Newvs from the American Heart
Association
7320 Greenville Ave., Dallas, Texas 75231 Telephone: 214 750-5300
Special Report Attributes of the General Internist The Subspecialist in Internal Medicine and Guidelines for Training in Cardiovascular Disease COUNCIL BOARD
ON OF
GENERAL INTERNAL MEDICINE, AMERICAN INTERNAL MEDICINE, PHILADELPHIA, PA.
Downloaded from http://ahajournals.org by on January 15, 2019
A GENERAL INTERNIST is a physician who provides scientifically based, empathic care for the non-surgical illnesses of adolescents and adults. This care tends to be characterized by a mutual personal commitment between doctor and patient, by stability over time, by substantial breadth, by availability, and by an appropriate attention to elements of human support, sensitivity and concern. It is marked by technical sophistication and major professional expertise. The general internist functions as a consultant to other specialists and is competent to handle critically ill patients and non-surgical disorders in adolescents and adults seeking aid in the emergency room setting. The well trained internists are unique in their ability to deliver with broad competence primary, secondary and tertiary care. The general internist provides continuing, comprehensive care for common and complex multisystem illnesses in the ambulatory as well as the hospital setting. The internist serves as the patient's advocate and accepts responsibility for all the patient's health needs, obtaining assistance from other specialists and from allied health professionals as required. One of the hallmarks of the general internist is a continuing personal interest in the patient. The practice of internal medicine requires the knowledge and application of advances in the science and technology of medicine. The internist provides care which combines the scientific and technological successes of recent decades with the empathic care of the patient. Progress in technology may complicate the relationship between the patient and physician. Therefore the personal and caring relationship takes on even greater significance.
cally competent in their subspecialty, they should always practice their subspecialty with a broad knowledge of its relationship to diseases of other organ systems. Teaching and learning should continue throughout the careers of subspecialists. Sincere dedication to continuing education will enable them to advance their competence with changes in medical knowledge and practice, to exercise appropriate clinical skill and thoughtful judgment in utilizing technological procedures, to demonstrate wisdom in the comprehensive evaluation of diagnostic tests, and to provide sound recommendations for therapeutic modalities or clinical management. Since experience in either fundamental research or clinical investigation fosters life-long habits of scholarship and critical thinking, they should be capable of interpreting experimental data and be familiar with the scientific basis for medical practice. Subspecialists should seek to cooperate with and provide consultation for physicians within and outside the field of internal medicine, as well as other allied health professionals, whose participation in the diagnosis and care of patients is essential.
General Guidelines for Training the Subspecialist in Internal Medicine Subspecialty training should be received in an institution with a residency program in internal medicine approved by the Liaison Committee on Graduate Medical Education, although training may be appropriate in certain outstanding institutions of recognized quality and enriched by an academic atmosphere which do not have an approved training program in internal medicine. During training, the subAttributes of the Subspecialist in Internal Medicine specialist should be afforded the opportunity to develop the cognitive knowledge, clinical skills, personal attributes and Subspecialists must first be certified by the American professional attitudes appropriate for an internist competent Board of Internal Medicine in the broad field of internal to practice the subspecialty both as a primary physician and medicine. They should be dedicated to excellence and comas a consultant. As in programs in the broad specialty of inpassion in patient care. They should appreciate the relationternal medicine, evaluation of the clinical skills of the subship of their particular discipline to the whole of internal specialty trainee to function as a consultant as well as an inmedicine, and, although mainly concerned with being clini691Al
CIRCULATION ternist will be required of program directors and should be expected by trainees. These guidelines are intended to provided direction and are not to be interpreted as requirements unless specifically stated. Guidelines for Training in Cardiovascular Diseases
Downloaded from http://ahajournals.org by on January 15, 2019
To gain the expertise required of a consultant, the trainee should complete two years of full-time training in the subspecialty of cardiovascular diseases. The training program in cardiovascular diseases should be conducted in an institution approved for three years of residency in internal medicine by the Liaison Committee for Graduate Medical Education. At least twenty of the minimal 24 months of training which the trainee must complete must be provided in hospitals with approved programs of residency training in internal medicine and surgery as well as an active program in adult cardiovascular surgery. The trainee should have a minimum of three years of training in general internal medicine preferably prior to beginning training in the subspecialty. The program must provide an opportunity for its trainees to maintain a high level of competence in general internal medicine, especially in those disease states in which cardiovascular complications may occur. During training, the cardiology trainee should learn to act as a consultant in the clinical management of a wide variety of cardiovascular disorders, both common and uncommon. In all activities, the trainees should be encouraged to cultivate an attitude of scholarship and dedication to continuing education which will remain throughout their professional careers. Program Director and Faculty
The program must be conducted under the auspices of a program director who is highly competent in the subspecialty of cardiovascular diseases, and fully committed to the training of the cardiovascular specialist. There should be a sufficient number of full-time and part-time faculty in the division of cardiology to guarantee close supervision of all trainees. The faculty members should be certified by the Subspecialty Board on Cardiovascular Disease or have equivalent credentials. Environment
Specialists in cardiovascular diseases must interact with specialists in other areas and have knowledge of other specialties in order to provide excellent patient care. Therefore, the training program must enable the trainee to cultivate an appreciation of the importance of interaction with other disciplines through the availability of collaborating consultants and suitable patients. The trainee must gain knowledge and experience in: * Radiology: the interpretation of cardiovascular roentgenograms with particular reference to the vascular structures, and special cardiovascular radiologic procedures. * Pathology: familiarity with the pathology of all major forms of heart disease, including the gross and microscopic alterations that accompany cardiovascular disease processes.
VOL 56, No 4, OCTOBER 1977
* Surgery: the risks and benefits of cardiovascular surgery and the rationale for selection of candidates for surgical treatment; close collaboration with surgical colleagues in pre- and post-operative management of patients with cardiac disease. * Obstetrics: the interrelationship of pregnancy and heart disease. * Pulmonary Disease. basic pulmonary physiology, pulmonary function testing, the evaluation of blood gases, and radioactive lung scanning methods; and experience with diseases involving the pulmonary circulation. * Nuclear Medicine: the fundamental principles of the modern techniques of nuclear medicine for diagnosis of cardiac and vascular disease. * Pharmacology: the pharmacology of commonly used cardiovascular drugs. Educational Program
The cardiovascular trainee should devote the equivalent of one of the two years of training to the broad area of clinical cardiovascular diseases. This should include experience with patients undergoing intensive care for acute cardiovascular disorders as well as closely supervised experience in a well run coronary care unit. The training should include exposure to both in-patients and out-patients and enable the trainee to follow the same patients over a long period of time. Outpatient consultation training should occur at least one-half day per week. There should be exposure to a wide age span of patients from adolescence to old age. Since taking a history and performing a physical examination remain of preeminent importance in a cardiovascular diagnosis, trainees must have instruction and the opportunity to develop these critical skills. They must acquire competence in the detection and quantification of clinical data concerning cardiovascular disease through bedside techniques. Trainees must also become conversant with the role of psychogenic factors in the production of symptoms and the behavioral adjustments to cardiovascular disease. They should learn the importance of preventive and rehabilitative measures in the management of heart disease. The training experience should enable trainees to become proficient in all the diseases and subject areas in which a cardiovascular subspecialist should be knowledgeable. They must become experienced in the procedural skills needed for the practice of cardiovascular medicine. There should be a documented core curriculum of training seminars and conferences on key subject areas. The trainee in cardiovascular disease must become well versed in the basic sciences. The program should provide opportunity for continuing education in those elements of anatomy, physiology, pharmacology, pathology, biophysics, computer science, genetics, and biochemistry that are pertinent to cardiology. Of special importance is a thorough understanding of the normal physiology of the circulatory system with emphasis on cardiovascular adaptation to exercise and stress, and of renal function and electrolyte balance. The trainees should have adequate opportunity for teaching and should be encouraged to attend national meetings of a recognized national professional society in cardiology. It is
ATTRIBUTES OF GENERAL INTERNIST recommended that cardiovascular trainees participate directly in the teaching of the discipline and gain familiarity with fundamental principles of the learning process. They should have experience acting as a consultant to other physicians.
Since experience in research, either basic or clinical, enhabits of scholarship and critical thinking trainee for the interpretation of new approaches to patient management, it is recommended that all trainees participate actively in research activities. Prolonged or continuous experience in investigation is not considered essential. Appropriate supervision, review, and/or audit of all trainees' activities should be documented. There should be regular, recorded evaluation and feedback concerning the trainee's clinical skills and knowledge in all of the individual areas with which the cardiovascular subspecialist should be familiar. Modern facilities to accomplish the foregoing educational program must be available. A comprehensive library must be readily accessible.
courages lifelong and prepares the
Specific Knowledge and Skills Required
Downloaded from http://ahajournals.org by on January 15, 2019
Disease areas The trainee must be well-educated in the following disease areas: (pathology, risk factors, * Coronary Artery Disease natural history, prevention, diagnosis by history, physical examination, and laboratory methods, and medical and surgical management). Complications * Hypertension and Resultant (pathogenesis, natural history and pharmacologic treatment). (clinical presentation, * Rheumatic Heart Disease management, bacteriologic association, prevention, pathology, complications, altered physiology, and medical and surgical treatment). (cardiovascular em* Congenital Heart Disease bryology, pathology and alterations in the circulation at birth, clinical presentation, natural history, altered physiology, diagnostic methods, and medical and surgical management of the principal types of congenital cardiac malformations). * Vascular Disease (diseases of the veins and diseases of the aorta, including aortic aneurysm and vascular disease of peripheral and cerebral vessels). * Cardiac A rrhythmias (current concepts of the electrophysiologic basis of cardiac arrhythmias and their pharmacologic management, cardiac monitoring, cardioversion, artificial pacing, interpretation of special electrophysiologic studies, e.g., His bundle electrograms, the technique of insertion of pacemakers, detection of malfunction of pacemakers, supervision of ambulatory patients with artificial pacemakers, the electrical hazards involved and the safe use and evaluation of equipment employed in intensive care and ambulatory monitoring of cardiac rhythm). (cardiomyopathy, * Other Cardiovascular Diseases pericardial disease, pulmonary heart disease, cardiac involvement by systemic disease, infective endocarditis, cardiac complications of chronic renal failure, traumatic heart disease, cardiac tumors, and cardiovascular -
syphilis).
693A
Skills - The training program should enable development of a thorough understanding of indications for cardiovascular laboratory procedures and the acquisition of skills required in the physiologic, chemical and pharmacologic evaluation of cardiovascular function, including the following: * Electrocardiography: The program must provide opportunity for the supervised interpretation of all electrocardiographic abnormalities and cardiac rhythm disturbances. The trainee must gain competence in the interpretation of electrocardiographic exercise and stress tests, and become familiar with the technique and basis for the interpretation of vectorcardiograms and His bundle electrograms. There must be experience with continuous monitoring of cardiac rhythm and interpretation of recordings. * Cardiovascular Roentgenograms and Angiograms: The training experience must enable development of expertise in the interpretation of the special radiologic techniques used in the study of cardiovascular problems, including radiologic contrast studies of the heart, coronary arteries, and peripheral vascular system. * Hemodynamic Data: The trainee must have the opportunity to become thoroughly conversant with the techniques of diagnostic cardiac catheterization, the principles underlying the rendering of physiologic data, and the characteristics of an adequate recording system. A thorough understanding of the data and ability to calculate and interpret results of cardiac catheterization must be instilled. * Graphic Methods: The cardiovascular trainee should have experience in the techniques and interpretation of recording phonocardiograms and pulse tracings. * Echocardiography: The contemporary trainee must have enough experience in echocardiography to become thoroughly conversant with its basic principles, technique, and interpretation. Experiences During the first 24 months, training must provide supervised experience with frequent evaluations in specific areas. These include: * Repeated and continuing responsibility for in-patient cardiovascular consultations. * Extensive experience in the care of patients in an active coronary care unit. * Regular attendance in a cardiovascular out-patient service. * Direct experience under supervision in a general adult cardiac catheterization laboratory performing both right and left heart catheterizations. The laboratory should meet the standards of the Intersociety Commission on Heart Disease, and the trainee should participate in all laboratory procedures, data analysis and report writing. * Major experience in the interpretation of electrocardiograms with appropriate review and audit. * Direct participation in performance and interpretation of exercise-function and/or exercise ECG tests. * Direct participation in performance of echocardiograms and graphics (pulse and phonocardiographic) examinations. Continued on ad page 59
Association
7320 Greenville Ave., Dallas, Texas 75231 Telephone: 214 750-5300
Special Report Attributes of the General Internist The Subspecialist in Internal Medicine and Guidelines for Training in Cardiovascular Disease COUNCIL BOARD
ON OF
GENERAL INTERNAL MEDICINE, AMERICAN INTERNAL MEDICINE, PHILADELPHIA, PA.
Downloaded from http://ahajournals.org by on January 15, 2019
A GENERAL INTERNIST is a physician who provides scientifically based, empathic care for the non-surgical illnesses of adolescents and adults. This care tends to be characterized by a mutual personal commitment between doctor and patient, by stability over time, by substantial breadth, by availability, and by an appropriate attention to elements of human support, sensitivity and concern. It is marked by technical sophistication and major professional expertise. The general internist functions as a consultant to other specialists and is competent to handle critically ill patients and non-surgical disorders in adolescents and adults seeking aid in the emergency room setting. The well trained internists are unique in their ability to deliver with broad competence primary, secondary and tertiary care. The general internist provides continuing, comprehensive care for common and complex multisystem illnesses in the ambulatory as well as the hospital setting. The internist serves as the patient's advocate and accepts responsibility for all the patient's health needs, obtaining assistance from other specialists and from allied health professionals as required. One of the hallmarks of the general internist is a continuing personal interest in the patient. The practice of internal medicine requires the knowledge and application of advances in the science and technology of medicine. The internist provides care which combines the scientific and technological successes of recent decades with the empathic care of the patient. Progress in technology may complicate the relationship between the patient and physician. Therefore the personal and caring relationship takes on even greater significance.
cally competent in their subspecialty, they should always practice their subspecialty with a broad knowledge of its relationship to diseases of other organ systems. Teaching and learning should continue throughout the careers of subspecialists. Sincere dedication to continuing education will enable them to advance their competence with changes in medical knowledge and practice, to exercise appropriate clinical skill and thoughtful judgment in utilizing technological procedures, to demonstrate wisdom in the comprehensive evaluation of diagnostic tests, and to provide sound recommendations for therapeutic modalities or clinical management. Since experience in either fundamental research or clinical investigation fosters life-long habits of scholarship and critical thinking, they should be capable of interpreting experimental data and be familiar with the scientific basis for medical practice. Subspecialists should seek to cooperate with and provide consultation for physicians within and outside the field of internal medicine, as well as other allied health professionals, whose participation in the diagnosis and care of patients is essential.
General Guidelines for Training the Subspecialist in Internal Medicine Subspecialty training should be received in an institution with a residency program in internal medicine approved by the Liaison Committee on Graduate Medical Education, although training may be appropriate in certain outstanding institutions of recognized quality and enriched by an academic atmosphere which do not have an approved training program in internal medicine. During training, the subAttributes of the Subspecialist in Internal Medicine specialist should be afforded the opportunity to develop the cognitive knowledge, clinical skills, personal attributes and Subspecialists must first be certified by the American professional attitudes appropriate for an internist competent Board of Internal Medicine in the broad field of internal to practice the subspecialty both as a primary physician and medicine. They should be dedicated to excellence and comas a consultant. As in programs in the broad specialty of inpassion in patient care. They should appreciate the relationternal medicine, evaluation of the clinical skills of the subship of their particular discipline to the whole of internal specialty trainee to function as a consultant as well as an inmedicine, and, although mainly concerned with being clini691Al
CIRCULATION ternist will be required of program directors and should be expected by trainees. These guidelines are intended to provided direction and are not to be interpreted as requirements unless specifically stated. Guidelines for Training in Cardiovascular Diseases
Downloaded from http://ahajournals.org by on January 15, 2019
To gain the expertise required of a consultant, the trainee should complete two years of full-time training in the subspecialty of cardiovascular diseases. The training program in cardiovascular diseases should be conducted in an institution approved for three years of residency in internal medicine by the Liaison Committee for Graduate Medical Education. At least twenty of the minimal 24 months of training which the trainee must complete must be provided in hospitals with approved programs of residency training in internal medicine and surgery as well as an active program in adult cardiovascular surgery. The trainee should have a minimum of three years of training in general internal medicine preferably prior to beginning training in the subspecialty. The program must provide an opportunity for its trainees to maintain a high level of competence in general internal medicine, especially in those disease states in which cardiovascular complications may occur. During training, the cardiology trainee should learn to act as a consultant in the clinical management of a wide variety of cardiovascular disorders, both common and uncommon. In all activities, the trainees should be encouraged to cultivate an attitude of scholarship and dedication to continuing education which will remain throughout their professional careers. Program Director and Faculty
The program must be conducted under the auspices of a program director who is highly competent in the subspecialty of cardiovascular diseases, and fully committed to the training of the cardiovascular specialist. There should be a sufficient number of full-time and part-time faculty in the division of cardiology to guarantee close supervision of all trainees. The faculty members should be certified by the Subspecialty Board on Cardiovascular Disease or have equivalent credentials. Environment
Specialists in cardiovascular diseases must interact with specialists in other areas and have knowledge of other specialties in order to provide excellent patient care. Therefore, the training program must enable the trainee to cultivate an appreciation of the importance of interaction with other disciplines through the availability of collaborating consultants and suitable patients. The trainee must gain knowledge and experience in: * Radiology: the interpretation of cardiovascular roentgenograms with particular reference to the vascular structures, and special cardiovascular radiologic procedures. * Pathology: familiarity with the pathology of all major forms of heart disease, including the gross and microscopic alterations that accompany cardiovascular disease processes.
VOL 56, No 4, OCTOBER 1977
* Surgery: the risks and benefits of cardiovascular surgery and the rationale for selection of candidates for surgical treatment; close collaboration with surgical colleagues in pre- and post-operative management of patients with cardiac disease. * Obstetrics: the interrelationship of pregnancy and heart disease. * Pulmonary Disease. basic pulmonary physiology, pulmonary function testing, the evaluation of blood gases, and radioactive lung scanning methods; and experience with diseases involving the pulmonary circulation. * Nuclear Medicine: the fundamental principles of the modern techniques of nuclear medicine for diagnosis of cardiac and vascular disease. * Pharmacology: the pharmacology of commonly used cardiovascular drugs. Educational Program
The cardiovascular trainee should devote the equivalent of one of the two years of training to the broad area of clinical cardiovascular diseases. This should include experience with patients undergoing intensive care for acute cardiovascular disorders as well as closely supervised experience in a well run coronary care unit. The training should include exposure to both in-patients and out-patients and enable the trainee to follow the same patients over a long period of time. Outpatient consultation training should occur at least one-half day per week. There should be exposure to a wide age span of patients from adolescence to old age. Since taking a history and performing a physical examination remain of preeminent importance in a cardiovascular diagnosis, trainees must have instruction and the opportunity to develop these critical skills. They must acquire competence in the detection and quantification of clinical data concerning cardiovascular disease through bedside techniques. Trainees must also become conversant with the role of psychogenic factors in the production of symptoms and the behavioral adjustments to cardiovascular disease. They should learn the importance of preventive and rehabilitative measures in the management of heart disease. The training experience should enable trainees to become proficient in all the diseases and subject areas in which a cardiovascular subspecialist should be knowledgeable. They must become experienced in the procedural skills needed for the practice of cardiovascular medicine. There should be a documented core curriculum of training seminars and conferences on key subject areas. The trainee in cardiovascular disease must become well versed in the basic sciences. The program should provide opportunity for continuing education in those elements of anatomy, physiology, pharmacology, pathology, biophysics, computer science, genetics, and biochemistry that are pertinent to cardiology. Of special importance is a thorough understanding of the normal physiology of the circulatory system with emphasis on cardiovascular adaptation to exercise and stress, and of renal function and electrolyte balance. The trainees should have adequate opportunity for teaching and should be encouraged to attend national meetings of a recognized national professional society in cardiology. It is
ATTRIBUTES OF GENERAL INTERNIST recommended that cardiovascular trainees participate directly in the teaching of the discipline and gain familiarity with fundamental principles of the learning process. They should have experience acting as a consultant to other physicians.
Since experience in research, either basic or clinical, enhabits of scholarship and critical thinking trainee for the interpretation of new approaches to patient management, it is recommended that all trainees participate actively in research activities. Prolonged or continuous experience in investigation is not considered essential. Appropriate supervision, review, and/or audit of all trainees' activities should be documented. There should be regular, recorded evaluation and feedback concerning the trainee's clinical skills and knowledge in all of the individual areas with which the cardiovascular subspecialist should be familiar. Modern facilities to accomplish the foregoing educational program must be available. A comprehensive library must be readily accessible.
courages lifelong and prepares the
Specific Knowledge and Skills Required
Downloaded from http://ahajournals.org by on January 15, 2019
Disease areas The trainee must be well-educated in the following disease areas: (pathology, risk factors, * Coronary Artery Disease natural history, prevention, diagnosis by history, physical examination, and laboratory methods, and medical and surgical management). Complications * Hypertension and Resultant (pathogenesis, natural history and pharmacologic treatment). (clinical presentation, * Rheumatic Heart Disease management, bacteriologic association, prevention, pathology, complications, altered physiology, and medical and surgical treatment). (cardiovascular em* Congenital Heart Disease bryology, pathology and alterations in the circulation at birth, clinical presentation, natural history, altered physiology, diagnostic methods, and medical and surgical management of the principal types of congenital cardiac malformations). * Vascular Disease (diseases of the veins and diseases of the aorta, including aortic aneurysm and vascular disease of peripheral and cerebral vessels). * Cardiac A rrhythmias (current concepts of the electrophysiologic basis of cardiac arrhythmias and their pharmacologic management, cardiac monitoring, cardioversion, artificial pacing, interpretation of special electrophysiologic studies, e.g., His bundle electrograms, the technique of insertion of pacemakers, detection of malfunction of pacemakers, supervision of ambulatory patients with artificial pacemakers, the electrical hazards involved and the safe use and evaluation of equipment employed in intensive care and ambulatory monitoring of cardiac rhythm). (cardiomyopathy, * Other Cardiovascular Diseases pericardial disease, pulmonary heart disease, cardiac involvement by systemic disease, infective endocarditis, cardiac complications of chronic renal failure, traumatic heart disease, cardiac tumors, and cardiovascular -
syphilis).
693A
Skills - The training program should enable development of a thorough understanding of indications for cardiovascular laboratory procedures and the acquisition of skills required in the physiologic, chemical and pharmacologic evaluation of cardiovascular function, including the following: * Electrocardiography: The program must provide opportunity for the supervised interpretation of all electrocardiographic abnormalities and cardiac rhythm disturbances. The trainee must gain competence in the interpretation of electrocardiographic exercise and stress tests, and become familiar with the technique and basis for the interpretation of vectorcardiograms and His bundle electrograms. There must be experience with continuous monitoring of cardiac rhythm and interpretation of recordings. * Cardiovascular Roentgenograms and Angiograms: The training experience must enable development of expertise in the interpretation of the special radiologic techniques used in the study of cardiovascular problems, including radiologic contrast studies of the heart, coronary arteries, and peripheral vascular system. * Hemodynamic Data: The trainee must have the opportunity to become thoroughly conversant with the techniques of diagnostic cardiac catheterization, the principles underlying the rendering of physiologic data, and the characteristics of an adequate recording system. A thorough understanding of the data and ability to calculate and interpret results of cardiac catheterization must be instilled. * Graphic Methods: The cardiovascular trainee should have experience in the techniques and interpretation of recording phonocardiograms and pulse tracings. * Echocardiography: The contemporary trainee must have enough experience in echocardiography to become thoroughly conversant with its basic principles, technique, and interpretation. Experiences During the first 24 months, training must provide supervised experience with frequent evaluations in specific areas. These include: * Repeated and continuing responsibility for in-patient cardiovascular consultations. * Extensive experience in the care of patients in an active coronary care unit. * Regular attendance in a cardiovascular out-patient service. * Direct experience under supervision in a general adult cardiac catheterization laboratory performing both right and left heart catheterizations. The laboratory should meet the standards of the Intersociety Commission on Heart Disease, and the trainee should participate in all laboratory procedures, data analysis and report writing. * Major experience in the interpretation of electrocardiograms with appropriate review and audit. * Direct participation in performance and interpretation of exercise-function and/or exercise ECG tests. * Direct participation in performance of echocardiograms and graphics (pulse and phonocardiographic) examinations. Continued on ad page 59
