Author + information
- ∗Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- †Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
- ↵∗Reprint requests and correspondence:
Dr. Ankur Kalra, Hennepin County Medical Center, 701 Park Avenue South, Cardiology O5, Minneapolis, Minnesota 55415.
Rounds are an integral part of a physician’s life. Efficient conduct of rounds on the inpatient service is an important skill that trainees must harness as they transition from being physicians-in-training to becoming independent practitioners. Rounds are not only critical for learning the science and art of medicine, they are also crucial for imbibing quintessential styles of interacting with patients and their families, as well as colleagues, advanced practice providers, and other allied health care professionals. For fellows-in-training, conducting daily rounds while attending the inpatient cardiology consultation service is an exercise that aids in the development of clinical skills of triaging consults in accordance with the acuity of illness encountered. In addition, it offers a perfect breeding ground for developing and transitioning into independent cardiovascular consultants.
At Hennepin County Medical Center, a teaching hospital of the University of Minnesota Medical School, traditional rounds are structured on the classic hierarchical teaching model that comprises medical students, residents, fellows, and the attending physician. Fellows-in-training are in charge of “the team”; they delegate new and follow-up consultations to the house staff, who then work with the medical students, with a goal of evaluating all patients before morning attending rounds. As medical students and residents present cases on rounds to the physician attending the ward service, the fellow is responsible for coordinating timely conduct of investigations by formulating management plans with the attending physician and by facilitating throughput in cardiovascular diagnostic laboratories (echocardiography, cardiac catheterization, coronary computed tomography, and nuclear cardiology) through direct communication with colleagues and faculty members providing care in respective areas. In addition, the fellow receives new consultation requisitions throughout the day that are triaged and staffed with the attending physician.
At our cardiovascular disease fellowship program at Hennepin County Medical Center and the Minneapolis Heart Institute at Abbott Northwestern Hospital, the fellows-in-training collaborated with program directors to alter the anatomy of conduct of everyday rounds on the inpatient cardiology consultation service to foster the vital transition from a cardiovascular disease fellow to an independent cardiovascular consultant. The new “Hennepin” model (Figure 1) was developed to nurture the core competencies of the Accreditation Council for Graduate Medical Education (ACGME) (1), and transition to the Next Accreditation System with implementation of the ACGME competency-based developmental outcomes program, the Milestones (2).
The new model delegated the attending physician’s role to the fellow “running” the cardiology consultation service in the afternoon hours (i.e., the fellow took charge of “the team,” staffed new consults with the house staff, provided recommendations to the providers requesting the consult, and engaged in bedside teaching with the house staff and medical students, discussing the physical examination and clinical details pertinent to the case). The attending physician was accessible for additional direction, if the fellow required help and mentoring with the clinical management, depending upon the year of fellowship and the fellow’s skillset and comfort level. In addition, the new model dedicated 15 to 30 min for multidisciplinary rounds on complex cardiovascular post-operative patients that were led by the fellow and included interactions with the cardiothoracic surgeon, nurse, pharmacist, physical therapist, and social worker. The model also allotted 30 min for classroom-style “protected teaching” of cardiovascular disease states of interest by the fellow to the house staff and medical students. The structure and conduct of the morning component of the rounds largely remained identical to the traditional skeleton, but the focus was redirected to bedside teaching of physical examination, pathophysiology, and management by the attending physician. This was reinforced by a selection of cases that were independently staffed by the fellow the day before, thereby enabling all patients to be seen and staffed by the attending physician within 24 h of the initial consultation requisition.
The “Hennepin” model promoted fellow independence with a “safety net” that was pivotal in enriching the following ACGME core competencies:
1. Medical knowledge. The model fortified fellows’ confidence in consultative cardiology skills by being the “first in line” providers and interacting directly with faculty from other subspecialties in medicine. As fellows shared their recommendations with the primary team, they also learned from faculty from other disciplines like pulmonary and critical care medicine and nephrology, engaging in “inter-organ crosstalk” (3). Also, the inculcation of classroom-type teaching into the curriculum was a robust learning experience for the fellow by learning through teaching.
2. Patient care. The model promoted a more “hands-on” experience for the fellow taking new consultations from various in-hospital services. By assuming responsibility as the primary cardiovascular consultant, the fellow felt more accountable for patient care and patient outcomes in the current duty hour-sensitive environment that has led to the disintegration of in-hospital patient course follow-up for the trainees (4).
3. Practice-based learning and improvement. The model also promoted self-learning for the fellow by “being in the trenches” and taking care of patients outside the comfortable shadow of the attending physician. It reinforced clinical decision-making and highlighted areas where the fellow needed improvement in medical knowledge, facilitating the impetus to read and reference the current published data and evidence base for formulating a treatment plan.
4. Systems-based practice. Allotment of dedicated time for multidisciplinary rounds was done in part to introduce systems-based practice in the daily workflow of the inpatient consultation service. This step was successful in engaging the fellow to work with interprofessional teams and learn about health care delivery, patient care coordination, patient care quality improvement, and patient safety. It also helped in the identification of system errors and implementing system-related solutions.
5. Interpersonal skills and communication. Independent 1-on-1 interactions with faculty members from other subspecialties and other allied health care professionals that formed the patient care team boosted the fellow’s communication skills development. It also garnered the respect of fellows and understanding of the importance of a heart team approach and patient-centered care in today’s complex health care environment, with complex patient comorbidities and ever-advancing technologies that can be offered to patients with various cardiovascular disease states.
In the current in-hospital environment of patient care delivery, where administrators and third-party payers have diverted physicians’ focus to relative value units–based care, and early hospital discharge is the fulcrum of inpatient care, it is foreseeable that the revered teaching rounds in academic institutions will lose their strong foothold in the development of tomorrow’s academicians and clinician teachers. It is pivotal for us as a cardiovascular community to seize this climacteric and to ensure that we preserve the sanctity of inpatient rounds that play an important role in shaping up the cardiovascular consultants of tomorrow. Inpatient rotations constitute a substantial part of the general cardiovascular disease fellowship program—according to the ACGME, fellows are required to spend 9 months in inpatient rotations to meet graduation requirements. Although inpatient rotations are not the highlight for fellows-in-training (5), it is incumbent upon the training programs that this invaluable time is utilized to sculpt their fellows into ideal cardiovascular consultants.
In conclusion, the “Hennepin” model is one such effort to provide the opportunity to fellows to hone their skills in delivering timely, efficient, and effective consultative services to their peers. Fellows have welcomed this change in the inpatient rounding curriculum and feel that the new model has been a significant addition to their training experience. Perhaps other cardiovascular disease fellowship programs can take a page from our book and hand over the baton of “running” the inpatient consultative services to their fellows to shape up the independent cardiovascular consultants of tomorrow.
- Patrick T. O'Gara, MD ()
RESPONSE: Reinvigorated Teaching Programs Require Metrics
Post-graduate clinical training in medicine and surgery has undergone significant change in recent times, without clear demonstration of improved learning or patient outcomes. Duty hour regulations are just 1 facet of the new reality in which we find ourselves. Attention to cost, utilization, and efficiency threaten the very existence of academic medical centers, where care is inherently more expensive and fragmented compared with models, such as that exemplified by the Geisinger Health System. The tension between service and education, as well as the imbalance between inpatient and ambulatory training, has become even more acute. In addition, there is widespread recognition of the gradual erosion in the precision and quality of traditional inpatient teaching rounds, along with the emasculation of the role of the cardiovascular fellow in their conduct.
Kalra and colleagues are to be congratulated for designing and implementing a new model for the delivery of inpatient cardiovascular consultation services that fosters a more substantive teaching role for fellows-in-training, while attempting to enhance opportunities for autonomy and accountability. However, metrics—including length of stay, test ordering, charges, and trainee/faculty/patient satisfaction scores—are needed to gauge the effectiveness of the program and compare it against historical baselines. In many centers, for example, all new consults are expected to be seen by the attending physician the day they are requested. Independence in decision making comes after a period of demonstrated competence. Hospitals differ with respect to the level of oversight needed to initiate invasive evaluation and management services. Faculty involved in the clinical training of cardiovascular fellows should recognize the plea inherent in this fellow-initiated codification of roles and responsibilities on the inpatient consultation service. Namely, that we, too, must try to detach ourselves from the crush of service and help identify ways on a daily basis to reinvigorate our teaching programs and revisit the methods used to facilitate the transition from trainee to independent consultant.
The authors acknowledge the enthusiastic participation of Drs. Avin Aggarwal, Kathymae Owens, Aileen Yew Haung, and Elizabeth Z. Miller, house staff at Hennepin County Medical Center, in the first iteration of the “Hennepin” model. The authors also acknowledge Gerry Yumul at the Minneapolis Heart Institute Foundation for his work on the infographic.
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