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Penn State Milton S. Hershey Medical Center Fellowship Handbook Cardiovascular Disease 2016-2017 I. II. III. IV. Cardiology Fellowships Program Information..................................................................................... 1 Cardiology Faculty ............................................................................................................................ 2-3 2016-2017 Block Schedule .................................................................................................................. 4 Curriculum .................................................................................................................................... 5-137 a. Cardiovascular Disease Fellowship Overview............................................................................... 5 b. Rotations....................................................................................................................................... 8 c. Conferences .............................................................................................................................. 137 V. Departmental Policies .............................................................................................................. 138-147 a. Selection, Evaluation, Renewal, Promotion, and Dismissal of Fellows .................................... 138 b. Grievance and Due Process ...................................................................................................... 142 c. Supervision ............................................................................................................................... 143 d. General Guidelines for Transitions of Care............................................................................... 144 e. Duty Hours, Call, and Fatigue Management............................................................................. 145 f. Moonlighting ............................................................................................................................ 146 VI. Institutional Graduate Medical Education Policies .................................................................. 148-151 a. Statement of Commitment to GME ......................................................................................... 148 b. Additional Work Policy ............................................................................................................. 148 c. Away Rotation Policy ................................................................................................................ 149 d. C.O.R.E (Culture of Respect in Education) ............................................................................... 150 e. Disaster Policy........................................................................................................................... 150 f. Non-Competition Policy............................................................................................................ 151 g. Physician Impairment & Substance Abuse Policy..................................................................... 151 VII. Benefits .................................................................................................................................... 152-157 a. Annual Fellow Stipend .............................................................................................................. 152 b. Educational Support Fund ........................................................................................................ 152 c. Meetings ................................................................................................................................... 153 d. Insurances ................................................................................................................................. 155 i. Medical, Dental, Vision ii. Flexible Spending and Health Reimbursement Accounts iii. Short- and Long-Term Disability iv. Group Term Life v. Tuition Reimbursement vi. Employee Assistance Program e. Employee Discounts ................................................................................................................. 155 f. Leave of Absence ...................................................................................................................... 156 i. Vacation and CME ii. Medical/Parental/Family Leave iii. Personal Leave iv. Professional Leave v. Effect of Leave g. ComPsych Guidance Resources ................................................................................................ 156 h. Meal Allowance ........................................................................................................................ 157 i. Meals On-Call ........................................................................................................................... 157 VIII. Miscellaneous Information ...................................................................................................... 158-172 a. Graduate Medical Education Office ......................................................................................... 158 b. Notary ....................................................................................................................................... 158 c. Parking ...................................................................................................................................... 158 d. ID Badging ................................................................................................................................. 158 e. f. g. h. i. j. k. l. George T. Harrell Library .......................................................................................................... 158 Gift Shop ................................................................................................................................... 158 Fitness Center ........................................................................................................................... 159 ATM .......................................................................................................................................... 159 Mail Services ............................................................................................................................. 159 Work-Related Injuries ............................................................................................................... 159 Telephone/Pager Instructions .................................................................................................. 159 Dictation System Instruction ............................................................................................. 160-162 I. CARDIOLOGY FELLOWSHIPS PROGRAM INFORMATION Program Director: Deborah Wolbrette, MD [email protected] Associate Program Directors: Michael Pfeiffer, MD [email protected] Eric Popjes, MD [email protected] Program Coordinator: Mandi Smith [email protected] Cell Phone: 717-269-8046 Cardiology Fellowships Office Information Coordinator’s Room #: C1517 Fellows’ Lounge #: C1518 Phone: 717-531-6746 Fax: 717-531-7969 Mailing Address: 500 University Drive, Room C1517 PO Box 850, MC H047 Hershey, PA 17033 Conference Rooms H1154 - Hamilton Conference Room H1222 - IO Silver Conference Room Helpful Phone Numbers X8521 - Operator X6281 - IT Help Desk CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 1 II. CARDIOLOGY FACULTY Name Title Peter Alagona, MD Program Director Diagnostic Cardiology Co-Director Cardiac Rehabilitation and Wellness Associate Professor of Medicine and Radiology Assistant Professor of Medicine Assistant Professor of Medicine Assistant Professor of Medicine Interim Medical Director, Adult Echocardiography Lab Assistant Professor of Medicine and Public Health Sciences Assistant Professor of Medicine State College Campus Professor of Medicine Associate Professor of Medicine Associate Professor of Medicine Professor of Medicine Professor of Medicine Assistant Professor of Medicine Assistant Professor of Medicine Assistant Professor of Medicine Professor of Medicine Director, Penn State Hershey Heart and Vascular Institute ELECTROPHYSIOLOGY Professor of Medicine Program Director, Clinical Electrophysiology Assistant Professor of Medicine Bernard Trabin Chair in Cardiology Professor of Medicine Chief, Division of Cardiology Associate Clinical Director, PSHVI Robert Aronoff, MD Eric Chan, MD Joy Cotton, MD Andrew Foy, MD Jason Fragin, DO Joseph Gascho, MD Annick Haouzi, MD Edward Lankford, MD David Leaman, MD Urs Leuenberger, MD Edward Liszka, MD Brandon Peterson, MD Michael Pfeiffer, MD Lawrence Sinoway, MD Mario Gonzalez, MD Sarah Hussain, MD Gerald Naccarelli, MD GENERAL CARDIOLOGY Email Pager [email protected] 4381 [email protected] [email protected] [email protected] 3304 2475 3742 [email protected] [email protected] 4313 1866 [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] 2082 5319 5284 2081 1626 2535 4888 3342 2083 [email protected] 3229 [email protected] [email protected] 5073 0440 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 2 Soraya Samii, MD, PhD Deborah Wolbrette, MD Charles Chambers, MD Steven Ettinger, MD Ian Gilchrist, MD Mark Kozak, MD Pradeep Yadav, MD Omaima Ali, MD John Boehmer, MD Dwight Davis, MD Eric Popjes, MD David Silber, MD Beth Adams, DO William Davidson, MD John Kelleman, MD Associate Professor of Medicine Program Director, Clinical Cardiac Electrophysiology Fellowship Professor of Medicine Program Director, Cardiology Fellowship Program Director, Cardiac Pacing and Electrocardiography INTERVENTIONAL Professor of Medicine and Radiology Director, Nuclear Cardiology and Cardiac Catheterization Laboratory Professor of Medicine Program Director, Interventional Cardiology Professor of Medicine Director of Clinical Research Associate Professor of Medicine Program Director, Interventional Cardiology Fellowship Assistant Professor of Medicine HEART FAILURE Assistant Professor of Medicine Professor of Medicine Medical Director, Heart Failure Program Professor of Medicine Heart Failure / Transplant Service Co-director, Cardiac Rehabilitation and Wellness Program Heart and Vascular Institute Associate Dean for Admissions and Student Affairs Penn State College of Medicine Assistant Professor of Medicine Associate Professor of Medicine Director, IO Silver Clinic CONGENITAL Children’s Heart Group Professor of Medicine Director, Adult Congenital Heart Disease Assistant Professor of Medicine [email protected] 2651 [email protected] 0425 [email protected] 2114 [email protected] 1207 [email protected] 0351 [email protected] 1624 [email protected] 6121 [email protected] [email protected] 5903 1240 [email protected] 1202 [email protected] [email protected] 3119 2109 [email protected] [email protected] 5296 0675 [email protected] 3053 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 3 III. DATES: SWITCH: Fellow 1st Year 2nd Year 3rd Year 2016-2017 BLOCK SCHEDULE 7/1-7/27 14-Jul 7/28 - 8/24 11-Aug 1 8/25 - 9/21 8-Sep 2 9/22 - 10/19 6-Oct 3 10/20 - 11/16 3-Nov 4 11/17 - 12/14 1-Dec 5 12/15 - 1/11/17 29-Dec 6 1/12 - 2/8 26-Jan 7 2/9 - 3/8 23-Feb 8 3/9 - 4/5 23-Mar 9 4/6 - 5/3 20-Apr 10 5/4 - 5/31 18-May 11 6/1 - 6/30 15-Jun 12 13 VP EP CA CA CA E E E E R R CA CA N N C C S S IM IM CHF CHF CHF C EP TA N N CA CA CA CA E E E E R R S S IM IM CHF CHF EP EP C C CA N CHF EP C RW EP EP N N CA CA CA CA E E E E CHF CHF CA N IM IM C C S S R R C CHF BD E E E E EP EP CA CA CA CA N N IM IM S S C C CHF CHF R R C CHF CA N DF E E E E N N R R CA CA CA CA C C CHF CHF EP EP S S IM IM N CA S S SA S S CHF R IM IM C C CHF CA CA CA E E EP CA R CCU N N CA CA E E CA CA RD CA N S N C C IM IM C E CHF CHF CA CA CA CA E E CA CA CCU CCU R R CA CA E TL C C IM IM CHF CHF CCU EP CA C E E CA CA E E N CA R R N CA S CCU E AP IM IM C C CA CA R E E S S C E EP CCU CCU CA R CA CA E N CCU S E E AU CHF CHF CA CA S S CA CCU IM IM C S R CA E E CA CA E E CA R CA CA N CA CB E E R CHF E CCU CHF N N N E E E R N CA CCU E EP EP R E ACHD ACHD Elective Elective MF CA R E CCU CCU E S S N N ACHD ACHD R E EP EP E E E E E E R E Elective Elective MS N CA EP S ACHD ACHD N EP EP EP N N EP E E R CA CA CCU CCU E E E EP Elective Elective RM R R CCU E N N EP CHF S CCU CCU EP N R CA N E E E E ACHD ACHD E E Elective Elective TS CA CA N EP E E E CA CCU CHF R CCU CA N R E E N CA CA CA CA CA CA Elective Elective CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 4 IV. CURRICULUM A. CARDIOVASCULAR DISEASE FELLOWSHIP OVERVIEW Introduction: This overview will describe the program in general, the impact the ACGME Outcomes have on the fellowship program, expectations of the fellows, the evaluation process, schedule of conferences and journal club meetings, the quarterly benchmarks each fellow is to obtain, and then cover specific subjects that the fellow will see during their training or that of which they should have a thorough knowledge. This document should be reviewed early in the fellowship. General Program Information: Entry into the adult Cardiovascular Disease fellowship is after completion of an Internal Medicine residency. Fellows entering the program must be in good standing and be eligible to sit for Internal Medicine boards. The fellowship is a three-year program. During the fellowship, fellows will spend time on rotations related to (1) non-invasive methods for evaluating patients (echo [TTE, TEE, pharmacologic and stress echo], MRI, CT, ECG, EP, nuclear cardiology), (2) invasive methods for evaluating patients (cardiac catheterization) and (3) diagnosis and treatment of patients with peripheral vascular disease. Other rotations are more directly related to learning to diagnosis and treat patients with a wide array of cardiac problems; these rotations are (1) a general cardiology service, (2) in an HV (heart and vascular) ICU housing patients with medical problems (acute myocardial infarction, acute coronary syndrome, arrhythmias) and surgical problems (post-op CABG, valve replacement and/or cardiac transplant, peripheral vascular surgery), and (3) a service designed for caring for patients with congestive heart failure. Fellows spend a half-day each week in a continuity clinic, as well as time at the Lebanon VA Medical Center. Fellows also receive training in cardiac rehabilitation and the management of hyperlipidemia. There is dedicated time set aside for research and fellows are expected to have at least one manuscript submitted for publication prior to leaving the program. Fellows will be expected to meet the ACGME program requirement of conducting at least one Quality Improvement/Patient Safety project. This may be the same project as the publication. Expectations: Each fellow in the program will be expected to perform at a level commensurate with his/her training. The fellow will demonstrate that compassionate and appropriate care of the patient is of first priority, in whatever setting the patient-physician encounter occurs (testing laboratories, outpatient clinic, hospital). The fellow will be professional in dealing with other physicians and all other persons caring for patients. The fellow will continually expand his cardiology knowledge base. The fellow will perform self-assessments on a semi-annual basis to ensure that his/her own practice-based learning is complete. By the time of completion of the fellowship, the fellow will be expected to have a comprehensive understanding of Cardiovascular Diseases in the larger context of practicing medicine. He/she will be equipped to independently diagnosis and treat patients with a wide variety of cardiac and vascular problems and will have the background to enter subspecialty areas of training. On a professional level, the fellow will be expected to be on time, appropriately dressed and groomed for work each day, display a positive attitude and a strong work ethic. Evaluations: The evaluation process is to ensure that the fellows fulfill the requirements of the fellowship, specifically related to the six ACGME core competencies,* and are on track to graduate with the ability to independently practice Cardiovascular Medicine. The formal evaluation process will be conducted at several levels during the year. It will consist of: CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 5 • • • Evaluations by the faculty after each rotation. The comments will be based on the fellows’ performance and on the level of experience to that point. The evaluations will be completed in the New Innovations web-based portal. The original evaluations will be reviewed by the Program Director. A summary evaluation will be reviewed by the Clinical Competency Committee semiannually and the Program Director will review this summary evaluation, as well as milestone levels, with the fellow in private and he/she can have a discussion with the Program Director about the comments. At that time, the fellow can offer general comments about the program. Evaluations of the faculty after each rotation by each fellow. The evaluations will be completed in the New Innovations web-based portal. Comments should be professional and constructive in nature. In the event that there is a significant issue between a fellow and the faculty, a meeting will be set up by the Program Director and minutes of that meeting will be included in the evaluation process. 360 Evaluations. Semi-annually, a 360-degree evaluation will be sent to the personnel working with the fellow, including fellow colleagues. Those results (names of evaluators will be removed) will be reviewed with the fellow by the Program Director and the fellow will be encouraged to offer comments. *ACGME CORE COMPETENCIES • Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. • Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. • Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. • Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals. • Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. • Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Each of these is applicable to the Cardiovascular Disease fellowship and will be individually evaluated during the year (see evaluations section). It will be very important for you to review the competencies and understand their implication to your educational program. Conferences and Journal Clubs Schedule: • HVI and/or Cardiology Grand Rounds. This conference occurs monthly from September-June. Presenters are HVI faculty, outside speakers, and fellows. • HVI Multidisciplinary Conference. This conference occurs twice monthly from October-May. The fellow and an attending co-lead presentation and discussion. • Evening Journal Club. This occurs monthly from July-May, in the home of an attending. Several fellows present synopses of pertinent cardiology articles provided by a faculty member. The content of each article is then discussed. • Cardiac Catheterization. This conference is held every other week (opposite of EP/ECG Conference), with presentation by fellow or Interventional Cardiology faculty. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 6 • • • • • • • EP/ECG Conference. This conference is held every other week (opposite of Cath Conference). Instruction is provided by an EP faculty member. Some conferences are didactic; others include presentations of ECG or EP study records. Echo Conference. This conference occurs three times per month with presentation by fellow or Echo faculty. It includes didactic lectures about echocardiography and case presentations. Core Conference. This conference occurs twice monthly. A broad overview of cardiology is presented at these conferences by an attending. Nuclear Conference. This conference occurs twice monthly, with presentation by faculty. Noon Journal Club and Research Conference. These occur monthly opposite of each other. Imaging Conference. This occurs monthly, with presentation by faculty. Core Competencies Conference. This occurs monthly and is a conference for all fellows and residents in the institution. It is sponsored by the Office of Graduate Medical Education and covers topics pertinent to the ACGME Program Requirements and are mandatory for housestaff at all levels. The Curriculum, including overview, training goals and objectives, expectations, supervision, recommended reading and resources, curricular milestones by level of training, and methods of evaluation are included for each rotation. B. ROTATIONS CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 7 CARDIAC CATHETERIZATION CURRICULUM Penn State Hershey Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date ROTATION INFORMATION Name of Rotation CARDIAC CATHETERIZATION Supervising / Evaluating Faculty Members Charles Chambers, MD; Steven Ettinger, MD; Ian Gilchrist, MD; Mark Kozak, MD; Pradeep Yadav, MD Facility / Location Cardiac Catheterization Lab / Hershey Medical Center Clinical Experience All fellows must have a minimum of 4 months of direct cardiac catheterization experience. Many fellows (who desire COCATS Level II training) will have a 6-8 months direct cardiac catheterization experience. Additional elective time for interested fellows is available. Further exposure to cardiac catheterization content comprised of, but not limited to, performing arterial and/or venous access for bedside procedures; correlation of catheterization results with other multimodality imaging studies; as well as ordering, review, and clinical correlation of invasive cardiac procedures is anticipated for all fellows on the following rotations: • Inpatient Acute Service • CHF Service • CCU • Consults • Outpatient Continuity Clinics (HMC and VA) • Nuclear Cardiology • Echocardiography Didactics Cardiac Cath Lecture Series ; Every other Tuesday @ 7am in Hamilton Conference Room Additional cardiac catheterization related cases and topics are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference • ECHO Conference (stress/cath correlate) • Nuclear Conference (stress/cath correlate) Overview The goal of the cardiac catheterization laboratory rotation is to provide the general cardiology fellow with the requisite cognitive and technical knowledge of invasive cardiology. This will include pre-procedural, procedural, and postprocedural planning and management, including the appropriateness of the planned procedure. The general fellow will learn to perform venous and arterial puncture and sheath placement, coronary angiography, ventriculography, and right heart catheterization. Furthermore, they will learn the interpretation of hemodynamic data, angiographic data and the appropriateness for diagnostic catheterization and coronary revascularization. Fellows will learn the fundamentals of radiation safety as it pertains to the catheterization laboratory. Finally, the fellows will participate in the post-procedure management of the patients, particularly management of complications. Ultimately the cardiac catheterization laboratory rotation provides a platform for teaching and learning the core knowledge base of cardiac anatomy, physiology, pathology and therapeutics that all cardiologists should possess regardless of whether they perform invasive CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 8 cardiovascular procedures. The cardiac catheterization rotations are also a component of the fellows’ exposure to ECG interpretation with routine review of pre-procedure ECGs. Training Goals and Objectives The cardiac catheterization rotation and associated training is designed to provide the fellow, within the standard three year program, two potential levels of COCATS training: • COCATS Level I: (4 months experience minimum) o All fellows are expected to achieve COCATS Level I training during the fellowship. o Trainee should participate in minimum of 100 diagnostic procedures. o At least 50 of these should involve coronary angiography and 25 should involve hemodynamic assessment of valvular, myocardial, pericardial, or congenital disease. • COCATS Level II: (6 months experience minimum) o All fellows have the opportunity to achieve COCATS Level II training during the fellowship program. o Participation in the performance of 300 diagnostic catheterization procedures. COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. Penn State Hershey offers a subspecialty Level III training program which can be applied for following general cardiology fellowship. Specific curricular milestones for cardiac catheterization, as they relate to the Core Competencies promulgated by the ACGME, are adopted as outlined in the COCATS 4 Task Force 10 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Expectations and Responsibilities • • • Attend the Cardiac Catheterization conferences throughout the year. o When assigned, prepare a topic or case review for presentation during Cardiac Cath conference. Track participation in performing cardiac catheterization procedures. The following specific responsibilities pertain to all fellows during the rotation: o See and evaluate the patient prior to the planned procedure. o Review and understand the indication for each planned procedure. o Complete the History and Physical (H&P) note for the first patient of the day. Subsequent H&P’s may be written by the CRNP or PA, but the fellow is expected to help with additional review, examination, and documentation when available or necessary. Know pertinent details of each patient on whom you expect to perform a procedure regardless of who completed the H&P. o Obtain informed consent from the patient or their designated representative. Review the procedure along with its indication, risks, benefits, and alternatives. o Discuss the indications, history, examination, prior cardiac work-up, and planned procedure strategy with the designated faculty prior to each case. o Discuss appropriate use criteria (AUC) for diagnostic catheterization, pertaining to the case. When indicated, discuss the AUC for coronary revascularization. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 9 o o o o o o o Participate in the planned procedure in a manner commensurate with the fellow’s current level of experience under the direct guidance of the involved faculty. Participate in analyzing the angiographic and hemodynamic data obtained during the procedure. Participate in discussion on formulation of treatment plan. Preparation and completion of the procedure report. To be completed as timely as possible, no later than the end of the day. Communicate procedural findings and/or testing results to the referring team. Explain procedural findings and/or testing results, along with any new recommendations or plans to the patient or their designated representative. Assess the patient post procedure, including evaluation and treatment of any complications related to the procedure. Vacation/CME Time Time off for vacation and CME may be requested during this rotation. It is the fellow’s responsibility to make sure the minimum required fellow presence is available for this rotation: • • The catheterization lab requires the presence of at least one fellow, preferably two fellows. First year fellows should not be left alone during their first month. When coverage is required to satisfy these minimum requirements, it is the fellow’s responsibility to arrange this coverage and notify any involved faculty. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. Faculty Supervision and Responsibilities • • • One or more faculty members will be assigned to the Cardiac Cath lab for cases each day. These attendings will: o Discuss with the fellow(s), the indication for cardiac catheterization, history, examination, prior cardiac work up, investigations and plan procedure strategy. o Supervise the fellow(s) involved in the catheterization procedure to varying degrees, commensurate with their experience and skill level. o Supervise the fellow(s) in the interpretation of hemodynamic and angiographic data. o Review methodology – scientific research, published guidelines and expert opinion, used to assist with clinical decision making and learning. o Explain how to evaluate and risk stratify patients for further diagnostic or therapeutic options in real time (i.e. FFR, IVUS, PCI, Nitric Oxide). o Evaluate the fellow through standardized evaluations and provide direct feedback. Attend, participate in, and provide didactics for the cardiac catheterization conference and when possible multidisciplinary conferences and catheterization correlate conferences to provide added insight and expertise in cardiac catheterization and intervention to fellow and department education. Attend and participate in the catheterization laboratory morbidity and mortality conference. Recommended Resources and Reading • • COCATS 4 Task Force 10: Training in Cardiac Catheterization Society for Cardiovascular Angiography and Interventions: Guidelines & Documents o http://www.scai.org/Guidelines/default.aspx CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 10 • • • • Recommended Journal Articles by Faculty/Fellows ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 Appropriate Use Criteria for Diagnostic Catheterization. JACC 2012; 59 (22): 1995-2027 o http://content.onlinejacc.org/article.aspx?articleid=1182705#tbl1a ACCF/SCAI/STS/AATS/AA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update. JACC 2012; 59(9):857-881 o http://content.onlinejacc.org/article.aspx?articleid=1201161 Chambers CE, et al. Radiation Safety Program for the Cardiac Catheterization Laboratory. CCI 2011; 77: 546-5 Grossman & Baim’s Cardiac Catheterization, Angiography and Intervention, 8th Ed. Moscucci • The Cardiac Catheterization Handbook, 6th Ed. Kern, Sorajja, and Lim • Introductory Guide to Cardiac Catheterization, 2nd Edition • Ragosta M. Textbook of Clinical Hemodynamics, 1st Ed. Saunders Inc, Philadelphia, PA, 2008 • CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 11 Core Competency Components and Curricular Milestones for Training in CARDIAC CATHETERIZATION Medical Knowledge 1st Year 2nd Year 3rd Year Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the indications/contraindications and potential complications of cardiac catheterization for assessment of coronary, valvular, myocardial, and basic adult congenital heart diseases. I 2. Know the principles of radiation safety. I 3. Know the use and complications of contrast media and the role of renal protection measures. I 4. Know the indications for, and clinical pharmacology of, antiplatelet and anticoagulant drugs, and vasopressor and vasodilator agents, used in the cardiac catheterization laboratory. I 5. Know normal cardiovascular hemodynamics and the principles and interpretation of waveforms, pressure, flow, resistance, and cardiac output measurements. I 6. Know the characteristic hemodynamic findings with myocardial, valvular, pericardial, and pulmonary vascular diseases. I 7. Know the methods to detect and estimate the magnitude of intracardiac and extracardiac shunts. I 8. Know coronary anatomy, its variations and congenital abnormalities, and its coronary blood flow physiology. I 9. Know the angiographic features of coronary artery disease and how to assess the anatomic and physiologic severity. I 10. Know the vascular anatomy and the indications and contraindications for, and complications of, peripheral vascular angiography. I 11. Know the indications and potential complications of percutaneous coronary, peripheral, valvular, and structural heart interventions. I 12. Know the indications and contraindications for, and the complications of, endomyocardial biopsy and pericardiocentesis. I 13. Know the indications for, and the mechanisms of action of, mechanical circulatory support devices. I 14. Know the indications for, and complications of, vascular access and closure strategies and devices. I Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training Exam CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 12 Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of cardiac catheterization. 1. Skill to perform pre-procedural evaluation, assess appropriateness, obtain informed consent, and plan procedure strategy. I 2. Skill to perform venous and arterial access and obtain hemostasis. I 3. Skill to perform right heart catheterization. I 4. Skill to analyze hemodynamic, ventriculographic, and angiographic data, and to integrate with clinical findings for patient management. I 5. Skill to manage post-procedural patients, including complications and coordination of care. I 6. Skill to perform endomyocardial biopsy. II 7. Skill to perform pericardiocentesis. II 8. Skill to perform diagnostic left heart catheterization, ventriculography, and coronary angiography. II 9. Skill to place an intra-aortic balloon pump emergently. II 10. Skill to perform diagnostic peripheral (excluding carotid) angiography. II Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Procedure/Activity Logbook Systems-Based Practice 1st Year 2nd Year 3rd Year Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Coordinate care in an interdisciplinary approach for patient management, including transition of care. I 2. Utilize cost-awareness and risk/benefit analysis in patient care. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, 360 Reviews Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Locate, appraise, and assimilate information from scientific studies, guidelines, and registries in order to identify knowledge and performance gaps. I 2. Document number and outcomes of diagnostic and therapeutic procedures. I Evaluation Methods: Attending Evaluations, Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Procedure/Activity Logbook, Self-Evaluation CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 13 Professionalism 1st Year 2nd Year 3rd Year Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Practice within the scope of expertise and technical skills. I 2. Know and promote adherence to guidelines and appropriate use criteria. I 3. Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. Communicate with and educate patients and families across a broad range of socioeconomic, ethnic, and cultural backgrounds, including obtaining informed consent. I 2. Communicate and work effectively with physicians and other professionals on the healthcare team regarding procedure findings, treatment plans, and follow-up care coordination. I 3. Complete procedure records and communicate testing results to physicians and patients in an effective and timely manner. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluation, 360 Reviews If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 14 Faculty Evaluation of Cardiology Fellow on Cardiac Catheterization Instructions: The following evaluation questions have been devised using the COCATS 4 Core Competency Components and Curricular Milestones for Training in Cardiac Catheterization. The evaluation scale is modeled after the ACGME Milestones categories, which are competencybased developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. Subject Name Evaluated by: Status Employer Program Evaluator Name Status Employer Program Rotation Evaluation Dates MEDICAL KNOWLEDGE 1* Knows the indications/contraindications and potential complications of cardiac catheterization for assessment of coronary, valvular, myocardial, and basic adult congenital heart diseases. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 2* Knows the principles of radiation safety. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 3* Knows the use and complications of contrast media and the role of renal protection measures. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 4* Knows the indications for, and clinical pharmacology of, antiplatelet and anticoagulant drugs, and vasopressor and vasodilator agents, used in the cardiac catheterization laboratory. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 5* Knows normal cardiovascular hemodynamics and the principles and interpretation of waveforms, pressure, flow, resistance, and cardiac output measurements. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 15 Not Yet Assessed / Not Observed 6* Knows coronary anatomy, its variations and congenital abnormalities, and its coronary blood flow physiology. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 7* Knows the vascular anatomy and the indications and contraindications for, and complications of, peripheral vascular angiography. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 8* Knows the indications and potential complications of percutaneous coronary, peripheral, valvular, and structural heart interventions. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 9* Knows the indications and contraindications for, and the complications of, endomyocardial biopsy and pericardiocentesis. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 10* Knows the indications for, and the mechanisms of action of, mechanical circulatory support devices. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 11* Knows the indications for, and complications of, vascular access and closure strategies and devices. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 PATIENT CARE AND PROCEDURAL SKILLS 12* Possesses skills to perform preprocedural evaluation, assess appropriateness, obtain informed consent, and plan procedure strategy. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 16 Not Yet Assessed / Not Observed 13* Possesses skills to perform venous and arterial access and obtain hemostasis. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 14* Possesses skills to perform right heart catheterization. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 15* Possesses skills to analyze hemodynamic, ventriculographic, and angiographic data, and to integrate with clinical findings for patient management. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 16* Possesses skills to manage postprocedural patients, including complications and coordination of care. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 17* Possesses skills to perform endomyocardial biopsy. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 18* Possesses skills to perform pericardiocentesis. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 19* Possesses skills to perform diagnostic left heart catheterization, ventriculography, and coronary angiography. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 17 Not Yet Assessed / Not Observed 20* Possesses skills to place an intraaortic balloon pump emergently. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 5 Not Yet Assessed / Not Observed 21* Possesses skills to perform diagnostic peripheral (excluding carotid) angiography. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 5 Not Yet Assessed / Not Observed SYSTEMSBASED PRACTICE 22* Coordinates care in an interdisciplinary approach for patient management, including transition of care. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 5 Not Yet Assessed / Not Observed 23* Utilizes costawareness and risk/benefit analysis in patient care. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 5 Not Yet Assessed / Not Observed PRACTICEBASED LEARNING AND IMPROVEMENT 24* Locates, appraises, and assimilates information from scientific studies, guidelines, and registries in order to identify knowledge and performance gaps. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 5 Not Yet Assessed / Not Observed 25* Documents number and outcomes of diagnostic and therapeutic procedures. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 PROFESSIONALISM CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 18 Not Yet Assessed / Not Observed 26* Practices within the scope of expertise and technical skills. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 27* Interacts respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 INTERPERSONAL AND COMMUNICATION SKILLS 28* Communicates with and educates patients and families across a broad range of socioeconomic, ethnic, and cultural backgrounds, including obtaining informed consent. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 29* Communicates and works effectively with physicians and other professionals on the healthcare team regarding procedure findings, treatment plans, and followup care coordination. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 30* Completes procedure records and communicates testing results to physicians and patients in an effective and timely manner. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 OVERALL ASSESSMENT 31* Overall Assessment of this fellow on their Cardiac Catheterization rotation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 32 Comments: Please use the comment box below to offer detailed strengths and/or weaknesses of this fellow on their Cardiac Catheterization rotation. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 19 33* Is there any reason this fellow should not move to the next level of responsibility? Yes No Comment 34* Was this evaluation discussed with the fellow at the end of the rotation? *ACGME Program Requirement V.A.2.a).(1) states "faculty must evaluate fellow performance in a timely manner during each rotation and discuss this evaluation with each fellow at the completion of the assignment." Yes No Overall Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 20 CARDIAC CRITICAL CARE CURRICULUM Penn State Hershey Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date: ROTATION INFORMATION Name of Rotation Heart & Vascular Intensive Care Unit (HVICU or CCU) Supervising / Evaluating Faculty Members CHF Service: Omaima Ali, MD; John Boehmer, MD; Dwight Davis, MD; Eric Popjes, MD; David Silber, MD General Cardiology: Eric Chan, MD; Joy Cotton, MD; Andrew Foy, MD; Annick Haouzi, MD; John Kelleman, MD; Edward Liszka, MD; Michael Pfeiffer, MD; John Field, MD HVI Intensivists: Christoph Brehm, MD; Dirk Pabst, MD Anesthesia Intensivists: Octavio Falcucci, MD; Kane High, MD; Amit Prasad, MD; Kai Singbartl, MD Facility / Location Heart and Vascular ICU / Hershey Medical Center Clinical Experience All fellows will have a minimum of 1 month of direct Cardiac Critical Care experience. Cardiac Critical Care rounds will also occur routinely on all inpatient services. Additional elective time for interested fellows is available. Further exposure and overlap experience to Cardiac Critical Care content is anticipated for all fellows on the following rotations: • Inpatient Acute Service • Heart Failure Service • Inpatient Consults • Cardiac Catheterization • Echocardiography • Electrophysiology Didactics There is no dedicated Cardiac Critical Care Lecture Series. Cardiac critical care lectures will occur as a part of the Core Conference Series. Additional cardiac critical care related cases and topics are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference • Echocardiography Conference • Cath Conference • EP Conference Overview The cardiac critical care rotation, in conjunction with other inpatient cardiology rotations, provides direct exposure to the essentials of evaluation and management of patients with acute, life-threatening cardiovascular disease and conditions. This rotation places an emphasis on, and provides the opportunity for, the cardiology trainee to participate in interdisciplinary care teams in the critical care environment. The fellow will also achieve competency in appropriate and safe transitions of care out of the critical care environment to other care teams. The cardiac critical care rotation is also a component of the fellows’ exposure to ECG interpretation with routine and urgent evaluation of ECGs across a variety of scenarios. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 21 Training Goals and Objectives The cardiac critical care rotation is designed to provide the trainee, within the standard three year program, training that meets or exceeds COCATS Level I expectations. • COCATS Level I (2 months experience minimum) o All fellows are expected to achieve COCATS Level I training during the fellowship. o Experience will come during dedicated rotation and frequent ICU level rounds while on all inpatient service rotations. COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. At the present time, Penn State Hershey does not offer subspecialty training in Cardiac Critical Care. Specific curricular milestones for cardiac critical care as they relate to the Core Competencies promulgated by the ACGME are adopted from the ACC COCATS 4 Task Force 13 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Expectations and Responsibilities • • • • • • • • • Five consecutive weekdays, 12-hour shifts. Attend 7AM and 7PM ICU handoff rounds. Round with Intensivist team and act as a liaison between the Cardiology and Intensivist teams and assist in decision-making. Provide cardiology consultation on patients in the ICU, as requested. Responsible for consult note on cardiology consult patients and rounding with appropriate cardiology attending. Assist in the scheduling of cardiac procedures in HVICU patients (cath lab, TEE). Teach the ICU staff about cardiology topics. Assist in procedures performed in the HVICU (PA catheter and art line placements, IABP placement, TEE, ECMO). Participate in end-of-life issues, family discussions and meetings. Vacation/CME Time It is expected that fellows do NOT request routine time off for vacation or CME during this rotation. In the event of an urgent or unavoidable absence, coverage should be arranged by the fellow in advance. It is the fellow’s responsibility to notify any involved faculty and team members. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. Faculty Supervision and Responsibilities • • • The fellow will be supervised jointly by the Cardiology attendings on service and the Intensivist team attending. The appropriate attending will supervise the fellow, as required, during procedures done in the HVICU. The attendings will be available for ICU rounds and discuss acute patient problems. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 22 • • Attendings will provide input to patient notes provided by the fellow. Faculty will provide teaching to fellows in their area of expertise. Recommended Resources and Reading • • • COCATS 4 Task Force 13: Training in Critical Care Cardiology Recommended Journal Articles by Faculty/Fellows Braunwald’s Heart Disease 10th Ed, Mann, Zipes, Libby, Bonow CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 23 Core Competency Components and Curricular Milestones for Training in CARDIAC CRITICAL CARE Medical Knowledge 1st Year 2nd Year 3rd Year Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the pathophysiology, differential diagnosis, and characteristic clinical, hemodynamic, radiographic, and laboratory findings of cardiogenic, hypovolemic, septic, and mixed circulatory shock, and of the systemic inflammatory response syndrome. I 2. Know the indications for, and characteristic findings with, bedside invasive and noninvasive hemodynamic monitoring. I 3. Know the indications, contraindications, and clinical pharmacology for vasoactive and inotropic medications used in the treatment of patients with advanced heart failure, hypotension, or shock. I 4. Know the indications, contraindications, and clinical pharmacology for anticoagulant, antiplatelet and fibrinolytic agents. I 5. Know the indications for, contraindications to, and clinical pharmacology of agents used to treat hypertensive urgencies and emergencies. I 6. Know the indications, contraindications, and clinical pharmacology for agents used to treat pulmonary hypertension, including intravenous, inhalational and oral agents. I 7. Know the indications, contraindications, and clinical pharmacology for agents used to treat supraventricular and ventricular arrhythmias. I 8. Know the indications for, contraindications to, and risks of catheter-based techniques to treat supraventricular and ventricular arrhythmias. I 9. Know the characteristic clinical, electrocardiographic, echocardiographic, and radiographic findings with pulmonary embolism, aortic dissection, pericardial tamponade, acute decompensated severe heart failure, severe valvular heart disease, and myocardial infarction. I 10. Know the indications for oxygen supplementation, endotracheal intubation, and mechanical ventilator support for patients with hypoxia and/or respiratory failure. I 11. Know the differential diagnosis and characteristic laboratory findings of oliguria and acute kidney injury. I 12. Know the characteristic physical examination, echocardiographic, angiographic, and hemodynamic findings of mechanical complications of myocardial infarction (e.g., ventricular septal defect, mitral regurgitation, and right ventricular infarction). I 13. Know the types of, and indications for, mechanical circulatory support, including intraaortic balloon counterpulsation, ventricular assist (both surgical) devices, and extracorporeal membrane oxygenation. I 14. Know the principles of treatment of hypotension in special populations, including patients with cardiogenic shock, hypertrophic obstructive cardiomyopathy, right ventricular infarction, massive pulmonary embolism, pericardial tamponade, and h k 15. di Knowibthei indications for emergency surgery in patients with aortic dissection. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 24 I I 16. Know the indications for emergent/urgent surgery and transcatheter valve replacement/repair in patients with severe valvular heart disease. I 17. Know the differential diagnosis of heart failure or shock in cardiac transplant patients. I 18. Know the elements of risk scoring systems for the assessment of prognosis in acute coronary syndrome, advanced heart failure, and pulmonary hypertension, including demographics and findings from the clinical examination, electrocardiogram, biomarker i the indications i h forhuse of di hypothermia h d iprotocols i h and the d principles i 19. Know of postresuscitation bundled care. 20. Know the elements of scoring systems for assessment of the risk of major bleeding in patients treated with antithrombotic medications. I I I Evaluation Methods: Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of cardiac critical care. 1. Skill to manage patients with acute myocardial infarction and any associated rhythm, conduction, or mechanical complications. I 2. Skill to evaluate and manage acutely unstable cardiac patients by integrating the findings from clinical, electrocardiographic, telemetry, imaging, and hemodynamic assessment – and to develop a plan for bedside intervention. I 3. Skill to place arterial, central venous, and pulmonary artery catheters and temporary transvenous pacemakers in sequence with cardiac catheterization laboratory rotations. I 4. Skill to recognize when renal replacement therapy is indicated, and to manage in conjunction with nephrology consultants. I 5. Skill to utilize appropriately therapeutic hypothermia protocols in survivors of cardiac arrest in conjunction with neurologic consultants. I 6. Skill to evaluate and manage patients with hemodynamic instability following cardiac surgery. I 7. Skill to evaluate and manage patients with hemodynamic instability following transcatheter valve therapy. I 8. Skill to evaluate and manage supraventricular and ventricular arrhythmias and conduction disturbances in unstable patients in collaboration with electrophysiology specialists. I 9. Skill to use vasopressor and inotropic therapy appropriately in various types of shock. I 10. Skill to incorporate mechanical circulatory support in the management of critically ill patients. I 11. Skill to place intra-aortic balloon pump emergently. I CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 25 12. Skill to identify and manage pericardial tamponade, including emergency pericardiocentesis. I 13. Skill to participate in the perioperative care of heart transplant and ventricular assist device patients, in collaboration with heart failure experts, interventional cardiologists, and surgical consultants. I 14. Skill to monitor blood pressure and hemodynamic state in patients with continuous flow left ventricular assist devices, in collaboration with heart failure specialists, interventional cardiologists, and/or surgeons. I 15. Skill to manage hypertensive urgencies and emergencies. I 16. Skill to manage special populations of critically ill cardiovascular patients including those with aortic dissection, massive or submassive pulmonary embolism, acute severe valvular regurgitation, and advanced pulmonary hypertension with right ventricular dysfunction. I 17. Skill to manage patients with acute bleeding, including bleeding from vascular access or spontaneous bleeding. I 18. Skill to perform noninvasive ventilation and CO2 monitoring. I 19. Skill to incorporate oxygen supplementation and mechanical ventilation in patient management. I 20. Skill to utilize risk assessment scoring systems when appropriate in patient management and counseling. I 21. Skill to identify when further medical care is futile and to counsel families on end-of-life care. I 22. Skill to coordinate safe and effective transitions of care in collaboration with other members of the care team. I Evaluation Methods: Systems-Based Practice 1st Year 2nd Year 3rd Year Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Work effectively with all members of the critical care unit team including heart failure/transplant specialists, electrophysiologists, interventionalists, surgeons, pulmonary critical care physicians, nephrologists, neurologists, nurses, physician’s assistants, pharmacists, social workers, and other team members as required. I 2. Participate in hospital quality and safety initiatives in the critical care units. I 3. Utilize interdisciplinary input and expertise in comanagement of critically ill patients, including transitions of care. I Evaluation Methods: CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 26 Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement. I 2. Utilize point-of-service resources to enhance adherence to guidelines and protocols and obtain new information from trials and professional societies. I 3. Incorporate appropriate use criteria, risk/benefit analysis, and cost considerations in the use of testing and treatment. I Evaluation Methods: Professionalism 1st Year 2nd Year 3rd Year Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Work effectively in an interdisciplinary critical coronary care unit environment. I 2. Demonstrate sensitivity to patient preferences and values and end-of-life issues. I 3. Practice within the scope of expertise and technical skills. I 4. Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. I Evaluation Methods: Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic backgrounds. I 2. Communicate and work effectively with physicians and other professionals on the healthcare team in the management of critically ill patients and their transition to other care environments. I 3. Communicate with families with regard to end-of-life decisions with respect to programming of pacemakers and implantable cardioverter-defibrillators. I Evaluation Methods: If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 27 Faculty Evaluation of Cardiology Fellow on Cardiac Critical Care Instructions: The following evaluation questions have been devised using the COCATS 4 Core Competency Components and Curricular Milestones for Training in Cardiac Critical Care. The evaluation scale is modeled after the ACGME Milestones categories, which are competencybased developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. Subject Name Evaluated by: Status Employer Program Evaluator Name Status Employer Program Rotation Evaluation Dates MEDICAL KNOWLEDGE 1* Knows the pathophysiology, differential diagnosis, and characteristic clinical, hemodynamic, radiographic, and laboratory findings of cardiogenic, hypovolemic, septic, and mixed circulatory shock, and of the systemic inflammatory response syndrome. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 2* Knows the indications for, and characteristic findings with, bedside invasive and noninvasive hemodynamic monitoring. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 3* Knows the indications, contraindications, and clinical pharmacology for anticoagulant, antiplatelet and fibrinolytic agents. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 4* Knows the indications for, contraindications to, and clinical pharmacology of agents used to treat hypertensive urgencies and emergencies, pulmonary hypertension, and supraventricular and ventricular arrhythmias. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 28 Not Yet Assessed / Not Observed 5* Knows the characteristic clinical, electrocardiographic, echocardiographic, and radiographic findings with pulmonary embolism, aortic dissection, pericardial tamponade, acute decompensated severe heart failure, severe valvular heart disease, and myocardial infarction. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 PATIENT CARE AND PROCEDURAL SKILLS 6* Possesses skills to manage patients with acute myocardial infarction and any associated rhythm, conduction, or mechanical complications. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 7* Possesses skills to evaluate and manage acutely unstable cardiac patients by integrating the findings from clinical, electrocardiographic, telemetry, imaging, and hemodynamic assessment and to develop a plan for bedside intervention. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 8* Possesses skills to evaluate and manage patients with hemodynamic instability following cardiac surgery and transcatheter valve therapy. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 9* Possesses skills to participate in the perioperative care of heart transplant and ventricular assist device patients, in collaboration with heart failure experts, interventional cardiologists, and surgical consultants. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed SYSTEMSBASED PRACTICE 10* Works effectively with all members of the critical care unit team, including heart failure/transplant specialists, electrophysiologists, interventionalists, surgeons, pulmonary critical care physicians, nephrologists, neurologists, nurses, physician's assistants, pharmacists, social workers, and other team members as required. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 29 Not Yet Assessed / Not Observed PRACTICEBASED LEARNING AND IMPROVEMENT 11* Identifies knowledge and performance gaps and engages in opportunities to achieve focused education and performance improvement. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 12* Incorporates appropriate use criteria, risk/benefit analysis, and cost considerations in the use of testing and treatment. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 PROFESSIONALISM 13* Works effectively in an interdisciplinary critical coronary care unit environment. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 14* Demonstrates sensitivity to patient preferences, values, and endoflife issues. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 INTERPERSONAL AND COMMUNICATION SKILLS 15* Communicates with and educates patients and families across a broad range of cultural, ethnic, and socioeconomic backgrounds. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 16* Communicates and works effectively with physicians and other professionals on the healthcare team in the management of critically ill patients and their transition to other care environments. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 30 Not Yet Assessed / Not Observed OVERALL ASSESSMENT 17* Overall Assessment of this fellow on their Cardiac Critical Care rotation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 18 Comments: Please use the comment box below to offer detailed strengths and/or weaknesses of this fellow on their Cardiac Critical Care rotation. 19* Is there any reason this fellow should not move to the next level of responsibility? Yes No Comment 20* Was this evaluation discussed with the fellow at the end of the rotation? *ACGME Program Requirement V.A.2.a).(1) states "faculty must evaluate fellow performance in a timely manner during each rotation and discuss this evaluation with each fellow at the completion of the assignment." Yes No Overall Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 31 ECHOCARDIOGRAPHY CURRICULUM Penn State Hershey Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date: ROTATION INFORMATION Name of Rotation ECHOCARDIOGRAPHY Supervising / Evaluating Faculty Members Peter Alagona, MD; Omaima Ali, MD; Eric Chan, MD; Joy Cotton, MD; William Davidson, MD; Andrew Foy, MD; Joseph Gascho, MD; Annick Haouzi, MD; John Kelleman, MD; Edward Liszka, MD; Urs Leuenberger, MD; Michael Pfeiffer, MD; Eric Popjes, MD Facility / Location Echo Lab, Inpatient Units, Operating Rooms / Hershey Medical Center Clinical Experience All fellows will have a minimum of 6 months of direct echocardiography experience. Additional elective time for interested fellows is available. Further exposure to echocardiography content comprised of, but not limited to, the ordering, review, and clinical correlation of echocardiographic studies is anticipated for all fellows on the following rotations: • Inpatient Acute Service • Heart Failure Service • CCU • Consults • Outpatient Continuity Clinics (HMC and VA) Didactics Echocardiography Lecture Series – Every Tuesday @ 12:30pm in Hamilton Conference Room (4th Tuesday of each month is multimodality imaging) Additional echocardiography related cases and topics are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference Overview The echocardiography rotation is a comprehensive approach to learning the use of cardiac ultrasound imaging to diagnose and guide treatment of cardiovascular disease. The objective of this rotation is to provide a broad exposure to the field including an understanding of the fundamentals of cardiac ultrasound imaging and image acquisition, the approach to obtaining and optimizing images on different ultrasound systems, as well as accurate interpretation of transthoracic, transesophageal, and stress imaging. Fellows will be trained to perform transthoracic and transesophageal echocardiograms, learn appropriate supervision of stress echocardiography, and will gain improved understanding on the appropriate use of echocardiography to diagnose and guide therapy of cardiovascular diseases. The echocardiography rotations are also a component of the fellows’ exposure to ECG interpretation and stress testing (pharmacologic and exercise modalities) with routine review of rest and stress ECGs. Training Goals and Objectives The echocardiography rotation and associated training are designed to provide the trainee, within the standard three year program, three potential levels of COCATS training: CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 32 • • • COCATS Level I: (3 months experience minimum) o All fellows are expected to achieve COCATS Level I training within the first 2 years of fellowship. Minimum number of TTE examinations performed/interpreted: 75/150 COCATS Level II: (6 months experience minimum) o Required to perform and interpret echocardiographic studies independently in practice. o All fellows are expected to achieve COCATS Level II training during the fellowship. Minimum number of TTE examinations performed/interpreted: 150/300 Minimum number of SE/DSE examinations interpreted: 100 Minimum number of TEE examinations performed & interpreted: 50 • A minimum of 100 TEEs is strongly recommended. o Many fellows will achieve this in time to take the NBE Certification Exam in their 3rd year of fellowship. COCATS Level III: (9 month experience minimum) o Interested fellows must discuss the opportunity to achieve COCATS Level III training during the general fellowship with the echo lab director. This will include (but is not limited to): More intensive exposure to and experience with all areas of echocardiography including: • Echo Lab Administration • Quality Improvement • Advanced Echo Modalities/Techniques • Echo Focused Teaching Minimum number of TTE examinations performed/interpreted: 300/750 Although not formally outlined in COCATS, a substantially higher number of stress echoes and TEEs is also anticipated for those fellows who desire to attain Level III training. o This decision should be made before the beginning of the 3rd year of training to ensure proper preparation of the schedule and training experience. Specific curricular milestones for Echocardiography, as they relate to the Core Competencies promulgated by the ACGME, are adopted from the COCATS 4 Task Force 5 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Expectations and Responsibilities • • • Attend and participate in the echocardiography conference series throughout the year. o When assigned, prepare a topic or case review for presentation during Echocardiography conference. Track participation in performing and interpreting studies. o Separate tracking of TTEs, stress echoes, and TEEs is required. o Studies performed or interpreted during conferences and while not on the echocardiography rotation should also be tracked. Be present in the echo lab area throughout the working day to maximize education and learning from direct experience, faculty supervision, and focused teaching. This includes: o Be available to answer the phones and field questions from sonographers, staff, and referring providers. o Assist with the evaluation and management of critical findings, patient complaints, and test complications. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 33 Prepare comprehensive preliminary reads on transthoracic, exercise stress, and dobutamine stress echocardiographic studies. Provide preliminary interpretation of the resting and stress ECGs for all stress echoes. o Supervise stress echocardiogram exams when required. All fellows are expected to directly supervise at least 10 stress echoes. o When necessary, contact ordering physicians directly with significantly abnormal or unexpected findings (such as abnormal stress test, cardiac tamponade, or new diagnosis severe aortic stenosis). o Learn the appropriate technique for ultrasound contrast preparation and administration including agitated saline and microbubble contrast. Assist with preparation and administration of ultrasound contrast when nursing is not available. One fellow in the lab must be assigned to transesophageal echocardiography studies on a daily basis. This responsibility should not be assigned to 1st year fellows during their first 2 months in the lab. The following responsibilities pertain to TEE: o There should be one upper year fellow assigned and available to cover TEE each day. When more than one qualified fellow is available on the rotation, the fellows are responsible for arranging daily coverage assignments. o Carry the TEE pager (#3335) or have this forwarded to your pager. If forwarded, this forward should be removed at the end of the day. o Review each request for a TEE to determine appropriateness. o Review patient history, physical, and prior studies. o Understand and evaluate any potential contraindications for a TEE procedure. o Discuss each case with the supervising faculty before arranging or performing the study. o When appropriate arrange for TEE with anesthesia. o Be aware of the risk and benefits of sedation and of the TEE and provide informed consent to the patient or surrogate. o Administer moderate conscious sedation and perform the TEE under the direct guidance and supervision of the TEE attending. o Communicate results of the study to the patient and/or family. o Contact the referring provider with results when appropriate. o When there are no TEEs to perform, or all TEE responsibility for the day is completed, the TEE fellow should continue all other general responsibilities for the echo lab as outlined. Senior fellows are encouraged to participate in the orientation, supervision, and guidance of new 1st year fellows in the echo lab. Fellows on call will also be expected to triage, perform, interpret, and communicate results from STAT TTE and TEE studies requested during nights and weekends while sonographer coverage is not available. o An on call echo faculty will always be available for TEEs and as back-up for TTEs. o Please refer to addendum for additional information. Fellows who desire Level III Training should discuss additional expectations with the Echo Lab Director. o • • • • Vacation/CME Time Time off for vacation and CME may be requested during this rotation. It is the fellow’s responsibility to make sure the minimum required fellow presence is available for this rotation: • The Echocardiography Rotation requires the presence of at least one upper year fellow to cover TEE. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 34 When coverage is required to satisfy these minimum requirements, it is the fellow’s responsibility to arrange this coverage and notify any involved faculty. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. Faculty Supervision and Responsibilities • • • Multiple faculty members will be assigned to echo reading and TEE each day. These attendings will: o Be readily available to provide guidance and supervision for fellows as they perform the tasks of the rotations as outlined above. o Provide teaching and feedback to fellows on preliminary interpretation of TTEs, stress echoes, and TEEs. Ideally this will occur one-on-one in the reading room when possible. o Assist with answering questions/calls, communicating results, and supervising stress tests when a fellow requires guidance or is unavailable. o Attendings assigned to TEE will directly supervise and assist the fellow in triaging, preparing, and performing TEEs as outlined above. Attend and participate in echocardiography conferences and, when possible, multidisciplinary conferences to provide added insight and echocardiography expertise to fellow and department education. Evaluate the fellow through direct feedback and standardized evaluations. Recommended Resources and Reading • • • • COCATS 4 Task Force 5: Training in Echocardiography American Society of Echocardiography: Guidelines & Standards o http://asecho.org/guidelines/guidelines-standards/ National Board of Echocardiography o http://www.echoboards.org/content/ascexam%C2%AE Appropriate Use Criteria for Echocardiography o http://asecho.org/files/AUCEcho.pdf Recommended Journal Articles by Faculty/Fellows Textbook of Clinical Echocardiography, 5th Ed., Otto • The Echo Manual, 3rd Ed., Oh, Seward, Tajik • • CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 35 • Feigenbaum’s Echocardiography, 7th Ed., Armstrong, Ryan CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 36 Core Competency Components and Curricular Milestones for Training in ECHOCARDIOGRAPHY 1st Year 2nd Year 3rd Year Medical Knowledge Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the physical principles of ultrasound, and the instrumentation used to obtain images. I 2. Know the appropriate indications, including the AUC, for: M-mode, 2-dimensional, and 3dimensional transthoracic echocardiography; Doppler echocardiography and color flow imaging; transesophageal echocardiography; tissue Doppler and strain imaging; and contrast echocardiography. I 3. Know the limitations and potential artifacts of the echocardiographic examination. I 4. Know the standard views included in a comprehensive transthoracic echocardiography. I 5. Know the standard views included in a comprehensive transesophageal echocardiography. I 6. Know the techniques to quantify cardiac chamber sizes and evaluate left and right ventricular systolic and diastolic function and hemodynamics. 7. Know the characteristic findings of cardiomyopathies. II I 8. Know the use of echocardiographic and Doppler data to evaluate native and prosthetic valve function and diseases. 9. Know the echocardiographic and Doppler findings of cardiac ischemia and infarction, and the complications of myocardial infarction. 10. Know the echocardiographic findings of pericardial disease, pericardial effusion, and pericardial constriction. II I II 11. Know the characteristic findings of basic adult congenital heart disease. II 12. Know the findings of complex/postoperative adult congenital heart disease. III*+ 13. Know the techniques to evaluate cardiac masses and suspected endocarditis. II 14. Know the techniques to evaluate diseases of the aorta. II 15. Know the techniques to assess pulmonary artery pressure and diseases of the right heart. II 16. Know the use and characteristic findings in the evaluation of patients with systemic diseases involving the heart. II 17. Know the indications for, and the echocardiographic findings in, patients with known or suspected cardioembolic events. II 18. Know key aspects of contrast echocardiography including interpretation, administration techniques, and safety information. II 19. Understand the principles and applications of 3-dimensional echocardiography. II 20. Recognize and treat the potential complications of stress, contrast, and transesophageal echocardiography. II Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training Exam CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 37 Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of echocardiography. 1. Skill to perform and interpret a basic transthoracic echocardiography exam. I 2. Skill to perform and interpret comprehensive transthoracic echocardiography exam. II 3. Skill to perform and interpret comprehensive transesophageal echocardiography exam. II 4. Skill to recognize pathophysiology, quantify severity of disease, identify associated findings, and recognize artifacts in echocardiography. II 5. Skill to integrate echocardiographic findings with clinical and other testing results in the evaluation and management of patients. I 6. Skill to interpret stress echocardiography. II 7. Skill to incorporate stress hemodynamic information in the management of complex valve disease or hypertrophic cardiomyopathy. II 8. Skill to utilize echocardiographic techniques during cardiac interventions, including intraoperative transesophageal echocardiography. III+ 9. Skill to perform and interpret basic 3-dimensional echocardiography. II 10. Skill to utilize advanced 3-dimensional echocardiography during guidance of procedures and/or surgery. III+ 11. Skill to perform and interpret contrast echocardiography studies. Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Procedure/Activity Logbook II 1st Year 2nd Year 3rd Year Systems-Based Practice Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Work effectively and efficiently with the echocardiography laboratory staff. I 2. Incorporate risk/benefit, safety, and cost considerations in the use of ultrasound techniques. I 3. Participate in echocardiographic quality monitoring and initiatives. II Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Conference Presentations, SelfEvaluation, 360 Reviews Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement. I Evaluation Methods: Attending Evaluations, Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 38 1st Year 2nd Year 3rd Year Professionalism Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Know and promote adherence to guidelines and appropriate use criteria. I 2. Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic backgrounds. II 2. Communicate testing results to physicians and patients in an effective and timely manner. II 3. Communicate detailed information on cardiac anatomy for surgical planning or guidance of interventional procedures. II Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluation *Because of its unique and specialized nature, competency in interpreting complex and post-operative congenital heart disease echocardiography studies will usually require training beyond Level II. +See definition of Level III training in Section 1.2 of COCATS Task Force 5. If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 39 POLICY CONCERNING STAT TRANSTHORACIC AND TRANSESOPHAGEAL ECHOCARDIOGRAMS DURING NIGHTS AND HOLIDAYS When a STAT echocardiogram is requested, the on call cardiology fellow should be called. Indications for STAT echocardiography generally include but are not limited to the following: 1. 2. 3. 4. 5. Assessment of hemodynamic collapse or cardiogenic shock when other diagnostic modalities have not elucidated the diagnosis. Assessment of suspected cardiac tamponade when suggested by a clinical history, physical exam or hemodynamic monitoring. Suspected aortic dissection. Patients with bona fide suspicion for traumatic aortic dissection should be directly studied by transesophageal echo. Suspected cardiac contusion in the hemodynamically unstable patient or in patients requiring urgent surgical intervention. Patients with suspected cardiac contusion, who are clinically stable without suspicion of traumatic aortic dissection, can be studied routinely in the Echo Lab. On the weekends, we request that contusion studies be performed within 24 hours of request. In addition, the 12 lead EKG should be reviewed at the time the echo is performed. Evaluation of LV function or valvular heart function in the acutely ill patient requiring urgent percutaneous coronary revascularization, percutaneous valvuloplasty, or cardiac surgery. The fellow is expected to contact the cardiology attending on call for TEEs when an after hour STAT TEE is ordered. Coordination of the TEE should be made with the attending. For STAT transthoracic echoes, the fellow should fill out a preliminary report on Synapse and communicate the findings verbally or by writing a preliminary note in the chart. The fellow should discuss any questions with the on call echo attending. When the patient is clinically unstable, the TEE team should be mobilized without further delay. The echo attending must be present for all TEEs. The only exception to this policy would be the hemodynamically unstable patient when the transesophageal echocardiography is an absolute emergency and the fellow has sufficient experience to operate semiindependently. In this extremely rare situation, the senior cardiology fellow on call should communicate the specifics of the procedure as soon as it is completed. A TEE attending is always available on call. As with any emergent imaging study, the results of the study must be fully documented in the progress notes and directly communicated to the responsible physician. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 40 Faculty Evaluation of Cardiology Fellow on Echocardiography Instructions: The following evaluation questions have been devised using the COCATS 4 Core Competency Components and Curricular Milestones for Training in Echocardiography. The evaluation scale is modeled after the ACGME Milestones categories, which are competencybased developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. Subject Name Evaluated by: Status Employer Program Evaluator Name Status Employer Program Rotation Evaluation Dates 1* Knows and promotes adherence to guidelines and appropriate use criteria. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 2* Possesses skills to perform and interpret comprehensive transthoracic echocardiography exam. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 3* Possesses skills to perform and interpret comprehensive transesophageal echocardiography exam. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 4* Possesses skills to interpret stress echocardiography. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 5* Knows the techniques to quantify cardiac chamber sizes and evaluate left and right ventricular systolic and diastolic function and hemodynamics. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 41 Not Yet Assessed / Not Observed 6* Knows the use of echocardiographic and Doppler data to evaluate native and prosthetic valve function and diseases. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 7* Works effectively and efficiently with the echocardiography laboratory staff. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 8* Communicates testing results to physicians and patients in an effective and timely manner. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 9* Interacts respectfully with patients, families, and all members of the healthcare team. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 10* Identifies knowledge and performance gaps and engages in opportunities to achieve focused education and performance improvement. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 OVERALL ASSESSMENT 11* Overall Assessment of this fellow on their Echocardiography rotation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 12 Comments: Please use the comment box below to offer detailed strengths and/or weaknesses of this fellow on their Echocardiography rotation. 13* Is there any reason this fellow should not move to the next level of responsibility? Yes No Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 42 14* Was this evaluation discussed with the fellow at the end of the rotation? *ACGME Program Requirement V.A.2.a).(1) states "faculty must evaluate fellow performance in a timely manner during each rotation and discuss this evaluation with each fellow at the completion of the assignment." Yes No Overall Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 43 ELECTROPHYSIOLOGY CURRICULUM Penn State Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date: ROTATION INFORMATION Name of Rotation ELECTROPHYSIOLOGY Supervising / Evaluating Faculty Members Mario Gonzalez, MD; Sarah Hussain, MD; Gerald Naccarelli, MD; Soraya Samii, MD; Deborah Wolbrette, MD Facility / Location EP Lab, Inpatient Units, Device Clinic / Hershey Medical Center Clinical Experience All fellows will have a minimum of 2 months of direct electrophysiology experience. Additional elective time for interested fellows is available. Further exposure and overlap experience to electrophysiology content comprised of, but not limited to, ECG review and interpretation, arrhythmia diagnosis and management, and pacemaker/AICD exposure is anticipated for all fellows on the following rotations: • Inpatient Acute Service • Heart Failure Service • Consults • CCU • Outpatient Continuity Clinics (HMC and VA) • Nuclear Cardiology • Echocardiography Didactics Electrophysiology Lecture Series; Every other Tuesday @ 7am in Hamilton Conference Room Additional electrophysiology related cases and topics are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference Overview The clinical cardiac electrophysiology rotation provides direct exposure to the fundamentals of diagnosis and management of cardiac arrhythmias and conduction disorders. This includes understanding the mechanisms and management of arrhythmias required to provide comprehensive patient care. The trainee will participate in electrophysiology focused consultation and management in the inpatient and outpatient settings; observe and participate in EP studies, testing, and procedures; and work with appropriate staff on the interrogation and programming of implanted cardiac devices. The electrophysiology rotation is a key component of the fellows’ exposure to ECG interpretation. Training Goals and Objectives The electrophysiology rotation and associated training is designed to provide the trainee, within the standard three year program, two potential levels of COCATS training. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 44 • COCATS Level I: (2 months experience minimum) o All fellows are expected to achieve COCATS Level I training within the standard 3-year training program. Minimum number of procedure involvement: • Electrocardioversions: 20 • Temporary Pacemakers: 5 • COCATS Level II: (6 months experience minimum) o Interested fellows must discuss the opportunity to achieve COCATS Level II training during general fellowship with a member of the EP faculty. This will include (but is not limited to): Requisite number of EP rotations. Minimum number of device interrogations/programming: 100 (25 remote) Arranging additional EP focused outpatient clinic exposure o It is anticipated this level of training will be pursued by fellows who desire to move on to Level III subspecialty training in electrophysiology or who intend a career in an area with limited access to EP specialists. COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. Penn State Hershey offers subspecialty training in Electrophysiology which can be applied for following general cardiology fellowship. Specific curricular milestones for electrophysiology as they relate to the Core Competencies promulgated by the ACGME are adopted from the ACC COCATS 4 Task Force 11 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Expectations and Responsibilities • • • • Attend and participate in the electrophysiology conference series throughout the year. o When assigned, prepare a topic or case review for presentation during electrophysiology conference. Track participation in at least the following procedures: o Temporary Pacemaker Placement o Electrocardioversion (ECV) Temporary Pacemakers and ECVs performed while not on EP rotation should also be tracked. Daily availability to see new EP consults and write an appropriate consult note, present pertinent data to the assigned EP faculty, communicate recommendations and provide longitudinal follow-up to the referring team as appropriate. In addition to daily assistance with EP consults the fellow is expected to participate in AT LEAST one of the following activities on a daily basis: o Observe and participate in electrocardioversions, electrophysiology studies, ablations, and device implantations in the EP lab. The minimum numbers for participation in temporary pacemakers and ECVs are outlined, but observing all the procedures at least once is encouraged. Check with EP lab staff about procedure availability on a daily basis o Review and provide preliminary interpretation for exercise ECG testing. Performed on most days. Contact person: Rich Bradford (or any exercise physiologist) CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 45 o o o o Review and provide preliminary interpretation for ambulatory ECG monitoring (Holter monitors) Performed in Lumedex Observe and participate in device interrogations and programming in the outpatient device clinic and on the inpatient units. Shadowing an EP technologist during the rotation is strongly encouraged. With appropriate training, fellows should perform their own interrogations Outpatient appointments occur every Monday, Wednesday, and Friday in the Device Clinic; Tuesday and Thursdays are telephonic interrogation and potentially not as useful for the fellows’ experience. Observe and participate in tilt table testing This occurs every other Monday morning in the Non-Invasive Lab (Stress Lab 1) Contact person: Barbara Bentz, CRNP (pager 2853) Attend outpatient EP clinic with an EP faculty member for one half day per week. This will occur on Fridays at Nyes Road clinic with Drs. Samii and Hussain The fellowship coordinator will confirm these dates with you 2 weeks before the start of your rotation so new patient visits can be specifically assigned for you to see with EP faculty supervision. The availability of several of the activities outlined above for the EP rotation fluctuates on a weekly basis. In general, it is anticipated the fellow will spend, on a daily basis, the equivalent of a half day seeing and following up on consults as needed and the equivalent of a half day participating in one of the other recommended or required activities. Reasonable adjustments will be suggested by faculty when appropriate, but are ultimately the responsibility of the fellow to maximize their educational opportunities. Vacation/CME Time Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless specified by the involved faculty. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. It is the fellow’s responsibility to ensure time off does not significantly impact or limit total exposure to any given rotation. Faculty Supervision and Responsibilities • • • • There will be at least one faculty member assigned to EP consults on a daily basis. This attending will: o Be available to review and round on new EP consults and follow-up issues. o Provide teaching and feedback to fellows on their EP focused history and physical, evaluation, and treatment plans. Guide the fellows through their observation and participation in electrocardioversions, electrophysiology studies, ablation procedures, and implantable cardiac devices. Attend and participate in electrophysiology conferences and, when possible, multidisciplinary conferences to provide added insight and electrophysiology expertise to fellow and department education. Evaluate the fellows through direct feedback and standardized evaluations. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 46 Recommended Resources and Reading • • • • COCATS 4 Task Force 11: Training in Arrhythmia Diagnosis and Management, Cardiac Pacing, and Electrophysiology Heart Rhythm Society Clinical Guidelines & Documents o http://www.hrsonline.org/Practice-Guidance/Clinical-GuidelinesDocuments?SearchText=&seeall=1#axzz3ikBeD6uL Recommended Journal Articles by Faculty/Fellows The Complete Guide to ECG, 4th Ed, O’Keefe, Hammill, Freed • Clinical Arrhythmology and Electrophysiology: A Companion to Braunwald's Heart Disease, 2nd Ed, Issa, Miller, Zipes • Josephson's Clinical Cardiac Electrophysiology, 5th Ed, Josephson • Cardiac Electrophysiology: From Cell to Bedside, 6th Ed, Zipes, Jalife • Handbook of Cardiac Electrophysiology: A Practical Guide to Invasive EP Studies and Catheter Ablation, 1st Ed, Murgatroyd, Krahn, Yee, Skanes, Klein CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 47 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 48 Core Competency Components and Curricular Milestones for Training in ELECTROPHYSIOLOGY 1st Year 2nd Year 3rd Year Medical Knowledge Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the mechanism and characteristics of normal sinus rhythm and of sinus node dysfunction. I 2. Know the pathophysiology, differential diagnosis, clinical significance, and approach to management of reentrant tachycardia (atrioventricular nodal re-entrant tachycardia; atrioventricular reciprocating tachycardia), ectopic atrial tachycardias, and accelerated atrioventricular junctional rhythm. I 3. Know the pathophysiology, differential diagnosis, clinical significance, and approach to management of atrial fibrillation and flutter, including the assessment of stroke and bleeding risk, indications of anticoagulation, and selection of anticoagulant medications. I 4. Know the risk factors for stroke and for bleeding in patients with atrial fibrillation or atrial flutter, as well as the indications for, and use of, anticoagulant medications. I 5. Know the pathophysiology, differential diagnosis, clinical significance, and approach to management of sustained and nonsustained ventricular tachyarrhythmias. I 6. Know the pathophysiology, differential diagnosis, and approaches to risk stratification and management of sudden cardiac death and cardiac arrest, including sudden cardiac death in athletes. I 7. Know the types, mechanisms, differential diagnosis, clinical significance, and approach to management of atrioventricular dissociation and atrioventricular heart blocks (first, second, and third degree). I 8. Know the physical examination characteristics of arrhythmias (e.g., findings of atrioventricular dissociation). I 9. Know the significance of underlying structural or congenital heart disease in the likelihood and significance of cardiac arrhythmias, including sudden death risk, and their impact in clinical management decisions. I 10. Know the indications, contraindications, and clinical pharmacology of antiarrhythmic medications, including drug-drug and drug-device interactions and proarrhythmia potential (including acquired long QT syndrome). I 11. Know the indications and limitations of noninvasive testing in the diagnosis and management of patients with arrhythmias: electrocardiogram, ambulatory, event, implantable loop recorder, and tilt-table testing. I 12. Know the indications for, and limitations and complications of, invasive electrophysiologic testing, as well as catheter ablation for cardiac arrhythmias. I 13. Know the indications and contraindications for permanent pacemaker placement, cardiac resynchronization therapy, and implantable cardioverter-defibrillator placement. I 14. Know the pathophysiology, differential diagnosis, natural history, and approach to management of syncope, including neurocardiogenic causes and syncope in athletes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 49 I 15. Know the mechanisms, findings, clinical significance, and approach to management of ventricular pre-excitation. I 16. Know the pathology, clinical significance, and approach to evaluation (including the role of genetic testing) and management of inherited diseases that may cause cardiac arrhythmias due to ion channel abnormalities or structural changes in the heart (including the long QT syndrome, Brugada syndrome, arrhythmogenic right ventricular dysplasia, hypertrophic dilated cardiomyopathy, and myotonic dystrophy). I 17. Know the principles and practice of radiation safety as applied to the evaluation and management of cardiac electrical disorders. I 18. Know the basic principles of programming and interrogating implanted devices (permanent pacemakers, implantable cardioverter-defibrillators, cardiac resynchronization therapies, and implantable monitors). I Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training Exam Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of electrophysiology. 1. Skill to evaluate and manage patients with palpitations. I 2. Skill to evaluate and manage patients with syncope. I 3. Skill to evaluate and manage patients with supraventricular tachyarrhythmias. I 4. Skill to evaluate and manage patients with atrial fibrillation and flutter (including rate and rhythm control and anticoagulation strategies). I 5. Skill to evaluate and manage patients with wide-QRS tachycardia. I 6. Skill to manage patients with nonsustained and sustained ventricular arrhythmias. I 7. Skill to evaluate and manage patients with bradycardia and/or heart block. I 8. Skill to perform electrical cardioversion. I 9. Skill to perform defibrillation. I 10. Skill to perform tilt-table testing. II 11. Skill to perform temporary pacemaker placement. I 12. Skill to select and manage patients requiring a permanent pacemaker, implantable cardioverter-defibrillator, or biventricular pacing. 13. Skill to integrate the information provided in cardiac electrophysiology consultation, and reports of procedures and device interrogation, into the overall clinical assessment of the patient and plan of management. 14. Skill to perform pacemaker and implantable cardioverter-defibrillator interrogation, programming, and surveillance. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 50 I I II 15. Skill to perform single- and dual-chamber permanent pacemaker implantation and manage complications, including device infections and chronic lead failure. II 16. Skill to perform implantation of implantable loop recorders, interpret results to guide patient management, and manage complications. II 17. Skill to follow-up, interrogate, and troubleshoot patients with implanted devices (permanent pacemakers, implantable cardioverter-defibrillators, cardiac resynchronization therapies), including remote interrogation. II 18. Skill to evaluate and manage patients with cardiac arrest. I 19. Skill to prescribe and interpret the results of electrocardiographic recording devices. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Procedure/Activity Logbook 1st Year 2nd Year 3rd Year Systems-Based Practice Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Utilize an interdisciplinary coordinated approach for patient management, including transfer of care and employment-related issues. I 2. Use technology and available registries to assess appropriateness, performance, and safety of implanted devices. I 3. Incorporate risk/benefit analysis and cost considerations in diagnostic and treatment decisions. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, 360 Reviews Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement. I 2. Utilize decision support tools for accessing guidelines and pharmacologic information at the point of care. I Evaluation Methods: Attending Evaluations, Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation 1st Year 2nd Year 3rd Year Professionalism Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Demonstrate sensitivity to patient preferences and end-of-life issues. I 2. Practice within the scope of expertise and technical skills. I 3. Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 51 Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic backgrounds. I 2. Engage in shared decision-making with patients, including decisions regarding options for diagnosis and treatment. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluation, 360 Reviews If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 52 Faculty Evaluation of Cardiology Fellow on Electrophysiology Instructions: The following evaluation questions have been devised using the COCATS 4 Core Competency Components and Curricular Milestones for Training in Cardiac Catheterization. The evaluation scale is modeled after the ACGME Milestones categories, which are competencybased developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. Subject Name Evaluated by: Status Employer Program Evaluator Name Status Employer Program Rotation Evaluation Dates MEDICAL KNOWLEDGE 1 Knows the mechanism and characteristics of normal sinus rhythm and of sinus node dysfunction. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 2 Knows the pathophysiology, differential diagnosis, clinical significance, and approach to management of atrial fibrillation and flutter, including the assessment of stroke and bleeding risk, indications of anticoagulation, and selection of anticoagulant medications. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 3* Knows the risk factors for stroke and for bleeding in patients with atrial fibrillation or atrial flutter, as well as the indications for, and use of, anticoagulant medications. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 4 Knows the types, mechanisms, differential diagnosis, clinical significance, and approach to management of atrioventricular dissociation and atrioventricular heart blocks (first, second, and third degree). Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 53 Not Yet Assessed / Not Observed 5 Knows the indications, contraindications, and clinical pharmacology of antiarrhythmic medications, including drugdrug and drugdevice interactions and proarrhythmia potential (including acquired long QT syndrome). Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 6 Knows the indications and limitations of noninvasive testing in the diagnosis and management of patients with arrhythmias: electrocardiogram, ambulatory, event, implantable loop recorder, and tilttable testing. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 7 Knows the indications for, and limitations and complications of, invasive electrophysiologic testing, as well as catheter ablation for cardiac arrhythmias. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 8 Knows the indications and contraindications for permanent pacemaker placement, cardiac resynchronization therapy, and implantable cardioverterdefibrillator placement. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 9 Knows the pathophysiology, differential diagnosis, natural history, and approach to management of syncope, including neurocardiogenic causes and syncope in athletes. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 10 Knows the pathology, clinical significance, and approach to evaluation (including the role of genetic testing) and management of inherited diseases that may cause cardiac arrhythmias due to ion channel abnormalities or structural changes in the heart (including the long QT syndrome, Brugada syndrome, arrhythmogenic right ventricular dysplasia, hypertrophic dilated cardiomyopathy, and myotonic dystrophy). Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 54 Not Yet Assessed / Not Observed 11 Knows the basic principles of programming and interrogating implanted devices (permanent pacemakers, implantable cardioverterdefibrillators, cardiac resynchronization therapies, and implantable monitors). *Pacer clinic educator, please complete this question. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 PATIENT CARE AND PROCEDURAL SKILLS 12 Possesses skills to evaluate and manage patients with palpitations. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 13 Possesses skills to evaluate and manage patients with syncope. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 14 Possesses skills to evaluate and manage patients with supraventricular tachyarrhythmias. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 15 Possesses skills to evaluate and manage patients with atrial fibrillation and flutter (including rate and rhythm control and anticoagulation strategies). Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 16 Possesses skills to perform electrical cardioversion. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 55 Not Yet Assessed / Not Observed 17 Possesses skills to perform temporary pacemaker placement. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 18 Possesses skills to integrate the information provided in cardiac electrophysiology consultation, and reports of procedures and device interrogation, into the overall clinical assessment of the patient and plan of management. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 19 Possesses skills to perform pacemaker and implantable cardioverterdefibrillator interrogation, programming, and surveillance. *Pacer clinic educator, please complete this question. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 SYSTEMSBASED PRACTICE 20 Utilizes an interdisciplinary coordinated approach for patient management, including transfer of care and employmentrelated issues. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 21 Incorporates risk/benefit analysis and cost considerations in diagnostic and treatment decisions. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed PRACTICEBASED LEARNING AND IMPROVEMENT 22 Identifies knowledge and performance gaps and engages in opportunities to achieve focused education and performance improvement. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 56 Not Yet Assessed / Not Observed 23 Utilizes decision support tools for accessing guidelines and pharmacologic information at the point of care. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed PROFESSIONALISM 24 Demonstrates sensitivity to patient preferences and endoflife issues. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 25 Practices within the scope of expertise and technical skills. *Pacer clinic educator, please complete this question. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 26* Interacts respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed INTERPERSONAL AND COMMUNICATION SKILLS 27 Communicates with and educates patients and families across a broad range of socioeconomic, ethnic, and cultural backgrounds. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 28 Engages in shared decisionmaking with patients, including decisions regarding options for diagnosis and treatment. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 OVERALL ASSESSMENT CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 57 Not Yet Assessed / Not Observed 29* Overall Assessment of this fellow on their Electrophysiology rotation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 30 Comments: Please use the comment box below to offer detailed strengths and/or weaknesses of this fellow on their Electrophysiology rotation. 31* Is there any reason this fellow should not move to the next level of responsibility? Yes No Comment 32* Was this evaluation discussed with the fellow at the end of the rotation? *ACGME Program Requirement V.A.2.a).(1) states "faculty must evaluate fellow performance in a timely manner during each rotation and discuss this evaluation with each fellow at the completion of the assignment." Yes No Overall Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 58 HEART FAILURE CURRICULUM Penn State Hershey Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date ROTATION INFORMATION Name of Rotation HEART FAILURE Supervising / Evaluating Faculty Members Omaima Ali, MD; John Boehmer, MD; Dwight Davis, MD; Eric Popjes, MD; David Silber, MD Facility / Location Inpatient Units / Hershey Medical Center Clinical Experience All fellows will have a minimum of 2 months of direct heart failure experience. Additional elective time for interested fellows is available. Further exposure to Heart Failure content comprised of, but not limited to, acute inpatient care of heart failure patients, long-term management and follow-up of heart failure patients, imaging review and clinical correlation is anticipated for all fellows on the following rotations: • Inpatient Acute Service • CCU • Consults • Outpatient Continuity Clinics (HMC and VA) • Echocardiography Didactics There is no dedicated Heart Failure Lecture Series. Heart Failure lectures will occur as a part of the Core Conference Series. Additional heart failure related cases and topics are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference • Echocardiography Conference • Cath Conference Overview The heart failure service rotation provides the opportunity to diagnose, evaluate and treat patients who encompass a broad range of heart failure disorders. This rotation will allow the trainee to acquire the appropriate foundational tools to care for this unique population including knowledge pertaining to medical management, procedural techniques and advanced heart failure therapies including mechanical circulatory support. The rotation will also provide exposure to transplant medicine and management of patients both pre- and post-transplant. The heart failure rotations are also a component of the fellows’ exposure to ECG interpretation with routine review of inpatient ECGs. General Goals and Objectives The heart failure service rotation is designed to provide the trainee, within the standard three year program, two potential levels of COCATS training: • COCATS Level I: (2 months experience minimum) o All fellows are expected to achieve COCATS Level I training within the first two years of fellowship. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 59 • COCATS Level II: (4 months experience minimum) o Interested fellows must discuss the opportunity to achieve COCATS Level II training during the general fellowship with a member of the CHF faculty. This will include (but is not limited to): The requisite minimum number of CHF service rotations. Arranging CHF focused outpatient clinic exposure during the 3rd year of fellowship. Dedicated experience in right heart catheterization and biopsies with CHF faculty. CHF Focused Teaching. o It is anticipated this level of training will be pursued by fellows who desire to move on to Level III subspecialty training in heart failure or who intend a career in an area with limited access to CHF specialists. COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during the general fellowship in cardiovascular disease. At the present time, Penn State Hershey does not offer subspecialty training in Heart Failure. Specific curricular milestones for heart failure as they relate to the Core Competencies promulgated by the ACGME are adopted from the ACC COCATS 4 Task Force 12 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Expectations and Responsibilities • • • • • • • • Daily triage, evaluation, continuing care and disposition of patients admitted to the general cardiology heart failure service including: o Evaluation and triage of new patients from the emergency department and consultative service. o Review and confirm patient assessments performed by medicine resident and fellow coverage from night and weekend admissions. o On admitted patients a history and physical is performed to supplement the admitting resident’s comprehensive history and physical as needed. Develop an evidenced-based, individualized diagnostic and management plan for testing and treatment based on the current ACC/AHA, HFSA or ISHLT guidelines as it pertains to each patient. Present the history, physical examination, testing and/or treatment plans to the attending physician. o When the presentation is provided by residents or medical students, provide supplementary information as necessary. Communicate the provisional diagnosis, recommendations, test results and plan of care with the patient and/or family in addition to potential complications associated with recommended testing or treatment. Provide education to the patient and/or family about their disease process. Serve as a team leader and role model for the heart failure service team. o Attend, supervise or perform any necessary bedside procedures based on the skill level of associated house staff team members. o Review patient care plans and directly supervise residents and medical students. o Provide education to the residents, medical students and other heart failure team members. Serve as a liaison between the heart failure team and other services that may be providing non-cardiac treatment for heart failure patients. Assist in the management of patients who are undergoing evaluation for or who have had cardiac transplantation in conjunction with designated transplant coordinators. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 60 Vacation/CME Time It is expected that fellows do NOT request routine time off for vacation or CME during this rotation. In the event of an urgent or unavoidable absence, coverage should be arranged by the fellow in advance. It is the fellow’s responsibility to notify any involved faculty and team members. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. Faculty Supervision and Responsibilities • • A cardiology faculty member, with heart failure and transplant expertise, will be assigned to the heart failure service at all times. This faculty member will: o Attend rounds with the fellow at least once during the course of each day. o Be available by pager for concerns, questions on admitted patients, and urgent matters. o Provide guidance for patient care, consults, and use of appropriate testing procedures. o Provide supervision during procedures when appropriate and indicated. o Provide consultative services with the fellow on heart transplant, mechanically-assisted, and advanced heart failure patients admitted to the hospital on non-heart failure services. o Review and interpret with the fellow relevant data on patients under their care. o Help facilitate detailed discussions with patients and family members and be present for family meetings regarding patient’s condition, prognosis and plan of care. o Provide opportunity for teaching and raise teaching points during rounds and provide and lead more formal discussions and lectures at additional times during the work day/week. Evaluate the fellow through standardized evaluations and direct feedback based on clinical, procedural, professional, and academic interactions. Recommended Resources and Reading • • • • • COCATS 4 Task Force 12: Training in Heart Failure Heart Failure Society of America: Guidelines o http://www.hfsa.org/heart-failure-guidelines-2/ International Society for Heart & Lung Transplantation: Standards, Guidelines, and Consensus Documents o http://ishlt.org/guidelines/standardsStatements.asp Recommended Journal Articles by Faculty/Fellows Braunwald’s Heart Disease 10th Ed, Mann, Zipes, Libby, Bonow CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 61 Core Competency Components and Curricular Milestones for Training in HEART FAILURE 1st Year 2nd Year 3rd Year Medical Knowledge Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the pathophysiology, differential diagnosis, stages, and natural history of heart failure. 2. Know the characteristic history and physical exam findings, and their limitations, in evaluation of heart failure syndromes. I I 3. Know the pathophysiology of heart failure at the molecular, cellular, organ, and organismal levels, with emphasis on the roles of neurohormonal activation and left ventricular remodeling in disease progression. 4. Know the indications, contraindications, and clinical pharmacology for drugs used for treatment of heart failure, including adverse effects. I I 5. Know the indications, contraindications, and clinical pharmacology for the drugs used for the treatment of heart failure of all etiologies and degrees of severity and in special populations. II 6. Know the indications, contraindications, and clinical pharmacology for intravenous, vasoactive, and inotropic drugs used for cardiovascular support in advanced/refractory heart failure. 7. Know the appropriate pharmacologic or nonpharmacologic treatment for the prevention of heart failure in patients with either “pre” or “established” heart failure. I I 8. Know the clinical pharmacology and use of immunosuppressive medications and other interventions in heart transplant patients in the treatment of acute rejection. II 9. Know the types of and indications for mechanical circulatory support. II 10. Know the effects and interactions of heart failure with other organ systems (kidney, nutritional, metabolic) and in the setting of other systemic disease. I 11. Know the management of cardiac arrhythmias in heart failure patients, as well as the indications and risks of use of implantable cardioverter-defibrillator and cardiac resynchronization therapies. I 12. Know the indications for referral for cardiac transplantation. I 13. Know the management and diagnostic strategies for populations with heart failure not due to ischemic heart disease, including infiltrative and restrictive cardiomyopathies, inherited cardiomyopathies, and those associated with pregnancy and chemotherapy. II Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training Exam CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 62 Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of heart failure. 1. Skill to evaluate and manage patients with new-onset, chronic, and acute decompensated heart failure. I 2. Skill to evaluate and manage patients with severe heart failure despite treatment. 3. Skill to appropriately obtain and incorporate data from the history, laboratory studies, and imaging modalities in evaluation and management of heart failure patients. II I 4. Skill to interpret imaging results in the evaluation of heart failure patients. I 5. Skill to use history and physical examination findings to accurately assess volume status and perfusion in patients with heart failure. 6. Skill to perform invasive hemodynamic monitoring. II I 7. Skill to incorporate the results of hemodynamic measurements and monitoring to make appropriate management decisions in heart failure patients of all etiologies and severity. II 8. Skill to identify appropriate candidates for palliative care and hospice. I 9. Skill to recognize and manage cardiac arrhythmias, including the identification of appropriate candidates for implantable cardioverter-defibrillators, cardiac resynchronization therapy, or arrhythmia ablation. I 10. Skill to select and implement appropriate arrhythmia management, including utilization of implantable cardioverter-defibrillators, cardiac resynchronization therapy, and ablation of arrhythmias in patients with heart failure of all etiologies and severity. 11. Skill to recognize and manage comorbidities in heart failure patients. II I 12. Skill to manage heart failure patients with complex contributing comorbidities. II 13. Skill to identify and manage patients who require transition from hospital to home or to a care facility while on infusion of inotropic or vasoactive agents. II 14. Skill to appropriately utilize initial screening studies to determine patient eligibility for advanced therapies of individuals cared for at non-transplant / non-ventricular assist device facilities, in collaboration with Level III-trained individuals, who work at advanced therapy sites. II 15. Skill to interpret and incorporate results of cardiopulmonary exercise testing into management of heart failure patients, including physical activity and exercise recommendations. II 16. Skill to recognize, manage, and seek appropriate consultation for depression or undue anxiety in heart failure patients as part of their overall care. Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, Procedure/Activity Logbook CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 63 I 1st Year 2nd Year 3rd Year Systems-Based Practice Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Utilize appropriate care settings and teams for various levels and stages of heart failure. I 2. Incorporate risk/benefit analysis and cost considerations in diagnostic and treatment decisions. I 3. Identify and address financial, cultural, and social barriers to diagnostic and treatment recommendations. I 4. Utilize an interdisciplinary, coordinated, team approach for patient management, including care transitions, palliative care, and employment-related issues. I 5. Effectively utilize an interdisciplinary approach to monitor the progress of ambulatory patients with heart failure to maintain stability and avoid preventable hospitalization. II Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, 360 Reviews Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement. I 2. Utilize decision support tools for accessing guidelines and pharmacologic information at the point of care. II Evaluation Methods: Attending Evaluations, Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation 1st Year 2nd Year 3rd Year Professionalism Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Show compassion and effective management of end-of-life issues, including family meetings across the spectrum of patients with heart failure. I 2. Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic backgrounds. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 64 I 2. Engage in shared decision-making with patients, including options for diagnosis and treatment. I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluation, 360 Reviews If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 65 Faculty Evaluation of Cardiology Fellow on Heart Failure Instructions: The following evaluation questions have been devised using the COCATS 4 Core Competency Components and Curricular Milestones for Training in Heart Failure. The evaluation scale is modeled after the ACGME Milestones categories, which are competencybased developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. Subject Name Evaluated by: Status Employer Program Evaluator Name Status Employer Program Rotation Evaluation Dates MEDICAL KNOWLEDGE 1* Knows the pathophysiology, differential diagnosis, stages, and natural history of heart failure. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 2* Knows the characteristic history and physical exam findings, and their limitations, in evaluation of heart failure syndromes. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 3* Knows the indications, contraindications, and clinical pharmacology for the drugs used for the treatment of heart failure of all etiologies and degrees of severity and in special populations. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 4* Knows the types of, and indications for, mechanical circulatory support. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 5* Knows the indications for referral for cardiac transplantation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 66 Not Yet Assessed / Not Observed PATIENT CARE AND PROCEDURAL SKILLS 6* Possesses skills to evaluate and manage patients with newonset, chronic, and acute decompensated heart failure. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 7* Possesses skills to appropriately obtain and incorporate data from the history, laboratory studies, and imaging modalities in evaluation and management of heart failure patients. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 8* Possesses skills to identify appropriate candidates for palliative care and hospice. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 9* Possesses skills to recognize and manage comorbidities in heart failure patients. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 SYSTEMSBASED PRACTICE 10* Utilizes an interdisciplinary, coordinated, team approach for patient management, including care transitions, palliative care, and employmentrelated issues. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed PRACTICEBASED LEARNING AND IMPROVEMENT 11* Identifies knowledge and performance gaps and engages in opportunities to achieve focused education and performance improvement. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 67 Not Yet Assessed / Not Observed PROFESSIONALISM 12* Shows compassion and effective management of endoflife issues, including family meetings across the spectrum of patients with heart failure. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 13* Interacts respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 INTERPERSONAL AND COMMUNICATION SKILLS 14* Communicates with and educates patients and families across a broad range of cultural, ethnic, and socioeconomic backgrounds. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 15* Engages in shared decisionmaking with patients, including options for diagnosis and treatment. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 OVERALL ASSESSMENT 16* Overall Assessment of this fellow on their Heart Failure rotation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 17 Comments: Please use the comment box below to offer detailed strengths and/or weaknesses of this fellow on their Heart Failure rotation. 18* Is there any reason this fellow should not move to the next level of responsibility? Yes No Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 68 19* Was this evaluation discussed with the fellow at the end of the rotation? *ACGME Program Requirement V.A.2.a).(1) states "faculty must evaluate fellow performance in a timely manner during each rotation and discuss this evaluation with each fellow at the completion of the assignment." Yes No Overall Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 69 NUCLEAR CARDIOLOGY CURRICULUM Penn State Hershey Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date ROTATION INFORMATION Name of Rotation NUCLEAR CARDIOLOGY Supervising / Evaluating Faculty Members Charles Chambers, MD; Eric Chan, MD; Edward Liszka, MD; Michael Pfeiffer, MD Facility / Location Nuclear Radiology Ground Floor / Hershey Medical Center Clinical Experience All fellows must have a minimum of 2 months of direct nuclear cardiology experience. The average experience is 3-4 months. Additional elective time for interested fellows is available. Further exposure to nuclear cardiology content comprised of, but not limited to, ordering, reviewing, and applying results from nuclear cardiology studies is anticipated for all fellows on the following rotations: • Inpatient Acute Service • CHF Service • Consults • Outpatient Continuity Clinics (HMC and VA) Didactics Nuclear Lecture Series – Every 2nd and 4th Thursday @ 7am in Hamilton Conference Room Additional nuclear cardiology related cases and topics are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference Overview The nuclear cardiology rotation provides direct exposure to the fundamentals of nuclear imaging as they pertain to cardiovascular disease. This includes the ordering, administration, and interpretation of nuclear cardiology studies in patients with suspected or known cardiovascular disease. These rotations also include a high level overview of radiation biology and safety training. Fellows who desire to sit for the CBNC Board Exam and/or obtain Level II status will need to complete an external course to satisfy the requirements of the NRC. The nuclear cardiology rotations are also a component of the fellows’ exposure to ECG interpretation and stress testing (pharmacologic and exercise modalities) with routine review of rest and stress ECGs. Training Goals and Objectives The nuclear cardiology rotation and associated training is designed to provide the trainee, within the standard three year program, two potential levels of COCATS training. • COCATS Level I: (2 months experience minimum) o All fellows are expected to achieve COCATS Level I training within the first 2 years of fellowship. Minimum number of nuclear cardiology studies: 100 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 70 • COCATS Level II: (4 months experience minimum) o All fellows have the opportunity to achieve COCATS Level II training during the fellowship program. Minimum number of nuclear cardiology studies: 300 o Required to perform and interpret nuclear cardiology studies independently in practice. o Many or all can achieve this in time to take the CBNC Board Exam in their 3rd year of fellowship. An external radiation safety training course is required to fulfill the NRC requirement for Classroom and Laboratory Training and sit for the CBNC Board Exam. COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. At the present time, Penn State Hershey does not offer subspecialty training in Nuclear Cardiology. Specific curricular milestones for nuclear cardiology as they relate to the Core Competencies promulgated by the ACGME are adopted from the ACC COCATS 4 Task Force 6 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Expectations and Responsibilities • • • • • • Attend the Nuclear Cardiology and Nuclear/Cath Correlate Conferences throughout the year. o When assigned, prepare cases for the Nuclear/Cath Correlate Conferences with appropriate correlations to coronary angiography and other imaging modalities. o When assigned, prepare one topic review for Nuclear Cardiology Conference during 2nd or 3rd year of fellowship. Track participation in performing and interpreting cases. o Studies performed or interpreted during conferences and while not on the nuclear cardiology rotation should also be tracked. Daily supervision of nuclear stress testing (at the Medical Center) including: o Documentation of the reason for the stress test. o Obtain an appropriate history and physical (H&P) to ensure the test can safely and appropriately be performed. o Oversee the performance of the stress test with the clinical nurse in nuclear radiology. o Review and provide preliminary interpretation of the resting and stress ECGs (at the Medical Center). o Attend the daily afternoon reading session held jointly with Nuclear Radiology. o Review and provide preliminary interpretation of the nuclear imaging results (at the Medical Center and those performed at satellite locations). Communicate with the patient as necessary during the time surrounding their testing. Communicate abnormal test results to requesting/ordering physicians. Participate in the following activities under the guidance of a nuclear cardiology technician and/or health physicist: o Radiopharmaceutical Handling and Dose Preparation. Performed at 6am on all weekdays. Must notify nuclear technologist at least 24-48 hours in advance. o Image Acquisition and Processing. Performed throughout the morning on all weekdays. May ask nuclear technologist to participate on a daily basis. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 71 o Dedicated Health Physics Experience. Performed one-on-one with the Health Physics Department. Can be done in a single day or broken up over 2-4 days. Can be done at any time, but is recommended in the 2nd or 3rd year before taking boards. Must be set up through Karen Brown in advance. Vacation/CME Time Time off for vacation and CME may be requested during this rotation. It is the fellow’s responsibility to make sure the minimum required fellow presence is available for this rotation: • • The Nuclear Rotation requires the presence of at least one fellow. First year fellows should not be left alone on the nuclear rotation during their first month. When coverage is required to satisfy these minimum requirements, it is the fellow’s responsibility to arrange this coverage and notify any involved faculty. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. Faculty Supervision and Responsibilities • • • • A cardiology faculty member will be assigned to nuclear reading each day. This attending will: o Be available by pager for any questions or issues during triage and acquisition of the daily nuclear cardiology studies. o Review all resting and stress ECGs for final interpretation. Provide feedback on preliminary ECG interpretations. o Attend the afternoon reading session of the nuclear cardiology studies. o Review and finalize nuclear cardiology reports. Provide feedback on preliminary nuclear cardiology reports. Attend and provide didactic lectures as a part of the Nuclear Cardiology Lecture Series. Attend the Nuclear/Cath Correlate lectures held jointly with Radiology. Evaluate the fellow through direct feedback and standardized evaluations. The afternoon reading sessions will also be attended and supervised by radiology faculty who will interact with fellows and provide additional direct feedback for all trainees in the group setting. Recommended Resources and Reading • • • • COCATS 4 Task Force 5: Training in Nuclear Cardiology American Society of Nuclear Cardiology: Guidelines/Statements o http://www.asnc.org/content_184.cfm?navID=73 Certification Board of Nuclear Cardiology o http://www.cbnc.org Recommended Journal Articles by Faculty/Fellows CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 72 • Essentials of Nuclear Medicine Physics and Instrumentation 3rd Ed., Powsner, Palmer, & Powsner • Nuclear Cardiology Practical Applications 2nd Ed., Heller & Hendel • Nuclear Cardiology Technical Applications 1st Ed., Heller, Mann, & Hendel CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 73 Core Competency Components and Curricular Milestones for Training in Nuclear Cardiology 1st Year 2nd Year 3rd Year Medical Knowledge Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the principles of single-photon emission computed tomography and radionuclide ventriculography image acquisition and display, including the standard tomographic I planes and views. 2. Know the properties and use of standard perfusion tracers. I 3. Know the principles of radiation safety and how to minimize radiation exposure. II 4. Know the indications for myocardial perfusion imaging and the appropriate selection of exercise versus pharmacologic stress testing. I 5. Know the principles and use of pretest probability and sequential probability analysis to assess posttest probability. I 6. Know the mechanism of pharmacologic stress agents, methods of their administration, and safety issues in using the agents. I 7. Know the protocols for administration of standard perfusion agents and the influence of the clinical situation on choice of imaging protocol. I 8. Know the quality control issues, how to review raw data, and recognize artifacts. II 9. Know the use of nuclear cardiology in the assessment of ventricular function. I 10. Know the protocols for the use of perfusion imaging to assess myocardial viability. I 11. Know the indications for positron emission testing imaging and use of positron emission testing tracers. II Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training Exam Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of nuclear cardiology. 1. Skill to select the appropriate imaging study. I 2. Skill to integrate perfusion imaging findings with clinical and other test results in the evaluation and management of patients. I 3. Skill to identify results that indicate a high-risk state. I 4. Skill to perform and interpret gated stress-rest perfusion study. II 5. Skill to perform and interpret a radionuclide ventriculography study. II Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Procedure/Activity Logbook CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 74 1st Year 2nd Year 3rd Year Systems-Based Practice Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Work effectively and efficiently with the nuclear laboratory staff. II 2. Incorporate risk/benefit and cost considerations in the use of radionuclide imaging techniques. I 3. Participate in laboratory quality monitoring and initiatives. II Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, 360 Reviews Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Identify knowledge and performance gaps and engage in opportunities to achieve I focused education and performance improvement. Evaluation Methods: Attending Evaluations, Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation 1st Year 2nd Year 3rd Year Professionalism Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Know and promote adherence to guidelines and appropriate use criteria. 2. Interact respectfully with patients, families, and all members of the health care teamincluding ancillary and support staff. I I Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. Communicate effectively and timely with patients, families, and referring physicians. I 2. Communicate test results in a comprehensive and user-friendly manner. II Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluation If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 75 Faculty Evaluation of Cardiology Fellow on Nuclear Cardiology Instructions: The following evaluation questions have been devised using the COCATS 4 Core Competency Components and Curricular Milestones for Training in Nuclear Cardiology. The evaluation scale is modeled after the ACGME Milestones categories, which are competencybased developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. Subject Name Evaluated by: Status Employer Program Evaluator Name Status Employer Program Rotation Evaluation Dates 1* Knows and promotes adherence to guidelines and appropriate use criteria for nuclear cardiology imaging. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 2* Knows the indications for myocardial perfusion imaging and the appropriate selection of exercise versus pharmacologic stress testing. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 3* Knows the principles of singlephoton emission computed tomography acquisition and display, including the standard tomographic planes and views. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 4* Knows the mechanism of pharmacologic stress agents, methods of their administration, and safety issues in using the agents. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 5* Possesses skills to perform and interpret gated stressrest perfusion study. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 76 Not Yet Assessed / Not Observed 6* Possesses skills to identify results that indicate a highrisk state. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 7* Communicates test results in a comprehensive and userfriendly manner. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 8* Works effectively and efficiently with the nuclear laboratory staff. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 9* Interacts respectfully with patients, families, and all members of the healthcare team including ancillary and support staff. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 10* Identifies knowledge and performance gaps and engages in opportunities to achieve focused education and performance improvement. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 OVERALL ASSESSMENT 11* Overall Assessment of this fellow on their Nuclear Cardiology rotation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 12 Comments: Please use the comment box below to offer detailed strengths and/or weaknesses of this fellow on their Nuclear Cardiology rotation. 13* Is there any reason this fellow should not move to the next level of responsibility? Yes No Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 77 14* Was this evaluation discussed with the fellow at the end of the rotation? *ACGME Program Requirement V.A.2.a).(1) states "faculty must evaluate fellow performance in a timely manner during each rotation and discuss this evaluation with each fellow at the completion of the assignment." Yes No Overall Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 78 VASCULAR CURRICULUM Penn State Hershey Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date ROTATION INFORMATION Name of Rotation VASCULAR / IMAGING Supervising / Evaluating Faculty Members Robert Atnip, MD (Vascular Surgery), David Han, MD (Vascular Surgery) Facility / Location Vascular Lab, Outpatient Clinics/ Hershey Medical Center, IO Silver Clinical Experience All fellows will have 2 months of vascular experience. This will be obtained during the combined Vascular/Imaging rotation and in aggregate exposure on other rotations. Additional elective time for interested fellows is available. Further exposure to vascular content comprised of, but not limited to, the presentation, evaluation, and management of peripheral vascular disease as well as the ordering, reviewing, and applying results from multimodality imaging of the central and peripheral vasculature is anticipated for all fellows on the following rotations: • Inpatient Acute Service • CHF Service • Consults • CCU • Outpatient Continuity Clinics (HMC and VA) • ACHD Didactics Vascular Imaging Lectures will occur individually during the Vascular/Imaging rotation. Additional vascular related cases and topics are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference • Core Conference • Multimodality Imaging Overview The vascular portion of the Vascular/Imaging rotation exposes the fellow to evaluation and management of peripheral vascular disease. The vascular portion of the rotation experience is designed to emphasize exposure to vascular ultrasound imaging and outpatient management of peripheral vascular disease. Additional multimodality imaging of the peripheral vasculature as well as inpatient care of non-coronary cardiovascular disease is anticipated in aggregate throughout other rotations. Training Goals and Objectives The vascular portion of the Vascular/Imaging rotation and associated training are designed to provide the fellow, within the standard three year program, two potential levels of COCATS training: • COCATS Level I: (2 months experience minimum) o All fellows are expected to achieve COCATS Level I training within the first two years of fellowship. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 79 • COCATS Level II: (training duration not defined) o Interested fellows must discuss the opportunity to achieve COCATS Level II training during general fellowship with Dr. Atnip. This will include: Additional scheduled time (as elective rotation or concomitant with other rotations) in the vascular imaging lab. To sit for the Physician’s Vascular Interpretation Examination requires interpretation of a minimum of 500 total vascular studies across the vascular testing areas. COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. Specific curricular milestones for vascular imaging, as they relate to the Core Competencies promulgated by the ACGME, are adopted as outlined in the COCATS 4 Task Force 9 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Expectations and Responsibilities • • • • • • Attend Vascular Laboratory reading sessions with Dr. Atnip on Tuesday afternoons and Thursday mornings. o Participate in the review and interpretation of peripheral vascular studies. Attend weekly Vascular lectures during your rotation on Thursday mornings at 8am o Schedule to be confirmed at the start of the rotation. Attend outpatient clinic with Dr. Han to shadow and participate in the evaluation and treatment of patients with peripheral vasculature disease. Track reading of peripheral vascular studies for documentation. o New Innovations is the preferred method of tracking. Refer to and follow the Vascular/Imaging Rotation Schedule. Notify the respective faculty of your expected attendance or if you are unable to attend the scheduled sessions as a courtesy for their involvement in your education. Vascular/Imaging Rotation Schedule: The Vascular/Imaging rotation has two primary goals: • • Exposure to Vascular Medicine o Level I exposure to ultrasound imaging o Basic outpatient management of PVD Exposure to Cardiac MRI o Review of study indications and appropriate use o Study protocol, acquisition, and interpretation There is flexible time in this rotation designed to allow for self-directed exposure based on areas of interest and availability. The following secondary goals can be distributed by the fellow during the rotation based on availability, need, and their personal interest: CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 80 • • • Exposure to Cardiac CT o Check for planned coronary CT studies with Drs. Ettinger or Singh o Review Cardiac CT planning for structural heart disease cases with Dr. Kozak or Pfeiffer o Independent study of Cardiac CT review materials Supplemental ECHO exposure o First years in the second half of their year can observe TEE under the guidance of the upper year fellow and can start performing TEEs with the permission of the TEE attending o Additional time in the ECHO lab as needed Supplemental Nuclear exposure o Attend afternoon reading sessions for cardiac SPECT imaging. o Schedule and perform your required Nuclear Radiation Hands-On Safety training o Assist with coverage for nuclear studies as needed. The following template serves as a guideline for expected attendance at planned activities (highlighted) to meet the primary goals, as well as a proposed schedule of secondary activities. AM PM Monday TEE shadowing (1st years) TEE back-up (upper years) Tuesday Cardiac MRI acquisition Wednesday Vascular clinic OR VA Clinic (when assigned) Nuclear/CT Reading Vascular Lab Cardiac MRI interpretation Thursday Friday Vascular Lab TEE shadowing/ (Lecture @ 8am) back-up OR VA Clinic (when assigned) Fellows Clinic Nuclear/CT (when assigned) Reading Vacation/CME Time Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless specified by the involved faculty. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. Faculty Supervision and Responsibilities • Drs. Atnip and Han are available for the scheduled activities to promote our vascular training in the vascular laboratory and the outpatient clinic. Recommended Resources and Reading • • • COCATS 4 Task Force 9: Training in Vascular Imaging (Create Hyperlink) Alliance for Physician Certification & Advancement: Physicians’ Vascular Interpretation Examination o https://www.apca.org/certifications-examinations/Registered-Physician-in-VascularInterpretation/Pages/Physicians-Vascular-Interpretation-(PVI).aspx Recommended Journal Articles by Faculty/Fellows (Create Hyperlink) CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 81 Core Competency Components and Curricular Milestones for Training in VASCULAR IMAGING Medical Knowledge 1st Year 2nd Year 3rd Year Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the anatomy of the peripheral arterial and venous systems. 2. Know the causes and clinical epidemiology of atherosclerotic peripheral vascular disease, including the incidence and prevalence, sex and ethnic differences, role of genetics, and the influence of traditional risk factors and demographics on outcomes. I I 3. Know the pathophysiology of peripheral artery disease, including atherosclerosis, thrombosis, embolism, entrapment, vasculitis, and vasospasm. 4. Know the pathophysiology, causes and clinical epidemiology of aortic aneurysms. I I 5. Know the pathophysiology, causes, and clinical epidemiology of acute aortic syndromes such as dissection and intramural hematoma. 6. Know the pathophysiology, causes, and clinical epidemiology of deep vein thrombosis and pulmonary embolism. I I 7. Know the pathophysiology, causes, and clinical epidemiology of cerebrovascular disease. I 8. Know the pathophysiology, causes, and clinical epidemiology of chronic venous insufficiency and varicose veins. I 9. Know the pathophysiology, causes, and clinical epidemiology of lymphedema. II 10. Know the cardinal symptoms and physical findings of peripheral atherosclerotic vascular diseases, including peripheral artery disease, renal and mesenteric artery disease, extracranial cerebrovascular disease, and abdominal aortic aneurysm. I 11. Know the cardinal symptoms and physical findings of venous diseases including venous thromboembolism, chronic venous insufficiency, and varicose veins. I 12. Know the differentiating characteristics between arterial, venous, and neurotrophic lower extremity ulcers. 13. Know the natural history and prognosis of deep vein thrombosis and pulmonary embolism. 14. Know the natural history and prognosis of peripheral atherosclerotic vascular diseases including peripheral artery disease, renal and mesenteric artery disease, extracranial carotid artery disease, and abdominal aortic aneurysm. 15. Know the indications for noninvasive screening for abdominal aortic aneurysm. 16. Know the indications for duplex ultrasound of the peripheral veins and carotid arteries and for duplex and physiological testing of the peripheral arteries. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 82 II I I I I 17. Know the indications for duplex ultrasonography of the renal and mesenteric arteries, arterial bypass grafts and stents, aortic endografts, and intracranial vessels (i.e., transcranial Doppler). II 18. Know the indications and contraindications for computed tomographic angiography and magnetic resonance angiography in patients with suspected vascular disease. I 19. Know the appropriate indications and laboratory tests to assess for inherited and acquired thrombophilia. I 20. Know the appropriate indications and laboratory tests to assess for vasculitis. I 21. Know the indications, contraindications, risks, clinical pharmacology, and interactions of drugs used to treat atherosclerotic vascular diseases. I 22. Know the indications, contraindications, risks, clinical pharmacology, and interactions of drugs used to treat thrombotic disorders. I 23. Know the indications, contraindications, risks, and expected outcomes for thrombolytic therapy for venous thromboembolism (pulmonary embolism and deep vein thrombosis). I 24. Know the indications and risks for surgical and endovascular treatments for acute aortic syndromes; and, the expected outcomes. I 25. Know the indications and risks for surgical and endovascular treatments for aortic aneurysm; and, the expected outcomes. I 26. Know the indications and risks for surgical and endovascular treatments for peripheral atherosclerotic vascular diseases, including peripheral artery disease, renal and mesenteric artery disease, and extracranial cerebrovascular disease; and the expected outcomes. I Evaluation Methods: Conference Presentations, Direct Observation and Feedback. In-Training Exam Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of cardiac catheterization. 1. Skill to perform the comprehensive physical examination of the peripheral arteries, including palpation of the abdominal aorta and peripheral pulses and auscultation for bruits. 2. Skill to perform physical examination for suspected peripheral venous disorders, including deep vein thrombosis, varicose veins, and chronic venous insufficiency. 3. Skill to perform and interpret an ankle-brachial index measurement. 4. Skill to interpret limb segmental blood pressure measurements, pulse volume recordings and Doppler waveforms, and treadmill vascular exercise tests. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 83 I I I II 5. Skill to interpret duplex ultrasound examinations of the extracranial carotid arteries, peripheral arteries, abdominal aorta, renal and mesenteric arteries, and peripheral veins. 6. Skill to evaluate and manage aortic aneurysms including identification of patients for whom surgical or endovascular repair is indicated. I 7. Skill to evaluate and manage acute aortic syndromes including identification of patients for whom surgical or endovascular therapy is indicated. I 8. Skill to evaluate and manage patients with deep venous thrombosis and pulmonary embolism, including identification of patients for whom thrombolytic therapy is indicated. I 9. Skill to perform preoperative risk assessment and manage patients undergoing vascular surgery. I II 10. Skill to evaluate and manage lower extremity peripheral artery disease. I 11. Skill to evaluate and manage extracranial carotid artery disease. I 12. Skill to evaluate lymphedema. II Evaluation Methods: Direct Observation and Feedback, Procedure/Activity Logbook Systems-Based Practice 1st Year 2nd Year 3rd Year Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Practice in a manner that balances appropriate utilization of finite resources with the net clinical benefit for the individual patient. I 2. Utilize an interdisciplinary, coordinated approach for patient management. II 3. Know the components of quality assurance in the noninvasive vascular laboratory, including certification of technical and medical personnel, laboratory accreditation, and internal quality improvement initiatives. II Evaluation Methods: Direct Observation and Feedback, 360 Reviews Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement. I 2. Utilize decision support tools for accessing guidelines and pharmacologic information at the point of care. I Evaluation Methods: Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 84 Professionalism 1st Year 2nd Year 3rd Year Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Forego recommending unvalidated diagnostic testing or treatments. I 2. Demonstrate a commitment to carry out professional responsibilities, appropriately refer patients, and respond to patient needs in a way that supersedes self-interest. II 3. Know and promote adherence to guidelines and appropriate use criteria. 4. Interact respectfully with patients, families, and all members of the healthcare team, including ancillary and support staff. I I Evaluation Methods: Direct Observation and Feedback, Self-Evaluations, 360 Reviews Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic backgrounds. 2. Communicate with other specialists for optimal interdisciplinary management of patients. I II Evaluation Methods: Direct Observation and Feedback, Self-Evaluation, 360 Reviews If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 85 CARDIAC COMPUTED TOMOGRAPHY CURRICULUM Penn State Hershey Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date ROTATION INFORMATION Name of Rotation VASCULAR / IMAGING Supervising / Evaluating Faculty Members Steven Ettinger, MD; Mark Kozak, MD; Michael Pfeiffer, MD Harjit Singh, MD (Radiology) Facility / Location Ground Floor CT / Hershey Medical Center Clinical Experience All fellows will have 1 month of cardiac computed tomography experience. This will be obtained during the combined Vascular/Imaging rotation and in aggregate exposure on other rotations. Additional elective time for interested fellows is available. Further exposure to cardiac computed tomography content comprised of, but not limited to, ordering, reviewing, and applying results from cardiac CT studies is anticipated for all fellows on the following rotations: • Inpatient Acute Service • Consult Service • Cath • Outpatient Continuity Clinics (HMC and VA) Didactics There is no dedicated cardiac CT Lecture Series. Cardiac CT lectures will occur as a part of the Multimodality Imaging Series on the 4th Tuesday of every month (September – June) @ 12:30pm in Hamilton conference room. Additional cardiac CT related cases and topics are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference Overview The cardiac CT portion of the Vascular/Imaging rotation exposes the fellow to the basics of cardiac CT. They will gain familiarity with clinical indications and appropriate use criteria for cardiac CT. They will also be involved with the manipulation, interpretation, and application of the data from a cardiac CT study. Training Goals and Objectives The cardiac CT portion of the Vascular/Imaging rotation and associated training are designed to provide the fellow, within the standard three year program, one potential level of COCATS training: • COCATS Level I: (1 month experience minimum) o All fellows are expected to achieve COCATS Level I training within the first two years of fellowship. COCATS Level II training requires a minimum of 3 months of dedicated training in cardiac CT. At the current time, Level II training is not available during the standard fellowship. Fellows who wish to achieve Level II in cardiac CT should discuss this with Dr. Ettinger as well as fellowship leadership to see if arrangements external to Penn State can be made. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 86 COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. Penn State Hershey does not offer subspecialty training in cardiac CT. Specific curricular milestones for computed tomographic imaging, as they relate to the Core Competencies promulgated by the ACGME, are adopted as outlined in the COCATS 4 Task Force 7 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Expectations and Responsibilities • • • • • • • Attend and participate in the monthly Multimodality Imaging conferences throughout the year. Discuss upcoming/planned cardiac CT cases with the responsible faculty member. Review planned cardiac CT cases for clinical background and medical history prior to the cardiac CT study. o Evaluate the appropriateness of the study and anticipated clinical data. o Review prior CT studies and/or other imaging modalities. o Discuss planned protocol with the responsible faculty. Attend planned cardiac CT studies when possible. Observe and/or participate in the measurement and interpretation of the cardiac CT studies under the guidance of the interpreting faculty member. Independent review of cardiac CT materials. Refer to and follow the Vascular/Imaging Rotation Schedule for recommended schedules. Due to the current structure of cardiac CT at our institution, availability and timing of cardiac CT studies may not be predictable. Independent learning will comprise a significant portion of the fellows’ exposure to cardiac CT. Interested fellows are encouraged to proactively seek out hands-on opportunities. Vacation/CME Time Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless specified by the involved faculty. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. Vascular/Imaging Rotation Schedule: The Vascular/Imaging rotation has two primary goals: • • Exposure to Vascular Medicine o Level I exposure to ultrasound imaging o Basic outpatient management of PVD Exposure to Cardiac MRI o Review of study indications and appropriate use o Study protocol, acquisition, and interpretation CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 87 The flexible time in this rotation is designed to allow for self-directed exposure based on areas of interest and availability. The following secondary goals can be distributed by the fellow during the rotation based on availability, need, and their personal interest: • • • Exposure to Cardiac CT o Check for planned coronary CT studies with Drs. Ettinger or Singh o Review Cardiac CT planning for structural heart disease cases with Dr. Kozak or Pfeiffer o Independent study of Cardiac CT review materials Supplemental ECHO exposure o First years in the second half of their year can observe TEE under the guidance of the upper year fellow and can start performing TEEs with the permission of the TEE attending o Additional time in the ECHO lab as needed Supplemental Nuclear exposure o Attend afternoon reading sessions for cardiac SPECT imaging. o Schedule and perform your required Nuclear Radiation Hands-On Safety training o Assist with coverage for nuclear studies as needed. The following template serves as a guideline for expected attendance at planned activities (highlighted) to meet the primary goals, as well as a proposed schedule of secondary activities. AM PM Monday TEE shadowing (1st years) TEE back-up (upper years) Tuesday Cardiac MRI acquisition Wednesday Vascular clinic OR VA Clinic (when assigned) Nuclear/CT Reading Vascular Lab Cardiac MRI interpretation Thursday Friday Vascular Lab TEE shadowing/ (Lecture @ 8am) back-up OR VA Clinic (when assigned) Fellows Clinic Nuclear/CT (when assigned) Reading Faculty Supervision and Responsibilities • • When possible faculty participating in cardiac CT will notify the fellow on rotation of studies being performed or interpreted. These attendings will: o Review the indications and appropriateness of the cardiac CT studies. o Discuss the protocol for the study and expected clinical information. o Review the acquired images and techniques for measurement and interpretation. o Share significant and/or pertinent cardiac CT findings from the studies and discuss potential clinical implications of the study. Attend and participate in the multimodality imaging conferences, and when possible, multidisciplinary conferences to provide added insight and cardiac CT expertise to fellow and department education. Recommended Resources and Reading • • • COCATS 4 Task Force 7: Training in Cardiovascular Computed Tomographic Imaging (Create Hyperlink) Society of Cardiovascular Computed Tomography: Guidelines and Training o http://www.scct.org/tools/index.cfm 2010 Appropriate Use Criteria for Cardiac Computed Tomography o http://circ.ahajournals.org/content/circulationaha/122/21/e525.full.pdf CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 88 • • • SCCT Guidelines for Performance of Coronary Computed Tomographic Angiography o http://www.scct.org/tools/guidelines_performance.pdf SCCT Guidelines for the Interpretation and Reporting of Coronary Computed Tomographic Angiography o http://www.scct.org/advocacy/coverage/PubGuidelines.pdf Recommended Journal Articles by Faculty/Fellows (Create Hyperlink) Cardiac CT Imaging: Diagnosis of Cardiovascular Disease, 3rd Ed.; Matthew Budoff and Jerold Shinbane. • Cardiac CT Angiography Manual, 2nd Ed.; Robert Pelberg • CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 89 Core Competency Components and Curricular Milestones for Training in Cardiac CT Medical Knowledge 1st Year 2nd Year 3rd Year Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the principles of cardiovascular computed tomographic scanning and the scanning modes. I 2. Know the risks and safety measures for cardiovascular computed tomographic scanning, including radiation reduction strategies. I 3. Know the appropriate indications for cardiovascular computed tomography for screening or evaluating symptoms in patients with suspected cardiac disease. I 4. Know the indications, potential adverse effects, prevention, and treatment of complications of iodinated contrast agent use in cardiovascular computed tomographic studies. I 5. Know the characteristic cardiovascular computed tomographic images of normal cardiac chambers and great vessels, normal coronary arteries and veins, and normal variants. I 6. Know when to request help with interpretation of difficult studies, such as patients with complex congenital heart disease. I Evaluation Methods: Conference Presentations, Direct Observation and Feedback. In-Training Exam Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of cardiac catheterization. 1. Skill to appropriately utilize cardiovascular computed tomography in the evaluation and management of patients with known or suspected cardiovascular disease. I 2. Skill to integrate cardiovascular computed tomographic findings with other clinical information in patient evaluation and management. I 3. Skill to recognize and treat contrast-related adverse reactions. I Evaluation Methods: Direct Observation and Feedback, Procedure/Activity Logbook Systems-Based Practice 1st Year 2nd Year 3rd Year Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Incorporate appropriate use criteria, risk/benefit, and cost considerations in the use of cardiovascular computed tomography and alternative imaging modalities. Evaluation Methods: Direct Observation and Feedback, 360 Reviews CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 90 I Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement. I 2. Utilize point-of-care educational resources (e.g., guidelines, appropriate use criteria, and clinical trial results). I Evaluation Methods: Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation Professionalism 1st Year 2nd Year 3rd Year Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Work effectively in an interdisciplinary CCT environment. 2. Reliably obtain patient informed consent, ensuring that patients understand the risks and benefits of, and alternatives to, cardiovascular computed tomographic testing. 3. Know and promote adherence to clinical practice guidelines. I I I Evaluation Methods: Direct Observation and Feedback, Self-Evaluations, 360 Reviews Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. Communicate testing results to physicians and patients in an effective and timely manner. I Evaluation Methods: Direct Observation and Feedback, Self-Evaluation, 360 Reviews If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 91 CARDIAC MRI CURRICULUM Penn State Hershey Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date ROTATION INFORMATION Name of Rotation VASCULAR / IMAGING Supervising / Evaluating Faculty Members John Kelleman, MD; Michael Pfeiffer, MD Carlos Jamis-Dow, MD (Radiology) Facility / Location Ground Floor MRI / Hershey Medical Center Clinical Experience All fellows will have 1 month cardiac magnetic resonance imaging experience. This will be obtained during the combined Vascular/Imaging rotation and in aggregate exposure on other rotations. Additional elective time for interested fellows is available. Further exposure to cardiac magnetic resonance imaging content comprised of, but not limited to, ordering, reviewing, and applying results from cardiac MRI studies is anticipated for all fellows on the following rotations: • Inpatient Acute Service • CHF Service • Consults • CCU • Outpatient Continuity Clinics (HMC and VA) • ACHD Didactics There is no dedicated cardiac MRI Lecture Series. Cardiac MRI lectures will occur as a part of the Multimodality Imaging Series on the 4th Tuesday of every month (September –June) @ 12:30pm in Hamilton conference Room. Additional cardiac MRI related cases and topics are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference Overview The cardiac MRI portion of the Vascular/Imaging rotation exposes the fellow to the basics of cardiac MRI protocols, acquisition, measurement, and interpretation. Fellows will gain an understanding of clinical indications of cardiac MRI with attention to published appropriate use criteria. Evaluation of cardiac structure, function, and tissue characterization will be reviewed. An overview of cardiac MRI physics and general MRI safety will be included in the training. Training Goals and Objectives The cardiac MRI portion of the Vascular/Imaging rotation and associated training are designed to provide the fellow, within the standard three year program, one potential level of COCATS training: • COCATS Level I: (1 month experience minimum) o All fellows are expected to achieve COCATS Level I training within the first two years of fellowship. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 92 COCATS Level II training requires a minimum of 3 months of dedicated training in cardiac MRI. At the current time, Level II training is not available during the standard fellowship. Fellows who wish to achieve Level II in cardiac MRI should discuss this with Dr. Kelleman or Dr. Pfeiffer as well as fellowship leadership to see if arrangements external to Penn State can be made. COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. Penn State Hershey does not offer subspecialty training in cardiac MRI. Specific curricular milestones for magnetic resonance imaging, as they relate to the Core Competencies promulgated by the ACGME, are adopted as outlined in the COCATS 4 Task Force 8 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Expectations and Responsibilities • • • • • Attend and participate in the monthly Multimodality Imaging conferences throughout the year. Review planned cardiac MRI cases for clinical background and medical history prior to the cardiac MRI study. o Evaluate the appropriateness of the study and anticipated clinical data. o Review prior CMR studies and/or other imaging modalities. o Discuss planned protocol with the responsible faculty. Attend the Tuesday morning cardiac MRI acquisitions. o Scheduled adult cardiac MRI cases are on Tuesdays from 8:30am – 2:30pm. Observe and/or participate in the measurement and interpretation of the cardiac MRI studies under the guidance of the interpreting faculty member. Refer to and follow the Vascular/Imaging Rotation Schedule. Vacation/CME Time Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless specified by the involved faculty. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. Vascular/Imaging Rotation Schedule: The Vascular/Imaging rotation has two primary goals: • • Exposure to Vascular Medicine o Level I exposure to ultrasound imaging o Basic outpatient management of PVD Exposure to Cardiac MRI o Review of study indications and appropriate use o Study protocol, acquisition, and interpretation CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 93 The flexible time in this rotation is designed to allow for self-directed exposure based on areas of interest and availability. The following secondary goals can be distributed by the fellow during the rotation based on availability, need, and their personal interest: • • • Exposure to Cardiac CT o Check for planned coronary CT studies with Drs. Ettinger or Singh o Review Cardiac CT planning for structural heart disease cases with Dr. Kozak or Pfeiffer o Independent study of Cardiac CT review materials Supplemental ECHO exposure o First years in the second half of their year can observe TEE under the guidance of the upper year fellow and can start performing TEEs with the permission of the TEE attending o Additional time in the ECHO lab as needed Supplemental Nuclear exposure o Attend afternoon reading sessions for cardiac SPECT imaging. o Schedule and perform your required Nuclear Radiation Hands-On Safety training o Assist with coverage for nuclear studies as needed. The following template serves as a guideline for expected attendance at planned activities (highlighted) to meet the primary goals, as well as a proposed schedule of secondary activities. AM PM Monday TEE shadowing (1st years) TEE back-up (upper years) Tuesday Cardiac MRI acquisition Wednesday Vascular clinic OR VA Clinic (when assigned) Nuclear/CT Reading Vascular Lab Cardiac MRI interpretation Thursday Friday Vascular Lab TEE shadowing/ (Lecture @ 8am) back-up OR VA Clinic (when assigned) Fellows Clinic Nuclear/CT (when assigned) Reading Faculty Supervision and Responsibilities • • One faculty member will be assigned to cardiac MRI on a weekly basis. These attendings will: o Review the indications and appropriateness of the CMR studies. o Discuss the protocol for the study and expected clinical information. o Review the acquired images and techniques for measurement and interpretation. o Share significant and/or pertinent CMR findings from the studies and discuss potential clinical implications of the study. Attend and participate in the multimodality imaging conferences, and when possible, multidisciplinary conferences to provide added insight and CMR expertise to fellow and department education. Recommended Resources and Reading • • • COCATS 4 Task Force 8: Training in Cardiovascular Magnetic Resonance Imaging (Create Hyperlink) Society of Cardiovascular Magnetic Resonance: Guidelines and Position Statements (includes Appropriate Use Criteria) o http://scmr.org/?page=guidelines Recommended Journal Articles by Faculty/Fellows (Create Hyperlink) CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 94 • Cardiovascular Magnetic Resonance, 2nd Ed., Manning & Pannell • Cardiovascular MRI Tutorial: Lectures and Learning, 1st Ed., Biedermann, Doyle, Yamrozik CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 95 Core Competency Components and Curricular Milestones for Training in Cardiac MRI Medical Knowledge 1st Year 2nd Year 3rd Year Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the principles of cardiovascular magnetic resonance image acquisition. I 2. Know the principles of safety and contraindications for cardiovascular magnetic resonance imaging. I 3. Know the uses, potential side effects, and contraindications of using gadolinium based contrast agents in cardiovascular magnetic resonance imaging. I 4. Know the indications for cardiovascular magnetic resonance to assess left and right heart chamber sizes and function. I 5. Know the cardiovascular magnetic resonance indications for assessment of myocardial viability. I 6. Know the cardiovascular magnetic resonance indications and characteristic findings of myocardial ischemia. I 7. Know the cardiovascular magnetic resonance indications and characteristic findings of acute myocardial infarction. I 8. Know the cardiovascular magnetic resonance indications and characteristic findings of acute coronary syndromes and other causes of myocardial injury. I 9. Know the cardiovascular magnetic resonance indications and differential findings in cardiomyopathies of uncertain cause. I 10. Know the cardiovascular magnetic resonance indications to assess diseases of the pericardium. I 11. Know the cardiovascular magnetic resonance indications to evaluate valvular heart disease. I 12. Know the cardiovascular magnetic resonance indications and characteristic findings of myocardial masses and thrombi. 13. Know the cardiovascular magnetic resonance indications for left atrial and pulmonary vein mapping prior to ablation of atrial fibrillation. I I 14. Know the cardiovascular magnetic resonance indications for evaluation of adult congenital heart disease including identification of coronary artery anomalies. I 15. Know the cardiovascular magnetic resonance indications to detect and evaluate diseases of the aorta and peripheral arteries. I Evaluation Methods: Conference Presentations, Direct Observation and Feedback. In-Training Exam CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 96 Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of cardiac catheterization. 1. Skill to appropriately order and integrate the results of cardiovascular magnetic resonance testing with other clinical findings in the evaluation and management of patients. I 2. Skill to interpret cardiovascular magnetic resonance tissue characterization (late gadolinium enhancement) to distinguish the etiology of cardiomyopathy and acute myocardial injury. I Evaluation Methods: Direct Observation and Feedback, Procedure/Activity Logbook Systems-Based Practice 1st Year 2nd Year 3rd Year Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Incorporate risk/benefit and cost considerations in the use of cardiovascular magnetic resonance testing. I Evaluation Methods: Direct Observation and Feedback, 360 Reviews Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement. I Evaluation Methods: Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation Professionalism 1st Year 2nd Year 3rd Year Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Practice within the scope of expertise and technical skills. 2. Know and promote adherence to guidelines and appropriate use criteria. I I Evaluation Methods: Direct Observation and Feedback, Self-Evaluations, 360 Reviews Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 97 Evaluation Methods: Direct Observation and Feedback, Self-Evaluation, 360 Reviews If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 98 RESEARCH CURRICULUM Penn State Hershey Heart and Vascular Institute Cardiovascular Disease Fellowship Revision Date ROTATION INFORMATION Name of Rotation RESEARCH Supervising / Evaluating Faculty Members All Participating Faculty Facility / Location Hershey Medical Center and Related Facilities Clinical Experience All fellows will have a minimum of 3 months of dedicated research time. Additional elective time for interested fellows is available. It is anticipated that fellows will engage in cardiovascular research and scholarly activities during the dedicated rotations as well as longitudinally, concurrent with other rotations, throughout the three year fellowship. Discussion and application of current medical research and literature as it pertains to clinical cardiology will also be an active part of all cardiac rotations. Didactics Research Lecture Series – 1st Thursday of every even month @ 12noon in Hamilton Conference Room Journal Club Lecture Series; Every 3rd Monday (Exact time and locations TBA) Additional research related topics and critical review are anticipated as a part of: • Grand Rounds • Multidisciplinary Case Conference Overview The research rotation provides the ability for cardiology fellows to directly participate in cardiovascular research and scholarly activity (CRSA). This includes exposure to conducting research, increasing knowledge of the scientific method and enhancing the ability to critically evaluate published scientific data. These exposures will allow emerging cardiologists to adapt their knowledge and practice as new scientific investigations occur. Training Goals and Objectives The research rotation, along with longitudinal effort occurring concomitantly with other training, is designed to provide the trainee, within the standard three year program, training that meets or exceeds COCATS Level I expectations. • COCATS Level I: o Trainees should establish a relationship with a research mentor and devote 6-12 months to 1 or more scholarly activities or cardiac research projects. o Trainees are encouraged to develop a quality improvement project to enhance system based practices that will help him or her throughout their professional careers. This could be part of the research project mentioned above; however, for it to count as research project it must include a specific research question (i.e. did a particular QI measure lead to a change in behavior or outcomes?). CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 99 • Advanced Training: o Trainees preparing for careers in research need an extensive foundation in scientific investigation. o These skills can be achieved in combined degree programs including (MD/PhD, MD/MPH and MD/MS). o Trainees seeking a career in investigative cardiology without an advance degree are encouraged to obtain necessary scientific analytical course work and clinical research experience to promote a productive research career. Graduate level course work is available through the Penn State College of Medicine’s master’s degree program in Public Health Sciences. Specific curricular milestones for cardiovascular research and scholarly activity, as they relate to the Core Competencies promulgated by the ACGME, are adopted from the COCATS 4 Task Force 15 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship. Fellow Responsibilities • • • • • Trainee should find a faculty member to assist with the development of clinical questions and to oversee the scientific method as it pertains to cardiovascular research or scholarly activity. o After developing clinical questions, research project should be followed until completion. o Project results should be written up and submitted for presentation at a cardiovascular conference or publication in a peer reviewed journal. o The minimum research requirement is one project, however it is strongly encouraged to spend additional time on other cardiovascular research or scholarly activity. Trainee is encouraged to work on a quality improvement project to enhance patient care and improve systems based practice. Become more knowledgeable about the scientific method including hypothesis generation, reading background literature, developing methods to test hypothesis and examining data to determine if it confirms or denies the hypothesis. Develop competency in critically interpreting cardiovascular research literature. Develop an understanding of the issues concerning scientific integrity and ethical conduct. Vacation/CME Time Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless specified by the involved faculty. It is the fellow’s responsibility to ensure time off does not significantly impact or limit total exposure to any given rotation. In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship coordinator and approved by the fellowship director. Supervision of the Fellow by, and Responsibilities of, the Attending • • Faculty should be available to act as mentors throughout the research process. Provide didactic lectures as part of the Research Lecture Series. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 100 • • Quarterly conference to discuss and brainstorm research topic ideas with faculty. Faculty will host monthly journal clubs where fellows will be guided through review and analysis of recent or prior landmark cardiovascular research literature. Recommended Resources and Reading • • • • COCATS 4 Task Force 15: Training in Cardiovascular Research and Scholarly Activity Wikibook of Statistics o https://en.wikibooks.org/wiki/Statistics Recommended Journal Articles by Faculty/Fellows Fundamentals of Clinical Trials, 4th Ed., Friedman, Furberg and Demets • Designing Clinical Research 4th Ed., Hully, Cummings, Browner, Grady and Newman CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 101 Core Competency Components and Curricular Milestones for Training in RESEARCH 1st Year 2nd Year 3rd Year Medical Knowledge Goal – Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. 1. Know the roles and functions of DNA, RNA and proteins. I 2. Know the principles of genetics, genomics, proteomics, metabolomics and pharmacogenomics. I 3. Know the principles of epidemiological methods. I 4. Know the principles of outcomes evaluation. I 5. Know the basic principles of biostatistics. I 6. Know the principles underlying hypothesis formation, specific goals definition, hypothesis testability, and statistical power achievable. I Evaluation Methods: Conference Presentations, Direct Observation and Feedback, In-Training Exam Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year Goal – Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of RESEARCH. 1. Skill to review published research data and assess the adequacy of research design, data analysis, and logical deduction. I 2. Skill to integrate appropriately scientific concepts and research advances in routine clinical encounters. I 3. Skill to routinely assess the quality of evidence in clinical decisions. I 4. Skill to apply principles of biomedical ethics as they pertain to human subject research in the identification of patients as potential research subjects, presentation of alternatives, obtaining informed consent and assuring the security of clinical data used for research. I Evaluation Methods: Conference Presentations, Direct Observation and Feedback 1st Year 2nd Year 3rd Year Systems-Based Practice Goal – Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. 1. Effectively access and utilize national registry data for research. I 2. Know the role of and how to interact with Institutional Review Boards. I Evaluation Methods: Direct Observation and Feedback CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 102 Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year Goal – Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. 1. Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement. I 2. Appropriately integrate new or emerging medical evidence. I Evaluation Methods: Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation 1st Year 2nd Year 3rd Year Professionalism Goal – Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. 1. Demonstrate sensitivity to patient autonomy and safety in research. I 2. Practice with integrity in the conduct of research, including understanding issues relating to relationships with industry. 3. Interact respectfully with ancillary and support staff. I I Evaluation Methods: Direct Observation and Feedback, Self-Evaluations, 360 Reviews Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year Goal – Demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. 1. Communicate with fellow trainees and faculty about cardiovascular science and how this might impact clinical care (for example, through journal clubs). I 2. Effectively communicate study results during presentations. I Evaluation Methods: Conference Presentations If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information should be relayed to the Chief Fellow for scheduling purposes. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 103 Faculty Evaluation of Cardiology Fellow on Research Instructions: The following evaluation questions have been devised using the COCATS 4 Core Competency Components and Curricular Milestones for Training in Cardiac Catheterization. The evaluation scale is modeled after the ACGME Milestones categories, which are competencybased developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. Subject Name Evaluated by: Status Employer Program Evaluator Name Status Employer Program Rotation Evaluation Dates MEDICAL KNOWLEDGE 1* Knows the basic principles of molecular biology, genetics, genomics, proteomics, metabolomics and pharmacogenomics. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 2* Knows the principles of epidemiological methods. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 3* Knows the principles of outcomes evaluation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 4* Knows the basic principles of biostatistics. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 5* Knows the principles underlying hypothesis formation, specific goals definition, hypothesis testability, and statistical power achievable. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 104 Not Yet Assessed / Not Observed PATIENT CARE AND PROCEDURAL SKILLS 6* Possesses skills to review published research data and assess the adequacy of research design, data analysis, and logical deduction. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 5 Not Yet Assessed / Not Observed 7* Possesses skills to integrate appropriately scientific concepts and research advances in routine clinical encounters. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 5 Not Yet Assessed / Not Observed 8* Possesses skills to routinely assess the quality of evidence in clinical decisions. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 9* Possesses skills to apply principles of biomedical ethics as they pertain to human subject research in the identification of patients as potential research subjects, presentation of alternatives, obtaining informed consent and assuring the security of clinical data used for research. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed SYSTEMSBASED PRACTICE 10* Effectively accesses and utilizes national registry data for research. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 11* Knows the role of and how to interact with Institutional Review Boards. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 PRACTICEBASED LEARNING AND IMPROVEMENT CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 105 Not Yet Assessed / Not Observed 12* Identifies knowledge and performance gaps and engages in opportunities to achieve focused education and performance improvement. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 13* Appropriately integrates new or emerging medical evidence. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed PROFESSIONALISM 14* Demonstrates sensitivity to patient autonomy and safety in research. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 15* Practices with integrity in the conduct of research, including understanding issues relating to relationships with industry. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 16* Interacts respectfully with ancillary and support (research) staff. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed INTERPERSONAL AND COMMUNICATION SKILLS 17* Communicates with fellow trainees and faculty about cardiovascular science and how this might impact clinical care (for example, through journal clubs). Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 106 Not Yet Assessed / Not Observed 18* Effectively communicates study results during presentations. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 OVERALL ASSESSEMENT 19* Overall Assessment of this fellow's research. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 20 Comments: Please use the comment box below to offer detailed strengths and/or weaknesses of this fellow's research. 21* Is there any reason this fellow should not move to the next level of responsibility? Yes No Comment 22* Was this evaluation discussed with the fellow at the end of the rotation? *ACGME Program Requirement V.A.2.a).(1) states "faculty must evaluate fellow performance in a timely manner during each rotation and discuss this evaluation with each fellow at the completion of the assignment." Yes No Overall Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 107 ADULT CONGENITAL HEART DISEASE Goal: The purpose of this one-month rotation is to provide an introduction to the appropriate care for adults with congenital heart disease (ACHD). This includes providing appropriate inpatient care for acutely ill patients, outpatient care for chronic issues related to lifelong cardiovascular disease and consultation for cardiac and non-cardiac surgery in addition to pregnancy counseling. This introductory rotation to ACHD will provide the fellow with an infrastructure on which to build more subspecialty training and to recognize and potentially refer patients to a specialized ACHD clinic from a general cardiology or other subspecialty cardiology field after graduation. Objectives: By the end of this month’s rotation, the fellow should: • Describe common congenital heart defects’ anatomy, their surgical palliation and subsequent pathophysiologic sequelae. (MK) • Manage heart failure, as it pertains to congenital heart disease (commonly systolic right ventricular failure and valvular disease), on an in- and outpatient basis. (PC, MK, SBP) • Diagnose and manage arrhythmias common to the ACHD patient and understand complexity of sudden cardiac death risk assessment. (PC, MK, SBP) • Correctly identify congenital heart defects’ anatomy and surgical sequelae using multi-modality imaging. (MK, PBLI, P) • Manage medical comorbidities that ACHD patients acutely or chronically manifest, such as pregnancy, cirrhosis, renal failure, anemia, infectious disease, or malignancy. Interact with other subspecialists in a professional manner regarding other medical issues and expedite appropriate care. (MK, PC, ISC, P, SBP) • Describe the hemodynamic consequences of pregnancy and their potential effect on adults with congenital heart disease; identify which types of ACHD patients have high maternal or fetal mortality. Manage valvular heart disease in pregnancy, particularly prosthetic valves, and learn anticoagulation plans for use during pregnancy. (PC, MK, ISC, P, SBP) • Understand cardiac and non-cardiac surgical risk for different types of ACHD patients; recommend appropriate endocarditis prophylaxis. (MK, ISC) • Use revised Ghent criteria to diagnose Marfan syndrome and provide appropriate plan of care to expectantly manage Marfan patients through adulthood. (PC, MK) • Understand various syndromes and their medical comorbidities that may affect patients with ACHD, including Down syndrome and other genetic syndromes causing intellectual, developmental or maturational delay. (PC, MK, PBLI) • Recognize which genetic mutations, for example 22q11 microdeletion, NKX2.5, are associated with congenital heart disease and counsel patients about necessary screening of family members. (PC, MK) • Evaluate and understand management issues of pulmonary hypertension, including understanding uses/contraindications/side effects of pulmonary vasodilator drug therapy. (PC, MK, PBLI) • Interact with patients and their families in a compassionate and caring manner, observing confidentiality as well ethnic/religious background. (ISC, P) Fellow Responsibilities/Duties: • The fellow will participate in outpatient clinics with ACHD cardiologists two days each week. Participation includes obtaining a detailed medical and surgical history, performing a physical exam, reviewing pertinent imaging and electrocardiographic data, making an assessment and plan of care and compiling/proofreading letters to the referring physician. At this time, the outpatient clinic CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 108 • • • • • • schedule is as follows. Dr. Davidson has clinic Wednesdays at I.O. Silver Clinic from 8 am until 5 pm and Thursdays at Nyes Road from 9 am until 11:30 am. Dr. Kelleman has clinic on Thursdays at Nyes Road from 8:30 am until 5 pm. Dr. Ting has clinic on Fridays at Nyes Road from 8 am until 5 pm. The fellow will participate in pediatric cardiology clinic one day per week, on Mondays. This requires monthly coordination with Dr. Devyani Chowdhury, the director of the pediatriac cardiology fellowship program. The fellow will round on ACHD inpatients with the ACHD physician after gathering appropriate data and formulating plans of care. The fellow will provide inpatient consultation for new or established ACHD patients. The fellow will attend weekly ACHD conference on Tuesdays from 2 pm until 4 pm in the Hamilton conference room. He or she will participate by presenting cases recently seen in-house or in clinic and reviewing appropriate data with faculty members. The fellow should attend pediatric catheterization conference on Tuesday mornings at 7 am until 8 am or pediatric cardiac surgery conference on Thursday mornings at 7:30 am until 8:30 am if an ACHD patient is being discussed for future procedures or cardiac surgery. The fellow may participate in specialty imaging of ACHD patients, including cardiac MRI and TEE, when scheduling permits. Faculty Supervision: ACHD cardiology patient care by the fellow will be supervised in person or discussed by phone with the appropriate attending. Consults will be staffed with a cardiology attending in the Program for Adult Congenital Heart Disease. Fellows’ care of the ACHD patient will be supervised by faculty within the Program for Adult Congenital Heart Disease. Procedures/Patient Characteristics/Disease Mix/Types of Encounters: ACHD inpatients can be on the acute cardiology service, heart failure service, and the mechanical circulatory support service. Inpatient consultations may be sought from surgery, medicine, hepatology, transplant or oncology services. The fellow, as stated above, is expected to engage in the patients’ care regardless of where the patient is in the hospital. The mix of congenital heart disease will vary from simple to complex (as reviewed in ACC/AHA guidelines for the care of the adult patient with congenital heart disease) with excellent potential for exposure to various genetic syndromes. There is an appropriate gender mix with a wide span of ages. The ethnicity of our patient population may vary slightly, including the local Amish population, given that some congenital heart disease lesions are of genetic origin. The ACHD fellow may participate in procedures, such as cardiac catheterization, electrical or chemical cardioversion, imaging (TEE or cardiac MRI) as the time and circumstances permit. In cases where cardiac catheterization is performed by faculty within the Children’s Heart Group, additional coordination will be required. Evaluations: The ACHD fellow will be evaluated by faculty within the Program for Adult Congenital Heart Disease at the end of the month’s rotation. Feedback will be given to the fellow verbally and in writing. The written evaluation is based on the ACGME 6 core competencies. The fellows have taken part in the design of this rotation and development of the curriculum. They are also given the opportunity to evaluate the curriculum and rotation. The fellows also confidentially evaluate the attending cardiologists. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 109 Teaching Methods: Informal teaching at the inpatient bedside and in the clinic is provided by faculty of the Program for Adult Congenital Heart Disease. The fellow also learns by instructing medical students and nurses involved in the patients’ care. The fellow will also educate patients and their families about their condition. Fellows will also be educated at the weekly conference on Tuesday afternoons. Fellows are encouraged to review current literature about the particular lesion or the pathophysiologic process that pertains to the patient who will be discussed and share with the faculty at that meeting. Self-study is a must during this rotation because of the wide variety and number of congenital heart disease lesions observed in ACHD; some lesions may not be encountered in only one months’ time. Conference Topics: Fellows on the ACHD rotation will have attended conferences pertaining to simple, moderate and severely complex congenital heart disease in the adult, pre-pregnancy risk assessment, and multi-modality imaging as parts of their other rotations or general cardiology curriculum lecture series. Additional Tuesday conference topics will be variable and pertain directly to patient-care, similar to problem-based learning curricula during medical school. It is imperative the fellow actively participate in these conferences for further understanding of management of the adult with congenital heart disease. Suggested Reading/Educational Resources: Websites • www.achaheart.org: Adult Congenital Heart Association • www.isachd.org: International Society for Adult Congenital Heart Disease Books (in addition to standard general cardiology text) • Freedom RM. The Natural and Modified History of Congenital Heart Disease. Blackwell Publishing, 2004. • Gatzoulis MA, Webb GD, Daubeney PEF. Diagnosis and Management of Adult Congenital Heart Disease. Churchill Livingstone, 2003. • Broberg CS, Webb GD, Uemura H, Gatzoulis MA. Cases in Adult Congenital Heart Disease. Churchill Lingstone, 2009. • Oakley C, Warnes CA. Heart Disease in Pregnancy, 2nd Edition. Blackwell Publishing, 2007. • Allen, Hugh D, and David Driscoll, and Robert Shaddy, and Timothy Feltes. Moss and Adams' Heart Disease in Infants, Children and Adolescents: Including the Fetus and Young Adult, 2 Volume Set. Philadelphia: Lippincott Williams, 2008. Guidelines • 2008 ACC/AHA Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2008 Dec 2;118(23):e714-833. Epub 2008 Nov 7. • 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2010 Apr 6;121(13):e266-369. Epub 2010 Mar 16. Erratum in: Circulation. 2010 Jul 27;122(4):e410. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 110 • 1991 "Congenital heart disease after childhood: an expanding patient population. 22nd Bethesda Conference, Maryland, October 18-19, 1990." J Am Coll Cardiol 18(2): 311-42. Articles (regarding selected ACHD topics and conditions) ACHD population issues: • Karamlou, T., B. S. Diggs, et al. (2008). "National practice patterns for management of adult congenital heart disease: operation by pediatric heart surgeons decreases in-hospital death." Circulation 118(23): 2345-52. • Diller, G. P. and M. A. Gatzoulis (2007). "Pulmonary vascular disease in adults with congenital heart disease." Circulation 115(8): 1039-50. • Diller, G. P., K. Dimopoulos, et al. (2005). "Exercise intolerance in adult congenital heart disease: comparative severity, correlates, and prognostic implication." Circulation 112(6): 828-35. • Mackie, A. S., L. Pilote, et al. (2007). "Health care resource utilization in adults with congenital heart disease." Am J Cardiol 99(6): 839-43. • Mackie, A. S., R. Ionescu-Ittu, et al. (2008). "Hospital readmissions in children with congenital heart disease: a population-based study." Am Heart J 155(3): 577-84. • Marelli, A. J., A. S. Mackie, et al. (2007). "Congenital heart disease in the general population: changing prevalence and age distribution." Circulation 115(2): 163-72. • Dimopoulos, K., G. P. Diller, et al. (2009). "Anemia in adults with congenital heart disease relates to adverse outcome." J Am Coll Cardiol 54(22): 2093-100. • Bouchardy, J., J. Therrien, et al. (2009). "Atrial arrhythmias in adults with congenital heart disease." Circulation 120(17): 1679-86. • Dimopoulos, K., G. P. Diller, et al. (2008). "Prevalence, predictors, and prognostic value of renal dysfunction in adults with congenital heart disease." Circulation 117(18): 2320-8. • Diller, G. P. and M. A. Gatzoulis (2007). "Pulmonary vascular disease in adults with congenital heart disease." Circulation 115(8): 1039-50. • Dimopoulos, K., D. O. Okonko, et al. (2006). "Abnormal ventilatory response to exercise in adults with congenital heart disease relates to cyanosis and predicts survival." Circulation 113(24): 2796802. • Verheugt, C. L., C. S. Uiterwaal, et al. "Mortality in adult congenital heart disease." Eur Heart J 31(10): 1220-9. • Yetman, A. T. and T. Graham (2009). "The dilated aorta in patients with congenital cardiac defects." J Am Coll Cardiol 53(6): 461-7. Tetralogy of Fallot and variants: • Bashore, T. M. (2007). "Adult congenital heart disease: right ventricular outflow tract lesions." Circulation 115(14): 1933-47. • Broberg, C. S., J. Aboulhosn, et al. "Prevalence of Left Ventricular Systolic Dysfunction in Adults With Repaired Tetralogy of Fallot." Am J Cardiol. • Khairy, P., J. Aboulhosn, et al. "Arrhythmia burden in adults with surgically repaired tetralogy of Fallot: a multi-institutional study." Circulation 122(9): 868-75. • Khairy, P., L. Harris, et al. (2008). "Implantable cardioverter-defibrillators in tetralogy of Fallot." Circulation 117(3): 363-70. • Therrien, J., Y. Provost, et al. (2005). "Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair." Am J Cardiol 95(6): 779-82. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 111 • • • • • Ghai, A., C. Silversides, et al. (2002). "Left ventricular dysfunction is a risk factor for sudden cardiac death in adults late after repair of tetralogy of Fallot." J Am Coll Cardiol 40(9): 1675-80. Oosterhof, T., A. van Straten, et al. (2007). "Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance." Circulation 116(5): 545-51. Henkens, I. R., A. van Straten, et al. (2007). "Predicting outcome of pulmonary valve replacement in adult tetralogy of Fallot patients." Ann Thorac Surg 83(3): 907-11. Gatzoulis, M. A., J. A. Till, et al. (1995). "Mechanoelectrical interaction in tetralogy of Fallot. QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death." Circulation 92(2): 231-7. Niwa, K., S. C. Siu, et al. (2002). "Progressive aortic root dilatation in adults late after repair of tetralogy of Fallot." Circulation 106(11): 1374-8. ASD/PFO: • Attie, F., M. Rosas, et al. (2001). "Surgical treatment for secundum atrial septal defects in patients >40 years old. A randomized clinical trial." J Am Coll Cardiol 38(7): 2035-42. • Gutierrez-Roelens, I., L. De Roy, et al. (2006). "A novel CSX/NKX2-5 mutation causes autosomaldominant AV block: are atrial fibrillation and syncopes part of the phenotype?" Eur J Hum Genet 14(12): 1313-6. • Sachweh, J. S., S. H. Daebritz, et al. (2006). "Hypertensive pulmonary vascular disease in adults with secundum or sinus venosus atrial septal defect." Ann Thorac Surg 81(1): 207-13. • Meissner, I., B. K. Khandheria, et al. (2006). "Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study." J Am Coll Cardiol 47(2): 440-5. • Cabanes, L., J. Coste, et al. (2002). "Interobserver and intraobserver variability in detection of patent foramen ovale and atrial septal aneurysm with transesophageal echocardiography." J Am Soc Echocardiogr 15(5): 441-6. • Lamy, C., C. Giannesini, et al. (2002). "Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atrial Septal Aneurysm." Stroke 33(3): 706-11. • Hara, H., R. Virmani, et al. (2005). "Patent foramen ovale: current pathology, pathophysiology, and clinical status." J Am Coll Cardiol 46(9): 1768-76. • Homma, S., R. L. Sacco, et al. (2002). "Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study." Circulation 105(22): 2625-31. Fontan for various single ventricle anatomy: • Rychik, J. (2007). "Protein-losing enteropathy after Fontan operation." Congenit Heart Dis 2(5): 288300. • Fredriksen, P. M., J. Therrien, et al. (2001). "Lung function and aerobic capacity in adult patients following modified Fontan procedure." Heart 85(3): 295-9. Eisenmenger syndrome/Pulmonary Hypertension • Galie, N., M. Beghetti, et al. (2006). "Bosentan therapy in patients with Eisenmenger syndrome: a multicenter, double-blind, randomized, placebo-controlled study." Circulation 114(1): 48-54. • Gatzoulis, M. A., M. Beghetti, et al. (2008). "Longer-term bosentan therapy improves functional capacity in Eisenmenger syndrome: results of the BREATHE-5 open-label extension study." Int J Cardiol 127(1): 27-32. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 112 • • • • • Berger, R. M., M. Beghetti, et al. "Atrial septal defects versus ventricular septal defects in BREATHE5, a placebo-controlled study of pulmonary arterial hypertension related to Eisenmenger's syndrome: a subgroup analysis." Int J Cardiol 144(3): 373-8. Duffels, M. G., J. C. Vis, et al. (2009). "Down patients with Eisenmenger syndrome: is bosentan treatment an option?" Int J Cardiol 134(3): 378-83. Somerville, J. (1998). "How to manage the Eisenmenger syndrome." Int J Cardiol 63(1): 1-8. Daliento, L., J. Somerville, et al. (1998). "Eisenmenger syndrome. Factors relating to deterioration and death." Eur Heart J 19(12): 1845-55. Broberg, C. S., B. E. Bax, et al. (2006). "Blood viscosity and its relationship to iron deficiency, symptoms, and exercise capacity in adults with cyanotic congenital heart disease." J Am Coll Cardiol 48(2): 356-65. Bicuspid aortic valve: • Biner, S., A. M. Rafique, et al. (2009). "Aortopathy is prevalent in relatives of bicuspid aortic valve patients." J Am Coll Cardiol 53(24): 2288-95. • Schaefer, B. M., M. B. Lewin, et al. (2007). "Usefulness of bicuspid aortic valve phenotype to predict elastic properties of the ascending aorta." Am J Cardiol 99(5): 686-90. Syndromes (Marfan, Down, Turner, etc.): • Loeys, B. L., H. C. Dietz, et al. "The revised Ghent nosology for the Marfan syndrome." J Med Genet 47(7): 476-85. • Bondy, C. A. (2007). "Care of girls and women with Turner syndrome: a guideline of the Turner Syndrome Study Group." J Clin Endocrinol Metab 92(1): 10-25. • Vis, J. C., M. G. Duffels, et al. (2009). "Down syndrome: a cardiovascular perspective." J Intellect Disabil Res 53(5): 419-25. • Vis, J. C., H. Thoonsen, et al. (2009). "Six-minute walk test in patients with Down syndrome: validity and reproducibility." Arch Phys Med Rehabil 90(8): 1423-7. • Gupta, P., J. D. Tobias, et al. "Sudden cardiac death under anesthesia in pediatric patient with Williams syndrome: a case report and review of literature." Ann Card Anaesth 13(1): 44-8. • Lashkari, A., A. K. Smith, et al. (1999). "Williams-Beuren syndrome: an update and review for the primary physician." Clin Pediatr (Phila) 38(4): 189-208. Pregnancy: • Siu, S. C., M. Sermer, et al. (2001). "Prospective multicenter study of pregnancy outcomes in women with heart disease." Circulation 104(5): 515-21. • Khairy, P., D. W. Ouyang, et al. (2006). "Pregnancy outcomes in women with congenital heart disease." Circulation 113(4): 517-24. • Lui, G. K., C. K. Silversides, et al. "Heart rate response during exercise and pregnancy outcome in women with congenital heart disease." Circulation 123(3): 242-8. • Balint, O. H., S. C. Siu, et al. "Cardiac outcomes after pregnancy in women with congenital heart disease." Heart 96(20): 1656-61. • Tobler, D., S. M. Fernandes, et al. "Pregnancy outcomes in women with transposition of the great arteries and arterial switch operation." Am J Cardiol 106(3): 417-20. • Tzemos, N., C. K. Silversides, et al. (2009). "Late cardiac outcomes after pregnancy in women with congenital aortic stenosis." Am Heart J 157(3): 474-80. • Silversides, C. K., J. M. Colman, et al. (2003). "Early and intermediate-term outcomes of pregnancy with congenital aortic stenosis." Am J Cardiol 91(11): 1386-9. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 113 • • • Walker, F. (2007). "Pregnancy and the various forms of the Fontan circulation." Heart 93(2): 152-4. Drenthen, W., P. G. Pieper, et al. (2006). "Pregnancy and delivery in women after Fontan palliation." Heart 92(9): 1290-4. Canobbio, M. M., D. D. Mair, et al. (1996). "Pregnancy outcomes after the Fontan repair." J Am Coll Cardiol 28(3): 763-7. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 114 ACUTE CARDIOLOGY INPATIENT SERVICE Overview: The cardiovascular fellow on the ward rotation will be responsible for the evaluation and ongoing care of patients admitted to the general cardiology ward service. Specific responsibilities include: • • • • • See new patients admitted to the ward and HVICU (the fellow is not responsible to see all patients; generally patients with non-critical health issues admitted overnight will be seen by the resident on call and not by the fellow). For patients that are seen: Document the indication for admission. Perform of an appropriate history and physical (H&P) examination. Review and document, by independent interpretation (when appropriate), all relevant diagnostic information including ECG’s, images including chest x-rays, CT scans, echo-Doppler data, nuclear images, MRI scans, catheterization lab images, hemodynamic data and other information.. Review and document relevant biochemical lab data Define a plan for inpatient care, including testing and treatment. Base recommendations for testing and treatment on, when available, ACC/AHA guidelines. Indications for withholding standard treatment and testing must be documented. Be able to present the history, physical examination and testing and/or treatment plans to the attending physician; if the presentation is given by a medical student or resident, be able to provide appropriate information not detailed by the presenter Communicate to the patient the diagnosis and recommend to the patient of any tests/or and treatments thought to be appropriate Discuss in an appropriate manner with the patient the risks and benefits of tests and/or treatments Promptly notify the patient of any relevant test results Education of the patient As appropriate, about the disease(s)/diagnose(s) About health measures (such as diet, weight loss, cessation of smoking) Oversee the residents and medical students on the service in regards to patient care Provide education to the residents and medical students on the service Educational Goals: Cardiovascular fellows will acquire the necessary skills to diagnose and manage a wide spectrum of cardiovascular diseases including but not limited to coronary artery disease, valvular heart disease, diseases of the myocardium, diseases of the pericardium and congenital heart disease, cardiac arrhythmias, conduction disorders and syncope. Fellows will develop the necessary skills to obtain a thorough cardiac history and perform a physical examination. This shall include the evaluation of normal and abnormal heart sounds, evaluation of heart murmurs, including provocative maneuvers that accentuate or decrease intensity of murmurs. The fellow will acquire the necessary skills to recognize the peripheral manifestations of cardiac dysfunctions. The fellow will learn the indications and contraindications for performing diagnostic studies. Adherence to published “appropriateness criteria” for diagnostic tests is expected. In addition, the fellow will become proficient in analyzing diagnostic data to establish a cardiovascular diagnosis and treatment plan. The fellow will acquire experience in the clinical analysis of surface and intracardiac ECG recordings, chest radiographs, stress echo and nuclear images, CT scans, M-mode and 2-D echocardiograms, Doppler and catheter CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 115 hemodynamics, coronary angiography, and contrast ventriculography. Opportunities to review new imaging modalities including cardiac MRI and 3-D echo will be encouraged. The fellow will enhance his/her abilities to teach medical students and residents, both formally and informally (didactically and at the bedside). The fellow will enhance his/her abilities to communicate to patients. Training Objectives: • To develop the knowledge and skills required to obtain a proper cardiac history. Specific areas include, but are not limited to, characterization of chest pain (including the differential diagnosis of various etiologies of chest pain syndrome based on historical description), dyspnea (with differentiating cardiac from pulmonary causes of dyspnea), exercise capacity and functional class. In addition, special emphasis should be paid to medications, medication compliance, dietary habits, smoking and alcohol consumption as well as other risk factors for cardiac diseases. (Patient Care, Medical Knowledge, Practice-Based Learning, Interpersonal and Communication Skills) • To become proficient in cardiac physical examination. The complete bedside examination includes palpation of all pulses, recognition of pulse characteristics, and blood pressure examinations in both upper and lower extremities, especially when delayed or absent femoral pulses are obtained. The cardiac resident should also be able to estimate jugular venous pressure as well as characterize different waves in the neck, detect bruits, examine lung fields, and define the precise location and characterization of left and right ventricular impulses. Proficiency is required for auscultation of heart sounds as it relates to intensity, splitting and additional heart sounds such as murmurs, rubs and clicks. To accurately assess the characterization of murmurs with regard to timing pitch, grade, maximal intensity and radiation and the effect of provocative maneuvers in eliciting the origin of the murmur. To recognize the peripheral manifestations of heart dysfunction such as palpable and/or pulsatile liver, anasarca, ascites, peripheral edema or sacral edema. (Patient Care, Medical Knowledge) • To accurately assess the presence or absence of congestive heart failure. To evaluate whether murmurs of valvular heart disease such as mitral regurgitation, mitral stenosis, aortic regurgitation and tricuspid regurgitation contribute singularly or in combination to the clinical picture of congestive heart failure. (Patient Care, Medical Knowledge) • To accurately assess the presence or absence of abdominal aneurysms and the presence or absence of peripheral vascular disease. (Patient Care, Medical Knowledge) • To assess the normal auscultatory findings in pregnant patients and to be able to differentiate pregnant patients with valvular heart disease or congenital heart disease from physiological heart sounds of pregnancy. (Patient Care, Medical Knowledge, Practice-Based Learning) • To become skilled in ECG interpretation of hypertrophy, conduction disturbances, heart block, WPW, acute infarction versus chronic infarction pattern as well as other syndromes and conditions. (Patient Care, Medical Knowledge, Practice-Based Learning) CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 116 • To learn how to interpret cardiac images (chest X-ray, CT, MRI, nuclear, echo, and angiograms) focusing on assessment of heart structure and function. (Patient Care, Medical Knowledge, PracticeBased Learning) • To learn to interpret laboratory data to assist with risk stratification and treatment. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning) • To understand the clinical value of different therapeutic interventions including medical, percutaneous, surgical and device as well as device therapy in the management of all types of adult cardiovascular disease. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning, Interpersonal and Communication Skills) • To learn to assess the risk of and treat adverse cardiac events in the perioperative period for patients referred for non-cardiac surgery (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning) • To learn about the chronicity and long-term characteristics of various cardiac diagnoses, such as congestive heart failure, valvar disease (such as aortic stenosis and mitral regurgitation), and chronic coronary artery disease. (Patient Care, Medical Knowledge, Practice-Based Learning) • To interact in a professional manner with the patient in a compassionate and caring manner; to demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues; to adhere to principles of confidentiality, scientific/academic integrity and informed consent. (Patient Care, Communication Skills, Professionalism) • To interact with the health care team including nurses, physician assistants, technicians, social workers, nutritionists, physical therapists, respiratory therapists as well as other physicians. (Patient Care, Medical Knowledge, Systems-Based Practice, Interpersonal and Communication Skills, Professionalism) • Learn how to utilize hospital and community resources for managing cardiac patients in the outpatient setting. (Systems-Based Practice, Practice-Based Learning, Patient Care and Interpersonal and Communication Skills) • Access and critically evaluate current medical information and scientific evidence. Use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning and Improvement) Principle Teaching Methods • The attending cardiologist on the ward service will serve as a mentor for the fellow. The mentor– student relationship will be utilized as the main teaching method after the fellow has seen and examined the patient and presented the patient’s findings and plans to the attending. The fellow is expected to utilize available scientific research, published guidelines and expert opinion to assist with decision making and learning. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 117 • Discrepant findings on diagnostic data, controversial issues and differences of opinion will be discussed with the attending cardiologists. When appropriate the attending will examine the patient and discuss discrepancies of examination with the fellow. Evaluation Methods: The attending cardiologist will utilize a standardized evaluation process to assess the performance of the cardiac resident. A written evaluation of the cardiac fellows’ performance on the consultative service will be made each six months by the cardiology attendings assigned to the outpatient continuity clinic. The cardiology attending will evaluate each fellow according to the ACGME general competencies including: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. In addition, bedside skills such as obtaining history, physical examination and performance of cardiac procedures will be evaluated. The fellowship director will meet with each cardiac fellow at the end of each six month rotation to review the written evaluation. Fellows are required to electronically sign each evaluation in the New-Innovations program. Educational Content: On the general cardiology ward service patients may be admitted to a general cardiology floor, to an area allowing intermediate care monitoring, or to an intensive care unit. Patients may be referred for admission or may be admitted via the emergency room or outpatient clinic. Patients with a variety of cardiac disorders including but not limited to coronary artery disease, hypertension, peripheral vascular disease, hyperlipidemia, valvular heart disease, myocardial and peripheral disease, endocarditis, pericardial diseases and congenital heart disease will form the service. Obviously patients of both genders are on the ward service. The age spectrum is from 18 years of age to occasional patients 100 years of age or more. Patients are of rural or urban background, from a wide range of socioeconomic groups, and of various ethnic backgrounds. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 118 CONSULT SERVICE Overview: The cardiovascular fellow on the consult service will be responsible for the performance and follow-up of all consultations on patients assigned to the consult attending. Specific responsibilities include: • • • • • • • • • • • Timely response to consultation request. Documentation of the indication for the consultation. Completion of a comprehensive history and examination. Review and documentation of an independent interpretation of all relevant diagnostic information including ECG’s, images including chest x-rays, CT scans, echo-Doppler data, nuclear images, MRI scans, catheterization lab images and/or hemodynamic data. Relevant biochemical lab data will also be reviewed and documented. Documentation of all cardiovascular diagnoses. Documentation of clinical impressions with particular attention to questions posed by the requesting physician. Recommendations for testing and treatment will be consistent with the ACC/AHA guidelines. Indications for withholding standard treatment must be delineated. Define a plan for inpatient and outpatient follow up. Communication of diagnosis, recommendations and follow-up plan to the requesting physician and patient. Assist with the implementation of treatment including computer order entry and communication with the bedside nurse. Cardiology fellows will be responsible for in hospital follow-up of all patients on the consult service. Documentation of patient response to treatment, change in clinical status or plan of care is required. Function as a coordinator of the consult team by assigning patients to students or medical residents, and supervise them with formulating the plans for the patients so assigned, and prepare more junior trainees for attending rounds. Educational Goals: Cardiology fellows will acquire the necessary skills to diagnose and manage patients with coronary artery disease, valvular heart disease, and diseases of the myocardium, pericardium and congenital heart disease. In addition, fellows will be required to understand, recognize and manage patients with cardiac arrhythmias, conduction disorders and patients presenting with syncope. They will develop bedside cardiology skills with emphasis on cardiac history taking, bedside physical examination including evaluation of normal and abnormal heart sounds, evaluation of heart murmurs, including provocative maneuvers that accentuate or decrease intensity of murmurs, allowing the cardiac residents to better delineate the origin of the murmur. Cardiology fellows will acquire the necessary skills to recognize the peripheral manifestations of cardiac dysfunction. They will learn the indications and contraindications of diagnostic studies. Adherence to published “appropriateness criteria” for diagnostic tests is expected. Fellows will learn to explain the purpose and nature of procedures and be able to explain what the patient should expect during procedures. The common complications, incidence, and expected benefits will be learned and explained to patients. Cardiology fellows will become proficient in analyzing diagnostic data to establish a cardiovascular diagnosis and treatment plan. Fellows will be expected to review laboratory data including ECGs, chest radiographs, resting transthoracic and transesophageal echocardiograms, stress echo and nuclear stress tests, and catheterization images to formulate a patient diagnosis and treatment plan. An understanding of the limitations of each modality to resolve inconsistent or contradictory findings is expected as the fellow progresses through training. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 119 Training Objectives: • To develop the knowledge and skills required to obtain a proper cardiac history. Specific areas include characterization of chest pain (including the differential diagnosis of various etiologies of chest pain syndrome based on historical description), dyspnea (with differentiating cardiac from pulmonary causes of dyspnea), exercise capacity and functional class. In addition, special emphasis should be paid to medications, medication compliance, dietary habits, smoking and alcohol consumption as well as other risk factors for cardiac diseases. (Patient Care, Medical Knowledge, Practice-Based Learning, Interpersonal and Communication Skills) • To become proficient in bedside cardiac physical examination. The complete bedside examination includes palpation of all pulses, recognition of pulse characteristics, and blood pressure examinations in both upper and lower extremities, especially when delayed or absent femoral pulses are obtained. The cardiac resident should also be able to estimate jugular venous pressure as well as characterize different waves in the neck, detect bruits, examine lung fields, and define the precise location and characterization of left and right ventricular impulses. Proficiency is required for auscultation of heart sounds as it relates to intensity, splitting and additional heart sounds such as murmurs, rubs and clicks. To accurately assess the characterization of murmurs with regard to timing pitch, grade, maximal intensity and radiation and the effect of provocative maneuvers in eliciting the origin of the murmur. To recognize the peripheral manifestations of heart dysfunction such as palpable and/or pulsatile liver, anasarca, ascites, peripheral edema or sacral edema. (Patient Care, Medical Knowledge) • To accurately assess the presence or absence of congestive heart failure and discern the signs of cardiac tamponade at the bedside. To evaluate whether murmurs of valvular heart disease such as mitral regurgitation, mitral stenosis, aortic regurgitation and tricuspid regurgitation contribute singularly or in combination to the clinical picture of congestive heart failure. (Patient Care, Medical Knowledge) • To accurately assess the presence or absence of abdominal aneurysms and the presence or absence of peripheral vascular disease. (Patient Care, Medical Knowledge) • To assess the normal auscultatory findings in pregnant patients and to be able to differentiate pregnant patients with valvular heart disease or congenital heart disease from physiological heart sounds of pregnancy. (Patient Care, Medical Knowledge, Practice-Based Learning) • To become skilled in ECG interpretation of hypertrophy, conduction disturbances, heart block, WPW, acute infarction versus chronic infarction pattern. In addition to recognizing electrolyte disturbances and its effect on the ECG, the cardiac resident should be able to accurately interpret supraventricular arrhythmias, especially with regard to the differentiation of atrial fibrillation, from atrial flutter, re-entrant supraventricular tachycardia and multifocal atrial tachycardia. To be able to evaluate wide complex tachycardias and differentiate ventricular tachycardia from supraventricular tachycardia with aberration or pre-excitation and to recognize the different forms of ventricular tachycardia, monomorphic from polymorphic and torsade-des-pointes. (Patient Care, Medical Knowledge, Practice-Based Learning) • To learn how to interpret cardiac images (chest X-ray, CT, MRI, nuclear, echo, and angiograms) focusing on assessment of heart structure and function. (Patient Care, Medical Knowledge, Practice-Based Learning) CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 120 • To learn to interpret laboratory data to assist with risk stratification and treatment. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning) • To understand the clinical value of different therapeutic interventions including medical, percutaneous, and surgical therapies as well as device therapy in the management of all types of adult cardiovascular disease. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning, Interpersonal and Communication Skills) • To interact with the health care team including nurses, physician assistants, technicians, social workers, nutritionists, physical therapists, respiratory therapists as well as other physicians. (Patient Care, Medical Knowledge, Systems-Based Practice, Interpersonal and Communication Skills, Professionalism) • Learn how to utilize hospital and community resources for managing cardiac patients in the outpatient setting. Interact with staff in referring physician’s offices, lipid clinics, Coumadin clinics, cardiac rehabilitation, visiting nursing services (VNA), the OASIS program, and hospice. (Systems-Based Practice, Practice-Based Learning, Patient Care and Interpersonal and Communication Skills) • Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families and colleagues. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues. Adhere to principles of confidentiality, scientific/academic integrity and informed consent. (Patient Care, Professionalism) • Access and critically evaluate current medical information and scientific evidence. Use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning and Improvement) Principle Teaching Methods: • An attending cardiologist will serve as a mentor for the cardiac resident. The mentor and student relationship will be utilized as the main teaching method during daily clinical rounds. The resident is expected to utilize all available scientific research, published guidelines and expert opinion to assist with decision making and learning. • Discrepant findings on diagnostic data, controversial issues and differences of opinion will be discussed with the attending cardiologists. • Combined management teaching rounds will be held with the consult fellow and other members of the consult services (i.e., medical residents and students) The daily teaching round component must occur at least three times per week for a minimum of 4 1/2 hours per week. Generally, a few cases will be presented on teaching rounds as a basis for discussion of such points as interpretation of clinical data, pathophysiology, differential diagnosis, specific management of the patient and the appropriate use of technology. Teaching rounds must include direct bedside interaction with the patient by the resident and the scheduled teaching physician. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 121 • The cardiac residents will be responsible, on a rotating basis, for presenting educational information at selected conferences. Reporting the outcome of individual patients or groups of patients will be required. Outcome assessments should include both short term and long term follow-up. Evaluation Methods: The attending cardiologist will utilize a standardized evaluation process to assess the performance of the cardiac resident. A written evaluation of the cardiac fellows’ performance on the consultative service will be made at the end of each rotation by the cardiology attending assigned to the consultative service. At the conclusion of each consultative rotation, the cardiology attending will evaluate each fellow according to the ACGME general competencies including: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. In addition, bedside skills such as obtaining history, physical examination and performance of cardiac procedures will be evaluated. The cardiology teaching attending will meet with each cardiac fellow at the end of the rotation to review the written evaluation. Fellows are required to sign each evaluation in the presence of the cardiac attending. Educational Content: The consultation service will provide evaluations and patient care throughout the hospital including the medical and surgical floors, maternity suites, operation suites, recovery room and in the emergency department. Patients with a variety of cardiac disorders including coronary artery disease, hypertension, peripheral vascular disease, hyperlipidemia, valvular heart disease, myocardial and peripheral disease, endocarditis, pericardial diseases and congenital heart disease will form the case mix for the consultative service. Each patient is seen on a daily basis and if necessary more frequently and each patient will be reviewed by an attending cardiologist. Cardiac residents will follow each patient throughout their hospitalization. Major procedures such as a cardiac catheterization, angioplasty, pericardiocentesis, cardioversion, tilt table testing, echo Doppler cardiography and stress testing will be performed in the appropriate laboratories. Emergent evaluations for acute chest pain, respiratory failure and cardiac arrhythmias will occur at the bedside. Strengths and Limitations: The strengths of the cardiology consultation service include the large volume and diversity of cardiac patients. The attending cardiologists are experienced teachers with a strong focus on bedside teaching. A high volume of noninvasive and invasive procedures are performed by the cardiology staff. Participation in the hospitals quality improvement programs is strongly encouraged. Clinical research including involvement in local, national and international clinical trials is ongoing. The cardiac resident is expected to participate in these activities. Bibliography: • • • • • Carithers, Jr. R L. Liver Transplantation, Vol 6, No 1 AASLD Practice Guidelines, Jan 2000; 122-135. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G Jr., Prevention of Bacterial Endocarditis. Recommendations by the American Heart Association, Circulation, 1997 Jul 1; 96(1): 35866. Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Pressure in Adults (Adult Treatment Panel III), www.nhlbi.nih.gov, 2002. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and treatment of High Blood Pressure, JNC 7 Complete Report, American Heart Association 2003, Hypertension 2003;42:1206. www.nhlbi.nih.gov. Kapoor W. Current Evaluation and Management of Syncope, Circulation. 2002;106:1606-1609. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 122 • • • • • • • • • • • • Facts about the DASH Eating Plan. U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute, 2003. www.nhlbi.nih.gov. Sale, DN, Daudelin DH, Levine HJ, Pauker SG, Eckman MH, Riff J. Antithrombotic Therapy in Valvular Heart Disease. Chest, Jan 2001; 119:207S-219S. Crawford MH, Berstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A Jr, Green LA, Greene HL, Silka MJ, Stone PH, Tracy CM ACC/AHA Guidelines for Ambulatory Electrocardiography: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography). J Am Coll Cardiol, 1999;34:912-48 www.aca.org. Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA, Kerber RE, Naccarelli GV, Schoenfeld MH, Silka MJ, Winters SL.ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee on Pacemaker Implantation). J Am Coll Cardiol, 2002 www.acc.org/clinical/guidelines/pacemaker/pacemaker.pdf. Jessup M, Brozena S. Heart Failure. New Engl J Med 2003; 348: 2007-2018. Bayer AS, Bolger AF, Taubert KA, Wilson W, Steckelberg J, Karchmer AW, Levison M, Chambers H F, Dajani AS, Gewitz MH, Newburger JW, Gerber MA, Shulman St, Pallasch TJ, Gage TW, Ferrieri P. Diagnosis and Management of Infective Endocarditis and its Complications, Circulation, 1998; 98:2936-2948. www.circulationsaha.org. Eagle, KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O’Connor GT, Orszulak TA, Rieselbach RE, Winters WL Yusuf S. ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery), J Am Coll Cardiol 1999; 34: 1262-1346. Erhardt L, Herlitz J, Bossaert L, Halinen M, Keltai M, Koster R, Marcassa C, Quinn T, vanWeert H. Task Force on the Management of Chest Pain. European Heart Journal 2002; 23: 1153-1176. Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell, WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli, GF. ACC/AHA/ESC Guidelines for the Management of Patients with Supraventricular Arrhythmias–Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Supraventricular Arrhythmias. J Am Coll Cardiol 2003;42: 1493-1531. Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HF, Frye RL, Halperin JL, Kay GN, Klein WW, Levy S, McNamara FL, Prystowsky EN, Wan, LS, Wyse, DG. ACC/AHA/ESC Guidelines for the Update for the Management of Patients with Atrial Fibrillation,: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillations). J Am Coll Cardiol 2001 38: 1266i-lxx Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS, Ganiats TG, Goldstein S, Gregoratos G, Jessup, ML, Noble RJ, Packer MP, Silver, MA, Stevenson LW. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure), 2001; www.acc.org/clinical/guidelines/failfure/ hf_index.htm. Adams RJ, Chimowitz MI, Alpert JS, Awad IS, Cerqueria MD, Fayad P Taubert KA. Coronary Risk Evaluation in Patients with transient Ischemic Attach and Ischemic Stroke: A Scientific Statement for Healthcare CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 123 • • • • • • • • • • • • • • • • • • • • Professionals from the Stroke Council and the Council on Clinical Cardiology of the American Heart Association/American Stroke Association, Circulation 2003; 108: 1278-1290. www.circulationha.org Budoff MJ, Achenbach S, Duerinckx A. Clinical Utility of Computed Tomography and Magnetic Resonance Techniques for Noninvasive Coronary Angiography, J Am Coll Cardiol 2003;42: 1867-78. Barbaro G. Cardiovascular Manifestations of HIV Infection, Circulation. 2002;106:1420-1425; www.circulationha.org. Greenland P, Gaziaro M. Selecting Asymptomatic Patients for Coronary Computed Tomography or Electrocardiographic Exercise Testing. New Engl J Med 2003;349:465-73. Reimold SC, Rutherford JD. Valvular Heart Disease in Pregnancy, New Engl J Med 2003; 49-529. McNamara RL, Tamariz LJ, Segal JB, Bass EB. Management of Atrial Fibrillation: Review of the Evidence for the Role of Pharmacologic Therapy, Electrical Cardioversion, and Echocardiography, Ann Intern Med 2003;139:1018-1033. Snow V, Weiss KB, LeFevre M, McNamara R, Bass E, Green LA, Michl K, Owens DK, Susman J, Allen DI, Mottur-Pilson C. Management of Newly Detected Atrial Fibrillation: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians, Ann Intern Med 2003;139:1009-1017. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson Jr. TB, Fihn SD, Fraker Jr. TD, Gardin JM, O’Rourke RA, Pasternak RC, Williams SV. ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic Stable Angina: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina), www.acc.org/clinical/guidelines/stable/stable.pdf. Fagard R. Athletes Heart, Heart 2003;89:1445-1461. Grundy SM, Pasternak R, Greenland P, Smith Jr. S, Fuster V. Assessment of Cardiovascular Risk by use of Multiple-Risk-Factor Assessment Equations: A Statement of Healthcare Professionals from the American Heart Association and the American College of Cardiology, J Am Coll Cardiol 1999;34:1348-1359. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleishchmann KE, Fleisher LA, Froelhich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters Jr. WL. ACC/AHA Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) www.acc.org/clinical/guidelines/perio/ dirIndex. htm. Carabello BA, Crawford FA Jr. Valvular Heart Disease. N Engl J Med 337:32-41, 1997. Dajani AS. Prevention of Bacterial Endocarditis. JAMA, Vol 277(22):1794-1801. Drugs for Hypertension. The Medical Letter, May 26, 1995, Vol 37(949):44-50. Ganz LI, Friedman P. Supraventricular Tachycardia. N Engl J Med, Jan 19, 1995, Vol 332(3):162-173. Hollander JE. The Management of Cocaine-Associated Myocardial Ischemia, N Engl J Med, Nov 9, 1995, Vol 333(19):1267-1272. Iskandrian AE, Nallamothu N, Heo J. Nonatherosclerotic Causes of Myocardial Ischemia. J of Nuc Card, Vol 3(5):428-435. Kinch JW, Ryan TJ, Right Ventricular Infarction. N Engl J Med, Apr 28, 1994; Vol 330(17):1211-1217. Kouchoukos NT, Dougenis D. Surgery of the Thoracic Aorta. N Engl J Med, June 26, 1997: Vol 336(26):1876-1888. Moraes D, Loscalzo J. Pulmonary Hypertension: Newer Concepts in Diagnosis and Management. Clin Card, Vol 20:676-682. Perloff JK. Congenital Heart Disease. Clin Card, Nov 1994; Vol17:579-587. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 124 Faculty Evaluation of Cardiology Fellow Instructions: The following evaluation scale is modeled after the ACGME Milestones categories, which are competencybased developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. Subject Name Evaluated by: Status Employer Program Evaluator Name Status Employer Program Rotation Evaluation Dates MEDICAL KNOWLEDGE 1* Demonstrates knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, as well as the application of this knowledge to patient care. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations Ready for Unsupervised Practice / Proficient 3 4 Aspirational / Expert Not Yet Assessed / Not Observed 5 PATIENT CARE AND PROCEDURAL SKILLS 2* Provides patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for practice. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed SYSTEMBASED PRACTICE 3* Demonstrates an awareness of and responsiveness to the larger context and system of healthcare, as well as the ability to call effectively on other resources in the system to provide optimal healthcare. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 PRACTICEBASED LEARNING AND IMPROVEMENT CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 125 Not Yet Assessed / Not Observed 4* Demonstrates the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant selfevaluation and life long learning. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 PROFESSIONALISM 5* Demonstrates a commitment to carrying out professional responsibilities and adherence to ethical principles. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 INTERPERSONAL AND COMMUNICATION SKILLS 6* Demonstrates interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 Comment OVERALL ASSESSMENT 7* Overall Assessment of this fellow on this rotation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 Comment 8 Comments: Please use the comment box below to offer detailed strengths and/or weaknesses of this fellow on this rotation. 9* Is there any reason this fellow should not move to the next level of responsibility? Yes No Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 126 10* Was this evaluation discussed with the fellow at the end of the rotation? *ACGME Program Requirement V.A.2.a).(1) states "faculty must evaluate fellow performance in a timely manner during each rotation and discuss this evaluation with each fellow at the completion of the assignment." Yes No Overall Comment CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 127 AMBULATORY CONTINUITY CLINIC Overview: The cardiovascular fellow on the continuity clinic rotation will be responsible for the evaluation and ongoing care of patients referred to the fellow in the outpatient clinic. Specific responsibilities include: • • • • • • • • • • • See the patient at the arranged time and date. Documentation of the indication for the referral and cardiac problem. Complete an appropriate history and physical (H&P) examination. o For first visits, this H&P will be comprehensive o On follow-up visits, the H&P will generally be less comprehensive but appropriate to the situation Review and document, by independent interpretation (when appropriate), of all relevant diagnostic information including ECG’s, images including chest x-rays, CT scans, echo-Doppler data, nuclear images, MRI scans, catheterization lab images and/or hemodynamic data. Review and document relevant biochemical lab data. Document all cardiovascular diagnoses. Document clinical impressions with particular attention to addressing the question(s) asked by the requesting physician. Recommendations for testing and treatment will be consistent with the ACC/AHA guidelines. Indications for withholding standard treatment and testing must be defined. Define a plan for inpatient and outpatient follow up. Present the history, physical examination and testing and/or treatment plans to the attending physician Communicate promptly the diagnosis, recommendations and follow-up plan to the referring physician in the form of a letter, and if appropriate, by phone. o Notification of the referring physician the results of tests that were ordered Communication to the patient of the diagnosis; recommend to the patient any tests/or and treatments thought to be appropriate o Discussusion in an appropriate manner with the patient of the risks and benefits of tests and/or treatments o Prompt notification the patient of the results of any tests Education of the patient o As appropriate about the disease(s)/diagnoses o Preventive health measures (such as diet, weight loss, cessation of smoking) Educational Goals: Cardiovascular fellows will acquire the necessary skills to diagnose and manage patients with coronary artery disease, valvular heart disease, diseases of the myocardium, diseases of the pericardium and congenital heart disease, cardiac arrhythmias, conduction disorders and syncope. Fellows will develop cardiology skills with emphasis on cardiac history taking, physical examination including evaluation of normal and abnormal heart sounds, evaluation of heart murmurs, including provocative maneuvers that accentuate or decrease intensity of murmurs. The fellow will acquire the necessary skills to recognize the peripheral manifestations of cardiac dysfunctions. The fellow will learn the indications and contraindications for performing diagnostic studies. Adherence to published “appropriateness criteria” for diagnostic tests is expected. In addition, the fellow will become proficient in analyzing diagnostic data to establish a cardiovascular diagnosis and treatment plan. The fellow will acquire experience in the clinical analysis of surface and intracardiac ECG recordings, chest radiographs, stress echo and nuclear images, CT scans, M-mode and 2-D echocardiograms, Doppler and catheter hemodynamics, coronary angiography, and contrast ventriculography. Opportunities to review new imaging modalities including cardiac MRI and 3-D echo will be encouraged. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 128 Training Objectives: • To develop the knowledge and skills required to obtain a proper cardiac history. Specific areas include characterization of chest pain (including the differential diagnosis of various etiologies of chest pain syndrome based on historical description), dyspnea (with differentiating cardiac from pulmonary causes of dyspnea), exercise capacity and functional class. In addition, special emphasis should be paid to medications, medication compliance, dietary habits, smoking and alcohol consumption as well as other risk factors for cardiac diseases. (Patient Care, Medical Knowledge, Practice-Based Learning, Interpersonal and Communication Skills) • To become proficient in cardiac physical examination. The complete bedside examination includes palpation of all pulses, recognition of pulse characteristics, and blood pressure examinations in both upper and lower extremities, especially when delayed or absent femoral pulses are obtained. The cardiac fellow should also be able to estimate jugular venous pressure as well as characterize different waves in the neck, detect bruits, examine lung fields, and define the precise location and characterization of left and right ventricular impulses. Proficiency is required for auscultation of heart sounds as it relates to intensity, splitting and additional heart sounds such as murmurs, rubs and clicks. To accurately assess the characterization of murmurs with regard to timing, pitch, grade, maximal intensity and radiation and the effect of provocative maneuvers in eliciting the origin of the murmur. To recognize the peripheral manifestations of heart dysfunction such as palpable and/or pulsatile liver, anasarca, ascites, peripheral edema or sacral edema. (Patient Care, Medical Knowledge) • To accurately assess the presence or absence of congestive heart failure. To evaluate whether murmurs of valvular heart disease such as mitral regurgitation, mitral stenosis, aortic regurgitation and tricuspid regurgitation contribute singularly or in combination to the clinical picture of congestive heart failure. (Patient Care, Medical Knowledge) • To accurately assess the presence or absence of abdominal aneurysms and the presence or absence of peripheral vascular disease. (Patient Care, Medical Knowledge) • To assess the normal auscultatory findings in pregnant patients and to be able to differentiate pregnant patients with valvular heart disease or congenital heart disease from physiological heart sounds of pregnancy. (Patient Care, Medical Knowledge, Practice-Based Learning) • To become skilled in ECG interpretation of hypertrophy, conduction disturbances, heart block, WPW, acute infarction versus chronic infarction pattern. (Patient Care, Medical Knowledge, Practice-Based Learning) • To learn how to interpret cardiac images (chest X-ray, CT, MRI, nuclear, echo, and angiograms) focusing on assessment of heart structure and function. (Patient Care, Medical Knowledge, Practice-Based Learning) • To learn to interpret laboratory data to assist with risk stratification and treatment. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning) • To understand the clinical value of different therapeutic interventions including medical, percutaneous, and surgical therapies as well as device therapy in the management of all types of adult cardiovascular CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 129 disease. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning, Interpersonal and Communication Skills) • To learn to assess the risk of adverse cardiac events in the perioperative period for patients referred for non-cardiac surgery (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning) • To learn about the chronicity and long-term characteristics of various cardiac diagnoses, such as congestive heart failure, valvar disease (such as aortic stenosis and mitral regurgitation), and chronic coronary artery disease. (Patient Care, Medical Knowledge, Practice-Based Learning) • To develop skills in communication by letter to referring physicians (Interpersonal and Communication Skills) • To interact with the patient in a compassionate and caring manner; to demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues; to adhere to principles of confidentiality, scientific/academic integrity and informed consent. (Patient Care, Communication Skills, Professionalism) • To interact with the health care team including nurses, physician assistants, technicians, social workers, nutritionists, physical therapists, respiratory therapists as well as other physicians. (Patient Care, Medical Knowledge, Systems-Based Practice, Interpersonal and Communication Skills, Professionalism) • To learn how to utilize hospital and community resources for managing cardiac patients in the outpatient setting. Interact with staff in referring physician’s offices, lipid clinics, Coumadin clinics, cardiac rehabilitation, visiting nursing services (VNA), the OASIS program, and hospice. (Systems-Based Practice, Practice-Based Learning, Patient Care and Interpersonal and Communication Skills) • To access and critically evaluate current medical information and scientific evidence. Use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning and Improvement) Principle Teaching Methods: • An attending cardiologist will serve as a mentor for the fellow. The mentor–student relationship will be utilized as the main teaching method after the fellow has seen and examined the patient and presented the patient’s findings and plans to the attending. The fellow is expected to utilize all available scientific research, published guidelines and expert opinion to assist with decision making and learning. • Discrepant findings on diagnostic data, controversial issues and differences of opinion will be discussed with the attending cardiologists. When appropriate the attending will examine the patient and discuss discrepancies of examination with the fellow. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 130 Evaluation Methods: • The attending cardiologist will utilize a standardized evaluation process to assess the performance of the cardiac fellow. A written evaluation of the cardiac fellows’ performance on the consultative service will be made each six months by the cardiology attendings assigned to the out-patient continuity clinic. The cardiology attending will evaluate each fellow according to the ACGME general competencies including: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. In addition, bedside skills such as obtaining history, physical examination and performance of cardiac procedures will be evaluated. The cardiology teaching attending will meet with each cardiac fellow at the end of each six month rotation to review the written evaluation. Fellows are required to electronically sign each evaluation in the New-Innovations program. • The cardiology attending will perform a yearly chart review of each fellow’s work, analyzing letters/chart entries made about at least three patients. All letters/chart entries for the year for each patient will be analyzed. An assessment form will be filled out for each patient and the attending will discuss these forms with the fellow at the time of the attending meets with the fellow. See attached evaluation form. Educational Content: The out-patient continuity clinic will provide evaluations and patient care for patients referred by non-cardiology physicians and from in-hospital units after hospitalizations. Patients with a variety of cardiac disorders including coronary artery disease, hypertension, peripheral vascular disease, hyperlipidemia, valvular heart disease, myocardial and peripheral disease, endocarditis, pericardial diseases and congenital heart disease will form the case mix on this service. Fellows will follow each patient throughout their three years of training. Fellows will spend one morning each week in a continuity clinic. Two of these meet in the Outpatient Clinic on the ground of the Medical Center (UPC1, Suite 600). Two meet at the Lebanon Veteran’s Hospital on Lincoln Ave, near Lebanon, PA. Bibliography: • • • • Abraham W et al: Diagnosis and Management of Heart Failure. In : Hurst’s The Heart. 12th edit; pp 724-760, 2008. Mukherjee D, Eagle K: Perioperative evaluation and Management of Patients with Known or Suspected Cardiovascular Disease Who Undergo Noncardiac Surgery. In : Hurst’s The Heart. 12th edit; pp 2007-2020, 2008. O’Rourke RA et al: Diagnosis and Management of Patients with Chronic Ischemic Heart Disease. In : Hurst’s The Heart. 12th edit; pp 1474-1503, 2008. Fraker TD, Fihn SD: 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the for the Management of Patients With Chronic Stable Angina: A Report of the American College of Physicians/American Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the 2002 Guidelines for the Management of Patients with Chronic Stable Angina. Circ: 116:2762-2772, 2007. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 131 Faculty Evaluation of Fellow in Continuity Clinic Instructions: The evaluation scale is modeled after the ACGME Milestones categories, which are competencybased developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties. Subject Name Evaluated by: Status Employer Program Evaluator Name Status Employer Program Rotation Evaluation Dates 1* Quality of medical knowledge exhibited. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 2* Appropriateness of patient care exhibited. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner Indirect Supervision / Meets Expectations 2 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 3* Degree of professionalism exhibited. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 4* Quality of communication to referring physician. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 Not Yet Assessed / Not Observed 5* Quality of the chart documentation. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient 4 Aspirational / Expert 5 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 132 Not Yet Assessed / Not Observed 6* Overall Assessment of this fellow in clinic. Critical Deficiencies / Entry Level 1 Direct Supervision / Early Learner 2 Indirect Supervision / Meets Expectations 3 Ready for Unsupervised Practice / Proficient Aspirational / Expert 4 Not Yet Assessed / Not Observed 5 7 Comments: Please use the comment box below to offer detailed strengths and/or weaknesses of this fellow in clinic. 8* Is there any reason this fellow should not move to the next level of responsibility? Yes No Comment 9* Was this evaluation discussed with the fellow at the end of the rotation? *ACGME Program Requirement V.A.2.a).(1) states "faculty must evaluate fellow performance in a timely manner during each rotation and discuss this evaluation with each fellow at the completion of the assignment." Yes No CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 133 VETERANS ADMINISTRATION OUTPATIENT Purpose: This rotation provides exposure to general cardiology in an outpatient setting. The PURPOSE of this rotation is to acquire expertise and proficiency in the management of outpatient cardiovascular issues in a patient population with common cardiovascular diseases like coronary artery disease, valvular heart disease, peripheral vascular disease, heart failure, arrhythmias and preoperative evaluation. Fellows will gain experience in ECG interpretation, performance and interpretation of exercise and pharmacological stress testing, and performance and interpretation of transthorasic echocardiograms. Fellows will also perform transesophageal echocardiograms and elective cardio versions. Responsibility/Specific Duties: The fellow has primary responsibility for all patients referred to the service, under the supervision of one faculty member dedicated to this rotation. This rotation also provides the opportunity and time to acquire expertise in nuclear cardiology (haft day every Wednesday and Friday mornings, with one fellows doing a full day of clinic on Wednesday and Friday’s) on studies performed at the VA and basic training in cardiac CT. When responding to a request for consultation the trainee is expected to provide comprehensive evaluation of the patient’s cardiovascular illness in a prompt and concise manner, formulate a prioritized differential diagnosis, and outline the evaluation. The trainee is expected to document the evaluation and management plan in the patient’s electronic medical record. The trainee should communicate the evaluation in a clear and concise manner to the requesting physician and provide adequate follow up. Interactions with colleagues and allied personnel should be conscientious, respectful, responsible, punctual, and appropriate. The trainee must exhibit humanistic qualities when interacting with patients and their families and demonstrate integrity, respect and compassion. The VA outpatient fellow is expected in the VA clinic at 8:00 am. Fellows are expected to participate in the performance and interpretation of nuclear cardiology studies, CT coronary angiograms and also review echo studies done in the VA echo lab. Fellows are mandated to maintain a detailed procedure log. The fellows will perform and interpreting GXTs at the VA and following up the abnormal results as appropriate. The VA outpatient fellow is responsible for interpretation of all Holter monitors and will read half of all ECGs for the day. The ECG reading is to be shared with the VA attending. Supervision: The fellow is expected to discuss all cases with the supervising cardiology staff. However, complex cath cases and EP cases directly discussed with the cath lab and EP staff. All discussed cases must be documented in the VA electronic chart with the name of the attending physician. Learning Objectives: 1. Obtain training in the concepts and practice of effective outpatient cardiac consultation. This includes: a. Improving skills for acquiring a detailed and accurate history and physical examination. (A,B) b. Improving skills for insight review of laboratory data. (A,B) c. Obtain training in review of noninvasive and invasive cardiac tests and incorporation of the test results into the context of the patient’s presentation. (A,B) d. Obtain training in placing the cardiac findings in the patient’s overall medical context. (A, B) e. Obtain training in formulation of a broad differential diagnosis with focus on the most likely diagnosis. (A,B) f. Obtain training in formulation of an effective treatment plan. (A,B) CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 134 2. 3. 4. 5. 6. 7. g. Gain experience in providing support of the proposed diagnosis and treatment plan by citation of relevant clinical studies and guidelines. (B,C) h. Gain experience in effective communication and interaction with referring physicians. (D,E) Gain exposure to a broad range of cardiac conditions through individual outpatient consultations and supplemental reading. (A,B) Gain training in guideline-based preoperative cardiac risk assessment and effective preoperative risk reduction. (B,C) Obtain training in ECG interpretation. (B) Obtain training in exercise and pharmacological stress testing performance and interpretation. (B) Obtain training and understanding the indications, contraindications, and risks of carioversions. (B) Gain an appreciation for the role of the staff members in the non-invasive labs, including the technicians, nurses and administrative staff. (D,E,F) Patient characteristics/mix of diseases/types of clinical encounters: At the VA, most patients presenting to the non-invasive labs for cardiac procedures and those presenting to the outpatient consult clinic are adult males from a variety of ethnic backgrounds. Fellows will evaluate patients in the outpatient clinic setting. Fellows will also evaluate patient’s pre-and post-procedure. Cardiac conditions encountered will include chronic coronary disease, congestive heart failure, vavular heart disease and dysrhythmias. Teaching Methods: Teaching occurs by a variety of methods on this rotation. • Direct teaching related to technical skills occurs during the performance of elective procedures. • The supervising physician will over read fellow interpretation of stress ECGs and TEEs and offer constructive criticism and further instruction. Attendings will read echoes directly with the fellow and provide didactic teaching during the reading sessions. • The supervising physician will review the detailed consult notes written by the fellow on all patients seen in clinic. The attending cardiologist provides constructive suggestions for acquisition of additional relevant clinical information, alternate interpretations of the data presented, recommendations for additional diagnostic consideration, and additional treatment considerations. The attending cardiologist reviews the noninvasive and invasive study results performed on the consult patients with the fellow. Evaluation Methods: 1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation. 2. The fellow’s progress will be reviewed verbally at mid-rotation. 3. A standard fellow evaluation form will be completed by the VA attending cardiologist who worked with the fellow during his clinic duties. This will be attained in New Innovations. 4. The final evaluation will be based on the fulfillment of the rotation objectives as determined by: a. Personal observation during interaction with the fellow. b. Evidence of literature review related to individual patients seen in the consult clinic. c. Evidence of a thorough and accurate patient history and physical examination for each consult patient seen in clinic and evidence of an appropriate directed history and physical examination for each patient referred for pre-procedure evaluation. d. Accuracy in interpretation of invasive and non-invasive tests for the consult patient, with good insight into the role of those test results in arriving at an appropriate differential diagnosis and treatment plan. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 135 e. Performance of the fellow in arrivals at a broad, appropriate differential diagnosis with focus on a most likely diagnosis. f. Use of literature and guidelines to develop appropriate treatment plans. g. Improved accuracy in interpretation of ECGs, stress ECGs, and TEEs. h. Progression of technical skills in performing TEEs. i. Feedback from the support staff in the non-invasive, ECG lab and nurse managers. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 136 Conferences 1st Week of Month MONDAY Grand Rounds 5PM – TBD TUESDAY EP Conference 7AM – H1154 WEDNESDAY THURSDAY Core Conference 7AM – H1154 Echo Conference 12:30PM – H1154 2nd Week of Month Multidisciplinary Conference 5PM – T2500 Cath Conference 7AM – H1154 Nuclear Conference 7AM – H1154 Echo Conference 12:30PM – H1154 3rd Week of Month 4th Week of Month Evening Journal Club 6PM – Host Faculty’s Home Multidisciplinary Conference 5PM – T2500 EP Conference 7AM – H1154 Core Conference 7AM – H1154 Echo Conference 12:30PM – H1154 Noon Journal Club / Research Conference 12PM – H1154 Nuclear Conference 7AM – H1154 Cath Conference 7AM – H1154 Imaging Conference 12PM – H1154 5th Week of Month (as applicable) EP Conference 7AM – H1154 Core Conference 7AM – H1154 Echo Conference 12:30PM – H1154 CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 137 FRIDAY V. DEPARTMENTAL POLICIES A. SELECTION, EVALUATION, RENEWAL, PROMOTION, AND DISMISSAL OF FELLOWS Eligibility, Selection, and Appointment of Fellows Eligibility of Fellows It is the policy of The Milton S. Hershey Medical Center and its sponsored residency/fellowship programs to adhere to the guidelines published by the Accreditation Council on Graduate Medical Education with respect to the eligibility and selection of fellows. Fellows will be selected for the various programs based upon their previous records and accomplishments. Eligible applicants will be selected on the basis of preparedness, ability, aptitude, academic credentials, communications skills, motivation and integrity. Applicants are selected for interviews by the Program Director or Department Chair based on the eligibility criteria. Applicants with one of the following qualifications are eligible for appointment to a Residency Program: 1. Graduate of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education (LCME). 2. Graduate of colleges of Osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA). 3. Graduates of Medical Schools outside the United States and Canada who meet one of the following qualifications: 1) currently valid certificate for the Educational Commission for Foreign Medical Graduates or 2) have a full and unrestricted license to practice medicine in a US licensing jurisdiction. 4. Graduates of medical schools outside the United States who have completed a Fifth Pathway program. Candidates who are interviewed are given the Residency Benefit Summary that details the terms and conditions of employment, stipends and benefits of the residency programs. Selection of Fellows • Fellows will be selected for the various programs based upon their previous records and accomplishments. Eligible applicants will be selected on the basis of preparedness, ability, aptitude, academic credentials, communications skills, motivation and integrity. • All programs, where available, participate in an organized matching program, such as the National Resident Matching Program (NRMP). Conditions of Appointment • All fellows must have appropriate licensure from the Pennsylvania State Board of Medicine. It is the responsibility of the fellow to obtain the appropriate licensure. • The period of appointment shall not exceed twelve (12) months, with renewal being dependent upon performance and the requirements of the residency program. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 138 Offer of Appointment • Following the match, where applicable, or upon selection of a fellow for a residency position, a letter of acceptance will be mailed to the fellow. If he or she accepts the position, they are to sign and return the acceptance letter to the Division of Cardiology. • Approximately three months prior to expected matriculation, a formal contract will be sent to the fellow. The fellow will return a signed copy per instructions from the Graduate Medical Education office. Evaluation Procedure Resident Evaluation The Clinical Competency Committee (CCC), appointed by the Program Director, will meet semi-annually to evaluate the fellows. It is the responsibility of the Program Director to advise the fellow of his/her performance in the program. Every fellow must be evaluated in a timely manner by the faculty during each rotation. This evaluation will cover the six core competencies (Patient Care, Medical Knowledge, Practice-based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-based Practice). Additionally, the CCC will evaluate each fellow based on the specialty-specific Milestones. Each fellow will meet with the program director at least every six months to review his/her progress. The results of these evaluations will be kept on file in the fellow's evaluation folder in the Residency Coordinator’s office. The fellow’s evaluation folder will be available for his/her inspection. Faculty Evaluation Faculty performance must be evaluated as it relates to the educational program. These evaluations will include a review of the faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities. Evaluations will be solicited from the fellows annually and will be written and confidential. Fellows will also have the opportunity to provide confidential written evaluations at the end of each rotation. Program Evaluation The Program Evaluation Committee (PEC), appointed by the Program Director, will meet at least annually to plan, develop, implement, and evaluate the educational activities of the program. In addition, they will review and make recommendations for the curriculum and address areas of noncompliance with ACGME standards. The PEC will consider the written evaluations by the faculty, fellows, and others during this process. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 139 Renewal, Promotion, and Graduation Criteria for Promotion and Graduation: The Division of Cardiology utilizes performance criteria for the advancement and promotion of its fellows. Fellow contract will be renewed based on the established standards of clinical competence, knowledge, skills, professional character, interpersonal skills, evaluations and/or any other factors deemed necessary to advance to the next level in training. The Division has adapted the American Board of Internal Medicine’s (ABIM) educational milestones to create overall educational goals and objectives for fellows at each level of training. These milestones encompass the six core competencies and serve as the basis for performance expectations and evaluation of fellows. These milestones are distributed to the fellows for their review. Semi-annual evaluations of the fellows are conducted, and their level of performance in each of the milestones is assessed, by the Clinical Competency Committee. This is determined by their rotational evaluations and their scholarly activities. Each fellow meets with the Fellowship Program Director semi-annually to review their education and clinical progress. At this time, areas of weakness are addressed, and a plan of remediation is recommended if necessary. Renewal of Resident Agreement and Promotion: At least 90 days prior to the end of Fellow’s current appointment period, the Department Chairman or Program Director shall provide a written offer of reappointment detailing the terms and conditions of reappointment. Graduation of Fellow from Program: Fellows completing their training program in accordance with the appropriate ACGME Program Requirements and Specialty Board Requirements will be receive a diploma certifying completion of training at The Penn State Milton S. Hershey Medical Center Heart and Vascular Institute. By the end of fellowship training, the fellow is expected to have achieved a level 4 (ready for independent practice) in the majority of the 23 sub-specialty milestones, especially the ones important in their chosen career pathway, and have participated in at least one meaningful research project and quality improvement initiative. The aforementioned diploma will be issued upon a final recommendation to promote or graduate a fellow by the Clinical Competency Committee, taking into consideration input received by the teaching faculty in Cardiology, at the end-of-year Graduation Banquet. Non-Renewal (Dismissal) or Non-Promotion: In instances where a resident’s agreement will not be renewed, or when a resident will not be promoted to the next level of training, Penn State Hershey Medical Center will provide the resident with a written notice of intent no later than three months prior to the end of the fellow’s current agreement. If the primary reason(s) for the non-renewal or non-promotion occurs within the three months prior to the end of the agreement, Penn State Hershey Medical Center will provide the resident with as much written notice of the intent not to renew or not to promote as circumstances will reasonably allow, prior to the end of the agreement. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 140 A resident may be dismissed for cause during an appointment period. Examples of cause for dismissal include, but are not limited to, the following: • A violation of the rules and regulations of Penn State Milton S. Hershey Medical Center or a violation of the directions of the Program Director or of the director or coordinator of the service to which the Resident is assigned. • An abuse or assault of any patient. • A refusal of rehabilitation for substance abuse or reported abuse of substances. • Any conduct which is or would be detrimental to Penn State Milton S. Hershey Medical Center operations, activities or interests. • Persistent strife in interpersonal relations. The Department Chair shall give written notice of dismissal. The dismissal notice shall include a summary of the cause for dismissal and shall advise the resident of the right of appeal provided by this policy. Residents must be allowed to implement the institution’s grievance and due process policy if they receive a written notice either of intent not to renew their agreement or intent not to promote them to the next level of training. Dismissal of Fellows A fellow may be dismissed for cause during an appointment period. Examples of cause for dismissal include, but are not limited to, the following: • A failure of Fellow to meet the performance or conduct standards of the Program. • A violation of the rules and regulations of The Milton S. Hershey Medical Center or a violation of the directions of the Program Director or of the director or coordinator of the service to which the Fellow is assigned. • An abuse or assault of any patient. • A refusal of rehabilitation for substance abuse or reported abuse of substances. • Any conduct which is or would be detrimental to The Milton S. Hershey Medical Center operations, activities or interests. • Deficiencies in maintaining current medical records, including discharge summaries. • Lack of evidence of continuing self-education. • Persistent strife in interpersonal relations. • Lack of progress in developing acceptable clinical judgment. The Department Chair shall give written notice of dismissal. The dismissal notice shall include a summary of the cause for dismissal and shall advise the fellow of the right of appeal provided by this policy. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 141 An appeal of a dismissal may be filed within seven (7) days of the date of the dismissal notice by submitting a written notice of appeal of the Chair of the department. If an appeal is filed, the dismissal will be suspended pending conclusion of the appeal; provided, that when the cause for dismissal creates reasonable grounds to believe that there is a threat to the safety of patients, the fellow, or other persons or property, or a threat to disrupt the essential operations of the Medical Center, the Department Chair may direct that all or part of the fellow’s duties by suspended pending conclusion of the appeal. Upon receipt of an appeal, an Appeal Board will be appointed by the Senior Vice President for Health Affairs and Dean, consisting of the following: The Senior Associate Dean or Assistant Dean for Medical Education (presiding), the Medical Director of The Milton S. Hershey Medical Center, a senior fellow in the same program as the appealing fellow, a fellow designated by the Resident Council, and two senior members of the teaching faculty. The Appeal Board shall provide the fellow an opportunity to present oral and written statements by the fellow and other persons in support of the appeal. The Department Chair, or a designee, shall be responsible for presenting evidence in support of the dismissal. Specific procedures applicable to the appeal shall be adopted by the Appeal Board and furnished to the fellow and the Department Chair. The recommendation of the Appeal Board shall be submitted to the Senior Vice President for Health Affairs and Dean, who shall have final authority to review the dismissal. B. GRIEVANCE AND DUE PROCESS It is the policy that each residency program (or department) has a process for taking disciplinary action against a program fellow and a process for adjudicating complaints or grievance relevant to the program. Fellow is encouraged to seek resolution of grievances relating to duties. “Grievances” means any difference between Fellow and Medical Center with respect to the interpretation or application of, or compliance with the provisions of this Agreement. The procedure is as follows: 1. Fellow to Program Director or Department Chair - Fellow with a grievance is urged to first discuss it with the Program Director or Department Chair to which Fellow may be assigned from time to time. Issues can best be resolved at this stage and every effort should be made to affect a mutually agreeable solution. 2. Fellow to Ombudsperson - In situations when the concern relates to the Department Chair or Program Director, and Fellow believes that it cannot be presented to the Department Chair or Program Director, Fellow may present the grievance directly to the Ombudsperson for guidance. 3. Fellow to Senior Associate Dean for Medical Education – If, after discussion with the Department Chair or Program Director and Ombudsperson, the grievance is not resolved to the CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 142 satisfaction of Fellow, Fellow has the option to present the grievance to the Senior Associate Dean for Medical Education. 4. Upon failure to satisfactorily resolve the concern with the ombudsperson or the Senior Associate Dean for Medical Education, Fellow may request that the concern be brought before an ad hoc grievance committee. The composition of the committee will be determined by the degree of concern. For the most severe concern as determined by the Senior Associate Dean for Medical Education, the committee will be constituted as in the Residency Agreement, section 11.2.4. The committee will investigate the concern(s) by appropriate methods and reach a decision by simple majority vote. The decision of the committee shall be reached within a reasonable time period, and be final and binding upon the parties and documented. During the investigation, Fellow status will remain unchanged unless suspended from clinical duties for cause. C. SUPERVISION In all rotations, fellows are supervised by attending physician faculty. In addition to this policy, lines of responsibility are further delineated in the curriculum for each cardiology rotation. Fellows are supervised by an attending physician who has clinical privileges in the area they are supervising. Faculty schedules assign responsibility for supervision to specific faculty members, as well as on-call responsibilities, so as to provide fellows with appropriate supervision and consultation. The fellows are provided with a rapid, reliable system for identifying and communicating with their supervising faculty. Fellows and faculty members are expected to inform patients of their respective roles in their care. Fellows are provided with multiple tiers of support in their clinical activities. All patients seen by a fellow, as an outpatient or inpatient, are reviewed in a timely manner with a faculty member to discuss diagnosis and treatment plans. During interventional procedures in the cath or echo labs, the staff cardiologist is present throughout each procedure. All diagnostic studies are reviewed with the appropriate attending cardiologist. Four to six faculty are on night and weekend call to support the fellow and clinical activities. During the first six months of the academic year, upper level fellows are on back-up call for first year fellows. In addition, electrophysiology and interventional fellows provide support, as needed. Two fellows make hospital rounds on weekends and holidays to dispense the work load. All incoming fellows will pick a faculty research mentor, or be assigned one. The supervision of fellows is structured to provide them with progressively increasing responsibility, commensurate with their level of education, ability, and attainment of milestones. The Program Director, in conjunction with the Program’s Clinical Competency Committee, will make determinations on advancement of fellows to positions of greater responsibility and conditional independence through assessment of competencies. In recognition of their progress toward independence, senior fellows can supervise junior fellows when appropriate. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 143 Description of the lines of responsibility for the care of patients, and the levels of fellow supervision are provided in the curriculum for each rotation. The classification levels of supervision used are defined below: 1. Direct supervision: the supervising physician is physically present with the fellow and patient 2. Indirect supervision with direct supervision immediately available: the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide direct supervision 3. Indirect supervision with direct supervision available: the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephone and/or electronic modalities, and is available to provide direct supervision 4. Oversight: the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered The Penn State Hershey Heart and Vascular Institute gives fellows significant, but appropriately wellsupervised latitude in the management of patients and provides a comprehensive experience in cardiovascular diseases. This enables them to become independent and knowledgeable clinicians, with a commitment to the life-long learning process that is critical for maintaining professional growth and competency. D. GENERAL GUIDELINES FOR TRANSITIONS OF CARE • There is no resident or midlevel coverage for Cardiology patients in the Intensive Care Unit (ICU) and the home-call fellow is the first call person. Hence it is very important and expected that both service fellows (Acute and Heart Failure) provide a detailed sign-out of their patients in the ICU. • Ideally this sign-out between the fellows must be face to face, but at times this may not be possible and hence communication over the telephone is also acceptable. • Relevant information regarding patient’s medical history, presenting complaint, hospital course and potential issues overnight is expected. • An updated written sign-out on all patients on the Acute Cardiology and CHF services is always available electronically. This is shared by Internal Medicine residents (who cover IMC and Floor level patients) and Cardiology fellows (who cover the ICU patients): It is created in Powerchart (open Powerchart->then open AdHoc under the specific patient->click on Physician Documentation ->then click on Physician Handoff Communication form). The sign-outs themselves can be accessed and printed within the Explorer Menu within Connected by selecting specific patient lists from a pull-down menu (created previously in Powerchart). Both the Powerchart and Explorer Menu icons/applications are found within the main Cerner Connected page-the principal Electronic Medical Record used at Hershey Medical Center. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 144 • Verbal sign-out between the fellows on non-ICU patients is not necessary. However, handoff is encouraged on relatively “sick” patients including those with relatively high probabilities of decompensating overnight. • Information regarding expected hospital transfers must be relayed to the on-call fellow by the attending who accepted the transfer. The attending should also post a “transfer accept note” in the electronic record. • The consult fellow will provide a similar verbal and written handoff on patients followed by their service. • The overnight fellows will sign out overnight events, new admissions to all the service fellows. If the service fellow is away for any reason (clinic / day off), relevant information must be signed out to the attending on service. • If the service fellow has a day off over the weekend, the service attending may choose to directly sign out to the fellow on call. • Sign-outs will periodically be overseen by supervising attendings. If there is concern about the hand-off process or a specific fellow is felt to be deficient in the observed hand-offs, it will be brought to the attention of the fellowship director for review, alteration in this policy, or directed remediation for the fellow. E. DUTY HOURS, CALL, AND FATIGUE MANAGEMENT The Cardiology Training Program complies with the Penn State Milton S. Hershey Medical Center Graduate Medical Education Duty Hours policy. It should be noted that Cardiology fellows are upper level residents and do not take in-house call. Duty Hours: Fellows must have at least one full 24-hour day out of seven free of all educational and clinical patient care duties when averaged over four weeks. Moonlighting cannot be done on this free day. After 24hour home call on the weekend, the fellow can remain in the hospital up to four hours afterward for effective transitions of care. On a weekday post-call, the fellow may go home at noon if he or she is overly fatigued. Duty hours are limited to 80 hours per week averaged over a four-week period, inclusive of all in-house call activities and all moonlighting. Fellows should have eight hours free of duty between scheduled duty periods. The demands of home call will be monitored, and scheduling adjustments will be made as necessary to address excessive service demands and fatigue. Fellows must log duty hours in New Innovations in a timely manner. This will be monitored by the Program Director. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 145 Moonlighting: Moonlighting is permitted, with permission, for second and third year fellows. Time spent moonlighting must be included as part of the fellow’s duty hours. Fellows who moonlight must still have 24 consecutive hours per week free of clinical duties. Please refer to policy on moonlighting. Fatigue Management: Although Cardiology fellows are upper level residents who take home call, the potential for being in the hospital all or most of the night does exist. For this reason, we have established the following criterion for calling in a back-up fellow: • • • When there is more than one ongoing “heart alert” When there is more than one seriously or critically ill patient requiring immediate attention Any other time the on-call fellow feels he/she needs assistance or is overly fatigued We also encourage fellows to go home by noon post-call if they are experiencing signs of fatigue. The fellows and their attendings are collectively responsible for determining whether they are able to safely and effectively perform their duties. If another fellow is needed to take over the duties of a fellow for the rest of the day, the attending may call the chief fellow to find out who is available. In most instances, a replacement will not be required, or a senior resident on the inpatient team can work closely with the attending. Education with regards to recognizing the signs of fatigue is provided by the institution and is mandatory for fellows. Fatigue mitigation processes are outlined above. The following sleep facilities and safe transportation options are available: • • Non-assigned call rooms are located in the Biomedical Research building, room C1827, and on the 6th floor of the main hospital, room H6311. Fellows should contact the GME office at x5168 for the access code. The best option is C1518, which can be used as a locked call room. Capital City Cab is available to transport fellows home as needed. They can be reached at 717-9396363. F. MOONLIGHTING Moonlighting is permissible only by second and third year fellows, who have completed their first year of fellowship in good standing, under the following conditions/restrictions: Permission to moonlight must be approved in advance by the Program Director in writing. • A request for moonlighting must be submitted each year. Hours spent moonlighting must be logged into New Innovations as “moonlighting.” Fellows must be a US Citizen or Permanent Resident (Green Card Holder) to be eligible to moonlight. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 146 Moonlighting is not permitted: • If it interferes with education • While the fellow is on any inpatient services (HVICU, ward, CHF) or on the Cath service • More than two days per month • If the shift is more than 24 hours Weekend Moonlighting: • Fellow can moonlight on Sunday during the day, but not Sunday night • Fellow can moonlight on Sunday, only if they have not moonlighted on Saturday • Fellow must have one weekend day free each week Failure to comply with the moonlighting policy will result in loss of moonlighting privileges. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 147 VI. INSTITUTIONAL GRADUATE MEDICAL EDUCATION POLICIES A. STATEMENT OF COMMITMENT TO GME Penn State Hershey is fully committed to the education of health care professionals and providers as part of its core mission. This includes, but certainly is not limited to, allocation of substantial resources to support the educational programs, including those in graduate medical education. Penn State Hershey will continue to provide the clinical learning environment and opportunities to meet the needs of all students and trainees. The Graduate Medical Education Committee is committed to offer graduate medical education programs in which physicians in training develop personal, clinical and professional competence under the guidance and supervision of the faculty and staff. Graduate medical education programs will ensure the progression of responsibilities through demonstrated clinical experience, knowledge and skill. Penn State Hershey is committed to and responsible for promoting high quality care, patient safety and resident well-being, and to providing a supportive educational environment. This "Statement of Commitment" is supported by the governing authority, the Graduate Medical Education Committee, administration, the teaching faculty, and medical staff. It is the responsibility of the Graduate Medical Education Committee to assure that the necessary educational, financial and human resource provisions are made to support all graduate medical education training programs. B. ADDITIONAL WORK POLICY Purpose: Circumstance may arise in which a department/division/institute would wish to ask a resident/fellow to perform clinical duties that are outside their normal duties. In such a situation, it would be fair and appropriate to provide remuneration for this work. The purpose of this policy is to describe the principles to be used by a program director to develop a policy for their program and determine if compensation is allowable. Principles: 1. Each program that wishes to provide compensation for additional work under this policy must develop their own policy consistent with this policy, institutional policy, ACGME/RRC requirements, and relevant state/federal law, which provide details of the process for allocating these duties and the remuneration. This policy should be distributed to the residents and fellows of the program and be available for their review. 2. Additional Work policies should be used only for brief and self‐limited staffing needs. 3. The Graduate Medical Education Committee, via the Graduate Medical Education Office, must be informed of all instances in which this policy is implemented. This notification must include a justification for the additional work, a description of the duties and compensation, and the plan for solving the service‐need issue. 4. The Graduate Medical Education Committee reserves the right, after review, to terminate any Additional Work policies felt not to comply with this policy or to otherwise not serve the best interests of the residents/fellows or the institution. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 148 5. Residents and fellows cannot be paid for doing additional work that would, under other circumstances, be part of their training. This would include such things as taking call or covering a shift for another resident who has become sick, injured, or is on vacation/leave. 6. Under no circumstances can a resident or fellow be required or obligated to take on additional work under this policy. 7. Under no circumstances can a resident or fellow violate ACGME work hour rules by taking on additional duties. 8. Residents must be a US Citizen or Permanent Resident to be eligible for additional work. (Residents on J1 or H1B Visa are not eligible for additional work.) 9. Remunerated work hours performed under this policy must be tracked and included as duty hours. 10. The program director must indicate that the resident is in good standing and that this additional duty will not interfere with their didactic training or educational needs (e.g. this would not be appropriate for a resident who is on academic probation and needs to spend more time reading). 11. Residents and fellows cannot work outside their scope of practice, i.e. they must be appropriately supervised by qualified faculty. Fellows can work independently in the area of their qualified underlying specialty, consistent with hospital policy concerning licensure and privileging. C. AWAY ROTATION POLICY Residents and fellows may desire to take an elective rotation at an outside institution within the United States or abroad. Such away elective rotations should have as its primary goal an educational focus that cannot be obtained at Penn State Milton S. Hershey Medical Center. During the elective rotation Hershey Medical Center will continue to pay the resident’s or fellow’s salary, benefits, and malpractice insurance as currently provided. Malpractice coverage is not provided for rotations outside the United States. All other associated expenses (housing, meals, travel, etc.) will be the responsibility of the resident/fellow. Additional malpractice insurance beyond the current coverage will not be provided by Hershey Medical Center. Requirements and Process: 1. The “Application for Off‐Site ‘Away’ Elective Rotation” must be completed and signed/approved by the applicant’s Program Director and the Associate Dean for Graduate Medical Education and DIO (or his designee). All requests must be received by the Graduate Medical Education Office at least 60 days before the beginning of the rotation to be considered for approval. 2. The preceptor at the outside elective site must provide a letter agreeing to accept the resident/fellow for the time period requested, agreeing to the stated goals and objectives of the rotation, and agreeing to complete an evaluation of the resident’s/fellow’s performance during the rotation and to send this evaluation to the resident’s Program Director. 3. No more than one elective away month may be taken per resident/fellow during their training period. Programs that require four years or more of residency training may offer one additional away elective month. Exceptions may be granted by the Designated Institutional Official (DIO). CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 149 4. Elective rotations to countries either on the U.S. State Department’s Travel Warning list http://travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html or those with U.S. Treasury OFAC restrictions will not be permitted. The “Application for Off-Site ‘Away’ Elective Rotation” may be obtained from the Program Coordinator. D. C.O.R.E (CULTURE OF RESPECT IN EDUCATION) The Penn State College of Medicine is committed to assuring a safe, encouraging, and supportive learning environment that reflects our commitments to professionalism, respect, appreciation of diversity, and virtues such as honesty, integrity, compassion, and kindness. All Penn State Hershey Medical Center faculty and staff will conduct themselves in a professional manner and will contribute to creation of an environment supportive of learning. We will strive to treat our students and trainees the way we want them to treat everyone - with dedication, respect, and compassion. We expect that these policies will continue to be “living documents,” and that we will continue to improve and address issues pertaining to respect in our learning environment as they arise. Click Here to review the entire C.O.R.E. policy E. DISASTER POLICY In the event of a local or national disaster or public health emergency, Penn State Hershey will continue to provide financial and administrative support for its GME programs through the disaster. Trainees in ACGME accredited programs are considered essential personnel. In the event of a disaster, all residents and fellows shall report to work as scheduled unless personally notified by their supervisor or if reporting to work would put the resident at extreme risk. In the event that such a disaster or its after effects warrant reduction or closure of a program(s), then the Reduction/Closure Policy will take effect. If, because of a disaster, an adequate educational experience cannot be provided for each resident/clinical fellow the sponsoring institution will: A. Arrange temporary transfers to other programs/institutions until such time as the residency/fellowship program can provide an adequate educational experience for each of its house officers/fellows. B. Create Emergency GME Affiliation agreements retroactive to the date of the disaster to incorporate new host hospitals, even if the host hospital is outside the affected area. C. Cooperate in and facilitate permanent transfers to other programs/institutions. Programs/institutions will make the keep/transfer decision expeditiously so as to maximize the likelihood that each resident will complete the resident year on schedule. D. Inform each transferred resident of the minimum duration of his/her temporary transfer, and continue to keep each resident informed of the minimum duration. If and when a CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 150 program decided that a temporary transfer will continue to and/or through the end of a residency year, it must so inform each such transferred resident. The Designated Institutional Official (DIO) will notify the ACGME Institutional Review Committee Executive Director with information and/or requests for information. When appropriate, the DIO will contact executive directors of specific residency review committees (RRCs). Within ten days after the declaration of a disaster, the DIO will contact the ACGME to discuss due dates that the ACGME will establish for the programs: 1. To submit program reconfigurations to the ACGME and 2. To inform each program’s house officers of resident transfer decisions. The due dates for submission shall be no later than 30 days after the disaster unless other due dates are approved by the ACGME. F. NON-COMPETITION POLICY Penn State Hershey Medical Center, nor any of its ACGME‐accredited programs will require a resident/fellow to sign a non‐competition guarantee or restrictive covenant. G. PHYSICIAN IMPAIRMENT & SUBSTANCE ABUSE POLICY For the purposes of this policy, “impairment” is the inability of a resident to physically or mentally meet his or her responsibilities because of physical illness or injury, psychiatric or behavioral illness, dependency on alcohol and/or controlled substances or overuse of same or other condition. Program Directors, faculty, and other medical center professionals are encouraged to be observant for signs of impairment from alcohol, drugs, psychiatric or medical disorders among residents. When impairment is suspected, the appropriate Program Director or Department Chair should be informed and should utilize available resources to investigate the situation and take appropriate actions, including intervention, when warranted. It is our goal to provide intervention and rehabilitation for impaired residents and to support them during the process. However, dismissal is possible if the resident refuses such. Resources available to Program Directors, Department Chairs, faculty, or residents with respect to impairment include the ComPsych, the Student Mental Health Service, the Department of Psychiatry, professional counseling services and the Pennsylvania Medical Society’s Physicians Health Programs. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 151 VII. BENEFITS A. ANNUAL FELLOW STIPEND 2016-2017 Resident/Fellow Stipends have been determined at the following rates across the institution. Paychecks are issued on a bi-weekly basis. Direct deposit is required. R1 R2 R3 R4 R5 R6 R7 $55,000 $56,500 $58,000 $61,000 $63,000 $64,000 $65,500 B. EDUCATIONAL SUPPORT FUND Purpose: To define allowable expenditures related to Graduate Medical Education-Educational Support Funds (expense account 690240) for residents and fellows. Definition: Graduate Medical Education Educational Support Funds (GME ESF) is a specific form of financial support to help residents and fellows learn about new & developing areas of their field. This includes activities such as professional conferences, written publications, online programs, and other media forms. Procedure 1. During the annual budget process GME ESF funds are approved for each applicable training program. 2. Allowable GME ESF Fund expenditures for residents and fellows include: Professional conferences and related travel expenses Medical books, Professional literature, Medical journals/magazine subscriptions (including electronic books and subscriptions) Professional licensing exam fees Individual membership dues and fees to Professional Organizations/Societies, if the Penn State Hershey Medical Center does not pay separate organizational membership dues to the same Professional Organization/Society. Personal use items related to medical education or patient care activities (e.g., iPads or a tablet device that is for personal use, and that will be owned by the purchaser). The following rules/regulations apply: • The reimbursement will be reported as income to the resident/fellow and they will pay personal income tax on the item (as required by law). They will be reimbursed in their paycheck and applicable taxes will be deducted. The device is a "common or listed property" personal device, as classified by the IRS. Their W2 will reflect the reimbursement at the end of the year. • Residents must have money in their current year CME/ESP/book fund account to purchase the tablet. The resident may use part of their ESF fund to buy the tablet - and be reimbursed CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 152 • • • for only a part of the device. For example, if they purchase a higher-end tablet for $799 but only have $300 in their account, they may be reimbursed for the $300. Residents are not required to purchase any particular type of tablet, nor are they required to purchase a tablet at all. The tablet will belong to the resident. If the resident loses the tablet there will be no further reimbursement. Also, residents will be liable for any protected or sensitive information that is stored on the tablet. The best advice is to not store ANY such information on the personal tablet. Permission for such purchases must be approved by the resident's Program Director and the appropriate forms submitted to the GME Office. (The resident must show a proof of purchase receipt.) 3. Departments/Employees must follow established Accounts Payable policies & procedures for payment/reimbursement of GME ESF allowable expenditures. Please reference these policies and procedures at: Accounts Payable Policies. C. MEETINGS / TRAVEL Professional meetings serve a variety of important functions including provision of education about medical practice, current research, administrative issues and compliance issues. They also offer excellent opportunities for networking that can be invaluable for choosing future employment. All fellows are encouraged to attend National meetings such as ACC, AHA, TCT, SCAI, and HRS during their training. The conference must be within the 48 contiguous states of the United States or Canada, (Approval by Administration must be given to travel internationally. See Program Coordinator for special request form). Fellows planning to submit an abstract for consideration at a meeting need to discuss their research / abstract (and intended conference) with the research committee before submitting the abstract. Funding must also be approved prior to abstract submission. Fellows who have travel expenses associated with attendance for presenting at professional meetings that exceed their Educational Support Funds are eligible to apply for a Travel Funds grant through Penn State Hershey Heart and Vascular Institute*. It is the expectation that fellows planning to travel (as soon as they are aware of the possibility) will reserve their Educational Support Funds (ESF) for this purpose. The fellow will be required to fund at least $1,000 of the travel from their ESF before accessing departmental funds**. Fellows may be eligible for up to $1,000 of departmental funds by completing the Application for Travel Funds for Meeting Presentation form***. * The Application for Travel Funds for Presentation at a meeting may be obtained from the Program Coordinator. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 153 ** In the event that a fellow does not have $1,000 remaining in their ESF at the time they submit their abstract, the fellow should discuss this with their Program Director and special permission may be granted by the PD and the Research Committee Chair. *** The request to use departmental funds will be reviewed and approved by the Program Director and The Research Committee Chair. A fellow is only eligible to use departmental funds one time per academic year. MAKING TRAVEL PLANS The following guidelines for making travel plans apply when you are traveling to a meeting for CME, as well as if you are traveling to a meeting to present: Expenses eligible for reimbursement: • Meeting Registration Fees • Air, Rail, or Ground travel • Overnight Accommodations • Meals (reimbursement is based on actual receipts, but there is a maximum per diem, which varies depending on location of the meeting. The fellow should check with the Program Coordinator before traveling to find out per diem for their location) • Parking (airport or hotel) • Transfers to and from Airport/Hotel (taxi, shuttle, etc.) • Baggage Fees • Poster Printing (if presenting) • Abstract Submission Cost (if presenting) SUBMITTING EXPENSES FOR REIMBURSEMENT Upon the fellows return from travel, receipts must be submitted to the Program Coordinator within 30 days for reimbursement. Per Accounts Payable policy, the following rules apply in order to be eligible for reimbursement: • Meeting Registration Fees Receipt must show paid ($0.00 balance) • Air, Rail, or Ground travel Original ticket or e-ticket (not boarding pass) • Overnight Accommodations Original lodging invoice, which must indicate it was paid ($0.00 balance) • Meals All meal receipts must be itemized. There are NO exceptions to this rule. If your receipt is not itemized, you will not receive reimbursement for it. If you get room service and the charge appears on your hotel bill as a line item, this is not itemized. You will need to have the hotel provide you with an itemized room service receipt. Alcohol is not reimbursable. • Parking (airport or hotel) The Hershey Medical Center pays for long-term parking at the airport. If you choose not to use long-term parking, you will only be reimbursed at the long-term parking daily rate. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 154 Transfers to and from Airport/Hotel (taxi, shuttle, etc.) Taxi/shuttle transfers, including tip, will be reimbursed with original receipt indicating fee and date of transfer Poster Printing (if presenting) Poster printing can be done on campus. The Sign Shop will direct bill the department. Please see the Program Coordinator prior to placing a print request to ensure you are using the correct cost center/budget. ALL travel should be planned at least 60 days in advance and coordinated through the Fellowship Program Coordinator. D. INSURANCES We emphasize prevention, wellness, and health choices. We continue to encourage our employees to make informed decisions as engaged healthcare consumers. We offer an expansive preventive schedule and lifestyle health management program with incentives. We have maintained the Health Reimbursement Arrangement (HRA) and included opportunities for you and your spouse/domestic partner to earn additional financial contributions toward your HRA. You choose when to use your HRA to pay for medical deductible and coinsurance, further enabling you to plan and save for tomorrow's healthcare expenses today. (Human Resources - Benefits website) Other benefits offered with employment are: • Dental Plan • Vision Plan • Flexible Spending Accounts • Group Term Life Insurance • Accidental Death & Dismemberment • Travel Assistance & Business Travel Accident Insurance • Short-Term Disability • Long-Term Disability • Tuition • Employee Assistance Program Complete and detailed information on benefits can be viewed on the Human Resources - Benefits webpage. E. EMPLOYEE DISCOUNTS PSHMC has now partnered with Abenity to offer you not only local discounts but also national offers and discounts as well. Through the new Abenity discount portal, PSHMC employees can access a comprehensive group of local and national discounts and offers for hotels, restaurants, movie theaters, spas, theme parks and more as well as concierge services. Employees - register/login here: http://pshmc.employeediscounts.co/discountprogram CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 155 F. LEAVE OF ABSENCE Vacation and Continuing Medical Education (CME)*: Each resident is granted 15 to 20 working days of paid leave each year in keeping with program or departmental policy. The total amount of leave includes both vacation and CME paid time off. These days should also be used for interviewing and relocation. Medical/Parental/Family Leave*: A resident may request a maximum of twelve weeks of family leave. The first six weeks minus any vacation leave already used will be with full pay and benefits, and will include any remaining vacation leave for the contract period. The remainder of the twelve weeks will be without pay; however benefits will be billed at the employee rate. If the period of leave bridges two consecutive contract periods, the amount of paid and unpaid leave will be allocated proportionately, including available vacations days. Personal Leave*: A personal leave may be granted to a resident upon review of the circumstances by the Program Director. All eligible vacation time for that year must be used during this period. The period of personal leave time that is not covered by vacation time will be unpaid. Professional Leave*: A professional leave of absence may be granted to a resident upon review of the circumstances by the Program Director. All eligible vacation time for the academic year must be used during this period. The period of professional leave that is not covered by vacation time will be unpaid. Effect of Leave: All requirements of the residency training program must be fulfilled prior to the completion of training. The Program Director is responsible to notify the Resident as to the effect of leave on their training timeline. Residents may be required to extend their length of training to meet all residency program requirements. The Residency Review Committee for t h e residency program and the Residency Program Director determine the length of training and training to be completed following a leave of absence. *All requirements of the residents’ respective Board must be satisfied. Board requirements will take precedence over institutional leave of absence policies, when applicable. Specific specialty Board information can be accessed through the PSHMC internet, the Graduate Medical Education office, or the Program Office. (Institutional Requirements: IV.G.I) G. COMPSYCH GUIDANCE RESOURCES ComPsych® is the new provider for the Penn State Hershey Medical Center Employee Assistance Program (EAP) services. Personal issues, planning for life events or simply managing daily life can affect your work, health and family. ComPsych® GuidanceResources® provides support, resources and information for personal and work-life issues. GuidanceResources® is company-sponsored, confidential and provided at no charge to you and your dependents. You may contact ComPsych® Guidance Resources® anytime for confidential assistance. Toll-free Phone Number: 866-465-8935 Online: www.guidanceresources.com First time users – click “I am and first time user” to register, enter the Web ID: PSHMC to set-up your account. For each additional access you may use your personal User Name and Password to access the site 24 hours/day, 7 days/week. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 156 Your GuidanceResource® benefits are strictly confidential. To view the ComPsych® HIPAA privacy notice, please go to www.guidanceresources.com/privacy. H. MEAL ALLOWANCE The Penn State Hershey Graduate Medical Education program will fund a debit card/meal program for resident physicians. A. Individual debit card accounts will be established for all Penn State Hershey Medical Center residents who work in the hospital. B. The resident accounts will carry a maximum dollar limit of $450. C. Dollar amounts will be specified for each residency-training program*. Amounts will not be dependent, nor vary, based on the monthly rotation to which the resident is assigned or the post-graduate year of the resident. D. Graduate Medical Education will disburse credit to the individual resident account on a quarterly basis. E. The hospital identification (ID) badge of each resident will serve as the actual debit card. If the resident does not present a valid hospital ID badge, the cafeteria staff will be unable to charge the resident account. F. After each purchase utilizing the debit card, the resident will be given a receipt indicating the balance on their account. G. The debit card account will be valid at all on-campus Food Services locations. H. Residents may carry a monetary balance in their account from month-to-month and yearto-year. I. Residents will not receive any form of cash payment, in lieu of debit card funds. J. When a resident terminates from a residency program, all funds are removed from the resident account. K. The Food Services Department will maintain records of all resident charges. The charges will be allocated via interdepartmental transfer on a monthly basis, and paid by the Office of Graduate Medical Education. Cardiology Fellows will be given $150 per month, on a quarterly basis. I. MEALS ON-CALL A refrigerator is available in the back of the cafeteria for your use during overnight call. The refrigerator can be accessed using your employee ID badge, between the hours of 10 p.m. and 7 a.m. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 157 VIII. MISCELLANEOUS INFORMATION A. GRADUATE MEDICAL EDUCATION OFFICE The Graduate Medical Education office is located on the first floor, room C1630, and can be reached at ext 1368 or 5768. They are staffed by three ladies: Beth Herman, Colleen Nicholas, and Mary Forshey. B. NOTARY Services of a Notary Public are available in the Graduate Medical Education Office at no charge for official documents. (Personal documents may be notarized at the discretion of the GME office staff, for a fee.) C. PARKING The Parking Services office is located on the ground floor, room CG608, and can be reached at ext 3713. All persons that park on campus must register their vehicle. A parking sticker will be issued and it must be prominently displayed in the rear window of your vehicle. Parking Services will assign you to a specific lot. You must park in this lot or the Centerview Parking Garage when parking on campus. For additional information regarding parking, including hours of operation, handicap parking, etc. please visit their website. D. ID BADGING The ID Badging office is located on the ground floor with Parking Services in room CG608. They can be reached at ext 3548. Penn State Hershey Medical Center and College of Medicine photo identification badges are issued to all employees and students at the Hershey Campus. The ID badges include a picture of the employee or student along with other information such as name, PA Department of Health mandated clinical role and specified clinical certifications or a student/faculty designation. All students and employees are required to wear their ID badge while working or conducting other hospital or college-related activities on campus. You must present your ID badge to Security Officers or to hospital or college leadership upon request. For additional information regarding ID badging, including hours of operation, please visit their website. E. GEORGE T. HARRELL LIBRARY The George T. Harrell Library serves the faculty, students, and staff of Penn State Milton S. Hershey Medical Center and the Penn State College of Medicine, and users from the Central Pennsylvania community. Library collections and services support the informational needs of PSHMC users engaged in patient care, research, and education, including interlibrary loan, search services, and instruction. For additional information, or links to their resources, please visit their website. F. GIFT SHOPS The Hospital Gift Shop is located on the first floor of the medical center, across from Starbucks. You will find a wide selection of gifts, chocolates, fresh flowers and plants, magazines, books, toys, and greeting cards. There is also Penn State store in the main hallway on the first floor near the Rotunda. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 158 G. FITNESS CENTER Penn State Hershey University Fitness Center offers state-of-the-art equipment, as well as services and programs to fit your individual fitness needs. For additional information regarding membership fees, hours, and classes, please visit their website. H. ATM An Automated Teller Machine (ATM) is located in the hospital next to the Starbucks in the Main Hospital Lobby I. MAIL SERVICES The HMC Mailroom is located on the Ground Floor, immediately off of the College of Medicine elevators. It is open for HMC business from 8:00 am to 4:30 pm, Monday through Friday. Stamps and other mailing supplies are available for sale at the personal service window between the hours of 11:00 a.m. and 1:15 p.m., Monday through Friday. J. WORK-RELATED INJURIES All work related injuries and/or illnesses should be reported immediately to your supervisor. If treatment is required you should report to Employee Health. In a case of serious injury, the injured employee can report directly to the Emergency Department. All follow up care will be coordinated through Employee Health. These injuries/illnesses include percutaneous (needle sticks) or mucosal exposure to blood/body fluids and exposure to communicable diseases. K. TELEPHONE/PAGER INSTRUCTIONS Telephone Instructions: • For calls within the Medical Center complex, dial the four or six – digit extension number. • For local calls outside the Medical Center complex, and “local toll” (717), dial 9 + the seven digit telephone number. • To call long distance, dial 9 + area code + 7 digit phone number. Pager Instructions: USER: Dial access code 4311 on any HMC telephone or 531-4311 from any private or public telephone. SYSTEM: “Please dial the page ID.” USER: Dial ID number of intended party. SYSTEM: Speaks ID number or spoken name (if recorded). Speaks paging status, then prompts for a callback number if appropriate. Recipients can also be alpha (text) paged through SmartWeb. To Access a “Non-System” Pager: Any pager containing more than four digits as a pager ID is a non-system pager. These pagers cannot be reached using the HMC4311 paging system. Dial the pager ID as you would any phone number. One of two things will happen: • You hear a series of beeps. Enter your call back #, followed by the pound sign, and hang up. • Your page will be “answered” by a voice prompt message. Follow the instructions given by the paging company. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 159 L. DICTATION SYSTEM INSTRUCTIONS Dial 717-531-5279, 717-531-5291, or 888-244-4680 • Follow the voice prompt • Press 1 to Dictate (or) 3 to Listen • To Dictate, Enter: o 5 digit Confidential Author ID o 2 digit Work Type o Patient Number • After tone, press 4 to begin recording Hints for Optimal Dictation • Select a quiet location, review information and gather thoughts. • Dictate your name. • If applicable, dictate the Attending Physician. • Dictate the Patient Name (with spelling) • Dictate the Patient Number. • Dictate the Date of Service. • Dictate the Work Type. • Speak slowly, clearly and loudly. • Use PAUSE key (5) when needing to pause more than a few seconds. • Any landline (touch tone) phone is acceptable. HIPAA REGULATIONS PROHIBIT THE USE OF CELL PHONES. • To report problems, dial 6257. • For QA concerns, dial 283950. **Please remember that your 5-digit Author ID is a confidential password to the Enterprise system. CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 160 Keypad Keys for Dictation 4 Dictate 2 Rewind a few seconds and play. Press several times to go back further then press 4 to continue recording *1 Rewind to start and play 8 Forward a few seconds and play. Press several times to go further ahead then press 4 to continue recording 3 Jump to end of report and continue recording 5 Pause/Stop Recording or Playback 6 Hear confirmation number 0 Hear confirmation number, dictate new report *2 Hear confirmation number and disconnect *4 Hear confirmation number, dictate new report on same patient ** Go from dictate to listen *# Help prompts *7 Mark report priority CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 161 Keys for Listening To Listen, Enter: 5-digit Confidential Author ID Follow the voice prompts: 1. 2. 3. 4. Job Confirmation Number Author ID 7 digit Pt Number Work Type 6 Hear earlier report, same patient ID 1 Pause, press 4 to play 3 Rewind 4 Play 5 Fast Forward 7 Go to end of report 9 Go to start and play ** Go from Listen to Dictate # New Patient ID CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 162
