Inpatient/Outpatient US Clinical Experience in Cardiology in Los Angeles

Information about this clinical experience:

You will be under the supervision of one of two physicians board-certified in internal medicine and cardiology. Both have faculty appointments at the University of California Irvine School of Medicine – one is a Clinical Professor and the other is a Clinical Assistant Professor. Through these positions, they have gained extensive experience educating learners from diverse backgrounds. You will work with one of these attending physicians in both the inpatient and outpatient settings as their team performs and interprets a plethora of cardiac tests and procedures. These physicians hold staff appointments at MemorialCare and Fountain Valley Regional Hospital and Medical Center. 

Ordering and interpreting cardiac tests will be an important part of your practice during residency. However, few residents enter residency with adequate background knowledge in appropriate test ordering and interpretation. In one study of new internal medicine residents, trainees only read half of all ECGs correctly. Among the missed diagnoses were acute myocardial infarction, ventricular tachycardia, and complete heart block. The authors wrote that “internal medicine residents at the beginning of their residency training demonstrated low overall proficiency in interpreting ECGs and self-perceived confidence. Nearly all residents felt their training was insufficient.”

This experience focused on cardiac tests and procedures will allow you to gain comfort and confidence in your ability to appropriately order and interpret a variety of cardiac tests. By the end of the clinical experience, you will be able to answer the following questions:

• What are the indications for this test?

• What are the contraindications for this test?

• How is the test performed?

• How are patients monitored during the test?

• How is the test interpreted?

Below we outline the tests that you will encounter and provide links to important articles that will enhance your learning.

Echocardiography

The rotator will learn how echocardiograms are performed and interpreted, an important skill for your future residency training. In fact, sonography has been identified as an important competency to be developed during internal medicine residency by the Accreditation Council for Graduate Medical Education (ACGME). You will learn the appropriate indications for the various echocardiographic modes, the limitations and potential artifacts associated with this test, and the characteristic findings in different cardiac conditions. You will also learn how images are acquired utilizing different scan planes, how to operate the ultrasound equipment, and the standard study protocol. Useful resources include:

Clinical Indications for Echocardiography (British Society of Echocardiography

Standard Transthoracic Echocardiogram: Complete Imaging Protocol

Cardiac Ultrasound Made Easy

Exercise Stress Testing

Rotators will understand the indications and contraindications of exercise stress tests and how patients are screened immediately before the test. Time spent observing how the test is performed will allow you to become familiar with the normal end points of the test, abnormal responses to exercise, and complications that would lead to discontinuation of the test. You will also learn how to interpret the test results (e.g., ECG criteria for positive test). Useful resources include:

Exercise Stress Tests: Protocols, Evaluation, and Termination

Stress Testing and Noninvasive Coronary Imaging: What’s the Best Test for My Patient?

Nuclear Cardiac Stress Testing

The rotator will learn skills of interpreting nuclear cardiac studies in the context of the patient’s clinical presentation. Useful resources include:

Stress Testing and Noninvasive Coronary Imaging: What’s the Best Test for My Patient?

American Society of Nuclear Cardiology Imaging Guidelines for SPECT Nuclear Cardiology Procedures: Stress, Protocols, and Tracers

Noninvasive Vascular Testing

Rotators will spend time observing noninvasive vascular testing, exploring the role of these tests in the evaluation and management of patients with vascular disease. Useful resources include:

Carotid Duplex Ultrasound: Interpretations and Clinical Applications

Cardiac Catheterization

Rotators will learn the indications, contraindications, risks, and benefits of cardiac catheterization procedures. Useful resources include:

SCAI Expert Consensus Update on Best Practices in the Cardiac Catheterization Laboratory

Please note that this experience remains within the regulations of California pertaining to the unlicensed practice of medicine. During your experience, you will learn the following U.S. medical practices under the preceptor’s supervision:

• Taking patient histories under supervision.

• Performing physical exams under the physician's supervision.

• Presenting patients.

• Researching the literature to answer clinical questions at the point of care.

The activities above will mostly take place in the outpatient setting. As a result of hospital policies, inpatient activities will be more observational.