Legend for Learning Activities for Fellows

Outline of Curriculum & Line of Responsibility 1 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

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MEMORIAL HERMANN HOSPITAL

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LYNDON BAINES JOHNSON HOSPITAL

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ST. LUKE'S EPISCOPAL HOSPITAL/TEXAS HEART INSTITUTE

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UNIVERSITY OF TEXAS M.D. ANDERSON

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ADMINISTRATION OF THE PROGRAMS ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((=>?'

Outline of Curriculum & Line of Responsibility 2 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

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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.

Systems-Based Practice

Interpersonal and Communication Skills

Professionalis

Practice-Based Learning and Improvement

Medical KnowledgePatient

CDR

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.

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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. '

!"*"#+*,'!+*%'-#.$'+#1'!+*1."2"3,'4+*1'&%*5.!%'at Memorial Hermann 4 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Lines of Responsibility 7BLFMCLS'GV'LUM'-($('.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

!"*"#+*,'!+*%'-#.$'+#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.

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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

!"*"#+*,'!+*%'-#.$'+#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

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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'

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1. Take a complete medical history and perform a careful and accurate physical examination with a cardiology focus.

DPC, AR AE

2. Ability to recognize the physical findings of chronic congestive heart failure, acute pulmonary edema, mitral regurgitation, mitral stenosis, aortic stenosis, aortic regurgitation, and tricuspid regurgitation.

DPC, AR, FS

AE

!"*"#+*,'!+*%'-#.$'+#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

examinations and progress notes with a cardiology focus. DPC, AR AE

4. Ability to formulate comprehensive and accurate problem lists, differential diagnoses and plans of management for patients with acute cardiac illness.

DPC, AR, CC

AE

5. Effectively evaluate and manage patients with acute cardiac illness; particularly acute coronary syndromes, acute myocardial infarction, congestive heart failure, pulmonary edema, and acute valvular heart disease.

DPC, AR, CAC

AE

6. Effectively manage patients with undiagnosed chest pain, including the appropriate use of diagnostic testing.

DPC, AR AE

7. Ability to perform and recognize major abnormalities of cardiac stress tests, cardiac Echo and coronary angiograms.

DPC, DSP, EC

AE, DSP

8. Ability to interpret complex electrocardiograms and rhythm strips. DPC, AR, ECG, EP

AE

9. Effectively evaluate and manage patients who have undergone interventional procedures.

DPC, AR, CAC

AE

10. Ability to perform basic ventilator management. DPC, AR AE 11. Ability to place and manage pulmonary artery (Swan-Ganz)

catheters and temporary pacemakers. DPC, AR, DSP, EP

AE, DSP

12. Ability to administer emergency thrombolytic treatment. DPC, DSP, AR

AE

13. Ability to perform CPR and advanced cardiac life support. DPC, DSP, PC

AE

14. Willingness and ability to help patients undertake basic strategies for prevention of cardiovascular disease, including modifications of diet and physical activity, and cessation of use of tobacco.

DPC, AR AE

15. Participation in and later leading of discussion of end-of-life issues with families.

DPC, AR AE

16. Insert central venous lines and arterial lines with proper technique. DPC, DSP, AR

AE

17. Ability to perform endotracheal intubation, exercise and chemical stress tests, transthoracic and transesophageal ECHO

DPC, DSP, AR, IL

AE

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1. Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of patients with chest pain and acute cardiac disease.

DPC, AR AE

2. Access and critically evaluate current medical information and scientific evidence relevant to acute cardiac care.

DPC, AR AE

3. Understand indications for aggressive anticoagulant and antiplatelet therapy as well as the mechanisms of action of the various agents.

DPC, AR AE

4. Understand the physiologic and pathophysiologic principles of invasive hemodynamic monitoring including indications.

DPC, AR, HC

AE

5. Develop and demonstrate in-depth knowledge of the DPC, AR AE

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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 diagnosis and management of essential hypertension; ischemic 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.

DPC, AR, EP

AE

7. Develop and demonstrate in-depth knowledge of the indications for, principles, complications, and interpretation of ECG, inpatient 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.

DPC, DSP, AR, HC

AE, DSP

8. Fully understand principles of assessment of lifetime cardiovascular risk & cardiovascular risk prevention.

DPC, AR, PCF

AE

9. Develop in-depth knowledge of the strategies for cessation of use of tobacco.

DPC, AR AE

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1. Communicate effectively with patients and families in a stressful critical care environment.

DPC, AR AE, ECR

2. Communicate effectively with physician colleagues and members of other health care professions to assure timely, comprehensive patient care.

DPC, AR AE, PR, ECR

3. Communicate effectively with colleagues when signing out DPC or turning over care to another service.

DPC, AR AE, PR, ECR

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1. Interact professionally toward patients, families, colleagues, and all members of the health care team.

DPC AE, PR, ECR

2. Interacting with patients and families in a professionally appropriate manner.

DPC, PC AE, ECR

3. Acceptance of professional responsibility as the primary care physician for patients under his/her care.

DPC, PC AE, ECR

4. Appreciation of the social context of illness. DPC AE, ECR 5. Effective utilization of ethics knowledge and consultants. This

includes guidelines for CPR and DNR and end of life cardiac care. DPC, ET AE, PR,

ECR

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1. Identify and acknowledge gaps in personal knowledge and skills in care of acute cardiac patients.

DPC, CC, OWE

AE

2. Develop real-time strategies for filling knowledge gaps that will benefit patients in the coronary care unit.

DPC AE

3. Commitment to professional scholarship, including systematic and 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.

DPC, FS AE

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1. Understand and utilize the multidisciplinary resources necessary to care optimally for acutely ill cardiac patients.

DPC, PC AE

2. Collaborate with other members of the health care team to assure comprehensive coronary care.

DPC, PC AE

3. Use evidence-based, cost-conscious strategies in the care of patients with chest pain and other acute cardiac disease.

DPC AE

4. Knowing when to ask for help and advice from senior fellows and attending physicians.

DPC AE, PR

5. Effective professional collaboration with residents, other fellows, and faculty consultants from other disciplines such as Radiology and Surgery.

DPC, PC AE, ECR

6. Learning by participation in ward rounds, teaching conferences and other educational activities.

DPC, AR AE

7. Effective collaboration with other members of the health care 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.

DPC, PC AE, ECR

8. Effective utilization of ethics consultants, including knowing when and how to request consultation, and how best to utilize the advice provided.

DPC, PC AE

9. Consideration of the cost-effectiveness of diagnostic and treatment strategies.

DPC, ACS AE

10. Ability to lead team, including medical students, residents, nurses, clinical pharmacist, case manager, and social worker.

DPC, ACS AE, ECR

11. Willingness and ability to teach medical students and residents. DPC AE, PR '

!"*"#+*,'!+*%'-#.$'+#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.

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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.

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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

!+*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'

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1. Ability to obtain a complete medical history, perform a careful and accurate examination with emphasis on the cardiac exam, and review charts and pertinent records.

DPC, AR AE

2. Ability to write a concise evaluation, assess the cardiovascular risk of the patient and make therapeutic decisions and proper interventions based on patient preferences, scientific evidence, and sound clinical judgment.

DPC, AR, CAC, EC, ECG, DSP,

MC, FS AE

3. Effectively evaluate and manage patients with complex cardiac illnesses, particularly, acute coronary syndromes, congestive heart failure, valvular heart disease and cardiac transplantation patients.

DPC, AR, FS, CAC, EC, HC,

DSP, CC AE

4. Ability to risk stratify patients after being evaluated by echocardiography, cardiac stress test, coronary angiograms, nuclear cardiovascular procedures and other invasive and non-invasive procedures.

EC, ECG, CAC, HC, IC, CC AE

5. Ability to manage patients who have had interventional procedures including pacemaker placement and catheterization.

DPC, HC, CAC, CC, FS AE, DSP

6. Effectively direct the team performing CPR and advance cardiac life support. DPC, EP, IL AE

7. Ability to manage complications from invasive and non-invasive procedures. DPC, FS AE

8. Ability to participate in behavior modification and strategies to educate patients and other health professionals in the management of cardiovascular risk factors and life style modification.

DPC, AR, PCP, ACS AE

!+*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

with patients and their families. DPC, FS, ET AE, PR

10. Participation in all non-invasive and invasive cardiovascular procedures using the proper technique and under the supervision of a teaching faculty.

DPC, FS AE, DSP

B. @MDFOBH'ZCGWHMDIM 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Familiarity with the newest basic science concepts and mechanisms of cardiovascular disease.

CC, RC, HC, NC, JC AE, ECR

2. Familiarity with current medical literature, clinical trials, and evidence based medicine in cardiology. JC, CC AE

3. Familiarity with the broad spectrum of cardiovascular diseases. CC, NC, PR AE, ECR

4. Familiarity with the pathophysiologic principles of cardiovascular disease. AU, EP AE, DSP

C. .CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Communicate effectively the consult findings with physician colleagues and other members of the health care team in a timely fashion to assure a comprehensive patient care.

DPC, AR, PC AE, PR

2. Present professional findings to patient and family members in a compassionate and informative manner.

DPC, AR AE, PR

3. Provide educational instructions and other learning tools to patients to reinforce behavioral modification. DPC, AR AE, PR

D. 7EGVMSSFGCBHFST 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Interact professionally with patients, patients’ family, colleagues, and other members of the health care team.

DPC, AR, PC AE, PR

2. Appreciation of the spiritual and social context of wellness and illness. DPC, AR, ET AE

!+*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'


1. Commitment to scholarship and the use of evidence based cardiovascular medicine. CC, GR, LC, PR AE, ECR

2. Broad reading of the cardiovascular literature and access and research of Medline and internet tools. CC, GR, JC, RC AE, ECR

F. &JSLMTS[:BSMD'7EBOLFOM 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Understand the complexities of cardiovascular disease patients and utilize the multidisciplinary resources necessary to care for them.

DPC, AR AE

2. Collaborate with other member of the health care team to assure comprehensive cardiac care. DPC, AR AE

3. Understand the system complexities in invasive and noninvasive cardiology. DPC, AR, GR AE

4. Willingness to learn by participation in ward rounds, teaching conferences and other educational activities. DPC, AR AE

5. Effective utilization of risk stratification using evidence-based medicine. DPC, AR AE

6. Develop effective communication with referring physician, health care team, patient and their family, regarding purpose and findings of the consult.

DPC, AR AE

7. Expand learning in out-patient ultrasound and nuclear cardiology to optimize understanding of patients risk stratification.

DPC, AR AE

8. Consideration of cost effectiveness and outcome measurements of tests and interventions associated with consultations.

DPC, AR AE

+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).

!+*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.

#-!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.


#-!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.


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


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

Principle Educational Goals Learning Activities

Evaluation Methods

1.

Ability to obtain a complete medical history, perform a careful and accurate examination with a cardiology focus for the optimal performance of stress test and nuclear cardiology.

DPC, AR, ECG AE

2. Learn proper techniques of performing nuclear procedures, including chemical procedures.

DPC, DSP, NC, ECG AE, DSP

3. Understand nuclear physics and radiation safety. CC, NC AE, ECR


4.

Ability to risk stratify patients after being evaluated by cardiac stress test and nuclear cardiovascular procedures. Ability to correlate invasive and nuclear studies.

ECG, CAC, HC, IC, CC AE

5. Ability to manage patients who have had stress test and nuclear test.


6. Ability to perform all procedures with emphasis on patient comfort and safety ET, PC, DSP AE, PR

7. Ability to manage complications from stress test and nuclear studies, including nuclear decontamination procedures.

DPC, FS, CC, NC AE

8. Ability to understand nuclear safety for patients and health care workers. DPC, CC, NC AE

9. Ability to generate accurate test reports. DSP, CC AE, PR

B. Medical Knowledge


Evaluation Methods

1. Understand the newest basic science concepts and mechanisms in nuclear cardiology. CC, RC, NC, JC AE, ECR

2. Familiarity with current medical literature, clinical trials, and evidence based medicine in nuclear cardiology.

JC, CC AE

3. Learn the methods and technical aspects of cardiac stress tests SPECT nuclear cardiology, PET scan, and MRI/MRA

CC, NC, PR AE, ECR

4. Master the nuclear evaluation of patients with coronary artery disease, including reversible ischemia and myocardial viability.

CC, NC, DSP, PR AE, ECR

C. Interpersonal Skills and Communication


Evaluation Methods

1. Communicate effectively the risk and benefits of the procedure to the patient before obtaining consent for the procedure.

TPC AE, ECR


2.

Provide professional presentation of nuclear findings to patient and family members in a compassionate and informative manner. Provide complete and accurate report to consulting physician.

DPC AE, PR, ECR

3. Provide educational instructions and other learning tools to patients to reinforce behavioral modification.

DPC, PC AE, PR, ECR

D. Professionalism


Evaluation Methods

1. Interact professionally with patients, patients’ families, colleagues, and other members of the health care team.

DPC, AR, PC AE, PR, ECR


E. Practice-Based Learning and Improvement


Evaluation Methods

1. Identify and acknowledge gaps in personal knowledge and skills in performing and interpreting nuclear cardiology studies.

DPC, NC, CC AE

2. Commitment to scholarship and the use of evidence based nuclear cardiology. JC, RC, CC FP, PR

3. Broad reading of the cardiovascular literature and access and research of Medline and Internet tools.

JC, RC, CC FP, PR

#-!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


Evaluation Methods

1. Understand and utilize the multidisciplinary resources necessary to perform nuclear studies on acutely ill cardiac patients.

DPC, PC AE

2. Collaborate with other members of the health care team to assure comprehensive cardiac care. DPC, PC AE

3. Understand the system complexities in nuclear cardiology. DPC, AR, GR AE

4. Use evidence-based cost conscious strategies in the appropriate performance of nuclear studies. DPC AE

5. Knowing when to ask for help and advice from senior fellows and attending physicians. DPC AE, PR

6. Effective professional collaboration with residences other fellows, and faculty consultants from radiology and surgery.

DPC, PC AE, ECR

7.

Develop effective communication with referring physician, health care team, patient and their family, regarding purpose and findings of the nuclear test.

DPC, PC AE

8. Expand learning while reviewing nuclear images on daily basis. DPC, AR AE

9. Consideration of outcome measurements of tests and interventions associated with nuclear studies.

DPC, AR AE

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


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.

%!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.

%!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

%!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



'

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

%!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'


1. Take a pertinent medical history and perform a careful and accurate physical examination with a cardiology focus for the optimal performance of an echocardiographic study.

DPC, AR AE

2. Learn the proper techniques of performing echocardiographic procedures, including transthoracic, transesophageal, and stress echocardiography.

DPC, DSP, EC

AE, DSP

3. Know the common medications along with potential reactions and side effects of these medications given for echocardiographic procedures.

DPC, DSP AE

4. Perform all aspects of echocardiographic procedures, including two-dimensional, color flow Doppler, pulse and continuous wave Doppler, tissue Doppler, contrast and stress echocardiography.

DPC, DSP, EC

AE, DSP

5. Perform all procedures with emphasis on patient comfort and safety.

DPC, DSP AE, DSP

6. Recognize and manage complications associated with echocardiographic procedures.

DPC, AR AE

7. Produce accurate reports of the findings of an echocardiographic exam.

DPC, DSP AE

:(''@MDFOBH'ZCGWHMDIM''' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Understand the indications, contra-indications, potential complications, and benefits for performing transthoracic, transesophageal, and stress echos.

DPC, AR, EC

AE

2. Learn the methods and technical aspects of two-dimensional echo, color flow Doppler, pulse and continuous wave Doppler, tissue Doppler, contrast and stress echocardiography.

DPC, DSP, EC

AE, DSP

3. Master the echo evaluation of valvular heart disease, cardiac systolic and diastolic function, pericardial disease, cardiomyopathies, and diseases of the aorta.

DPC, DSP, EC

AE, DSP

4. Learn the echocardiographic evaluation of congenital heart disease, infective endocarditis, cardiac masses and tumors.

DPC, DSP, EC

AE, DSP

5. Echocardiographic evaluation of post-surgical cardiac patients including, valvular repair/replacement, aorta repair, ventricular assist devices, pacemakers, and cardiac defibrillators.

DPC, DSP, EC

AE, DSP

6. Access and critically evaluate current medical information and scientific evidence relevant to echocardiography.

DPC, AR, EC

AE

%!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'



DPC AE, ECR


DPC AE, PR, ECR

3. Communicate effectively with colleagues when reporting pertinent findings of echocardiographic studies.

DPC, EC AE, PR, ECR




DPC AE, PR, ECR


DPC, PC AE, ECR


DPC, PC AE, ECR



ECR %(''7EBOLFOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Identify and acknowledge gaps in personal knowledge and skills in performing and interpreting echocardiographic studies.

DPC, EC, OWE

AE

2. Develop real-time strategies for filling knowledge gaps that will benefit patients in the echo lab, coronary care units, or other intensive care units.

DPC AE


DPC, FS AE

%!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'


1. Understand and utilize the multidisciplinary resources necessary to perform echocardiographic studies optimally on acutely ill cardiac patients.

DPC, PC AE

2. Collaborate with other members of the health care team to assure comprehensive care.

DPC, PC AE

3. Use evidence-based, cost-conscious strategies in the appropriate performance of echocardiographic studies.

DPC AE


DPC AE, PR


DPC, PC AE, ECR

6. Learning by performance of echocardiographic studies, attending teaching conferences and other educational activities.

DPC, AR AE


DPC, PC AE, ECR


DPC, PC AE


DPC, ACS AE

10. Ability to lead team, including nurses, echo technicians, and stress ECG technicians.

DPC, ACS AE, ECR

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 ''

%!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.

!+*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

!+*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.

!+*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.

!+*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.

!+*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

!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 37 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum level 2 = 10-12 months (minimum 300 cases, typically> 700 cases). Fellows also gain experience in the insertion of temporary pacemakers, pericardiocentesis and intra-aortic balloon placement during this rotation. 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



'




DPC, AR AE

2. Explain the risks, benefits, and potential complications of cardiac catheterization and percutaneous interventions.

DPC, AR AE

3. Perform and interpret the results of diagnostic left and right heart catheterizations, coronary angiograms, and ventriculograms.

DPC, DSP, AR

AE, DSP

4. Perform and interpret the results of aortograms, carotid, renal and peripheral angiograms.

DPC, DSP, AR

AE, DSP

!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 38 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 5. Perform and interpret hemodynamic assessments of various

cardiac diseases including pericardial disease, restrictive heart disease, congenital heart disease, intra-cardiac shunts, and valvular heart disease.

DPC, DSP, AR

AE, DSP

6. Evaluate severity of coronary artery atherosclerotic disease using various methods including measurement of coronary flow reserve, fractional flow reserve, use of quantitative lesion assessment, and intravascular ultrasound.

DPC, DSP, AR

AE, DSP

7. Gain experience in various techniques of coronary intervention including balloon angioplasty, stenting, atherectomy, and brachytherapy.

DPC, DSP, AR

AE, DSP

8. Recognize and manage complications associated with cardiac catheterizations and interventions including care of the percutaneous sheath insertion site.

DPC, AR AE

9. Evaluate, manage, and perform cardiac catheterization and interventions in acute coronary syndromes, congestive heart failure.

DPC, DSP, AR

AE, DSP

10. Placement and management of intra-aortic balloon pumps and temporary pacemakers.

DPC, DSP, AR

AE, DSP

11. Assist in interventional procedures such as carotid artery stenting, transcatheter closure of patent foramen ovale and atrial septal defects, renal artery stenting, transcatheter repair of abdominal aortic aneurysms, peripheral angioplasty and stenting, and coil embolization of artero-venous malformations.

DPC, AR, DSP

AE, DSP

12. Follow up and routine care of the post catheterization and post-intervention patient.

DPC, AR AE




DPC, CC AE


DPC, NC AE


DPC, CC AE


DPC, HC AE

5. Develop and demonstrate in-depth knowledge of the pathophysiology, clinical manifestations, diagnosis and management of cardiac diseases.

DPC, CC, AR, GR

AE

6. Develop and demonstrate in-depth knowledge of the principles of diagnosis and management of ischemic heart disease including unstable angina pectoris and myocardial infarction; congestive heart failure; rheumatic heart disease, and congenital heart disease.

DPC, AR, CAC, IC

AE

!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 39 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 7. Develop and demonstrate in-depth knowledge of the indications

for, principles, complications, and interpretation of right and left heart catheterization, coronary angiography, ventriculography and percutaneous interventions.

DPC, DSP, AR

AE, DSP


DPC, AR AE


DPC, AR AE




DPC, FS AE, ECR


DPC, FS AE, PR, ECR

3. Communicate effectively with colleagues when discussing results of various cardiac catheterization and interventions and further management.

DPC, FS AE, PR, ECR




DPC AE, PR, ECR


DPC, PC AE, ECR


DPC, PC AE, ECR






DPC, CC, OWE

AE


DPC AE

!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 40 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 3. Commitment to professional scholarship, including systematic and

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.

DPC, FS AE

''<(''&JSLMTS[:BSMD'7EBOLFOM''' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'



DPC, PC AE


DPC, PC AE


DPC AE


DPC AE, PR

5. Effective professional collaboration with residents, other fellows, and faculty consultants from other disciplines such as Radiology, Neurology and Surgery.

DPC, PC AE, ECR


DPC, AR AE

7. Effective collaboration with other members of the health care team, including residents, medical students, nurses, and cath lab technicians.

DPC, PC AE, ECR


DPC, PC AE


DPC, ACS AE

10. Ability to lead team, including medical students, residents, nurses, and cath lab technicians.

DPC, ACS AE, ECR

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 - Heart Disease: A Textbook of Cardiovascular Medicine, Ed: Braunwald, Zipes, Libby; WB Saunders - Grossman’s Cardiac Catheterization, Angiography, and Intervention, Ed: Baim & Grossman;

Lippincott Williams & Wilkins. - 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

!+*1.+!'!+$6%$%*.8+$."#'*"$+$."# at Memorial Hermann Hospital 41 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, the entire teaching faculty and the rotations will be evaluated by all the trainees in the biannual evaluation of the program by the fellows.

%2%!$*"76,&."2"3,9'!+*1.+!'7+!.#3'+#1'+**6,$6@.+'@+#+3%@%#$ 42 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Line of Responsibility

!+*1.+!'%2%!$*"76,&."2"3,9'!+*1+.!'7+!.#3'+#1'

+**6,$6@.+'@+#+3%@%#$'at Memorial Hermann Hospital

CDRs spend a'minimum of 2 months in Cardiac Electrophysiology. CDRs will assist EP faculty with all inpatient arrhythmia/EP consults. The trainees are expected to perform a comprehensive history and physical and formulate a diagnostic and therapeutic strategy for each consult and present the case to the EP attending. Trainees will also perform tilt tests and will participate in invasive EP studies, ablations, pacemaker and defibrillator implants. Fellows will be expected to pre-op. and consent patients, participate actively in the procedure, prepare procedure reports and monitor patients in follow-up, under the supervision of the respective attending physician. Whenever the CDR is unable to pre-op. a patient, she/he will notify the appropriate attending physician to assume responsibility for the task. In addition, CDRs will be expected to read ECGs, Holter monitors and transtelephonic monitoring reports (event recorders and pacemaker surveillance) at the Hermann Heart Center on a daily basis Monday through Friday.

CDRs will attend the Arrhythmia Clinic two half-days a week and the Pacemaker Clinic on two half-days a week. It is anticipated the trainee will see at least 20 device patients each month at this latter clinic.

%2%!$*"76,&."2"3,9'!+*1.+!'7+!.#3'+#1'+**6,$6@.+'@+#+3%@%#$ 43 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

!+*1.+!'%2%!$*"76,&."2"3,9'!+*1+.!'7+!.#3'+#1'

+**6,$6@.+'@+#+3%@%#$'at Memorial Hermann Hospital

The principal goals for this rotation is to give fellows either level 1 or level 2 training in cardiac Electrophysiology as set out in the COCATS Guidelines. 2MNMH'=' Within the cardiology core-training program, level 1 is at least two months of clinical rotation designed for cardiology trainees to acquire knowledge and experience in the diagnosis and management of bradyarrhythmias and tachyarrhythmias. The cardiology trainees learn the indications for an limitation of electrophysiological studies, the appropriate use of pharmacological and non-pharmacological therapeutic options and the proper and appropriate use of antiarrhythmic agents, including drug interactions and proarrhythmias that including ambulatory electrocardiographic monitoring, event recorders, exercise test for arrhythmia assessment, tilt table testing, signal-averaged electrocardiography, invasive electrophysiological testing and implantation of cardiac arrhythmia control devices. The level 1 cardiology trainees experience also including the fundamentals of cardiac pacing; recognizing normal and abnormal pacemaker function; and knowing indications for temporary and permanent pacing, pacing modes and general approach to programming and surveillance of pacemakers and implanted cardioverter defibrillators. The cardiology trainee is also formally instructed in gains and experience with 1) the insertion, management and follow-up of temporary pacemakers, 2) measuring and sensing thresholds and recording electrograms for management of patients of temporary pacemakers, and 3) indications and techniques for elective and emergence cardioversions. Insertion of a minimum of 10 temporary pacemakers and performance of at least eight elective cardioversions is required. This experience can be obtained throughout the clinical training period. 2MNMH')' All candidates for level 2 training must meet all the requirements under level 1. Level 2 training consists of a minimum of six months of training as a noninvasive cardiac arrhythmia specialist with advanced competency and proficiency in the diagnosis, treatment and longitudinal care of patients with complex arrhythmias. Level 2 trainees should meet all level 1 requirements and, in addition, should obtain advanced training in normal and abnormal cardiac electrophysiology and mechanisms of arrhythmias and proficiency in performance and interpretation of noninvasive diagnostic procedures (ambulatory ECG monitoring, event monitoring, event recording, telephone ECG transmission, signal average electrocardiography, tilt table testing, heart rate variability and other test of autonomic nervous system). Level 2 trainees also acquire knowledge of basic and clinical pharmacology of antiarrhythmic agents and proficiency in their use. Of special importance for the level 2 trainee is acquisition of skills and experience for managing inpatients and outpatients with complex cardiac arrhythmias, including programming and follow-up management of all types of bradycardia pacing

%2%!$*"76,&."2"3,9'!+*1.+!'7+!.#3'+#1'+**6,$6@.+'@+#+3%@%#$ 44 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum systems. The trainee is expected to function as a primary operator who interrogates, interprets, prescribes and reprograms in at least 100 patients. The trainee at this level must also acquire advanced expertise in temporary pacing, transesophageal atrial pacing, cardioversion, interpretation of invasive electrophysiologic study data and complex arrhythmias ECG interpretation. Although level 2 trainee must have significant exposure to invasive electrophysiology, implanted cardioverter defibrillators and the surgical aspects of arrhythmia control device implantation; level 2 trainees will not qualify him or her to perform these procedures. The level 2 trainees have the option of obtaining additional training in the surgical aspects of pacemaker implantation or may choose the additional training required for invasive cardiac Electrophysiology (Level 3). "KLFGCBH'$EBFCFCI'FC'7METBCMCL':EBDJOBEDFB'7BOFCI'.TKHBCLBLFGC'/+KKHFOBYHM'LG'2MNMH')'"CHJ0(' Level 2 trainees may choose to obtain additional training in the surgical aspects of permanent bradycardia pacing implantation. This implantation training may be obtained concurrently or subsequently with level 2. The pacemaker implantation training includes developing expertise in permanent atrial and ventricular lead placement, threshold testing and programming of devices, principles of surgical asepsis, surgical techniques of implantation and management of implantation complications. Individuals receiving qualify training in pacemaker implantation must participate as the primary operator (but under direct supervision) in at least 50 primary implantations of transvenous pacemaker and 20 pacemaker system revision or replacements. At least half of the implantation should involve dual-chamber pacemakers. The trainee must also participate in the follow-up of at least 100 pacemaker patients visits and acquire proficiency in advanced pacemaker electrocardiography, interrogation and programming of complex pacemaker. Level 2 training (six months) with the option of the training in pacemaker implantation (six months) requires a total of one year of advanced training beyond the cardiology core level 1. This may be obtained with a three-year cardiology program if one of the three years is dedicated to acquiring pacemaker implantation skills plus related management and follow-up skills. This training does not meet the ABIM requirements for admission to the CCEP examination.

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



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 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[\9']'BCD'^'/3GBHS'BEM'VGE'LUM'VFESL9'SMOGCD'BCD'LUFED'JMBE'OBEDFGHGIJ'VMHHGW'HMNMH0''+('7BLFMCL'!BEM'

7EFCOFKHM'%DROBLFGCBH'3GBHS 2MBECFCI'+OLFNFLFMS %NBHRBLFGC'@MLUGDS

1.

Ability to obtain a complete medical history, perform a careful and accurate examination with emphasis on the cardiac exam, and review charts and pertinent records.

DPC, AR AE

2.

Ability to write a concise evaluation, assess the cardiovascular risk of the patient and make therapeutic decisions and proper interventions based on patient preferences, scientific evidence, and sound clinical judgment.


MC, FS AE

3. Effectively evaluate and manage patients with complex cardiac arrhythmia.

DPC, AR, FS, CAC, EC, HC, DSP, CC AE

4. Ability to risk stratify patients after being evaluated by EP study.


5. Ability to manage patients who have had arrhythmic disorder.



6. Effectively direct the team performing CPR and advance cardiac life support. DPC, EP, IL AE

7. Ability to manage complications from device implantation. DPC, FS AE

8. Ability to understand EP study and perform pacemaker implantation.


9. Participation in the interpretation of ECG, 24-hour holter. DPC, FS, ET AE, PR

10. Participation in all pacemaker and ICD follow-up and programming using the proper technique and under the supervision of a teaching faculty.

DPC, FS AE, DSP

'':. @MDFOBH'ZCGWHMDIM


1. Familiarity with the newest basic science concepts and mechanisms of cardiac electrophysiology.


2. Familiarity with current medical literature, clinical trials, and evidence based medicine in cardiac electrophysiology.

JC, CC AE

3. Familiarity with the broad spectrum of cardiac electrophysiology CC, NC, PR AE, ECR

4. Familiarity with the pathophysiologic principles of cardiovascular medicine.

AU, EP AE, DSP

!(' .CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC


1.

Communicate effectively the consult findings with physician colleagues and other members of the health care team in a timely fashion to assure a comprehensive patient care.

DPC, AR, PC AE, PR

2. Present professional findings to patient and family members in a compassionate and informative manner. DPC, AR AE, PR



1(' 7EGVMSSFGCBHFST



DPC, AR, PC AE, PR


%( '7EBOLFOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL


1. Commitment to scholarship and the use of evidence based cardiovascular medicine. JC, RC FP, PR

2. Broad reading of the cardiovascular literature and access and research of Medline and Internet tools. JC, RC FP, PR

<('''&JSLMTS[:BSMD'7EBOLFOM



DPC, AR AE


3. Understand the system complexities in electrophysiology. DPC, AR, GR AE




6. Develop effective communication with referring physician, health care team, patient and their family, regarding purpose and findings of the EP test.

DPC, AR AE

7. Expand learning in reading ECG and 24-holter on daily basis. DPC, AR AE

8. Consideration of cost effectiveness and outcome measurements of tests and interventions associated with EP study and device implantation

DPC, AR AE

+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). � Pertinent AHA/ACC 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 (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.

!1'7*%5%#$."#'+#1'*%6+:.2.$+$."# at Memorial Hermann Hospital 49 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Lines of Responsibility

!+*1."5+&!-2+*''1.&%+&%''7*%5%#$."#''+#1''*%6+:.2.$+$."#'

At Memorial Hermann

All CDRs spend approximately 2 days per week for 2 months in Cardiac Rehabilitation. CDR's responsibilities during the rotation include obtaining an informed consent and brief history and, if pertinent, perform a focused examination in patients undergoing stress testing. Trainees are also responsible for supervising and interpreting stress tests. She/he also participates in teaching rounds and weekly conferences which take the form of case presentations and review of the pertinent literature.

!1'7*%5%#$."#'+#1'*%6+:.2.$+$."# at Memorial Hermann Hospital 50 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum !+*1."5+&!-2+*''1.&%+&%''7*%5%#$."#''+#1''*%6+:.2.$+$."#'

At Memorial Hermann

This educational program provides opportunities for the cardiology fellows to develop clinical competence in the field of preventive cardiology, including primary prevention and secondary prevention, and rehabilitation to training level one in accordance with the COCATS Capital Guidelines. Cardiovascular disease prevention includes coronary artery disease risk factor, lipid disorders, epidemiology and biostatistics, and cardiovascular wellness. The in-patient facilities are located at Memorial Hermann Hospital for secondary prevention and phase I cardiac rehabilitation. The out-patient facilities are located in the Hermann Professional Building where primary prevention, cardiovascular wellness, phase II and phase III cardiac rehabilitation and secondary prevention are the didactic objective. Level I includes training that should be part of the knowledge base of all clinical cardiologists and includes exposure to the following general and specific areas. General Content Area:

1. Vascular biology of the heart and blood vessels 2. Clinical epidemiology and biostatistics 3. Principles of clinical trials and outcomes research 4. Priniciples of clinical pharmacology

Exposure to the following specific content areas is also included:

5. Diagnosis and treatment of primary and secondary hypertension 6. Diagnosis and treatment of primary and secondary dyslipidemias 7. Diagnosis and treatment of thrombosis and hypercoagulable states 8. Management of smoking cessation and nicotine addition 9. cardiac rehabilitation 10. exercise physiology 11. nutrition and its effect on the cardiovascular system 12. psychosocial and behavioral aspects of cardiovascular diseases 13. diagnosis and treatment of peripheral vascular disease

The Preventive and Cardiac Rehabilitation rotation training in these areas are integrated into consultative, impatient and outpatient rotations and didactic components of core cardiovascular medicine programs.

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 ET - Ethics in Cardiology MM - Cardio Morbidity & Mortality CAC - Catheterization Conference FS - Faculty Supervision NC - Noon Conferences CC - Core Curriculum GR - Grand Rounds PC - Professionalism Curriculum DPC - Direct Patient Care HC - Hemodynamic Conference PCF - Preventive Cardiology Forum DSP - Directly Supervised Proc IC - Interventional Cardiology Course PR - President's Rounds EC - Echocardiography Conference IL - Introductory Lecture Series RC - Research Conference

!1'7*%5%#$."#'+#1'*%6+:.2.$+$."# at Memorial Hermann Hospital 51 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 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(2 x annually) PR Peer Review FP Fellow Portfolios RR Record Review OWE Oral/Written Exams 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. '+( 7BLFMCL'!BEM'

Principle Educational Goals Learning Activities Evaluation Methods

1. To perform a complete evaluation of the patient with focus on cardiovascular prevention DPC, AR AE

2. Write a concise progress notes with emphasis in Return to Work, limitation of physical activities, behavior modification and education and long term management plan as well as referral to other areas of the subspecialty.

DPC, AR, PC AE

3. Ability to write concise, accurate, informative, and helpful consultation notes outlining the recommendation and explaining the rational.

CC, DPC, AR AE

4. Ability to interpret electrocardiographic stress test, rhythm strips, oxygen consumption, body fat evaluation.

DPC, AR, CC, EP, PCP AE, DSP

5. Ability to recognize any arrhythmias as well as exercise induced arrhythmias. DPC, AR, EP AE, DSP

6. Ability to educate and counsel patients on risk factor prevention and life style changes to reduce the risk of cardiovascular disease.

DPC, AR, PC AE, PR

7. Ability to diagnose and treat important cardiovascular complications occurring after Percutaneous cardiovascular interventions, surgery, or placement of devices, including LVAD, AICD, and other vascular intervention.

DPC, AR, CC, CAC, ICC, ILS AE, DSP

8. Ability to establish rehabilitation program and return to work conditions for patients with congestive heart failure, cardiac transplantation, or major surgical procedures.

DPC, AR, CC, HC, ICC AE, DSP

9. Ability to treat and help patients with noncardiac complications including neuromuscular diseases and cerebrovascular complications.

DPC, AR, CC, IC AE, DSP

10. Ability to educate patients in diet modification, behavior modification, tobacco cessation, and stress management. DPC, PCF AE, PR

!1'7*%5%#$."#'+#1'*%6+:.2.$+$."# at Memorial Hermann Hospital 52 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

B. @MDFOBH'ZCGWHMDIM


1. Familiarity with the effects of the risk factors on vascular biology on the heart and blood vessels. DPC, AR AE

2. Familiarity with the management of patients during out-patient surgical and interventional follow-up.

DPC, AR, CAC, CC, DSP AE, DSP

3. Familiarity with the use of clinical epidemiology, biostatistics, clinical trials, and out-come research. CC, JC, RC AE

4. Familiarity with strategies for diagnosis and treatment of hypertension. CC, DPC, PCF AE

5. Familiarity with the diagnosis and treatment of primary and secondary dyslipidemias. DPC, CC, JC, PCF AE

6. Familiarity with principals of assessment of lifetime cardiovascular risk and cardiovascular risk prevention. DPC, CC, PEF, JC AE

7. Familiarity with the management of the smoking cessation and nicotine addiction. DPC, AR AE

8. Familiarity with phase I through phase IV of cardiac rehabilitation and return-to-work recommendations. DPC, AR, CC AE

9. Familiarity with principle of exercise physiology and oxygen consumption. AE

10. Familiarity with principle of nutrition and its effect on the cardiovascular system. DPC, AR, PCF AE

11. Familiarity with psychosocial, behavioral, and stress management aspect of cardiovascular diseases. DPC, AR, PCF, ACS AE, PR

12. Familiarity with diagnosis and treatment of peripheral vascular disease and rehabilitation.

DPC, DSP, HC, CAC, EC, CC EE, DSP

C. .CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC



DPC, AR, PC AE, PR



D. 7EGVMSSFGCBHFST


1. Interact professionally with patients, patients’ family, colleagues, and other members of the health care team. DPC, AR AE, PR

2. Appreciation of the spiritual and social context of wellness and illness. DPC, AR, ET AE, PR

!1'7*%5%#$."#'+#1'*%6+:.2.$+$."# at Memorial Hermann Hospital 53 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

E. 7EBOLFOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL


1. Commitment to scholarship and the use of evidence-based preventive cardiology and rehabilitation. DPC, LC, RC, PR AE, ECR

2. Broad reading of the cardiovascular literature with emphasis on primary and secondary prevention, wellness, and cardiac rehabilitation.

JA, RC, GR, PCF AE, ECR

F. &JSLMTS[:BSMD'7EBOLFOM


1. Understand the complexities of patient care by a cardiac rehabilitation team and how this interaction affects the health of the patient and the community at large.

DPC, AR AE

2. Consideration of cost effectiveness of rehabilitation and prevention and outcome measurements strategies. DPC, ACS, AR AE

3. Understanding of the system complexities in cardiovascular prevention and rehabilitation. DPC, LC AE

4. Knowing how to partner with a team of health care providers to assess, coordinate, and improve the cardiac rehabilitation and preventive health care system.

AR, ACS AE, PR

5. Willingness and ability to teach medical students, residents, and other health care professionals involved in patient care or system activities.

DPC AE, PR

7EFCOFKBH'$MBOUFCI'@MLUGDS There are teaching rounds and weekly patient presentation with participation of the fellows. In addition, there is a biweekly presentation of a new aspect of preventive cardiology by the fellows and weekly conferences with case presentations and review by fellow and staff, where epidemiology and current literature are discussed. In the preventive cardiology rotatiuon, each fellow receives a preventive cardiology computer program. This is a problem-based learning program using hypertext language, covering 15 basic modules of preventive cardiology. Fellows also receive a package of the booklet by the CDC on cardiac rehabilitation as secondary prevention and the guidelines for stress test and cardiac rehabilitation by the American Heart Association. Practical training in clinical presentation is also accomplished by the fellow in the ongoing outpatient clinical preventive program. These are available to the fellow, health professional in the field of prevention to facilitate their research and practice.

!1'7*%5%#$."#'+#1'*%6+:.2.$+$."# at Memorial Hermann Hospital 54 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum %DROBLFGCBH'!GCLMCL This program provides training and experience in preventive and cardiac rehabilitation for the fellows as detailed in the Education Goals section. The program is characterized by medical evaluation of cardiac patientsd, exercise prescriptions, cardiac risk factors modification, patikent education, counseling and behavioral intervention assisted by staff psychologists. These services are fellow-directed and implemented by a team of health professionals. +COFHHBEJ'%DROBLFGCBH'@BLMEFBHS


available from fellowship office). ! Mayo Cardiovascular Board Review, (copies available from fellowship office). ! Pertinent AHA/ACC Scientific Statements and Guidelines

@MLUGD'GV'%NBHRBLFGC'GV'<MHHGW Fellows will be evaluated by one of the attending, typically one of the supervising UT clinical faculty, on a monthly basis (see attached form). @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, all the teaching faculty and the rotations will be evaluated by all the trainees in the annual evaluation of the program by the fellows.

!"#$.#-.$,'!2.#.! 55 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

!+*1."2"3,'!"#$.#-.$,'!2.#.! Throughout the duration of fellowship training, each fellow is assigned to one University of Texas cardiology faculty member’s clinic. Fellows will attend the assigned clinic for one-half day a week, every week, excluding vacations and holidays. The fellow will see on average five to ten clinic patients under the supervision of the attending faculty. The assigned clinic will be located either at the University Care Plus/Cardiology Clinic at the Hermann Professional Building or at the Cardiology Clinic at Lyndon Baines Johnson General Hospital. ''7EFCOFKBH'$MBOUFCI'@MLUGD'During time spent in continuity clinic, trainees will be principally taught by their supervising attending, who is one of the UT-faculty. Trainees will gain instruction and experience under their supervision. ' Additional teaching will occur through the didactic lectures and conferences. These are Preventive Cardiology Conferences, 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 these ongoing clinics, the trainee will gain experience in a variety of cardiovascular disorders. Fellows will gain experience in the follow-up and management of patients with a history of acute coronary syndromes, i.e., unstable angina and acute myocardial infarction and their complications. This includes primary, secondary, and tertiary prevention of cardiovascular diseases; permanent pacemaker and implantable defibrillator management; planning and follow-up of coronary interventions (PTCA and stenting) and coronary artery surgery. Fellows will gain experience in the role of preventive medicine in patients with coronary artery disease, including the use of aspirin, Beta-blockers, ACE-Inhibitors, HMG-CoA reductase inhibitors and the 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, valvular disease, pericardial disease, pulmonary

!"#$.#-.$,'!2.#.! 56 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum thromboembolic disease and disease of the great vessels. Fellows will also be involved in the post-hospital care of patients following cardiac surgery. 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


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

'




DPC, ACS AE, RR


DPC, FS AE

3. Write concise, accurate and informative histories, physical examinations and clinic notes with a cardiology focus.

DPC, ACS AE, RR

!"#$.#-.$,'!2.#.! 57 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 4. Ability to formulate comprehensive and accurate problem lists,

differential diagnoses and plans of management for patients with acute and chronic cardiac illness.

DPC, CC AE

5. Effectively evaluate and manage patients with chronic cardiac illness; particularly coronary atherosclerosis, congestive heart failure, arrhythmias and valvular heart disease.

DPC, ACS AE


DPC, ACS AE

7. Ability to perform/review and recognize major abnormalities of cardiac stress tests, cardiac Echo and coronary angiograms.

DPC, DSP, EC, CAC

AE, DSP

8. Ability to interpret complex electrocardiograms and rhythm strips. DPC, ECG AE 9. Effectively evaluate and manage patients who have undergone

interventional procedures. DPC AE

10. Effectively evaluate and manage cardiac risk factors such as hypertension, diabetes, hyperlipidemia, hyperhomocysteinemia, and smoking.

DPC, ACS AE

11. Ability to place and manage pulmonary artery (Swan-Ganz) catheters and temporary pacemakers.

DPC, EP, DSP

AE, DSP


DPC, ACS AE



1. Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of patients with chest pain and chronic cardiac disease.

DPC, CC AE


DPC, CC AE


DPC, CC AE

4. Develop and demonstrate in-depth knowledge of the pathophysiology, clinical manifestations, diagnosis and management of cardiac diseases, as seen in an outpatient basis.

DPC, ACS AE


DPC, EP, ACS

AE

6. Develop and demonstrate in-depth knowledge of the indications for, principles, complications, and interpretation of ECG, inpatient rhythm monitoring, exercise and chemical stress tests, electrophysiologic studies, transthoracic and transesophageal ECHO, nuclear cardiac imaging, right and left heart

DPC, DSP, EP, ECG

AE, DSP

!"#$.#-.$,'!2.#.! 58 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

catheterization, coronary angiography, and percutaneous interventions.


DPC, PCF AE


DPC, PCF AE

''!(''.CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Communicate effectively with patients and families in an office setting.

DPC, ACS AE, ECR


DPC, ACS AE, PR, ECR

3. Communicate effectively with colleagues when offering consultation service.

DPC, ACS AE, PR, ECR




DPC AE, PR, ECR


DPC, PC AE, ECR


DPC, PC AE, ECR





1. Identify and acknowledge gaps in personal knowledge and skills in care of chronic cardiac patients.

DPC, CC, OWE

AE

2. Develop real-time strategies for filling knowledge gaps that will benefit patients in the outpatient setting.

DPC AE


DPC, FS AE

!"#$.#-.$,'!2.#.! 59 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum <(''&JSLMTS[:BSMD'7EBOLFOM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Understand and utilize the multidisciplinary resources necessary to care optimally for chronically ill cardiac patients.

DPC, PC AE

2. Collaborate with other members of the health care team to assure comprehensive cardiac care.

DPC, PC AE

3. Use evidence-based, cost-conscious strategies in the care of patients with chest pain and other cardiac disease.

DPC AE


DPC AE, PR


DPC, PC AE, ECR

6. Learning by participation in clinic rounds, teaching conferences and other educational activities.

DPC, AR AE

7. Effective collaboration with other members of the health care team, including residents, medical students, nurses, clinical pharmacists, occupational therapists, physical therapists, nutrition specialists, patient educators, speech pathologists, social workers, case managers, and providers of home health services.

DPC, PC AE, ECR


DPC, PC AE


DPC, ACS AE

10. Ability to lead team, including medical students, residents, nurses, nurse assistants, clinical pharmacist, case manager, and social worker.

DPC, ACS AE, ECR

11. Willingness and ability to teach medical students and residents. DPC AE, PR +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) - 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 clinic 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.

!+*1."5+&!-2+*'*%&%+*!6''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 60 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

!+*1."5+&!-2+*'*%&%+*!6'''*"$+$."#'

%DROBLFGCBH'!GCLMCL'

Research training will ordinarily take place in one of three levels: Level 1=trainees entering the clinical practice of cardiovascular medicine; Level 2=trainees planning a commitment to teaching and clinical investigation; Level 3=trainees planning a substantive commitment to basic cardiovascular research Clinical Investigation

Clinical investigation is to be carried out under the supervision of an experienced faculty investigator and according to approved principles of biomedical ethics and institutional rules for patient protection. It must be recognized that clinical research is difficult because of the complexity of achieving valid scientific conclusions while working with a diverse population and simultaneously protecting the interests of each patient. Components of Research

The trainee should develop skills in at least the following areas:

1. Literature study, to ascertain the exact state of knowledge before undertaking new investigation. 2. Formulation of hypothesis and specific goals, ensuring that the hypothesis is testable, that the

goals are appropriate and statistical power is achievable. 3. Development of the research plan and the protocol, including study design, recruitment of

subjects, ethical considerations, informed consent and protection of privacy, data collection modes, full description of procedures and institutional approval of human investigation, where appropriate.

4. Data collection, including preparation of routine data forms. 5. Deve1opment of analytic methods or procedural skills, as required, and particularly the handling

of artifacts, missing data, outliers and statistical inference. 6. Presentation of results, preferably both oral and written, emphasizing that no investigation is

complete until it is reported in peer-reviewed journals. 7. Risk-benefit analysis, regarding both patient (subject) risk and benefit and societal risk and

benefit. The clinician lacking expertise in these areas may be unable to interpret critical reports bearing directly on his or her practice. New data may be accepted uncritically or important advances recognized tardily. Therefore, the training program provides opportunities for faculty and trainees to review and analyze small- and large-scale clinical and basic research reports in depth in the monthly Journal Club.

The fellows are required to submit a research project along with a faculty mentor who will supervise the project during the first year of the program. A list of possible projects is available from the Fellowship Office. If the fellow has not identified a mentor, then the Fellowship Director will help identify one. The

!+*1."5+&!-2+*'*%&%+*!6''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 61 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum fellows are required to complete the project by the end of their third year of training and are a pre-requisite for graduation from the program. Duration of Research Training

For trainees planning careers in the clinical practice of cardiovascular medicine (1evel 1), a minimum of six months (and in many instances up to 12 months) should be devoted to a specific project or projects. This time in part or in total may run concurrently with clinical training or in one of the non-invasive laboratories. For those planning a substantive commitment to teaching and clinical investigation (1evel 2), one full year (e.g., 100% of time for one year or 50% of time for two years) should be devoted to clinical research. For those planning a career in basic research (1evel 3), two to three full-time years, working directly with an experienced mentor, are now needed in most cases. Such training constitutes only the beginning of the education of an independent cardiovascular investigator. Advanced Training for Trainees Pursuing Investigative Cardiology.

Trainees preparing for clinical careers in research (1evel 3) need an extensive foundation in scientific investigation. Some trainees will have obtained thorough research preparation in combined MD/PhD programs, but may lack the special skills involved in clinical research or certain tools that are appropriate to their personal research goals. These may be obtained in a postdoctoral research fellowship experience or as part of the cardiology training period. For full-time training, the trainee should enter the laboratory of a productive and active scientist, MD or PhD, in any qualified institution (not necessarily where he or she is obtaining direct training). Trainees who aim for a career in investigative cardiology but who have not had the opportunity to obtain a PhD or equivalent training at the time they begin their cardiology fellowships should have the opportunity and be encouraged to obtain the necessary basic science course work and laboratory experience necessary for a productive research career. Current models of this type of training include the American Heart Association Clinician Scientist Award and the National Heart, Lung1 and Blood Institute program for clinical scientists and physician scientists (CIDA).

!"*"#+*,'!+*%'-#.$';'!+*1."2"3,'!"#&-2$'&%*5.!%'at Lyndon Baines Johnson Hospital 62 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Line of Responsibility !"*"#+*,'!+*%'-#.$'/!!-0';'!+*1."2"3,'!"#&-2$'&%*5.!%'

at Lyndon Baines Johnson Hospital Two CDRs (1 junior and 1 upper level) are assigned to the Cardiology Service at the LBJ General Hospital and report to the attending on the CCU and the non-invasive service, respectively. One CDR will be responsible for the CCU, Cardiology and Consult Services. Another CDR will be responsible for the noninvasive laboratory, with particular focus on TEEs and stress echo. One CDR is assigned to cardiac patients in the ICU (CCU) and in the Holding Unit of the Emergency Room. The trainee is notified of admissions by the house staff and sees the patients as soon as possible, takes a complete history, performs a physical exam and reviews the treatment plan with the house staff. The CDR is expected to write a comprehensive admitting note and daily progress notes as long as the patient is in the hospital. The CDR makes himself/herself available for placement of arterial lines, Swan-Ganz catheters and temporary pacemakers or the supervision thereof. If necessary, he/she will call in either the attending or the invasive fellow on call. The CDR is also expected to see all cardiology consults and to leave comprehensive notes and explicit recommendations. The CDR will meet daily with the attending on the consult service and round with the attending on all new and active consult patients. The trainee meets each day at 10:00 a.m. in the ICU with the attending for teaching rounds on patients on the cardiology service. When patients are discharged from the ICU or from the Holding Unit, the CDR continues to follow them as long as they are in the hospital. The typical number of patients that the trainee is responsible for is 10-12 patients, with a maximum limit of 18 patients. If this maximum limit is reached, the CDR should notify the attending or program director so that patients can be assigned to another CDR. The CDR’s duties include interpretations of electrocardiograms and Holter monitor.

!"*"#+*,'!+*%'-#.$';'!+*1."2"3,'!"#&-2$'&%*5.!%'at Lyndon Baines Johnson'Hospital 63 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum !"*"#+*,'!+*%'-#.$'/!!-0';'!+*1."2"3,'!"#&-2$'&%*5.!%'

at Lyndon Baines Johnson Hospital The Lyndon Baines Johnson General (LBJ) Hospital Coronary Care Unit (CCU) and Cardiology Consult Service rotation lasts for one month. One first year fellow is assigned to a team which consists of two or three residents and one or two medical students, and the cardiology attending. The fellow will NOT have any in-house calls, and will have on average 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 LBJ CCU/Cardiology Consult Service include patients of faculty physicians and unassigned patients admitted from the clinics or ER. ''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 fellow will gain experience in intensive care of patients with acute cardiovascular disorders, including coronary care; the trainee will also be responsible for the care of patients following transfer to the medicine service from the coronary care unit with the cardiology consult service. 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

!"*"#+*,'!+*%'-#.$';'!+*1."2"3,'!"#&-2$'&%*5.!%'at Lyndon Baines Johnson'Hospital 64 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum therapy; temporary pacemaker and Swan-Ganz catheter. Patients requiring coronary angiography and/or intervention or coronary surgery will be transferred to Ben Taub General Hospital for care. Patients that do not need acute intervention on the basis of findings at cardiac catheterization will return the same day to LBJ Hospital for further care. Fellows will also gain experience in the evaluation and management of patients with other acute cardiovascular disorders including cardiac arrhythmias, cardiac failure, infective endocarditis, valvular disease, pericardial disease, pulmonary thromboembolic disease and aortic dissection. The rotation also includes experience in the cardiology consult service for the hospital. Typically consultations are referred from the General Internal Medicine and Family Practice services. 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. They are also consultation for General Surgery which typically involves the pre-operative evaluation of patients as well as the management of peri-operative cardiac complications and the treatment of co-morbid cardiac conditions. In addition, consultations are requested by the Department of Obstetrics for the evaluation and management of patients in both the prenatal and postnatal periods. 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



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 Lyndon Baines Johnson Hospital is included in the front of the report for further information.

!"*"#+*,'!+*%'-#.$';'!+*1."2"3,'!"#&-2$'&%*5.!%'at Lyndon Baines Johnson'Hospital 65 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum +(''7BLFMCL'!BEM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'



DPC, AR AE


DPC, AR, FS

AE

3. Write concise, accurate and informative histories, physical examinations and progress notes with a cardiology focus.

DPC, AR AE

4. Ability to formulate comprehensive and accurate problem lists, differential diagnoses and plans of management for patients with acute cardiac illness.

DPC, AR, CC

AE

5. Effectively evaluate and manage patients with acute cardiac illness; particularly acute coronary syndromes, acute myocardial infarction, congestive heart failure, pulmonary edema, and acute valvular heart disease.

DPC, AR, CAC

AE


DPC, AR AE

7. Ability to perform and recognize major abnormalities of cardiac stress tests and cardiac Echo.

DPC, DSP, EC

AE, DSP

8. Ability to interpret complex electrocardiograms and rhythm strips. DPC, AR, ECG, EP

AE

9. Effectively evaluate and manage patients who have undergone interventional procedures.

DPC, AR, CAC

AE

10. Ability to perform basic ventilator management. DPC, AR AE 11. Ability to place and manage pulmonary artery (Swan-Ganz)

catheters and temporary pacemakers. DPC, AR, DSP, EP

AE, DSP

12. Ability to administer emergency thrombolytic treatment. DPC, DSP, AR

AE

13. Ability to perform CPR and advanced cardiac life support. DPC, DSP, PC

AE


DPC, AR AE

15. Participation in and later leading of discussion of end-of-life issues with families.

DPC, AR AE

16. Insert central venous lines and arterial lines with proper technique. DPC, DSP, AR

AE

17. Ability to perform endotracheal intubation, exercise and chemical stress tests, transthoracic and transesophageal ECHO

DPC, DSP, AR, IL

AE

!"*"#+*,'!+*%'-#.$';'!+*1."2"3,'!"#&-2$'&%*5.!%'at Lyndon Baines Johnson'Hospital 66 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum :(''@MDFOBH'ZCGWHMDIM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'



DPC, AR AE


DPC, AR AE


DPC, AR AE


DPC, AR, HC

AE

5. Develop and demonstrate in-depth knowledge of the pathophysiology, clinical manifestations, diagnosis and management of cardiac diseases, as seen on a coronary care unit.

DPC, AR AE


DPC, AR, EP

AE

7. Develop and demonstrate in-depth knowledge of the indications for, principles, complications, and interpretation of ECG, inpatient 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.

DPC, DSP, AR, HC

AE, DSP


DPC, AR, PCF

AE


DPC, AR AE




DPC, AR AE, ECR


DPC, AR AE, PR, ECR

3. Communicate effectively with colleagues when signing out DPC or turning over care to another service.

DPC, AR AE, PR, ECR

!"*"#+*,'!+*%'-#.$';'!+*1."2"3,'!"#&-2$'&%*5.!%'at Lyndon Baines Johnson'Hospital 67 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 1(''7EGVMSSFGCBHFST' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'



DPC AE, PR, ECR


DPC, PC AE, ECR


DPC, PC AE, ECR






DPC, CC, OWE

AE


DPC AE


DPC, FS AE

'<(''&JSLMTS[:BSMD'7EBOLFOM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'



DPC, PC AE


DPC, PC AE


DPC AE


DPC AE, PR


DPC, PC AE, ECR


DPC, AR AE

7. Effective collaboration with other members of the health care team, including residents, medical students, nurses, clinical

DPC, PC AE, ECR

!"*"#+*,'!+*%'-#.$';'!+*1."2"3,'!"#&-2$'&%*5.!%'at Lyndon Baines Johnson'Hospital 68 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

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.


DPC, PC AE


DPC, ACS AE

10. Ability to lead team, including medical students, residents, nurses, clinical pharmacist, case manager, and social worker.

DPC, ACS AE, ECR

11. Willingness and ability to teach medical students and residents. DPC AE, PR +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.

%!6"!+*1."3*+76,'*"$+$."#'at Lyndon Baines Johnson Hospital 69 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Line of Responsibility

%!6"!+*1."3*+76,'''*"$+$."#'at Lyndon Baines Johnson Hospital

%OUGP&LEMSS'2BY'One CDR is assigned to the noninvasive lab. The CDR is expected to perform a number of duties in the Heart Station including supervision of stress tests and their interpretation and interpretation of echocardiograms. The CDR’s responsibilities include obtaining an informed consent and brief history and, if pertinent, perform a focused examination in patients undergoing stress testing or TEE. The trainees are expected to be available for the final interpretation of the noninvasive tests by the attending. !BEDFGHGIJ'!HFCFO'CDRs are expected to attend the weekly continuity cardiology clinic on Wednesdays from noon until 5:00 p.m. On average, about 35 patients are seen together with the attending. The fellows are responsible for follow-up arrangements and prescriptions. #FIUL'BCD'4MMQMCD !BHH'Fellows are expected to take weekend and night call from home on alternating assignments, and will not be scheduled for night call at Hermann Hospital during these rotations.

%!6"!+*1."3*+76,'*"$+$."#'at Lyndon Baines Johnson Hospital 70 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

%!6"!+*1."3*+76,'''*"$+$."#'at Lyndon Baines Johnson Hospital

The Lyndon Baines Johnson (LBJ) Echocardiography (ECHO) rotation lasts for one month. One second or third year fellow is assigned each month. The fellow will have no in-house call, and will have two days a week off. During the rotation, the assigned fellow 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 LBJ ECHO rotation include patients of faculty physicians or unassigned patients admitted from the clinics or ER. 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 and 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 echo core lecture which all fellows attend, regardless of the rotation they are currently participating.

%!6"!+*1."3*+76,'*"$+$."#'at Lyndon Baines Johnson Hospital 71 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum Once a month each fellow rotating through the LBJ echocardiography lab will also prepare and present a conference in a subject within the spectrum of echocardiography. '%DROBLFGCBH'!GCLMCL'The echocardiography laboratory at LBJ Hospital has a volume of around 5,000 studies per year including between 300-400 transesophageal echos and around 100-200 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



'

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 Lyndon Baines Johnson Hospital is included in the front of the report for further information.

%!6"!+*1."3*+76,'*"$+$."#'at Lyndon Baines Johnson Hospital 72 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum +(''7BLFMCL'!BEM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Take a pertinent medical history and perform a careful and accurate physical examination with a cardiology focus for the optimal performance of an echocardiographic study.

DPC, AR AE

2. Learn the proper techniques of performing echocardiographic procedures, including transthoracic, transesophageal, and stress echocardiography.

DPC, DSP, EC

AE, DSP

3. Know the common medications along with potential reactions and side effects of these medications given for echocardiographic procedures.

DPC, DSP AE

4. Perform all aspects of echocardiographic procedures, including two-dimensional, color flow Doppler, pulse and continuous wave Doppler, tissue Doppler, contrast and stress echocardiography.

DPC, DSP, EC

AE, DSP

5. Perform all procedures with emphasis on patient comfort and safety.

DPC, DSP AE, DSP

6. Recognize and manage complications associated with echocardiographic procedures.

DPC, AR AE

7. Produce accurate reports of the findings of an echocardiographic exam.

DPC, DSP AE



1. Understand the indications, contra-indications, potential complications, and benefits for performing transthoracic, transesophageal, and stress echos.

DPC, AR, EC

AE

2. Learn the methods and technical aspects of two-dimensional echo, color flow Doppler, pulse and continuous wave Doppler, tissue Doppler, contrast and stress echocardiography.

DPC, DSP, EC

AE, DSP

3. Master the echo evaluation of valvular heart disease, cardiac systolic and diastolic function, pericardial disease, cardiomyopathies, and diseases of the aorta.

DPC, DSP, EC

AE, DSP

4. Learn the echocardiographic evaluation of congenital heart disease, infective endocarditis, cardiac masses and tumors.

DPC, DSP, EC

AE, DSP

5. Echocardiographic evaluation of post-surgical cardiac patients including, valvular repair/replacement, aorta repair, ventricular assist devices, pacemakers, and cardiac defibrillators.

DPC, DSP, EC

AE, DSP

6. Access and critically evaluate current medical information and scientific evidence relevant to echocardiography.

DPC, AR, EC

AE

%!6"!+*1."3*+76,'*"$+$."#'at Lyndon Baines Johnson Hospital 73 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum !(''.CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'



DPC AE, ECR


DPC AE, PR, ECR

3. Communicate effectively with colleagues when reporting pertinent findings of echocardiographic studies.

DPC, EC AE, PR, ECR




DPC AE, PR, ECR


DPC, PC AE, ECR


DPC, PC AE, ECR





1. Identify and acknowledge gaps in personal knowledge and skills in performing and interpreting echocardiographic studies.

DPC, EC, OWE

AE

2. Develop real-time strategies for filling knowledge gaps that will benefit patients in the echo lab, coronary care units, or other intensive care units.

DPC AE


DPC, FS AE

%!6"!+*1."3*+76,'*"$+$."#'at Lyndon Baines Johnson Hospital 74 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum <(''&JSLMTS[:BSMD'7EBOLFOM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Understand and utilize the multidisciplinary resources necessary to perform echocardiographic studies optimally on acutely ill cardiac patients.

DPC, PC AE

2. Collaborate with other members of the health care team to assure comprehensive care.

DPC, PC AE

3. Use evidence-based, cost-conscious strategies in the appropriate performance of echocardiographic studies.

DPC AE


DPC AE, PR


DPC, PC AE, ECR

6. Learning by performance of echocardiographic studies, attending teaching conferences and other educational activities.

DPC, AR AE


DPC, PC AE, ECR


DPC, PC AE


DPC, ACS AE

10. Ability to lead team, including nurses, echo technicians, and stress ECG technicians.

DPC, ACS AE, ECR

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

%!6"!+*1."3*+76,'*"$+$."#'at Lyndon Baines Johnson Hospital 75 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.

6%+*$'<+.2-*%'+#1'$*+#&72+#$+$."#'&%*5.!%'at St. Luke’s/THI/UT''''''''''''''''''''''''''''''''''''''''''''''76 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Line of Responsibility

6%+*$'<+.2-*%'+#1'$*+#&72+#$+$."#'&%*5.!% at St. Luke’s Episcopal Hospital/Texas Heart Institute/The University of Texas Health

Science Center at Houston

One cardiology fellow from the UT program will be assigned to the cardiac transplant service at SLEH. Service duties will include participation in the care of patients before and after cardiac transplantation. Night call responsibility will be limited to that assigned by the transplant service. Cardiac catheterization laboratory duties will be limited to the performance of endomyocardial biopsy and accompanying procedures on transplanted, or transplant accepted patients admitted to SLEH. For inpatient biopsy procedures in the above-described patients, the fellow assigned to the transplant service will have precedence over SLEH fellows regardless of the primary attending or SLEH fellow service assignment. Outpatient procedures and those performed on patients classified as "same day admission" are the responsibility of the SLEH fellow assigned to the attending physician's service. In addition, when transplant service duties have been fulfilled, the fellow assigned to the transplant service will have the opportunity to assist with other procedures performed in the cath lab providing the following criteria are met:

1. No SLEH fellow has been assigned to the case. 2. The attending physician is a member of the "teaching staff'. 3. A diagnostic procedure or endomyocardial biopsy is the planned procedure.

No attempts should be made to assist in planned interventional procedures.

6%+*$'<+.2-*%'+#1'$*+#&72+#$+$."#'&%*5.!%'at St. Luke’s/THI/UT''''''''''''''''''''''''''''''''''''''''''''''77 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

6%+*$'<+.2-*%'+#1'$*+#&72+#$+$."#'&%*5.!% at St. Luke’s Episcopal Hospital/Texas Heart Institute/The University of Texas Health

Science Center at Houston

During the heart failure and transplantation rotation at the cardiopulmonary transplantation program of St. Luke’s Episcopal Hospital/Texas Heart Institute/The University of Texas Health Science Center-Houston, the cardiology fellow is exposed to the management of patients before and after cardiac transplant, patients with severe heart failure and use of mechanical support devices. The cardiology fellow will have the opportunity to manage these patients, observe surgical procedures and perform myocardial biopsy, heart catheterization. As heart failure is increasing in prevalence, this educational experience will be an important component of the fellow’s training. It will give them the background to effectively manage end stage heart failure and determine appropriate time for referral for therapies such as transplant and use of the left ventricular assist device. A detailed description of the on-going learning activities at the cardiopulmonary transplantation program of St. Luke’s Episcopal Hospital/Texas Heart Institute/The University of Texas Health Science Center-Houston is included. 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



'

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

6%+*$'<+.2-*%'+#1'$*+#&72+#$+$."#'&%*5.!%'at St. Luke’s/THI/UT''''''''''''''''''''''''''''''''''''''''''''''78 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 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 St Luke’s Episcopal Hospital/Texas Heart Institute is included. 73[\'/3GBHS'BEM'VGE'VFESL'JMBE'OBEDFGHGIJ'VMHHGW'HMNMH0''+('7BLFMCL'!BEM'


1.


DPC, AR AE

2.



MC, FS AE

3.

Effectively evaluate and manage patients with complex cardiac illnesses, particularly, congestive heart failure, ventricular assist device and cardiac transplantation patients.


4.

Ability to risk stratify patients after being evaluated by echocardiography, cardiac stress test, coronary angiograms, nuclear cardiovascular procedures and other invasive and non-invasive procedures.


5. Ability to manage patients who have had left and right catheterization, heart transplantation and devices.


6. Effectively direct the team performing CPR and advance cardiac life support in heart failure and transplant service.

DPC, EP, IL AE

7. Ability to manage complications from invasive and heart transplantation related procedures. DPC, FS AE

8.

Ability to participate in behavior modification and strategies to educate patients and other health professionals in the management of heart transplant and heart failure.


9. Participation in the discussion of end-of-life issues with patients and their families. DPC, FS, ET AE, PR


10.

Participation in all non-invasive and invasive cardiovascular procedures using the proper technique and under the supervision of a teaching faculty. Observe heart transplantation operation and organ procurement.

DPC, FS AE, DSP



1. Familiarity with the newest basic science concepts and mechanisms of heart failure and transplantation.


2. Familiarity with current medical literature, clinical trials, and evidence based medicine in heart failure and transplantation.

JC, CC AE

3. Familiarity with the broad spectrum of heart failure and transplantation. CC, NC, PR AE, ECR

4. Familiarity with the pathophysiologic principles of heart failure and transplantation.

AU, EP AE, DSP



1.


DPC, AR, PC AE, PR



6%+*$'<+.2-*%'+#1'$*+#&72+#$+$."#'&%*5.!%'at St. Luke’s/THI/UT''''''''''''''''''''''''''''''''''''''''''''''80 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 1(' 7EGVMSSFGCBHFST



DPC, AR, PC AE, PR


''%('%NFDMCOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL



2. Broad reading of the cardiovascular literature and access and research of Medline and internet tools. JC, RC FP, PR

<(' &JSLMTS[:BSMD'7EBOLFOM



DPC, AR AE






DPC, AR AE


7. Expand learning in outpatient ultrasound and nuclear cardiology to optimize understanding of patients risk stratification.

DPC, AR AE


DPC, AR AE

+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). � Pertinent AHA/ACC Scientific Statements and Guidelines and Books and Journals in Heart

Failure and Transplantation @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.

!2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';'.#5+&.5%'!+*1."2"3,'''''''''''''''''''''''''''''''''''82' at St. Luke’s Episcopal Hospital/Texas Heart Institute The University of Texas-Houston Health Science Center Cardiology Fellowship Program Line of Responsibility

!2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';'.#5+&.5%'!+*1."2"3,'

at St. Luke’s Episcopal Hospital/Texas Heart Institute

The fellow is responsible for evaluation of all new admissions during the week. He is responsible for overseeing the orders of the house staff and for designating specific patients for student evaluations. On all consult patients, a complete "History & Physical" should be dictated and an inclusive "Admission Note" should be included. If the patient has been recently seen in the outpatient clinic by a staff cardiologist, a brief note covering the intervening period should be included. It is expected that the fellow's clinical evaluations will be concise and complete, including in specific terms every relevant clinical diagnosis whether a cardiologic problem or not. The fellow is responsible for writing the initial orders and for formulating diagnostic and therapeutic plans. He should assist the house officers and supervise their orders. Precatheterization orders are the fellow's responsibility. Similarly, it is his duty to assure that catheterization permits have been signed before the intended study. The fellow should write post-catheterization orders and a brief synopsis of the catheterization procedure. The CDR should be familiar with each patient on whom he will assist during the catheterization procedure. She/he should be thoroughly acquainted with the patient's past medical history and have reviewed all pertinent, noninvasive data. She/he is to assist the staff cardiologist to a degree appropriate for his level of training. She/he is to review all cineangiograms and is expected to evaluate all hemodynamic and electrophysiologic data. She/he is encouraged to make a pictorial assessment of the patient's coronary anatomy and to suggest appropriate therapy. The fellow is encouraged to attend all didactic lectures. If his assigned service is presenting at the cardiology catheterization and angiogram conference, he may be called upon to present at this conference.

!2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';'.#5+&.5%'!+*1."2"3,'''''''''''''''''''''''''''''''''''83''''''at St. Luke’s Episcopal Hospital/Texas Heart Institute The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

!2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';'.#5+&.5%'!+*1."2"3,'

at St. Luke’s Episcopal Hospital/Texas Heart Institute

The St. Luke’s Episcopal Hospital/Texas Heart Institute Clinical Cardiology, Cardiac Catheterization, & Invasive Cardiology rotation last for two months. One second or third year fellow is assigned to this rotation each month. This educational experience is an important component of the fellows’ training. It gives them the opportunity to effectively practice cardiology and perform cardiac catheterization and interventional procedures with an experience and distinguish cadre of faculty from St. Luke’s Episcopal Hospital/Texas Heart Institute. %DROBLFGCBH'2MNMHS''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.

!2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';'.#5+&.5%'!+*1."2"3,'''''''''''''''''''''''''''''''''''84''''''at St. Luke’s Episcopal Hospital/Texas Heart Institute The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 7EFCOFKBH'$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.

!2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';'.#5+&.5%'!+*1."2"3,'''''''''''''''''''''''''''''''''''85''''''at St. Luke’s Episcopal Hospital/Texas Heart Institute 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

!2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';'.#5+&.5%'!+*1."2"3,'''''''''''''''''''''''''''''''''''86''''''at St. Luke’s Episcopal Hospital/Texas Heart Institute The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum level 2 = 10-12 months (minimum 300 cases, typically> 700 cases). Fellows also gain experience in the insertion of temporary pacemakers, pericardiocentesis and intra-aortic balloon placement during this rotation. 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



'

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 St Luke’s Episcopal Hospital/Texas Heart Institute is included. 73[]'BCD'^'/3GBHS'BEM'VGE'LUM'SMOGCD'BCD'LUFED'JMBE'OBEDFGHGIJ'VMHHGW'HMNMH0''+('7BLFMCL'!BEM'


1.


DPC, AR AE


2.



MC, FS AE

3. Effectively evaluate and manage patients with complex cardiac illnesses, particularly, patients need cardiac catheterization and angiography.


4.

Ability to risk stratify patients after being evaluated by echocardiography, cardiac stress test, coronary angiograms, nuclear cardiovascular procedures and other invasive and non-invasive procedures.


5. Ability to manage patients who have had left and right catheterization and intervention.


6. Effectively direct the team performing CPR and advance cardiac life support in patients related to cardiac catheterization and intervention.

DPC, EP, IL AE

7. Ability to manage complications from cardiac catheterization and intervention related procedures. DPC, FS AE

8.

Ability to participate in behavior modification and strategies to educate patients and other health professionals in the management of cardiovascular disease.


9. Participation in the discussion of end-of-life issues with patients and their families. DPC, FS, ET AE, PR


DPC, FS AE, DSP



1. Familiarity with the newest basic science concepts and mechanisms of invasive cardiology.


2. Familiarity with current medical literature, clinical trials, and evidence based medicine in invasive cardiology.

JC, CC AE


3. Familiarity with the broad spectrum of invasive cardiology CC, NC, PR AE, ECR

4. Familiarity with the pathophysiologic principles of cardiovascular disease.

AU, EP AE, DSP



1.


DPC, AR, PC AE, PR



1(' 7EGVMSSFGCBHFST



DPC, AR, PC AE, PR


!2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';'.#5+&.5%'!+*1."2"3,'''''''''''''''''''''''''''''''''''89''''''at St. Luke’s Episcopal Hospital/Texas Heart Institute The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum E. 7EBOLFOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL



2. Broad reading of the cardiovascular literature and access and research of Medline and Internet tools. JC, RC FP, PR

<(' &JSLMTS[:BSMD'7EBOLFOM



DPC, AR AE


3. Understand the system complexities in invasive cardiology. DPC, AR, GR AE




DPC, AR AE

7. Expand learning in review of angiographic films on daily basis. DPC, AR AE


DPC, AR AE

!2.#.!+2'!+*1."2"3,9'!+*1.+!'!+$6%$%*.8+$."#9';'.#5+&.5%'!+*1."2"3,'''''''''''''''''''''''''''''''''''90''''''at St. Luke’s Episcopal Hospital/Texas Heart Institute 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 � 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 AHA/ACC Scientific Statements and Guidelines and Grossman’s Cardiac

Catheterization and Intervention. @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.

!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'at University of Texas M.D. Anderson'''''''''''''''''' 91 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Line of Responsibility

!+*1."5+&!-2+*''1.&%+&%''!"#&-2$''&%*5.!%'At University of Texas M. D. Anderson

The hospital is approximately 468 beds with a 52 bed intensive care unit and 27 operating rooms. The cardiology fellows will spend the majority of the rotation performing inpatient cardiology consultations. There will be daily teaching rounds with the attending cardiologist responsible for the inpatient consult service (monthly average of 110 new patient consults and 600 patient visits.) UTMDACC has daily EKG interpretation sessions, averaging 3,000 per month, and echo/Doppler interpretations in association with the patients on the inpatient consult service. There are opportunities to perform transesophageal echocardiography in the cardiology lab as well as in the operating room, 350-400 echocardiograms and 40-50 stress echos per month. UTMDACC has an ICAEL accredited echocardiography laboratory with monthly conferences. The lab currently averages 40-50 nuclear stress tests and shares equipment in another department. A nuclear cardiology laboratory is currently under construction and is anticipated to be operational in June 2002. The cardiology outpatient clinic averages 200 consultations monthly. The Department of Cardiology has weekly Grand Rounds featuring cardiologist from the Houston area and distinguished national speakers. In addition to the strength in clinical cardiology, the Department also has an active program in clinical research and one of the best vascular biology laboratories in the world. Through active participation, fellows rotating through MD Anderson Cancer Center will benefit from weekly meetings in these disciplines. The fellows will have direct contact through inpatient care under the direct supervision of UTMDACC faculty. They will examine patients in the hospital, performing diagnostic and therapeutic procedures to formulate care plans specific to the cancer patient with cardiovascular problems. The fellows will participate in conferences, rounds, Grand Rounds, echocardiography in the cardiology lab as well as in the operating room, nuclear cardiology lab, clinical and academic research, and EKG. The fellows will participate in rounding one weekend per month during their rotation.

!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'BL'-CFNMESFLJ'of Texas M.D. Anderson'''''''''''''''' 92 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

!+*1."5+&!-2+*''1.&%+&%''!"#&-2$''&%*5.!%'At University of Texas M. D. Anderson

The cardiology fellowship program at M.D. Anderson is an important part of the educational mission of the Department of Cardiology. It provides unique experience for the residents to learn how to manage cardiovascular problems in complicated and challenging cases. In addition to commonly seen cardiology problems, residents will be exposed to unique cardiovascular syndromes, such as carcinoid heart disease, cardiac tumors, malignant pericardial effusions, and infiltrative cardiomyopathies. Fellows will learn to identify and treat complications of cancer treatment such as chemotherapy and radiation induced cardiac disease. Fellows will develop consultative skills in an inpatient setting and gain exposure to clinical cardiology research. Through both didactic and practical teaching, the resident will gain expertise in the performance of diagnostic and therapeutic procedures, such as right heart cath, pacemaker placement, and pericardiocentesis. '''!BEDFGHGIJ'&MENFOM'

The hospital is approximately 468 beds with a 52 bed Intensive Care Unit and 27 operating rooms. The cardiology fellows will spend the majority of the rotation performing inpatient cardiology consultations. There will be daily teaching rounds with the attending cardiologist responsible for the inpatient consult service (monthly average of 110 new patient consults and 600 patient visits). UTMDACC has daily EKG interpretations sessions, averaging 3,000 per month, and echo/Doppler interpretations in association with the patients on the inpatient consult service. There will be opportunities to perform transesophageal echocardiography in the cardiology lab as well as in the operating room, 350-400 echocardiograms and 40-50 stress echos per month. UTMDACC frequently performs echo-guided pericardiocentesis for patients with cardiac tamponade. UTMDACC has an ICAEL accredited echocardiography laboratory with monthly conferences. The lab currently averages 40-50 nuclear stress tests and shares equipment in another department. A nuclear cardiology laboratory is currently under construction and is anticipated to be operational in May 2002. The cardiology outpatient clinic averages 200 consultations monthly. The Department of Cardiology has weekly Grand Rounds featuring cardiologists from the Houston area and distinguished national speakers. In addition to the strength in clinical cardiology, the Department also has an active program in clinical research and one of the best vascular biology laboratories in the world. Through active participation, fellows rotating through M.D. Anderson will benefit from weekly meetings in these disciplines. 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* - Grand Rounds 17! - Direct Patient Care 6! - Hemodynamic Conference 7!< - Preventive Cardiology Forum 1&7 - Directly Supervised Proc .! - Interventional Cardiology Course 7* - President's Rounds

7! - Professionalism Curriculum

%! - 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'

7*''' Peer Review'<7 Fellow Portfolios' ** Record Review "4% Oral/Written Exams '

%!*'''Educational Committee Review(2 x annually)'

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'


1. Ability to obtain a complete medical history, perform a careful and accurate examination with emphasis on the cardiac exam, and review charts and pertinent records.

DPC, AR AE

2. Ability to write a concise evaluation, assess the cardiovascular risk of the patient and make therapeutic decisions and proper interventions based on patient preferences, scientific evidence, and sound clinical judgment.


MC, FS AE

3. Effectively evaluate and manage patients with complex cardiac illnesses, particularly, acute coronary syndromes, congestive heart failure, valvular heart disease, unique cardiovascular syndromes, carcinoid heart disease, cardiac tumors, cardiomyopathies, and pericarditis.


DSP, CC AE

4. Ability to risk stratify patients after being evaluated by echocardiography, cardiac stress test, right heart catheterization, nuclear cardiovascular procedures and other invasive and non-invasive procedures.


5. Ability to manage patients prior to, during, and after interventional procedures including pacemaker 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

non-invasive procedures. DPC, FS AE

8. Ability to participate in behavior modification and strategies to educate patients and other health professionals in the management of cardiovascular risk factors and life style modification.


9. Participation in the discussion of end-of-life issues, cancer and cardiovascular disease with patients and their families.

DPC, FS, ET AE, PR


DPC, FS AE, DSP

B. @MDFOBH'ZCGWHMDIM 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Familiarity with the newest basic science concepts and mechanisms of cardiovascular disease.


2. Familiarity with current medical literature, clinical trials, and evidence based medicine in cardiology. JC, CC, GR AE

3. Familiarity with the broad spectrum of cardiovascular diseases. CC, NC, PR, GR AE, ECR

4. Familiarity with the pathophysiologic, genetic, and molecular principles of cardiovascular disease. AU, CC, GR AE, DSP

C. .CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'



DPC, AR, PC AE, PR


DPC, AR AE, PR


!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'BL'-CFNMESFLJ'of Texas M.D. Anderson'''''''''''''''' 95 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum D. 7EGVMSSFGCBHFST 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'



DPC, AR, PC AE, PR

2. Appreciation of the spiritual and social context of cancer and cardiovascular illness. DPC, AR, ET AE

E. 7EBOLFOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Commitment to scholarship and the use of evidence based cardiovascular medicine. CC, GR, LC, PR AE, ECR

2. Broad reading of the cardiovascular literature and the productive use of Medline and internet tools. CC, GR, JC, RC AE, ECR

F. &JSLMTS[:BSMD'7EBOLFOM 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Understand the complexities of cardiovascular disease and cancer patients and utilize the multidisciplinary resources necessary to care for them.

DPC, AR AE






DPC, AR AE

7. Expand learning in out-patient ultrasound and nuclear cardiology to optimize understanding of patients risk stratification.

DPC, AR AE


DPC, AR AE

!+*1."5+&!-2+*'1.&%+&%'!"#&-2$'&%*5.!%'BL'-CFNMESFLJ'of Texas M.D. Anderson'''''''''''''''' 96 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum +COFHHBEJ'%DROBLFGCBH'@BLMEFBHS


available from fellowship office). ! Mayo Cardiovascular Board Review, (copies available from fellowship office). ! Pertinent AHA/ACC Scientific Statements and Guidelines (see attached list).

@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, all the teaching faculty and the rotations will be evaluated by all the trainees in the annual evaluation of the program by the fellows. <MHHGWS_'*MSKGCSFYFHFLFMS''The fellows will have direct contact through inpatient care under the direct supervision of UTMDACC faculty. They will examine patients in the hospital, performing diagnostic and therapeutic procedures to formulate care plans specific to the cancer patient with cardiovascular problems. The fellows will participate in conferences, rounds, Grand Rounds, echocardiography in the cardiology lab as well as in the operating room, nuclear cardiology lab, clinical and academic research, and EKG. The fellows will participate in rounding one weekend per month during their rotation.

&RKMENFSFGC'GV'LUM'7BELFOFKBCL'FC'LUFS'7EGIEBT''

Joseph Swafford, MD, Associate Professor of Medicine, Director, Clinical Cardiology, Director, Noninvasive Laboratory, Department of Cardiology.

*M`RFEMD'1FDBOLFO'%NMCLS''Monday-Friday 8:30-9:30 am Cardiology Morning Report Wednesday 1:00-2:00 pm Cardiology Grand Rounds (lunch provided) Friday 1:00-2:00 pm Cardiology Clinical Practice Conference (lunch provided) 3rd Monday/Month 3:00-4:00 pm Clinical Research Meeting Tuesday 7:00-8:00 am Hemodynamic Conference at Memorial Hermann Thursday 7:00-8:00 am Core Curriculum at Memorial Hermann 12:00-1:00 pm Grand Rounds at Memorial Hermann 5:00-6:00 pm Cardiac Catheterization Conference at Memorial Hermann ''''

!+*1."5+&!-2+*'1.&%+&%'#"#.#5+&.5%'*"$+$."#'at University of Texas M.D. Anderson'''''' 97 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Line of Responsibility

!+*1."5+&!-2+*''1.&%+&%''#"#.#5+&.5%''*"$+$."#'At University of Texas M. D. Anderson

The hospital is approximately 468 beds with a 52 bed intensive care unit and 27 operating rooms. The cardiology fellows will spend the majority of the rotation performing inpatient cardiology consultations. There will be daily teaching rounds with the attending cardiologist responsible for the inpatient consult service (monthly average of 110 new patient consults and 600 patient visits.) UTMDACC has daily EKG interpretation sessions, averaging 3,000 per month, and echo/Doppler interpretations in association with the patients on the inpatient consult service. There are opportunities to perform transesophageal echocardiography in the cardiology lab as well as in the operating room, 350-400 echocardiograms and 40-50 stress echos per month. UTMDACC has an ICAEL accredited echocardiography laboratory with monthly conferences. The lab currently averages 40-50 nuclear stress tests and shares equipment in another department. A nuclear cardiology laboratory is currently under construction and is anticipated to be operational in June 2002. The cardiology outpatient clinic averages 200 consultations monthly. The Department of Cardiology has weekly Grand Rounds featuring cardiologist from the Houston area and distinguished national speakers. In addition to the strength in clinical cardiology, the Department also has an active program in clinical research and one of the best vascular biology laboratories in the world. Through active participation, fellows rotating through MD Anderson Cancer Center will benefit from weekly meetings in these disciplines. The fellows will have direct contact through inpatient care under the direct supervision of UTMDACC faculty. They will examine patients in the hospital, performing diagnostic and therapeutic procedures to formulate care plans specific to the cancer patient with cardiovascular problems. The fellows will participate in conferences, rounds, Grand Rounds, echocardiography in the cardiology lab as well as in the operating room, nuclear cardiology lab, clinical and academic research, and EKG. The fellows will participate in rounding one weekend per month during their rotation.

!+*1."5+&!-2+*'1.&%+&%'#"#.#5+&.5%'*"$+$."#'at University of Texas M.D. Anderson' 98 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

'!+*1."5+&!-2+*''1.&%+&%''#"#.#5+&.5%''*"$+$."#'

At University of Texas M. D. Anderson

The cardiology fellowship program at M.D. Anderson is an important part of the educational mission of the Department of Cardiology. It provides unique experience for the residents to learn how to manage cardiovascular problems in complicated and challenging cases. In addition to commonly seen cardiology problems, residents will be exposed to unique cardiovascular syndromes, such as carcinoid heart disease, cardiac tumors, malignant pericardial effusions, and infiltrative cardiomyopathies. Advance electrocardiography Holter monitoring interpretation, echocardiography including transesophageal echocardiography, Dopler and contrast echocardiography and perform echo guided pericardiocentesis, and exercise echocardiography with will motion recognition. Fellows will learn to identify and treat complications of cancer treatment such as chemotherapy and radiation induced cardiac disease. Fellows will develop consultative skills in an inpatient setting and gain exposure to clinical cardiology research. Through both didactic and practical teaching, the resident will gain expertise in the performance of diagnostic and therapeutic procedures, such as right heart cath, pacemaker placement, and pericardiocentesis. !BEDFGHGIJ'&MENFOM'The hospital is approximately 468 beds with a 52 bed Intensive Care Unit and 27 operating rooms. The cardiology fellows will spend the majority of the rotation performing inpatient cardiology consultations. There will be daily teaching rounds with the attending cardiologist responsible for the inpatient consult service (monthly average of 110 new patient consults and 600 patient visits). UTMDACC has daily EKG interpretations sessions, averaging 3,000 per month, and echo/Doppler interpretations in association with the patients on the inpatient consult service. There will be opportunities to perform transesophageal echocardiography in the cardiology lab as well as in the operating room, 350-400 echocardiograms and 40-50 stress echos per month. UTMDACC frequently performs echo-guided pericardiocentesis for patients with cardiac tamponade. UTMDACC has an ICAEL accredited echocardiography laboratory with monthly conferences. The lab currently averages 40-50 nuclear stress tests and shares equipment in another department. A nuclear cardiology laboratory is operational and myocardial profusion, viability studies, nuclear stress test, and magnetic resonance imaging are performed. The cardiology outpatient clinic averages 200 consultations monthly. The Department of Cardiology has weekly Grand Rounds featuring cardiologists from the Houston area and distinguished national speakers. In addition to the strength in clinical cardiology, the Department also has an active program in clinical research and one of the best vascular biology laboratories in the world. Through active participation, fellows rotating through M.D. Anderson will benefit from weekly meetings in these disciplines.

!+*1."5+&!-2+*'1.&%+&%'#"#.#5+&.5%'*"$+$."#'at University of Texas M.D. Anderson' 99 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum

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


'


'

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'


1. Ability to perform and interpret ECG, Holter monitor, echocardiography, nuclear cardiology, and magnetic resonance imaging.

DPC, AR AE

2. Ability to write a concise evaluation and interpretation of the above studies.


CC, FS AE

3. Effectively evaluate patients with complex cardiac illnesses and cancer by noninvasive methods


DSP, CC AE

4. Ability to risk stratify patients after being evaluated by echocardiography, cardiac stress test, nuclear cardiology and other noninvasive procedures.


!+*1."5+&!-2+*'1.&%+&%'#"#.#5+&.5%'*"$+$."#'at University of Texas M.D. Anderson' 100 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum :( @MDFOBH'ZCGWHMDIM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Familiarity with the newest concepts in EKG, Holter, echo, nuclear, and magnetic resonance imaging.


2. Familiarity with current medical literature, clinical trials, and evidence based medicine in cardiology. JC, CC AE

3. Familiarity with the broad spectrum of cardiovascular noninvasive literature. CC, NC, PR AE, ECR

''!( .CLMEKMESGCBH'&QFHHS'BCD'!GTTRCFOBLFGC' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Communicate effectively the noninvasive study findings with physician colleagues and other members of the health care team in a timely fashion to assure a comprehensive patient care.

DPC, AR, PC AE, PR


DPC, AR AE, PR

3. Provide educational instructions to patients and families when indicated. DPC, AR AE, PR

1( 7EGVMSSFGCBHFST' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'



DPC, AR, PC AE, PR

2. Appreciation of the spiritual and social context of illness in patients with cancer and cardiovascular disease.

DPC, AR, ET AE

%( 7EBOLFOM[:BSMD'2MBECFCI'BCD'.TKEGNMTMCL' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Commitment to scholarship and the use of modern technology. CC, GR, LC, PR AE, ECR

!+*1."5+&!-2+*'1.&%+&%'#"#.#5+&.5%'*"$+$."#'at University of Texas M.D. Anderson' 101 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum 2. Broad reading of the noninvasive cardiovascular

literature and access and research of Medline and internet tools.

CC, GR, JC AE, ECR

<( &JSLMTS[:BSMD'7EBOLFOM' 7EFCOFKHM'%DROBLFGCBH'3GBHS' 2MBECFCI'


1. Understand the complexities of noninvasive cardiology and utilize the technological resources available.

DPC, AR AE

2. Collaborate with other member of the health care team to assure patient comfort and safety. DPC, AR AE

3. Understand the system complexities in noninvasive cardiology. DPC, AR, GR AE

4. Willingness to learn by participation in teaching conferences and other educational activities. DPC, AR AE

5.

Develop effective communication with referring physician, health care team, patient and their family regarding purpose and findings of the noninvasive studies.

DPC, AR AE

6. Expand learning in the in-hospital evaluation of patients by noninvasive methods to optimize risk stratification.

DPC, AR AE

7. Consideration of cost effectiveness and outcome measurements of noninvasive procedures. DPC, AR AE

+COFHHBEJ'%DROBLFGCBH'@BLMEFBHS


available from fellowship office). ! Mayo Cardiovascular Board Review, (copies available from fellowship office). ! Pertinent AHA/ACC Scientific Statements and Guidelines (see attached list).

@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, all the teaching faculty and the rotations will be evaluated by all the trainees in the annual evaluation of the program by the fellows. ''

!+*1."5+&!-2+*'1.&%+&%'#"#.#5+&.5%'*"$+$."#'at University of Texas M.D. Anderson' 102 The University of Texas-Houston Health Science Center Cardiology Fellowship Program Curriculum <MHHGWS_'*MSKGCSFYFHFLFMS'''

The fellows will have direct contact through inpatient care under the direct supervision of UTMDACC faculty. They will examine patients in the hospital, performing diagnostic and therapeutic procedures to formulate care plans specific to the cancer patient with cardiovascular problems. The fellows will participate in conferences, rounds, Grand Rounds, echocardiography in the cardiology lab as well as in the operating room, nuclear cardiology lab, clinical and academic research, and EKG. The fellows will participate in rounding one weekend per month during their rotation. &RKMENFSFGC'GV'LUM'7BELFOFKBCL'FC'LUFS'7EGIEBT''

Joseph Swafford, MD, Associate Professor of Medicine, Director, Clinical Cardiology, Director, Noninvasive Laboratory, Department of Cardiology. *M`RFEMD'1FDBOLFO'%NMCLS' Monday-Friday 8:30-9:30 am Cardiology Morning Report Wednesday 1:00-2:00 pm Cardiology Grand Rounds (lunch provided) Friday 1:00-2:00 pm Cardiology Clinical Practice Conference (lunch provided) 3rd Monday/Month 3:00-4:00 pm Clinical Research Meeting Tuesday 7:00-8:00 am Hemodynamic Conference at Memorial Hermann Thursday 7:00-8:00 am Core Curriculum at Memorial Hermann 12:00-1:00 pm Grand Rounds at Memorial Hermann 5:00-6:00 pm Cardiac Catheterization Conference at Memorial Hermann

+1@.#.&$*+$."#'"<'$6%'7*"3*+@&''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''103 The University of Texas-Houston Health Science Center Cardiology Fellowship Program

+1@.#.&$*+$."#''"<''$6%''7*"3*+@&'Internal Medicine Department: Frank Arnett, MD, Chairman

Cardiology Division: Richard W. Smalling, MD, PhD, Director

Chairman: Frank Arnett, MD Internal Medicine Program

Director: Mark A Farnie, MD

Electrophysiology Program

Anne Dougherty, MD

Cardiovascular Disease Program

Francisco Fuentes, MD

Interventional Program Richard Smalling, MD,

PhD The cardiovascular disease program functions as an integral part of the Internal Medicine Department and provides acute and chronic cardiovascular care for internal medicine patients. Also, it provides consultative services and cardiovascular testing such as Holter monitoring, nuclear cardiology, and echocardiography for the internal medicine program. The faculty and CDRs provide training and experience in cardiovascular disease to the internal medicine resident. The internal medicine residents rotate through the clinical cardiology and cardiology consult services on a routine basis and have an opportunity to take elective periods in other cardiology services. Teaching faculty also participates in the internal medicine programs didactic lecture series. Internal medicine faculty has a major contribution in the teaching program of the CDRs. The Texas Medical Center, where all the four institutions are located, is known throughout the world for its leadership in cardiovascular medicine, surgery, and research. The program provides diversity in patient experience by including a number of different hospitals, including a number of not-for-profit and county hospitals. This gives the trainees experience with patients from all economic groups with a wide diversity of cardiovascular and co-morbid diseases. The teaching faculty at UT Houston Medical School has an international reputation, diverse backgrounds, and varied interest. The individual trainee experience in the program is modified to meet the trainee’s career plans. All the CDRs are required to meet all the minimum training requirements and also allows them to concentrate in whatever area they are most interested. A great strength of the program is the opportunity for research. The trainees have opportunities for research in many areas of clinical cardiology, in animal laboratories, and basic science laboratories, at the University of Texas Medical School, The Texas Hearth Institute and the University of Texas Institute of Molecular Medicine. The faculty of the cardiovascular disease program has a long history of making significant contributions to cardiovascular research. '

Documents

Legend for Learning Activities for Fellows