Outline of Curriculum & Line of Responsibility                                                                            ...
Outline of Curriculum & Line of Responsibility                                                            2
The University...
!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann                  3
The University of Texas-Houston Heal...
!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann                  4
The University of Texas-Houston Heal...
!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann                  5
The University of Texas-Houston Heal...
!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann                                       6
The University ...
!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann                                                 7
The U...
!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann                               8
The University of Texas...
!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann                                    9
The University of ...
!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann                                 10
The University of Te...
!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann                                   11
The University of ...
!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann                   12
The University of Texas-Houston H...
!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann                                               13
The U...
!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann                                       14
 The Universi...
!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann                               15
 The University of Te...
!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann                               16
The University of Tex...
!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann                                     17
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#-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital                                            18
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#-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital                                                19
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#-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital                                                 20
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#-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital                                    21
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#-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital                                22
The University of Texas-Houston...
#-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital                                             23
The University of ...
#-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital                                         24
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%!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann                                                         25
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%!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann                                                              26
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%!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann                                                                      27
The ...
%!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann                                                           28
The University ...
%!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann                                                       29
The University of T...
%!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann                                                       30
The University of T...
%!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann                                                          31
The University o...
!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital                                            32
The University...
!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital                                            33
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!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital                                          34
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!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital                                            35
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!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital                                          36
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Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
Legend for Learning Activities for Fellows
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Legend for Learning Activities for Fellows

  1. 1. Outline of Curriculum & Line of Responsibility 1 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum !"#$%#$&' ' OUTLINE OF CURRICULUM & LINE OF RESPONSIBILITY (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((()' MEMORIAL HERMANN HOSPITAL !"*"#+*,'!+*%'-#.$'/!!-0'+#1'!+*1."2"3,'4+*1'&%*5.!%...................................................................3 !+*1."5+&!-2+*''1.&%+&%''!"#&-2$''&%*5.!%''*"$+$."# .......................................................................12 #-!2%+*''!+*1."2"3,''*"$+$."# .......................................................................................................................18 %!6"!+*1."3*+76,'''*"$+$."# ..........................................................................................................................25 !+*1.+!''!+$6%$%*.8+$."#''*"$+$."# ............................................................................................................32 !+*1.+!'%2%!$*"76,&."2"3,9'!+*1+.!'7+!.#3'+#1 ...............................................................................42 !+*1."5+&!-2+*''1.&%+&%''7*%5%#$."#''+#1''*%6+:.2.$+$."# ...........................................................49 !+*1."2"3,''!"#$.#-.$,''!2.#.! ........................................................................................................................55 !+*1."5+&!-2+*''*%&%+*!6'''*"$+$."# ........................................................................................................60 LYNDON BAINES JOHNSON HOSPITAL !"*"#+*,'!+*%'-#.$'/!!-0';'!+*1."2"3,'!"#&-2$'&%*5.!%..............................................................62 %!6"!+*1."3*+76,'''*"$+$."# ..........................................................................................................................69 ST. LUKE'S EPISCOPAL HOSPITAL/TEXAS HEART INSTITUTE 6%+*$'<+.2-*%'+#1'$*+#&72+#$+$."#'&%*5.!%..........................................................................................76 !2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';.............................................................................82 UNIVERSITY OF TEXAS M.D. ANDERSON !+*1."5+&!-2+*''1.&%+&%''!"#&-2$''&%*5.!% ..............................................................................................91 !+*1."5+&!-2+*''1.&%+&%''#"#.#5+&.5%''*"$+$."# .................................................................................97 ADMINISTRATION OF THE PROGRAMS ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((=>?'
  2. 2. Outline of Curriculum & Line of Responsibility 2 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum ' "-$2.#%'"<''!-**.!-2-@';''2.#%''"<''*%&7"#&.:.2.$,' <"*' $6%'-#.5%*&.$,'"<'$%A+&' !+*1."2"3,''<%22"4&6.7''7*"3*+@'' The mission of the program is to train academic cardiologist to be among the best in the specialty. The Division of Cardiology will provide qualified physicians with a balanced, structured, and scholarly experience in clinical and experimental cardiology. To be among the best trainees in the specialty, the cardiology faculty will train fellows in every aspect of academic cardiovascular medicine. The training includes a curriculum in patient care, teaching, and the use of noninvasive and invasive techniques in cardiovascular diagnosis. The Division of Cardiology encourages scholarly productivity by providing opportunities for both basic and clinical research. The fellowship consists of three years of training, at the end of which the fellow will have met the requirements for the qualifying board examination in cardiovascular medicine. Patient Medical Knowledge Interpersonal and Professionalis CDR Communication Skills Systems-Based Practice-Based Learning Practice and Improvement The lines of responsibility and curriculum reflect the ACGME guidelines regarding the six general competencies, goals, and objectives for each rotation, learning activities, and evaluation tools. The fellows (CDR) on each rotation are evaluated using a 360 degrees measurement instrument, oral/written exams, procedure logs, hospital/patient surveys, CDR portfolios, and record reviews.
  3. 3. !"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 3 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Lines of Responsibility ' !"*"#+*,'!+*%'-#.$'/!!-0'BCD'!+*1."2"3,'4+*1'&%*5.!%' At Memorial Hermann Hospital ' !BEDFGHGIJ'.CKBLFMCL'&MENFOMP!GEGCBEJ'!BEM'-CFL''' The cardiology inpatient service at Memorial Hermann Hospital handles general cardiovascular problems. Private teaching cardiologist and UT faculty cardiologists are allocated to this team for purposes of patient care. This team consists of one faculty attending physician, one CDR, four internal medicine residents, and four interns. Three to four medical students are also assigned to this team on a monthly basis. 4GEQFCI'6GRES' The regular working hours of the cardiology fellow assigned to the CCU rotation (the CCU Fellow) are Monday through Friday (excluding holidays) from 7:00 am to 6:00 pm. The cardiology fellow on call for the CCU will cover all other hours, which include: Weekdays 6:00 pm to the following morning at 7:00 am Weekends from 7:00 am to the following day at 7:00 am (24 hours) Holidays from 7:00 am to the following day at 7:00 am (24 hours) During the week, each fellow is required to attend his/her respective half-day of continuity clinic. The CCU Fellow will pass the emergency call pagers to the first year cardiology fellow assigned to the Hermann Echo Lab or to the Hermann Cardiology Consult Fellow should the Echo Fellow be unavailable. If neither the Echo Fellow nor the Consult Fellow are available, the CCU Fellow will contact one of the Chief Cardiology Fellows to find an appropriate substitute. +DTFSSFGCS'LG'LUM'!!-'&MENFOM'''' Cardiology patients admitted to the CCU team will be defined as teaching or non-teaching patients depending on whether the patient’s attending cardiologist is on the U.T. Internal Medicine/Cardiology Teaching Service or not, respectively. 3MCMEBH'3RFDMHFCMS'LG'LUM'!!-'&MENFOM' The CCU fellow will be alerted to all admissions to the CCU by either the Cardiology or Emergency Room attending physicians and will assess all patients admitted to the CCU. On arrival, he or she will document, in writing in the patients chart, the patient’s medical status, major physical findings, and the clinical plan. All significant changes in status, such as severe hypo or hypertension, uncontrolled chest pain, need for mechanical ventilation, or major arrhythmias will be communicated by the fellow to the attending within ten minutes of the occurrence of such an event. '
  4. 4. !"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 4 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Lines of Responsibility 7BLFMCLS'GV'LUM'-($('.CLMECBH'@MDFOFCMP!BEDFGHGIJ'$MBOUFCI'&MENFOM' The internal medicine resident on duty for the CCU service (CCU Resident or CCU Intern) will have the primary responsibility for all admission, transfer, and discharge notes and orders for patients admitted to the CCU service, which includes both the CCU and the Cardiology Ward. The CCU Resident will also have the primary responsibility for daily notes and orders and any necessary admission or discharge dictations. The CCU Fellow will give appropriate guidance and supervision, including teaching, performing, or supervising any necessary invasive procedures. In addition, the CCU Fellow will document a history and physical in the medical record at the time of admission for those patients admitted to the CCU. 7BLFMCLS'#GL'GC'LUM'-($('.CLMECBH'@MDFOFCMP!BEDFGHGIJ'$MBOUFCI'&MENFOM' For patients whose cardiology attending is not on the U.T. Internal Medicine teaching service, the nurse practitioner service shall be notified. The nurse practitioner will have the primary responsibility for all admission, transfer, and discharge notes and orders for these patients. In addition, the nurse practitioner will have the primary responsibility for daily notes and orders and any necessary admission or discharge dictations. The nurse practitioner will work directly with the non-teaching attending regarding patient care. The CCU Fellow will be available to perform necessary invasive procedures. During non-regular working hours for the nurse practitioner, the non-teaching cardiology attending will be notified by the nurse taking care of the patient directly for admission orders. The CCU fellow will be available for any emergencies which may occur with any patient while in the CCU and, as outlined above, will assess all patients admitted to the CCU on their arrival after notification by the non-teaching attending and document their status, briefly, in the chart. For fellow assistance to occur in this setting, the non- teaching attending must notify the CCU fellow on duty directly and communicate his or her plans for the patient as well as the patient’s history and status. #FIUL'1RLFMS'GV'LUM'!!-'<MHHGW' The CCU Fellow On Call will also be responsible to take care of patients followed by the Cath Fellow during non-regular hours. %TMEIMCOFMS' As the code leader for the entire hospital, the CCU Fellow will provide assistance to any patient in the hospital when called upon for emergencies or impending emergencies. Once able, the CCU Fellow will subsequently notify the primary attending of the situation. The CDR is responsible for supervising the care of cardiology patients in the CCU and some patients in the CV-ICU. The trainee is responsible for evaluation of all new admissions to the CCU during the week. She/he is responsible for supervision of the house staff and actively participates in the formulation of the diagnostic and therapeutic plan for each admission. The CDR should make daily rounds with the house staff on all patients on the team and is expected to write progress notes on the patients. Patients who have undergone cardiac surgery will still be followed daily in the CV-ICU by the
  5. 5. !"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 5 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Lines of Responsibility team, although direct involvement in patient care is usually minimal until the patient transfers out of the CV-ICU back to the cardiology wards. Once the patient is moved out of these units to the CIMU, the house staff interacts directly with the cardiology attending. However, the CCU fellow will be expected to be available to help deal with any unexpected problems arising with these patients. All Swan-Ganz catheter insertions and transvenous pacing catheter insertions are performed by the CDR or by one of the residents under the direct supervision of the CDR or the cardiology attending. Attending rounds with the UT staff attending assigned to the team for the month generally are held from 10:00 a.m. to 12:00 noon every day. This may be modified on an individual daily basis depending upon work activities, etc. The level of supervision provided by the attending will depend on the complexity of the case and the ability and experience of the particular CDR involved. The CCU fellow is typically responsible for 15-20 patients with a maximum of 25 patients. If this maximum number is reached, the CDR should inform the program director who will assign one of the other clinical trainees to assist with this service. Occasional patients may be designated as “non-teaching patients”. In those instances, the attending staff physician is directly responsible for all aspects of the individual’s care. CDRs, medical residents, interns and students will not routinely participate in the care of these individuals, however, may perform specific tasks at the discretion of the attending staff. As with all patients, emergency medical services will be administered to non-teaching patients by CDRs in the course of their duties on the Code Team or as a bystander until the attending staff physician is directly available to assume these responsibilities.
  6. 6. !"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 6 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum ' !"*"#+*,'!+*%'-#.$'/!!-0'BCD'!+*1."2"3,'4+*1'&%*5.!%' At Memorial Hermann Hospital The Memorial Hermann Hospital Coronary Care Unit (CCU) and Cardiology Ward Service rotation lasts for one month. One first year fellow is assigned to a team which consists of four residents, four interns, three to four medical students, and the cardiology attending. The fellow will have on average six or seven calls, and have one day a week off. During the rotation, the fellow will have an opportunity to learn procedures under the direct supervision of the CCU attending or senior cardiology fellow. Patients seen on the Memorial Hermann Hospital CCU and the Cardiology Ward Service include patients of faculty physicians, unassigned patients admitted from the clinics or ER, and a select group of patients of community physicians who are authorized to admit patients to these services. ' ' 7EFCOFKBH'$MBOUFCI'@MLUGD' During time spent in clinical rotations, trainees will be principally taught by their supervising attending, who will be either one of the UT -faculty or by one of the private attending cardiologists who have a clinical appointment with the institution. Trainees will gain instruction and experience under their supervision. ' Additional teaching will occur through the didactic lectures and conferences. These are Hemodynamic Conference, Cardiac Catheterization Conference, Core Curriculum, Cardiovascular Grand Rounds, Research Conference, Echocardiography Conference, Electrophysiology Conference, Nuclear Cardiology Conference, ECG Conference, Board Review, and Journal Clubs. These constitute an important component of trainee's training and attendance is obligatory. However, it is important for the trainee also to be involved in continuous self-study during his/her training with the realization that this must be a lifelong commitment. All fellows receive a copy of Cardiovascular Medicine, Eds: Willerson and Cohn; other recommended texts are cited below. It is also expected that trainees keep abreast of the pertinent scientific literature published in the New England Journal of Medicine, Circulation and the Journal of the American College of Cardiology. The fellowship office has copies' of the American College of Cardiology Adult Clinical Cardiology Self- Assessment Program and Mayo Cardiovascular Board Review. %DROBLFGCBH'!GCLMCL During this rotation the trainee will gain experience in intensive care of patients with acute cardiovascular disorders, including coronary care. Fellows will gain experience in the evaluation and management of patients with acute coronary syndromes, i.e., unstable angina and acute myocardial infarction and their complications. This includes the indications and use of thrombolytic and antiplatelet therapy; inotropic and vasodilator therapy; temporary pacemaker, Swan-Ganz catheter and intra-aortic balloon placement; coronary interventions (PTCA and stenting) and coronary artery surgery. Fellows will gain experience in the role of secondary prevention in patients with coronary artery disease, including the use of aspirin, Beta-blockers, ACE-Inhibitors, HMG-CoA reductase inhibitors and the
  7. 7. !"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 7 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum treatment of risk factors for coronary artery disease. Fellows will also gain experience in the evaluation and management of patients with other cardiovascular disorders including cardiac arrhythmias, cardiac failure, infective endocarditis, valvular heart disease, pericardial disease, pulmonary thromboembolic disease and disease of the great vessels. Fellows will also be involved in the post-operative care of patients following cardiac surgery. 2MIMCD'VGE'2MBECFCI'+OLFNFLFMS'VGE'<MHHGWS'' ACS Ambulatory Care Series %!3' ECG Series X!' Journal Club AR Attending Rounds %7' Electrophysiology Conference 2!' Leadership in Cardiology AU Autopsy Report %.' Ethics in Cardiology @@' Cardio Morbidity & Mortality CAC Catheterization Conference <&' Faculty Supervision #!' Noon Conferences CC Core Curriculum 3*' Ground Rounds 7!' Professionalism Curriculum DPC Direct Patient Care 6!' Hemodynamic Conference 7!<' Preventive Cardiology Forum DSP Directly Supervised Procedure .!' Interventional Cardiology 7*' President’s Rounds EC Echocardiography Conference .2' Introductory Lecture Series *!' Research Conference 2MIMCD'VGE'%NBHRBLFGC'@MLUGDS'VGE'<MHHGWS' +%' Attending Evaluations 7%'' Patient/Health Professional Evaluation 1&7' Directly Supervised Procedures 72' Procedure Logs %!*' Educational Committee Review (2x annually) 7*' Peer Review <7' Fellow Portfolios **' Record Review "4%' Oral/Written Exams ' 7EFCOFKHM'%DROBLFGCBH'3GBHS'YJ'*MHMNBCL'!GTKMLMCOJ'' The principle educational goals for fellows on this rotation are indicated for each of the six ACGME competencies in the tables below and numbered in the first column. The second column of the table lists the goal, the third column lists the most relevant learning activities for that goal, and the fourth column indicates the correlating evaluation methods for that goal. A detailed description of the on-going learning activities at Memorial Hermann Hospital is included in the front of the report for further information. +(''7BLFMCL'!BEM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Take a complete medical history and perform a careful and DPC, AR AE accurate physical examination with a cardiology focus. 2. Ability to recognize the physical findings of chronic congestive DPC, AR, AE heart failure, acute pulmonary edema, mitral regurgitation, mitral FS stenosis, aortic stenosis, aortic regurgitation, and tricuspid regurgitation.
  8. 8. !"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 8 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 3. Write concise, accurate and informative histories, physical DPC, AR AE examinations and progress notes with a cardiology focus. 4. Ability to formulate comprehensive and accurate problem lists, DPC, AR, AE differential diagnoses and plans of management for patients with CC acute cardiac illness. 5. Effectively evaluate and manage patients with acute cardiac DPC, AR, AE illness; particularly acute coronary syndromes, acute myocardial CAC infarction, congestive heart failure, pulmonary edema, and acute valvular heart disease. 6. Effectively manage patients with undiagnosed chest pain, DPC, AR AE including the appropriate use of diagnostic testing. 7. Ability to perform and recognize major abnormalities of cardiac DPC, DSP, AE, DSP stress tests, cardiac Echo and coronary angiograms. EC 8. Ability to interpret complex electrocardiograms and rhythm strips. DPC, AR, AE ECG, EP 9. Effectively evaluate and manage patients who have undergone DPC, AR, AE interventional procedures. CAC 10. Ability to perform basic ventilator management. DPC, AR AE 11. Ability to place and manage pulmonary artery (Swan-Ganz) DPC, AR, AE, DSP catheters and temporary pacemakers. DSP, EP 12. Ability to administer emergency thrombolytic treatment. DPC, DSP, AE AR 13. Ability to perform CPR and advanced cardiac life support. DPC, DSP, AE PC 14. Willingness and ability to help patients undertake basic strategies DPC, AR AE for prevention of cardiovascular disease, including modifications of diet and physical activity, and cessation of use of tobacco. 15. Participation in and later leading of discussion of end-of-life issues DPC, AR AE with families. 16. Insert central venous lines and arterial lines with proper technique. DPC, DSP, AE AR 17. Ability to perform endotracheal intubation, exercise and chemical DPC, DSP, AE stress tests, transthoracic and transesophageal ECHO AR, IL :(''@MDFOBH'ZCGWHMDIM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Expand clinically applicable knowledge base of the basic and DPC, AR AE clinical sciences underlying the care of patients with chest pain and acute cardiac disease. 2. Access and critically evaluate current medical information and DPC, AR AE scientific evidence relevant to acute cardiac care. 3. Understand indications for aggressive anticoagulant and DPC, AR AE antiplatelet therapy as well as the mechanisms of action of the various agents. 4. Understand the physiologic and pathophysiologic principles of DPC, AR, AE invasive hemodynamic monitoring including indications. HC 5. Develop and demonstrate in-depth knowledge of the DPC, AR AE
  9. 9. !"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 9 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum pathophysiology, clinical manifestations, diagnosis and management of cardiac diseases, as seen on a coronary care unit. 6. Develop and demonstrate in-depth knowledge of the principles of DPC, AR, AE diagnosis and management of essential hypertension; ischemic EP heart disease including unstable angina pectoris and myocardial infarction; congestive heart failure; cardiac arrhythmias especially atrial fibrillation, supraventricular tachycardia, and ventricular arrhythmias; rheumatic heart disease, and congenital heart disease. 7. Develop and demonstrate in-depth knowledge of the indications DPC, DSP, AE, DSP for, principles, complications, and interpretation of ECG, inpatient AR, HC rhythm monitoring, exercise and chemical stress tests, electrophysiologic studies, transthoracic and transesophageal ECHO, nuclear cardiac imaging, right and left heart catheterization, coronary angiography, and percutaneous interventions. 8. Fully understand principles of assessment of lifetime DPC, AR, AE cardiovascular risk & cardiovascular risk prevention. PCF 9. Develop in-depth knowledge of the strategies for cessation of use DPC, AR AE of tobacco. !(''.CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Communicate effectively with patients and families in a stressful DPC, AR AE, ECR critical care environment. 2. Communicate effectively with physician colleagues and members DPC, AR AE, PR, of other health care professions to assure timely, comprehensive ECR patient care. 3. Communicate effectively with colleagues when signing out DPC DPC, AR AE, PR, or turning over care to another service. ECR 1(''7EGVMSSFGCBHFST' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Interact professionally toward patients, families, colleagues, and DPC AE, PR, all members of the health care team. ECR 2. Interacting with patients and families in a professionally DPC, PC AE, ECR appropriate manner. 3. Acceptance of professional responsibility as the primary care DPC, PC AE, ECR physician for patients under his/her care. 4. Appreciation of the social context of illness. DPC AE, ECR 5. Effective utilization of ethics knowledge and consultants. This DPC, ET AE, PR, includes guidelines for CPR and DNR and end of life cardiac care. ECR '
  10. 10. !"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 10 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum %(''7EBOLFOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Identify and acknowledge gaps in personal knowledge and skills DPC, CC, AE in care of acute cardiac patients. OWE 2. Develop real-time strategies for filling knowledge gaps that will DPC AE benefit patients in the coronary care unit. 3. Commitment to professional scholarship, including systematic and DPC, FS AE critical perusal of relevant print and electronic literature, with emphasis on integration of basic science with clinical medicine, and evaluation of information in light of the principles of evidence-based medicine. <(''&JSLMTS[:BSMD'7EBOLFOM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Understand and utilize the multidisciplinary resources necessary to DPC, PC AE care optimally for acutely ill cardiac patients. 2. Collaborate with other members of the health care team to assure DPC, PC AE comprehensive coronary care. 3. Use evidence-based, cost-conscious strategies in the care of DPC AE patients with chest pain and other acute cardiac disease. 4. Knowing when to ask for help and advice from senior fellows and DPC AE, PR attending physicians. 5. Effective professional collaboration with residents, other fellows, DPC, PC AE, ECR and faculty consultants from other disciplines such as Radiology and Surgery. 6. Learning by participation in ward rounds, teaching conferences DPC, AR AE and other educational activities. 7. Effective collaboration with other members of the health care DPC, PC AE, ECR team, including residents, medical students, nurses, clinical pharmacists, occupational therapists, physical therapists, nutrition specialists, patient educators, speech pathologists, respiratory therapists, enterostomy nurses, social workers, case managers, discharge planners, and providers of home health services. 8. Effective utilization of ethics consultants, including knowing DPC, PC AE when and how to request consultation, and how best to utilize the advice provided. 9. Consideration of the cost-effectiveness of diagnostic and treatment DPC, ACS AE strategies. 10. Ability to lead team, including medical students, residents, nurses, DPC, ACS AE, ECR clinical pharmacist, case manager, and social worker. 11. Willingness and ability to teach medical students and residents. DPC AE, PR '
  11. 11. !"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 11 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum +COFHHBEJ'%DROBLFGCBH'@BLMEFBHS'' - Cardiovascular Medicine, Eds: Willerson and Cohn; Churchill Livingston - Heart Disease, Ed: Braunwald; Saunders - Textbook of Cardiovascular Medicine, Ed: Topol. Lippincott-Raven - Coronary Care, Eds: Francis G, Alpert J. Little, Brown & Co. - Adult Clinical Cardiology Self-Assessment Program; American College of Cardiology (copies available from fellowship office) - Mayo Cardiovascular Board Review (copies available from fellowship office) - Pertinent AHAIACC Scientific Statements and Guidelines @MLUGD'VGE'%NBHRBLFGC'GV'*GLBLFGC' Each fellow is asked to complete an evaluation form for both the supervising faculty and the rotation. In addition, all teaching faculty and the rotations will be evaluated by all the trainees in the bi-annual evaluation of the program by the fellows.
  12. 12. !+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann 12 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Lines of Responsibility !+*1."5+&!-2+*''1.&%+&%''!"#&-2$''&%*5.!%''*"$+$."#' At Memorial Hermann The cardiology consult service provides consultative services for all other services and requesting physicians at Hermann Hospital. The team consists of an attending, 3 upper level medicine residents, and a variable number of fourth-year medical students. The CDR is expected to evaluate all consult patients on the day the consult is requested and to promptly discuss the case with the UT-Cardiology faculty. The CDR is responsible for supervision of the residents and actively participates in the formulation of the diagnostic and therapeutic plan for each admission. The CDR should make daily rounds with the house staff on all patients on the team and is expected to write daily progress notes on patients. Attending rounds are daily and will vary according to the preference of the individual attending. The typical number of patients the CDR is responsible for is 10-12 cases with a maximum of 20 patients. If this maximum number is reached, the fellow should inform the program director who will assign one of the other clinical CDRs to assist with this service. Emergency consults (5:00 p.m. to 8:00 a.m. and weekends) are first seen by the in-house cardiology medicine resident. The resident must then discuss the case with the in-house CDR. If necessary, the patient is then seen by the in-house CDR. During these hours the On-Call White Cardiology attending carries the ultimate responsibility and should be notified of the consult and the fellow’s assessment.
  13. 13. !+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann 13 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum !+*1."5+&!-2+*''1.&%+&%''!"#&-2$''&%*5.!%''*"$+$."#' At Memorial Hermann This rotation gives the fellow experience in clinical consultative skills in an in-patient setting. Typically this is a busy service with consultations referred from general internal medicine and its subspecialties. The reasons for consultation cover a broad spectrum of cardiovascular conditions, including the evaluation and management of cardiac failure, coronary artery disease and chest pain syndromes, valvular heart disease and infective endocarditis, hypertension, hyperlipidemia, peripheral vascular disease and cardiac arrhythmias. In addition, there are a large number of consultations for surgical specialties, including orthopedic and trauma surgery, neurosurgery, renal and liver transplant services, cardiovascular and vascular surgery and burns. The consultations from the surgical specialties typically involve the pre-operative evaluation of patients as well as the management of peri-operative cardiac complications and the treatment of con-morbid cardiac conditions. Consultations are also requested by the Department of Obstetrics for the evaluation and management of patients in both the pre-natal and post-natal periods. The fellow will be a member of the team which will consist of one of the UT-faculty, 1-2 internal medicine residents and typically 1-2 medical students. The fellow will be responsible for seeing all consultations either with or without the assistance of the resident and presenting the case to the faculty member. Between the hours of 6:00 PM and 8:00 AM, any consult will be seen by the in-house “float” resident and cardiology fellow who will discuss the case with on-call faculty. Also, during this rotation the fellow may spend time in the outpatient echo lab and nuclear cardiology laboratory under the supervision of the attending on that particular service. Legend for Learning Activities for Fellows ACS Ambulatory Care Series ECG ECG Series JC Journal Club AR Attending Rounds EP Electrophysiology Conference LC Leadership in Cardiology AU Autopsy Report EI Ethics in Cardiology MM Cardio Morbidity & Mortality CAC Catheterization Conference FS Faculty Supervision NC Noon Conferences CC Core Curriculum GR Ground Rounds PC Professionalism Curriculum DPC Direct Patient Care HC Hemodynamic Conference PCF Preventive Cardiology Forum DSP Directly Supervised Procedure IC Interventional Cardiology PR President’s Rounds EC Echocardiography Conference IL Introductory Lecture Series RC Research Conference Legend for Evaluation Methods for Fellows AE Attending Evaluations PE Patient/Health Professional Evaluation DSP Directly Supervised Procedures PL Procedure Logs ECR Educational Committee Review (2x annually) PR Peer Review FP Fellow Portfolios RR Record Review OWE Oral/Written Exams
  14. 14. !+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann 14 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 7EFCOFKHM'%DROBLFGCBH'3GBHS'YJ'*MHMNBCL'!GTKMLMCOJ' ' The principle educational goals for cardiology fellows in this training program are indicated for each of the six ACGME competencies in the tables below and numbered in the first column. The second column of the table lists the goal, the third column lists the most relevant learning activities for that goal and the fourth column indicates the correlating evaluation methods for that goal. A detailed description of the on-going learning activities at Memorial Hermann Hospital is included. 73[P]P^'/3GBHS'BEM'VGE'BHH'HMNMHS0' ' +( 7BLFMCL'!BEM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Ability to obtain a complete medical history, perform a careful and accurate examination with emphasis on DPC, AR AE the cardiac exam, and review charts and pertinent records. 2. Ability to write a concise evaluation, assess the cardiovascular risk of the patient and make DPC, AR, CAC, therapeutic decisions and proper interventions based EC, ECG, DSP, AE on patient preferences, scientific evidence, and sound MC, FS clinical judgment. 3. Effectively evaluate and manage patients with complex cardiac illnesses, particularly, acute DPC, AR, FS, coronary syndromes, congestive heart failure, CAC, EC, HC, AE valvular heart disease and cardiac transplantation DSP, CC patients. 4. Ability to risk stratify patients after being evaluated by echocardiography, cardiac stress test, coronary EC, ECG, CAC, AE angiograms, nuclear cardiovascular procedures and HC, IC, CC other invasive and non-invasive procedures. 5. Ability to manage patients who have had DPC, HC, CAC, interventional procedures including pacemaker AE, DSP CC, FS placement and catheterization. 6. Effectively direct the team performing CPR and DPC, EP, IL AE advance cardiac life support. 7. Ability to manage complications from invasive and DPC, FS AE non-invasive procedures. 8. Ability to participate in behavior modification and strategies to educate patients and other health DPC, AR, PCP, AE professionals in the management of cardiovascular ACS risk factors and life style modification.
  15. 15. !+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann 15 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 9. Participation in the discussion of end-of-life issues DPC, FS, ET AE, PR with patients and their families. 10. Participation in all non-invasive and invasive cardiovascular procedures using the proper technique DPC, FS AE, DSP and under the supervision of a teaching faculty. B. @MDFOBH'ZCGWHMDIM 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Familiarity with the newest basic science concepts CC, RC, HC, NC, AE, ECR and mechanisms of cardiovascular disease. JC 2. Familiarity with current medical literature, clinical JC, CC AE trials, and evidence based medicine in cardiology. 3. Familiarity with the broad spectrum of cardiovascular CC, NC, PR AE, ECR diseases. 4. Familiarity with the pathophysiologic principles of AU, EP AE, DSP cardiovascular disease. C. .CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Communicate effectively the consult findings with physician colleagues and other members of the health DPC, AR, PC AE, PR care team in a timely fashion to assure a comprehensive patient care. 2. Present professional findings to patient and family members in a compassionate and informative DPC, AR AE, PR manner. 3. Provide educational instructions and other learning DPC, AR AE, PR tools to patients to reinforce behavioral modification. D. 7EGVMSSFGCBHFST 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Interact professionally with patients, patients’ family, colleagues, and other members of the health care DPC, AR, PC AE, PR team. 2. Appreciation of the spiritual and social context of DPC, AR, ET AE wellness and illness.
  16. 16. !+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann 16 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum E. 7EBOLFOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Commitment to scholarship and the use of evidence CC, GR, LC, PR AE, ECR based cardiovascular medicine. 2. Broad reading of the cardiovascular literature and CC, GR, JC, RC AE, ECR access and research of Medline and internet tools. F. &JSLMTS[:BSMD'7EBOLFOM 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Understand the complexities of cardiovascular disease patients and utilize the multidisciplinary DPC, AR AE resources necessary to care for them. 2. Collaborate with other member of the health care DPC, AR AE team to assure comprehensive cardiac care. 3. Understand the system complexities in invasive and DPC, AR, GR AE noninvasive cardiology. 4. Willingness to learn by participation in ward rounds, DPC, AR AE teaching conferences and other educational activities. 5. Effective utilization of risk stratification using DPC, AR AE evidence-based medicine. 6. Develop effective communication with referring physician, health care team, patient and their family, DPC, AR AE regarding purpose and findings of the consult. 7. Expand learning in out-patient ultrasound and nuclear cardiology to optimize understanding of patients risk DPC, AR AE stratification. 8. Consideration of cost effectiveness and outcome measurements of tests and interventions associated DPC, AR AE with consultations. +COFHHBEJ'%DROBLFGCBH'@BLMEFBHS ! Cardiovascular Medicine, EDS: Willerson and Cohn; Churchill Livingston. ! Heart Disease, Ed: Braunwald; Saunders. ! Textbook of Cardiovascular Medicine, Ed: Topol. Lippincott-Raven ! Adult Clinical Cardiology Self-Assessment Program; American College of Cardiology (copies available from fellowship office). ! Mayo Cardiovascular Board Review (copies available from fellowship office).
  17. 17. !+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'*"$+$."#'at Memorial Hermann 17 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum @MLUGD'VGE'%NBHRBLFGC'GV'*GLBLFGC Each fellow is asked to complete an evaluation form for both the supervising faculty and the rotation (attached). In addition, the entire teaching faculty and the rotations will be evaluated by all the trainees in the annual evaluation of the program by the fellows.
  18. 18. #-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital 18 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum #-!2%+*''!+*1."2"3,''*"$+$."# at Memorial Hermann Hospital The facility performs between 270-300 procedures per month. The CDR’s responsibilities include obtaining an informed consent and brief history and, if pertinent, perform a focused examination. She/he is responsible for supervising all stress nuclear procedures, as well as regular exercise ECG testing. Supervision is provided by one of the nuclear cardiologists. CDRs are expected to interpret the resting and stress ECGs and nuclear images prior to the reading session with the attending to maximize the educational content. Nuclear studies and exercise ECGs are read by the attending staff each weekday between 4:00-6:00 p.m. CDRs are allowed educational leave to attend an appropriate course to fulfill the NRC requirements for 200 hours of classroom training. During the rotation, trainees are expected to correlate all nuclear cases with the clinical presentation and other imaging modalities if available.
  19. 19. #-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital 19 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum #-!2%+*''!+*1."2"3,''*"$+$."# at Memorial Hermann Hospital This rotation provides basic training (2 months) or specialized training (4 months) for fellows who wish to have special expertise in clinical nuclear cardiology and practice nuclear cardiology as set out in the COCATS Guidelines – American College of Cardiology. The trainee will be exposed to the fundamentals of nuclear cardiology during an initial 2 month period. This experience will provide exposure to nuclear medicine technology and practice sufficient for the practice of adult cardiology but not nuclear cardiology. For those trainees wishing to practice the specialty of nuclear cardiology, they will spend a minimum of an additional 2 months in the nuclear cardiology laboratory. $MBOUFCI'7EGIEBT' The teaching method is direct supervision and instruction from the attending nuclear cardiologist Fellows will evaluate patients prior to testing and performance of stress tests. The fellows will attend all the daily reading sessions and, in addition, follow-up on all patients that subsequently undergo cardiac catheterization. The fellow will provide a portfolio of such cases, including the nuclear report and images and cardiac catheterization report, at the end of each rotation Additional instruction is provided from the weekly Noon Conference, of which approximately 25% will be on Exercise Testing or Nuclear Cardiology and additional topics will be covered in the Core Curriculum lecture series. Fellows wishing specialized training will also be allowed educational leave, at the discretion of the Program Director, to attend an appropriate radiation safety training course to satisfy the NRC licensure requirements. %DROBLFGCBH'!GCLMCL' The educational content of the rotation will follow those set forth in the COCATS Guidelines - American College of Cardiology. The laboratory performs between 250-300 studies per month, of which most comprise stress SPECT myocardial perfusion studies and PET scan. The patients coming to the laboratory are primarily patients with known or suspected coronary artery disease. Approximately 40% of patients comprise the former group, and include patients with previous myocardial infarction, PTCA/stent or coronary bypass surgery. The remaining patients are patients with suspected, but not previously diagnosed, coronary artery disease. Trainees will gain experience in performing and interpreting exercise and pharmacologic (dipyridamole1 adenosine and dobutamine) stress testing. They will gain experience in the interpretation of planar and tomographic myocardial perfusion studies using the commonly used radiopharmaceuticals, i.e. Thahium201, Tc99m labeled sestamibi and rubidium. They will also gain experience in radionuclide ventriculography in the evaluation of ventricular function. In addition, the fellows will gain instruction in the indications, clinical utility including strengths and weaknesses of the techniques as applied to contemporary clinical cardiology.
  20. 20. #-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital 20 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum Legend for Learning Activities for Fellows ACS Ambulatory Care Series ECG ECG Series JC Journal Club AR Attending Rounds EP Electrophysiology Conference LC Leadership in Cardiology AU Autopsy Report EI Ethics in Cardiology MM Cardio Morbidity & Mortality CAC Catheterization Conference FS Faculty Supervision NC Noon Conferences CC Core Curriculum GR Ground Rounds PC Professionalism Curriculum DPC Direct Patient Care HC Hemodynamic Conference PCF Preventive Cardiology Forum DSP Directly Supervised Procedure IC Interventional Cardiology PR President’s Rounds EC Echocardiography Conference IL Introductory Lecture Series RC Research Conference Legend for Evaluation Methods for Fellows AE Attending Evaluations PE Patient/Health Professional Evaluation DSP Directly Supervised Procedures PL Procedure Logs ECR Educational Committee Review (2x annually) PR Peer Review FP Fellow Portfolios RR Record Review OWE Oral/Written Exams Principle Educational Goals by Relevant Competency The principle educational goals for cardiology fellows in this training program are indicated for each of the six ACGME competencies in the tables below and numbered in the first column. The second column of the table lists the goal, the third column lists the most relevant learning activities for that goal and the fourth column indicates the correlating evaluation methods for that goal. A detailed description of the on-going learning activities at Memorial Hermann Hospital is included. PG-4, 5 and 6 (Goals are for the first, second and third year cardiology fellow level) A. Patient Care Learning Evaluation Principle Educational Goals Activities Methods Ability to obtain a complete medical history, perform a careful and accurate examination with 1. DPC, AR, ECG AE a cardiology focus for the optimal performance of stress test and nuclear cardiology. Learn proper techniques of performing nuclear DPC, DSP, NC, 2. AE, DSP procedures, including chemical procedures. ECG 3. Understand nuclear physics and radiation safety. CC, NC AE, ECR
  21. 21. #-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital 21 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum Ability to risk stratify patients after being evaluated by cardiac stress test and nuclear ECG, CAC, HC, 4. AE cardiovascular procedures. Ability to correlate IC, CC invasive and nuclear studies. Ability to manage patients who have had stress DPC, HC, CAC, 5. AE, DSP test and nuclear test. CC, FS Ability to perform all procedures with emphasis 6. ET, PC, DSP AE, PR on patient comfort and safety Ability to manage complications from stress test 7. and nuclear studies, including nuclear DPC, FS, CC, NC AE decontamination procedures. Ability to understand nuclear safety for patients 8. DPC, CC, NC AE and health care workers. 9. Ability to generate accurate test reports. DSP, CC AE, PR B. Medical Knowledge Learning Evaluation Principle Educational Goals Activities Methods Understand the newest basic science concepts 1. CC, RC, NC, JC AE, ECR and mechanisms in nuclear cardiology. Familiarity with current medical literature, clinical 2. trials, and evidence based medicine in nuclear JC, CC AE cardiology. Learn the methods and technical aspects of 3. cardiac stress tests SPECT nuclear cardiology, CC, NC, PR AE, ECR PET scan, and MRI/MRA Master the nuclear evaluation of patients with 4. coronary artery disease, including reversible CC, NC, DSP, PR AE, ECR ischemia and myocardial viability. C. Interpersonal Skills and Communication Learning Evaluation Principle Educational Goals Activities Methods Communicate effectively the risk and benefits of 1. the procedure to the patient before obtaining TPC AE, ECR consent for the procedure.
  22. 22. #-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital 22 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum Provide professional presentation of nuclear findings to patient and family members in a 2. compassionate and informative manner. Provide DPC AE, PR, ECR complete and accurate report to consulting physician. Provide educational instructions and other 3. learning tools to patients to reinforce behavioral DPC, PC AE, PR, ECR modification. D. Professionalism Learning Evaluation Principle Educational Goals Activities Methods Interact professionally with patients, patients’ 1. families, colleagues, and other members of the DPC, AR, PC AE, PR, ECR health care team. Appreciation of the spiritual and social context of 2. DPC, AR, ET AE wellness and illness. E. Practice-Based Learning and Improvement Learning Evaluation Principle Educational Goals Activities Methods Identify and acknowledge gaps in personal 1. knowledge and skills in performing and DPC, NC, CC AE interpreting nuclear cardiology studies. Commitment to scholarship and the use of 2. JC, RC, CC FP, PR evidence based nuclear cardiology. Broad reading of the cardiovascular literature and 3. access and research of Medline and Internet JC, RC, CC FP, PR tools.
  23. 23. #-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital 23 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum F. Systems-Based Practice Learning Evaluation Principle Educational Goals Activities Methods Understand and utilize the multidisciplinary 1. resources necessary to perform nuclear studies DPC, PC AE on acutely ill cardiac patients. Collaborate with other members of the health 2. DPC, PC AE care team to assure comprehensive cardiac care. Understand the system complexities in nuclear 3. DPC, AR, GR AE cardiology. Use evidence-based cost conscious strategies in 4. DPC AE the appropriate performance of nuclear studies. Knowing when to ask for help and advice from 5. DPC AE, PR senior fellows and attending physicians. Effective professional collaboration with 6. residences other fellows, and faculty consultants DPC, PC AE, ECR from radiology and surgery. Develop effective communication with referring physician, health care team, patient and their 7. DPC, PC AE family, regarding purpose and findings of the nuclear test. Expand learning while reviewing nuclear images 8. DPC, AR AE on daily basis. Consideration of outcome measurements of tests 9. and interventions associated with nuclear DPC, AR AE studies. Ancillary Educational Materials ! Cardiovascular Medicine, Eds: Willerson and Cohn; Churchill Uvingston. ! Heart Disease, Ed: Braunwald; Saunders. ! Textbook of Cardiovascular Medicine, Ed: Topol. Lippincott-Raven. ! Adult Clinical Cardiology Self-Assessment Program; American College of Cardiology. ! Mayo Cardiovascular Board Review, copies available from fellowship office). ! Teaching file of interesting studies on the reading station. ! American Society of Nuclear Cardiology Self Assessment Program on reading station. ! AHA/ACC Guidelines for Exercise Testing and Nuclear Cardiology, COCATS Guidelines for Training in Nuclear Cardiology and review articles are provided in the Resource Folder in the
  24. 24. #-!2%+*'!+*1."2"3,'*"$+$."# at Memorial Hermann Hospital 24 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum Reading Room at the Hermann Heart Center. ! Fellows receive a monthly copy of the Journal of the American Society of Nuclear Cardiology. Method for Evaluation of Rotation Each fellow is asked to complete an evaluation form for both the supervising faculty and the rotation (attached). In addition, the entire teaching faculty and the rotations will be evaluated by all the trainees in the annual evaluation of the program by the fellows.
  25. 25. %!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann 25 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Lines of Responsibility ' %!6"!+*1."3*+76,'''*"$+$."#' at Memorial Hermann Hospital Approximately 6,000 studies per year, including between 300-400 transesophageal studies and around 100-200 stress studies, are performed in the echocardiographic laboratory in Hermann Hospital. The CDRs are under the supervision of an echo faculty at all times commensurate with the level of training of the trainee as determined by the echo faculty. CDRs will receive instruction on performing echocardiograms by ultrasonographers designated by the laboratory director and must perform 150 studies in the first 3 months. The CDR’s responsibilities include obtaining an informed consent and brief history and, if pertinent, perform a focused examination on all patients undergoing transesophageal or stress echocardiographic examinations. Trainees will be directly supervised for all transesophageal and stress studies by echo faculty. All studies interpreted by CDRs are over-read by the cho faculty when the trainee will gain one-on-one teaching from the faculty. Trainees are expected to enter echocardiographic measurements and quantitative data into the computerized reading station.
  26. 26. %!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann 26 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum ' %!6"!+*1."3*+76,'''*"$+$."#' at Memorial Hermann Hospital The Memorial Hermann Hospital Echocardiography (ECHO) rotation lasts for one month. One first year fellow and one second or third year fellow is assigned each month. The first year fellow will have on average three or four in-house calls, and have one or two days a week off. The upper level fellow will have no in-house call, and will have two days a week off. During the rotation, the assigned fellows will have an opportunity to perform and interpret transthoracic, transesophageal, contrast and stress echocardiography under the direct supervision of the ECHO attending. Patients seen on the Memorial Hermann Hospital ECHO rotation include patients of faculty physicians, unassigned patients admitted from the clinics or ER, and patients of community physicians. 7EFCOFKHM'%DROBLFGCBH'3GBHS'' The principle educational goals for fellows on this rotation are to give fellows either Level 2 or Level 3 training in Echocardiography as outlined by the American College of Cardiology, American College of Physicians, and the American Heart Association. The three levels of training are outlined below: Level 1 This rotation is designed to provide an understanding of the basic principles and the indications for, applications and limitations of echocardiography. All fellows are expected to achieve this level of echocardiographic training (in our institution, all fellows will achieve at least Level 2 training). Level 1 requires 3 months dedicated solely to echocardiography, including the performance and interpretation of 150 ultrasound imaging and Doppler hemodynamic examination under the supervision of the laboratory director, faculty, or cardiac sonographer. This level does not qualify a trainee to perform or interpret echocardiograms independently. Level 2 In addition to the Level 1 training requirements, Level 2 training requires an additional 3 months of echo rotation. Also, the fellow will perform an additional 150 complete echocardiographic studies. Level 3 In addition to the Level 2 training requirements, Level 3 training consists of an additional 6 months of echo rotation. An additional 450 examinations must be performed. In addition, special procedures in echocardiography (transesophageal, stress, and contrast echo) can be learned. 7EFCOFKBH'$MBOUFCI'@MLUGD' Fellows will perform and interpret transthoracic, transesophageal, contrast, and stress echos under the supervision of a designated faculty member. In addition, echos performed by cardiac sonographers will be interpreted by the fellow and reviewed directly with the faculty member. Once a week, there is an
  27. 27. %!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann 27 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum echo core lecture which all fellows attend, regardless of the rotation they are currently participating. Twice a month, there is an echo conference attended by both fellows and cardiac sonographers to review pertinent literature and/or technical skills in obtaining ultrasound images. Once a month each fellow rotating through the echocardiography lab will also prepare and present a conference in a subject within the spectrum of echocardiography. ' ' %DROBLFGCBH'!GCLMCL' The echocardiography laboratory at Memorial Hermann Hospital has a volume of around 7,000-8000 studies per year including between 600-700 transesophageal echos and around 200 stress studies. The patient population is mixed and the indications for echocardiography varied but are similar to those of other teaching institutions nationwide. The most frequent indications are the investigation for aortic or cardiac source of embolism, valvular disease assessment, left ventricular function, pericardial disease, infectious endocarditis, aortic dissection, cardiomyopathies and complications of acute myocardial infarction. The fellows are strongly encouraged to pursue a research project during the echo rotation - suggestions for projects can be obtained from the Fellowship Office or from the echo faculty. 2MIMCD'VGE'2MBECFCI'+OLFNFLFMS'VGE'<MHHGWS'' +!&' Ambulatory Care Series %!3' ECG Series X!' Journal Club +*' Attending Rounds %7' Electrophysiology Conference 2!' Leadership in Cardiology +-' Autopsy Report %.' Ethics in Cardiology @@' Cardio Morbidity & Mortality !+!' Catheterization Conference <&' Faculty Supervision #!' Noon Conferences !!' Core Curriculum 3*' Ground Rounds 7!' Professionalism Curriculum 17!' Direct Patient Care 6!' Hemodynamic Conference 7!<' Preventive Cardiology Forum 1&7' Directly Supervised Procedure .!' Interventional Cardiology 7*' President’s Rounds %!' Echocardiography Conference .2' Introductory Lecture Series *!' Research Conference 2MIMCD'VGE'%NBHRBLFGC'@MLUGDS'VGE'<MHHGWS' +%' Attending Evaluations 7%'' Patient/Health Professional Evaluation 1&7' Directly Supervised Procedures 72' Procedure Logs %!*' Educational Committee Review (2x annually) 7*' Peer Review <7' Fellow Portfolios **' Record Review "4%' Oral/Written Exams ' 7EFCOFKHM'%DROBLFGCBH'3GBHS'YJ'*MHMNBCL'!GTKMLMCOJ'' The principle educational goals for fellows on this rotation are indicated for each of the six ACGME competencies in the tables below and numbered in the first column. The second column of the table lists the goal, the third column lists the most relevant learning activities for that goal, and the fourth column indicates the correlating evaluation methods for that goal. A detailed description of the on-going
  28. 28. %!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann 28 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum learning activities at Memorial Hermann Hospital is included in the front of the report for further information. +(''7BLFMCL'!BEM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Take a pertinent medical history and perform a careful and DPC, AR AE accurate physical examination with a cardiology focus for the optimal performance of an echocardiographic study. 2. Learn the proper techniques of performing echocardiographic DPC, DSP, AE, DSP procedures, including transthoracic, transesophageal, and stress EC echocardiography. 3. Know the common medications along with potential reactions and DPC, DSP AE side effects of these medications given for echocardiographic procedures. 4. Perform all aspects of echocardiographic procedures, including DPC, DSP, AE, DSP two-dimensional, color flow Doppler, pulse and continuous wave EC Doppler, tissue Doppler, contrast and stress echocardiography. 5. Perform all procedures with emphasis on patient comfort and DPC, DSP AE, DSP safety. 6. Recognize and manage complications associated with DPC, AR AE echocardiographic procedures. 7. Produce accurate reports of the findings of an echocardiographic DPC, DSP AE exam. :(''@MDFOBH'ZCGWHMDIM' '' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Understand the indications, contra-indications, potential DPC, AR, AE complications, and benefits for performing transthoracic, EC transesophageal, and stress echos. 2. Learn the methods and technical aspects of two-dimensional echo, DPC, DSP, AE, DSP color flow Doppler, pulse and continuous wave Doppler, tissue EC Doppler, contrast and stress echocardiography. 3. Master the echo evaluation of valvular heart disease, cardiac DPC, DSP, AE, DSP systolic and diastolic function, pericardial disease, EC cardiomyopathies, and diseases of the aorta. 4. Learn the echocardiographic evaluation of congenital heart DPC, DSP, AE, DSP disease, infective endocarditis, cardiac masses and tumors. EC 5. Echocardiographic evaluation of post-surgical cardiac patients DPC, DSP, AE, DSP including, valvular repair/replacement, aorta repair, ventricular EC assist devices, pacemakers, and cardiac defibrillators. 6. Access and critically evaluate current medical information and DPC, AR, AE scientific evidence relevant to echocardiography. EC
  29. 29. %!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann 29 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum !(''.CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Communicate effectively with patients and families in a stressful DPC AE, ECR critical care environment. 2. Communicate effectively with physician colleagues and members DPC AE, PR, of other health care professions to assure timely, comprehensive ECR patient care. 3. Communicate effectively with colleagues when reporting pertinent DPC, EC AE, PR, findings of echocardiographic studies. ECR 1(''7EGVMSSFGCBHFST' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Interact professionally toward patients, families, colleagues, and DPC AE, PR, all members of the health care team. ECR 2. Interacting with patients and families in a professionally DPC, PC AE, ECR appropriate manner. 3. Acceptance of professional responsibility as the primary care DPC, PC AE, ECR physician for patients under his/her care. 4. Appreciation of the social context of illness. DPC AE, ECR 5. Effective utilization of ethics knowledge and consultants. This DPC, ET AE, PR, includes guidelines for CPR and DNR and end of life cardiac care. ECR %(''7EBOLFOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Identify and acknowledge gaps in personal knowledge and skills in DPC, EC, AE performing and interpreting echocardiographic studies. OWE 2. Develop real-time strategies for filling knowledge gaps that will DPC AE benefit patients in the echo lab, coronary care units, or other intensive care units. 3. Commitment to professional scholarship, including systematic and DPC, FS AE critical perusal of relevant print and electronic literature, with emphasis on integration of basic science with clinical medicine, and evaluation of information in light of the principles of evidence-based medicine.
  30. 30. %!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann 30 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum <(''&JSLMTS[:BSMD'7EBOLFOM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI' %NBHRBLFGC' +OLFNFLFMS' @MLUGDS' 1. Understand and utilize the multidisciplinary resources necessary to DPC, PC AE perform echocardiographic studies optimally on acutely ill cardiac patients. 2. Collaborate with other members of the health care team to assure DPC, PC AE comprehensive care. 3. Use evidence-based, cost-conscious strategies in the appropriate DPC AE performance of echocardiographic studies. 4. Knowing when to ask for help and advice from senior fellows and DPC AE, PR attending physicians. 5. Effective professional collaboration with residents, other fellows, DPC, PC AE, ECR and faculty consultants from other disciplines such as Radiology and Surgery. 6. Learning by performance of echocardiographic studies, attending DPC, AR AE teaching conferences and other educational activities. 7. Effective collaboration with other members of the health care DPC, PC AE, ECR team, including residents, medical students, nurses, clinical pharmacists, occupational therapists, physical therapists, nutrition specialists, patient educators, speech pathologists, respiratory therapists, enterostomy nurses, social workers, case managers, discharge planners, and providers of home health services. 8. Effective utilization of ethics consultants, including knowing DPC, PC AE when and how to request consultation, and how best to utilize the advice provided. 9. Consideration of the cost-effectiveness of diagnostic and treatment DPC, ACS AE strategies. 10. Ability to lead team, including nurses, echo technicians, and stress DPC, ACS AE, ECR ECG technicians. 11. Willingness and ability to teach medical students and residents. DPC AE, PR ' ' ' +COFHHBEJ'%DROBLFGCBH'@BLMEFBHS' - Cardiovascular Medicine, Ed: Willerson and Cohn; Churchill Livingston. Heart Disease, Ed: Braunwald; Saunders - Textbook of Cardiovascular Medicine, Ed: Topol. Lippincott-Raven - The Echo Manual, Jae, Seward and Tajik; Little Brown and Company - Adult Clinical Cardiology Self-Assessment Program; American College of Cardiology - Mayo Cardiovascular Board Review - ECG Self Assessment Program; American College of Cardiology . - Pertinent AHA / ACC Scientific Statements and Guidelines ' '
  31. 31. %!6"!+*1."3*+76,'*"$+$."#'at Memorial Hermann 31 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum ' @MLUGD'VGE'%NBHRBLFGC'GV'*GLBLFGC' Each fellow is asked to complete an evaluation form for both the supervising faculty and the rotation. In addition, all the teaching faculty and the rotations will be evaluated by all the trainees in the biannual evaluation of the program by the fellows.
  32. 32. !+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 32 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Line of Responsibility !+*1.+!''!+$6%$%*.8+$."#''*"$+$."#' at Memorial Hermann Hospital 4GEQFCI'6GRES'' Cath Fellows assigned to Memorial Hermann Hospital will be available to perform or assist in elective or emergency cardiac catheterization lab cases from 7:00 am to 5:00 pm Monday to Friday excluding Holidays. The Cath Fellow on call is also available for elective cases from 8:00 am to 12:00 pm on Saturdays. During all other times, including weeknights from 5:00 pm to the following morning at 7:00 am, weekends excluding Saturdays 8:00 am to 12:00 pm, or Holidays, the Cath Fellow on call will be available to perform or assist in true emergency cases only. During this rotation, it is expected that the Cath Fellows attend all scheduled conferences and their respective continuity clinics. To ensure that the Cath Fellow has the opportunity to attend all conferences, they will be excused from all non-emergent cases for the following times: Monday through Friday from 12:00 pm to 1:00 pm, Tuesday morning from 7:00 am to 8:00 am, and Thursdays from 7:00 am to 8:00 am and from 5:00 pm to 6:00 pm. 7BLFMCL'!BEM'BCD'<GHHGW[-K' The Cath Fellow is expected to interview and examine all patients whom they plan to perform a procedure. This includes recording a history and physical on the medical record, obtaining necessary consents as needed, writing pre-procedure orders, and reviewing pertinent data such as laboratory work, chest x-rays, electrocardiograms, echocardiograms, or nuclear stress tests. After the procedure is performed, the Cath Fellow is expected to produce an accurate report of the procedure, write post- procedure orders, and follow the patient for any complications. Should complications related to the procedure arise, the Cath Fellow is expected to take a leading role along with the cardiology attending to care for this patient and related complications. For uncomplicated cases for which the patient will go home within 48 hours from admission (observation patients), discharge orders should also be written, unless the patient is already followed by a primary team or service who will make the ultimate decision regarding discharge. Some patients are hospitalized longer than 48 hours for reasons not related to the procedure performed. If on the teaching service, these patients are followed by the CCU Service or Cardiology Consult Service. Non-teaching patients are followed by the nurse practitioner service. It is reasonable to expect the Cath Fellow to follow the patient for 24-48 hours post-procedure. If there are no complications related to the procedure, the Cath Fellow can “sign off,” and the patient will continue to be followed by the proper primary service as outlined above. In cases where complications develop and are related to the procedure performed, the Cath Fellow will continue to follow these patients until the complication has resolved. ' The fellow will participate in the initial evaluation of all patients scheduled for cardiac catheterization, and develop skills in diagnostic techniques under the direction of the attending. The CDR will see patients the day prior to the procedure, taking a complete history and physical, reviewing the chest x-ray and ECG, as well as the laboratory data. The patient will then be instructed on the procedure, and
  33. 33. !+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 33 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Line of Responsibility informed consent will be obtained. This applies for both patients being pre-admitted for outpatient procedures, as well as inpatients prior to catheterization. The day of the procedure, the CDR will perform the catheterization under the direction of the attending to the level of her/his experience. After each procedure, the CDR will notify the house staff, and write post-catheterization orders as appropriate; and will complete the cardiac catheterization report prior to leaving the catheterization area. In the event of complicated catheterization, such as valve cases, complete analysis of the data will occur prior to formulation of the final version of the catheterization report. The CDR will review the angiographic and hemodynamic results of the case with the attending prior to final completion of the catheterization report. After the procedure, the CDR will discontinue sheaths as appropriate. The fellow will write a note on the chart the evening of the procedure, noting status of distal pulses, presence or absence of hematoma and any other potential complications that may have occurred. The attending will be notified of any significant complications immediately. The day following the procedure (for inpatients), wound checks will be done by the CDR. Distal pulses will be noted in the chart on all catheterization patients. Any post-catheterization complications will be noted in the chart. The cardiac catheterization CDR who was involved in their diagnostic or therapeutic procedure will follow patients who subsequently undergo cardiac surgery.
  34. 34. !+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 34 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum !+*1.+!''!+$6%$%*.8+$."#''*"$+$."#' at Memorial Hermann Hospital The Memorial Hermann Hospital Cardiac Catheterization rotation lasts for one month. Three second or third year fellows are assigned to this rotation each month. Second year fellows will have one in-house call, while third year fellows will not have any in-house call. Second year fellows will have one or two days off a week, while third year fellows will have two days off a week. Patients seen on the Memorial Hermann Hospital Cardiac Catheterization rotation include patients of faculty physicians, unassigned patients admitted from the clinics or ER, and patients of community physicians. 7EFCOFKHM'%DROBLFGCBH'3GBHS'' The principal goal for this rotation is to give fellows either level 1 or level 2 training in cardiac catheterization as set out in the COCATS, Guidelines (J Am ColI Cardiol 1197;25:1-34). Level One All trainees must have a clear understanding of the indications, limitations, complications and medical and surgical implications of the findings at cardiac catheterization and angiography, as well as a general understanding of related interventional procedures. This includes an understanding of the pathophysiology of cardiovascular disease and the ability to interpret hemodynamic and angiographic data and to use this data to select cases for surgical and catheterization-based therapeutic procedures. All trainees must have a basic understanding and formal training in radiation physics, radiation safety, fluoroscopy and radiologic anatomy, as well as clinical cardiovascular physiology (e.g., pressure wave- forms, shunt calculations, blood flow, resistance with flow-directed by both the cut-down and Percutaneous (Subclavian, femoral and internal jugular) routes. All trainees must be capable of performing temporary right ventricular pacemaker insertion and should have some experience performing right and left heart catheterization, including ventriculography and coronary angiography. In addition, they should learn to perform pericardiocentesis. Level Two Trainees who plan to perform independent catheterization and angiography require additional training. They must have a working knowledge of catheterization laboratory equipment, including physiologic recorders, pressures transducers, blood gas analyzers, image intensifiers and other x-ray equipment, cine processing, digital imaging and quality control of films, is requisite. An understanding of the fundamental principles of shunt detection, cardiac output determination and pressure wave-form recording and analysis is mandatory. Trainees should receive training in the techniques of endomyocardial biopsy and intra-aortic balloon counterpulsation insertion and management. Catheterization of patients with complex congenital heart disease will require specialized training to include at least one month of rotational training in the pediatric catheterization laboratory.
  35. 35. !+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 35 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 7EFCOFKBH'$MBOUFCI'@MLUGD' In the initial week of experience the fellows primarily observe procedures and assist the primary operators (attending cardiologists). They are given a package of didactic materials as an orientation to the cardiac catheterization laboratory and procedures and they are encouraged to read a standard text in cardiac catheterization and coronary intervention. During this week they are also taught how to interpret films, hemodynamic tracings and become facile with cardiac catheterization report preparation. Pre-Procedure Assessment: The fellow assigned to the case will see the patient preoperatively, obtain a history and physical, review the chest X-ray, ECG and pertinent laboratory tests and obtain informed consent for the procedure if not already previously done. The fellows are expected to be familiar with all aspects of the patient's history and physical exam as well as the proposed procedure. Performance of Procedure (diagnostic): After the initial orientation period, the fellows are allowed to perform the procedure, in the presence of an attending physician at all times, to the level of their expertise. There is one-to-one supervision at all times during the procedures. If the fellow is unable to perform at a certain level, the attending will assume performance of the procedure immediately. Data Analysis & Report Generation: The fellows are responsible for analyzing the data and synthesizing the cardiac catheterization report, which is done immediately after the catheterization procedure. The films are reviewed with the attending cardiologist in digital form, both at the time of the procedure and immediately following the procedure. In complex hemodynamic cases, a report is generated within 24 hours of performing the procedure in order to allow for precise analysis of valve areas, shunt calculations, etc. Patient Follow-Up: Post procedure, the fellow is responsible for seeing the patients in the immediate post-procedure phase to ensure that no post procedure complications occur and that the vascular access site is stable. If the patients are referred for surgery, the fellows are encouraged to observe at least two surgical cases during their rotation on patients whom they have evaluated hemodynamically and angiographically. Hemodynamic Conference: The Hemodynamic Conference occurs weekly, ten months a year. One fellow is assigned to present an interesting hemodynamic case and a senior level attending cardiologist provides in-depth teaching on the subtleties of carefully hemodynamic evaluation of patients with heart disease. Cardiac Catheterization Conference: The Catheterization Conference is conducted weekly, ten months a year. Between two and four cases are presented during an hour and the cases are discussed by attending cardiologists from throughout the geographic region. The fellows assigned to the cardiac catheterization rotation are charged with presenting the cases in a concise and informative manner and frequently review literature regarding their cases.
  36. 36. !+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 36 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum %DROBLFGCBH'!GCLMCL'' General: Most procedures involve left heart catheterization and hemodynamic evaluation. Patients with a history of congestive heart failure or prior myocardial infarction generally are also subjected to right heart catheterization. Most cases involve coronary angiography and left ventriculography and ascending aortography is frequently performed. Valvular Disease & Congenital Heart Disease: Fellows are exposed to patients with coronary disease as well as patients with valvular disease and congenital heart disease. Patients with valvular heart disease are subjected to both a left and right heart catheterization with cardiac output determination and careful calculation of valve areas. Patients with congenital heart disease are also assessed with oximetry for calculation of cardiac, extra- or intra-cardiac shunts. Acute MI Intervention: Memorial Hermann Hospital has a large referral base for treatment of acute myocardial infarction with thrombolytics, rescue or direct infarct angioplasty and/or stenting. Therefore, fellows are exposed to a large number of cases that require intense intervention for acute myocardial infarction, including left ventricular support devices and acute coronary interventions. Coronary Artery Disease Intervention: The fellows are, responsible for placing sheaths and catheters, however, the majority of the intervention portion of the procedure is performed by either the interventional cardiology fellow (a separate 4th year of fellowship) or the attending cardiologist. Peripheral Vascular Angiography: Approximately 40 percent of the interventional cases involve peripheral vascular interventions. This gives the fellow important experience in the evaluation and management of patients with peripheral vascular disease. Therefore, the fellows are exposed to and become facile with peripheral angiography, including aortic arch angiography, carotid angiography, renal angiography, abdominal and pelvic aortography, and selective angiography of the lower extremities. Peripheral Vascular Intervention: The fellows are exposed to a number of peripheral vascular intervention cases including carotid artery stenting, vertebral artery stenting, renal artery stenting, transcatheter repair of abdominal aortic aneurysms, and stenting of lower extremity vessels; however, these cases are performed, for the most part, by the interventional cardiology fellow and the attending cardiologist. Aortic and Mitral Valvuloplasty: The incidence of aortic and mitral valvuloplasty cases has declined somewhat with changing indications; however, these procedures are performed in the laboratory on a regular basis. Atrial Septal Defect Closures: Fellows are exposed to transcather occlusion of small atrial septal defects and patent foramen ovale (PFO). These procedures are performed in the laboratory on a regular basis by the interventional cardiology fellow and the attending cardiologist. Average case exposure per month per cardiology fellow = 75-100 cases. The total average case exposure for level 1 = four months (minimum 100 cases, typically 280 cases). The total average case exposure for

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