Continuity Clinic Rotation

Fellows train at Louis Stokes Cleveland VA Medical Center clinics their first two years and University Hospitals Cleveland Medical Center their third year. This enhances the diversity of exposure to patients, mentors and systems and enriches the learning experience.

Longitudinal Health Care Training

The outpatient clinics provide a unique opportunity for understanding longitudinal health care issues relevant to an individual patient as well as larger system issues. The clinics are well-suited for fellows to participate and understand prevention, risk factor management and early detection of disease; management ranging from simple to complex chronic health maintenance and support for those with advanced disease. This is feasible due to fellows' participation in the continuity care clinics where they are expected to follow their patients throughout their training period.

Continuity Clinic Rotation Goals and Objectives

The rotation in the clinics is meant to enable fellows to achieve the knowledge, skills and attitudes of competent cardiologists in the care of patients with chronic cardiovascular illnesses, including:

• Management of outpatient consultative cardiology
• Management of risk factors for cardiovascular diseases
• Preventive aspects of cardiovascular conditions

Fellows are expected to gain proficiency in the diagnosis and management of cardiac conditions and triage of patients to appropriate patterns of care (e.g., inpatient vs. outpatient). Learning occurs through hands-on, supervised clinical experiences, bedside teaching and focused discussions with faculty. Attending physicians are expected to reinforce the understanding of the etiology, pathogenesis, clinical presentation and natural history of cardiovascular diseases relevant to patients in clinic.

The rotation should enhance fellows' understanding of the pathogenesis and management of cardiac conditions and risk factors. Trainees are expected to develop their skills in the following areas:

• Clinical problem solving
• Communication
• Cultural sensitivity
• Diagnosis
• Interviewing
• Navigating system issues impacting outpatient care
• Therapy

Fellows will play an integral role in the management of patients and the coordination of care among other specialists as needed. All fellows are expected to contribute to clinics by reading and applying the appropriate literature; responsibilities are based in part on their seniority. Senior fellows are expected to demonstrate increased clinical independence and junior fellows will require more supervision with an attending seeing each of their patients. The number of patients will vary according to PGY level, but will not exceed eight.

Fellows are expected to be intimately involved in patient care and be familiar with the results of diagnostic and therapeutic procedures; fellows are expected to review the actual source data rather than relying on reports of diagnostic/therapeutic imaging studies.

Appropriate utilization of the health system resources is particularly important. Fellows are expected to be cognizant of the impact of available resources on clinical decision-making. Fellows are expected, when feasible, to review the charts of scheduled patients prior to clinic in order to facilitate timely management of patients in clinic. Preparation in this manner will reduce the likelihood of missing relevant information during outpatient clinic. Fellows are expected to fully participate in decisions regarding the following:

• Additional testing
• Addressing lifestyle changes
• Care
• Drug therapy
• Following up on decisions made
• Providing access to educational resources

Fellows are expected to communicate effectively with house staff, nursing staff, referring physicians, cardiologists and other members of the health care team.

Practice-Based ACGME Competencies in Continuity Clinic Rotation

Thus, fellows are expected to progress in the six Accreditation Council for Graduate Medical Education (ACGME) competencies. Clinics are particularly well-suited for practice-based learning and improvement and understanding on a longitudinal basis. In conjunction with attending staff, fellows are expected to choose one relevant, focused area of clinic function and endeavor to evaluate and/or improve the overall quality in that area.

Principle Teaching Methods

Direct supervision of patient care: An attending physician provides supervision to all fellows via direct patient care.

Case-based learning: Attending physicians are expected to provide focused teaching during fellows' presentations in addition to discussing routine patient management. Fellows are expected to demonstrate their decision-making skills commensurate with their experience and knowledge. The expectation is that a fellow's clinical independence and learning will progress during the training period.

Clinical Teaching Methods

Patient characteristics: The mix of patients is typical for a clinic in a tertiary hospital and includes patients with the following conditions:

• Adult congenital heart diseases
• Arrhythmias
• Chronic systolic and diastolic heart failure
• Consultative evaluations for peri-op management
• Coronary artery disease
• Dyslipidemia
• Hypertensive vascular disease
• Peripartum management
• Peripheral vascular diseases
• Pre- and post-chemotherapy
• Pulmonary hypertension
• Valvular heart disease

Fellows will have the opportunity to interact with subspecialty attendings with expertise in electrophysiology, heart failure and interventional cardiology in the outpatient clinics.

Principal educational material used: Fellows have 24-hour access to the Core Library located in the hospital. Computer access to literature searching, online journals, UpToDate and textbooks is available on all wards. Fellows are expected to be proficient in obtaining requisite information from standard textbooks and current medical literature.

Current therapeutics should be guided by appropriate medical literature with particular weight given to clinical guidelines and consensus statements issued by the American College of Cardiology, the American Heart Association and similar professional bodies.

Objectives by Post-Graduate Year

Fellows are responsible for all patients assigned to their clinic and assume full responsibility for the evaluation and management of all the patients seen in the clinic. With the assistance of an attending, they are responsible for formulating a diagnostic and therapeutic plan for all patients seen.

In order to ensure optimal patient care, fellows are provided with 24-hour access to their attending physician and consultants. They have nurse practitioners, advanced nurse practitioners, physician assistants and other extenders to assist in providing optimal care and follow-up of patients. Attendings and surgical specialties are always in the hospital and available for emergent consultation. An attending physician is immediately available through paging. Attending physicians must document their involvement in the evaluation and management of patients.

First-year fellows are expected to discuss every patient they see in clinic with a supervising attending. As they progress, they are expected to master the subject content necessary to care for patients with cardiovascular diseases. Senior fellows will develop maturity and sophistication of clinical judgment. This is demonstrated by their ability to understand the nuances of an individual patient's health, particularly when multiple active disease processes are present.

Senior fellows are expected to demonstrate their experience by tailoring generally recommended therapy to individual patients. They are expected to be aware of leading-edge and experimental therapies that may be utilized for an individual patient. In addition, they are expected to take on a prominent role in being advocates for their patients with complex issues when collaborating care across multiple disciplines. In clinic, they are expected to participate in guiding education and patient care with medical students.

For More Information

For more information on the Continuity Clinic Rotation, please contact:

Ellen Sabik, MD
Ellen.Sabik@UHhospitals.org