Hypertension

HYPERTENSION. COMPETENCY-BASED CURRICULUM

RATIONALE and OVERVIEW

Hypertension is a multidisciplinary clinical problem which affects about one in four Americans. It is the most common "principal problem" in office visits to internists and is also seen frequently in inpatients and in consultative practice. Saint Barnabas Medical Center has a separate Section of Hypertension, recognizing the complexity and importance of high blood pressure.

GOALS:

A. Knowledge:

  1. Understand the epidemiology of hypertension.
  2. Know the JNC classification of hypertension.
  3. Understand Sir George Pickering's statement about normal and high blood pressure; "There is no dividing line."
  4. Be able to recognize a therapeutic definition of hypertension.
  5. Understand the interaction of hypertension with other cardiovascular risk factors and how this interaction effects the number (of patients) needed to treat (NNT) to prevent cardiovascular event.
  6. Be able to devise cost-effective diagnostic workups for secondary causes and target organ damage.
  7. Be aware of effective and ineffective non-pharmacologic therapies.
  8. Know the pharmacology and relative costs of antihypertensive drugs.
  9. Know the approach to the patient with resistant hypertension.
  10. Know the indications for ambulatory blood pressure monitoring.
  11. Understand the inpatient management of hypertension (i.e. pregnancy emergencies).

B. Skills

Upon completion of the program, the Internal Medicine resident will be able to :

  1. Demonstrate proper blood pressure measurement techniques.
  2. Interpret a 24-hour ABPM reading.
  3. Perform Osler's maneuver.
  4. Be able to communicate to patients the need for treatment of hypertension when they are asymptomatic.

C. Attitudes:

None specific for this content area.

Educational Experience

A. General

The monthly hypertension elective for residents is presented by division faculty. It is expected that at the time of presentation to the consulting physician, the residents are totally familiar with the patient's problem(s), have read and reviewed pertinent literature, and are prepared to knowledgeably discuss the problems at hand.

Residents will be responsible for seeing infectious diseases in-patient consultations and will also participate in the outpatient activities and practices of division staff/faculty.

B. Clinical Activities

1. Inpatient Experience (IP)

Residents will see inpatient consults prior to the attending. Consultations are presented on rounds to the consulting hematologist, at times to be mutually arranged. Usual practice is for the resident to join the consulting physician for hospital rounds each morning and evening, as applicable. It is expected that at the time of presentation to the consulting physician, the residents are totally familiar with the patient's problem(s), have read and reviewed pertinent literature, and are prepared to knowledgeably discuss the problem at hand. Literature references are available to all students and residents rotating through the service. In each instance, the consultation is discussed with referring housestaff or attending physician, as applicable.

2. Ambulatory Experience (AM)

  1. Outpatient activities for residents are conducted as arranged by their supervising attending
  2. Residents are expected to attend all sessions, outpatient activities, and practices.
  3. Patients are assigned in clinics and offices by the attending physicians. Every effort is made to select patients of "interest".
  4. Depending on numbers of individuals on the rotations and clinic/office loads attempts are made to permit residents to spend the first few experiences seeing patients together with attending physicians, so as to better introduce them to the patient evaluation.

3. Didactic Conferences (DC)

Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties

4. Experience in Developing Teaching Skills (Teaching)

EVALUATIONS

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

  • Evaluation of resident competence by faculty attendings (AE)-Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
  • Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
  • Self-evaluation by In-service training examination scores
  • MKSAP study plan (MKSAP)
  • Participation and presentations at didactic conferences (DC)
  • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

1) Medical Knowledge

Goals and Objectives-PGY1 Learning Activities* Assessment
Describe the epidemiology, genetics, natural history, clinical expression of hypertension IP, AM, DC AE, DC, MKSAP
Describe the causes of secondary hypertension IP, AM, DC AE, DC, MKSAP
Describe the epidemiology, genetics, natural history, clinical expression of related disorders encountered in the inpatient and outpatient setting. IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Summarize an approach to the evaluation of common presentations in hypertensive patients IP, AM, DC AE, DC, MKSAP
Interpret diagnostic tests used in the evaluation of in and outpatients with suspected related disease IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of inpatients with related disorders. IP, AM, DC AE, DC, MKSAP

2) Patient Care

Goals and Objectives-PGY1 Learning Activities* Assessment
Effectively perform a comprehensive history and complete physical examination in patients with symptoms affecting this system IP, AM, DC AE, DC, MKSAP
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of disorders affecting this system IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Construct a comprehensive treatment plan and assess response to therapy. IP, AM, DC AE, DC, MKSAP
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies. IP, AM, DC AE, DC, MKSAP
Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy. IP, AM, DC AE, DC, MKSAP

3) Practice-Based Learning and Improvement

Goals and Objectives-PGY1 Learning Activities* Assessment
Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills of patients related diseases IP, AM, DC AE, DC, MKSAP
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education. IP, AM, DC AE, DC, MKSAP
Demonstrate ability to critically assess the scientific literature IP, AM, DC AE, DC, MKSAP
Set and assess individualized learning goals IP, AM, DC AE, DC, MKSAP
Analyze clinical experience and employ a systematic methodology for improvement IP, AM, DC AE, DC, MKSAP
Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care IP, AM, DC AE, DC, MKSAP

4) Interpersonal Skills and Communication

Goals and Objectives-PGY1 Learning Activities* Assessment

Apply empathy in all patient encounters
IP, AM, DC AE, DC, MKSAP
Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team IP, AM, DC AE, DC, MKSAP
Present patient information concisely and clearly, verbally and in writing IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending IP, AM, DC AE, DC, MKSAP
Compose clear and timely admission and progress notes and consultations IP, AM, DC AE, DC, MKSAP
Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate IP, AM, DC AE, DC, MKSAP
Teach colleagues effectively IP, AM, DC AE, DC, MKSAP

5) Professionalism

Goals and Objectives-PGY1 Learning Activities* Assessment
Be prompt and prepared for all clinical duties IP, AM, DC AE, DC, MKSAP
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all IP, AM, DC AE, DC, MKSAP
Respect patients and their families, staff and colleagues IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Model ethical behavior by reporting back to the attending and referring providers any key clinical findings IP, AM, DC AE, DC, MKSAP
Demonstrate integrity IP, AM, DC AE, DC, MKSAP

Respond to phone calls and pages promptly
IP, AM, DC AE, DC, MKSAP

6) Systems-Based Practice

Goals and Objectives-PGY1 Learning Activities* Assessment
Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases IP, AM, DC AE, DC, MKSAP
Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty. IP, AM, DC AE, DC, MKSAP
Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information. IP, AM, DC AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Discuss how the health care system affects the management of inpatients with related diseases. IP, AM, DC AE, DC, MKSAP
Determine cost-effectiveness of alternative proposed interventions. IP, AM, DC AE, DC, MKSAP
Design cost-effective plans based on knowledge of best practices IP, AM, DC AE, DC, MKSAP
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized IP, AM, DC AE, DC, MKSAP

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY-2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

Educational Resources

a. Supervising clinicians-didactic and bedside rounds and concurrent patient care
b. Medical literature including assessment of knowledge using the MKSAP
c. Bedside rounds with team and faculty.
d. Medical Grand Rounds weekly.
e. Scheduled didactic conferences including: medicine morning report, journal club, ambulatory care conference, EBM conference
f. Saint Barnabas Medical Center library, librarians, and online references/resources

REFERENCES

Norman Kaplan: Clinical Hypertension , Williams & Wilkins

Drugs for Hypertension : The Medical Letter, 1995; 37:45-50 (Cursory overview of all drugs but includes Wholesale Costs of all available antihypertensives).

R. A. Reeves: Does this patient have Hypertension? How to Measure Blood Pressure, JAMA. 1995; 273:1211-18

SHEP Cooperative Research Group: Prevention of Stroke by Antihypertensive Drug Treatment in Older Person with Isolated Systolic Hypertension. Final Results of The Systolic Hypertension in the Elderly Program (SHEP), JAMA. 1991; 265:3255-64

The Fifth Report of The Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. NIH Publication No 93-1088. March 1994.

Norman Kaplan: American Society of Hypertension Core Curriculum for Clinical Hypertension.

A. V. Chobanian, et. al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA. 2003;289(19):2560-2571.

FACULTY

Lawrence Byrd, M.D.
Michael Gutkin, M.D.