Rotation Specific Guidelines
CCFP(EM) Residency Program
Coronary Care Unit
Family Medicine Expert
Overall Goal
To utilize the relevant competencies contained within the CanMEDS-FM roles to rapidly evaluate, diagnose, and treat the cardiac patient. Special emphasis will be placed on those clinical presentations and procedures common to the Emergency Department. This includes effective communication with patients, their families and the CCU team, and the use of the patient centered clinical method to understand the patient’s personal experience of the illness in the context of their life as a whole.
Specific Educational Objectives
The resident should:
Develop expertise in the evaluation and differential diagnosis of chest pain
List the common life threatening causes of chest pain and describe the clinical presentation of each.
Develop expertise in the ability to differentiate between patients with chest pain that can be risk stratified and managed effectively as outpatients from those who require immediate referral and inpatient management
Develop expertise in the diagnosis and management of acute coronary syndromes
Understand the role of cardiac markers in the diagnosis of the chest pain patient
Develop expertise in the interpretation of electrocardiograms;in particular, identification of cardiac ischemia, rhythm abnormalities and normal variants should be demonstrable.
Have an understanding of the interpretation of diagnostic tests commonly used to evaluate heart disease including treadmill testing, nuclear perfusion scans, echocardiography and coronary angiography.
List the indications, contraindications, and complications for the use of thrombolytic therapy.
List indications for primary angioplasty
Develop expertise in the diagnosis and management of acute decompensated congestive heart failure and chronic congestive heart failure.
Develop expertise in the recognition and management of dysrhythmias in both hemodynamically stable and unstable patients.
Describe the indications for transcutaneous and transvenous cardiac pacing.
Develop expertise in the insertion of transvenous pacemakers
Develop expertise in the recognition and management of cardiogenic shock
Develop expertise in the management of the cardiac arrest patient
Demonstrate bedside clinical skills pertaining to the cardiac exam. Conduct, record, and verbally report cardiac physical examination findings. In particular competency shall be demonstrated in evaluation of JVP elevation, cardiac heart sounds and murmurs, and clinical signs of CHF.
Support choice of medical management based on evidence in the current literature regarding benefit in terms of symptom relief and/or survival advantage.
Understand the pharmacology (indications, complications, side effects, toxic effects) of common cardiac medications.
Recognize personal limits of expertise by self-assessment. This includes the ability to decide if and when other professionals are needed to contribute to a patient’s care.
Manifest a systematic approach to clinical reasoning in order to solve the individual patient’s problems.
Develop expertise in understanding and discussing level of care decisions
Communicator
The resident should be able to:
Demonstrate the ability to communicate effectively with patients and their family members in a manner that displays an understanding of the patient’s experienceof illness, their ideas, feelings, expectations, and of the impact of illness on the lives of patients and families
Demonstrate the ability to explain medical information in a manner which is easily understood by the patient and their families empowering them to be able to make informed decisions with regards to their care
Encourage discussion and questions in the patient encounter
Communicate utilizing an interpreter if a language barrier prevents the patient from having a satisfactory understanding of their medical condition
Establish and maintain a therapeutic relationship with patients and their families while fostering an environment characterized by understanding, trust, respect, empathy and confidentiality.
Demonstrate an ability to effectively communicate with members of the multidisciplinary Coronary Care Team including staff cardiologists, consultants, nurses and nurse managers, resident colleagues, medical students, respiratory therapists, unit clerks, technicians and spiritual care advisors
Demonstrate an appreciation of how to compassionately deliver bad news including death-telling and discussing levels of care decisions
Use the patient centered clinical method to gather information not only about the disease but also about the patient’s beliefs, concerns and expectations about the illness
Consider the influence of factors such as the patient’s age, gender, ethnic, cultural and socio-economic background, and spiritual values on the illness.
Maintain clear, accurate and thorough written medical records.
Use appropriate medical terminology to provide an accurate verbal or written summary describing a patient’s clinical condition.
Engage patients, families, and relevant health professionals in shared decision-making to develop a plan of care
Collaborator
The resident shall:
Understand that the care of the cardiac patient is best undertaken in a multi-disciplinary manner involving physicians, nurses, spiritual care representatives, physiotherapists and other non-medical professionals
Demonstrate a respectful attitude towards colleagues, paramedical and non-medical staff, and respect differences and limitations in other professionals
Understand the role of the cardiologist as a consultant, and apply this knowledge to general family medical practice
Demonstrate a leadership role in the healthcare team as code team leader
Develop a care plan, including investigation, treatment and continuing care, in collaboration with the members of the interdisciplinary team
Participate in interdisciplinary team meetings, demonstrating the ability to accept, consider and respect the opinions of other team members, while contributing specialty-specific expertise.
Understand the roles and expertise of the other individuals involved, inform and involve the patient and his/her family in decision-making, and explicitly integrate the opinions of the patient and care givers into management plans.
Demonstrate an ability to promote the autonomy of patients and families and to promote their involvement in decision-making.
Manager
The resident shall:
Effectively manage the care of multiple cardiac patients in multiple areas, including the Emergency department, CCU and cardiology ward.
Effectively use patient-related databases, access computer-based information and understand the fundamentals of medical informatics.
Make clinical decisions and judgments based on sound evidence for the benefit of individual patients and the population served.
Work effectively both as a member of a team or as team leader, and accomplish the tasks set out for either role
Employ effective time management and self-assessment skills to formulate realistic expectations, and maintain a healthy balance between patient care responsibilities and personal/family responsibilities
Health Advocate
The resident shall:
Understand the health determinants for cardiovascular disease and develop basic counseling techniques to deal with these.
Understand how to provide access for the patient to other health care professionals who may assist in cardiac risk factor reduction (i.e. dietician, cardiac wellness physiotherapists)
Be able to identify the patient’s status with respect to one or more of the determinants of health (i.e. unemployment) and adapt the assessment and management accordingly
Be able to assess the patient’s ability to access various health and social services so as to promote health, foster coping abilities, and enhance active participation in informed decision-making.
Develop an understanding of living wills, advanced directives, durable power of attorney, and personal directives.
Scholar
The resident shall:
Identify learning needs and make use of available learning resources to address them accordingly
Demonstrate critical thinking and integrate critical appraisal of the literature into the bedside approach.
Analyze and interpret the validity and applicability of evidence contained in the medical literature.
Have a fundamental knowledge of statistical tools and their applicability to new information being reviewed
Apply new knowledge to daily practice.
Seek out assistance of colleagues and peers if applicability of literature to clinical practice is unclear
Professional
The resident will:
Be punctual for rounds, family conferences and educational events.
Follow through on assigned tasks.
Be respectful, honest and compassionate when dealing with patients, families and other professionals.
Demonstrate an enthusiasm for learning.
Demonstrate good self-assessment ability by being aware of one’s own limitations and seeking feedback.
Be aware of racial, cultural, and societal issues that impact on the delivery of care.
Beaccountable for personal actions, have a high degree of self-awareness, maintaining an appropriate balance between personal and professional roles, and addressing interpersonal differences in professional relations.
Recognize, analyze and know how to deal with unprofessional behaviors in clinical practice, taking into account local and provincial regulations.
Maintain an appearance that maintains a sense of dignity commensurate with the importance of the doctor-patient relationship