Ambulatory Clinic Curriculum
Dartmouth-Hitchcock Cardiology Fellowship
2008-2009
I. Overview
The expeditious and effective management of cardiovascular conditions in the ambulatory setting is a basic skill to be attained by all trainees. This environment incorporates all of the fundamental components of consultative practice with a significant element of primary cardiac care. The cardiology fellow needs to gain competence in the evaluation, triage and follow-up of a wide variety of cardiovascular conditions. Furthermore, this arena of care is well suited to understanding and applying preventative measures and noninvasive laboratory assessment.
Communication skills are key to patient and family education as well as the interrelationship of the specialist and generalist physician. Fellows will gain confidence in their ability to cogently identify and review the active cardiovascular issues germane to each patient. This information will be assembled in the framework of formal consultation or referral summaries, supplemented as necessary, by direct communications with referring physicians. Similarly, the fellow will complement office interaction with patients and families by phone or mail contact as conditions warrant. The ambulatory clinic structure and supervision will foster these crucial aspects of high quality care.
The fellow's activities in the clinic, both at DHMC and the VA, will be directly supervised by an attending cardiologist. Fellows will review new referrals and continuing care contacts with the attending present during the clinic sessions. The attending is expected to interview and examine the patient to identify the key components of the history, physical examination and plan of management as outlined by the fellow. Furthermore, the attending physician will dictate or write a note identifying the essential features of the assessment and plan. This staff notation, which is likely to vary in scope according to the complexity of the patient-related issues, should be proximate to the fellow's written or dictated summary of the clinic encounter in the medical record.
II. Medical Care and Medical Knowledge
The major educational objectives are similar to those outlined in the Consultation Rotation Curriculum. In addition to these goals, however, the fellows are strongly encouraged to review the following materials:
- ACC/SAP 6. Chapter 6: Epidemiology, Primary Prevention, and Management of Coronary Artery Disease
- Chapter 7: Risk Factor Management
- Chapter 10: Chronic Coronary Artery Disease
- Chapter 16: Hypertension
III. Professionalism
The ambulatory clinics are held in the afternoons as outlined in the schedule which accompanies this overview. The VA clinics will be on Tuesday afternoon, and the clinics at DHMC will occur on Wednesday and Friday afternoon. Unless otherwise indicated, clinic hours start at 1:30. Patients scheduled to see fellows will come from a variety of sources: referring physicians (both internal and external to DHMC), self-referrals, consultation service, in-patient follow-up requests, the emergency room or PRN clinic. The scheduling secretaries will make every effort to balance the volume of new patient assessments and follow-up care. The expectation is that fellows will require one hour to see a new patient and 30 minutes for a follow-up. It is not unreasonable to expect that more senior fellows may reduce follow-up visits to 20 minutes in duration.
The clinic is staffed by seven nurses whose role is to assist with the triage and initial evaluation of the patients. They will obtain vital signs and review the active medication list. It must be appreciated that the clinic nurses are frequently called upon to perform other duties such as electrocardiograms, answering the phone and supporting ambulatory activities such as warfarin tracking. Therefore, fellows are urged to be tolerant of these unpredictable activities. In addition, it is critical for fellows to report promptly to the clinic area when their appointments begin. One of the hallmarks of an efficient practitioner is the ability to balance one's time and demonstrate punctuality.
Transcription of office notes when required will be supported by the secretarial staff assigned to the fellow. Fellows are strongly encouraged to complete their dictations or direct entry CIS notations at the time of the office visit or, at the very least, before the conclusion of the day in which the visit occurred.
IV. Faculty
Fellows assigned to the ambulatory clinic will have a staff cardiologist providing backup for the sessions. The role of the faculty member is to provide direct oversight of the evaluation and management plan developed by the fellow. The faculty staffing the clinic will be expected to see each new patient or consultation, perform a focused history and physical exam and enter an “Add-On” notation in the medical record dovetailed with the fellow entry. As part of the faculty oversight, the fellow will ensure that subsequent decision-making for the patient is reviewed with the staff cardiologist performing the original assessment whenever possible.
V. Performance Evaluation
The faculty member with the most direct observation of the fellow during their ambulatory clinic time will be responsible for providing a performance assessment every six months. This evaluation will be tabulated on E*Value and discussed as part of the fellow’s twice yearly review by the program director.
EC 6/06
EC 7/07
