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  1. 1. ROYAL CHILDREN’S HOSPITAL Flemington Road, Parkville Vic. 3052, Australia FELLOWSHIPS IN CARDIOLOGY Available Cardiology Fellowships There are two funded Fellowships, one of which is geographically at the Royal Children’s Hospital full-time, and the other is half-time at R.C.H. and half-time at Monash Medical Centre on the other side of Melbourne. Fellowships are granted for one year in the first instance but are renewable for a second year. In addition to the above Funded Fellowships, Supernumerary Fellowships are available for applicants who have funding from their own institutions or outside bodies. For such applicants Occupational Trainee Visas are available. All Fellows are incorporated into the Fellowship training program (see attached document), which involves ward duties, assessment of neonates and other new patients with suspected congenital heart disease, examination of pa- tients referred from other services within the Hospital, outpatient clinic experience, echocardiography, arrhythmia monitoring - including exercise testing, and cardiac catheterisation and interventional procedures. The Fellows ros- ters are managed by the Senior Fellow. The precise program for individual Fellows is tailored to their previous experience and career intentions. Some exposure to Intensive Care occurs as part of the ward exposure, but training in Intensive Care is not part of the program. All Fellows are expected to be involved in Research projects, which will be set up early in their program in conjunc- tion with the co-ordinator of Cardiology Research (Prof. S. Menahem/Dr. R.G. Weintraub). There is a Consultant with special responsibility for Fellowship training (Dr. L.V. Fong). We have a number of Department meetings each week, including a Journal Club, meeting with Cardiology Social Workers and Nursing Staff, formal Fellowship tutorials, an Echo Meeting, and a Lunchtime Postgraduate Lecture Meeting. Previous experience in Paediatric Cardiology is not essential, but appointment of Fellows is essentially competitive and prior experience in the specialty is an advantage. Overseas candidates require an Occupational Trainee Visa, which may take some time to process (three to four months). Research Fellowships are also available, but are granted only on application with a fully worked out Research pro- posal. Such applications are competitive and normally only one such Fellowship would be granted within one Depart- ment of the Hospital in any one year. Successful applicants for Research Fellowships are normally people who have previously worked in the Hospital and are known to the Department personally.
  2. 2. ROYAL CHILDREN’S HOSPITAL Departments of Cardiology and Cardiac Surgery Background Information The Royal Children’s Hospital is one of the largest children’s hospital in the southern hemisphere, and from the point of view of paediatric cardiology and cardiac surgery, provides a service for the states of Victoria and Tasmania and the southern part of New South Wales. In addition a tertiary referral service is provided for patients with complex congenital heart disease and for infant cardiac surgery for the states of South Australia and Western Australia and also for the Northern Territory. The department also caters for a number of overseas patients from south east Asia. The surgical department carries out somewhere in excess of six hundred surgical procedures per year. Approximately one third of open heart procedures are performed in the first six months of life (half of these in the first month of life). The surgical practice encompasses the full range of palliative and reconstructive procedures, including heart and heart/lung transplants. The cardiology department has eight staff cardiologists, three of whom work part-time at the Royal Children’s Hos- pital and part-time at Monash Medical Centre, where a smaller paediatric cardiology service operates on a predomi- nantly out-patient basis. The department runs approximately 15 outpatient clinics per week in Melbourne, and pe- ripheral clinics in referral centres in Victoria, Tasmania and Southern New South Wales. Approximately 5,000 echocardiograms are carried out annually - these including M-mode, 2D, Doppler and colour flow mapping, and transoesophageal studies. Approximately 500 cardiac catheter procedures are performed each year, including interventional procedures such as balloon valvuloplasty, balloon dilatation of coarctation, coil embolization, device occlusion of persistent ductus arte- riosus, device closure of muscular VSDs, balloon angioplasty and stent implantation. A program of device closure of Atrial Septal Defects, using the Amplatzer Septal Occluder, was commenced in 1996. A comprehensive arrhythmia investigation and treatment service, includes Holter monitoring, exercise testing, elec- trophysiology studies, etc. and Radiofrequency ablation, for the elimination of arrhythmias. The city of Melbourne has a population of approximately three million, and is the second largest city in Australia. The state of Victoria is the southern-most state on the Australian mainland, and is also the smallest mainland state - having an area approximately the same as that of Great Britain. Melbourne is on a similar latitude in the southern hemisphere to Lisbon, Athens or San Francisco in the northern hemisphere. It has a moderate (Mediterranean) climate - being cool in winter (but without frost or snow) and hot and dry in the summer months (temperatures rising up to the high 30’s or low 40’s Celsius). The weather has a reputation for being rapidly changeable at all seasons of the year.
  3. 3. Royal Children’s Hospital. Department of Cardiology Fellowship Training. Introduction: Cardiology Fellowship training, at the Royal Children’s Hospital, offers a broad exposure to all aspects of clinical and investigative cardiology for children with suspected and actual heart disease - both congenital and acquired. The detailed programme for individual fellows is tailored to their particular level of experience and individual needs. Some of the fellows are relatively senior and may have been functioning at consultant level in their own institutions prior to commencing their period at RCH, whilst others are relatively inexperienced. Rosters: All fellows participate in the on call roster and are rotated through periods of ward responsibility and responsibility for performing inpatient echocardiograms and for involvement with arrhythmia investigation. The “senior fellow” keeps a roster for : A. general duties (outpatient clinics, cardiac catheter sessions, etc) B. on call duties, C. ward fellow duties D. echo fellow duties E. arrhythmia fellow duties Outpatient Clinics: Each fellow is allocated to one outpatient clinic session on a regular basis, where he assists the consultants with seeing and assessing new patients and reviewing old patients in the outpatient setting. Cardiac Catheterisation: Each fellow is allocated to at least one cardiac catheter session per week at which he assists or carries out one or two
  4. 4. cardiac catheter procedures. During a period of 12 months, each fellow would be likely to assist with or carry out between 50 and 100 cardiac catheter procedures, including diagnostic right and left heart studies, interventional procedures such as balloon atrial septostomy, balloon valvuloplasty (pulmonary and aortic), balloon dilatation of coarctation (both native and recurrent), device/coil closure of P.D.A., A.S.D., V.S.D. and other procedures. The stage at which fellows begin to perform procedures as first operator and the proportion of cases where this occurs depends on their aptitude and prior experience. All fellows present patients following cardiac catheterisation or with data which has been supplied from other insti- tutions at the joint conferences with the cardiac surgeons. They are responsible for compiling the catheter/ haemodynamic/anatomic/angiographic data and putting this into a concise and intelligible format for presentation to the cardiac surgeons. Our joint conferences involve the presence of several of the surgical and cardiological team and numerous cardiac surgical and cardiology fellows and other staff with a lively discussion concerning many manage- ment issues and abundant feedback to the cardiology fellows - particularly if their presentations do not meet up to the appropriate standard ! On Call Duties: During on call periods, each fellow would be expected to take responsibility for assessing and carrying out echocardiograms on newly referred babies or children coming in as inpatients and would also take responsibility for seeing patients in other wards/departments in the hospital, who are suspected of having a cardiac problem and for whom a cardiology opinion has been requested. Their conclusions are discussed with the responsible cardiologist subsequent to their initial assessment. Ward Fellow: Each fellow spends regular periods (2-4 weeks) as ‘ward fellow’, during which time he is responsible for coordinating the cardiological care / investigations on patients in the cardiology ward - either pre-operatively, post-operatively or being investigated or treated for other reasons, including transplant related problems. He is also responsible for inpatient consultations, during normal working hours, on other patients in the hospital and liaises closely with the consultant cardiologist on ward service each week. Echocardiography: In the course of their periods as “echo fellow” and during on call periods, as well as in relation to patients who they
  5. 5. are dealing with during cardiac catheter sessions, the fellows carrying out numerous echocardiograms both on their own and supervised. In the course of a 12 month period, most cardiology fellows would perform 200-400 echocardiograms on a very wide range of patients with suspected or actual heart disease ranging from simple to highly complex. These studies include pre and post operative echos and trans oesophageal examinations. Our regular echocardiogram review meetings allow them to present sample echos which they have carried out and to discuss the findings with the group. We currently have additional review meetings on a daily basis of those inpatient echos which have been carried out, particularly on post-operative patients in intensive care, and these provide further feedback to the fellows who have carried out these echos - some of which are performed with direct supervision of one of the cardiologists. Reports on echocardiograms are generated through the department database, after the fellows have entered the rel- evant data on the studies they have carried out. The recordings and reports are checked by the patient’s cardiologist prior to the report being ‘signed off’. ECG and Arrhythmia investigation: The ‘Arrhythmia’ fellow is responsible for supervising treadmill exercise tests, and providing preliminary reports thereof, and for assisting with ECG and Holter tape analysis. Most fellows would take responsibility for 20-30 exercise test in a year. They also provide provisional reports on routine ECGs which have been performed on patients who they are dealing with as inpatients or as outpatients. Additional options: All fellows have limited exposure to management of transplant patients and one fellow may be involved on a regular basis, over a period of six months or longer, with helping to run the transplant clinic, in conjunction with the transplant cardiologist, Dr Robert Weintraub. In addition to the above, fellows are given the option of specific involvement in the area of electrophysiology and/or foetal echocardiography - though these are not offered as part of routine training. Some fellows also elect to attend the adult congenital clinic which is performed alternate weekly in the adjacent adult hospital (Royal Melbourne Hospital). Research Activities: All fellows are encouraged to participate in research activities and to prepare presentations for National/International
  6. 6. meetings and contribute to (either as first author or co-author) publications in peer reviewed journals. Almost all our fellows would, through this means, present one paper or poster at a major meeting and be an author/co-author on one or two (or sometimes more) publications and published abstracts. Research activities are coordinated by Prof S Menahem and Dr RG Weintraub. Formal Training: The regular fellowship training sessions (each Thursday at 11.00 am) include discussions of a wide variety of topics, under the supervision of consultant staff and exposure to pathology specimens, from the pathology collection, which are demonstrated / examined at least once a month, in addition to the monthly ‘Pathology’ meetings, where recent biopsies and other pathology material is demonstrated / discussed. A program of lectures / tutorials on Fridays at 12.30 pm is currently being re-established after a gap of some months. Other meetings: There is a joint conference, with the cardiac surgeons, each Monday, lasting approximately two hours. At this meet- ing discussions involve patients who have had cardiac catheter procedures in the previous week, patients referred for possible investigation or treatment from interstate or overseas and other patients who require discussion in a forum with several senior members of the team. In addition, we have regular journal club meetings (currently once a fortnight), pathology meetings monthly (with the consultant in histopathology / morbid anatomy), audit meetings of cardiac surgical morbidity (monthly) and audit meetings of cardiology activity and morbidity (monthly) and morbidity and mortality meetings in conjunction with our intensive care colleagues every three months. Audit of Fellow’s activities: The department database allows us to audit the catheter procedures and echocardiograms, etc. which each fellow has performed during his or her period at RCH.