any service are eligible to cover CCU). Junior residents on CCU
for period 7 will typically be assigned to CCU service over the holiday period.
Junior residents on Consult service or Ward service during period 7 are eligible to cover CCU,
cardiology wards and cardiology consult service during the holiday period. Typically junior
36
residents on Consults will be assigned to cover the Ward and vise versa should there be an excess
of residents on once service for a particular day.
Once all work on a service is completed (e.g. rounding on all ward patients, performing all new
admission and completing all notes and orders), then the junior resident assigned to that service
will check in with the Senior Cardiology Fellow and be assigned to help out with any outstanding
work, patient care or procedures.
Daily service hours are from 8:00AM to 5:00 PM. Once all the work on each service is complete
the junior residents may check in with the “ON CALL” fellow and junior resident for that evening
and sign over.
37
EDUCATIONAL AIMS AND OBJECTIVES (SPECIFIC)
SUBSPECIALTY TRAINING PROGRAM IN CARDIOLOGY
UNIVERSITY OF MANITOBA
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Ambulatory Care
Education Director: Dr. Malek Kass
Introduction:
Two periods of Ambulatory Care (each in C1 and C2) and one continuity clinic (in the C3 year)
will take place in the 3 year training program in Adult Cardiology at the University of Manitoba.
This rotation will primarily take place in the cardiac outpatient clinic area at St Boniface Hospital.
Residents will also have an opportunity to attend clinics with some of the Community
Cardiologists in Winnipeg in C1 and C2 (Dr. Lyle Stronger is the education director for
Community Cardiology). The primary purpose of the clinics is to expose residents to nonemergent patients referred for cardiac consultation. During the clinic visits, the residents will also
be exposed to post hospital discharge, follow-up patients, patients returning for regular follow-up
of chronic cardiac conditions, and exposure to patients assigned to specific clinics including
congestive heart failure, transplant, adult congenital clinic, lipid disorders, and syncope. The
resident is expected to attend clinics for a minimum of 6 half-days per week for a total of 24 half
day clinic within a single ACF rotation. Of the 24 half day clinics, it is mandatory to attend a
minimum of 3 clinics per ACF rotation in the community setting.
CanMED 2005 Roles
Medical Expert:
•
Understand the clinical presentation, natural history, and prognosis of out-patient cardiac
conditions seen in various general and subspecialty clinics
•
Know the diagnostic tools available to investigate cardiac conditions
•
Understand the indications and pharmacology for use of cardiac medications
•
Know the indications and contraindications for cardiac diagnostic tests and interpret these tests
in the context of their patient's cardiac condition
•
Identify and treat IHD risk factors
•
Enhance cardiac history and physical exam skills and their pathophysiology correlation
Communicator:
•
Be able to inform patients and family about their problem, prognosis, management and followup using non-medical terminology
•
Be able to dictate concise and informative letters to referring physicians
38
Collaborator:
•
Work with nursing and other clinic staff
•
Perform tasks reliably
Manager:
•
Precise, cost-effective, evidence-based medicine
•
Organize time effectively to keep on schedule with patient appointments
Health Advocate:
•
Prioritize patient appointments based on clinical factors
•
Identify and treat cardiac risk factors
•
Educate patients in heart healthy lifestyles
•
Provide vocational counseling for patients with cardiac illnesses
Scholar:
•
Recognize gaps in knowledge regarding patient problems and develop strategies to fill the gap
through reading and consultation with other health care team members
•
Schedule reading timetable and comply with schedules for life long learning
•
Familiarize with tools such as Medline
Professional:
•
Deliver care with integrity, honesty, and compassion
•
Understand the professional, legal, and ethical codes to which physicians are bound
•
Be prepared for constructive criticism
Duties:
C1 and C2 Blocks:
• The resident is expected to attend clinics for a minimum of 6 half-days per week for a total of 24
half day clinic within a single ACF rotation. Of the 24 half day clinics, it is mandatory to attend a
minimum of 3 clinics per ACF rotation in the community setting.
• The resident is expected to attend cardiology core curriculum lectures and all other mandatory
rounds and lectures while on this block
• A clinic schedule will be provided by the program administrator
• The resident is expected to attend am clinics from 0800 am (or later depending on clinic) and
pm clinics from 1300 pm
• The resident will see new referrals as well as follow-up patients
• The resident will perform a clinical assessment and formulate a management plan in a
reasonable period of time
• The residents will also be expected to order the appropriate tests and follow up with the results of
these tests including the reviewing of the echocardiograms, various non-invasive arrhythmia
monitors, stress testing, nuclear imaging, as well as results from cardiac catheterization. All new
39
referrals will be reviewed with the attending Cardiologist
• The resident is expected to dictate a clear, concise letter for each patient assessed and to proof
read their letters
C3 Longitudinal Continuity Clinic:
• Residents will work with 1-2 staff cardiologists for the year to allow patient follow up once
residency completed, simplify test ordering and follow up, and allow evaluation.
• Attendance is mandatory unless: A) resident or staff vacation; B) pseudoattending rotation; C)
conference leave. Residents are excused from non-pseudoattending rotations. Residents will
not be post call for their clinic (chief resident to mandate/arrange.)
• In order not to overlap with other mandatory academic activities, clinics will be limited to
Tuesday AM or PM, Wednesday PM, or Friday AM or PM.
• Only General cardiology clinics will be permitted. Specialty clinics (EP, CHF, etc.) will be
discouraged. The RPC committee will determine appropriate staff cardiologists for supervising
the longitudinal clinic.
• Approximately 5 patients will be scheduled for the 1/2 day clinic.
• The staff attending cardiologist will be responsible for populating the clinic with a mix of new
consults and follow up patients seen by the resident.
• As the Royal College requires 3 periods of ambulatory care, a full year of continuity clinic will
count towards 1 ACF rotation
Assessment:
•
•
•
Daily feedback
Log sheets be reviewed by attending Cardiologists and forward to Kathy van der Vis at the end
of the rotation.
Completion of on-line web evaluation at the end of each rotation
40
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Cardiac Catheterization
Education Director: Dr. Minh Vo
Introduction:
A total of three periods are spent in the cardiac catheterization laboratory during the 3-year
training program in Adult Cardiology residency training at the University of Manitoba. The cath
rotation is performed at St. Boniface General Hospital where there are 3 labs. Each lab is equipped
with the ability to perform right and left heart catheterizations, selective coronary angiography,
percutaneous coronary interventions, myocardial biopsies, and percutaneous structural
interventions.
The residents are exposed to coronary artery disease, both acute and chronic coronary syndromes,
and all forms of valvular heart disease including hemodynamics. They are also exposed to
percutaneous coronary interventions, intravascular ultrasound, fractional flow reserve, intra-aortic
balloon pump insertion, and temporary pacemaker insertions. The resident does have the option of
performing additional time in the third year if desired. Additional time in the Cath Lab is strongly
encouraged if the resident is contemplating a fellowship and career in Interventional Cardiology.
During the academic year, two forms of cath related teaching sessions are scheduled, including
Hemodynamics rounds and Cath Potpourri rounds.
1. Hemodynamics Rounds
Hemodynamic rounds are presented once every two months on Thursday (0800-0900) from
September through June of the academic training year. It is aimed at the level of the Cardiology
residents and designed to showcase hemodynamics pertaining to the Royal College of Physicians
and Surgeons of Canada Objectives of Training in the Subspecialty of Adult Cardiology.
Attendance at these rounds are mandatory for the Cardiology resident trainees. The topics to be
covered in the hemodynamic rounds include:
i)
Hemodynamics: normal and abnormal systemic and pulmonary flows, pressures, and
resistances
ii)
Pulmonary hypertension
iii)
Pathophysiology and hemodynamics of valvular stenosis and regurgitation
iv)
Cardiomyopathies including dilated, hypertrophic, and restrictive disease
v)
Effects of pericardial disease on cardiac hemodynamics and function
vi)
Congenital heart disease including intra-cardiac shunt calculations
2. Cardiac Cath Potpourri rounds
Cardiac cath potpourri rounds are presented monthly on Monday (1200-1300) from September
through June of the academic training year. It is aimed at the level of the Cardiology residents and
designed to showcase interesting cardiac cath anatomy pertaining to the Royal College of
Physicians and Surgeons of Canada Objectives of Training in the Subspecialty of Adult
Cardiology. Attendance at these rounds is mandatory for the Cardiology resident trainees. The
topics to be covered in the potpourri rounds include:
41
i)
ii)
iii)
iv)
v)
Normal coronary anatomy
Coronary artery disease including saphenous vein grafts
Common congenital coronary anomalies
Ventriculography for determination of cardiac function, valvular abnormalities, and
congenital heart disease
Pulmonary angiography
On an annual basis, the Cardiology residents will also receive a lecture on radiation safety.
Medical Expert:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Know the indications for cardiac catheterization and percutaneous and surgical
revascularization
Know the rationale of the pharmacotherapy available in the treatment of angina and
unstable coronary syndromes in the Cardiac Catheterization Laboratory
Know indications for urgent catheterization and intervention in unstable coronary
syndromes
Know the indications for urgent cardiac catheterization for left ventricular dysfunction,
valvular heart disease, and infective endocarditis
Demonstrate diagnostic skills at the bedside which allow accurate diagnosis and
assessment of underlying cardiac pathology
Understand the clinical presentations, natural histories, and prognosis of various forms of
valvular heart disease, congenital heart disease as well as pericardial disease based on
hemodynamic findings
Know the indications for cardiac catheterization and appropriate timing for surgical
intervention of various forms of valvular, coronary, congenital, and pericardial diseases
Demonstrate the confidence to perform right heart catheterization, pericardiocentesis, and
transvenous pacemakers
Know potential complications and management of cardiac catheterization, pacemaker
insertion and coronary intervention
Demonstrate confidence in obtaining arterial hemostasis following arterial sheath removal
and the ability to deal with complications of arterial cannulation
Know how to calculate intracardiac shunts, valve areas, vascular resistance and
transpulmonary gradients
Recognize basic coronary angiographic anatomy including major coronary artery, their
branches and common anomalies
Recognize and grade angiographic severity of valvular heart disease
Recognize and grade left ventricular function
Recognize and treat acute cardiac and non-cardiac complications of cardiac catheterization
42
Communicator:
•
•
•
•
•
Obtain and synthesize relevant history from patients and their families – present the history
to attending physicians prior to patient’s cardiac catheterization
Be able to inform the patient and their family about their cardiac condition, its prognosis,
management and plans for follow-up
Write a report of the procedure results on the chart
Be able to write consultation and discharge letters to referring physicians including
angiographic findings and recommendations
Review angiographic findings with junior residents
Collaborator:
•
•
•
Work with the attending physician, nurses, cardiopulmonary and X-ray technicians in the
Cardiac Catheterization Laboratory
Work appropriately with nurses in the Pre Admission Unit, Pre and Post area, and Wards
prior to cardiac catheterization
Collaborate with other members of the health care team including junior residents
Manager:
•
•
•
Utilize catheterization laboratory equipment and time in an efficient manner - work
closely with booking and triage office for appropriate scheduling
Respect and adhere to both the laboratory schedule and the patients' needs for timely
examination
Understand the indications and contraindications of cardiac catheterization
Health Advocate:
•
•
•
Help patients identify risk factors and implement strategies for secondary prevention
Review the triage system for patients undergoing cardiac cath and prioritize based on
clinical details
Understand the importance and measurements of outcomes for invasive procedures –
including attending quarterly morbidity and mortality rounds
Scholar:
•
•
Recognize gaps in knowledge base and use appropriate materials (ie textbooks, journals,
web-based systems) to fill – present articles on invasive cardiology at journal club
Provide instruction to other health care professionals, including referring physicians, on the
results of hemodynamic testing
43
Professional:
•
•
Deliver care with integrity, honesty, and compassion – follow role models and mentoring
of the senior attending physicians and their interactions with patients
Understand the professional, legal and ethical codes to which physicians are bound
Duties:
•
•
•
•
•
•
•
•
•
•
•
It is expected that the resident will be present for the entire lab schedule except during the
cardiology core curriculum lectures and all other mandatory rounds and lectures
All assigned readings must be completed by the end of the rotation
The residents are required to spend a minimum of 3 days in the cath lab each week
The resident is expected to see all patients prior to cardiac catheterization and perform a
history and physical examination with appropriate orders. The resident must identify the
indications and contraindications to cardiac catheterization and ensure that any potential
complications are minimized by prophylactic treatment
The resident will spend their time with physicians performing both diagnostic and
interventional procedures including right and left heart catheterization
The resident will be expected to manage the arterial puncture site following sheath removal
The resident will need to acquire the skills to deal with procedural complications including
o allergic dye reactions,
o arterial site hematomas,
o cerebral vascular accidents
o other acute cardiac emergencies including acute coronary syndrome, congestive
heart failure, and cardiac arrhythmias.
They will also be responsible, in conjunction with the attending cardiologist, to provide
appropriate feedback to the patient and their families and make appropriate referral for
surgery or percutaneous coronary intervention.
4 half-days in the first cath rotation period is spent in pre-and-post for sheath and
hemostasis management.
1 half-day per cath rotation period is spent with waitlist coordinators to understand aspects
of waitlist and triaging cath lab requests.
At least one mandatory 10-min presentation at complex case round during each cath
rotation.
Specific responsibilities of the cardiology resident in the first year (C-1) include:
•
Learning the indications, contraindications, and complications of cardiac catheterization
•
Learning about the various types of catheterization dyes including indications,
contraindications, and complications
•
Learning how to assess and prepare a patient for cardiac catheterization (i.e., history,
physical, and orders)
•
Developing proper arterial puncture skills including percutaneous vascular access via
femoral artery and vein, radial and brachial artery access using the modified Seldinger
technique.
•
Perform temporary right ventricular pacemaker insertion
44
•
•
•
•
•
Learning to manage arterial punctures following sheath removal
Learning how to advance a catheter into the coronary arteries
Learning basic cardiac anatomy
Learning views taken during coronary angiography and left ventriculography at the time of
cardiac catheterization
The resident is expected to perform approximately 70 procedures during the first year
Specific responsibilities of the cardiology resident in the second year (C-2) include:
•
Learn how to obtain the appropriate angiographic views
•
Perform left heart catheterization and coronary angiography of native arteries and grafts
under supervision (minimum of 100 logged cases by 1st year and an additional 200 cases
by end of 2nd year)
•
Interpretation of hemodynamic tracings of typical cardiac problems including heart failure
(including constrictive, dilated, and restrictive cardiomyopathy), cardiac tamponade and
constrictive cardiomyopathy, cardiac tamponade, and pericarditis, common valvular heart
disease
•
Learn how to calculate valve areas, ejection fractions, shunt fractions and cardiac output
•
Learn the role and performance of an appropriate right heart catheterization using a balloon
flotation catheter
•
Perform intra-aortic balloon pump insertion
•
Exposure to percutaneous coronary interventions including balloon angioplasty, coronary
stenting, intravascular ultrasound
•
Develop skill in interpreting abnormalities in coronary artery anatomy and abnormalities in
ventricular function
•
The resident is expected to perform a minimum of 140 procedures during the second and
third year
Assessment:
• Daily feedback
• Logbook be reviewed by attending Cardiologists
• Completion of on-line web evaluation at the end of each rotation
Shortcut to: http://www.wrha.mb.ca/prog/diagnostic/files/Manual_XRaySafety.pdf
References:
•
Braunwald, E., Zipes D.P., Libby, P. Heart Disease 6th Edition
•
Baim, J. Grossman's Cardiac Catheterization, Angiography and
Intervention. 2005 Lippincott Williams & Wilkins
•
ACC Expert Consensus document – Radiation Safety in the Practice of Cardiology
•
ACC/SCAI Expert Consensus Document – Cardiac Angiography and Interventions
Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards
•
Catheterization Questions – Prepared by Dr. Chi Ming Chow (St. Michael’s Hospital,
Toronto, ON)
•
Approach to Angiographic Assessment (Dr. Peter Seidelin, Toronto, ON)
•
Cardiology Resident Training Manual – Prepared by Dr. F. Hussain
45
Syllabus for Residents
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
Cardiology Resident Training Manual – Prepared by Dr. F. Hussain
Catheterization Questions – Prepared by Dr. Chi Ming Chow (St. Michael’s
Hospital, Toronto, ON)
Hemodynamic Rounds – Constrictive Physiology,
Variants in Coronary Anatomy
Approach to Angiographic Assessment (Dr. Peter Seidelin, Toronto, ON)
Atlas of Radiographic Congenital Heart defects (MAYO Clinic TEXT)
Atlas of Coronary Angiograms, Ventriculograms and Aortograms (MAYO
Clinic TEXT)
Basic of Diagnostic Coronary Angiography and Ventriculography (MAYO
Clinic TEXT)
Atlas of Hemodynamic Tracings (MAYO Clinic TEXT)
Basics of Invasive hemodynamics (MAYO Clinic TEXT)
Radiation Safety in the Cardiac Cath. Lab (Aldridge et. Al)
ACC Expert Consensus document – Radiation Safety in the Practice of
Cardiology
ACC/SCAI Expert Consensus Document – Cardiac Angiography and
Interventions Clinical Expert Consensus Document on Cardiac Catheterization
Laboratory Standards
Chapters from Grossman’s Cardiac Catheterization :
a) Shunt Detection and Quantification
b) Calculation of stenotic Valve orifice area
c) Coronary angiography
d) Cardiac Ventriculography
e) Intra-aortic Balloon counterpuslation and other circulatory assist devices
f) Profiles in Valvular Heart Disease
g) Profiles in Dilated (Congestive) and Hypertrophic cardiomyopathies
h) Profiles in Constrictive pericarditis, restrictive cardiomyopathy and cardiac
tamponade
i) Profiles in congenital heart disease
46
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Coronary Care Unit (CCU)
Education Director: Dr. Kunal Minhas
Introduction:
The coronary care unit (CCU) at St. Boniface General Hospital is currently situated on A5.
Approximately 1/3 of these are patients with acute myocardial infarction and another 1/3 are
patients with other unstable ischemic syndromes. The remaining 1/3 include patients with severe
congestive heart failure of multiple etiologies, pre or post heart transplant patients, patients with a
wide spectrum of brady and tachyarrhythmias, patients with acute pericardial disease as well as
pre or postoperative patients, those with acute hypertensive syndromes, those with acute valvular
heart disease and those with complex congenital heart disease.
The critically ill cardiac patients, requiring invasive hemodynamic monitoring, inotrope therapy,
intra-aortic balloon counterpulsation and mechanical ventilation will be admitted under the
attending CCU cardiologist into the cardiac surgical ICU or medical-surgical ICU. These patients,
as well as others, may develop multi-system complications requiring the trainee to deal with the
complex interactions between the cardiovascular system and other organ systems. This intensive
care unit supports patients who require mechanical ventilation, invasive hemodynamic monitoring,
invasive hemodynamic support. The resident is expected to participate fully in the management of
the broad spectrum of patients who are admitted to this unit.
The normal work hours are Monday to Friday, 0800-1700 (except for cardiology core curriculum
lectures and all other mandatory rounds and lectures)
CanMED 2005 Roles
Medical Expert
Although the points listed below are key areas on which to focus during this rotation the trainee is
expected to develop a broad based expertise in the assessment, diagnosis and management of all
cardiovascular disease during core training. Many of the disease entities will also be encountered
in the cardiac clinical teaching unit.
•
Emergency assessment of patients with unstable angina, acute myocardial infarction, life
threatening arrhythmias, and other acute cardiologic problems requiring admission to the CCU
•
Conventional emergent and urgent treatment of patients with acute ischemic syndromes
•
Pharmacological and mechanical treatment of myocardial infarction and acute coronary
syndromes
•
Recognition and principles of the treatment of complications following myocardial infarction,
such as:
o Post infarction angina, infarct extension, and pericarditis
o Tachyarrhythmias
o Conduction defects and bradyarrhythmias
47
o Mechanical events (Acute ventricular septal defect, Acute mitral regurgitation, Infarct
expansion and extension, Pseudoaneurysm formation, Myocardial rupture with
tamponade)
o Hemodynamic problems unrelated to mechanical complications
(left and right ventricular failure, high output states, etc)
•
Indications for, and timing of, specific techniques:
o Arterial line insertion
o Central venous line insertion
o Swan-Ganz catheter insertion
o Intra-aortic balloon pump insertion
o Cardiac catheterization in the setting of acute infarction and unstable angina
o Pericardiocentesis (under ECG, fluoroscopic, or echo guidance)
o Temporary pacemaker insertion
o Emergency and elective cardioversion
•
•
•
Indications for and techniques of endotracheal intubation, ventilator management, and
indications for and techniques of ventilator weaning
Indications for heart and heart/lung transplantation, and management of both pre and posttransplantation patients
Treatment of patients with other disorders, which frequently present to the coronary care unit
including:
o Cardiopulmonary arrest of uncertain etiology
o Acute pulmonary embolism
o Acute pericarditis without tamponade
o Hypertensive crisis
o Syncope of suspected cardiac origin
o Aortic dissection
Communicator
•
Establish therapeutic relationships with patients (and families where applicable), including
encouraging discussion and participation in clinical decision-making
•
Obtain and synthesize relevant history from patients (and families / communities where
applicable), including information regarding patients beliefs, concerns and expectations
•
Discuss appropriate information with patients (and families where applicable) including
breaking bad news and end of life discussions
•
Involve all appropriate health care team members to ensure accurate, effective patient
management
48
•
Maintain clear, accurate, and appropriate records (written and/or electronic)
•
The following central line check list must be completed accordingly on all patients.
Collaborator
•
Describe the roles and responsibilities of the members of the health care team
•
Consult effectively with other physicians, CCU nursing staff and other health care
professionals for effective patient care
•
Contribute effectively to other interdisciplinary team activities including daily CCU rounds
and family conferences
49
Manager
•
Work effectively and efficiently in health care organization – acting as CCU team leader
(organizing junior residents and medical students)
•
Utilize resources effectively to balance patient care, learning needs, and outside activities
•
Allocate finite health care resources wisely including triage of patients and prioritizing patient
assessment and admission
•
Utilize information technology to optimize patient care, life-long learning and other activities
Health Advocate
•
Identify the important determinants of health affecting patients – in the CCU this includes
appropriate advice regarding secondary prevention of heart disease
•
Contribute effectively to improved health of patients and communities
•
Recognize and respond to those issues where advocacy is appropriate
Scholar
•
Develop, implement and monitor a personal continuing education strategy
•
Critically appraise sources of medical information and apply this appropriately to health care
decisions
•
Facilitate learning of patients, junior residents, students and other health professionals
•
Contribute to development of new knowledge
Professional
•
Deliver highest quality care with integrity, honesty and compassion
•
Exhibit appropriate personal and interpersonal professional behaviors
•
Practice medicine ethically consistent with obligations of a physician
Duties
Four rotations will be completed over the three year program, 2 in the first year and 2 in the
second year. An additional 2 weeks will be completed in the third year in the role of Pseudoattending. The rotations will be at St. Boniface General Hospital. Under the leadership and
direction of the attending CCU cardiologist, the resident is the physician in charge of the unit and
as such should be completely familiar with all of the patients in the unit, including any patients
under the care of the CCU team in the cardiovascular intensive care unit or the medical-surgical
intensive care unit.
Specific responsibilities of the cardiology trainee in the first year (C-1) include:
•
Daily rounds with attending staff
•
Screening of all admissions and approval of all discharges and transfers
50
•
•
Supervision and education of junior residents and medical students
Ensure that daily progress notes are made on all patients and written synopsis/dictated
discharge summaries where applicable.
Perform or supervise all technical procedures in the unit. (In cases where the procedure is
performed by a junior resident, the resident must remain in attendance and perform the
procedure directly if the junior resident is unsuccessful)
If unfamiliar or inexperienced in any CCU procedure, must ensure that staff cardiologist
or more senior resident is in attendance for procedure
Ensure a clear detailed note is provided for any procedure
Approve all orders (investigations, consultations and treatments)
•
Sign out rounds with junior and senior residents
•
Attendance (and presentation if applicable) at case conferences (including cath conference,
morbidity and mortality rounds, family case conferences)
•
•
•
The resident is excused from all responsibilities in the CCU during the cardiology core curriculum
lectures and all other mandatory rounds and lectures
Specific responsibilities of the cardiology resident in the second year (C-2) include:
•
Independent rounds at least 3 days a week (specific arrangements to be made with the
attending cardiologist)
•
Screening of all admissions and approval of all discharges and transfers
•
•
•
Supervision and education of junior residents and medical students
Ensure that daily progress notes are made on all patients and written synopsis/dictated
discharge summaries where applicable.
Perform or supervise all technical procedures in the unit. (In cases where the procedure is
performed by a junior resident, the resident must remain in attendance and perform the
procedure directly if the junior resident is unsuccessful)
Ensure a clear detailed note is provided for any procedure
Function in the role of junior attending staff in all matters relating to patient care and
management of the coronary care unit and for admitted cardiology patients in the cardiac
intensive care unit and/or medical-surgical intensive care unit.
Approve all orders (investigations, consultations and treatments)
•
Sign out rounds with junior and senior residents
•
Attendance (and presentation if applicable) at case conferences (including cath conference,
morbidity and mortality rounds, family case conferences)
•
•
•
The resident is excused from all responsibilities in the CCU during the cardiology core curriculum
lectures and all other mandatory rounds and lectures
Specific responsibilities of the cardiology resident in the third year (in the role of Pseudoattending) include all of the responsibilities listed above for second year. Additional
responsibilities include:
•
Independent rounds all 14 days of the 2 week rotation (including both weekends)
•
•
Outside calls (in discussion with the Staff Cardiology attending)
Management of CCU beds allocation through appropriate screening, bed management and
accepting potential patients during the daytime/nighttime hours
51
•
•
Learning shadow billing for consultations
Discuss all new admissions and daily management of patients, after independent rounds (in
the absence of CCU attending) are completed, with the Staff attending
Assessment:
•
•
Daily feedback
Completion of on-line web evaluation at the end of each rotation
52
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Clinical Teaching Unit (CTU)
Education Director: Dr. Anita Soni
Introduction:
The clinical training unit (CTU) at St. Boniface General Hospital is currently situated on A5. The
unit has 16-18 beds and is staffed by an attending cardiologist with an academic affiliation to the
University of Manitoba. The unit has telemetry capability for 12-14 beds. Patients are admitted to
the unit from the emergency room, from clinic, (e.g. heart failure clinic) and from home for further
management. Patients are also transferred to this unit from the CCU (including CVICU and
medical-surgical ICU). The resident staff on the unit include a cardiology resident, 1-2 junior
residents (usually from internal medicine), and 1-2 medical students.
The patients on the ward are generally stable, requiring optimization of their cardiac condition.
Approximately 1/3 of the patients are post-myocardial infarction, another 1/3 are patients with
other unstable ischemic syndromes. The remaining 1/3 include patients with congestive heart
failure of multiple etiologies, pre or post heart transplant patients, patients with a wide spectrum of
brady and tachyarrhythmias, patients with acute pericardial disease as well as pre or postoperative
patients, those with valvular heart disease and those with complex congenital heart disease.
The normal work hours are Monday to Friday, 0800-1700 (except for cardiology core curriculum
lectures and all other mandatory rounds and lectures)
CanMED 2005 Roles
Medical Expert
Although the points listed below are key areas on which to focus during this rotation the trainee is
expected to develop a broad based expertise in the assessment, diagnosis and management of all
cardiovascular disease during core training. Many of the same disease entities will also be
encountered in the coronary care unit (CCU) rotation.
•
Assessment of patients with unstable angina, acute myocardial infarction, life threatening
arrhythmias, and other acute cardiologic problems requiring admission to the hospital
•
Treatment of patients with acute ischemic syndromes including medical, interventional, social
and psychological measures
•
Attaining excellence in bedside clinical diagnosis in cardiac patients
•
Logical, evidence-based approach to cardiovascular investigations in hospitalized patients
•
Recognition and management of psychological problems associated with cardiac disease
•
Recognition and principles of the treatment of complications following myocardial infarction,
such as:
o Post infarction angina, infarct extension, and pericarditis
53
o Tachyarrhythmias
o Conduction defects and bradyarrhythmias
o Mechanical events (acute ventricular septal defect, acute mitral regurgitation)
o Pseudoaneurysm formation
o Myocardial rupture with tamponade
o Indications for heart and heart/lung transplantation, and management of both pre
and post-transplantation patients.
•
Treatment of patients with other disorders, including:
o Cardiopulmonary arrest of uncertain etiology
o Acute pulmonary embolism
o Acute pericarditis without tamponade
o
Syncope of suspected cardiac origin
Communicator
•
Establish therapeutic relationships with patients (and families where applicable), including
encouraging discussion and participation in clinical decision-making
•
Obtain and synthesize relevant history from patients (and families / communities where
applicable), including information regarding patients beliefs, concerns and expectations
•
Discuss appropriate information with patients (and families where applicable) including
breaking bad news and end of life discussions
•
Involve all appropriate health care team members to ensure accurate, effective patient
management
•
Maintain clear, accurate, and appropriate records (written and/or electronic)
Collaborator
•
Describe the roles and responsibilities of the members of the health care team
•
Consult effectively with other physicians, CTU nursing staff and other health care
professionals for effective patient care
•
Contribute effectively to other interdisciplinary team activities including daily CTU rounds
and family conferences
Manager
•
Work effectively and efficiently in a health care organization - acting as CTU team leader
(organizing junior residents and medical students)
•
Allocate finite health care resources wisely
•
Utilize resources effectively to balance patient care, learning needs, and outside activities
54
•
Rational and cost-conscious hospital bed utilization by cardiac patients in the setting of bed
pressure and cost containment
•
Utilize information technology to optimize patient care, life-long learning and other activities
Health Advocate
•
Identify the important determinants of health affecting patients – in the CTU this includes
appropriate advice regarding secondary prevention of heart disease
•
Contribute effectively to improved health of patients and communities
•
Recognize and respond to those issues where advocacy is appropriate
Scholar
•
Develop, implement and monitor a personal continuing education strategy
•
Critically appraise sources of medical information and apply this appropriately to health care
decisions
•
Facilitate learning of patients, junior residents, students and other health professionals
•
Contribute to development of new knowledge
Professional
•
Deliver highest quality care with integrity, honesty and compassion
•
Exhibit appropriate personal and interpersonal professional behaviors
•
Practice medicine ethically consistent with obligations of a physician
Duties
Four rotations will be completed over the three year program, 2 in the first year and 2 in the
second year. An additional 2 weeks will be completed in the third year in the role of Pseudoattending. The rotations will be at St. Boniface General Hospital. Under the leadership and
direction of the attending CTU cardiologist, the resident is the physician in charge of the unit and
as such should be completely familiar with all of the patients in the unit. Progressive
autonomy/independence will be expected as the resident progresses from the first ward rotation to
the fourth.
Specific responsibilities of the cardiology trainee in the first year (C-1) include:
•
Daily rounds with attending staff (by the second rotation in the first year, this may decrease
depending on resident progression)
•
Screening of all admissions and approval of all discharges
•
Evaluation of all admissions during normal working hours, including those seen by junior
residents; the resident should write a note on each new admission or transfer
•
•
Supervision and education of junior residents and medical students
Ensure that daily progress notes are made on all patients and written synopsis/dictated
discharge summaries where applicable.
Approve all orders (investigations, consultations and treatments)
•
55
•
Sign out rounds with junior and senior residents
•
Attendance (and presentation if applicable) at case conferences (including cath conference,
morbidity and mortality rounds, family case conferences)
The resident is excused from all responsibilities in the CTU during the cardiology core curriculum
lectures and all other mandatory rounds and lectures
Specific responsibilities of the cardiology resident in the second year (C-2) include:
•
Independent rounds at least 3 days a week (specific arrangements to be made with the
attending cardiologist)
•
Screening of all admissions and approval of all discharges
•
•
•
Supervision and education of junior residents and medical students
Ensure that daily progress notes are made on all patients and written synopsis/dictated
discharge summaries where applicable.
Function in the role of junior attending staff in all matters relating to patient care and
management of the CTU
Approve all orders (investigations, consultations and treatments)
•
Sign out rounds with junior and senior residents
•
Attendance (and presentation if applicable) at case conferences (including cath conference,
morbidity and mortality rounds, family case conferences)
•
The resident is excused from all responsibilities in the CTU during the cardiology core curriculum
lectures and all other mandatory rounds and lectures.
Specific responsibilities of the cardiology resident in the third year (in the role of Pseudoattending) include all of the responsibilities listed above for second year. Additional
responsibilities include:
•
Independent rounds all 14 days of the week (including 1 weekend (ideally, when the Staff
Cardiology Ward A attending is on)
•
•
Outside calls (in discussion with the Staff Cardiology attending)
Management of Cardiology ward beds allocation through appropriate screening, bed
management and accepting potential patients during the daytime/nighttime hours
Learning shadow billing for consultations
Discuss all new admissions and daily management of patients, after independent rounds (in
the absence of Cardiology staff attending) are completed, with the Staff attending
•
•
Assessment:
•
•
Daily feedback
Completion of on-line web evaluation at the end of each rotation
56
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Consults/ Coronary Care Unit (CCU) at HSC
Education Director: Dr. Kunal Minhas
Introduction:
The Cardiology service at HSC is composed of CCU inpatient care and general cardiology
consultation throughout the HSC hospital and emergency room. The Cardiology Service is
designed to provide urgent and emergent cardiac consultation for adults within the hospital as well
as care for the admitted CCU patients. The Cardiology service at HSC is composed of the
Attending Cardiologist, Clinical Assistant (CA), and senior Cardiology resident (when on
rotation). The role of the senior Cardiology resident is to act in the capacity as a junior attending
physician. The CA is typically responsible for seeing and writing notes on all new consults and
admissions to CCU, which will be reviewed with the senior Cardiology resident. The senior
Cardiology resident is responsible for creating management plans for all patients cared for by the
Cardiology service, reviewing the management plans with the Attending Cardiologist, and
ensuring appropriate follow-up. The senior Cardiology resident is also responsible for ensuring a
clearly documented cardiology assessment and management plan in the patient chart, appropriate
follow-up, and clear and concise communication with the consulting service where appropriate.
The Coronary Care Unit (CCU) consists of 3 beds in the MICU of the Ann Thomas Building at
Health Sciences Centre.
The CCU is a specialized unit that cares for patients with primary cardiac disorders, and are
admitted from a variety of locations:
1. Admissions from the HSC Emergency Room (ER)
2. Admissions from the SBGH Cath Lab requiring tertiary care
3. Transfers from within HSC
4. Transfers from other hospitals within Manitoba and Northwest Ontario
The following are the criteria for admissions to the HSC CCU:
INCLUSION CRITERIA:
Patients must be reviewed and accepted by the HSC CCU Attending Physician prior to
admission to CCU on the third floor of the Ann Thomas MICU/CCU
Acute Coronary Syndrome:
• STEMI
• Unstable angina requiring intravenous nitroglycerin
• Documented/suspected ACS (unstable angina, NSTEMI, STEMI) complicated by:
i.
Sustained ventricular tachycardia (> 30 seconds)
ii.
Symptomatic bradyarrhythmias/ ventricular tachyarrhythmias
iii.
CHF (not requiring Positive Pressure ventilation)
iv.
Pericardial tamponade
57
Arrhythmic Syndrome:
• Bradyarrhythmias/conduction disturbances requiring monitoring and /or
transvenous pacing
• Tachyarrhythmias requiring intravenous pharmacologic treatment not available on
general medical ward or cardioversion
Hypertensive Syndrome:
• Aortic dissection requiring intensive medical treatment
• Acute hypertensive crisis requiring hemodynamic blood pressure monitoring
Allowed interventions include:
• Infusion of isoproterenol
• Infusion of dobutamine
• Infusion of dopamine
• Infusion of milrinone
• Transvenous/transcutaneous pacing
• Established nocturnal CPAP/BIPAP
• Central venous catheter
• Arterial catheter
• Intermittent Hemodialysis
• Pericardiocentesis – for admitted CCU patient
• Transesophageal echocardiography (TEE) – for admitted CCU patient*
• DC Cardioversion*
* Due to use of conscious sedation, coverage issues of other CCU patients needs to
be arranged with the MICU/CCU charge nurse and CCU attending PRIOR to
initiation of the TEE or DC cardioversion
EXCLUSION CRITERIA:
•
•
•
•
•
•
•
Patient’s requiring more than1:3 nurse/patient ratio
Mechanically ventilated patients
Urgent BIPAP may be initiated but arrangements for increased nursing coverage and
transfer to MICU must be in place
Intra-Aortic Balloon Pump
Pulmonary Artery Catheters
Continuous Renal Replacement Therapy
Patients requiring Phenylephrine, Norepinephrine, Vasopressin, Epinephrine
RESPONSIBILITIES OF THE SENIOR CARDIOLGY SERVICE
RESIDENT
Weekdays
0830hrs:
Arrive 08:30 in CCU to receive sign-over from the on call HMO/housestaff
covering the Cardiology Service.
0830 – 0900hrs: Review all patients admitted in the CCU with a focused history and physical
examination and review relevant laboratory results (CXR’s, ECG’s, telemetry
banks, and blood tests).
58
0900 – 1100hrs: Round with the Attending Cardiologist and CA on the patients admitted on the
CCU.
1100 – 1700hrs: CCU and general cardiology consult related work (progress notes, new
admissions or transfers, new consults, follow-up of active patients on the wards
and in MICU/SICU)
1700hr:
Arrive in CCU to give sign-over to the on call HMO who will be covering the
Cardiology service.
OBJECTIVES
1. To gain a sound understanding on clinical cardiology as it pertains to the following:
§ Coronary artery disease: Acute coronary syndromes and their complications including
cardiogenic shock, papillary muscle dysfunction, and ventricular septal defects
§ Acute cardiogenic pulmonary edema
§ Congestive heart failure including issues regarding transplantation
§ Acute pulmonary embolism
§ Valvular heart disease
§ Hypertension
§ Dyslipidemia
§ Brady- and tachyarrhythmias
§ Diseases of the pericardium
§ Endocarditis
§ Diseases of the aorta including aortic dissection
§ Syncope
§ Cardiac pharmacology
2. To gain a basic understanding of the role of non-invasive and invasive cardiac procedures
(ECG’s, stress testing, echocardiography, MUGA, cardiac catheterization)
3. To further develop skills in obtaining a relevant cardiac history
4. To further develop skills in the focused cardiac physical examination
5. To develop skills in basic ECG interpretation
6. To effectively communicate verbally and in writing in areas relevant to clinical cardiology
7. To develop procedural skills which could include:
§
management of femoral sheaths post angiography
§
insertion of temporary transvenous pacemakers
§
placement of transcutaneous pacemakers
§
elective and emergent electrical cardioversion
8. To develop the efficient consultation and managerial skills required to run a in-patient care unit
and consultation service.
59
2005 CanMED Roles
Medical Expert
• Elicit a history that is accurate, concise, and relevant to the patient’s potential cardiac problems
in the context of other medical problems that may be present
•
Perform a full cardiac physical examination and more limited examination of the other systems
when relevant
•
Collect and organize previous relevant cardiac investigations
•
Formulate and prioritize a problem list with emphasis on the relative role of the cardiac
problems to other problems
•
Initiate further investigations in the cost effective, ethical, and useful manner with emphasis on
acquiring information that will influence treatment and outcomes
•
Develop a management plan for the cardiac problems that take into account the possible
effects on other compromised systems
•
Be able to investigate and estimate the cardiac risks in non-cardiac surgery and initiate
strategies to reduce those risks
•
Recognize and manage post operative complications including acute coronary syndromes,
arrhythmias and congestive heart failure
•
Emergency assessment of patients with unstable angina, acute myocardial infarction, life
threatening arrhythmias, and other acute cardiac problems requiring admission to the CCU
•
Conventional emergent and urgent treatment of patients with acute ischemic syndromes
•
Pharmacological and mechanical treatment of myocardial infarction and acute coronary
syndromes
•
Recognition and principles of the treatment of complications following myocardial infarction,
including:
o Post infarction angina, infarct extension, and pericarditis
o Tachyarrhythmias
o Conduction defects and bradyarrhythmias
o Mechanical complications (Acute ventricular septal defect, Acute mitral regurgitation,
Infarct expansion and extension, Pseudoaneurysm formation, Myocardial rupture with
tamponade)
o Hemodynamic problems unrelated to mechanical complications
(left and right ventricular failure, high output states, etc)
•
Indications for, and timing of, specific techniques:
o Arterial line insertion
o Central venous line insertion
o Swan-Ganz catheter insertion
60
o Intra-aortic balloon pump insertion
o Cardiac catheterization in the setting of acute infarction and unstable angina
o Pericardiocentesis (under ECG, fluoroscopic, or echo guidance)
o Temporary pacemaker insertion
o Emergency and elective cardioversion
•
Indications for and techniques of endotracheal intubation, ventilator management, and
indications for and techniques of ventilator weaning
•
Indications for heart and heart/lung transplantation, and management of both pre and posttransplantation patients
•
Treatment of patients with other disorders, which frequently present to the coronary care unit
including:
o Cardiopulmonary arrest of uncertain etiology
o Acute pulmonary embolism
o Acute pericarditis without tamponade
o Hypertensive crisis
o Syncope of suspected cardiac origin
o Aortic dissection
Communicator
•
Ensure proper communication to the primary care team by written and spoken word regarding
the cardiac management plan and how it affects other problems and changes in the patient's
overall condition
•
Discuss the cardiac problems with the patient and their family and how it relates to their
overall care and specifically the role that cardiology is planning in their care
•
Recognize when the cardiology problem is the primary issue in the patient's care and arrange
appropriate investigations and care including transfer to a cardiac unit
•
Establish therapeutic relationships with patients (and families where applicable), including
encouraging discussion and participation in clinical decision-making
•
Obtain and synthesize relevant history from patients (and families / communities where
applicable), including information regarding patients beliefs, concerns and expectations
•
Discuss appropriate information with patients (and families where applicable) including
breaking bad news and end of life discussions
•
Involve all appropriate health care team members to ensure accurate, effective patient
management
•
Maintain clear, accurate, and appropriate records (written and/or electronic)
61
Collaborator
•
Develop a management plan for the cardiac condition for patients in collaboration with
members of the primary health care team - effectively interact with other health care givers in
both written and oral forms to provide optimum care for the patient
•
Coordinate the care of complex medical and surgical patients with the referring service
including the organization of investigations and other cardiac therapies
•
Participate in inter-disciplinary meetings respecting the opinion of others and their expertise
being cognizant of the consultative process
•
Describe the roles and responsibilities of the members of the health care team
•
Consult effectively with other physicians, CCU nursing staff, and other health care
professionals for effective patient care
•
Contribute effectively to other interdisciplinary team activities including daily CCU rounds
and family conferences
Manager
•
Organize schedule to see admitted CCU patients as well as new consults and review previous
consults with staff cardiologists in a timely and efficient manner
•
Organize and utilize appropriate testing, especially pre-operative evaluation
•
Understand cost-effectiveness of testing and treating complex patients with multi-system
disease
•
Allocate finite health care resources wisely including triage of patients and prioritizing patient
assessment and admission
Health Advocate
•
Identify and treat cardiac risk factors
•
Educate patients in heart healthy behaviors
•
Integrate cardiac risk factors with other complex medical and surgical illnesses
•
Ensure continuity of care including follow up after hospital discharge
•
Recognize and respond to those issues where advocacy is appropriate
Scholar
•
•
Recognize the interplay of the cardiovascular system with other systems in health and
disease, and expand knowledge in those areas that overlap
•
Develop expertise in the assessment of risk of life threatening cardiac conditions in nonlife threatening non-cardiac surgery
•
Contribute knowledge independently learned to the consultative process
Critically appraise sources of medical information and apply this appropriately to health care
decisions
62
•
Facilitate learning of patients, junior residents, students and other health professionals
Professional
•
Deliver highest quality care with integrity, honesty and compassion
•
Exhibit appropriate personal and interpersonal professional behaviors
•
Practice medicine ethically consistent with obligations of a physician
63
FREQUENTLY ASKED QUESTIONS
What is the role of the senior
Cardiology resident on the HSC
rotation?
What are the responsibilities of the
Attending Cardiologist?
The senior Cardiology resident should act in the capacity of a
junior attending physician. The Clinical Assistant (CA) is
responsible for seeing and writing notes on new consults and
admissions to CCU, which will be reviewed with the senior
Cardiology resident. The senior Cardiology resident is then
responsible for creating and documenting a management plan
and discussing the cases and treatment plans with the
Attending physician.
Review the cardiac history, the cardiac physical examination,
the ECG’s, laboratory results and your initial management
plan with you on each admission, transfer or new consult and
provide direct and meaningful feedback. Review the pertinent
daily issues such as complications, responses to therapy,
results of investigations and focus the management plan.
How many clinical assistants are
there on the service?
Generally 1 CA.
Who is responsible for “code blues”
(imminent or actual respiratory or
cardiac arrests) in the CCU?
The housestaff covering MICU. However, the Cardiology
service should be present at all CODE BLUES in the CCU.
What happens if the senior
Cardiology resident receive an
outside call related to CCU or the
Cardiology Service?
Redirect the outside call back to paging. All outside calls are
dealt with by the Attending Cardiologist
Can the senior Cardiology resident
attend the core weekly academic
component?
Yes. The senior Cardiology resident is expected to attend all
mandatory teaching sessions at St. Boniface Hospital. The
senior Cardiology resident must inform the attending
physician and the Clinical Assistant when he/she will be at
the mandatory teaching sessions at SBGH.
64
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Echocardiography
Education Director: Dr. Amrit Malik
Introduction:
Six periods are spent in the echo lab, two in each of the three years of the training program. The
rotations will take place primarily at the St Boniface General Hospital site but as the program
maintains echo services at Health Sciences Centre, some of the rotations will also take place there.
Each location has an on-site staff cardiologist during normal working hours, specializing in echo.
The normal working hours are 0800 – 1700, Monday to Friday. The timetable for the resident is
generally as follows:
• At 0800h, residents will report to the assigned “academic” sonographer and work with him or
her for the remainder of that day or half-day
• During the first two rotations, the resident will spend 2 afternoon half days per week on echo
interpretation with the staff cardiologist (echocardiologist )
• By the third and fourth rotations, the resident will spend 4 afternoon half days interpreting
echos
• By the fifth and sixth rotations, the resident will spend 6 half days per week on echo
interpretation with the staff cardiologist as well as have active involvement in transesophageal
and stress echocardiography
CanMED 2005 Roles
Medical Expert
•
Demonstrate an understanding of cardiac anatomy, physiology, hemodynamics and pathology
•
Demonstrate a thorough understanding of the principles of image formation and blood flow
velocity measurement using ultrasound.
•
Demonstrate familiarity with echocardiographic equipment and understanding of its safe,
effective use.
•
Relate the knowledge of echocardiographic methods used to evaluate cardiac anatomy and
function in the clinical arena.
•
Demonstrate the ability to perform an excellent M-mode/2D echocardiographic examination
himself/herself using all standard views and ancillary views when indicated.
•
Demonstrate the ability to obtain accurate measurements of chamber size, wall thicknesses,
valve motion and orifice size by M-mode and 2D techniques.
•
Discuss the echo criteria for diagnosis of all types of valvular heart disease, myocardial disease
pericardial disease and diseases of the great arteries.
•
Demonstrate the ability to identify, semiquantitate and quantitate regional and global
abnormalities in ventricular function.
65
•
Discuss the Doppler methods for determining flow velocities, calculating pressure gradients,
determining the severity of valvular stenoses and regurgitation, measuring cardiac output, and
detecting intracardiac shunts.
•
Demonstrate the ability reliably differentiate normal and abnormal images and blood flow
patterns.
•
Demonstrate sufficient expertise in cardiac auscultation, ECG and chest x-ray interpretation,
and cardiac catheterization techniques to relate echocardiographic findings to the results of
these investigations.
•
Demonstrate the ability to synthesize available clinical information to produce differential
diagnoses.
•
Demonstrate the ability to direct and modify the echocardiographic examination as necessary
in the investigation of differential diagnoses.
Communicator
•
Effectively communicate with the echocardiographic technnologists to ensure appropriate
patient care
•
Obtain and synthesize relevant history from patients (and families, where applicable)
•
Discuss appropriate information with patients/families and the health care team
•
Formulate a clinically relevant clear and accurate report for the referring physician
Collaborator
•
Consult effectively with attending physicians and echocardiographic technologists
•
Contribute effectively to other interdisciplinary team activities
Manager
•
Utilize resources effectively to balance patient care, learning needs, and outside activities
•
Allocate finite health care resources wisely
•
Work effectively and efficiently in a health care organization
•
Utilize information technology to optimize patient care, life-long learning and other activities
Health Advocate
•
Identify the important determinants of health affecting patients
•
Contribute effectively to improved health of patients and communities
•
Recognize and respond to those issues where advocacy is appropriate – for example, in
echocardiography ensure acceptable time delay in obtaining this investigation
Scholar
•
Facilitate learning of patients, junior residents, medical students and other health professionals
•
Develop, implement and monitor a personal continuing education strategy
66
•
Contribute to development of new knowledge by participating in the clinical trials in the
echocardiography department
•
Critically appraise sources of medical information and apply this appropriately to health care
decisions
Professional
•
Deliver highest quality care with integrity, honesty and compassion
•
Exhibit appropriate personal and interpersonal professional behaviors
•
Practice medicine ethically consistent with obligations of a physician
Duties
Report to the echo lab at 0800 for morning sessions and 1300 for afternoon sessions. The majority
of the rotations will be performed at SBGH unless otherwise specified. The resident is excused
from the echo lab during the cardiology core curriculum lecture and all other mandatory rounds
and lectures.
Specific responsibilities of the cardiology resident in the first year (C-1) include:
•
Rotations 1 and 2 the resident will spend 2 afternoon half days per week on echo
interpretation with the echocardiologist
•
Remainder of time to be spent on scanning with the sonographers à 14 scans per week
(keep accurate logbook which should be signed off weekly by echocardiologist). Each am
at 0800h, residents will report to the assigned “academic” sonographer and work with him
or her for the remainder of that day or halfday. Participation in echo guided
pericardiocentesis will be expected.
•
Rotation 1 will concentrate on image acquisition, machinery, cardiac anatomy and
application of 2D and M-mode echocardiography (including measurements and
recognition of normal limits). No contact with TEE or stress echo during this rotation.
•
Rotation 2 will include 2D and M-mode calculations including LV volume, mass,
fractional shortening and ejection fraction, as well as expand into qualitative and
quantitative Doppler and basic cardiac hemodynamics. No contact with TEE nor stress
echo at this point
Expectations by the end of first year:
•
•
•
•
Completion of 100 scans (including partial scans, to be documented in logbook)
Be able to acquire complete TTE including basic measurement
Be able to utilize basic calculations (gradients, half time, valve area, NOT PISA)
Be able to recognize normal variants from abnormal pathology
Specific responsibilities of the cardiology resident in the second year (C-2) include:
•
Rotation 3 – the resident will spend 2 afternoon half days per week on echo interpretation
with the echocardiologist
67
•
Remainder of time to be spent on scanning with the sonographers à 14 scans per week
(keep accurate logbook which should be signed off weekly by echocardiologist). Each am
at 0800h, residents will report to the assigned “academic” sonographer and work with him
or her for the remainder of that day or halfday. Participation in echo guided
pericardiocentesis will be expected.
•
Rotation 3 will expand further into assessment and quantitation of native and prosthetic
valve function, complex cardiac hemodynamics including diastolic function assessment,
constriction and tamponade. The resident should be comfortable with the indications and
utility considerations for echocardiography for a variety of conditions.
•
Rotation 4 – the resident will spend 4 afternoon half days per week on echo interpretation
with the echocardiologist
•
Remainder of time to be spent on scanning with the sonographers à 5 scans per week
(keep accurate logbook which should be signed off weekly by echocardiologist). Each am
at 0800h, residents will report to the assigned “academic” sonographer and work with him
or her for the remainder of that day or halfday. Participation in echo guided
pericardiocentesis will be expected.
•
Rotation 4 will emphasize heavily on the complete assessment of the patient by
echocardiography, including reviewing the requisition and study question to determining
and acquiring the proper images, techniques, measurements and calculations in order to
obtain the best qualitative and quantitative assessment.
•
This will be the first formal application of TEE. Knowledge of the risks, benefits and
limitations of TEE and observation of TEE will take place on this rotation (sometimes at
HSC).
Expectations by the end of second year:
•
•
•
•
•
•
Completion of 150 scans as required by Royal College requirements
(to be documented in logbook)
Be able to prioritize various TTE requests
Be able to acquire complete TTE
Be able to utilize all calculations
Be able to interpret most pathology
Recognize the indications and utility of TEE
Specific responsibilities of the cardiology resident in the third year (C-3) include:
• Rotations 5 and 6 – the resident will spend 6 half-days per week on echo interpretation
with the echocardiologist
•
Remainder of time to be spent on scanning with the sonographers à > 3 scans per week
(keep accurate logbook which should be signed off weekly by echocardiologist).
Residents will report to the assigned “academic” sonographer and work with him or her for
the remainder of that half-day. Participation in echo guided pericardiocentesis will be
expected. Active involvement in transesophageal and stress echocardiography will be
expected.
68
•
Supervised dictations or other method of formal interpretation of images will be carried
with graduated responsibility and increasing independence as skills allow.
Expectations by the end of third year:
•
As above + independent interpretation/reporting of all required TTE
Assessment:
•
•
•
Daily feedback
Logbook be reviewed by attending cardiologists
Completion of on-line web evaluation at the end of each rotation
Resources:
•
•
•
•
•
Otto C. Textbook of Clinical Echocardiography, 2004, Elsevier
Feigenbaum H, Armstrong W, Ryan T. Echocardiography, Sixth Edition. Lippincott
Williams & Wilkins
ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography
Full Text
Canadian Society of Echocardiography Practice Guidelines
Journal of the American Society of Echocardiography, published monthly
Assignments
Assignment #1
Draw and label all of the cardiac structures that can be seen on the following view: (parasternal
long axis, RV inflow view, RV outflow view, parasternal basal short axis, parasternal mid short
axis, apical short axis, apical 4 chamber, apical 5 chamber, apical 3 chamber, apical long axis,
subcostal 4 chamber, suprasternal)
Draw, label and describe the method of M-mode measurement of the LV in the parasternal long
and short axis views as well as the aorta-LA in the parasternal long and short axis view.
Name and describe the formula that translates left ventricular end diastolic diameter into left
ventricular end diastolic volume
Describe the M-mode method of ejection fraction determination. Provide an example and provide
2 advantages and 3 pitfalls of this method.
Find a reference describing normal values for the LV, Ao, LA dimensions and be able to describe
variations that exist as a function of gender, age, body size
Define the meaning of the term: left ventricular mass and provide the currently accepted
echocardiographic calculation of LV mass.
Define LVH as a function of LV mass, taking into consideration age, gender and body size.
Contrast the meaning of the following terms: (normal left ventricular mass, concentric LVH,
eccentric LVH, concentric LV remodeling)
69
Assignment # 2
Describe 3 methods of assessment of LA size; provide 1 advantage and 1 pitfall of each method
Describe 3 methods of assessment of RV size; provide 1 advantage and 1 pitfall of each method.
Describe 2 methods of assessment of RA pressure; provide 1 advantage and 1 pitfall of each
method.
Draw and label M-mode pattern of aortic valve opening and closure
Draw and label M-mode pattern of mitral valve opening and closure
Draw and label M-mode pattern of mitral valve opening and closure for the following pathological
conditions (MV endocarditis, mitral stenosis, MV prolapse, elevated left ventricular end diastolic
pressure, obstructive hypertrophic cardiomyopathy, severe acute aortic regurgitation)
Draw and label M-mode pattern of aortic valve opening and closure for the following pathological
condition (valvular aortic stenosis, obstructive hypertrophic cardiomyopathy)
Describe the Doppler equation
Assignment #3
Describe the various factors to determine whether a particular request for echocardiography
constitutes an appropriate “indication” for evaluation
Describe the technique, risks and complications of transesophageal echocardiography
Draw and describe 5 methods of assessment of mitral regurgitation, list 2 advantages and
disadvantages of each
Draw and describe 3 methods of assessment of aortic regurgitation, list 2 advantages and
disadvantages of each
Draw and describe 3 methods of assessment of aortic stenosis, list 2 advantages and disadvantages
of each
Draw and describe 3 methods of assessment of mitral stenosis, list 2 advantages and disadvantages
of each
Assignment #4
Describe the normal filling pressures in all of the cardiac chambers and the great vessels
Classify left ventricular diastolic function as normal, mildly impaired, moderately impaired,
severely impaired or indeterminate using the combination of 2D, M-mode and Doppler data.
Describe the pitfalls of the various techniques.
Classify intracardiac shunts (interatrial, interventricular, intergreatvessel), describe the anatomy of
each and the echo-Doppler method of determining shunt ratio.
70
Calculate cardiac output, regurgitant volume, pulmonary vascular resistance using Doppler
echocardiography. Describe the pitfalls of the methods used and the level of agreement with
invasively determined parameters.
Assignments #5
Calculate the following parameters of prosthetic valve function:
Peak and mean transvalvular gradients
Effective orifice area and indexed effective orifice area
Contrast and describe the anatomic and echocardiographic appearance of the following types of
prosthetic valves: homograft, autograft, stentless bioprosthetic, stented bioprosthetic, bileaflet
mechanical, tilting disc mechanical and ball in cage mechanical
Relate the size and type of prosthesis (above) to the expected transvalvular gradients and effective
orifice area (use tables provided by valve manufacturers if necessary)
Describe an algorithm that you may use to determine the role of transthoracic and transesophageal
echocardiography in the following entities:
Suspected infective endocarditis
Source of embolism NYD
Prosthetic valve dysfunction
Unexplained pulmonary hypertension
Differentiate between the following entities using Doppler echocardiography:
Pericardial Effusion
Effusive constrictive pericarditis
Constrictive pericarditis
Restrictive cardiomyopathy
Assignment#6
Contrast the role of TTE, TEE with nonecho based modalities (angiography, CT, MRI, nuclear
cardiology) in the assessment of the following entities:
Coronary artery disease
Cardiomyopathy NYD
Suspected aortic dissection
Hibernating vs stunned myocardium
Classify cardiac neoplasms and describe the role of TTE and TEE in the assessment of cardiac
masses
Describe the basic technique used in undifferentiated congenital heart disease (situs, connections,
etc.)
71
Assignment #7 (for those with special interest in echocardiography and/or congenital heart disease)
Describe the typical echo findings of the following entities:
Unrepaired tetralogy of Fallot
Repaired tetralogy of Fallot
Partial and complete AV canal defects
L transposition of the great arteries
D transposition of the great arteries with venous switch (Mustard)
D transposition of the great arteries with arterial switch
Unrepaired and repaired coarctation of the aorta
Palliative shunts
Truncus arteriosus
72
CanMEDS Objectives
Section of Cardiology, Department of Internal Medicine, Faculty of Medicine
University of Manitoba
Rotation: Advanced Multimodality Cardiac Imaging: Cardiac CT/MRI
Education Director: Dr. Davinder S. Jassal
Introduction:
One 4-week period in advanced cardiovascular imaging (cardiac CT and cardiac MRI) can be
substituted for cardiac catheterization as per the RCPSC Subspecialty Training Requirements in
Adult Cardiology (2010) in either the C2 or C3 years. The rotation will take place at St. Boniface
General Hospital site under the supervision of both Cardiology (Dr. Jassal) and Radiology (Dr.
Iain Kirkpatrick, Dr. Bruce Maycher, Dr. Brett Memauri, and Dr. Jacek Strzelczyk). The normal
working hours are 0800 – 1700, Monday to Friday. The timetable for the resident is generally as
follows:
•
•
•
•
•
•
•
At 0830 am on the first day of the rotation, meet with Dr. Jassal to review the objectives of the
advanced cardiovascular imaging rotation, an introduction to cardiac CT angiography and
cardiac MRI
Discuss with the head technologists in both cardiac CT and cardiac MRI to find the times and
locations of patient scans during the four week rotation. Join the technologists in both cardiac
CT and MRI to learn the techniques involved in scanning.
Review SCCT Board Review DVD (18 hours of lectures on CCTA)
Review online lectures on the SCMR website
Introduction to post-processing of cardiac CT and cardiac MRI images on a daily basis
Reading cardiac CT and MRI with the staff attendings from both Cardiology and/or Radiology
Work on expansion of teaching files and augment pre-existing log of pertinent reading
materials
Medical Expert
Understand cardiovascular anatomy, physiology and hemodynamics
Understand the physical principles and instrumentation of cardiac CT and CMR
Understand the indications, contraindications, strengths, weaknesses and clinical utility of
cardiac CT and CMR
Know the normal variants and CT/CMR appearance of cardiac structures including cardiac
chambers, valves and major blood vessels.
Develop familiarity with the abnormal cardiac CT and CMR appearance of cardiac structures
during disease.
Communicator
Develop rapport, trust, and ethical therapeutic relationships with patients.
Establish positive therapeutic relationships with patients and their families that are
characterized by understanding, trust, respect, honesty and empathy
Develop a good patient relationship during the CT/CMR exam with appropriate attention to
patient comfort and privacy.
Be aware of and responsive to nonverbal cues
73
Respect patient confidentiality, privacy and autonomy
Interpret the relevant questions to be answered by the CT/CMR examination using information
from the initial medical evaluation.
Collaborator
Participate effectively and appropriately in an interprofessional health care team
Describe the cardiac imaging specialist’s roles and responsibilities to other professionals
Describe the roles and responsibilities of other professionals within the health care team
Recognize and respect the diversity of roles, responsibilities and competences of other
professionals in relation to their own
Work closely with the staff in the cardiac CT/CMR laboratory, including technologists, to
assist in the study preparation, performance, and patient discharge from the laboratory.
Interact and work with other physicians or allied health care professionals when performing or
interpreting the cardiac CT/CMR examinations.
Respect team ethics, including confidentiality, resource allocation and professionalism
Manager
Participate in activities that contribute to the effectiveness of their health care organizations
and systems
Utilize the cardiac CT/CMR equipment, facilities, personnel and time in an efficient manner.
Participate in systemic quality process evaluation and improvement, such as patient safety
initiatives
Respect and adhere to the cardiac CT/CMR laboratory schedule and the patient’s need for a
timely examination.
Allocate finite health care resources appropriately
Recognize the importance of just allocation of health care resources, balancing effectiveness,
efficiency and access with optimal patient care
Apply evidence and management processes for cost-appropriate care
Understands the appropriate indications, contraindications and clinical utility of cardiac CT
and CMR imaging
Health Advocate
Respond to individual patient health needs and issues as part of patient care
Identify the health needs of an individual patient
Understand the role of cardiac CT/CMR in diagnosing and managing cardiovascular disease.
Use information from cardiac CT/CMR to help patients modify their cardiovascular risk
factors.
Use cardiac CT/CMR to help patients understand their cardiovascular disease.
74
Scholar
Maintain and enhance professional activities through ongoing learning
Describe the principles of maintenance of competence
Describe the principles and strategies for implementing a personal knowledge management
system
Recognize and reflect on learning issues in practice
Recognize and understand knowledge gaps in the technical and interpretive facets of cardiac
CT/CMR for the diagnosis and management of relevant cardiovascular diseases.
Critically evaluate medical information and its sources, and apply this appropriately to practice
decisions
Describe the principles of critical appraisal
Critically evaluate the literature on topics related to cardiac CT/CMR
Integrate critical appraisal conclusions into clinical practice
Participate in rounds or presentations on cardiac CT/CMR
Professional
Demonstrate a commitment to their patients, profession, and society through ethical practice
Exhibit appropriate professional behaviours in practice, including honesty, integrity,
commitment, compassion, respect and altruism
Demonstrate a commitment to delivering the highest quality care and maintenance of
competence
Interact with patients coming to the cardiac CT/CMR laboratory with integrity, honesty and
compassion.
Work with other physicians and allied healthcare professionals in cardiac CT/CMR in an
appropriate, colleagial and professional manner.
Manage conflicts of interest
Recognize the principles and limits of patient confidentiality as defined by professional
practice standards and the law
Maintain appropriate relations with patients
Assessment:
•
•
•
Daily feedback
Logbook be reviewed by attending cardiologist and radiologists
Completion of on-line web evaluation at the end of each rotation
75
Schedule:
AM
All-day
PM
Monday
HSC TEE
(Call to check)
CCT/CMR
(check with
radiology
staff/resident/
Dr. Jassal)
SBGH
Stress Echo
Ongoing Activities:
Tuesday
CCT/CMR
(check with
radiology
staff/resident/
Dr. Jassal)
Wednesday
SBGH TEE
(Call to check)
CCT/CMR
(check with
radiology
staff/resident/ Dr.
Jassal)
Thursday
CCT/CMR
(check with
radiology
staff/resident/
Dr. Jassal)
SBGH
Stress Echo
Friday
SBH TEE
(Call to check)
CCT/CMR
(check with
radiology
staff/resident/
Dr. Jassal)
SBGH
CMR Readout
(12:30-2:00)
Daily teaching With Dr. Jassal
CT Cases TerraRecon (Jassal Lab in St. Boniface Research Centre)
CMR/CCT textbooks and teaching material
Resources:
Lee, Vivian, Cardiovascular MRI: Physical Principles to Practical Protocols, Lippincott Williams
and Wilkins, 2006.
Bogaert, J et al, Clinical Cardiac MRI, Springer, (2nd edition due out March 2012)
U. Joseph Schoepf, CT of the Heart: Principles and Applications
Miller, Stephen et al , Cardiac Imaging: The Requisites, Mosby 2009.
Reddy, G and Steiner, R, Cardiac Imaging: Case Review Series, Mosby 2005
http://libguides.lib.umanitoba.ca/content.php?pid=459574&sid=403930
76
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Nuclear Cardiology/ Stress Testing
Education Director: Dr. Ivan Barac
Introduction:
Two periods are spent in nuclear cardiology during the 3 year program in Adult Cardiology. The
resident is under the supervision of an attending cardiologist with specialized training in nuclear
cardiology as well as nuclear medicine physicians with training in nuclear cardiology. This
rotation provides experience in both nuclear cardiology and exercise testing. About 1000 exercise
stress tests and more than 2000 imaging procedures are performed annually in the Nuclear
Cardiology Laboratory in the University of Manitoba Health Sciences Centre site where the
residents do their rotations. These include exercise and/or pharmacological perfusion scans, and
rest radionuclide angiograms. The trainees should become familiar with the techniques of nuclear
cardiac imaging through day-to-day lab operations, interaction with technical and attending staff,
independent reading, and attendance at reporting sessions. The rotation is designed to make
trainees conversant in the field of nuclear cardiology but will NOT prepare them to assume full
responsibility for performance of independent clinical nuclear cardiac investigations. This will
require an additional 6 months of fellowship training in Nuclear Cardiology after the
completion of a three year training period in Adult Cardiology and is not currently offered at
this program. Additional experience in Cardiopulmonary Exercise Stress Testing is provided
during this rotation at St. Boniface Hospital.
CanMED 2005 Roles
Medical Expert
•
Describe normal hemodynamics at rest and normal physiological changes with upright or
supine exercise
•
Demonstrate competence in the supervision of exercise stress tests and exercise nuclear
cardiology procedures.
•
Describe the determinants of coronary blood flow at rest and with exercise in patients with
normal coronary arteries and coronary artery disease. Demonstrate a detailed understand of
indications, contraindications, completion and interpretation of cardiac exercise stress testing.
(including indications for pharmacological stress)
•
Describe the basic principles of radiation physics and radiation safety as they relate to
radiopharmaceutical administration in nuclear cardiology.
•
Obtain a basic understanding of and be able to describe the principles of nuclear cardiology
instrumentation including the basic structure and operation of a gamma camera.
•
Discuss the understanding of indications, contraindications, technical aspects and limitations
of myocardial perfusion imaging, gated blood pool scintigraphy and infarct avid imaging.
•
Describe and briefly demonstrate the methods of data manipulation and analysis employed in
post processing of nuclear cardiac studies above.
•
Participate in the interpretation of all nuclear cardiology procedures
77
•
Demonstrate an understanding of probability analysis for the noninvasive detection of
coronary artery disease.
Communicator
•
Establish therapeutic relationships with patients (and families where applicable)
•
Effectively communicate with nuclear technologists and the cardiac technologists (during
stress testing)
•
Obtain and synthesize relevant history from patients (and families where applicable)
•
Discuss appropriate information with patients (and families where applicable) and the health
care team
•
Formulate a clinically relevant clear and accurate report for the referring physician
Collaborator
•
Consult effectively with nuclear physicians, referring physicians and other health care
professionals
•
Contribute effectively to other interdisciplinary team activities – such as presenting cases at
imaging rounds
Manager
•
Utilize resources effectively to balance patient care, learning needs, and outside activities
•
Allocate finite health care resources wisely
•
Work effectively and efficiently in a health care organization
•
Utilize information technology to optimize patient care, life-long learning and other activities
Health Advocate
•
Identify the important determinants of health affecting patients
•
Contribute effectively to improved health of patients and communities
•
Recognize and respond to those issues where advocacy is appropriate – ensuring appropriate
prioritization of nuclear imaging requests based on patients clinical status
Scholar
•
Develop, implement and monitor a personal continuing education strategy
•
Critically appraise sources of medical information
•
Contribute to development of new knowledge
Professional
•
Deliver highest quality care with integrity, honesty and compassion
78
•
Exhibit appropriate personal and interpersonal professional behaviors
•
Practice medicine ethically consistent with obligations of a physician
Duties
•
Attendance in the exercise laboratory is expected during exercise tests. The trainee should
obtain a brief cardiovascular history and physical examination on each patient and if no
contraindications to exercise testing exist, should supervise the exercise test, monitoring the
patient’s blood pressure, clinical response and electrocardiogram. At the conclusion of the test,
the trainee should formulate conclusions and write a report for review with attending staff.
•
The trainee will be responsible for the direct supervision of all nuclear exercise and
pharmacological stress procedures during his/her time on the specific rotation.
o During the first period, the resident will be based entirely at HSC. Mornings will
consist of supervising the lab, which deals with primarily with nuclear testing and
injection of persantine or dobutamine and appropriate antidotes. Afternoons will
consist of scan interpretation and supervision of exercise tests.
o During the second period, the resident will be based at SBH in the mornings and HSC
in the afternoons. Mornings will consist of supervising the exercise stress lab, which
deals with a mix of exercise testing and nuclear testing. Afternoons will be spent at
HSC, consisting of scan interpretation and supervision of exercise tests.
•
Working hours are 8:00 to 17:00. The resident is excused from the lab during the cardiology
core curriculum lecture and all other mandatory rounds and lectures. The resident is allowed to
leave HSC 20 minutes before the educational session and are expected to return to the stress
lab after the session.
•
Observation and participation is expected in the preparation and calibration of the
radiopharmaceuticals, application and operation of the gamma camera, and operation of the
computer system during image acquisition and processing
Attendance is mandatory at review/reporting sessions with attending staff. A schedule of
review/reporting sessions (at both sites) will be coordinated with Dr. Ivan Barac and Dr. Francisco
Cordova. A general weekly schedule is outlined on the table below: Test interpretation and
feedback:
• For all exercise tests supervised at SBH and the exercise components of nuclear studies
supervised at HSC, the resident will make a copy and complete a preliminary
interpretation. These interpretations will be reviewed with the attending Nuclear
Cardiologist at their next contact
• For all exercise treadmill tests supervised at HSC, the resident will complete a preliminary
interpretation and affix it to the test printout. The resident will review the interpretation
with the attending echocardiographer at HSC on the next working day
A general weekly schedule is outlined on the table below:
Period 1 (All Activities at HSC):
79
Period 2 (Morning Activities at SBH, Afternoon Activities at HSC):
MONDAY AM STRESS LAB PM INTERPRET SCANS PM STRESS LAB TUESDAY STRESS LAB INTERPRET SCANS DIDACTIC SEMINAR LAB WEDNESDAY STRESS LAB INTERPRET SCANS STRESS LAB THURSDAY STRESS LAB INTERPRET SCANS STRESS LAB FRIDAY STRESS LAB INTERPRET SCANS STRESS LAB •
Weekly didactic seminar will be scheduled based on availability of Dr. Barac or Dr. Cordova
•
The trainee will be responsible for active participation in weekly Nuclear Cardiology
Didactic Seminars dealing with:
o Basics of nuclear physics and instrumentation and basics of radiation safety
o Radiopharmaceuticals: physical and biological properties, kinetics, application
o Nuclear cardiology tests, procedures and protocols: assessment of perfusion,
function and viability
o Pre-test patient evaluation, interpretation of test results, post-test evaluation of
probability of disease and risk, Bayesian analysis
The Didactic Seminars are 1-2hr weekly sessions during which above topics are discussed
between the Nuclear Cardiologist and trainees. This implies that the trainees get ready for
the Seminar by reading the recommended material.
Arrangements will be made for the residents to observe Cardiopulmonary Stress Tests at the
Lab at St. Boniface hospital at least one half day during this rotation.
Arrangements will be made for the residents to participate in reading of Radionuclide
Ventriculography (MUGA) studies.
In addition, the presentation of stress and/or nuclear data for patients discussed at the cath
conference should be undertaken by the resident who is doing the nuclear/stress rotation
wherever possible. Each resident is expected to complete at least five cases in which clinical
and angiographic correlations are made with nuclear perfusion study.
Residents are expected to present a scientific paper dealing with a relevant topic from the
field of nuclear cardiology on Nuclear Medicine Grand Rounds. The paper may be selected
by the resident and should be approved by the Nuclear Medicine physician in charge of the
Grand Rounds.
Residents are encouraged to participate in research projects dealing with/involving Nuclear
Cardiology, however this is not a mandatory activity.
•
•
•
•
•
•
Assessment:
•
•
Daily feedback – a case by case basis by the supervising physician
Completion of on-line web evaluation at the end of each rotation
80
Recommended Reading:
Please, refer to the updated reading material on the CD submitted by Dr. Barac (references 1-18)
1.
Klocke, FJ et al. ACC/AHA/ASNC Guidelines for the Clinical Use of Cardiac
Radionuclide Imaging. JACC 2003; 42:1318-33
2.
Brindis, RG et al. ACCF/ASNC Appropriateness Criteria for Single-Photon Emission
Computed Tomography Myocardial Perfusion Imaging (SPECT MPI). JACC 2005; 46: 1587-605
3.
Schuijf, JD et al. Diagnostic and Prognostic Value of Non-invasive Imaging in Known or
Suspected Coronary Artery Disease. Eur J Nucl Med Mol Imaging, 2006; 33: 93-104
4.
Hachamovitch R and Berman DS. New Frontiers in Risk Stratification Using Stress
Myocardial Perfusion Single Photon Emission Computed Tomography. Curr Opin Cardiol 2003;
18:494-502
5.
Gibbons RJ et al. ACC/AHA 2002 Guideline Update for Exercise Testing. JACC 2002;
40:1531-40
6.
Fletcher GF et al. Medical/Scientific Statements: Special Report: Exercise Standards: A
Statement for Healthcare Professionals From the American Heart Association. Circulation 1995;
91(2): 580-615
7.
Eagle, KA et al. ACC/AHA Guideline Update on Perioperative Cardiovascular Evaluation
for Noncardiac Surgery. JACC 2002; 39: 542-53
8.
Kertai, MD et al. A Meta-analysis Comparing the Prognostic Accuracy of Six Diagnostic
Tests for Predicting Perioperative Cardiac Risk in Patients Undergoing Major Vascular Surgery.
Heart, 2003; 89: 1327-34
9.
Rizzello, V et al. Assessment of Myocardial Viability in Chronic Ischemic Heart Disease:
Current Status. Q J Nucl Mol Imaging 2005; 49:81-96
10.
Allman, KC et al. Myocardial Viability Testing and Impact of Revascularization on
Prognosis in Patients With Coronary Artery Disease and Left Ventricular Dysfunction: A Metaanalysis. JACC 2002; 39: 1151-8
11.
Travin, MI et al. The Prognostic Value of ECG-gated SPECT Imaging in Patients
Undergoing Stress Tc-99m Sestamibi Myocardial Perfusion Imaging. J Nucl Cardiol 2004;
11:253-62
12.
Hachamovitch R et al. Comparison of Short-term Survival Benefit Associated With
Revascularization Compared with Medical Therapy in Patients With No Prior Coronary Artery
Disease Undergoing Stress Myocardial Perfusion Single Photon Emission Computed
Tomography. Circulation 2003; 107: 2900-6
13.
Geleijnse, ML et al. Dobutamine Stress Myocardial Perfusion Imaging. JACC 2000; 36:
2017-27
14.
Maganti, K and Rigolin, VH. Stress Echocardiography Varsus Myocardial SPECT For
Risk Stratification of Patients With Coronary Artery Disease. Curr Opin Cardiol 2003; 18: 486-93
15.
Beattie, WS et al. A Meta-analytic Comparison of Preoperative Stress Echocardiography
and Nuclear Scintigraphy Imaging. Anesth Analg 2006; 102:8-16
16.
Henzlova, MJ et al. Stress Protocols and Tracers. J Nucl Cardiol 2006; 13:e80-90
17.
Mahmarian, JJ et al. A Multinational Study to Establish the Value of Early Adenosine
Technetium-99m Sestamibi Myocardial Perfusion Imaging in Identifying a Low-risk Group for
Early Hospital Discharge After Acute Myocardial Infarction. JACC 2006; 48: 2448-57
18.
Mahmarian, JJ et al. An Initial Strategy of Intensive Medical Therapy Is Comparable to
That of Coronary Revascularization for Suppression of Scintigraphic Ischemia in High-risk But
Stable Survivors of Acute Myocardial Infarction. JACC 2006; 48: 2458-67
Also may consider:
81
1.
Geleijnse, M.L., et al. Dobutamine Stress Myocardial Perfusion Imaging JACC
2000;36:2017-27
2.
Berman DS et al The role of Nuclear Cardiology in Clinical Decision Making. Seminars
in Nuclear Medicine 1999;29:280-97
3.
Hachamovitch R et al Incremental Prognostic Value of Myocardial Perfusion Single
Photon Emission Computed Tomography for the Prediction of Cardiac Death Circulation
1998;97:535-543
4.
Dilsizian V, & Bonow RO. Current Diagnostic Techniques of Assessing Myocardial
Viability in Patients with Hibernating and Stunned Myocardium Circulation 1993;87:1-20
5.
Brown KA Prognostic Value of Thallium – 201 Myocardial Perfusion Imaging.
Circulation 1991;83:363-381
Additional Recommended Nuclear Cardiology Resources:
Recommended Websites:
Website of the American Society of Nuclear Cardiology:
http://www.asnc.org/
Information about Radiation Safety in Nuclear Medicine:
1.
http://www.epa.gov/rpdweb00/understand/index.html
2.
http://www.ccohs.ca/oshanswers/phys_agents/ionizing.html
3.
http://www-ns.iaea.org/standards/
Note: These books/CDs/video tapes can be found in Room GC337 – Nuclear Medicine
Library. Each of these items has a sign-out card attached to it. Please sign and date the
card, and leave the card on the secretary’s desk for her attention. You are allowed to have
the item out-on-loan for a 2 week period. If you require the item for a longer duration,
please notify the NM secretary of your intent at telephone 787-3837.
Cardiac Nuclear Medicine
author: Myron C. Gerson, James T. Morgan & Peter J. Boyle
publisher: McGraw-Hill, c: 1997
NM Library code: WG200 C264
Video Seminar Series on Nuclear Cardiology
author: Dr. Daniel S. Berman
publisher: American College of Cardiology, c: 1997
-Volume 1: Clinical Applications of Myocardial Perfusion SPECT
-Volume 2: Technetium-99m Myocardial Perfusion Agents
-Volume 3: Pharmacologic Stress
Physical & Technical Aspects of Nuclear Cardiology
NM Cardiology: Self-Study Program III
author: Elias H. Botvinick, E.V. Garcia & M.W. Dae
publisher: Society of Nuclear Medicine, Inc., c: 1997
NM Library code: WG18.2 N964a
82
NM Cardiology: Self-Study Program III
author: Elias H. Botvinick
publisher: Society of Nuclear Medicine, Inc., c: 1997
NM Library code: WG18.2 N964b
Cardiac PET Imaging & Congenital Heart Disease
NM Cardiology: Self-Study Program III
author: Elias H. Botvinick
publisher: Society of Nuclear Medicine, Inc., c: 1997
NM Library code: WG18.2 N964c
Cardiac SPECT Imaging
author: E.Gordon DePuey, Ernest V. Garcia & Daniel S. Berman
publisher: Lippincott Williams & Wilkins, c: 2000
NM Library code: WG141.5 R3
Atlas of Gated SPECT (on CD-ROM)
author: Daniel S. Berman & Guido Germano
publisher: Lippincott Williams & Wilkins, c: 2000
Nuclear Medicine: The Requisites
author: James H. Thrall & Harvey A. Ziessman
publisher: Mosby-Year Book, Inc., c: 1995 & c. 2001
NM Library code: WN445 T529n
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
83
Rotation: Research
Education Director: Dr. Davinder S. Jassal
Introduction:
As part of the Royal College requirements, all residents are required to perform a minimum of 2
blocks of research (and a maximum of 6 blocks) during their three-year program.
The Adult Cardiology Residency program at the University of Manitoba has appointed a clinician
scientist, Dr. Davinder S. Jassal, who has also taken on the role of resident research co-ordinator.
Dr. Jassal meets with the residents at the beginning of the academic year and assists them in
developing their project(s), including matching them with the appropriate mentor, through the
Discovery course. The Discovery research course takes place once a month on Mondays at lunch.
The schedule for the Discovery Research Course for 2013-2014 is:
Sept 2015
Introduction to course: Dr. Jassal
Oct 2015
Ethics 101
Nov 2015
How to write a grant?
Dec 2015
Holidays
Jan 2016
Clinical trials
Feb 2016
Critical appraisal of medical literature
Mar 2016
Abstract writing 101
Apr 2016
CCS abstract submission and discussion of Internal Medicine Research Day and
Cardiac Sciences Research Day
May 2016
Practice Resident Research Day presentations
All forms of research are encouraged program including both basic science (in collaboration with
the St Boniface Research centre) as well as clinical and applied translational research.
Residents in their 2nd and 3rd year are expected to present their projects at the Cardiac Sciences
Research Day, held in May. It is expected that the R5 and R6 residents present at this research day
as well as the Internal Medicine Research Day. During the 3 year Cardiology residency, it is
expected that the Cardiology resident must present on at least 2 separate occasions, of which
one must be an oral presentation, at either Cardiac Sciences and/or Internal Medicine
Research Days.
Additionally, the Cardiology resident must complete the RCPSC Medical Curriculum in
Bioethics (http://rcpsc.medical.org/bioethics/) during the first year of training.
84
RESEARCH AWARDS
1. THE SANOFI AVENTIS/HEART AND STROKE FOUNDATION OF MANITOBA
AWARD IN CARDIOLOGY
The objective behind the establishment of this award is to stimulate and support excellence in
research and scholarly activity in the discipline of Cardiology at the University of Manitoba. The
award will fund a clinical cardiology resident.
Eligibility:
Cardiology residents within the division of cardiology in the Faculty of Medicine, University of
Manitoba who are currently in their residency training. The clinical research/training will normally
be conducted within Manitoba.
Award Amount:
One annual award with a value in the amount of $10,000.
Award Criteria:
1) demonstrated academic excellence within the clinical residency program (this can encompass
research projects, presentations, clinical teaching).
2) humanistic qualities with respect to patient care, collegiality and interpersonal dealings with
medical and paramedical staff.
3) clinical competence in the field.
4) awardee is expected to pursue further academic training beyond core cardiology.
Application Package:
Applicants should submit to the office of the Associate Dean (Research) by spring of 2012:
1) a complete Curriculum Vitae
2) a brief biography
3) a summary of research and/or clinical accomplishments
Candidate Selection:
The awards selection committee comprising the Associate Dean (Research), The Director of the
Core Cardiology training program, a Cardiologist with research background and a Representative
of the Heart and Stroke Foundation of Manitoba will review all applications and select the
appropriate candidate on a yearly basis. Candidates may receive the award only once during their
residency training. The award funding may be deferred if a suitable applicant can not be identified.
2. DONALD PETERS AWARD
Donald John Peters became a member of the Department of Anesthesia at St.Boniface General
Hospital in 1972. He has been involved in the care of cardiac patients at SBGH for over 30 years.
Dr. Peters was honored with the 2005 Canadian Anesthetists Society Clinical Practitioner Award
for excellence in clinical care. He has also been involved with Medical Ministries International for
many years. Medical Ministries is an international organization that prides itself in providing
spiritual and medical care to the world's poor. Dr. Peters and his wife Margaret have traveled to
many third world countries to help those less fortunate. Dr.Peters has always practiced with
personal integrity, compassion, and a true dedication to patient needs.
85
The Donald Peters Cardiac Sciences Award was created to establish a legacy that honors the
outstanding contributions to cardiac anesthesia and the personal integrity that defined his care of
patients. These are qualities that are critically important to instill in our young trainees.
This award will be eligible to all trainees in the Cardiac Sciences Program (Cardiac Anesthesia,
Cardiology, Cardiac Surgery and Cardiac Critical Care) and will be presented annually at the
Cardiac Sciences Research Day. The Don Peters Award will be given to the trainee who best
demonstrates integrity, compassion, and dedication to the care of patients as individuals. The
award will recognize high standards of character, conduct, leadership, and the promotion of those
qualities in others.
The Medical Director of the Cardiac Sciences Program will be responsible for the management of
the award. There will be consensus reached by the Medical Director of the Cardiac Sciences
Program and the Residency/Residentship coordinators for Cardiac Anesthesia, Cardiac Surgery,
Cardiology and Cardiac Critical Care. The award will be presented annually at the Cardiac
Sciences Resident Research Day.
Further information about the Award can be obtained from the office of the Medical Director of
Cardiac Sciences
3. CSCI/CIHR RESIDENT RESEARCH AWARD
Canadian Society for Clinical Investigation (CSCI) / Canadian Institute of Health Research
(CIHR)
Resident Research Prize
Visit the CSCI Website for nomination guidelines http://www.csci-scrc.org/english/awards.htm
CanMED 2005 Roles
Medical Expert:
•
Obtain skills required to understand different types of research, ethical issues, legal issues, and
statistic knowledge to design a research project through attendance at core curriculum lectures
and at Journal Club
•
Obtain skills for critical appraisal of literature
Communicator:
•
Write up research proposal, ethics, submission, and consent forms as required
•
Write interim research reports
•
Presentation of data in oral, abstract, and manuscript form
•
•
Presentation at peer reviewed meetings
Attendance at Research in Progress meetings when applicable
86
•
•
Attendance at Journal Club
Present research work results at Resident Research Day
Collaborator:
•
Learn to collaborate with all health care professionals and basic scientists involved in your
research – attend all meetings related to project
Manager:
•
Learn the skills for setting a budget for proposed or ongoing research
•
Learn time management skills to balance research with ongoing clinical commitments
Health Advocate:
•
Evaluate research initiatives with patients’ best interests in mind
•
Evaluate all research initiatives with ethical principles as a primary basis
Scholar:
•
Learn basic skills including literature searching and grant/proposal writing
•
Review drafts with supervisor
•
Presentation at meetings
Professional:
•
Conduct all research with primary objectives of maintaining highest degree of professional
conduct
•
Develop insights into present personal strengths and weakness in the research arena
•
Understand ethical codes of behaviour
Duties:
•
It is expected that with all research projects that the residents use appropriate and good
laboratory practice and abide by all the ethical rules guiding research
•
It is anticipated that the research projects will lead to a minimum of a presentation and most
importantly to a manuscript in a peer-reviewed journal
•
All residents are expected to present in their 2nd and 3rd year at the Cardiac Sciences Research
Day
•
All residents are encouraged to submit their research projects with their supervisor's
permission to both national and international meetings.
•
Appropriate support is given for the resident to attend these meetings. Although all residents
are required to do at least one project, most residents are now encouraged to do a couple of
projects during their three-year program.
•
Usually one project is the most dominant project while the second project may be one of
smaller scope to allow for its successful completion.
87
Assessment:
•
•
•
Regular feedback
Assessment of research project at the annual resident research day
Completion of on-line web evaluation at the end of each rotation
88
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Electrophysiology (including ECG and ambulatory ECG monitoring)
Education Director: Dr. Ali Khadem
Introduction:
This rotation is located entirely at the St Boniface General Hospital site. The rotation consists of 3
periods over the three-year cardiology residency at the University of Manitoba. Prior to 2011,
residents in Adult Cardiology at the University of Manitoba spent 2 months locally and an
additional 1 month of training in electrophysiology/pacemaker/ICD at the University of Calgary
during their final year of training. Historically, our trainees from 1989 to the present have spent
educational time at the University of Calgary due to the shortage of qualified
personnel/infrastructure in the field of Cardiac Electrophysiology at the University of Manitoba.
As the personnel, infrastructure and educational resources in electrophysiology/pacemaker
Cardiology have been in place and excelled at the University of Manitoba, the inter-university
affiliation with the University of Calgary was officially removed by the Royal College of
Physicians and Surgeons on January 28, 2011. As such, all Cardiology trainees can now complete
the required 3 months of training in electrophysiology at the University of Manitoba. The
following are the revised CANMEDS objectives for EP (approved by the RPC in May 2011).
Residents are expected to contact the EP Rotation Physician Co-ordinator or Delegate prior to
the rotation and/or meet on the first day of the rotation, to finalize a timetable and review the
objectives. Generally, time is spent between ambulatory cardiology (arrhythmia and syncope
clinics), the cardiac device clinic and both the cardiac device lab and the EP lab. Residents are
expected to see in-patient consults to the service. There is a half day per week for self-directed
learning as well as 1-2 didactic teaching sessions per week during the rotation by the EP
physician on call for the week. These sessions may be formal or informal, in the context of
assessing patients/reviewing consults. Residents may be asked to present at Device Rounds.
CanMED 2005 Roles
Medical Expert:
•
•
•
•
•
•
Understand the basic mechanisms of cardiac arrhythmias.
Know the nomenclature of simple and more complex arrhythmias and the criteria for their
electrocardiographic diagnosis.
Know the consequences and natural history of simple and more complex cardiac
arrhythmias.
Know the principles of specialized diagnostic procedures for arrhythmia diagnosis (exercise
testing, ambulatory ECGs, trans-telephonic monitoring, intracardiac electrograms,
programmed stimulation, pharmacologic provocation studies).
Know the diagnostic utility, indications for, and management of the maneuvers that alter
autonomic tone in the treatment of arrhythmias (Valsalva, carotid sinus massage, cold
pressor, dive reflex).
Know how to classify antiarrhythmic drugs.
89
•
•
•
•
•
•
•
Know the relevant basic and clinical pharmacology of antiarrhythmic drugs.
Know the value and limitations of therapeutic drug monitoring as it applies to
antiarrhythmic drug therapy.
Recognize the availability of non-pharmacologic therapies for tachyarrhythmias (catheter
ablation, implanted devices).
Understand the principles of and indications for bradycardia cardiac pacing, the general
types of available devices, their uses, limitations and complications.
Understand the basic pacemaker malfunction diagnosis from the ECG.
Understand the indications for ICD implantation and mechanisms of defibrillation and
antitachycardia pacing.
Know the indications for tilt table testing.
Communicator:
•
•
•
•
Obtain and synthesize relevant history from patients and their families – present the history to
attending physicians prior to patient’s procedure
Be able to inform the patient and their family about their cardiac condition, its prognosis,
management and plans for follow-up
Write a report of the procedure results on the chart
Be able to write consultation and discharge letters to referring physicians
Collaborator:
•
Work with the attending physician, nurses, and X-ray technicians in the EP and cardiac device
laboratories
•
Work appropriately with nurses in the preadmission unit, pre and post area, and wards prior to
procedure
•
Collaborate with other members of the health care team including junior residents
•
Identify social rehabilitative and dietetic concerns with patients and consult appropriate allied
health care
Manager:
•
Utilize laboratory equipment and time in an efficient manner - work closely with booking and
triage office for appropriate scheduling
•
Respect and adhere to both the laboratory schedule and the patients' needs for timely
examination
•
Understand the indications and contraindications of EP and cardiac device implantations
•
Understand the cost benefit ratio of cardiac device implantations, particularly ICD’s
Health Advocate:
•
Participate in the ICD support group coordinated by the device clinic.
•
Advocate for device implantation in appropriate patients
90
•
Review the triage system for patients undergoing device implantation and EP studies and
prioritize based on clinical details
•
Understand the importance and measurements of outcomes for invasive procedures – including
attending quarterly morbidity and mortality rounds
Scholar:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Recognize simple and more complex arrhythmias from their ECG manifestations.
Perform and analyze the maneuvers that alter autonomic tone (as described in medical
expert)
Assess the hemodynamic significance of arrhythmias in patients.
Know how to administer commonly use antiarrhythmic medications.
Be familiar with the techniques used, electrograms obtained and clinical interpretation of
invasive electrophysiologic studies.
Perform consultations on patients referred for assessment and write a consultation note
under the supervision of a staff Electrophysiologist.
Perform clinical non-invasive and invasive electrophysiologic studies including reading of
records and preparation of clinical reports under the supervision of a staff
Electrophysiologist.
Attend Arrhythmia Clinic – a minimum of 1 clinic per week
Attend a minimum of 5 invasive EP studies.
Assist in obtaining venous access for both electrophysiology studies and pacemaker and
ICD implantations
Be able to evaluate the function of pacemakers and ICD’s including interpretation of ECG's
interrogation and programming of the device.
Attend a minimum of 5 permanent cardiac pacemaker implantations and make the
appropriate intracardiac measurements.
Attend a minimum of 5 ICD implantations and understand the principles of arrhythmia
induction and termination.
Attend Pacemaker Clinic and participate in device interrogation under the supervision of
clinic staff (nursing and/or physician)
Professional:
•
Deliver care with integrity, honesty, and compassion – follow role models and mentoring of
the senior attending physicians and their interactions with patients
•
Understand the professional, legal and ethical codes to which physicians are bound.
Expectations:
1.
Residents are expected to see all in-patient consults to the service during their rotation.
Consults are sent directly to the staff cardiologist who in turn will contact the resident with
details of the consult. Once seen, the consult must be reviewed with a staff cardiologist.
2.
During days in the lab, the resident is expected to arrive at 07:30, assess the first patient
and then review the case with the staff cardiologist.
3.
When residents are attending ambulatory clinics, start time is usually 0830 for am clinic
and 1300 for pm clinic.
4.
When residents are attending device clinic, start time is 0900 in am and 1300 in pm.
Lab Days:
Pacemakers:
Monday, Wednesday, Thursday, Friday: 0730-1600
91
Defibrillators:
Tuesday: 0730-1600
EP studies/ablations: Monday, Wednesday, Thursday: 0730-1600
Ambulatory Care: (Dates should be checked with Kathy Van Der Vis as there are often junior
residents rotating in clinic)
Physician clinic days:
Dr Seifer:
Monday pm, Tuesday pm, Friday pm
Dr Tischenko: Tuesday am
Dr Khadem: Thursday pm
Dr Wolfe:
Friday am and pm
Pacemaker Clinic (Cardiac Device Clinic):
The device clinic is nurse-led but there is an EP physician on-call to the clinic everyday if there
are any device problems.
Period specific duties/expectations:
Period 1:
Duty:
Assess all in-patient consults to the service
Expectation: Know the indications for cardiac devices
Know the indications for EP studies/ablations
Diagnose common arrhythmias including atrial fibrillation, atrial
flutter, atrial tachycardia, AVNRT, AVRT, ventricular
tachycardia
Duty:
Expectation:
A minimum of 1 half-day ambulatory care per week
Be able to take a complete history and physical and order
appropriate laboratory investigations
Know indications and procedure for elective electrical
cardioversion
Duty:
A minimum of 1 half day each in EP and device labs per week
Expectation: Obtain informed consent from patients
Explain in detail a typical EP study and device procedure
Duty:
Expectation:
Period 2:
A minimum of 1 day in Pacemaker clinic per week
Understand basic programming of pacemakers and defibrillators
including turning off ICD therapies
Duty:
Assess all in-patient consults to the service
Expectation: Interpret rhythm strips
Formulate a detailed management plan for common arrhythmias,
including pharmacologic and non-pharmacologic treatment.
Describe the classification and pharmacology of common antiarrhythmic drugs (including Vaughn Williams Classification)
including effects on the action potential
Independently perform elective cardioversion
Duty:
Expectation:
A minimum of 1 half-day ambulatory care per week
Formulate a detailed management plan including communication
to referring physician(s)
92
Duty:
A minimum of 1 half day each in EP and device labs per week
Expectation: Describe the cellular mechanisms of arrhythmias
Interpret intracardiac measurements from devices/catheters
List indications and contraindications to defibrillation threshold
testing
List and identify device and EP procedural complications
including complex ablations
Assist and perform catheter deployment for the various EP
studies
Duty:
Expectation:
Period 3:
A minimum of 1 day in Pacemaker clinic per week
Begin programming devices and interpreting electrograms
Duty:
Assess all in-patient consults to the service
Expectation: Be able to function at the level of a junior consultant
Duty:
Expectation:
A minimum of 1 half-day ambulatory care per week
Be able to independently assess patients and complete a
management plan at the level of a junior consultant
Duty:
A minimum of 2 days in Pacemaker clinic as first on-call
physician per week
Independently identify and manage common device problems
including ICD shocks, device infections, troubleshoot lead
problems, independently program device therapies in
ICD’s/CRT’s
Expectation:
Recommended Reading:
Textbooks
1. Zipes D, Jalife J. Cardiac Electrophysiology, 3rd Edition
2. Prystowsky EN, Klein GJ. Cardiac Arrhythmias
3. Furman, S., Hayes, DL, Holmes DR. A Practice of Cardiac Pacing. 4th Edition
4. Fogoros R. Electrophysiologic Testing. 4th Edition
5. Grubb B, Olshansky B. Syncope Mechanisms and Management. 2nd Edition
6. Ellenbogen K, Kay G, Lau CP, Wilkoff B. Clinical Cardiac Pacing, Defibrillation, and
Resynchronization Therapy. 3rd Edition
7. Wellens H, Conover M. The ECG in Emergency Decision Making. 2nd Edition
8. Issa Z, Zipes D., Clinical Arrhythmology and Electrophysiology : A Companion to
Braunwald’s Heart Disease
9. Hayes D., Cardiac Pacing Defibrillation and Resynchronization
Guidelines/Position Papers
1. Canadian Cardiovascular Society/Canadian Heart Rhythm Society position paper on
implantable cardioverter defibrillator use in Canada. Can J Cardiol Vol 21 Suppl A May 15,
2005
2. Standardized Approaches to the Investigation of Syncope: Canadian Cardiovascular Society
Position Paper. Can J Cardiol 27(2011) 246-253.
3. Recommendations for the Use of Genetic Testing in the Clinical Evaluation of Inherited
Cardiac Arrhythmias Associated with Sudden Cardiac Death: Canadian Cardiovascular
93
4.
5.
6.
7.
Society/Canadian Heart Rhythm Society Joint Position Paper. Can J Cardiol 27 (2011) 232245.
ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and
the prevention of sudden cardiac death. Europace (2006) 8, 746-837.
ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm
Abnormalities. Heart Rhythm, Vol 5, No 6, June 2008.
ACC/AHA Guidelines for Clinical Intracardiac Electrophysiological and Catheter Ablation
Procedures.
ACC/AHA guidelines for ambulatory electrocardiography: A report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to
Revise the Guidelines for Ambulatory Electrocardiography) developed in collaboration with
the North American Society for Pacing and Electrophysiology. J Am Coll Cardiol
1999;34;912-948
University of Manitoba Cardiology
Electrophysiology Rotation Assignments
Assignment #1
1. Draw an action potential and label its phases and channels. Draw the corresponding surface
EKG QRS / T wave complex in relation to the action potential.
2. Describe the normal activation of the heart, starting from sinus node firing. At each stage of
activation, give the corresponding wave/segment on surface EKG.
3. What are the 3 mechanisms of arrhythmias?
4. Describe the techniques for a) carotid sinus massage, b) valsalva maneuvers and c)
administration of adenosine
5. For each of the following, describe a) the underlying mechanism(s), b) usual atrial rate, and c)
characteristic EKG findings that aid in diagnosis and d) potential effect of adenosine / vagal
maneuver:
i. Sinus tachycardia
ii. SANRT
iii. Atrial tachycardia
iv. Atrial flutter
v.
AVNRT
vi. AVRT
vii. Atrial fibrillation
6. Draw the following QRS patterns in lead V1 and V6:
i. normal QRS
ii. typical LBBB
iii. typical RBBB
Describe the diagnostic and key features of typical LBBB and RBBB on EKG.
7. Describe Vereckeis algorithm and Brugada’s criteria. List the other key EKG features
suggestive of ventricular tachycardia. Describe the morphological features of LBBB-like pattern
and RBBB-like pattern QRS that would suggest VT.
94
8. List the differential diagnosis for recurrent ICD defibrillations. For each, give the key
diagnostic features on CXR, maneuvers, and ICD interrogations.
9. Define syncope and list the differential diagnosis of syncope.
10. List the low risk features and high risk features of transient loss of consciousness (TLOC).
11. For a temporary VVI transvenous pacemaker, describe the steps you would perform to check
the following: a) capture threshold, b) sensitivity
12. For a permanent pacemaker, give a differential diagnosis for a) failure to capture, b) failure to
output, c) failure to sense, and d) pacemaker related tachycardia
13. In a patient with a permanent pacemaker, describe the effect seen with the application of a
magnet in the following scenarios:
i. Failure to capture
ii. Failure to sense
iii. Oversensing
iv. Pacemaker mediated tachycardia (endless loop tachycardia)
v.
SVT with pacemaker tracking (failure to mode switch)
14. In a patient with an ICD, describe the effect seen with the application of a magnet in the same
scenarios as question 13.
Assignment #2
1. Define paroxysmal, persistent, and permanent atrial fibrillation. Define lone atrial fibrillation
2. List the CHADS2, CHADS2-VASc, and HAS-BLED scores and their associated predicted
risks.
3. Compare and contrast the following devices, including a) potential length of monitoring, b)
number of channels recorded and c) invasiveness of device:
i. Holter monitor
ii. Event recorder
iii. Loop recorder
4. List the Class I indications according to ACC/AHA/HRS guidelines for the following:
i. permanent pacemaker insertion
ii. temporary pacemaker insertion in the setting of acute MI
5. List the steps required to obtain consent for a PPM implant. Include the potential risks and
their frequency of occurrences for implant.
6. List the Class I indications for an ICD implantation. Compare and contrast the indications
from ACC/AHA, ESC, and CCS guidelines.
7. List the high risk factors for SCD in hypertrophic cardiomyopathy.
95
8. For the each of the ICD interrogations (appendix), answer the following:
a) Initial ICD Event Dot Plot i. Identify the device
ii. Identify the axis, atrial markers, and ventricular markers
iii. Identify the VT and VF zones
iv. Is the atrial rate regular?
v.
What is the atrial rate? (either in terms of cycle length or bpm)
vi. Is the ventricular rate regular?
vii. What is the ventricular rate? (either in terms of cycle length or bpm)
viii. What is the association between the atrial and ventricular rates (ie 1:1, 2:1, none, etc)?
ix. Based on rate and regularity, what is the likely atrial rhythm or its differential diagnosis?
x.
Is there a change in rhythm (atrial, ventricular, or both)?
xi. What occurs before and after the rhythm change? Describe in terms of suddenness,
regularity, initiating beats (PAC, PVC, or neither), and therapies.
b) EGM –
i. If present, identify the “surface” lead, atrial and ventricular EGMs.
ii. Identify the marker channels
iii. Define the atrial rhythm
iv. Define the ventricular relationship to the atria
v.
Do the marker channel interpretation correlate with the EGMs?
vi. Compare the atrial and ventricular morphology before, during, and after the arrhythmia
event.
Assignment #3
1. Give a differential diagnosis of cardiac arrest / ventricular arrhythmias in a structurally normal
heart.
2. For each of the above differential diagnosis, describe a) usual VT pattern, b) characteristic
baseline EKG abnormalities, c) associated gene defect if any, d) different variants if any, and e)
further testing that may be required.
3. List the Vaughns-Williams classification of antiarrhythmics. Describe the effects of
antiarrhythmics on the action potential. List common side effects of each drug.
4. Describe the mechanistic difference between orthostatic hypotension and neuromediated
syncope (reflex syncope). Give the possible conservative, medical and invasive therapies for each.
5. In regards to Holter monitoring, define the following terms:
i. Simple PVC
ii. Complex PVC
iii. Frequent PVC
iv. Significant bradycardia
v.
Significant pause
vi. Rhythm-symptom correlation
6. Describe the difference between Elective Replacement Time (ERT) and Recommended
Replacement Time (RRT) in the setting of a permanent pacemaker. NB: RRT was previously
known as EOL, End of Life.
96
7. As a pacemaker approaches RRT, describe the trend or changes in the following:
i. battery voltage
ii. battery impedence
iii. magnet response
iv. pacing function
8. List the indications and criteria for cardiac resynchronization therapy. Compare and contrast
the ACC/AHA, ESC, and CCS guidelines. Describe the potential expected benefit of CRT
(symptoms, mortality etc).
9. Define adequate rate control for atrial fibrillation.
10. Define rhythm control for atrial fibrillation. List landmark trials regarding the issue of ‘Rate
vs. Rhythm Control’.
11. Compare and contrast ASA, warfarin, dabigatran, apixaban, and rivabroxaban in terms of: a)
mechanism, b) efficacy, c) advantages, and d) contraindications and precautions in the setting of
atrial fibrillation.
12. List the indications for referral for pulmonary vein isolation. List the potential complications
of PVI and expected timeline for their occurrence.
13. List the indications for referral for invasive electrophysiology study. List the potential
complications of EPS and expected timeline for their occurrence.
14. List the different forms of accessory pathways. List the high risk features of accessory
pathways that may warrant an EPS and ablation.
97
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Adult Congenital Cardiology
Education Director: Dr. Reeni Soni
Supervisors:
Pediatric Congenital Cardiology: Dr. R Soni
Adult Congenital Cardiology: Dr. J Tam
All residents will be provided exposure to the assessment and management of pediatric patients
with congenital heart disease, the natural history of these lesions, and the assessment and
management of adult patients with congenital heart disease with the following goals and
objectives. The first training block will be spent entirely within the Pediatric setting. The second
training block will be spent as a longitudinal experience participating in 24 weekly Adult
Congenital clinics over the course of 3 years. In addition, participation in monthly Western
Canadian Children’s Heart Network adult congenital conference discussions will be mandated.
Additional elective time in Pediatric or Adult Congenital Heart disease may be undertaken at the
discretion of the trainee and the program director. Such elective time may be chosen in an off site
facility.
Fundamental Skills/Knowledge
1. Understanding of the anatomy, pathophysiology, natural and "unnatural” history and long-term
complications of common adult congenital heart defects which can be cared for exclusively in the
community:
isolated secundum ASD (except ASD with anomalous pulmonary venous connection and
superior/inferior sinus venosus defect)
isolated VSD
isolated aortic coarctation or associated with bicuspid aortic valve
bicuspid aortic valve with or without association with aortic coarctation
isolated pulmonary valvular stenosis/regurgitation
isolated mitral valve disease (except parachute mitral valve, atrioventricular septal defect)
isolated tricuspid valve disease (except Ebstein anomaly)
repaired partial pulmonary venous connection
2. Understanding of the long-term outcome and complications in adults with
complex congenital heart defects
tetralogy of Fallot
98
D-transposition of the great arteries
congenitally corrected transposition of the great arteries
Ebstein anomaly
Shone syndrome
cyanotic congenital heart defects
3. Diagnosis of the patient with adult congenital heart disease including skills in
history, physical exam, ECG interpretation, echocardiography interpretation,
chest x-ray and other radiographic interpretation (CXR/MRI), and use of ancillary
testing
4. Management of the adult patient with simple congenital heart defects (as listed
above under #1), including use of appropriate pharmacologic agents, indications
for surgical intervention, percutaneous intervention and coronary angiography
5. Understanding of the common surgical procedures in patients with congenital
heart disease.
6. Understanding of the indications for pacemaker insertion, and electrophysiologic testing
7. Understanding of the psychosocial issues/impaired neurocognitive development in ACHD
patients.
8. Understanding of the organization of care for ACHD patients in Canada and of the requirement
of when to refer a patient to a regional or supraregional (national) Adult Congenital Heart Disease
(ACHD) referral centre
9. Skills in cardiac physical diagnosis
10. Skills in electrocardiographic interpretation as it pertains to patients with
congenital heart disease interventions and technical challenges.
11. Skills in echocardiographic interpretation as it pertains to patients with simple
congenital heart disease
Medical Knowledge
1. Understanding of cardiac embryology and the embryologic development of the
cardiovascular system
2. Skills in cardiac physical diagnosis
3. Understanding of simple congenital heart defects (isolated ASD, VSD, ductus
arteriosus, pulmonary valve stenosis/regurgitation, mitral valve defects, tricuspid
valve defects, bicuspid aortic valve, isolated aortic coarctation and repaired
partial anomalous pulmonary venous connection).
99
4. Diagnosis of adults with simple congenital heart disease including skills in
history, physical exam, ECG interpretation, chest x-ray interpretation and other
radiographic interpretation (CXR/MRI), and use of ancillary testing
5. Management of adult patients with simple congenital heart defects, including
appropriate use of diagnostic testing, pharmacologic agents, indications for
surgical intervention, percutaneous intervention and coronary angiography
6. Understanding of long-term outcome and complications in adults with complex congenital heart
defects and with ability to develop an approach to the common clinical
conditions related to congenital heart conditions, i.e. congestive heart failure
7. Understanding of common surgical procedures in patients with congenital heart
disease.
8. Understanding of the indications and technical challenges for surgery and catheter based
interventions, e.g. pacemaker insertion, and electrophysiologic
interventions.
9. Development of an approach to the common clinical conditions related to congenital
conditions, i.e. congestive heart failure, arrhythmias, cyanotic heart disease,
psychosocial issues
10. Understanding of the effects of congenital heart disease on neurocognitive
development and psychosocial impact
11. Understanding of the effects of common congenital cardiac conditions in pregnancy
12. Skills in electrocardiographic interpretation as it pertains to patients with
congenital heart disease
13. Skills in echocardiographic interpretation as it pertains to patients with simple
congenital heart disease
14. Understanding of the organization of care for ACHD patients in Canada and the
requirement when to refer a patient to a regional or supraregional (national)
ACHD referral centre
Communicator
1. Learns to be able to obtain a history of patients and their families as this is
particularly important in the congenital heart disease population
2. Understands the effects of congenital heart disease on the family
3. Establishes therapeutic relationships with patients/families
4. Delivers understandable information about simple congenital heart defects to
patients/families
5. Maintains professional relationships with other health care providers
100
Collaborator
1. Works effectively with other physicians involved in patient care
2. Works effectively in a team environment
3. Consults effectively with other physicians and other health care providers
Manager
1. Manages time effectively
2. Allocates health care resources effectively & uses diagnostic investigations in a clinically
efficient and cost effective manner
3. Utilizes information technology effectively
4. Works effectively in a health care organization
Health Advocates
1. Educates adults about the effects of congenital cardiac conditions
2. Promotes heart healthy lifestyle
3. Provides vocational counseling considering the cardiac condition
4. Is attentive to preventive measures
5. Is attentive to issues of public policy for health
6. Recognizes important social, environmental and biological determinants of health
7. Demonstrates concern that patients have access to appropriate supports, information and
services
Scholar
1. Develops a life time ability for personal education
2. Learns to research uncommon cardiac conditions utilizing modern search
techniques
Attends rounds, seminars and other learning events
4. Accepts and acts on constructive feedback
5. Reads around patient cases and takes an evidence-based approach to
management problems
101
6. Contributes to the education of patients
Professional
1. Delivers the highest quality health care with integrity, honesty and
compassion
2. Exhibits appropriate personal and intrapersonal professional behaviors
3. Practices medicine ethically consistent with the obligations of a physician
4. Recognizes limitations and seeks advice and consultation when needed
5. Exercises initiative within limits of knowledge and training
6. Discharges duties and assignments responsibly and in a timely and ethical
Manner
7. Reports facts accurately, including own errors
8. Maintains appropriate boundaries in work and learning situations
Technical Skills
There are no specific technical skills specific to this rotation. The trainee will perform and
interpret transthoracic echocardiographic studies on adults with simple, isolated congenital heart
defects (as outlined above) during his/her rotation in echocardiography. Based on the goals and
objectives, the trainee will not to be in the position to perform and interpret independently
complex congenital heart defects.
References:
1. Paediatric Cardiology, 3rd Edition Robert H. Anderson BSc MD FRCPath, Edward J. Baker,
Andrew Redington, Michael L. Rigby, Daniel Penny, Gil Wernovsky MD FACC FAAP
2. Congenital Heart Disease in Adults, Edition 3e
Joseph K. Perloff MD , John S. Child MD FACC , Jamil Aboulhosn
3. CK Silversides, A. Marelli, L Beauchesne, et al. Canadian Cardiovascular Society 2009
Consensus Conference on the Management of Adults with Congenital Heart Disease: Executive
Summary. Can J Cardiol 2010;26(3) 143-150
4. CK Silversides, A Dore, N Poirier, et al. Canadian Cardiovascular Society 2009 Consensus
Conference on the Management of Adults with Congenital Heart Disease: Shunt Lesions. Can J
Cardiol 2010;26(3) e70-e79.
5. ESC Guidelines for the Management of Grown-up Congenital Heart Disease (new version
2010) http://eurheartj.oxfordjournals.org/content/31/23/2915.full.pdf
102
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Heart Failure/Transplantation Rotation: Educational Program and Objectives
Education Director: Dr. Allan Schaffer
Overall goals:
1) To achieve competencies required to successfully pass the Royal College of Physicians and
Surgeons of Canada examination in cardiology
2) To develop exceptional skills as a heart failure physician in any type of practice setting
Heart Failure – Royal College Specific Objectives for Cardiology Residents
Knowledge
Physiology of normal and abnormal ventricular systolic and diastolic function
Hemodynamic abnormalities in heart failure
Neurohormonal abnormalities in congestive heart failure
Ventricular remodeling
Etiology, prognosis, and natural history of congestive heart failure
Pharmacology of diuretics, vasodilators, inotropes, and beta blockers in patients with congestive
heart failure
Clinical Problems
Chronic congestive heart failure
Acutely decompensated heart failure
Congestive heart failure in the patient with coronary artery disease
Dilated cardiomyopathy
Myocarditis
Hypertrophic cardiomyopathy: obstructive and non-obstructive
Infiltrative cardiomyopathies
Restrictive cardiomyopathy
Cardiorenal syndrome
Cardiac transplantation: indications, contraindications, prognosis, management of the posttransplant patient
Medical Expert: Ambulatory Clinic Experience
103
To develop expertise in outpatient follow-up of chronic heart failure patients with either preserved
or low ejection fraction
To evaluate newly diagnosed ventricular dysfunction or heart failure
To apply the Canadian Cardiovascular Society Heart Failure Guidelines to ambulatory clinical
practice
To understand device optimization in heart failure patients including primary prevention ICD’s
and Cardiac Resynchronization Therapies
To understand the indications, limitations and contraindications to mechanical circulatory support
To understand common complications associated with long term ventricular assist devices and
principles of troubleshooting/management
To become familiar with the evaluation of patients with heritable or acquired cardiomyopathies
To understand the principles of management of patients within the first year post transplant,
including basic transplant pharmacology
To understand the major co-morbidities and competing risks in transplant patients beyond the first
year post transplant
Medical Expert: Inpatient Management Experience
To recognize the prognosis of individual patients following admission with acutely
decompensated heart failure
To develop expertise in the management of acute decompensated heart failure, including role of
pharmacologic therapy, inotropes, invasive monitoring and hemodynamic tailoring
To participate in urgent transplant and LVAD evaluation
To be able to delineate various options for short term and long term left, right or biventricular
assist device support and the indications/contraindications for each
Specific Knowledge Objectives:
To be able to describe the neuro-hormonal contribution to ventricular remodeling
To know the indications for revascularization in ischaemic cardiomyopathy
To know the etiologies of non-ischaemic cardiomyopathy and indications for additional diagnostic
testing in the evaluation of non-ischaemic cardiomyopathy
To know the indications for endomyocardial biopsy in the evaluation of cardiomyopathies
To recognize the following hemodynamic patient profiles:
a) acute decompensated heart failure
104
b) chronic compensated heart failure
c) pulmonary hypertension due to left heart disease (reversible, irreversible)
d) pulmonary arterial hypertension
To be able to interpret cardiopulmonary stress test results and understand the following measures:
peak VO2, anaerobic threshold, respiratory exchange ratio, VE/VCO2
To be able to list the indications and contraindications for cardiac transplantation
To understand the indications and options for mechanical circulatory support in acute and chronic
cardiogenic shock
To gain familiarity with the INTERMACS mechanical circulatory support status
To understand the basic principles of continuous flow ventricular assist devices
To know how to treat haemodynamically significant acute cardiac rejection (suspected or
confirmed)
To know the common side effects of calcineurin inhibitors in transplant patients
Communicator:
To develop effective communication skills regarding important heart failure-specific patient
decisions, including implantable device therapy, potential heart replacement therapy, palliative
care
Patient Management and Advocacy:
To take responsibility for the management of assigned advanced heart failure patients
To participate in weekly Transplant Listing Rounds and be able to provide comprehensive clinical
background on individual patients being considered for transplant or mechanical circulatory
support
Collaborator:
Understand the role and responsibilities of other professionals in the Interdisciplinary heart failure
clinic.
Work with the other professionals in clinic to develop appropriate care plans for advanced heart
failure patients.
Clinical Scholar:
To participate in formal teaching rounds
Independent reading based on clearly defined Heart Failure/Transplantation Rotation specific
questions (Appendix B). Reference material with mandatory and recommended reading is
provided.
105
To review answers to rotation specific questions with attending staff
To prepare a brief talk (20-30 min) for presentation
Manager:
Participate in listing rounds, to familiarize with resource limitations (blood group specific donors
and how this impacts clinical decision making.
Understand transplant triage system (CCTN listing algorithm), its limitations and its impact on the
overall advanced heart failure population.
Professional:
Demonstrate adherence to professional code of ethics and a commitment to clinical competence,
the embracing of appropriate attitudes and behaviors, integrity, altruism, personal well-being, and
to the promotion of the public good.
106
Appendix A: Weekly schedule for cardiology residents during the HF/Transplant rotation
1) What are the indications for heart tx?
Monday
Tuesday
Wednesday
Thursday
Friday
8 a.m.
Cardiology
Grand Rounds
9-12
HF Follow-up
Clinic
HF New
Patient
Clinic
HF New Patient
Clinic
Noon
Rounds
VAD/Tx
Listing Rounds
Case of The
Week
Fellow
Rounds
Service
rounds/Journal
Club
p.m.
Transplant/VAD
clinic
Notes
Opportunities to observe organ procurement, VAD surgery occur on an ad-hoc basis
HF Follow-up
Clinic
Cardiopulmonary
stress tests
HF Follow-up
Clinic
2) What are the contraindications?
3) What is the median survival post transplant? Median survival conditional on survival past
the first year?
107
4) What are the components to a routine transplant work up?
5) What is the utility and indication for stress test with respiratory gas analysis (ie.
cardiopulmonary stress test)?
6) What is the prognostic significance of peak VO2? Percent predicted VO2? VE/VCO2?
What is the “anaerobic threshold”
7) What prognostic tools are useful in advanced heart failure? What are some of the
limitations of these traditional tools?
8) Given pulmonary artery pressure, PCWP, and cardiac output, calculate TPG, PVR. What
are the acceptable PAPs (systolic), TPG and PVR (in Woods units) for transplantation?
9) Name 5 strategies to lower pulmonary hypertension to facilitate transplantation? Name 2
strategies to manage “fixed” pulmonary hypertension to facilitate transplantation?
10) What’s the difference between status 0, 1, 2, 3a, 3b, 4,4s?
11) What is the approximate in-hospital mortality of acute decompensated HF patients? In the
subgroup admitted to CCU on inotropes?
12) List the indications for mechanical circulatory support?
13) Name 3 short-term mechanical support devices and 3 durable mechanical support devices.
What complications might you expect?
14) How do you determine which patients require LVAD, or BiVAD support?
15) Early post transplant is the highest risk period. Name 3 immediate/early post-transplant
complications?
16) What is the difference between hyperacute rejection, acute cellular rejection, antibody
mediated rejection and chronic allograft vasculopathy?
17) What are the manifestations of hyperacute rejection? Of acute cellular rejection? Of
antibody mediated rejection?
18) How can we monitor for evidence of rejection?
19) Beyond the first year post transplant, name 3 commonly anticipated complications? In
other words, what are the competing risks with life-long immunosuppression?
20) What is meant by “induction” therapy?
21) Name 6 drugs that affect cyclosporine levels?
22) Name 6 side effects of calcinurin inhibitors?
23) Three side effects of sirolimus? Of MMF?
108
24) What is the standard work up of non-ischemic cardiomyopathy? What ancilliary, nonroutine investigations can be considered when clinically indicated?
25) How do you classify myocarditis? What specific therapies can be considered after
establishing the diagnosis of myocarditis?
109
CanMEDS 2005 Objectives
Section of Cardiology, University of Manitoba
Rotation: Cardiovascular Prevention and Rehabilitation
Education Director: Dr. Thang Nguyen
Overall goal:
To achieve competency in assessment and management of primary and secondary cardiovascular
prevention. To understand the role of cardiac rehabilitation in various cardiac pathologies.
Duration: 2-4 weeks
CanMEDS Role:
Medical Expert
To understand the principles of atherosclerosis development and determinants of plaque stability
To understand the concept global cardiovascular risk assessment in primary cardiovascular
prevention
To understand the impact of traditional and non-traditional risk factors on cardiovascular events
To understand the impact of socio-economic factors on CV disease
To understand the impact of supplementary biochemical testing and CV imaging on
cardiovascular risk assessment
To understand the impact of non-pharmacological risk factor management on cardiovascular
events
To understand the impact of pharmacologic risk factor management
To be knowledgeable and be able to utilize contemporary risk factor guidelines
To understand the role of coronary artery and peripheral artery revascularization
To understand the impact cardiac rehabilitation program on CV risk factors and CV events
To understand the basic principles of exercise physiology and the influence of cardiac pathology
on exercise physiology
To understand the principle of the ischemic cascade and exercise stress testing
To understand the impact of CR on heart failure outcomes
To understand the impact of CR on various cardiac pathologies
Communicator
To be able to explain the risks of benefits of various cardiovascular prevention therapies to
patients
To learn basic concepts in behavior change techniques such as motivational interviewing
To be able to give a presentation on CV prevention to the general public
Collaborator
To be able to work with nurses and dieticians in lipid management
To be able to work with a multi-disciplinary team for CV prevention, including endocrinologists,
general internists, and vascular surgeons
To be able to work with nurses, kinesiologists, occupational therapists and physiotherapists in a
cardiac rehabilitation program
Manager
To experience the role of case manager for cardiac rehabilitation class
To appreciate the importance of resource allocation with respect to healthy lifestyle behavior and
CV prevention
110
Health Advocate
To be able to promote cardiovascular healthy lifestyle to general population
To be able to promote cardiovascular prevention therapies to health professionals
To appreciate the importance of physician advocacy for CV health at multiple organizational
levels
Scholar
To review the most recent evidence on non-traditional or novel risk factors
To review the most recent evidence on pharmacology for secondary CV prevention
To review and critically appraise recommendations from various society guidelines
To appreciate the current knowledge gaps in CV prevention and cardiac rehabilitation
Professional
To appreciate the role of autonomy, beneficence, non-maleficence and justice with respect to
primary and secondary cardiovascular risk prevention therapies
Objectives will be obtained by the following:
1. Ambulatory clinics in respective risk factors
2. Supervision and assessment of cardiac rehabilitation patients
3. Evidence review or critical appraisal project in a CV prevention topic
Weekly Schedule
Monday
Rehfit GXT
Tuesday
Rehfit GXT
WI GXT
Vasc Clinic
Lipid Class
(2x month)
Wednesday
Rehfit GXT
Lipid Clinic
Thursday
Friday
AM
Rehfit GXT Rehfit GXT
WI GXT
CPX
WI case
review
Lipid Clinic
PAD Clinic
PM
CR Class
Vasc Clinic Lipid Clinic Lipid Clinic CR Class
CR Class
Rehfit GXT CR Class
CR Class
Lipid Rnds
(1x month)
PAD Clinic
Vascular clinic (Junaid), PAD clinic (Guzman), HTN clinic (Penner), Bariatric Surgery clinic
(VGH)
111
Resources:
Most recent edition or update of the following guidelines:
1. CACR or CACPR (Canadian Association of Cardiovascular Prevention and Rehabilitation)
Guidelines
2. CACR/EACPR Aerobic Exercise Intensity Assessment and Prescription in Cardiac
Rehabilitation Position Statement
3. CCS Dyslipidemia Guidelines
4. CHEP Hypertension Guidelines
5. CCS Smoking Cessation and the Cardiovascular Specialist Position Statement
6. CCS Antiplatelet Guidelines
7. CDA Diabetes Guidelines
8. ACC/AHA Stable Ischemic Heart Disease Guidelines
9. ACC/AHA Secondary Prevention for Patients with Coronary or Other Atherosclerotic
Vascular Disease Guidelines
10. ACC/AHA Blood Cholesterol Guidelines
11. ACC/AHA Thoracic Aorta Guidelines
12. AHA Exercise Standards for Testing and Training
13. AHA Clinician’s Guide to Cardiopulmonary Exercise Testing in Adults
14. ESC Dyslipidemia Guidelines
15. ESC Cardiovascular Disease Prevention in Clinical Practice Guidelines
16. ESC Secondary Prevention through Cardiac Rehabilitation Position Statement
17. ESC Stable Coronary Artery Disease Guidelines
18. ESC Aortic Disease Guidelines
19. ESC Myocardial Revascularization Guidelines
Journal Review Articles:
1. Warburton et al. Prescribing Exercise as Preventive Therapy. CMAJ 2006;174(7):961-74
112
LOG SHEET - AMBULATORY CARE
PERIOD
DIAGNOSIS
1
PERIOD 2
PERIOD 3
PERIOD 4
CAD – Medical
- Surgical
VHD - Aortic Stenosis
- Aortic Regurgitation
- Mitral Stenosis
- Mitral Regurgitation
- Tricuspid Stenosis
- Tricuspid Regurgitation
- Pulmonary Stenosis
- Pulmonary Regurgitation
- Mitral Valve Prolapse
- Endocarditis
- Prostheses
PERICARDIAL DISEASE - Pericarditis
- Cardiac Tamponade
- Constrictive Pericarditis
CARDIAC MYOPATHY - Hypertrophic
- Restrictive
- Dilated
- Myocarditis
CONGESTIVE HEART FAILURE
ARRHYTHMIAS – Supraventricular
- Ventricular
- Pro-arrhythmia
- Syncope
TUMORS – Myxoma
AORTIC – Aneurysm
- Aortitis
PULMONARY - Cor pulmonale
- Embolism
- Hypertension
SYSTEMIC DISEASES - Renal
- Diabetes
- Pregnancy
PRE-OP ASSESSMENT
CONGENITAL HEART DISEASEAST
- VSD
- Coarctation
- Tetrology
113
LOG SHEET - CARDIOLOGY CTU
DIAGNOSIS
PERIOD 1
PERIOD 2
PERIOD 3
PERIOD 4
CAD - Medical
- Surgical
VHD - Aortic Stenosis
- Aortic Regurgitation
- Mitral Stenosis
- Mitral Regurgitation
- Tricuspid Stenosis
- Tricuspid Regurgitation
- Pulmonary Stenosis
- Pulmonary Regurgitation
- Mitral Valve Prolapse
- Endocarditis
- Prostheses
PERICARDIAL DISEASE - Pericarditis
- Cardiac Tamponade
- Constrictive Pericarditis
CARDIAC MYOPATHY - Hypertrophic
- Restrictive
- Dilated
- Myocarditis
CONGESTIVE HEART FAILURE
ARRHYTHMIAS - Supraventricular
- Ventricular
- Proarrhythmia
- Syncope
TUMORS - Myxoma
AORTIC - Aneurysm
- Aortitis
PULMONARY - Cor pulmonale
- Embolism
- Hypertension
SYSTEMIC DISEASES - Renal
- Diabetes
- Pregnancy
PRE-OP ASSESSMENT
CONGENITAL HEART DISEASEAST
- VSD
- Coarctation
- Tetrology
114
LOG SHEET - NUCLEAR CARDIOLOGY
EXERCISE THALLIUM
PERIOD 1
PERIOD 2
PERSANTINE THALLIUM
PERIOD 1
PERIOD 2
EXERCISE MUGA
PERIOD 1
PERIOD 2
115
LOG SHEET - ECHOCARDIOGRAPHY LABORATORY
PERIOD 1
PERIOD 2
PERIOD 3
PERIOD 4
TOTAL PROCEDURES
PERFORMED
TOTAL PROCEDURES
REPORTED
QUANTITATIVE
EF
MS
AS
PROSTHETIC VALVES
SEMI-QUANTITATIVE
MITRAL REGURGITATION
AORTIC REGURGITATION
TRICUSPID REGURGITATION
PERICARDIAL EFFUSION
CONGENITAL
ASD
VSD
TETRALOGY
EPSTEIN'S
TRANSPOSITION
116
LOG SHEET - CORONARY CARE UNIT
PERIOD 1
PERIOD 2
PERIOD 3
PERIOD 4
PROCEDURES
TPM
SWAN GANZ
ART LINE
CARDIOVERSION
DIAGNOSIS
TREATMENT OF ACUTE
MYOCARDIAL INFARCTION:
Thrombolysis
PTCA
Cardiogenic Shock
Myocardial Rupture
VSD
Papillary Muscle Rupture
Right Ventricular Infarct
TREATMENT OF AORTIC
DISSECTION:
TREATMENT OF
PULMONARY EMBOLISM
117
LOG SHEET - ELECTROPHYSIOLOGY LABORATORY
CONSULTED
STUDIED
ANALYZED
VT
HBE
SVT
MAPPING - WPW
118
LOG SHEET - CARDIAC PACING
PERIOD 1
PERIOD 2
IMPLANTS
1) SINGLE CHAMBER
A) FIXED RATE
B) RATE RESPONSIVE
2) DUAL CHAMBER
A) FIXED RATE
B) RATE RESPONSIVE
PACEMAKERS PROGRAMMED
1) SINGLE CHAMBER
A) FIXED RATE
B) RATE RESPONSIVE
2) DUAL CHAMBER
A) FIXED RATE
B) RATE RESPONSIVE
PACEMAKER EKGs REPORTED
1) SINGLE CHAMBER
A) FIXED RATE
B) RATE RESPONSIVE
2) DUAL CHAMBER
A) FIXED RATE
B) RATE RESPONSIVE
119
LOG SHEET – ADULT CONGENITAL CARDIOLOGY
PRE-OPERATIVE
POST-OPERATIVE
PROCEDURES
EKG
ECHOCARDIOGRAPHY
CATHETERIZATION
PATIENTS
1. CONGENITAL:
Ventricular Septal Defect
Atrial Septal Defect
Coarctation of Aorta
Patent Ductus Arteriosis
Tetralogy of Fallot
Aortic Valve Stenosis
Aortic Valve Regurgitation
Mitral Valve Stenosis
Pulmonary Valve Stenosis
Tricuspid Atresia
Epstein's Anomaly
2. ACQUIRED:
Rheumatic Fever
Kawasaki's Disease
Myocarditis
120
EKG/HOLTER LOG
WEEK OF
E.K.G.
HOLTER
WEEK OF
July
December
July
January
July
January
July
January
July
January
August
February
August
February
August
February
August
February
September
March
September
March
September
March
September
March
October
April
October
April
October
April
October
April
October
April
November
May
November
May
November
May
November
May
December
June
December
June
December
June
December
June
E.K.G.
HOLTER
121
CARDIAC CATH CHECK LIST
The rotating resident must ensure that the following have been discussed. Attending(s) must
initial after reviewing the area(s) below. All areas should be covered after four months of cardiac
catheterization.
1) Pressure wave forms in health and disease indications/contra-indications
Right atrial ______
Right ventricular
Pulmonary Capillary wedge
Left atrial
______
Left ventricular
Aortic
______
Femoral/radial
______
______
______
______
______
2) Cardiac output determination indications
Fick
______
Thermodilution
______
______
3) Shunt quantitation indications
Oximetry
______
______
4) Calculation of valve areas indications
Mitral
______
Aortic
______
______
5) Calculation of vascular resistance indications
PVR
______
SVR
______
______
6) General angiography indications/contra-indications
Normal anatomy
Anatomy of bypass grafts
Anatomy of left and right subclavian artery
Optimal views of above
Anatomy of the groin, wrist and antecubital fossa
______
______
______
______
______
______
7) Ventriculography indications/contra-indications
Normal anatomy
______ Optimal views
Assessment of mitral regurgitation (1-4+)
______
______
______
8) Aortography indications/contra-indications
Normal anatomy
______ Optimal views
Assessment of aortic regurgitation (1-4+)
______
______
______
10) Diagnostic catheterization equipment
Sheaths
______
Wires
Contrast
______
Manifold
Transducers ______
Catheters
10) Endomyocardial biopsy indications/contra-indications
______
______
______
______
122
11) Specific indications/contra-indications for cardiac cath in
• Acute coronary syndromes
a) non ST elevation ______ b) ST elevation
• Stable angina
a) CCS I/II
______ b) CCS III/IV
• CHF/cardiomyopathy
______
• Pre-operative assessment
______
12) Assessment and management
Renal insufficiency
Anticoagulation
Metformin use
Contrast allergies
______
______
______
______
13) Radiation physics/safety
______
______
______
123
Objectives of Training in the Subspecialty of
Adult Cardiology
2010
EDITORIAL REVISION – APRIL 2013
VERSION 1.1
This document applies to those who begin training on or after July 1st, 2010.
DEFINITION
Cardiology is the medical subspecialty concerned with the prevention, diagnosis,
management, and rehabilitation of patients with diseases of the cardiovascular system. A
Cardiologist is a specialist who is an expert in the diagnosis and management of all aspects
of cardiovascular disease.
GOALS
Upon completion of training, a resident is expected to be a competent specialist in
Cardiology capable of assuming a consultant’s role in the specialty. The resident must
acquire a working knowledge of the theoretical basis of the specialty, including its
foundations in the basic medical sciences and research.
Residents must demonstrate the requisite knowledge, skills, and attitudes for effective
patient-centered care and service to a diverse population. In all aspects of specialist
practice, the graduate must be able to address issues of gender, sexual orientation, age,
culture, ethnicity and ethics in a professional manner.
CARDIOLOGY COMPETENCIES
At the completion of training, the resident will have acquired the following competencies and
will function effectively as a:
Medical Expert
Definition:
As Medical Experts, Cardiologists integrate all of the CanMEDS Roles, applying medical
knowledge, clinical skills, and professional attitudes in their provision of patient-centered
care. Medical Expert is the central physician Role in the CanMEDS framework.
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright © 2010 The Royal College of
Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Specialty Education, attn: Associate Director,
Specialties. Written permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact: [email protected].
For questions regarding the use of this document, please contact: [email protected].
Page 1 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
Key and Enabling Competencies: Cardiologists are able to…
1. Function effectively as consultants, integrating all of the CanMEDS Roles to
provide optimal, ethical and patient-centered medical care
1.1. Perform a consultation, including the presentation of well-documented assessments
and recommendations in written and/or verbal form in response to a request from
another health care professional
1.2. Demonstrate use of all CanMEDS competencies relevant to Cardiology
1.3. Identify and appropriately respond to relevant ethical issues arising in patient care
1.4. Demonstrate the ability to prioritize professional duties when faced with multiple
patients and problems
1.5. Demonstrate compassionate and patient-centered care
1.6. Recognize and respond to the ethical dimensions in medical decision-making
1.7. Demonstrate medical expertise in situations other than patient care, such as
providing expert legal testimony or advising governments, as needed
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to
Cardiology
2.1. Apply knowledge of the clinical, socio-behavioural, and fundamental biomedical
sciences relevant to Cardiology including:
2.1.1.
Coronary Artery Disease
2.1.1.1.
Normal coronary anatomy
2.1.1.2.
Physiology of normal and abnormal coronary blood flow
2.1.1.3.
Normal and abnormal endothelial function
2.1.1.4.
Pathogenesis of atherosclerosis
2.1.1.5.
Risk factors for atherosclerosis and their management
2.1.1.6.
Pathophysiology of acute coronary syndromes
2.1.1.7.
Non-atherosclerotic causes of ischemia and infarction
2.1.1.8.
Diagnostic techniques for coronary disease, including their sensitivity
and specificity
2.1.1.9.
Pharmacology 1 of anti-ischemic, antiplatelet, anticoagulant,
thrombolytic and lipid-lowering agents
2.1.1.10. Revascularization procedures: percutaneous coronary intervention
(PCI) and coronary artery bypass graft (CABG), their indications,
contraindications and benefits
2.1.1.11. Non-pharmacologic management of end-stage coronary artery disease
1
Pharmacology refers to mechanisms of action, clinically relevant pharmacokinetics, indications, contraindications,
and adverse effects.
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 2 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
2.1.1.12. Sex differences important in the presentation, diagnosis and
management of coronary artery disease
2.1.1.13. Ethnic differences important in the incidence of coronary artery disease
2.1.2.
Valvular Heart Disease
2.1.2.1.
Normal valve structure and function
2.1.2.2.
Pathology of valvular disease
2.1.2.3.
Pathophysiology and hemodynamics of valvular stenosis and
regurgitation
2.1.2.4.
Diagnostic techniques
2.1.2.5.
Valve surgery: indications, including timing, contraindications, benefits
and outcomes
2.1.2.6.
Prosthetic valves: types, complications, natural history
2.1.3.
Congenital Heart Disease
2.1.3.1.
Basic cardiac embryology
2.1.3.2.
Intracardiac shunting: hemodynamics, pathophysiologic effects
2.1.3.3.
Congenital lesions in which natural survival to adulthood is likely
2.1.3.4.
Congenital lesions in which post-operative survival to adulthood is
likely
2.1.4.
Congestive Heart Failure and Cardiomyopathies
2.1.4.1.
Physiology of normal and abnormal ventricular systolic and diastolic
function
2.1.4.2.
Hemodynamic abnormalities in heart failure
2.1.4.3.
Neurohormonal abnormalities in congestive heart failure
2.1.4.4.
Ventricular remodeling
2.1.4.5.
Etiology, prognosis, and natural history of congestive heart failure
2.1.4.6.
Pharmacology of medications commonly used in patients with
congestive heart failure
2.1.4.7.
Non-pharmacologic management options (e.g. resynchronization,
surgery)
2.1.5.
Hypertension
2.1.5.1.
Definition of hypertension
2.1.5.2.
Diagnosis of hypertension
2.1.5.3.
Effect of hypertension on target organs
2.1.5.4.
Effect of treatment on mortality and complications
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 3 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
2.1.5.5.
Secondary causes: screening, diagnosis, and management
2.1.5.6.
Pharmacology of antihypertensive agents
2.1.6.
Pulmonary Vascular Disease
2.1.6.1.
Normal pulmonary vascular physiology
2.1.6.2.
Hemodynamics of pulmonary hypertension
2.1.6.3.
Pharmacology of pulmonary vasodilator agents
2.1.7.
Pericardial Disease
2.1.7.1.
Normal pericardial anatomy and function
2.1.7.2.
Effect of pericardial disease on cardiac hemodynamics and function
2.1.7.3.
Pathology and etiology of pericardial diseases
2.1.8.
Vascular Medicine
2.1.8.1.
Cerebrovascular disease: etiology and risk factors, presentations,
cardiac causes of stroke and transient ischemic attack (TIA), treatment
options
2.1.8.2.
Pathology and etiology of aortic disease
2.1.8.3.
Peripheral vascular disease: risk factors, clinical presentations,
treatment options
2.1.9.
Acute Cardiac Care
2.1.9.1.
Hemodynamics: normal and abnormal systemic and pulmonary flows,
pressures, and resistances
2.1.9.2.
Ventilation in patients with primary cardiac disease: indications,
principles of management
2.1.9.3.
Pharmacology of inotropes, vasopressors, vasodilators
2.1.9.4.
Systemic and non-cardiac complications in the critically ill patient
2.1.9.5.
Non-pharmacologic, mechanical support devices
2.1.10. Electrophysiology
2.1.10.1. Normal cellular electrophysiology
2.1.10.2. Normal sinoatrial (SA) node, atrioventricular (AV) node, and
conducting system function
2.1.10.3. Mechanisms of arrhythmogenesis
2.1.10.4. Mechanisms of conduction abnormalities
2.1.10.5. Pharmacology of antiarrhythmic agents
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 4 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
2.1.10.6. Temporary and permanent cardiac pacing: techniques, indications, and
follow-up
2.1.10.7. Implantable cardiovertor/defibrillators (ICDs)
2.1.10.8. Resynchronization devices
2.1.10.9. Invasive electrophysiology studies: indications, techniques,
complications
2.1.10.10. Invasive ablative techniques for tachyarrhythmias: indications,
complications
2.1.11. Pregnancy in Patients with Cardiovascular Disease
2.1.11.1. Normal cardiovascular physiologic changes in pregnancy and their
effect in patients with heart disease
2.1.11.2. Use of cardiovascular drugs in pregnancy and the peripartum period
2.1.11.3. Assessment of the cardiac risks of pregnancy
2.1.11.4. Preconception genetic counseling with respect to cardiac disease
2.2. Describe the CanMEDS framework of competencies relevant to Cardiology
2.3. Apply lifelong learning skills of the Scholar Role to implement a personal program
to keep up-to-date, and enhance areas of professional competence
2.4. Contribute to the enhancement of quality care and patient safety in Cardiology,
integrating the available best evidence and best practices
3. Perform a complete and appropriate assessment of a cardiac patient
3.1. Identify and explore issues to be addressed in a patient encounter effectively,
including the patient’s context and preferences
3.2. Elicit a history that is relevant, concise and accurate to context and preferences for
the purposes of prevention and health promotion, diagnosis and/or management
3.3. Perform a focused physical examination that is relevant and accurate for the
purposes of prevention and health promotion, diagnosis and/or management
3.4. Select medically appropriate investigative methods in a resource-effective and
ethical manner
3.5. Demonstrate effective clinical problem solving and judgment to address patient
problems, including interpreting available data and integrating information to
generate differential diagnoses and management plans
4. Use preventive and therapeutic interventions effectively
4.1. Implement a management plan in collaboration with a patient and their family
4.2. Demonstrate appropriate and timely application of preventive and therapeutic
interventions relevant to Cardiology
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 5 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
4.3. Ensure appropriate informed consent is obtained for therapies
4.4. Ensure patients receive appropriate end-of-life care
5. Demonstrate proficient and appropriate use of procedural skills, both
diagnostic and therapeutic
5.1. Demonstrate effective, appropriate and timely interpretation application of results
and technical performance of the following diagnostic and therapeutic procedures:
5.1.1.
Clinical Electrophysiology
5.1.1.1.
Electrocardiography
5.1.1.2.
Exercise (stress) testing
5.1.1.3.
Ambulatory monitors (Holter and loop recorders)
5.1.2.
Echocardiography (M-mode, 2D, and Doppler)
5.1.2.1.
5.1.3.
Cardiac Catheterization
5.1.3.1.
5.1.4.
Transthoracic
Right heart catheterization and hemodynamics
Therapeutic Procedures
5.1.4.1.
Temporary transvenous pacemakers
5.1.4.2.
DC cardioversion and defibrillation
5.1.4.3.
Pericardiocentesis
5.2. Demonstrate effective, appropriate and timely interpretation and application of
results of the following diagnostic and therapeutic procedures:
5.2.1.
Clinical Electrophysiology
5.2.1.1.
Permanent pacemakers and implanted devices
5.2.1.2.
Invasive electrophysiology studies
5.2.2.
Echocardiography (M-mode, 2D, and Doppler)
5.2.2.1.
Transesophageal
5.2.2.2.
Stress
5.2.3.
Nuclear Cardiology Imaging
5.2.3.1.
5.2.4.
Rest and stress perfusion imaging and radionuclide angiography
Cardiac Catheterization
5.2.4.1.
Left heart catheterization and hemodynamics
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 6 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
5.2.4.2.
5.2.5.
Other Cardiac Imaging Modalities
5.2.5.1.
5.2.6.
Angiography and coronary arteriography
Chest X-ray
Therapeutic Procedures
5.2.6.1.
Intra-aortic balloon counterpulsation
5.3. Demonstrate effective, appropriate and timely application of results of the following
diagnostic and therapeutic procedures:
5.3.1.
Other Cardiac Imaging Modalities
5.3.1.1.
Positron Emission Tomography (PET)
5.3.1.2.
Computed Tomography (CT)
5.3.1.3.
Magnetic Resonance Imaging (MRI)
5.3.2.
Therapeutic Procedures
5.3.2.1.
Percutaneous cardiac interventions
5.4. Ensure appropriate informed consent is obtained for procedures
5.5. Document and disseminate information related to procedures performed and their
outcomes
5.6. Ensure adequate follow-up is arranged for procedures performed
6. Seek appropriate consultation from other health professionals, recognizing the
limits of their expertise
6.1. Demonstrate insight into their own limitations of expertise
6.2. Demonstrate effective, appropriate, and timely consultation of another health
professional as needed for optimal patient care
6.3. Arrange appropriate follow-up care services for a patient and their family
Communicator
Definition:
As Communicators, Cardiologists effectively facilitate the doctor-patient relationship and the
dynamic exchanges that occur before, during, and after the medical encounter.
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 7 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
Key and Enabling Competencies: Cardiologists are able to…
1. Develop rapport, trust, and ethical therapeutic relationships with patients and
families
1.1. Recognize that being a good communicator is a core clinical skill for physicians, and
that effective physician-patient communication can foster patient satisfaction,
physician satisfaction, adherence and improved clinical outcomes
1.2. Establish positive therapeutic relationships with patients and their families that are
characterized by understanding, trust, respect, honesty and empathy
1.3. Respect patient confidentiality, privacy and autonomy
1.4. Listen effectively
1.5. Be aware of and responsive to nonverbal cues
1.6. Facilitate a structured clinical encounter effectively
2. Accurately elicit and synthesize relevant information and perspectives of
patients and families, colleagues, and other professionals
2.1. Gather information about a disease and about a patient’s beliefs, concerns,
expectations and illness experience
2.2. Seek out and synthesize relevant information from other sources, such as a
patient’s family, caregivers and other professionals
3. Convey relevant information and explanations accurately to patients and
families, colleagues and other professionals
3.1. Deliver information to a patient and family, colleagues and other professionals in a
humane manner and in such a way that it is understandable, encourages
discussion and participation in decision-making
4. Develop a common understanding on issues, problems and plans with patients,
families, and other professionals to develop a shared plan of care
4.1. Identify and explore problems to be addressed from a patient encounter
effectively, including the patient’s context, responses, concerns, and preferences
4.2. Respect diversity and difference, including but not limited to the impact of gender,
religion and cultural beliefs on decision-making and ability to comply with a
therapeutic program
4.3. Encourage discussion, questions, and interaction in the encounter
4.4. Engage patients, families, and relevant health professionals in shared decisionmaking to develop a plan of care
4.5. Address challenging communication issues effectively such as obtaining informed
consent, delivering bad news, and addressing anger, confusion and
misunderstanding
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 8 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
5. Convey effective oral and written information about a medical encounter
5.1. Maintain clear, accurate, and appropriate records (e.g., written or electronic) of
clinical encounters and plans
5.2. Present verbal reports of clinical encounters and plans
5.3. Present medical information to the public or media about a Cardiology-related
medical issue
Collaborator
Definition:
As Collaborators, Cardiologists effectively work within a health care team to achieve optimal
patient care.
Key and Enabling Competencies: Cardiologists are able to…
1. Participate effectively and appropriately in an interprofessional health care
team
1.1. Describe the specialist’s roles and responsibilities to other professionals
1.2. Describe the roles and responsibilities of other professionals within the health care
team
1.3. Recognize and respect the diversity of roles, responsibilities and competences of
other professionals in relation to their own
1.4. Work with others to assess, plan, provide and integrate care for individual patients
(or groups of patients)
1.5. Work with others to assess, plan, provide and review other tasks, such as research
problems, educational work, program review or administrative responsibilities
1.6. Participate in interprofessional team meetings
1.7. Enter into interdependent relationships with other professions for the provision of
quality care
1.8. Describe the principles of team dynamics
1.9. Respect team ethics, including confidentiality, resource allocation and
professionalism
1.10. Demonstrate leadership in a health care team, as appropriate
2. Work with other health professionals effectively to prevent, negotiate, and
resolve interprofessional conflict
2.1. Demonstrate a respectful attitude towards other colleagues and members of an
interprofessional team
2.2. Work with other professionals to prevent conflicts
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 9 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
2.3. Employ collaborative negotiation to resolve conflicts
2.4. Respect differences and address misunderstandings and limitations in other
professionals
2.5. Recognize one’s own differences, misunderstanding and limitations that may
contribute to interprofessional tension
2.6. Reflect on interprofessional team function
Manager
Definition:
As Managers, Cardiologists are integral participants in health care organizations, organizing
sustainable practices, making decisions about allocating resources, and contributing to the
effectiveness of the health care system.
Key and Enabling Competencies: Cardiologists are able to…
1. Participate in activities that contribute to the effectiveness of their health care
organizations and systems
1.1. Work collaboratively with others in their organizations
1.2. Participate in systemic quality process evaluation and improvement, such as
patient safety initiatives
1.3. Describe the structure and function of the health care system as it relates to
Cardiology, including the roles of physicians
1.3.1.
Describe the advantages and disadvantages of cardiac care in a variety of
settings, including hospitals, ambulatory care clinics, offices, homecare, and
chronic care and rehabilitation facilities
1.4. Describe principles of health care financing as it relates to Cardiology, including
physician remuneration, budgeting and organizational funding
2. Manage their practice and career effectively
2.1. Set priorities and manage time to balance patient care, practice requirements,
outside activities and personal life
2.2. Manage a Cardiology practice including finances and human resources
2.3. Implement processes to ensure personal practice improvement
2.4. Employ information technology appropriately for patient care
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 10 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
3. Allocate finite cardiac care resources appropriately
3.1. Recognize the importance of just allocation of health care resources, balancing
effectiveness, efficiency and access with optimal patient care
3.2. Apply evidence and management processes for cost-appropriate care
4. Serve in administration and leadership roles, as appropriate
4.1. Chair or participate effectively in committees and meetings
4.2. Lead or implement change in health care
4.3. Plan relevant elements of health care delivery (e.g., work schedules)
Health Advocate
Definition:
As Health Advocates, Cardiologists responsibly use their expertise and influence to advance
the health and well-being of individual patients, communities, and populations.
Key and Enabling Competencies: Cardiologists are able to…
1. Respond to individual patient health needs and issues as part of patient care
1.1. Identify the health needs of an individual patient
1.2. Identify opportunities for advocacy, health promotion and disease prevention with
individuals to whom they provide care
2. Respond to the health needs of the communities that they serve
2.1. Describe the practice communities that they serve
2.2. Identify opportunities for advocacy, health promotion and disease prevention in the
communities that are at risk for cardiovascular disease and its complications
2.2.1.
Apply knowledge of primary and secondary prevention of cardiovascular
disease
2.3. Appreciate the possibility of competing interests between the communities served
and other populations
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 11 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
3. Identify the determinants of health for the populations that they serve
3.1. Identify the biologic, psychosocial, environmental, and economic determinants of
health of the populations, including barriers to access to care and resources
3.1.1.
Utilize this information in a management and prevention plan, and ensure
access to appropriate health and social services in the management of
individual patients
3.2. Identify vulnerable or marginalized populations within those served and respond
appropriately
4. Promote the health of individual patients, communities, and populations
4.1. Describe an approach to implementing a change in a determinant of health of the
populations they serve
4.2. Describe how public policy impacts on the cardiovascular health of the populations
served
4.3. Identify points of influence in the health care system and its structure
4.4. Describe the ethical and professional issues inherent in health advocacy, including
altruism, social justice, autonomy, integrity and idealism
4.5. Appreciate the possibility of conflict inherent in their role as a health advocate for a
patient or community with that of manager or gatekeeper
4.6. Describe the role of the medical profession in advocating collectively for health and
patient safety
Scholar
Definition:
As Scholars, Cardiologists demonstrate a lifelong commitment to reflective learning, as well
as the creation, dissemination, application and translation of medical knowledge.
Key and Enabling Competencies: Cardiologists are able to…
1. Maintain and enhance professional activities through ongoing learning
1.1. Describe the principles of maintenance of competence
1.2. Describe the principles and strategies for implementing a personal knowledge
management system
1.3. Recognize and reflect on learning issues in practice
1.4. Conduct a personal practice audit
1.5. Pose an appropriate learning question
1.6. Access and interpret the relevant evidence
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 12 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
1.7. Integrate new learning into practice
1.8. Evaluate the impact of any change in practice
1.9. Document the learning process
2. Critically evaluate medical information and its sources, and apply this
appropriately to practice decisions
2.1. Describe the principles of critical appraisal
2.2. Critically appraise retrieved evidence in order to address a clinical question
2.3. Integrate critical appraisal conclusions into clinical care
3. Facilitate the learning of patients, families, students, residents, other health
professionals, the public and others, as appropriate
3.1. Describe principles of learning relevant to medical education
3.2. Identify collaboratively the learning needs and desired learning outcomes of others
3.3. Select effective teaching strategies and content to facilitate others’ learning
3.4. Demonstrate effective delivery of lectures or presentations
3.5. Assess and reflect on a teaching encounter
3.6. Provide effective feedback
3.7. Describe the principles of ethics with respect to teaching
4. Contribute to the development, dissemination, and translation of new
knowledge and practices
4.1. Describe the principles of research and scholarly inquiry
4.2. Describe the principles of research ethics
4.3. Pose a scholarly question
4.4. Conduct a systematic search for evidence
4.5. Select and apply appropriate methods to address the question
4.6. Disseminate the findings of a study by presentation or publication
Professional
Definition:
As Professionals, Cardiologists are committed to the health and well-being of individuals and
society through ethical practice, profession-led regulation, and high personal standards of
behaviour.
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 13 of 14
OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010)
Key and Enabling Competencies: Cardiologists are able to…
1. Demonstrate a commitment to their patients, profession, and society through
ethical practice
1.1. Exhibit appropriate professional behaviors in practice, including honesty, integrity,
commitment, compassion, respect and altruism
1.1.1.
Understand the nature of professional interpersonal relationships and
boundaries with patients, co-workers, and students
1.2. Demonstrate a commitment to delivering the highest quality care and maintenance
of competence
1.3. Recognize and appropriately respond to ethical issues encountered in practice
1.4. Manage conflicts of interest
1.5. Recognize the principles and limits of patient confidentiality as defined by
professional practice standards and the law
1.6. Maintain appropriate relations with patients
2. Demonstrate a commitment to their patients, profession and society through
participation in profession-led regulation
2.1. Demonstrate knowledge and an understanding of the professional, legal and ethical
codes of practice
2.2. Fulfill the regulatory and legal obligations required of current practice
2.3. Demonstrate accountability to professional regulatory bodies
2.4. Recognize and respond to others’ unprofessional behaviours in practice
2.5. Participate in peer review
3. Demonstrate a commitment to physician health and sustainable practice
3.1. Balance personal and professional priorities to ensure personal health and a
sustainable practice
3.2. Strive to heighten personal and professional awareness and insight
3.3. Recognize other professionals in need and respond appropriately
REVISED – Specialty Standards Review Committee – April 2010
EDITORIAL REVISION – April 2013
© 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 14 of 14
Subspecialty Training Requirements in
Adult Cardiology
2013
VERSION 2.0
These training requirements apply to those who begin training on or after July 1st, 2013.
ELIGIBILITY REQUIREMENTS
Royal College Certification in Internal Medicine or enrolment in a Royal College approved
training program in Internal Medicine (see requirements for these qualifications). All
candidates must be certified in their primary specialty in order to be eligible to write the
Royal College certification examination in Adult Cardiology.
MINIMUM TRAINING REQUIREMENTS
Three (3) years of approved residency in an approved Adult Cardiology residency program
The following core experiences are required:
1. A minimum of fifteen (15) blocks of clinical residency:
1.1. Four (4) blocks of acute cardiac care/coronary care unit (CCU)
1.2. Six (6) blocks of clinical cardiology (including cardiology clinical teaching unit (CTU)
and consultations)
1.3. Three (3) blocks of ambulatory cardiology clinics
1.4. One (1) block of pediatric cardiology
1.5. One (1) block of adult congenital heart disease
2. A minimum of fifteen (15) blocks of laboratory based residency:
2.1. Three (3) blocks of cardiac catheterization
2.2. Three (3) blocks of electrophysiology/pacemaker cardiology (to include
electrocardiogram (ECG) and ambulatory ECG monitoring)
2.3. Two (2) blocks of nuclear cardiology (to include exercise stress testing)
2.4. One (1) block advanced cardiac imaging (to include CT scan and may include
magnetic resonance imaging (MRI), positron emission tomography (PET))
2.5. Six (6) blocks of echocardiography
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright © 2013 The Royal College of
Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Specialty Education, attn: Associate Director,
Specialties. Written permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact: [email protected].
For questions regarding the use of this document, please contact: [email protected].
Page 1 of 2
SUBSPECIALTY TRAINING REQUIREMENTS IN ADULT CARDIOLOGY (2013)
Research
3. A minimum of two (2) blocks dedicated to a research project, with completion
acceptable to the Program Director
Electives
4. A minimum of four (4) blocks of electives approved by the Program Director, which may
be used for further research training
NOTES:
The experiences outlined in items 1.3, 1.5, 2.2, 2.4, and 3 can occur longitudinally (e.g.,
electrocardiogram (ECG) interpretation, ambulatory clinics).
Royal College certification in Adult Cardiology requires all of the following:
1. Certification in Internal Medicine;
2. Successful completion of a 3-year Royal College accredited program in Adult
Cardiology;
3. Successful completion of the certification examination in Adult Cardiology;
4. Successful completion of a scholarly project related to Adult Cardiology, as attested
by the program director.
The 3-year program outlined above is to be regarded as the minimum training requirement.
Additional year(s) of training may be required by the program director to ensure that clinical
competence has been achieved.
REVISED – Specialty Standards Review Committee – April 2010
REVISED – Specialty Standards Review Committee – January 2013
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 2 of 2
Specific Standards of Accreditation for Residency
Programs in Adult Cardiology
2013
VERSION 2.0
INTRODUCTION
A university wishing to have an accredited program in adult Cardiology accredited must also
sponsor an accredited program in Internal Medicine.
The purpose of this document is to provide program directors and surveyors with an
interpretation of the general standards of accreditation as they relate to the accreditation of
programs in adult Cardiology. This document should be used in conjunction with the
General Standards of Accreditation, the Objectives of Training and the Specialty Training
Requirements in Adult Cardiology.
STANDARD B1: ADMINISTRATIVE STRUCTURE
There must be an appropriate administrative structure for each residency
program.
Please refer to Standard B1 in the General Standards of Accreditation for the interpretation
of this standard. The program director should be a fellow of the Royal College in Cardiology.
The program director or faculty designate must attend at least one Specialty Committee in
Cardiology meeting annually, in person or by teleconference.
STANDARD B2: GOALS AND OBJECTIVES
There must be a clearly worded statement outlining the goals of the residency
program and the educational objectives of the residents.
The general goals and objectives for adult Cardiology are outlined in the Objectives of
Training and the Specialty Training Requirements in adult Cardiology. Based upon these
general objectives each program must develop rotation specific objectives suitable for that
particular program, as noted in Standard B2 of the General Standards of Accreditation.
STANDARD B3: STRUCTURE AND ORGANIZATION OF THE PROGRAM
There must be an organized program of rotations and other educational
experiences, both mandatory and elective, designed to provide each resident with
the opportunity to fulfil the educational requirements and achieve competence in
the specialty or subspecialty.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright © 2013 The Royal College of
Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Education, attn: Associate Director. Written
permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact: [email protected]. For questions
regarding the use of this document, please contact: [email protected].
Page 1 of 7
SPECIFIC STANDARDS OF ACCREDITATION FOR ADULT CARDIOLOGY (2013)
Adult Cardiology is a three-year residency program, based on certification in Internal
Medicine which should include a clinical core experience, organized to include mandatory
components (those elements essential for all residents) and elective components (those
elements dependent upon the resident's interest and career plans). In some cases these
experiences may be offered as horizontal experiences rather than in sequential blocks of
time.
The structure and organization of each accredited program in adult Cardiology must be
consistent with the specialty training requirements as outlined in the Objectives of Training
and the Specialty Training Requirements in adult Cardiology.
The program must be organized such that residents are given graded responsibility, under
appropriate supervision, according to their level of training, ability and experience.
It must be recognized that the usual three years of residency does not permit the resident
to achieve competence in all subspecialty areas of Cardiology. To achieve expertise in
highly specialized facets of Cardiology, the resident will require additional training.
STANDARD B4: RESOURCES
There must be sufficient resources including teaching faculty, the number and
variety of patients, physical and technical resources, as well as the supporting
facilities and services necessary to provide the opportunity for all residents in the
program to achieve the educational objectives and receive full training as defined
by the Royal College specialty training requirements.
In those cases where a university has sufficient resources to provide most of the training in
adult Cardiology but lacks one or more essential elements, the program may still be
accredited provided that formal arrangements have been made to send residents to another
accredited residency program for periods of appropriate prescribed training.
Learning environments must include experiences that facilitate the acquisition of knowledge,
skills, and attitudes relating to aspects of age, gender, culture, and ethnicity appropriate to
adult Cardiology.
1. Teaching Faculty
There must be:
a) a sufficient number of qualified and dedicated teaching faculty to supervise residents
at all levels and in all aspects of Cardiology and provide teaching in the basic and
clinical sciences related to Cardiology.
b) a member of the faculty specified as the person responsible for each rotation and,
whenever possible, this should be a Cardiologist.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 2 of 7
SPECIFIC STANDARDS OF ACCREDITATION FOR ADULT CARDIOLOGY (2013)
2. Number and Variety of Patients
There must be a sufficient number and variety of patients available to the program to
provide each resident registered in the program with the opportunity to meet the following
specific objectives:
a) to provide each resident extensive opportunity for exposure to major cardiac
diseases, including coronary artery disease, valvular heart disease, rheumatic heart
disease, pericardial heart disease, congenital heart disease, arrhythmias,
cardiomyopathies, hypertensive heart disease, heart disease in diabetics, heart
disease in patients with renal disorders, heart disease in pregnancy and congestive
heart failure;
b) to provide each resident extensive opportunity in the initial assessment and
consultative service to patients presenting with emergency cardiac conditions.
3. Clinical Services Specific to Adult Cardiology
There must be:
a) a coronary care unit organized as a clinical teaching unit under the direction of an
appropriately qualified Cardiologist. This must have the facilities for the complete
management of seriously ill cardiac patients including invasive hemodynamic
monitoring, temporary pacemaker insertion, and Intra-Aortic Balloon Pump (IABP)
management. Facilities for ventilatory support should be available in the unit or in
an adjacent facility. Access to a medical intensive care unit with expertise in
management of multi-system disease is also essential. All necessary consultative
and laboratory services must be available;
b) Cardiology service organized for teaching the investigation and treatment of patients
with a wide variety of cardiac pathologies;
c) a consultation service to provide experience in elective and emergency consultations
in patients with cardiac diseases;
d) Laboratories appropriately organized for teaching and dedicated to:
i.
ii.
iii.
iv.
v.
vi.
cardiac catheterization and interventional cardiology
echocardiography including transesophageal echocardiography
electrophysiology/pacemaker
electrocardiography including stress testing and ambulatory electrocardiography
nuclear cardiology
advanced cardiac imaging, including but not limited to CT
e) ambulatory care facilities to provide residents with experience in the broad range of
non-hospitalized patients with cardiac problems. This experience should include, but
not be limited to, pre-admission work-up and post-discharge follow-up care.
f)
an active clinical teaching service in pediatric cardiology;
g) access to a cardiac rehabilitation program is desirable.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 3 of 7
SPECIFIC STANDARDS OF ACCREDITATION FOR ADULT CARDIOLOGY (2013)
4. Supporting Services - Clinical, Diagnostic, Technical
There must be:
a) an active clinical teaching service in cardiac surgery, given the importance of cardiac
surgery in the management of patients with heart disease and the need for
Cardiologists to manage these patients in the early and late post-operative period;
b) an active clinical teaching service in internal medicine;
c) an Emergency Department;
d) a department of pathology - able to provide gross anatomical, histological,
biochemical and microbiological services for the study of cardiovascular problems;
e) a department of diagnostic imaging - with a radiologist experienced in the basic
investigative techniques in cardiovascular radiology, and access to newer
investigative techniques such as MRI, PET, fast CT;
f)
the sponsoring university must support an active academic program in the basic
cardiac sciences, particularly biochemistry, pharmacology and physiology;
g) a respiratory medicine service with a pulmonary function laboratory;
h) other supporting services including nuclear medicine,
nutrition, psychology and biomedical electronics.
genetics,
immunology,
5. Resources for Community Learning Experiences
In order for residents to develop experience with the community practice of clinical
cardiology, wherever possible, linkages should be developed with community cardiologists
who are willing and able to provide an excellent learning experience.
STANDARD B5:
CLINICAL,
PROGRAM
ACADEMIC
AND
SCHOLARLY
CONTENT
OF
THE
The clinical, academic and scholarly content of the program must be appropriate
for university postgraduate education and adequately prepare residents to fulfill
all of the CanMEDS Roles of the specialist. The quality of scholarship in the
program will, in part, be demonstrated by a spirit of enquiry during clinical
discussions, at the bedside, in clinics or in the community, and in seminars,
rounds, and conferences. Scholarship implies an in-depth understanding of basic
mechanisms of normal and abnormal states and the application of current
knowledge to practice.
Please refer to Standard B5 in the General Standards of Accreditation, the Objectives of
Training, the Specialty Training Requirements in Adult Cardiology, and the CanMEDS
Framework for the interpretation of this standard. Each program is expected to develop a
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 4 of 7
SPECIFIC STANDARDS OF ACCREDITATION FOR ADULT CARDIOLOGY (2013)
curriculum for each of the CanMEDS roles, which reflects the uniqueness of the program and
its particular environment. Specific additional requirements are listed below.
1. Medical Expert
In addition to the General Standards of Accreditation, the following requirements apply:
-
There must be a regular series of rounds including such topics as Cardiology grand
rounds, case conferences, mortality rounds, journal club, research rounds, diagnostic
rounds, etc. The program should endeavour to have a seminar program or clinical
half day where topics can be discussed for the benefit of the residents alone in an indepth fashion. Service demands must not interfere with the ability of the residents
to follow the academic program.
-
The educational program must provide opportunities for residents to learn and
demonstrate their knowledge of:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
cardiac metabolism and biochemistry
cardiocirculatory physiology
cardiovascular anatomy and embryology
cardiovascular electrophysiology and electrocardiology
cardiovascular pathology
cardiovascular pathophysiology
cardiovascular pharmacology
cardiovascular rehabilitation principles
congenital heart disease
heart disease in pregnancy
hypertension
imaging, especially chest radiography, echo/Doppler, nuclear techniques and
cardiac catheterization
m) lipid disorders
n) prevention of cardiovascular disease
o) physical diagnosis skills
The program must also provide teaching in the following areas:
a)
b)
c)
d)
e)
f)
cardiovascular epidemiology
molecular biology and genetics as it relates to the cardiovascular system
peripheral and cerebral vascular disease
principles of newer techniques such as MRI, fast CT, PET scanning etc.
pulmonary vascular disease
principles and application relating to the improvement of quality of care and
resource utilization
g) transplantation
h) medical-legal issues as they apply to Cardiology
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 5 of 7
SPECIFIC STANDARDS OF ACCREDITATION FOR ADULT CARDIOLOGY (2013)
2. Communicator
The General Standards of Accreditation apply to this section.
3. Collaborator
The General Standards of Accreditation apply to this section.
4. Manager
The General Standards of Accreditation apply to this section.
5. Health Advocate
The General Standards of Accreditation apply to this section.
6. Scholar
In addition to the General Standards of Accreditation, the following requirements apply:
-
Each resident must carry out an appropriate research project during their residency
program. Protected time must be developed to carry out the project and faculty
must provide appropriate supervision. Faculty support for hypothesis generation,
study design and data analysis and presentation must be available.
-
An opportunity to acquire an understanding of the scientific method, the ability to
critically appraise the cardiology literature, and to formulate, execute and present a
research project and prepare a manuscript.
-
The program must provide opportunities to prepare for lifelong continuing medical
education.
-
The program must provide opportunities to develop professional attitudes and selfappraisal for consultant practice.
7. Professional
The General Standards of Accreditation apply to this section.
STANDARD B6: EVALUATION OF RESIDENT PERFORMANCE
There must be mechanisms in place to ensure the systematic collection and
interpretation of evaluation data on each resident enrolled in the program.
Please refer to Standard B6 in the General Standards of Accreditation for the interpretation
of this standard.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 6 of 7
SPECIFIC STANDARDS OF ACCREDITATION FOR ADULT CARDIOLOGY (2013)
In addition to the General Standards of Accreditation, the following requirements apply:
These assessment tools must include all STACERs that have been approved by the Specialty
Committee in Cardiology.
ADOPTED BY COUNCIL – April 1996
REVISED – Education Committee – May 2007
REVISED – Specialty Standards Review Committee – May 2010
REVISED – Specialty Standards Review Committee – January 2013
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 7 of 7
The Royal College of Physicians and Surgeons of Canada
Le Collège royal des médecins et chirurgiens du Canada
774 promenade Echo Drive, Ottawa, Canada K1S 5N8
Tel: (613) 730-8191 — 1-800-668-3740 — Fax: (613) 730-3707
OVERALL PERFORMANCE
Adult Cardiology In-Training History and Physical Examination (HPE) Assessment*.
Name:
University:
This resident completed the standardized assessment of history-taking, physical examination and
synthesis of a patient’s problems. A complete record is in the resident’s file. The following is a
summary of the overall performance with comments on strengths and weaknesses summarized by the
program director.
Overall Performance:

Satisfactory**
 Below Expectations
Strengths:
Weaknesses:
(Print Name of Program Director)
Date
Program Director’s signature
Resident’s signature
** Passing marks 70%
© 2007 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
This document may be reproduced for educational purposes only provided that the following phrase is included in all related
materials: Copyright © 2007 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with
permission. Please forward a copy of the final product to the Office of Education, attn: Associate Director
Written permission from the Royal College is required for all other uses. For further information regarding intellectual
property, please contact: [email protected]. For questions regarding the use of this document, please contact:
[email protected].
Final in-Training Evaluation Report (FITER)/
Comprehensive Competency Report (CCR)
ADULT CARDIOLOGY
Reference No:
Name and Identification No:
Evaluation covering the last
year as a Resident:
Address:
In the view of the Residency Program Committee, this resident has acquired the
competencies of the specialty/subspecialty as prescribed in the Objectives of
Training and is competent to practice as a specialist.
YES

NO

The following sources of information were used for this evaluation:


written examinations
clinical observations (e.g. ITERs) from faculty




feedback from health care professionals
completion of a scholarly project


oral examinations
Structured Assessment of a Clinical
Encounter (STACER)
OSCEs
other evaluations_____________________
COMMENTS
Date
Name of Program Director/Assessor
for CCR
Signature
Date
Name of Postgraduate Dean/
Assessor for CCR
Signature
Date
Name of Resident
Signature
This is to attest that I have read this document.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright © 2013 The Royal College of
Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Education, attn: Associate Director. Written
permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact: [email protected]. For questions
regarding the use of this document, please contact: [email protected].
Page 1 of 2
Identification number: ___________________________
RESIDENT’S COMMENTS:
Note: If during the period from the date of signature of this document to the completion of
training, the Residency Program Committee judges that the candidate's demonstration of
competence is inconsistent with the present evaluation, it may declare the document null
and void and replace it with an updated FITER. Eligibility for the examination would be
dependant on the updated FITER.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 2 of 2
Identification number: _________________________________________
405 – 2013
REVISED – APRIL 2013
ADULT CARDIOLOGY FITER (2013)
(Please read the attached Explanatory Notes before completing this report)
* Consistently
exceeds
Sometimes
exceeds
Generally meets
* Inconsistently
meets
A rationale must be provided to support ratings with asterisks.
* Rarely meets
EXPECTATIONS
MEDICAL EXPERT
At a consultant level:
a. Demonstrates expertise and applies basic scientific knowledge
relevant to adult Cardiology
b. Demonstrates expertise and applies clinical knowledge relevant to
adult Cardiology
c. Elicits and records
cardiovascular history
a
complete,
d. Performs and records a complete,
cardiovascular physical examination
accurate
accurate
and
organized
and
organized
e. Integrates pertinent information to make appropriate clinical
decisions, including a differential diagnosis and management plan
f.
Orders appropriate laboratory investigations, interprets the results
accurately and modifies patient management accordingly
g. Applies the principles of cardiovascular
therapeutics to the care of the adult patient
pharmacology
and
h. Recognizes and manages emergency conditions and acutely ill or
unstable patients promptly, effectively and efficiently (includes
acute cardiac care in CCU/ICU)
i.
Demonstrates expertise in the basic principles of cardiac surgery
and extracorporeal cardiac support
j.
Delivers appropriate peri-operative care
undergoing cardiac or non-cardiac surgery
to
cardiac
patients
Please comment on the strengths and weaknesses of the candidate and provide a rationale for
your ratings. Make direct reference to the specific objectives and give specific examples wherever
possible.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 1 of 9
Identification number: _________________________________________
405 – 2013
REVISED – APRIL 2013
ADULT CARDIOLOGY FITER (2013)
EXPECTATIONS
* Consistently
exceeds
Sometimes
exceeds
Generally meets
* Inconsistently
meets
* Rarely meets
A rationale must be provided to support ratings with asterisks.
PROCEDURES AND CLINICAL SKILLS
Demonstrates effective, appropriate and timely interpretation of images, application of
results and technical performance of the following diagnostic and therapeutic
procedures described in the Medical Expert section 5.1 of the Objectives of Training in
Adult Cardiology document:
a. Clinical Electrophysiology

Electrocardiography

Exercise (stress) testing

Ambulatory monitors (Holter and loop recorders)
b. Echocardiography (M-mode, 2D, and Doppler)

Transthoracic echocardiography (TTE)
c. Cardiac Catheterization

Right heart catheterization and hemodynamics
d. Therapeutic Procedures

Temporary transvenous pacemakers

DC cardioversion and defibrillation

Pericardiocentesis
Demonstrates effective, appropriate and timely interpretation of images and application
of results of the following diagnostic and therapeutic procedures described in the
Medical Expert section 5.2 of the Objectives of Training in Adult Cardiology document:
e. Clinical Electrophysiology

Permanent pacemakers and implanted devices

Invasive electrophysiology studies
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 2 of 9
Identification number: _________________________________________
405 – 2013
REVISED – APRIL 2013
ADULT CARDIOLOGY FITER (2013)
f. Echocardiography (M-mode, 2D, and Doppler)

Transesophageal

Stress Echocardiography
g. Nuclear Cardiology Imaging

Rest and stress
angiography
perfusion
imaging
&
radionuclide
h. Cardiac Catheterization
i.

Left heart catheterization and hemodynamics

Angiography and coronary arteriography
Other Cardiac Imaging Modalities

j.
Chest X-ray
Therapeutic Procedures

Intra-aortic balloon counterpulsation
Demonstrates effective, appropriate and timely application of
results of the following diagnostic and therapeutic procedures
described in the Medical Expert section 5.3 of the Objectives of
Training in Adult Cardiology document:
k. Other Cardiac Imaging Modalities

l.
PET, CT and MRI
Therapeutic Procedures

Percutaneous cardiac interventions
Minimizes risks and discomforts to the patient
Overall is proficient in clinical and procedural skills
Please comment on the strengths and weaknesses of the candidate and provide a rationale for
your ratings. Make direct reference to the specific objectives and give specific examples wherever
possible.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 3 of 9
Identification number: _________________________________________
405 – 2013
REVISED – APRIL 2013
ADULT CARDIOLOGY FITER (2013)
* Consistently
exceeds
Sometimes
exceeds
* Inconsistently
meets
* Rarely meets
A rationale must be provided to support ratings with asterisks.
Generally meets
EXPECTATIONS
COMMUNICATOR
a. Establishes a therapeutic relationship with adult patients and
families, listens effectively and provides clear and thorough
explanations
b. Prepares documentation (records and reports) that is accurate,
appropriately detailed, organized and timely
Please comment on the strengths and weaknesses of the candidate and provide a rationale for
your ratings. Make direct reference to the specific objectives and give specific examples wherever
possible.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 4 of 9
Identification number: _________________________________________
405 – 2013
REVISED – APRIL 2013
ADULT CARDIOLOGY FITER (2013)
* Consistently
exceeds
Sometimes
exceeds
* Inconsistently
meets
* Rarely meets
A rationale must be provided to support ratings with asterisks.
Generally meets
EXPECTATIONS
COLLABORATOR
a. Collaborates effectively and constructively with other members of
the cardiac care team and contributes effectively to team activities
b. Consults effectively with other physicians and health professionals
c. Interacts effectively with other health professionals in the cardiac
team by recognizing and acknowledging their roles and expertise
d. Establishes good relationships with peers and other
professionals. Provides and receives information effectively
health
Please comment on the strengths and weaknesses of the candidate and provide a rationale for
your ratings. Make direct reference to the specific objectives and give specific examples wherever
possible.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 5 of 9
Identification number: _________________________________________
405 – 2013
REVISED – APRIL 2013
ADULT CARDIOLOGY FITER (2013)
EXPECTATIONS
* Consistently
exceeds
Sometimes
exceeds
Generally meets
* Inconsistently
meets
* Rarely meets
A rationale must be provided to support ratings with asterisks.
MANAGER
a. Makes cost effective use of health care resources
b. Sets realistic priorities and uses time and resources effectively
c. Demonstrates leadership skills in organizing,
coordinating the work of the health care team
delegating
and
d. Describes the principles of quality assurance and improvement
programs and their application in improving patient care
e. Demonstrates expertise in and makes effective use of information
technology (e.g. searching medical databases) to enhance patient
care
Please comment on the strengths and weaknesses of the candidate and provide a rationale for
your ratings. Make direct reference to the specific objectives and give specific examples wherever
possible.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 6 of 9
Identification number: _________________________________________
405 – 2013
REVISED – APRIL 2013
ADULT CARDIOLOGY FITER (2013)
EXPECTATIONS
* Consistently
exceeds
Sometimes
exceeds
Generally meets
* Inconsistently
meets
* Rarely meets
A rationale must be provided to support ratings with asterisks.
HEALTH ADVOCATE
a. Identifies the determinants of cardiovascular health in individual
patients
b. Identifies patients and patient groups at increased risk of
cardiovascular disease and implements appropriate prevention
strategies
c. Recognizes and acts upon issues and opportunities for health
advocacy
Please comment on the strengths and weaknesses of the candidate and provide a rationale for
your ratings. Make direct reference to the specific objectives and give specific examples wherever
possible.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 7 of 9
Identification number: _________________________________________
405 – 2013
REVISED – APRIL 2013
ADULT CARDIOLOGY FITER (2013)
EXPECTATIONS
* Consistently
exceeds
Sometimes
exceeds
Generally meets
* Inconsistently
meets
* Rarely meets
A rationale must be provided to support ratings with asterisks.
SCHOLAR
a. Develops and implements an ongoing, effective learning strategy
b. Applies the principles of evidence-based standards of care
c. Completes a research project to the satisfaction of the Residency
Program Committee
d. Critically appraises
different sources
and
integrates
medical
information
from
e. Helps others learn by providing guidance, teaching and constructive
feedback
f.
Demonstrates awareness of the importance of research to the
advancement of medical knowledge and supports and participates
in scientific inquiry
g. Provides verbal communications (case presentations, rounds,
conferences etc.) that are lucid, appropriately detailed and well
organized
Please comment on the strengths and weaknesses of the candidate and provide a rationale for
your ratings. Make direct reference to the specific objectives and give specific examples wherever
possible.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 8 of 9
Identification number: _________________________________________
405 – 2013
REVISED – APRIL 2013
ADULT CARDIOLOGY FITER (2013)
* Consistently
exceeds
Sometimes
exceeds
* Inconsistently
meets
* Rarely meets
A rationale must be provided to support ratings with asterisks.
Generally meets
EXPECTATIONS
PROFESSIONAL
a. Practises with integrity, honesty, compassion and respect for
diversity
b. Fulfills the medical, professional and legal obligations of the
specialist
c. Describes and applies the principles of medical ethics, including
informed consent
d. Demonstrates an awareness of personal limitations, seeking and
accepting advice when necessary
e. Observes appropriate boundaries in professional relationships with
patients, families, colleagues and students
Please comment on the strengths and weaknesses of the candidate and provide a rationale for
your ratings. Make direct reference to the specific objectives and give specific examples wherever
possible.
© 2013 The Royal College of Physicians and Surgeons of Canada. All rights reserved.
Page 9 of 9
Policy:
Interactions between the University of Manitoba’s Faculty of Medicine and the
Pharmaceutical, Biotech, Medical Device, and Hospital and Research Equipment
and Supplies Industries (“Industry”)
June 3, 2009
December 11, 2012
Effective Date:
Revised Date:
Review Date:
Approving Body: Faculty Executive Council
Faculty of Medicine, University of Manitoba
Authority:
Implementation:
Applies to:
Faculty, staff, students and trainees
1.0 Background
The University of Manitoba’s Faculty of Medicine strives: to develop, deliver and evaluate high quality
educational programs; to conduct research and other scholarly enquiry into the basic and applied medical
sciences; to plan for the development and delivery of health care services; and to help improve health status and
service delivery to the Province of Manitoba and the wider community.
This mission requires that faculty, staff, students and trainees interact with representatives of the
pharmaceutical, biotechnology, medical device, and hospital and research equipment and supplies industry
(“Industry”) in a manner that advances the use of the best available evidence so that medical advancements and
new technologies become broadly and appropriately used. Interactions with Industry occur in a variety of
contexts, including marketing of new pharmaceutical products, medical devices and/or equipment; on-site
training for newly purchased devices; educational support of medical students and trainees, and continuing
medical education; and in research activities. Faculty, staff, students and trainees also participate in interactions
with Industry off campus and in scholarly publications. While the interaction with Industry can be beneficial,
these interactions must be ethical and avoid any actual, potential or perceived conflicts of interest that may
affect the integrity of the Faculty’s education, training and research programs, or the reputation of either the
faculty member or the institution.
This policy is intended to provide a set of guiding principles that faculty, staff, students, and trainees, as well as
representatives of Industry will use to assure that their interactions result in optimal benefit to clinical care,
education and research, and maintenance of the public trust. It is also intended as a guide to equitable and fair
treatment of Industry members. Faculty members, staff, students, and trainees from the Faculty of Medicine
should also refer to the University of Manitoba Conflict of Interest Policy and the University of Manitoba Gifts
and Gratuities Offered to University Employees Policy.
2.0. Statement of Policy
In the interests of eliminating any actual, potential or perceived influence by Industry over clinical decision
making, educational or research activities, all relationships between the Faculty of Medicine of the University
of Manitoba, its faculty members, staff, students or trainees and Industry shall be guided by the principles set
forth in this policy.
At the University of Manitoba Faculty of Medicine, all clinical decisions, education, and research activities will
be free from influence or perceived influence created by improper relationships with, or gifts provided by,
Industry. The principles outlined in this document shall guide all potential relationships or interactions between
members of the Faculty of Medicine and Industry representatives. However, this policy is meant to be consistent
with and compliant the University of Manitoba Conflict of Interest Policy and the University of Manitoba Gifts
1
and Gratuities Offered to University Employees Policy. Where any portion of this policy conflicts with the
foregoing University policies, the latter will govern. Where this policy is silent on a matter, the foregoing
University policies shall govern the matter.
2.1. Definitions
Conflict of Interest (COI): A conflict of interest may be actual, potential, or perceived. A conflict of interest
occurs when an individual has a financial or personal interest that may compromise, or have the potential to
compromise or the perception of compromising, the individual’s professional judgment or integrity and
independence in clinical responsibilities, teaching, conducting or reporting research, or performing other
obligations.
Industry: For the purpose of this policy, “Industry” includes pharmaceutical, biotechnology, medical device, and
hospital and research equipment and supplies industries.
Faculty: For the purpose of this policy, “faculty” includes all full-time, part-time or nil-appointee in the
University of Manitoba Faculty of Medicine.
Gifts: For the purpose of this policy, “Gifts” are defined as any items of any value that are given by a business
or individual that do, or seeks to do, business with the Faculty of Medicine or its affiliates, to either the
individual or a related party of the individual (including but not limited to family members such as parent,
sibling, grandparent, aunt or uncle, another person living in the same household as the individual, or anyone
with whom the individual shares a direct or indirect financial or personal interest), and for which the recipient
neither paid nor provided services. This includes, but is not limited to items such as pens, notepads, textbooks,
electronic media, meals, gift certificates, tickets, devices, products or services, travel, hotel accommodations,
entertainment, research equipment or funding, and payments for attending a meeting.
2.2 Scope of Policy
This policy applies to all faculty and staff (whether independent contractor or employee), students, and trainees
of the University of Manitoba’s Faculty of Medicine. Industry representatives are also expected to be aware of
this policy and to adhere to its principles.
This policy incorporates the following types of interactions with Industry:
a)
b)
c)
d)
e)
f)
g)
Gifts, Meals and Compensation
Drug, Instrument, and Device Samples
Access by Industry Representatives to Faculty, Staff, Students and Trainees
Industry Support for Educational Programs Developed by the Faculty of Medicine
Off-Campus Industry Sponsored Meetings or Activities
Industry-Sponsored Scholarships or Other Educational Funds for Students and Trainees
Industry Support for Research
a) Gifts, Meals and Compensation
i.
Gifts
Consistent with the University of Manitoba Gifts and Gratuities Offered to Employees Policy, individual
faculty members, staff, students, and trainees of the University of Manitoba Faculty of Medicine shall not
accept Gifts from representatives of Industry, regardless of the nature or value of the gift.
2
Gifts of educational materials directed at patients are permitted only if appropriate materials are not available
from a public source (e.g. government agency, foundation, or disease-related association) or commercially
available. Gifts of educational materials directed at patients will only be accepted if use of the Gift is
unrestricted and the gift is made to the Faculty rather than an individual. The acceptance of gifts of
educational materials will be made by the Dean’s Office in consultation with the Department Head from the
involved Department. If there is any doubt, the matter should be referred to the Vice-President
(Administration) for approval.
ii. Meals
Meals or other hospitality funded directly by Industry may not be offered in any facility owned, operated or
affiliated with the University of Manitoba Faculty of Medicine.
It is appropriate to accept meals in the context of off-campus educational programs and events that comply
with section 2.2.d or 2.2.e of this policy.
iii. Compensation
While receiving compensation is acceptable for providing substantial professional services, faculty
members, staff, students, and trainees of the University of Manitoba Faculty of Medicine may not accept
compensation unless the individual has played a substantial role. Individuals shall not accept compensation
in exchange for listening to a sales talk, for attending a Continuing Medical Education session, or for any
other activity in which the attendee has no other role. Compensation for these sorts of activities shall be
considered Gifts and are consequently prohibited.
Consulting arrangements that simply pay Faculty of Medicine faculty, staff, students, or trainees a
guaranteed amount without any associated duties (such as participation on scientific advisory boards that do
not regularly meet and provide scientific advice) or excessive compensation shall be considered Gifts and
are consequently prohibited.
Where Faculty of Medicine faculty or staff are engaged by Industry to provide consulting services or
speaking services, a contract must provide specific tasks and deliverables, with payment commensurate with
the tasks assigned. This is necessary in order to avoid Gifts being disguised as contracts. All such
arrangements between individuals or units and outside commercial interests must be reviewed and approved
prior to initiation by the Department Head or, in the case of a Department Head, by the Dean.
The Faculty reserves the right to require faculty and employees to request changes in the terms of their
consulting agreements to bring those consulting agreements into compliance with University and/or Faculty
of Medicine policies.
Appendix A provides guidance as to what is considered reasonable compensation for services provided to
Industry.
b) Drug, Instrument, and Device Samples
University of Manitoba faculty, staff, students, and trainees should utilize clinical evaluation packages (drug
samples), instruments, or device samples only within the policies and procedures established by the affiliated
healthcare facility and/relevant regional health authority. University of Manitoba faculty, staff, students, and
trainees are expected to ensure that the distribution or clinical use of these samples is inconsistent with
established ‘best practices’ and should utilize samples only when appropriate and within the standards of
care in Manitoba.
3
c) Access by Industry Representatives to Faculty, Staff, Students, and Trainees
Faculty, staff, students, and trainees at affiliated sites (i.e., Winnipeg Regional Health Authority) must abide
by the policies and procedures established by the affiliated facility and/or relevant regional health authority
with regard to meeting with Industry representatives.
In general, Industry representatives are permitted in non-patient care areas, and then only by appointment
and with appropriate consent by the patient or surrogate.
Industry representatives are prohibited from having any non-Faculty-mentored interaction with students or
trainees. In the event that interactions are initiated by Industry, the involved student(s) may conduct some
initial discussions that do not involve arrangements for gifts, meals, or compensation, but are required to
involve a Faculty-designated individual in all subsequent interactions that may or may not lead to
arrangements for sponsorship.
Students and/or trainees are prohibited from soliciting financial or non-financial support from Industry for
any educational or non-educational activity.
Commercial exhibits intended to showcase Industry products are permitted if directly related to an
educational activity and must comply with the Division of Continuing Professional Development Policy on
Commercial Exhibits.
d) Industry Support for Educational Programs Developed by the Faculty of Medicine
When accepted, Industry support for educational programs must be free of any actual or perceived conflict
of interest and must be provided in the form of an unrestricted grant or unrestricted use of donated product.
Funds that are provided by educational groups or other entities that act as “intermediaries” for Industry must
also be provided as unrestricted grants.
Funds for educational activities may be provided to the Faculty of Medicine, or to an individual Department,
but must not be given to an individual faculty member, staff, student, or trainee. The Dean’s Office must be
informed in advance of requests to or offers from Industry for grants to support educational events.
Agreements governing grants supporting educational activities must receive prior approval by the Dean’s
Office.
Appendix B provides guidance as to what is considered appropriate use of commercial support from
Industry for educational programs.
e) Off-Campus Industry Sponsored Meetings or Activities
Faculty, staff, students, and trainees may attend programs and events organized by professional
organizations or associations, universities, or regulatory bodies that receive educational grants from
Industry. Faculty and staff shall only accept off-campus industry-sponsored meals that are held in
conjunction with an accredited educational event.
Faculty who speak, moderate, or participate in any aspect of the organization or delivery of Industrysponsored meetings or activities must abide by the following requirements:
1. Financial support should be fully disclosed to participants by the meeting sponsor;
2. All of the content of the meeting or session must be determined by the speaker(s), not the
industry sponsor;
3. The speaker(s) must provide a fair and balanced discussion of the current science and treatment
options;
4
4. The speaker(s) must make clear that the comments and content reflects the individual views of
the speaker(s) and not the University of Manitoba Faculty of Medicine; and
5. Compensation is reasonable and limited to reimbursement of reasonable travel expenses and an
honorarium proportional to the defined service (see Appendix A).
f) Industry-Sponsored Scholarships or Other Educational Funds for Students and Trainees
Industry support for students’ and trainees’ participation in education programs must be free of any real or
perceived conflict of interest. All educational grants or support of educational programs must be specifically
for the purposes of education and must comply with the following requirements:
1. The Faculty of Medicine’s Department, Program or Division must select the student(s)
or trainee(s) for participation;
2. The funds must be provided to the Department, Program or Division and not directly to the
student or trainee;
3. The Department, Program, or Division determines that the education conference or program has
educational merit; and
4. There is no implicit or explicit expectation that the participant must provide something in return
for participation in the educational program.
This provision does not apply to regional, national or international merit-based awards which will be
considered on a case-by-case basis.
g) Industry Support for Research
A prerequisite for faculty, staff, student, and trainee participation in research activities is that these activities
are ethically defensible, socially responsible, and scientifically valid. All faculty, staff, students and trainees,
who participate in the design, conduct, analysis, or reporting of Industry-funded research shall ensure a
signed multi-partner agreement is in place which is satisfactory to the researcher, the head of the department
in which the researcher holds his/her primary appointment, the Industry partner, and the institution(s) where
the research will be conducted. All research projects must be approved by the Research Ethics Board of the
University of Manitoba and comply with policies of the Office of Research Services.
Research grants should not be accepted or utilized to support research unless it is carried out independently
and objectively for the purposes of the advancement of scientific knowledge or clinical efficacy. Faculty,
staff, student and trainee shall not enter into agreements that limit their right to publish or disclose results of
the study or report adverse events which occur during the course of the study.
Because of the potential to influence judgment, remuneration for participating in research studies must not
constitute enticement. Remuneration may cover reasonable time and expenses and must be approved by the
relevant research ethics board. Finder’s fees, whereby the sole activity performed by the faculty or staff is to
submit the names of potential research subjects, are not acceptable.
All research grants received from Industry will be administered through special purpose project-specific
accounts at the University of Manitoba or at an affiliated institute, centre, or teaching hospital. Statements
disclosing all expenditures, transfers and transactions from these accounts will be provided to departments
on a quarterly basis.
5
3.0 Disclosure of Relationships with Industry
Consistent with the University of Manitoba Conflict of Interest Policy and the University of Manitoba
Conflict of Interest Procedures, faculty and staff will formally disclose relationships with Industry to his or
her Department Head or supervisor in writing as soon as the faculty or staff member becomes aware of the
existence of a conflict of interest. In this situation, the Department Head or Director acts as the Initial
Reviewer for a conflict of interest disclosure. The Initial Reviewer will subsequently submit a written
recommendation regarding the disclosed conflict of interest to the Associate Dean (Academic), who will act
as the Secondary Reviewer. Details on the expected procedure to be followed regarding conflict of interest
disclosure can be found in the University of Manitoba Conflict of Interest Procedure. In the case of a
conflict of interest disclosure by a Department Head or Director, the Associate Dean (Academic) will act as
the Initial Reviewer an the Dean as the Secondary Reviewer. If the conflict of interest involves the Associate
Dean (Academic), the Dean will assume the role of Initial Reviewer.
The presence of relationships with Industry must be disclosed by faculty or staff, verbally or by way or a
slide, to learners prior to any educational activity such as lectures, seminars or workshops. Information
provided in this manner includes the name of the individual, the name of the commercial interest, and the
nature of the relationship the person has with each commercial interest. Information that an individual has no
relevant financial relationship must also be disclosed in advance to the learning audience.
Faculty or staff with supervisory responsibilities for students, trainees, or staff should ensure that the
potential or perceived conflict of interest of the faculty or staff member does not affect or appear to affect his
or her supervision of the student, trainee, or staff member.
University of Manitoba Faculty of Medicine faculty, staff, students, and trainees are prohibited from
publishing articles, presentations or producing other forms of media, under their names that are written in
whole or in part by Industry representatives.
In scholarly publications, individuals must disclose their related financial interests in accordance with the
International Committee of Medical Journal Editors (http://www.icmje.org).
Individuals having a direct role in institutional decision-making regarding equipment or drug procurement
must, prior to making any such decision, disclose in writing to the Initial Reviewer, any relationship with
Industry they or a party related to the individual have in companies that may derive an actual, potential, or
perceived benefit from the decision. Such relationships can include, but are not limited to, equity ownership,
compensated positions on advisory boards, a paid consultancy, or other forms of compensated relationship.
The individual(s) must also disclose to the Initial Reviewer any interest they or their department may have
that has the potential to benefit from the decision.
Individuals leading research involving human subjects must inform participants whether the researcher will
or will not receive a fee for their participation. If the researcher will be receiving such a fee for this
participation, the individuals leading the research must also disclose by whom the fee will be paid. In
addition, individuals may not conduct research with human subjects if they or a party related to the
individual have a financial or personal interest in an existing or potential product or a company that could be
affected by the outcome of the research. Exceptions may be permitted only if it is determined through
reasonable and independent scrutiny that an individual’s participation is essential for the conduct of the
research and an effective mechanism for managing the conflict and protecting the integrity of the research,
as well as the integrity, interests, and reputation of the individual and the University has been established.
6
4.0 Training of Faculty, Staff, Students, and Trainees Regarding Interactions with Industry
All students, trainees, faculty, and staff within the University of Manitoba’s Faculty of Medicine shall
receive appropriate initial and subsequent awareness training regarding interactions with Industry. The
Faculty of Medicine will develop appropriate education materials and methods, and each program will
oversee such training and its quality.
5.0 Reporting and Non-compliance
Suspected breaches of this policy shall be referred to the individual’s immediate supervisor and Department
Head, who shall determine what actions, if any, shall be taken.
Breaches of this policy may result in the following actions (singly or in any combination), depending upon
the seriousness of the breach, whether the breach is a first or repeat occurrence and whether the individual
knowingly breached the policy or attempted to conceal the breach:
a)
b)
c)
d)
Counselling of the individual involved;
Written reprimand, entered into the individual’s employment, faculty or student record;
Banning the individual from any further outside engagements for a period of time;
Requiring that the individual return any monies received from the improper relationship with a third
party in contravention of this policy;
e) Requiring the individual to complete additional training on conflict of interest;
f) Removing the individual from supervision of trainees or students; and/or
g) Termination for cause.
Any disciplinary action taken hereunder shall follow the established procedures of the University of
Manitoba.
Violations of these policies by Industry representatives will be managed through progressive warnings and
restrictions on access.
Faculty, staff, students or trainees witnessing contraventions of these policies shall report such breaches to
the Department Head or to the Associate Dean of Academic Affairs. Contraventions of these policies by the
Associate Dean (Academic) shall be reported to the Dean.
6.0 Questions
Questions about this policy should be directed to the Dean’s Office.
7.0 Review of policy
This policy will be reviewed every 3 years.
Relevant University of Manitoba policies:
Conflict of Interest Policy and Procedures
Division of CPD CME/CPD Honoraria Policy
Division of CPD Commercial Support Policy
Gifts and Gratuities Offered to University Employees Policy
Guidelines on Responsibilities of Research Ethics
7
Nepotism Policy
Research Agreement Policy
Responsibilities of Academic Staff with Regards to Students Policy
Relevant Regional Health Authority policies:
Winnipeg Regional Health Authority (WRHA) Conflict of Interest Policy
Winnipeg Regional Health Authority (WRHA) Industry Relationships Policy
Source documents:
Association of American Medical Colleges. “Industry Funding of Medical Education: Report of an AAMC
Task Force” (2008)
Canadian Medical Association. “Guidelines for Physicians in Interactions with Industry” (2007)
Department of Internal Medicine, University of Manitoba. “Policy Governing Relationships Between the
Pharmaceutical Industry and Physicians”(2005)
St-Boniface General Hospital. “Relationship with Pharmaceutical Manufacturing Industry Policy” (2006)
Winnipeg Regional Health Authority. “Conflict of Interest Policy” (2004)
8
Appendix A: Guidelines for compensation for services provided to Industry
1. Honoraria and expense reimbursement for Industry-sponsored Continuing Education
For speaking engagements that require overnight travel, the provided honoraria shall not exceed $3 000 per day
plus reimbursement of reasonable out-of-pocket expenses documented with receipts.
For speaking engagements that do not require overnight travel, the provided honoraria shall not exceed $1 500
per day plus reimbursement of reasonable out-of-pocket expenses documented with receipts.
For the development of enduring materials, the provided honoraria shall not exceed $1 500 per day plus
reimbursement of reasonable out-of-pocket expenses documented with receipts.
For the review of enduring materials, the provided honoraria shall not exceed $1 000 per day plus
reimbursement of reasonable out-of-pocket expenses documented with receipts.
Fees exceeding the above guidelines must be approved in advance by the Department Head.
2. Compensation for acting as a consultant to Industry
Compensation for consulting work shall not exceed $3 000 per day plus reimbursement of reasonable out-ofpocket expenses documented with receipts.
Fees exceeding the above guideline must be approved in advance by the Department Head.
3. Compensation for work-related to Industry-sponsored research
Compensation to an investigator for administrative activities required to initiate a research study (including
budgeting, ethics submission, etc…) shall not exceed $1 500 in total.
Compensation for attendance at an investigators’ meeting shall not exceed $1 500 per day plus reimbursement
of reasonable out-of-pocket expenses documented with receipts.
Payments to an investigator for study-related procedures, examinations, follow-up visits required by protocol
may not exceed the Manitoba Health tariff for these services.
Payments to an investigator for research-related services required for the conduct of a study not covered by
Manitoba Health tariffs (administrative work, letters, reports, etc…) may not exceed $750 per patient enrolled in
the study.
Fees exceeding or in addition to the above guidelines must be approved in advance by the Department Head.
9
Appendix B: Guidelines for appropriate use of commercial support from Industry for educational programs
1. Expenditures and expenses for individuals providing educational programming
The identification of needs, determination of educational objectives, topics, format, speakers and evaluation
are the responsibility of the event planning committee.
Honoraria for faculty are paid directly by the University of Manitoba or an educational partner when
specifically designated in the commercial support letter of agreement. Honoraria amounts are calculated in
accordance with the Division of CPD’s CME/CPD Honoraria Policy.
Faculty or planning committee members may only accept reimbursement for travel, lodging, and meal
expenses directly by the University of Manitoba or an educational partner when specifically designated in the
commercial support letter of agreement.
2. Expenditures for learners
Commercial support funds may not in any way be used to defray any part of the cost of attending an
educational activity including but not limited to travel or lodging costs or other personal expenses of
faculty/staff, their spouses, or family members attending an activity sponsored by the University of Manitoba.
3. Registration fees
A registration fee must be charged for all educational activities that would normally have a registration fee
associated with them.
A commercial sponsor must not cover the entire cost of an educational activity. Commercial support may help
reduce the cost of registration but a registration fee should be paid by the participants in order to avoid a
perceived or real influence on learning.
Exceptions to this general principle might include rounds, journal clubs, established professional meetings,
faculty development activities and research oriented continuing education activities since these activities
would normally be carried out without charge to participants. Any exceptions to these principles are at the sole
discretion of the Office of the Dean (or designate).
4. Meals and social events
Since all funds from commercial interests must be in the form of unrestricted educational grants, subsidies
specifically designated for hospitality will not be accepted.
Commercially supported social events (including meals) at educational activities must not compete with nor
take precedence over educational events. In general, travel and accommodation arrangements, social events,
and venues for educational events receiving commercial sponsorship should be in keeping with arrangements
that would normally be made without commercial sponsorship.
Commercial support shall not be used defray the costs of meals associated with off-campus educational events
held in restaurants or hotels. Commercial support may be used defray the costs of meals associated with oncampus/in-hospital educational events (rounds, journal clubs, small-group learning events or conferences).
Planners shall use the designated on-campus/in-hospital catering service at the event site and the maximal
10
budget for meals shall be 20$ per person for breakfast/breaks, 30$ per person for lunch and 50$ per person for
supper.
Exceptions to this general principle might include events that cannot be accommodated on campus due to size,
national-scope events, and rural/northern events. Any exceptions to these principles are at the sole discretion
of the Dean (or designate). If there is any doubt, the matter should be referred to the Vice-President
(Administration) for approval.
5. Approval of funds
All commercial support associated with an educational activity will only be accepted if the details of the
commercial support have been fully disclosed to, and approval to accept the commercial support has been
received from, the Office of the Dean (or designate).
The Faculty of Medicine makes all decisions regarding the acceptance and disposition of commercial support
funds in-kind support received for educational activities.
No prerequisite conditions, except for the designation of topic areas under which the educational grant is
given, will be allowed with regard to the receipt of commercial support funds.
All commercial support expenditures are documented in the form of a written letter of agreement. The terms,
conditions, amount of grant, name of the supporter must be included in the written agreement.
The Faculty of Medicine will not retroactively accept a grant from a commercial interest.
S:\Legal\Medicine, Faculty of\2012\0506 - Industry Relations Policy\Industry Relations Policy Revisions June 2012 bl.doc
11
Faculty of Medicine
PGME Resident Safety Policy
Policy Name:
Application/Scope:
Approved (Date):
Review Date:
Revised (Date):
Approved By:
FPGME Resident Safety Policy
Residents, Faculty, and Staff in the Faculty of Medicine
June 12, 2012
June 2015
Faculty Executive Council
1. PURPOSE
1.1. The University of Manitoba is committed to promoting and supporting the safety and
well-being of its learners in all areas of their working and learning environment.
1.2. The Faculty Postgraduate Medical Education (PGME) Office at the University of
Manitoba recognizes that residents have the right to a safe workplace and a safe
learning environment. The responsibility for resident safety jointly rests with the Faculty
of Medicine at the University of Manitoba, the Winnipeg Regional Health Authority
(WRHA), individual clinical departments, their residency programs, and the residents.
1.3. The concept of resident safety includes physical, emotional and professional security.
These will be outlined in detail in this document.
1.4. The WRHA, clinical departments and several residency programs have their own
resident and workplace safety policies which will complement the PGME Resident
Safety Policy document.
2. KEY RESPONSIBILITIES
2.1 Residents have a right to a safe and equitable workplace and learning environment. As
such, residents have a professional duty to learn and to comply with the safety policies
of the institution in which they are working, as outlined by the University of Manitoba
Faculty PGME Office. Furthermore, residents have a professional duty to communicate
safety concerns and incidents to the residency programs or to the University of
Manitoba Faculty PGME Office promptly.
2.2 The University of Manitoba Faculty PGME Office has a duty to ensure a safe and
equitable environment for residents to work and to learn. This includes but is not limited
to the following:
2.2.1 Ensuring that the workplace is free of harassment or intimidation on the basis of
gender, race, sexual orientation, physical (dis)abilities and level of training.
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 1 of 14
Faculty of Medicine
FPGME Resident Safety Policy
2.2.2 Ensuring that residents are educated and informed with respect to the safety
policies which govern the workplace and the learning environment.
2.2.3 To record in writing and to act promptly on any safety concerns and incidents
reported to its office by residents.
2.2.4 Ensuring that every reasonable effort be made to record resident concerns in
confidence and in good faith and that residents' rights to privacy and anonymity
be ensured at all times.
2.2.5 Strive to prevent workplace-related and learning environment-related personal
retribution against residents in order to foster an open environment where
genuine concerns can be raised freely and without fear of reprisal.
3. SPECIFIC SAFETY CONCERNS
3.1 Travel
3.1.1 Residents must be compliant with all provincial laws pertaining to the safe
operation and maintenance of motor vehicles.
3.1.1.1 In the event of severe weather or poor road conditions, residents are
expected to exercise common sense and to use caution for shortdistance travel. If residents do not feel safe traveling to or from the
workplace or learning environment, they should communicate their
concerns to their residency program and/or the University of Manitoba
Faculty PGME Office.
3.1.1.2 Where reasonable concerns for personal safety have been
communicated to the above parties, residents are not expected to
undertake short-distance travel in adverse conditions. In these
situations, residents are advised to contact their Program
Directors/coordinators for guidance with respect to adjustments of
schedules and itineraries. Residents who have conveyed reasonable
concerns for their personal safety to the above parties are ensured the
full support of the University of Manitoba Faculty PGME Office.
3.1.1.3 Where travel to and from the workplace and the learning environment
is deemed essential by the residency programs and where residents
have communicated reasonable concerns for their personal safety,
then residents should be able to access safer modes of transportation
such as, but not limited to, public transportation or taxi cabs with the
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 2 of 14
Faculty of Medicine
FPGME Resident Safety Policy
guarantee of full compensation by the residency program.
3.1.1.4 If the travel to and from the workplace and the learning environment
involves distances which exceed the city limits, then the following
should apply:
a.
The residents' itineraries must be communicated to their residency
programs.
b.
Residents must keep informed with respect to severe adverse
road or weather conditions and are expected to exercise common
sense and to avoid travel under those conditions which may pose
reasonable concerns for personal safety. In these situations, the
residents should communicate with the residency Program
Directors and/or the University of Manitoba Faculty PGME Office
for guidance. Furthermore, the residents should communicate any
anticipated delays to their attending physicians in order to allow for
adjustments of schedules.
c.
Residents should ensure that they are well-rested before driving
for longer than one hour at a time for clinical or academic
activities. The residents are not expected to travel long-distance
following overnight call shifts. Residents are entitled to reasonable
accommodation of their call requests should travel be deemed
necessary. If unavoidable, a travel day may be considered at the
start of a rotation outside of the city limits in order to provide
residents with sufficient time to rest before embarking on longdistance travel.
d.
Where there exists reasonable concerns for personal safety and
these concerns have been communicated to the residency
Program Directors and/or the University of Manitoba Faculty
PGME Office, residents are not expected to undertake longdistance travel. Residents who have conveyed reasonable
concerns for personal safety to the above parties are ensured the
full support of the University of Manitoba Faculty PGME Office.
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 3 of 14
Faculty of Medicine
FPGME Resident Safety Policy
e.
For residents involved in neonatal transport, please see Appendix I:
Neonatal Transport Safety which was developed and kindly donated
by Dr. Eleanor MacDougall, Pediatric Residency Program Director.
f.
For residents who travel to northern remote locations, please see
Appendix II: Northern and Rural Rotations and/or Northern Medical
Trips, developed and kindly donated by Dr. Eleanor MacDougall,
Pediatric Residency Program Director.
3.2 Personal Security
3.2.1
Residents are entitled to the support of Security Services when working alone
after-hours. Residents have a duty to inform Security Services of their situations
should they require support and assistance. Every reasonable effort should be
made by the residency programs to ensure that residents are not exposed to
undue personal risk when working alone. If risks cannot be mitigated with the
help of Security Services, then residents are entitled to request changes in
scheduling or staffing to ensure that a safe workplace and a safe learning
environment are provided.
3.2.2
Residents should not make home visits unaccompanied.
3.2.3
Residents should not disclose their personal and/or private information in the
course of their daily professional and/or academic duties, including but not
limited to telephone numbers, banking information, credit card information,
personal passwords, email addresses, social media sites and home addresses.
Residents have a duty to make every effort to avoid inadvertent disclosure of
their personal and/or private information through the use of telephones,
computers or other electronic devices in the workplace or learning environment.
To this end, residents are encouraged to password-protect all sensitive
information and to use data encryption and data protection services (e.g. Caller
ID Blocking) when using such devices.
3.2.4
Residents are entitled to a safe and secure environment when using health care
facilities, including parking lots and parkades. Residents are strongly
encouraged to notify and utilize Security Services when walking outdoors in the
areas of health care facilities and parking lots at night. Residents are reminded
to contact Security Services immediately should they witness any activities that
might compromise the safety of the health care facilities. Furthermore, it is
recommended that residents ask the Security Service the locations of panic
alarms at their health care facilities and adjacent parking buildings.
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 4 of 14
Faculty of Medicine
FPGME Resident Safety Policy
3.2.5
Residents who are anticipating interactions with potentially violent or aggressive
patients or family members should make certain that members of Security
Services are present during these interactions.
3.2.6
Residents are entitled to education and training in identifying and managing
potentially violent, aggressive and/or threatening situations involving staff,
patients and/or family members in the clinical and academic environment.
3.2.7
Residents will be provided safe and clean on-call facilities (call rooms and
lounges) as per the PARIM contract. Access to these areas will be with coded
door systems. Any deficiencies with respect to fire alarms, smoke detectors,
adequate lighting, coded access and telephone services should be brought to
the attention of the residency Program Directors and the University of Manitoba
Faculty PGME Office.
3.3 Infection Control
3.3.1
Residents are entitled to education on the location and the services offered by
the Occupational Health and Safety Offices at their assigned facilities. This
includes familiarity with the policies and procedures for infection control and
protocols for exposure to contaminated fluids, needle stick injuries and
reportable infectious diseases. Residents have the duty to ensure that they
attend educational sessions provided and that they are compliant with the abovementioned policies.
3.3.2
Residents must comply with all isolation and infection control precautions and
procedures when indicated. All entry-level residents must undergo training in
infection control precautions provided by the University of Manitoba Faculty
PGME Office at the start of their residency programs.
3.3.3
Residents are entitled access to appropriate immunization services. Residents
have a duty to ensure that they appropriate immunization status as stated in the
institutional policy documents. Overseas travel immunization and advice should
be sought well in advance when travelling abroad for electives or meetings.
3.4 Radiation Safety
3.4.1
Residents are not expected to work in areas of high and long-term exposure to
radiation without receiving prior appropriate education on radiation safety.
Residents working in areas of high and long- term exposure to radiation must
follow radiation safety policies and minimize their exposure according to current
guidelines.
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 5 of 14
Faculty of Medicine
FPGME Resident Safety Policy
3.4.2
Residents are entitled to access to appropriate radiation protection garments.
Residents must wear proper-fitting radiation protection garments (aprons, gloves
and neck shields) when performing fluoroscopic techniques.
3.5 Safety During Pregnancy
3.5.1
Residents who are pregnant are entitled to a safe and equitable work and
learning environment. Where such an environment cannot realistically be
provided (e.g. unacceptable radiation hazard or risk of infection), residents who
are pregnant are entitled to appropriate education and warning. Residents who
are pregnant have a duty to inform their residency program that they will be
unable to work in such environments. Residents are never expected to
compromise their personal safety or the safety of their unborn children in the
course of their clinical or academic duties. The University of Manitoba Faculty
PGME Office will make every effort to ensure that the workplace and learning
environments are free from discrimination against residents who become
pregnant during their training. Residents who are pregnant should make every
reasonable effort to be informed of the specific risks to themselves and to their
fetuses in the work and learning environment and should request
accommodation where indicated. Further consultation with Occupational Health
and Safety may be advised wherever concerns about safety arise.
3.6 Emotional (Psychological) Safety
3.6.1
Learning Environment
All learning and work environments must be free from intimidation, harassment
and discrimination (see: University of Manitoba Faculty of Medicine: Guidelines
for Conduct in Teacher-Learner Relationships)
3.6.2
Health Concerns
Residents are entitled to freedom from discrimination on the basis of their
physical or psychological health. Residents have a professional duty to seek
professional advice whenever they are concerned with physical or psychological
health issues that may affect their clinical or academic performance. Residents
are entitled to confidential and non-discriminatory advice and counseling from
one or more of the following:
a.
b.
c.
d.
e.
Residency Program Director
Associate Dean for PGME
Associate Dean for Student Affairs
Faculty Student Mental Health Service
Doctors Manitoba Physician at Risk Help Line
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 6 of 14
Faculty of Medicine
FPGME Resident Safety Policy
f.
College of Physicians and Surgeons of Manitoba
3.6.3
Residents are entitled to leaves of absence (see: University of Manitoba Faculty
of Medicine PGME Leave of Absence and Waiver of Training Policy).
3.6.4
Residents are entitled to notification in writing from any of the individuals listed
above (3.6.2. a. to f.) if their physical or psychological health issues are deemed
sufficiently concerning as to require cessation of their clinical and/or academic
duties. Residents have a duty to abide by the professional code of conduct that
governs all medical professionals as stipulated by the College of Physicians and
Surgeons of Manitoba (CPSM) with respect to physical and/or psychological
health.
3.7 Professional Safety
3.7.1
Professional Environment
3.7.1.1 All residents are entitled to work and learn in a culture of respect (see:
WRHA Respectful Workplace Policy). Any act of discrimination based
on religion, gender, race, colour, age or health condition (not limited to
this list) should be reported to the residency Program Director and to
the University of Manitoba Faculty PGME Office. Residents are
encouraged to be familiar with this policy and they can expect prompt
attention to any reported concern. All resident concerns will be
documented in writing and will be kept on record in the strictest
confidentiality by the residency program and by the University of
Manitoba Faculty PGME Office.
3.7.1.2 All PGME programs are bound by the PARIM contract allowances for
religious holidays. Residents are entitled to request that special
allowances be made for travel and/or for time-off at the discretion of
the residency Program Directors on the basis of religious observances,
practices and holidays.
3.7.2
Critical Incidents
3.7.2.1 Residents are entitled to participate in the investigation and the review
of critical incidents which occur without fear of negative consequences.
Residents have a professional duty to report all critical incidents.
3.7.2.2 Residents will be guaranteed confidentiality for any critical incidents in
which they are involved, unless the incidents were sufficiently severe
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 7 of 14
Faculty of Medicine
FPGME Resident Safety Policy
as to compromise their own safety, in which case these critical
incidents must be reported to the Associate Dean for PGME or the
College of Physicians of Manitoba (CPSM).
3.7.3
Confidentiality of Resident Information
3.7.3.1 Residents will be guaranteed confidentiality for any critical incidents in
which they are involved (see above).
3.7.3.2 Residents are entitled to protection of their personal and/or private
information in their resident files and elsewhere, especially where it
does not concern their professional duties and responsibilities.
3.7.3.3 Residents are not required to disclose personal and/or private
information to any staff without prior written request. Residency
programs must obtain verbal and written consent from the residents for
disclosure or use of any personal and/or private information to third
parties.
3.7.3.4 Residents are not expected to disclose their personal and/or private
information including but not limited to telephone numbers, residential
addresses, email addresses and social media profile to any clinical
and/or academic faculty members, where the information does not
directly relate to the performance of their professional duties and
responsibilities.
3.7.3.5 Residents should not be contacted by clinical and/or academic faculty
members outside of working hours without prior notice. Exceptions to
this policy include emergencies which personally affect the residents.
3.7.3.6 Residents should be contacted by means of appropriate lines of
communication such as email, pagers and work telephone numbers
whenever possible. Communication using personal telephones or
electronic devices should be limited strictly to emergency situations.
3.7.3.7 Residents are reminded that the use of social media in the
professional environment may expose them to unwanted or unintended
personal scrutiny. The University of Manitoba Faculty PGME Office
cannot guarantee the protection of personal and/or private information
when social media access is granted by residents.
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 8 of 14
Faculty of Medicine
FPGME Resident Safety Policy
3.7.3.8 Residents are not expected to use their personal telephones,
computers and/or other electronic devices in the performance of their
clinical duties. Residents are entitled to refuse to use the
aforementioned equipment.
3.7.3.9 Residents will be guaranteed that any feedback regarding their
teachers, rotations and clinical experiences will be kept anonymous as
per the RCPSC "B" Standards.
3.7.3.10 Residents will be guaranteed protection from discrimination and
retribution regarding feedback provided in confidence with respect to
the performance of clinical and academic faculty members, including
Program Directors and Heads of Sections. Residents should not be
pressured or coerced in any way to share information regarding
personal evaluations of clinical and/or academic faculty members.
3.7.4
Professional Responsibilities
3.7.4.1 Residents must be members of the Canadian Medical Protective
Association (CMPA).
3.7.4.2 Residents must possess current educational licenses from the College
of Physicians and Surgeons of Manitoba (CPSM).
3.7.4.3 PARIM Residents must procure mandatory life, accidental death, and
disability insurance from Doctors Manitoba. This insurance coverage is
valid throughout Canada.
3.7.4.4 Sponsored Residents may choose to become a member of Doctors
Manitoba and opt to apply for insurance through Doctors Manitoba.
Successful acquisition of coverage would be at the discretion of the
insurer and the specific circumstances of each applicant.
3.7.4.5 Residents must report any changes to their licensure status
immediately to their Residency Program Director and to the University
of Manitoba Associate Dean for PGME.
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 9 of 14
Faculty of Medicine
FPGME Resident Safety Policy
IMPORTANT RESIDENT SAFETY CONTACTS
4.1 University of Manitoba Faculty PGME Office
[email protected]
Bannatyne Campus
Dean’s Office, 260 Brodie Centre
204-789-3290
4.2 University of Manitoba Faculty Student Affairs Office
204-272-3190
Bannatyne Campus Student Services
[email protected]
T245 Basic Science Building
http://umanitoba.ca/student/bannatyne/media/BC_Student_Serv.pdf
4.3 Doctors Manitoba Physicians at Risk
204-237-8320
(24 hour hotline - checked daily)
4.4 Faculty of Medicine Mental Health Services
A120 Chown Building
204-789-3328
(Call for an initial appointment)
Free confidential consultation and treatment for students experiencing emotional
stress from the Department of Psychiatry. Service is available to students of the
Faculty of Medicine, their spouses and immediate family.
4.5 Student Counseling and Career Centre
204-789-3857
Bannatyne Campus – S207 Basic Medical Science Building
http://umanitoba.ca/faculties/medicine/student_affairs/oncampuscrisis.html
4.6 The College of Physicians & Surgeons of Manitoba (CPSM) 204-774-4344
[email protected]
1000 – 1661 Portage Ave
Winnipeg MB R3J 3T7
Fax: (204) 774-0750
Toll Free (In Manitoba): (877) 774-4344
4.7 Campus Security Safewalk Program
204-474-9312
http://umanitoba.ca/campus/security/programs/safewalk.html
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 10 of 14
Faculty of Medicine
FPGME Resident Safety Policy
REFERENCES
5.1
University of Manitoba Faculty of Medicine Pediatrics Neonatal Transport Safety
Guideline (attached as Appendix I)
5.2
Northern and Rural Rotations and/or Northern Medical Trips Guideline (attached as
Appendix II)
5.3
University of Manitoba Faculty of Medicine: Guidelines for Conduct in TeacherLearner Relationships
5.4
University of Manitoba Faculty of Medicine PGME Leave of Absence and Waiver of
Training Policy
5.5
Winnipeg Regional Health Authority (WHRAH) Respectful Workplace Policy
5.6
Appendix III includes electronic links to policies and procedures for the University of
Manitoba Faculty of Medicine Policies and Procedures page, WRHA Policies and
Procedures pages, the PGME policies page, and to the University of Manitoba
Faculty of Medicine Professionalism policy.
4. POLICY CONTACT
Please contact the Associate Dean, Postgraduate Medical Education should you have
any questions about this policy.
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 11 of 14
Faculty of Medicine
FPGME Resident Safety Policy
Appendix I
Neonatal Transport Safety
General Guidelines:
Air, water and ground transportation are components of Neonatal transportation of patients.
When functioning as part of the Transport Team, the paediatric resident must follow the safety
measures as appropriate for the vehicle. In the ambulance and aircraft, seatbelts must be used
when the vehicles are in motion. In some communities, water craft may be needed for patient
transport. In this case, water floatation devices must be used.
The medical staff and flight crew have been trained in flight safety. Their instructions must be
followed as situations arise, to minimize risk to the resident. These risks include direct exposure
to various types of aircraft on the tarmac, and in flight emergencies.
On the tarmac/ramp, noise can be excessive. Extra caution should be taken to identify dangers
visually. Also, ear protection to prevent hearing damage might be a consideration. Interaction
with propellers, in motion or not, should be avoided. When in the vicinity of jet engines, caution
should be used to avoid clothing, or loose materials from being drawn in to an engine. Smoking
should be avoided near any aircraft or engine fuel. If in doubt, follow the safety instructions of
the trained Transport Team or flight crew.
Weather conditions can be severe, in particular in northern destinations. Appropriate outer
clothing is important in consideration of the season and destination.
Stressors of flight exist which may affect the resident physically. Their awareness of these
stressors will allow them to prevent undue physical discomfort. These stressors and
precautions include:
1. Trapped gases- avoid foods and drinks that are gas producing (e.g. carbonated
beverages). Avoid flying if suffering from a URTI, ear or sinus infection. Avoid flying
following some types of dental procedures.
2. Hypoxia - be aware of lower oxygen as flight altitude increases. Be familiar with oxygen
sources for team members in case of sudden need.
3. Temperature- dress appropriately for cabin temperature. Increase fluid intake to offset
any effect from low cabin humidity.
4. Vibration- significant aircraft vibration can be part of the flight experience. Ensure wellpadded seating is used. Avoid direct contact with the bulkhead of an aircraft.
5. Noise- noise levels in the aircraft may be prolonged and intense. Ear protection should
be considered.
6. Gravitational Forces- with takeoff and landing of an aircraft, gravitational forces are
significant. Seatbelts and shoulder straps should be used, as per flight instruction.
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 12 of 14
Faculty of Medicine
FPGME Resident Safety Policy
Appendix II
Northern and Rural Rotations and/or Northern Medical Trips
General guidelines:
Northern and Rural rotations, as well as Northern Medical Trips augment a trainee’s clinical
experiences but are not without risks. These opportunities bring residents into unknown
locations where unfamiliarity, isolation and travel can cause potential harm. At all times during
these experiences residents should exercise caution and abide by the Resident Safety Policy.
All Provincial and Highway driving acts and laws should be followed. Residents should always
be prepared for unexpected cold weather and dress appropriately. Residents are required to
know the safety policies and procedures of the rural sites (details of these will be provided to
the resident during the first day of orientation in the rural sites). If safety concerns arise
residents should contact the Director of Northern and Rural Medical Education and/or the
Program Director.
If travelling by car, residents should ensure that the vehicle is in good driving condition. No
resident should drive long distances when extremely fatigued. Driving conditions should be safe
before a resident proceeds to travel. Residents should have highway safety gear and/or a
cellular phone in case of unexpected occurrences while driving. Vehicles should be parked in
assigned parking areas at the rural sites. Should any violation occur to the vehicle while on a
rural rotation, police should be notified immediately, as well as the Director of Northern and
Rural Medical Education and/or Program Director.
If a resident chooses to travel to rural sites by bus, a certified reputable company (such as
Greyhound) should be selected for travel. Residents should abide by all travel regulations set
by the company and attempt to travel during daytime hours. Travel to and from the bus depot
must be done in a safe matter, either by someone whom the resident knows and trusts or by a
taxi driver. When travelling by taxi, residents must assure their own safety. Only taxis with clear
driver identification and license should be used.
When travelling by plane, residents need to abide by all Transport Canada air travel
regulations. Full details of the regulations can be reviewed at www.tc.gc.ca. Residents are
required to listen and follow in-flight crew directions.
Residents may be placed in shared accommodations during the northern and rural rotations. All
efforts are in place to ensure that same sex members are grouped in the same floor of a house
or apartment. Caution should be used when in using shared accommodations. It is
recommended that residents lock their room doors while sleeping and bathrooms be locked
when in use. Valuable goods should not be left unsupervised.
During the rural and northern rotations, residents should use caution when outdoors alone.
Residents should always be in visible, well trafficked areas. It is not recommended to be alone
outdoors after daylight hours. Taxi vouchers or financial remuneration will be provided to
residents who do not have access to vehicles during these rotations. Security escort should be
considered if walking outdoors at night in the hospital areas.
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 13 of 14
Faculty of Medicine
FPGME Resident Safety Policy
Appendix III
Links to Policies and Procedures
1. WRHA Policies and Procedures:
WRHA> For Health Care Professionals > Index
WRHA > For Health Care Professionals > Students
2. Health Sciences Centre (HSC) Policies and Procedures:
Can be accessed through the HSC Intranet once you are set up for
access
3. St. Boniface General Hospital (SBGH) Policies and Procedures
Can be accessed through the SBGH Intranet once you are set up for
access
4. University of Manitoba Faculty of Medicine:
University of Manitoba - Faculty of Medicine - Policies & Procedures
PGME
University of Manitoba - Faculty of Medicine - PGME - Policies
Professionalism
http://umanitoba.ca/faculties/medicine/professionalism.html
Approved at Dean’s Council – 5 June 2012
Approved at Faculty Executive Council – 12 June 2012
Page 14 of 14
Cardiology Training Program Responsibilities on Call
Overall Call Responsibilities:
The residents (both cardiology senior resident and junior rotating resident) on call in the hospital
are responsible for the care of the admitted cardiology patients (5A Cardiology ward, CCU and
ICMS), any direct to cardiology service admissions (direct “CODE STEMI” to the cath lab, direct
to emergency or CCU/Cardiology ward/ICMS), and any new consultations arising from the
emergency department or hospital wards at SBGH. The primary responsibility of both residents
on call is to the admitted cardiology patients and patients direct to the cardiology service.
Consults to the cardiology service arising from ICMS, the emergency department, and other
hospital wards will be triaged by the call team and prioritized to ensure optimal patient safety and
care while providing consultation and guidance to other services. The “junior rotating resident”
refers to all off-service residents rotating through the cardiology service, including residents from
Internal Medicine, Anesthesia, Emergency Medicine, Family Medicine, Neurology,
Neurosurgery, and Cardiac Surgery. The priorities of care for patients while on call for
Cardiology include:
1) “CODE STEMI” patients direct to cath lab, any “CODE BLUE” called on a cardiology
patient
2) Patients admitted to cardiology in CCU and ICMS
3) Direct to cardiology admissions and patients on 5A Cardiology ward
4) New consults to cardiology service from ICMS, the emergency department, and hospital
wards
The roles of the cardiology senior resident and junior rotating resident are outlined as follows:
Roles of Cardiology Senior Resident on call:
• Function at the level of a junior attending physician, oversee patient care, review
admissions and new consultations to the cardiology service with the junior rotating
resident, provide teaching to the junior resident when appropriate and to help ensure
patient safety. (CanMeds – Health advocate, Scholar, Manager, Medical expert)
•
To prioritize professional duties when faced with multiple patients and problems.
(CanMeds – Manager, Health advocate, Medical expert)
•
To assess and stabilize all “CODE STEMI” (777 on pager) patients brought direct to the
cath lab prior to cath lab staff arrival. (CanMeds – Manager, Medical expert)
To be present at any “CODE BLUE” on a patient admitted to the cardiology service or
patient in the cardiac cath lab. (CanMeds – Health advocate, Collaborator, Medical
Expert)
• Screen all admissions to the CCU, ICMS under cardiology, and cardiology ward services
if not assessed by the day service or attending, to ensure appropriate documentation and
orders from the junior resident. (CanMeds Collaborator, Scholar, Medical expert)
• Perform consultations (complete consult form), after initial assessment by junior rotating
resident (complete detailed history and physical), with well documented assessments and
recommendations in response to a request from another health care professional
(CanMeds- Scholar, Communicator, Medical expert)
•
Call responsibilities
Page 1 of 3
CARDIOLOGY
•
•
•
•
•
•
It is the duty of the on call cardiology senior resident to review all admissions and
consultations in a timely manner unless acute patient care duties as listed above occur.
To provide advice and help to the junior resident with patient care. (CanMeds –
Collaborator, Scholar, Professional, Communicator, Medical expert)
To supervise junior resident when emergency procedures are required (central line
insertion, temporary pacemaker, arterial lines, pulmonary artery line, etc). (CanMeds –
Medical expert, Scholar, Communicator)
To determine indications for and performing emergency echocardiograms if appropriate.
(CanMeds – Scholar, Manager, Medical expert)
To effectively communicate the new admissions, consultations and patient concerns with
the appropriate cardiology staff physician. (CanMeds –Professional, Communicator)
To understand their own limitations and know when to ask the attending Cardiology staff
physicians for help when needed. (CanMeds –Professional)
Call responsibilities
Page 2 of 3
CARDIOLOGY
Roles of the junior rotating resident on call:
• Obtain appropriate and timely sign over from CCU, ward, and consult teams. (CanMeds –
Professional, Communicator)
• To follow up on any tasks signed over from the ward, consult or CCU team, such as,
patient re-assessment and following up on labs and imaging studies. (CanMeds –
Collaborator, Professional)
• Carry the CCU “on call” pager and promptly answer any pages for the cardiology service.
The junior rotating resident is expected to take “first call” for the cardiology service.
(CanMeds – Communicator, Professional)
• To prioritize, be present and help stabilize all “CODE STEMI” (777 on pager) patients
brought direct to the cath lab prior to cath lab staff arrival. (CanMeds – Collaborator,
Communicator)
• To be present at any “CODE BLUE” called on a patient admitted to the cardiology
service or in the cardiac cath lab in order to provide help. (CanMeds –Collaborator,
Health Advocate)
• Assess and appropriately document a full history and physical examination and
management plan on admissions to the cardiology service (CCU, ICMS under cardiology,
or ward). All admissions to a cardiology service must be reviewed with the cardiology
senior resident if not already seen by the day staff. (CanMeds - Scholar, Communicator,
Medical expert)
• Assess and appropriately document a full history and physical examination and
management plan on all consultations to the cardiology service (arising from hospital
wards or emergency department). All consultations to a cardiology service must be
reviewed with the cardiology senior resident if not already seen by the day staff.
(CanMeds- Scholar, Communicator, Medical expert)
• It is the responsibility of the on call junior resident to see all consultations and admissions
in a timely manner unless acute patient care duties occur as listed above. (CanMeds –
Professional, Communicator, Medical expert)
• To perform any required procedures with the help of the cardiology senior resident as
appropriate (i.e. arterial lines, central lines, pulmonary arterial catheter, temporary
pacemaker, etc.). (CanMeds – Medical expert, Scholar, Communicator)
• To be present with the cardiology resident and staff physician for the discussion of
patients seen over night, weekend or weekdays, prior to returning to their service duties.
(CanMeds –Collaborator, Professional, Communicator)
• To provide concise and appropriate patient sign over to the oncoming CCU, consults,
ward and/or call teams and handover of the appropriate pager.
• To understand their own limitations and know when to ask for help when needed.
(CanMeds – Professional)
Call responsibilities
Page 3 of 3
CARDIOLOGY
University of Manitoba Travel Policy for Residents, Faculty and Staff Using University Funds Pre-­‐Approval All travel requires pre-­‐approval 21 DAYS before you can book your travel. Submit the Travel Preauthorization form (copy attached – download form from U of M Website -­‐ Finance-­‐Travel Services Forms) and send to Department of Medicine GC425. Once approved and only when approved by Travel Services (you will receive an email confirmation that your travel has either been approved or denied) you may begin booking your travel: Conference fees The responsibility for booking conferences/course registration is vested with the traveller. You may elect to use your own credit card or/and UM travel card. Original receipts will be required for reimbursement including proof of attendance through the submission of conference \id tag, registration and proof of payment including your credit card statement. Air Travel: Concur, Preferred Airline Agreements, and Exclusive Travel Agencies Air travel arrangements must be made using one of the following alternatives: (a) Concur is the recommended booking method for domestic, trans-­‐border (Canada-­‐USA), and direct international flights. (b) Carlson Wagonlit Travel is the recommended booking method for flights which are complex in nature (for example, group flights, multi-­‐city destinations, and most international flights). A transaction fee applies, and any University negotiated discounts will automatically be applied by the travel agent. (c) Student air travel may be booked using either Concur, Carlson Wagonlit Travel, or Merit Travel @ Fort Garry Campus, University Centre (telephone 204 269-­‐9530) where special fares related to students are available. (d) Direct airfare bookings can be made when traveling to remote areas within a foreign country not available through Concur or Carlson Wagonlit Travel. The University issued Travel Credit Card or cash may be used in these cases. (e) Airfare selected must be lowest cost available, not to exceed full economy class. (f) Scheduling and routing preferences can be used to justify airfare up to the greater of $100 or 10% above lowest cost available. (g) Exceptions must be made in writing and provided to Travel Services before the airfare is booked and by seeking Vice-­‐President Approval Ground Transportation Taxi and airport shuttle service fees related to the conference are allowable expenses. Where available hotel shuttles should be used to and from the airport. Receipts should include documentation of travel from and to in order to be approved. For residents, when a taxi or suitable public transportation is not available and the need to rent a car is necessary and the need to rent a car is necessary, please obtain Program director approval prior to travel and submit explanation with student claim reimbursement form. Car Rental: Claimants are recommended to use Concur to take advantage of special car rental rates Parking Parking expenses related to off-­‐campus University business are allowable expenses and must be supported by receipts. For airport parking: the lesser cost of taxi or parking will be reimbursed unless the Claimant resides in an area that does not have access to taxis. Private Automobile: (a) The allowance for use of personal automobile while on approved University business is $0.43 per kilometer. (b) Use of private automobiles should be limited to those trips where no suitable public transportation is available or where a private automobile is more economical considering all costs. (c) Only incremental kilometers driven above the distance from residence to normal work location may be claimed. (d) For long distance trips when a private automobile is used strictly for personal convenience, only actual costs ( for example, kilometers driven, hotels, meals, etc.) for the time spent traveling will be reimbursed up to but not exceeding the costs of equivalent public transportation such as lowest cost airfare. Where relevant, a lowest cost airfare quote must be obtained from Concur prior to departure and be attached to the Claimant’s Claim. (e) Transportation to a Claimant’s normal work location may not be claimed, except where the Claimant has been called back to work outside of their normal work schedule and is required to make an additional trip. Accommodation a) It is recommended that hotel accommodations be arranged through Concur in order to obtain the most economical rate and take advantage of the University’s preferred suppliers. b) Reimbursement for accommodation will be limited to reasonable amounts in the particular circumstance and normally will not exceed the single occupancy rate. For example, the University will not reimburse for any additional cost of accommodations for a traveling companion such as spouses, children and friends. c) Private arrangements for overnight accommodation with friends or relatives, where not inconvenient to the program, are allowable. Reimbursement for a token of appreciation may be claimed based on receipts, not to exceed $50 per night. This would not be allowable if the Claimant has any ownership or rental interest in the premises d) If more than one traveler is traveling to the same conference and arrangements are made to share accommodations, please request separate invoices for each room occupant from the hotel. Meals while traveling Reasonable expenses for meals while traveling on University business may be reimbursed by claiming actual costs incurred up to the daily maximum limit, or by claiming a per diem up to the per diem limits: Actual costs (meals with receipts): Claims for each meal (food and beverages) must be listed separately on the Claim including taxes and gratuity and supported by detailed receipts (see attached Meal Tracker Form). Any reimbursement for alcoholic beverages must be coded separately to account 713314. See chart below for maximum daily limits. Daily limit for actual costs of meals including alcohol Supervisor may approve up to (+$25) Dean or Associate) In Canada Foreign 50 75 V.P. may approve up to (+$50 100 60 85 110 Per Diem allowance (meals without receipts): instead of being reimbursed for actual costs, a daily allowance may be claimed. Where this allowance is claimed, no additional amount may be claimed for meals. The per diem allowance must be adjusted when meals are included in transportation charges, conference registration fees, in the event of a partial day’s travel, etc. See chart below for per diem rates. Total Per diem Canada -­‐ $50 Foreign -­‐ $60 Breakfast 10 15 Lunch Dinner 15 15 25 30 Expense Claims Procedures and Supporting Documentation Requirements: Employees and Students A separate Claim must be prepared for each Claimant and must detail the purpose for the Claim and must be submitted within 60 days of your return travel. The Claim should include all relevant expenses, including but not limited to travel, accommodations, meals, and registrations. It should also include the registration the submission of conference \id tag, registration and proof of payment, (travel itinerary (TA number, itinerary and boarding pass), ground transportation (taxis, public transportation, shuttles and parking) accommodation (detailed hotel folio with payment indicated) meals, including receipts), and conference agenda. All expenses must indicate the business purpose and if applicable, the relationship to the research being conducted. Travel and other business expenses for employees will be reimbursed through Concur. Travel and other business expenses for guests and students will be reimbursed through the Guest /Student Travel and Business Claim form (attached). Go to U of M Website – Finance – Travel Services – Forms to download forms. Documentation of expenses must be comprehensive and the original detailed receipts or other original documents must be scanned or faxed and attached to the electronic claim. In the case of a lost or missing receipt the Claimant must complete a Missing Receipt Affidavit form (attached – download from U of M Website – Finance – Travel Services – Missing Affidavit form) in order to claim the expense. Failure or refusal to provide Receipts along with necessary documentation will result in suspension of reimbursement until documentation is brought up to date. Failure to comply with the new Travel Policy such as meeting requirements might result in student/guest not getting reimbursement. HOSPITALITY AND MEETING EXPENSES Occasionally faculty may be in the position of inviting guests for coffee or a meal. These hospitality events may be approved. Hospitality/staff events (with receipts): Meals, food and beverages (including alcoholic beverages) other than for an individual travelling on University business may be reimbursed when: (i) directly related to a University business purpose; (ii) approved by the one-­‐over-­‐one Approver at the level of Dean, Associate Vice-­‐President, Vice-­‐
Provost, Vice-­‐President, or President; (see attached form – download form U of M Website – search – Hospitality Event Pre-­‐Approval Form online) (iii) costs are reasonable in the circumstances; and Reimbursement must be coded under 70676 except for alcohol which must be coded separately to account 706760. Per person total meal maximum: Dean can approve up to $40.00 per person; Vice-­‐president $65 per person per day. Travel Request Approval Form
Form #: FIN-TRVREQ01 - Last Revised Jul 1,2009
Name (please print)
Position
Office Address
Program
Conference / Event
Cost Centre
Phone #
Travel Date(s)
Conf/Event Location
Regular Pay During Absence?
No
Yes
Item
Amount Recoverable
(if applicable)
Costs
Net Cost to SBGH
Airfare
$
-
Ground
$
-
____
$
-
____
$
-
$
-
$
-
$
-
Accommodation
# of Nights
Per Diem
# of Days
Registration Fees
Other (specify)
______________________
TOTAL
$
-
$
-
Purpose of Trip
Conference Delegate
Speaker
Professional Affiliation
Departmental Representative
Contract Negotiations
Resource Person
Professional Development
Executive Member
Upgrading
Other (specify)
_______________________________________________
Justification
Reviewed by Director
Approval (Executive Director or Designate)
Date
Date
Special Instructions
THIS IS A PRE-APPROVAL FORM ONLY.
SUBMIT THIS FORM TO FINANCE, A9010, AT TIME OF BOOKING AIRLINE TICKETS.
IF TRAVEL REQUEST IS FOR A CONFERENCE, ATTACH A COPY OF CONFERENCE BROCHURE.
FOR REGISTRATION FEES: Submit a completed CHEQUE REQUISITION with a copy of this form and the original completed registration
form.
FOR EXPENSE CLAIMS: Submit a completed EXPENSE CLAIM FORM with a copy of this form & the original receipts upon completion of
travel.
FOR QUESTIONS, CONTACT FINANCE AT (237) 2847.
Forward to: SBGH Finance, A9010
Meal Tracker for Conference Travel
Per Diems Rates
Name: __________________________
Dates of Travel: ________________________
Conference: _____________________________________________________________
Canada
Outside CDA.
$ 10 $ 15
$ 15 $ 15
$ 25 $ 30
Are you claiming:
Per Diem
Meals with Receipts
If you are claiming per diems, was the travel in: Canada
Outside Canada
Please provide in detail, by date, which meals are being claimed as per diems and which meals are provided at the conference
DATES
Breakfast
Lunch Dinner
$ -­‐
Total Per Diems
$ -­‐
$ -­‐
$ -­‐
$ -­‐
$ -­‐
$ -­‐
$ -­‐
$ -­‐
Travel Preauthorization Form
Destination(s)
Purpose
Employee ID:
Name:
Department:
Proposed date of departure:
Proposed date of return:
Conference
Research
Collaboration
Other
Business
Estimated Costs
Flight
Hotel
Meals/per diems
Conference
Taxi/car rental
Other
Fund
Total Trip Costs
$ -­‐
Remaining Budget in FOAP
Remaining Budget after trip
$ -­‐
$ -­‐
Which FOAP(s) will be paying for this trip?
Org.
Acct.
Prog.
Budget
$ -­‐
Current Remaining Budget Commitments
in FOAP
$ -­‐
$ -­‐
$ -­‐
$ -­‐
$ -­‐
$ -­‐
$ -­‐
Business purpose of trip (completed by traveler)
Reason why you think this employee should take this trip (completed by supervisor, one-­‐over-­‐one)
By signing this form I agree that I have read the University of Manitoba Travel and Business Expense Claim Policy and Procedure documents available on the UofM website, I am familiar with their contents and agree to adhere to any and all policies within the Travel and Business Expense Claim Policy's and Procedures.
Signature: ____________________________________________________________________Date___________________________________________
Signature of one-­‐over-­‐one:________________________________________________________________Date_________________________________________
Signature of Business Manager, Dean's Office or Department Head:________________________________________________Date_______________________
RESET FORM
Missing Receipt Affidavit
Instructions:
1.
2.
3.
4.
Complete all fields below, Print and Sign the declaration
Scan the declaration
Attach completed declaration to expense line or report in lieu of receipt
Submit with the related Receipt Submission Report
I understand that a Missing Receipt Form may not be completed on a routine basis and that
overuse may revoke the privilege of providing a Missing Receipt Form in lieu of a receipt.
Name (Please Print): ____________________________________________________________________
RN# and Report Name:
Date of Purchase:
Vendor Name:
Vendor City of expenditure:
Purchase Total:
Description of items purchased:
Reason receipt is missing:
Declaration:
I acknowledge that this expense was incurred on behalf of The University of Manitoba and
that it is an allowable expense as defined by The University of Manitoba Travel Policy and/or
the appropriate Granting Agency Policy.
Employee Signature: __________________________________
Please return form to:
Travel Services
405 Administration Building
[email protected] or Fax 204-474-7925
Date: ______________________________