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UNIVERSITY OF MANITOBA Adult Cardiology Residency Training Manual 2013/2014 TABLE OF CONTENTS Introduction .............................................................................................. 4 Rounds, Meetings and Courses .................................................................... 8 University of Manitoba Cardiology Teaching Faculty ................................ 12 Cardiology RPC Terms of Reference .......................................................... 13 Career and Stress Reduction Counselling/ Harassment and Intimidation ... 15 Resident Safety Policy for Adult Cardiology Residents………………….. 18 Assessment and Evaluation of Adult Cardiology Residents……………… 21 Remediation and Probation Process for Adult Cardiology Residents…….. 23 Industry Relations and Quality Assurance/ Improvement ........................... 26 Chief Cardiology Resident Duties………………………………………… 27 Educational Aims and Objectives (Rotation specific) ................................. Ambulatory Care.............................................................................. 33 Cardiac Catheterization .................................................................... 36 Coronary Care Unit (CCU) .............................................................. 41 Clinical Training Unit (CTU) .......................................................... 47 Cardiac Consultation Service ........................................................... 51 Echocardiography ............................................................................ 54 Advanced Multimodality Cardiac Imaging: Cardiac CT/MRI ....... 62 Nuclear Cardiology/ Stress Testing ................................................. 66 Research ........................................................................................... 72 Electrophysiology (ECG and Ambulatory ECG Monitoring) ......... 77 Adult Congenital Cardiology ........................................................... 86 Heart Failure/Transplant ................................................................. 91 Log Sheets .............................................................................................. 98 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 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 6 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 10 Grand Rounds 0800-0900 Medical Expert/ Communicator/ Collaborator 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 7 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. 8 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. 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: Each trainee is allowed up to 5 consecutive days of conference leave (including travel) per academic year. The Section of Cardiology will fund each Cardiology resident to attend one conference per year and a resident may choose to do up to two electives during the three year program at another institution. The section will fund up to $2000.00 per year for either a conference or one elective rotation. Funding includes economy airfare, hotel, conference registration, and a daily meal allowance ($35.00) up to a maximum of $2000. All conference and course requests must be submitted, in writing (or email), to the Program Director 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, and must include name of institution, supervisor at institution, date of departure, and date of return. 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). 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. 9 Cardiology conference dates for 2013/2014 Canadian Cardiovascular Conference (CCC) Montreal, Canada, October 17-20, 2013 American Heart Association (AHA) Dallas TX, US, November 16-20, 2013 American College of Cardiology (ACC) Washington DC, US, TBA 2014 WECREEP 2014 TBA 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: The program will fund one exam ‘prep course’ in the third year of training. Funding will include course fees, economy airfare and accommodation – for a maximum of 3 nights. Requests for prep courses must be made at least 2 months in advance of travel. The request must be in writing (or email) to the Program Director and must include the name of the course, where the course will be held, date of departure and date of return. For reimbursement, you must submit original receipts including flight boarding passes or you will not be reimbursed. Call Schedules and Responsibilities: 2013-2014 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. 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. 10 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. 11 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. F. Hussain (Interim-Cath Lab Director/Assistant Program Director of Adult Cardiology, resident education for ambulatory care), Dr J. Ducas, Dr. M. Kass (postgraduate coordinator for residents rotation through Cardiology), Dr. K. Minhas (resident education for CCU), Dr. Minh Vo (resident education for cath), Dr. Amir Rivandi, Dr. Gurpreet Parmar 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 A. Miller (ACF cardiology) Dr D. Mymin (ACF, lipid clinic, consult service) Dr S. Cleghorn (Community cardiology, ward) 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. 12 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. Tony Wassef) • Assistant Chief resident (Dr. Mehrdad Golian) • 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: 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. 13 that the Training Program has adequate facilities, personnel and support services to function adequately. that the resources for patient care and for medical education within the three teaching facilities are being effectively utilized by the Teaching Program. 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: residents are effectively and fairly evaluated mid way through and at the completion of each of the rotations. 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. residents have a clearly defined mechanism for appealing evaluations which they feel to be inaccurate or unfair. 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. 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. 14 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 15 Barakat (Associate Dean of Professionalism; Department of Psychiatry) within the Core Academic 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 16 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. 17 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 18 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. 19 • Residents must have current educational licenses from the College of Physicians and 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 20 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 21 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. 22 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. 23 b) The program may decide to proceed with Probation as outline in the section on Probation (see below). 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 24 process outlined above will be followed. 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. 25 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. 26 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 27 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. 28 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 29 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 30 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 31 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. 32 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. Farrukh Hussain 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 Collaborator: 33 • 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 referrals will be reviewed with the attending Cardiologist 34 • 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 35 CanMEDS 2005 Objectives Section of Cardiology, University of Manitoba Rotation: Cardiac Catheterization Education Director: Dr. Minh Vo Introduction: Four periods are spent in the cardiac catheterization laboratory during the 3 year training program in Adult Cardiology at the University of Manitoba. The fourth rotation is not mandatory and could be replaced with an advanced cardiac imaging rotation (Cardiac CT and CMR) with approval from the program director. The cath rotation is performed primarily 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, and myocardial biopsies. There is one lab at Health Sciences Centre, which operates 3 days per week, performing outpatient diagnostic studies and intervention. The first cath lab rotation is scheduled at Health Sciences Centre and thereafter, all subsequent rotations will be at St. Boniface Hospital. The residents are exposed to coronary artery disease, both chronic and acute coronary syndromes, and all forms of valvular heart disease. 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. The extra time in the Cath Lab is strongly encouraged if the resident is contemplating a career in Interventional Cardiology. There are scheduled cath related teaching sessions throughout the academic year. Residents are provided with 1hr hemodynamics teaching rounds every 2 months and there are monthly cath potpourri rounds, which consist of a wide variety of interventional Cardiology cases. On an annual basis, the Cardiology residents will also receive a lecture on radiation safety. CanMED 2005 Roles 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 36 • • • • • • • 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 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 • Identify social rehabilitative and dietetic concerns with patients and consult appropriate allied health care 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 37 • 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, webbased 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 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 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. 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 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 of catheterization dyes including indications, 38 • 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 • During each cath rotation, the resident is expected to prepare one brief (15-20 minute) presentation to be presented at Catheterization rounds (Wednesdays 4 p.m.) on a interventional cardiology related topics 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 39 References: • Braunwald, E., Zipes D.P., Libby, P. Heart Disease 6th Edition • Baim, J. Grossman's Cardiac Catherization, 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 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 40 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 41 o Tachyarrhythmias o Conduction defects and bradyarrhythmias 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 42 • 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) • 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 43 • Contribute effectively to other interdisciplinary team activities including daily CCU rounds and family conferences 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. 44 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 • • • • 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 45 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 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 46 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: 47 o Post infarction angina, infarct extension, and pericarditis 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 48 • Utilize resources effectively to balance patient care, learning needs, and outside activities • 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 49 • 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) • 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 50 CanMEDS 2005 Objectives Section of Cardiology, University of Manitoba Rotation: Cardiac Consultation Service Education Director: Dr. Anita Soni Introduction: Two periods are spent on the cardiology consult service, one in second year and the other in third year. There are 1-3 junior residents on the rotation, mainly from internal medicine, and anesthesia. This rotation will take place at St Boniface Hospital. This is a large teaching hospital with numerous specialty and subspecialty services. Consults come from the emergency department, surgical and general medicine wards (including vascular surgery) as well as family medicine. CanMED 2005 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 Communicator: 1. 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 2. 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 51 3. 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 4. Present on a regular basis to the Attending Consulting Cardiologist 5. Present interesting consultation cases at Cardiology Grand Rounds 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 Manager: • Use scarce resources appropriately • Organize schedule to see 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 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 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 non-life threatening non-cardiac surgery • Contribute knowledge independently learned to the consultative process Professional: • Deliver the highest quality of care with integrity, honesty, and compassion • Exhibit appropriate personal and interpersonal behavior, respecting the rights and dignity of patients and their families and the expertise and opinion of other health care workers 52 • Practice medicine in an ethically responsible manner understanding the professional, legal, and ethical bounds to which physicians are bound Duties: • The normal working hours are Monday to Friday, 0800 – 1700 • The resident is excused from the service for cardiology core curriculum lectures and all other mandatory rounds and lectures It is expected that the consultations will be performed on the same day that they are received Consults that are received after 5:00PM will be performed by the resident on call and signed over to the consult service the following morning It is anticipated that all consults be reviewed with the Attending Cardiologist on the day of the consult The resident is anticipated to write a consultation note which is to be reviewed with the Attending Cardiologist Subsequent follow-up of investigations as well as daily progress notes in the chart are among the duties of the resident The resident is expected to coordinate both invasive and non-invasive investigations of noncardiac patients, obtain these results and communicate with the consulting service to provide comprehensive care for patients • • • • • • Assessment: • • Daily feedback Completion of on-line web evaluation at the end of each rotation 53 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. 54 • 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 55 Scholar • Facilitate learning of patients, junior residents, medical students and other health professionals • Develop, implement and monitor a personal continuing education strategy • 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 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 56 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 • Remainder of time to be spent on scanning with the sonographers 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 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: 57 • 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 > 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. • 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. 58 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) 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 59 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 (ineratrial, interventricular, intergreatvessel), describe the anatomy of each and the echo-Doppler method of determining shunt ratio. 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 folloowng 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 mechnical, 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 60 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.) 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 61 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 62 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. 63 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 64 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 65 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. 66 • 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 • 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 67 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 • 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. • 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: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY A M STRESS LAB STRESS LAB STRESS LAB STRESS LAB STRESS LAB P M INTERPRET SCANS INTERPRET SCANS INTERPRET SCANS INTERPRET SCANS INTERPRET SCANS P M STRESS LAB DIDACTIC SEMINAR* STRESS LAB STRESS LAB 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 68 • • • • • • 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 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 69 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: 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/ 70 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 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 71 CanMEDS 2005 Objectives Section of Cardiology, University of Manitoba 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 2013 Introduction to course/ Dr. Jassal and Dr. Ravandi Oct 2013 Databases and Outcomes Research (DS Jassal, R Arora, S Zieroth, F Hussain, C Seifer, R Manji, J Tam, Dr. Ravandi) Nov 2013 CCS abstract ideas/ Statistics by Dr. Leigh Ann Shafer Dec 2013 Holidays Jan 2014 Ethics (Pat Murphy) Feb 2014 Participating in clinical trials (J Ducas) Mar 2014 CCS abstract review Apr 2014 CCS abstract submission and discussion of Cardiac Sciences Research Day, Internal Medicine Research Day and Faculty of Medicine Resident Research Day May 2014 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. 72 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. 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 73 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 Attendance at Journal Club Present research work results at Resident Research Day 74 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. Assessment: • • Regular feedback Assessment of research project at the annual resident research day 75 • Completion of on-line web evaluation at the end of each rotation 76 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. 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. 77 • • • • • 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 • Review the triage system for patients undergoing device implantation and EP studies and prioritize based on clinical details 78 • 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 Defibrillators: Tuesday: 0730-1600 EP studies/ablations: Monday, Wednesday, Thursday: 0730-1600 79 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) Duty: A minimum of 1 half day each in EP and device labs per week Expectation: Describe the cellular mechanisms of arrhythmias 80 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 Society/Canadian Heart Rhythm Society Joint Position Paper. Can J Cardiol 27 (2011) 232245. 81 4. 5. 6. 7. 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. 82 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. 8. For the each of the ICD interrogations (appendix), answer the following: 83 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. 7. As a pacemaker approaches RRT, describe the trend or changes in the following: 84 i. ii. iii. iv. battery voltage battery impedence magnet response 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. 85 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 D-transposition of the great arteries 86 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). 4. Diagnosis of adults with simple congenital heart disease including skills in 87 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 88 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 89 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 90 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 91 Medical Expert: Ambulatory Clinic Experience 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: 92 a) acute decompensated heart failure 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. 93 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. 94 Appendix A: Weekly schedule for cardiology residents during the HF/Transplant rotation Monday Tuesday Wednesday Thursday 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 HF Follow-up Clinic Friday Cardiopulmonary stress tests HF Follow-up Clinic Notes Opportunities to observe organ procurement, VAD surgery occur on an ad-hoc basis 1) What are the indications for heart tx? 2) What are the contraindications? 95 3) What is the median survival post transplant? Median survival conditional on survival past the first year? 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? 96 23) Three side effects of sirolimus? Of MMF? 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? 97 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 98 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 99 LOG SHEET - NUCLEAR CARDIOLOGY EXERCISE THALLIUM PERIOD 1 PERIOD 2 PERSANTINE THALLIUM PERIOD 1 PERIOD 2 EXERCISE MUGA PERIOD 1 PERIOD 2 100 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 101 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 102 LOG SHEET - ELECTROPHYSIOLOGY LABORATORY CONSULTED STUDIED ANALYZED VT HBE SVT MAPPING - WPW 103 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 104 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 105 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 106 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 ______ ______ ______ ______ 107 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 ______ ______ ______ 108 Objectives of Training in the Subspecialty of Adult Cardiology 2010 VERSION 1.0 This document applies to those who begin training on or after July 1st, 2010. (Please see also the “Policies and Procedures.”) 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 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 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. Pharmacology1 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. 5.2.3. Nuclear Cardiology Imaging 5.2.3.1. 5.2.4. Transesophageal Rest and stress perfusion imaging and radionuclide angiography Cardiac Catheterization 5.2.4.1. Left heart catheterization and hemodynamics 5.2.4.2. Angiography and coronary arteriography © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 6 of 14 OBJECTIVES OF TRAINING IN ADULT CARDIOLOGY (2010) 5.2.5. Other Cardiac Imaging Modalities 5.2.5.1. 5.2.6. 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. Echocardiography (M-mode, 2D, and Doppler) 5.3.1.1. 5.3.2. Stress Other Cardiac Imaging Modalities 5.3.2.1. Positron Emission Tomography (PET) 5.3.2.2. Computed Tomography (CT) 5.3.2.3. Magnetic Resonance Imaging (MRI) 5.3.3. Therapeutic Procedures 5.3.3.1. 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 © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 14 of 14 Subspecialty Training Requirements in Adult Cardiology 2010 VERSION 1.0 These training requirements apply to those who begin training on or after July 1st, 2010. 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. Some learning experiences can occur simultaneously and/or longitudinally (e.g. electrocardiogram (ECG) interpretation, ambulatory clinics). 1. Fifteen (15) blocks of clinical residency: 1.1. Four (4) blocks of acute cardiac care/CCU 1.2. Six (6) blocks of clinical cardiology (including cardiology CTU and consultations) 1.3. Three (3) blocks of ambulatory cardiology clinics 1.4. Two (2) blocks of pediatric cardiology (which may include adult congenital heart disease) 2. Fifteen (15) blocks of laboratory based residency: 2.1. Four (4) blocks of cardiac catheterization (may include one block of cardiac CT/MRI) 2.2. Six (6) blocks of echocardiography 2.3. Three (3) blocks of electrophysiology/pacemaker cardiology (to include ECG and ambulatory ECG monitoring) 2.4. Two (2) blocks of nuclear cardiology (to include exercise stress testing) © 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 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 SUBSPECIALTY TRAINING REQUIREMENTS IN ADULT CARDIOLOGY (2010) Research 3. Minimum two (2) blocks dedicated to a research project, with completion acceptable to the Program Director Electives 4. Four (4) blocks of electives acceptable to the Program Director, which may be used for further research training NOTES: 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 - 2010 © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 2 of 2 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 GUIDELINES FOR ASSESSMENT OF HISTORY-TAKING AND PHYSICAL EXAMINATION SKILLS IN ADULT CARDIOLOGY TRAINING PROGRAMS Introduction: PL Requirements and process: E Effective 2005 the format of the Royal College examination in Adult Cardiology will change to meet the guidelines set by the Evaluation Committee. The new examination format will eliminate the traditional “long” and “short” case clinical encounters, which will be replaced by a new OSCE examination containing multiple stations. These stations will include structured orals (“case scenarios”) and standardized patients. Trainees will be required to perform a satisfactory observed history and physical examination during a patient encounter in the final year of their training. Certification by the Program Director that this has been accomplished is necessary in order for the trainee to be eligible for the examination. This certification forms part of the completed trainee FITER and will be forwarded to the College as part of the FITER document. The assessment is to be performed during the final year of training. Trainees who fail to demonstrate a satisfactory level of performance must repeat the procedure until this has been attained. 2. The assessment is to be conducted by a faculty member selected by the Program Director. The Program Director must not perform the assessment personally. Where feasible, Program Directors are encouraged to employ visiting cardiology faculty from other universities/programs for this purpose. 3. The patient chosen should be clinically stable, able to give informed consent and be reasonably representative of a common cardiovascular disease process. The Program Director should either select or approve the patient to be used for the assessment process. 4. The trainee will be allocated up to 45 minutes to obtain the history and perform a physical examination. A further 15-30 minutes will be devoted to case presentation by the trainee, synthesis, analysis and development of initial management plan. The examiner will observe and evaluate the skills demonstrated using the standardized scoring sheet provided. 5. At the completion of the assessment the trainee will be asked to review and sign the evaluation form. The Program Director will retain a copy for the trainee’s file and forward the complete original along with the remainder of the completed FITER to the Royal College. SA M 1. © 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]. 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 IN-TRAINING ASSESSMENT OF HISTORY-TAKING and PHYSICAL EXAMINATION SKILLS ADULT CARDIOLOGY TRAINEE’S NAME: PROGRAM/UNIVERSITY: Strengths: Weaknesses: meets expectations exceeds expectations SA M COMMENTS: below expectations PL OVERALL PERFORMANCE: E This trainee has completed a standardized observed assessment of history-taking and physical examination skills, including a synthesis and analysis of the patient’s clinical problem(s), during the last 12 months. The following is a summary of the trainee’s performance with comments on strengths and weaknesses compiled by the Program Director. Date Name of Program Director Signature Date Name of Trainee Signature © 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]. The patient’s personal, social and risk factor profile • The chief (presenting) complaint • A thorough description of the chief complaint • Inquiry about symptoms associated with the chief complaint • Inquiry about other cardiovascular symptoms (chest pain/discomfort, dyspnea, palpitations, fatigue, dizziness/syncope, claudication, edema) • Past cardiovascular history (including rheumatic fever, MI, heart failure and cardiovascular surgery) • Relevant other past medical history • Relevant family history of cardiovascular problems/disease • Relevant review of other organ systems • Medication history including allergies • Overall history-taking skills SA M PL E • 405 Exceeds expectations The trainee obtained an appropriate history which included: Meets expectations HISTORY-TAKING *Fails to meet expectations Identification number: _________________________________________ * Explanatory comments required: © 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]. Overall general assessment • Pulse (rate/rhythm/character), BP (both arms, appropriately sized cuff) • Carotid & peripheral pulses, auscultation for bruits • JVP height, waveform, hepato-jugular reflux • Inspection and palpation of the precordium (apex beat, parasternal lift, thrills, abnormal impulses) • Evaluation of first and second heart sounds (intensity, splitting) and any added sounds (S3 or S4, clicks, opening sounds etc) • Evaluation of systolic and diastolic murmurs (location, shape, intensity, radiation, pitch) • Dynamic auscultation (positional change, respiration, Valsalva strain, exercise, isometrics - as appropriate) • Palpation, percussion and auscultation of chest • Abdominal examination for bruits, hepato-splenomegaly, aneurysm, ascites • Examination of the extremities for cyanosis, clubbing, vascular insufficiency, edema • Overall physical examination skills SA M PL E • 405 Exceeds expectations The trainee performed an appropriate physical examination which included: Meets expectations PHYSICAL EXAMINATION *Fails to meet expectations Identification number: _________________________________________ * Explanatory comments required: © 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]. An appropriately lucid, succinct and organized summary of the case • An assessment of the patient’s functional capacity (NYHA, CCS) • Accurate interpretation of physical examination findings • Appropriate emphasis on important positive and negative findings • An appropriately detailed and prioritized cardiovascular differential diagnosis • An initial plan for patient management and follow-up • Overall presentation, synthesis and analysis skills PL E • Exceeds expectations The trainee demonstrated the following: 405 Meets expectations CASE PRESENTATION, SYNTHESIS and ANALYSIS *Fails to meet expectations Identification number: _________________________________________ SA M * Explanatory comments required: © 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]. 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. Satisfactory** Below Expectations E Overall Performance: Weaknesses: SA M PL Strengths: (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) 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 in Cardiology. YES NO The following sources of information were used for this evaluation: written exams clinical observations feedback from health care professionals STACER orals 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. © 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 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. © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 2 of 2 Identification number: _________________________________________ 405 – 2010 ADULT CARDIOLOGY FITER (2010) (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. © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 1 of 9 Identification number: _________________________________________ 405 – 2010 ADULT CARDIOLOGY FITER (2010) 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 ¾ Electrocardiography ¾ Exercise (stress) testing ¾ Ambulatory monitors (Holter and loop recorders) b. Echocardiography (M-mode, 2D, and Doppler) ¾ c. Transthoracic echocardiography (TTE) Cardiac Catheterization ¾ Right heart catheterization and hemodynamics d. Therapeutic Procedures ¾ Temporary transvenous pacemakers ¾ DC cardioversion and defibrillation ¾ 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 f. ¾ Permanent pacemakers and implanted devices ¾ Invasive electrophysiology studies Echocardiography (M-mode, 2D, and Doppler) ¾ Transesophageal © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 2 of 9 Identification number: _________________________________________ 405 – 2010 ADULT CARDIOLOGY FITER (2010) g. Nuclear Cardiology Imaging ¾ Rest and stress angiography perfusion imaging & radionuclide h. Cardiac Catheterization ¾ Left heart catheterization and hemodynamics ¾ Angiography and coronary arteriography Other Cardiac Imaging Modalities i. ¾ Chest X-ray Therapeutic Procedures j. ¾ 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. Echocardiography (M-mode, 2D, and Doppler) ¾ l. Stress Other Cardiac Imaging Modalities ¾ PET, CT and MRI m. Therapeutic Procedures ¾ 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. © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 3 of 9 Identification number: _________________________________________ 405 – 2010 ADULT CARDIOLOGY FITER (2010) EXPECTATIONS * Consistently exceeds Sometimes exceeds Generally meets * Inconsistently meets * Rarely meets A rationale must be provided to support ratings with asterisks. 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. © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 4 of 9 Identification number: _________________________________________ 405 – 2010 ADULT CARDIOLOGY FITER (2010) EXPECTATIONS * Consistently exceeds Sometimes exceeds Generally meets * Inconsistently meets * Rarely meets A rationale must be provided to support ratings with asterisks. 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. © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 5 of 9 Identification number: _________________________________________ 405 – 2010 ADULT CARDIOLOGY FITER (2010) 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. © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 6 of 9 Identification number: _________________________________________ 405 – 2010 ADULT CARDIOLOGY FITER (2010) 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. © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 7 of 9 Identification number: _________________________________________ 405 – 2010 ADULT CARDIOLOGY FITER (2010) 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. © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 8 of 9 Identification number: _________________________________________ 405 – 2010 ADULT CARDIOLOGY FITER (2010) EXPECTATIONS * Consistently exceeds Sometimes exceeds Generally meets * Inconsistently meets * Rarely meets A rationale must be provided to support ratings with asterisks. 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. © 2010 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 9 of 9 Policy Number: Department of Internal Medicine Section: Education Policy and Procedure Manual Effective Date: Sec 11 - 01 Page: 1 of 1 Oct. 29, 2002 Resident Travel Guidelines and Travel Policy Review/Revision Dates: May 19, 2004; July 2006; June 18, 2008; May 9, 2012 Rev. 1; The Department of Internal Medicine encourages residents to attend a conference in Internal Medicine or its subspecialties. Funding is derived from department overhead. Resident Travel Guidelines (effective July 1, 2012) 1. Residents may request financial assistance for travel to attend a meeting or a conference during the academic year. Funding will be $800 per annum. If this award is not used, $800 per year may be carried over to the second year. 2. If a resident is presenting a paper or poster at a conference, a copy of the letter of confirmation or invitation received from the society or organization must be submitted. 3. Residents presenting at national and international conferences may apply for up to $2000 once per year for an additional meeting. Total funding of $2,800 will be provided for two meetings. 4. Residents must apply in writing using the “Resident’s Request to Travel” form prior to travel. These forms are available from the subspecialty Education Coordinators. 5. The ‘Resident’s Request to Travel’ form must be completed, approved and signed by the Program and the Subspecialty Program Director. The Program Director will evaluate all requests for travel forms based upon the potential benefits to the resident and the department. 6. Completed applications for resident travel should be returned to the Assistant Business Manager, room GC421 – Department of Internal Medicine. 7. The Assistant Business Manager will provide confirmation of the amount of funding available to the Education Coordinator and resident. 8. There are no travel advances. Resident Travel Policy 1. Allowable expenses include: • • • • • registration fees for convention/meeting reimbursement for economy return airfare hotels (room and tax charges only) ground transportation (taxis) internet Policy Title: Resident Travel Guidelines and Travel Policy • Policy Number: Sec. 11 - 01 Date Revised: May 9, 2012 Rev. 1 Page: 2 of 2 Reasonable expenses for meals may be reimbursed by: a) Actual costs – claims for meals and incidentals must be listed separately on the expense claim including taxes and gratuity and supported by detailed receipts; or b) Per diem allowance – instead of being reimbursed for actual costs, a daily allowance may be allowed. 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, in conference registration fees, in the event of a partial day’s travel, etc. • The maximum per diem allowance for meals when travelling: - Within Canada $50.00 per day (CDN) Partial per diem Breakfast - $10.00, Lunch - $15.00, Supper - $25.00 - Outside Canada: $60.00 per day (CDN) Partial per diem Breakfast - $15.00, Lunch - $15.00, Supper - $30.00 2. Non-allowable expenses include: • automobile rental • entertainment costs • health club expenses • video rentals • telephone calls 3. The Department of Internal Medicine will not reimburse expenses unless original receipts are provided. Original proof of payment (e.g. credit card statement, hotel statement, airline boarding passes) must be included. Claims for expense reimbursement without proper supporting documentation will not be processed. 4. Original receipts must be attached to the ‘Resident Travel Expense’ form completed by the Education Coordinator who is responsible for submitting the completed information to the Assistant Manager, room GC421 – Department of Internal Medicine. 5. The Assistant Business Manager will review documentation and submit for payment within seven (7) business days. 6. Reimbursement cheques, once available, will be sent to the respective Education Coordinator for distribution. Department of Internal Medicine RESIDENT’S REQUEST TO TRAVEL FORM RESIDENT’s NAME (please print) _____________________________________________________ Requests a leave of absence to attend the following meeting: DETAILS OF REQUEST Conference: Dates: Place: Specify purpose of travel or reason for attendance * Presenting Paper/Poster Academic interest Other _______________________ * Append letter of invitation and/or abstract At this time, the resident shall be on the ____________________rotation at HSC / SBGH / Grace ESTIMATED EXPENSES Registration Fee Airfare $ Hotel $ (Actual Costs or Per Diem Rate) Meals $ Other $ TOTAL $ Date: RESIDENT’s SIGNATURE: Authorization: The above plans have been approved by the resident’s Program Director and Program Director on whose subspecialty the resident will be rotating at the time. ___________________________________ ___________________________________ Internal Medicine Program Director Subspecialty Program Director INTERNAL MEDICINE OFFICE USE ONLY Amount of Funding Approved: ____________________________________________________________ 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: Approved at Dean’s Council – 5 June 2012 Approved at Faculty Executive Council – 12 June 2012 Page 1 of 14 Faculty of Medicine PGME Resident Safety Policy . 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. 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. Approved at Dean’s Council – 5 June 2012 Approved at Faculty Executive Council – 12 June 2012 Page 2 of 14 Faculty of Medicine PGME Resident Safety Policy . 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 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 PGME 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 Approved at Dean’s Council – 5 June 2012 Approved at Faculty Executive Council – 12 June 2012 Page 4 of 14 Faculty of Medicine PGME Resident Safety Policy . alarms at their health care facilities and adjacent parking buildings. 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 Approved at Dean’s Council – 5 June 2012 Approved at Faculty Executive Council – 12 June 2012 Page 5 of 14 Faculty of Medicine PGME Resident Safety Policy . follow radiation safety policies and minimize their exposure according to current guidelines. 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: Approved at Dean’s Council – 5 June 2012 Approved at Faculty Executive Council – 12 June 2012 Page 6 of 14 Faculty of Medicine PGME Resident Safety Policy . a. b. c. d. e. f. Residency Program Director Associate Dean for PGME Associate Dean for Student Affairs Faculty Student Mental Health Service Doctors Manitoba Physician at Risk Help Line 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. Approved at Dean’s Council – 5 June 2012 Approved at Faculty Executive Council – 12 June 2012 Page 7 of 14 Faculty of Medicine PGME Resident Safety Policy . 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 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 Approved at Dean’s Council – 5 June 2012 Approved at Faculty Executive Council – 12 June 2012 Page 8 of 14 Faculty of Medicine PGME Resident Safety Policy . 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. 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 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 PGME Resident Safety Policy . 4. 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 PGME Resident Safety Policy . 5. 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. 6. 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 PGME 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 PGME 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 Approved at Dean’s Council – 5 June 2012 Approved at Faculty Executive Council – 12 June 2012 Page 13 of 14 Faculty of Medicine PGME Resident Safety Policy . considered if walking outdoors at night in the hospital areas. 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
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