Kuwait Adult Cardiology Residency Training Program

Transcription

1 Kuwait Adult Cardiology Residency Training Program Head of Faculty: Professor Mohammad Zubaid Program Director: Dr. Raja Dashti Sponsoring Institution: KIMS

2 INTRODUCTION Goals... General Objectives.. Specific Objectives (CanMeds Core Competencies) A. Medical Expert/Clinical Decision-Maker.. C. Collaborator... D. Manager... E. Health Advocate... F. Scholar... G. Professional... ROTATION SPECIFIC OBJECTIVES AND SKILLS... Coronary Care Unit... Cardiac Catheterization Laboratory... Echocardiography Electrophysiology Nuclear Cardiology... Advance Cardiac Imaging CT/MRI.. Consultative Cardiology... Cardiology Ward... Heart Failure/Cardiac Transplantation Congenital Cardiology... Research... Elective Rotations... Community Cardiology... Ambulatory Care Requirements... TRAINING PROGRAM STRUCTURE Resources Entry and examination Eligibility. Resident Rotations... Program Coordinators... On-Call Responsibilities... Teaching Rounds... Core Teaching Program/Core Lecture Series... Procedure log book... Evaluation / Appeal Procedures... Quality Assurance And Biomedical Ethics... Vacation and Leaves... Career Counseling... Counseling... RESIDENT ADVOCATE... RESEARCH REQUIREMENTS... CURRICULUM DESIGN REFERENCES LOG BOOK.

3 INTRODUCTION Cardiology is the medical subspecialty concerned with the prevention, diagnosis, management, and rehabilitation of patients with diseases of the cardiovascular system. A Cardiologist is a specialist who is an expert in the diagnosis and management of all aspects of cardiac diseases. The Adult Cardiology Residency Training Program is a three year program in general adult cardiology. It is designed and implemented in a fashion to ensure future accreditation by the Royal college of Physicians and Surgeons of Canada and other international academic organizations/institutions. The responsibility for the organization and conduct of the Adult Cardiology Training Program rests with the head of Faculty, Dr. Mohammad Zubaid, the Program Director, Dr. Raja Dashti, and the Residency Training Program Committee. The Program Director chairs the Residency Training Committee. Other members include program co- coordinators from each of the teaching hospital sites participating in the program, faculty members with special skills/interest and resident representatives from each of the teaching hospitals, from each year of training (first, second and third years), elected by their peers. The Residency Training Committee meets on a regular basis at the call of the Chair, at least quarterly, and supervises, administers, and evaluates all aspects of the Training Program.. GOALS 1. Upon completion of training, a resident is expected to be a competent independent cardiologist and capable of assuming a consultant s role in the specialty. 2. The resident must acquire a working knowledge of the theoretical basis of the specialty, including its foundations in the basic medical sciences and research. 3. Residents must demonstrate the requisite knowledge, skills, and attitudes for effective patient-centered care and service. 4. In all aspects of specialist practice, the graduate must be able to demonstrate ethics in a professional manner. 5. Be able to undertake advanced training in a subspecialty (such as interventional cardiology, Echocardiography, electrophysiology, imaging, heart failure, etc.)

4 GENERAL OBJECTIVES At the completion of training, the resident will have acquired certain competencies that enable him/her to function effectively as a medical expert/clinical decision maker, communicator, collaborator, manager, health advocate, scholar and professional. The graduate cardiologist will have achieved the following general educational objectives and be able to: 1. Provide excellent, comprehensive, and evidence based diagnosis and management for patients with cardiovascular diseases. 2. Have a role in patient and community prevention and rehabilitation of diseases of the cardiovascular system. 3. have a compassionate relationship with patients and their families. 4. Appropriately communicate with other physicians and other health care professionals. 5. Function as a member of the health care team, and coordinate the team as appropriate. 6. Contribute to the education of students, other physicians, other health care professionals, and patients and their families. 7. Perform necessary technical skills specific to management of patients with cardiovascular diseases. 8. Document accurate medical records. 9. Be able to undertake accurate self-appraisal and continuing life long medical education. 10. Be able to critically dissect the cardiology literature and apply valid information to patient Management.

5 SPECIFIC OBJECTIVES (CanMEDS core competencies) This curriculum is designed to assure the teaching and assessment of Can Meds competencies. The following listing of general core competency elements applies to all rotations of the fellowship. In addition, there are rotation- specific core competency- related teaching and assessment A. Medical Expert/Clinical Decision maker General Requirements Demonstrate diagnostic and therapeutic skills for ethical and effective patient care. Access and apply relevant information to clinical practice. Demonstrate effective consultation services with respect to patient care, education, and legal opinions. Specific Requirements Key and Enabling Competencies: Cardiologists are able to 1. Function effectively as consultants to provide optimal, ethical and patient-centered medical care 1.1. Perform a consultation, including the presentation of well-documented assessments and recommendations in written and/or verbal form in response to a request from another health care professional Identify and appropriately respond to relevant ethical issues arising in patient care Demonstrate the ability to prioritize professional duties when faced with multiple patients and problems Demonstrate compassionate and patient-centered care Demonstrate medical expertise in situations other than patient care, such as providing expert legal testimony or advising governments, as needed. 2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Cardiology 2.1. Apply knowledge of the clinical, socio-behavioral, and fundamental biomedical sciences relevant to cardiology including: Coronary Artery Disease Normal coronary anatomy Physiology of normal and abnormal coronary blood flow Normal and abnormal endothelial function Pathogenesis of atherosclerosis Risk factors for atherosclerosis and their management Pathophysiology of acute coronary syndromes

6 Non-atherosclerotic causes of ischemia and infarction Diagnostic techniques for coronary disease, including their sensitivity and specificity Pharmacology of anti-ischemic, antiplatelet, anticoagulant, thrombolytic and lipid-lowering agents Revascularization procedures: percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG), their indications, contraindications and benefits Non-pharmacologic management of end-stage coronary artery disease Sex differences important in the presentation, diagnosis and management of coronary artery disease Ethnic differences important in the incidence of coronary artery disease Valvular Heart Disease Normal valve structure and function Pathology of valvular disease Pathophysiology and hemodynamics of valvular stenosis and regurgitation Diagnostic techniques Valve surgery: indications, including timing, contraindications, benefits and outcomes Prosthetic valves: types, complications, natural history Congenital Heart Disease Basic cardiac embryology Intracardiac shunting: hemodynamics, pathophysiologic effects Congenital lesions in which natural survival to adulthood is likely Congenital lesions in which post-operative survival to adulthood is likely Congestive Heart Failure and Cardiomyopathies Physiology of normal and abnormal ventricular systolic and diastolic function Hemodynamic abnormalities in heart failure Neurohormonal abnormalities in congestive heart failure Ventricular remodeling Etiology, prognosis, and natural history of congestive heart failure Pharmacology of medications commonly used in patients with congestive heart failure Non-pharmacologic management options (e.g. resynchronization, surgery) Hypertension Definition of hypertension Diagnosis of hypertension Effect of hypertension on target organs Effect of treatment on mortality and complications Secondary causes: screening, diagnosis, and management Pharmacology of antihypertensive agents Pulmonary Vascular Disease Normal pulmonary vascular physiology Hemodynamics of pulmonary hypertension Pharmacology of pulmonary vasodilator agents Pericardial Disease Normal pericardial anatomy and function Effect of pericardial disease on cardiac hemodynamics and function Pathology and etiology of pericardial diseases Vascular Medicine Cerebrovascular disease: etiology and risk factors, presentations, cardiac causes of stroke and transient ischemic attack (TIA), treatment options Pathology and etiology of aortic disease Peripheral vascular disease: risk factors, clinical presentations, treatment options

7 Acute Cardiac Care Hemodynamics: normal and abnormal systemic and pulmonary flows, pressures, and resistances Ventilation in patients with primary cardiac disease: indications, principles of management Pharmacology of inotropes, vasopressors, vasodilators Systemic and non-cardiac complications in the critically ill patient Non-pharmacologic, mechanical support devices Electrophysiology Normal cellular electrophysiology Normal sinoatrial (SA) node, atrioventricular (AV) node, and conducting system function Mechanisms of arrhythmogenesis Mechanisms of conduction abnormalities Pharmacology of antiarrhythmic agents Temporary and permanent cardiac pacing: techniques, indications, and follow-up Implantable cardiovertor/defibrillators (ICDs) Resynchronization devices Invasive electrophysiology studies: indications, techniques, complications Invasive ablative techniques for tachyarrhythmias: indications, complications Pregnancy in Patients with Cardiovascular Disease Normal cardiovascular physiologic changes in pregnancy and their effect in patients with heart disease Use of cardiovascular drugs in pregnancy and the peripartum period Assessment of the cardiac risks of pregnancy Preconception genetic counseling with respect to cardiac disease 2.2. Apply lifelong learning skills of the Scholar Role to implement a personal program to keep upto-date, and enhance areas of professional competence 2.3. Contribute to the enhancement of quality care and patient safety in Cardiology, integrating the available best evidence and best practices 3. Perform a complete and appropriate assessment of a cardiac patient 3.1. Identify and explore issues to be addressed in a patient encounter effectively, including the patient s context and preferences 3.2. Elicit a history that is relevant, concise and accurate to context and preferences for the purposes of prevention and health promotion, diagnosis and/or management 3.3. Perform a focused physical examination that is relevant and accurate for the purposes of prevention and health promotion, diagnosis and/or management 3.4. Select medically appropriate investigative methods in a resource-effective and ethical manner 3.5. Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans 4. Use preventive and therapeutic interventions effectively 4.1. Implement a management plan in collaboration with a patient and their family 4.2. Demonstrate appropriate and timely application of preventive and therapeutic interventions relevant to Cardiology 4.3. Ensure appropriate informed consent is obtained for therapies 4.4. Ensure patients receive appropriate end-of-life care

8 5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic 5.1. Demonstrate effective, appropriate and timely interpretation application of results and technical performance of the following diagnostic and therapeutic procedures: Clinical Electrophysiology Electrocardiography Exercise (stress) testing Ambulatory monitors (Holter and loop recorders) Echocardiography (M-mode, 2D, and Doppler) Transthoracic Cardiac Catheterization Right heart catheterization and hemodynamics Therapeutic Procedures Temporary transvenous pacemakers DC cardioversion and defibrillation Pericardiocentesis 5.2. Demonstrate effective, appropriate and timely interpretation and application of results of the following diagnostic and therapeutic procedures: Clinical Electrophysiology Permanent pacemakers and implanted devices Invasive electrophysiology studies Echocardiography (M-mode, 2D, and Doppler) Transesophageal Stress Nuclear Cardiology Imaging Rest and stress perfusion imaging and radionuclide angiography Cardiac Catheterization Left heart catheterization and hemodynamics Angiography and coronary arteriography Other Cardiac Imaging Modalities Chest X-ray Therapeutic Procedures Intra-aortic balloon counterpulsation 5.3. Demonstrate effective, appropriate and timely application of results of the following diagnostic and therapeutic procedures: Other Cardiac Imaging Modalities Positron Emission Tomography (PET) Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Therapeutic Procedures Percutaneous cardiac interventions 5.4. Ensure appropriate informed consent is obtained for procedures 5.5. Document and disseminate information related to procedures performed and their outcomes 5.6. Ensure adequate follow-up is arranged for procedures performed 6. Seek appropriate consultation from other health professionals, recognizing the limits of their expertise 6.1. Demonstrate insight into their own limitations of expertise

9 6.2. Demonstrate effective, appropriate, and timely consultation of another health professional as needed for optimal patient care 6.3. Arrange appropriate follow-up care services for a patient and their family KNOWLEDGE These objectives are based on the major disease processes encountered in cardiology. Objectives are listed once in the most appropriate category. Each section includes specific domains of knowledge, and clinical problems that should be mastered by the graduate cardiologist. For each clinical problem the graduate cardiologist is able to perform a complete and accurate cardiovascular history and physical examination, formulate appropriate differential and provisional diagnoses, develop an appropriate plan of investigation and interpret the results, develop a therapeutic plan, develop a plan of secondary prevention, and demonstrate appropriate clinical judgment including consideration of such factors as: the patient's age and other health status; risks, benefits, and costs of diagnostic and therapeutic strategies; and alternative management approaches. Where the term "pharmacology" is used it refers to mechanisms of action, clinically relevant pharmacokinetics, indications, contraindications, and adverse effects.

10 1. Coronary Artery Disease Knowledge Clinical Problems Normal coronary anatomy Physiology of normal and abnormal coronary blood flow Normal and abnormal endothelial function Pathogenesis of atherosclerosis Risk factors for atherosclerosis and their management Pathophysiology of acute coronary syndromes Non-atherosclerotic causes of ischemia and infarction Diagnostic techniques for coronary disease, including their sensitivity and specificity Pharmacology of anti-ischemic, antiplatelet, anticoagulant, thrombolytic and lipid-lowering agents Revascularization procedures: percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG), their indications, contraindications and benefits. Non-pharmacologic management of end-stage coronary artery disease Gender differences important in the diagnosis and management of coronary artery disease Ethnic differences important in the incidence of coronary artery disease chest pain - acute and chronic chronic stable angina acute coronary syndromes acute myocardial infarction including complications hypotension/shock post-myocardial infarction management asymptomatic coronary artery disease.

11 2. Valvular Heart Disease Knowledge Clinical Problems Normal valve structure and function Pathology of valvular disease Pathophysiology and hemodynamics of valvular stenosis and regurgitation Diagnostic techniques Valve surgery: indications, timing, outcome Prosthetic valves: types, complications, natural history New modalities for AVR (TAVI) All manifestations of aortic, mitral, pulmonary and tricuspid valve disease including: acute and chronic conditions, native and prosthetic valve conditions; management and follow-up issues Endocarditis: diagnosis, treatment, and prophylaxis Rheumatic fever: diagnosis and prophylaxis 3. Congenital Heart Disease Knowledge Clinical Problems Basic cardiac embryology Intracardiac shunting: hemodynamics, pathophysiologic effects Congenital lesions in which survival to adulthood is likely Congenital lesions in which post-operative survival to adulthood is likely Intra- and extracardiac shunts Cyanotic and acyanotic conditions Pressure and volume overload conditions Palliated and corrected conditions Pulmonary hypertension caused by congenital heart disease

12 4. Congestive Heart Failure & Cardiomyopathies Knowledge Clinical Problems Physiology of normal and abnormal ventricular systolic and diastolic function Hemodynamic abnormalities in heart failure Neurohormonal abnormalities in congestive heart failure Ventricular remodeling Etiology, prognosis, and natural history of congestive heart failure Pharmacology of commonly used medication in patients with congestive heart failure Non-pharmacologic management options (ie resynchronization, surgery) Chronic congestive heart failure Acute exacerbation of congestive heart failure Congestive heart failure in the patient with coronary artery disease Dilated cardiomyopathy Myocarditis Hypertrophic obstructive and non-obstructive cardiomyopathy Restrictive cardiomyopathy Cardiac transplantation: indications, contraindications, prognosis, management of the post-transplant patient 5. Hypertension Knowledge Clinical Problems Definition Diagnosis Effect of hypertension on target organs Effect of treatment on mortality and complications Secondary causes: screening, diagnosis, and management Pharmacology of antihypertensive agents The "new" hypertensive patient Chronic hypertension Resistant hypertension Hypertensive urgencies and emergencies

13 6. Pulmonary Vascular Disease Knowledge Clinical Problems Normal pulmonary vascular physiology Hemodynamics of pulmonary hypertension Pharmacology of pulmonary vasodilator agents Pulmonary embolism Primary pulmonary hypertension: natural history, diagnosis, and management Secondary causes of pulmonary hypertension: etiology, diagnosis, and management Cor Pulmonale 7. Pericardial Disease Knowledge Clinical Problems Pericardium: normal anatomy and function Effect of pericardial disease on cardiac hemodynamics and function Pathology and etiology of pericardial diseases Pericarditis: acute, chronic, and relapsing Post-cardiotomy syndrome Pericardial effusion Pericardial tamponade Pericardial constriction

14 8. Vascular Medicine Knowledge Clinical Problems Cerebrovascular disease: etiology and risk factors, presentations, cardiac causes of stroke and transient ischemic attack (TIA), treatment options Aortic disease: pathology, etiology Peripheral vascular disease: risk factors, clinical presentations, treatment options Aortic dissection: diagnosis, medical management, indications for surgery, and follow-up Aortic aneurysms: prognosis, indications for surgery Marfan's syndrome & other connective tissue diseases Acute peripheral arterial occlusion: principles of diagnosis and management Claudication: principles of diagnosis and management Stroke and transient ischemic attack: principles of diagnosis and management Cardiac causes of TIA/stroke Management of patients with combined cardiac disease and carotid or peripheral vascular disease 9. Acute Cardiac Care Knowledge Clinical Problems Hemodynamics: normal and abnormal systemic and pulmonary flows, pressures, and resistances Ventilation in patients with primary cardiac disease: indications, principles of management Pharmacology of inotropes, vasopressors, vasodilators Systemic and non-cardiac complications in the critically ill patient Non-pharmacologic, mechanical support devices Acute Myocardial Infarction and acute coronary syndromes Acute pulmonary edema Shock states :(Cardiogenic & others) Cardiac arrest Arrhythmias

15 10. Electrophysiology Knowledge Clinical Problems Normal cellular electrophysiology Normal sinoauricular (SA) node, atrioventricular (AV) node, and conducting system function Mechanisms of arrhythmogenesis Mechanisms of conduction abnormalities Pharmacology of antiarrhythmic agents Temporary and permanent cardiac pacing: techniques, indications, and follow-up Resynchronization devices and implantable defibrillators/cardiovertors Invasive electrophysiology studies: indications, techniques, complications Invasive ablative techniques for tachyarrhythmias: indications, complications Palpitations Syncope Resuscitated sudden death Supraventricular tachyarrhythmias Atrial fibrillation Pre-excitation syndrome Ventricular tachyarrhythmias Bradyarrhythmias & conduction disturbances Prevention of sudden cardiac death 11. Pregnancy in Patients with Cardiovascular Disease Knowledge Clinical Problems Normal cardiovascular physiologic changes in pregnancy and their effect in patients with heart disease Use of cardiovascular drugs in pregnancy and the peri-partum period Assessment of the cardiac risks of pregnancy Preconception genetic counselling High-risk cardiac lesions in pregnancy (cyanotic congenital heart disease, pulmonary hypertension, cardiomyopathy and congestive heart failure, Marfan's syndrome, valvular disease) Common congenital and valvular diseases Patients with prosthetic valves Ischemic heart disease in pregnancy Cardiomyopathies in pregnancy Arrhythmia Hypertension

16 12. Other topics Cardiac rehabilitation & preventive cardiology Perioperative evaluation and management of the patient with cardiovascular disease undergoing non cardiac surgery Cardiac trauma: diagnosis and management Cardiac tumors: diagnosis, natural history, management Cardiac complications of systemic diseases Genetic and Molecular basis of cardiovascular disease Palliative and end-of-life care

17 SKILLS 1. Expertise in the complete cardiovascular history and assessment. 2. Mastery of all aspects of the cardiovascular examination including carotid and peripheral arterial assessment, jugular veins, precordium, auscultation, and systemic manifestations of cardiovascular disease. 3. Problem solving and clinical decision making, including the ability to correlate, evaluate, and prioritize information acquired by clinical assessment, formulate an appropriate problem list, and develop and implement a diagnostic and therapeutic plan using appropriate knowledge derived from clinical appraisal of relevant literature. 4. Technical skills: the resident will understand the indications, contraindications, complications, and interpretation and have experience in the performance of the following: electrocardiogram (ECG), exercise stress testing, Holter monitoring, transthoracic echocardiography, pericardiocentesis, temporary transvenous pacing, hemodynamic monitoring (arterial line and Swan-Ganz catheter), and electrical cardioversion. The resident will understand the indications, contraindications, complications, and interpretation of the following techniques: cardiac catheterization and angiography, echocardiography (transthoracic, transesophageal, and Doppler studies), percutaneous coronary interventions, invasive electrophysiological studies, nuclear imaging techniques, permanent pacemaker insertion, and intra-aortic balloon counterpulsation. 5. Consultation skills, including the ability to present clear and pertinent assessments and recommendations in written and verbal form, participate constructively as part of a team of other physicians and other health professionals, ensure appropriate follow-up and reassessment of the patient's progress, and ensure maintenance of appropriate records.

18 B. Communicator As Communicators, Cardiologists effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter. Key and Enabling Competencies: Cardiologists are able to 1. Develop rapport, trust, and ethical therapeutic relationships with patients and families 1.1. Recognize that being a good communicator is a core clinical skill for physicians, and that effective physician-patient communication can foster patient satisfaction, physician satisfaction, adherence and improved clinical outcomes 1.2. Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy 1.3. Respect patient confidentiality, privacy and autonomy 1.4. Listen effectively 1.5. Be aware of and responsive to nonverbal cues 1.6. Facilitate a structured clinical encounter effectively 2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals 2.1. Gather information about a disease and about a patient s beliefs, concerns, expectations and illness experience 2.2. Seek out and synthesize relevant information from other sources, such as a patient s family, caregivers and other professionals 3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals 3.1. Deliver information to a patient and family, colleagues and other professionals in a humane manner and in such a way that it is understandable, encourages discussion and participation in decision-making 4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care 4.1. Identify and explore problems to be addressed from a patient encounter effectively, including the patient s context, responses, concerns, and preferences 4.2. Respect diversity and difference, including but not limited to the impact of gender, religion and cultural beliefs on decision-making and ability to comply with a therapeutic program 4.3. Encourage discussion, questions, and interaction in the encounter 4.4. Engage patients, families, and relevant health professionals in shared decision-making to develop a plan of care 4.5. Address challenging communication issues effectively such as obtaining informed consent, delivering bad news, and addressing anger, confusion and misunderstanding 5. Convey effective oral and written information about a medical encounter

19 5.1. Maintain clear, accurate, and appropriate records (e.g., written or electronic) of clinical encounters and plans 5.2. Present verbal reports of clinical encounters and plans 5.3. Present medical information to the public or media about a Cardiology-related medical issue C. Collaborator As Collaborators, Cardiologists effectively work within a health care team to achieve optimal patient care. Key and Enabling Competencies: Cardiologists are able to 1. Participate effectively and appropriately in an inter professional health care team 1.1. Describe the specialist s roles and responsibilities to other professionals 1.2. Describe the roles and responsibilities of other professionals within the health care team 1.3. Recognize and respect the diversity of roles, responsibilities and competences of other professionals in relation to their own 1.4. Work with others to assess, plan, provide and integrate care for individual patients (or groups of patients) 1.5. Work with others to assess, plan, provide and review other tasks, such as research problems, educational work, program review or administrative responsibilities 1.6. Participate in interprofessional team meetings 1.7. Enter into interdependent relationships with other professions for the provision of quality care 1.8. Describe the principles of team dynamics 1.9. Respect team ethics, including confidentiality, resource allocation and professionalism 1.10.Demonstrate leadership in a health care team, as appropriate 2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict 2.1. Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team 2.2. Work with other professionals to prevent conflicts 2.3. Employ collaborative negotiation to resolve conflicts 2.4. Respect differences and address misunderstandings and limitations in other professionals 2.5. Recognize one s own differences, misunderstanding and limitations that may contribute to interprofessional tension 2.6. Reflect on interprofessional team function D. Manager

20 As Managers, Cardiologists are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system. Key and Enabling Competencies: Cardiologists are able to 1. Participate in activities that contribute to the effectiveness of their health care organizations and systems 1.1. Work collaboratively with others in their organizations 1.2. Participate in systemic quality process evaluation and improvement, such as patient safety initiatives 1.3. Describe the structure and function of the health care system as it relates to Cardiology, including the roles of physicians Describe the advantages and disadvantages of cardiac care in a variety of settings, including hospitals, ambulatory care clinics, offices, homecare, and chronic care and rehabilitation facilities 1.4. Describe principles of health care financing as it relates to Cardiology, including physician remuneration, budgeting and organizational funding 2. Manage their practice and career effectively 2.1. Set priorities and manage time to balance patient care, practice requirements, outside activities and personal life 2.2. Manage a Cardiology practice including finances and human resources 2.3. Implement processes to ensure personal practice improvement 2.4. Employ information technology appropriately for patient care 3. Allocate finite cardiac care resources appropriately 3.1. Recognize the importance of just allocation of health care resources, balancing effectiveness, efficiency and access with optimal patient care 3.2. Apply evidence and management processes for cost-appropriate care 4. Serve in administration and leadership roles, as appropriate 4.1. Chair or participate effectively in committees and meetings 4.2. Lead or implement change in health care 4.3. Plan relevant elements of health care delivery (e.g., work schedules) E. Health Advocate As Health Advocates, Cardiologists responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations. Key and Enabling Competencies: Cardiologists are able to 1. Respond to individual patient health needs and issues as part of patient care 1.1. Identify the health needs of an individual patient

21 1.2. Identify opportunities for advocacy, health promotion and disease prevention with individuals to whom they provide care 2. Respond to the health needs of the communities that they serve 2.1. Describe the practice communities that they serve 2.2. Identify opportunities for advocacy, health promotion and disease prevention in the communities that are at risk for cardiovascular disease and its complications Apply knowledge of primary and secondary prevention of cardiovascular disease 2.3. Appreciate the possibility of competing interests between the communities served and other populations 3. Identify the determinants of health for the populations that they serve 3.1. Identify the biologic, psychosocial, environmental, and economic determinants of health of the populations, including barriers to access to care and resources Utilize this information in a management and prevention plan, and ensure access to appropriate health and social services in the management of individual patients 3.2. Identify vulnerable or marginalized populations within those served and respond appropriately 4. Promote the health of individual patients, communities, and populations 4.1. Describe an approach to implementing a change in a determinant of health of the populations they serve 4.2. Describe how public policy impacts on the cardiovascular health of the populations served 4.3. Identify points of influence in the health care system and its structure 4.4. Describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism 4.5. Appreciate the possibility of conflict inherent in their role as a health advocate for a patient or community with that of manager or gatekeeper 4.6. Describe the role of the medical profession in advocating collectively for health and patient safety F. Scholar As Scholars, Cardiologists demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge. Key and Enabling Competencies: Cardiologists are able to 1. Maintain and enhance professional activities through ongoing learning 1.1. Describe the principles of maintenance of competence 1.2. Describe the principles and strategies for implementing a personal knowledge management system 1.3. Recognize and reflect on learning issues in practice 1.4. Conduct a personal practice audit 1.5. Pose an appropriate learning question 1.6. Access and interpret the relevant evidence 1.7. Integrate new learning into practice 1.8. Evaluate the impact of any change in practice

22 1.9. Document the learning process 2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions 2.1. Describe the principles of critical appraisal 2.2. Critically appraise retrieved evidence in order to address a clinical question 2.3. Integrate critical appraisal conclusions into clinical care 3. Facilitate the learning of patients, families, students, residents, other health professionals, the public and others, as appropriate 3.1. Describe principles of learning relevant to medical education 3.2. Identify collaboratively the learning needs and desired learning outcomes of others 3.3. Select effective teaching strategies and content to facilitate others learning 3.4. Demonstrate effective delivery of lectures or presentations 3.5. Assess and reflect on a teaching encounter 3.6. Provide effective feedback 3.7. Describe the principles of ethics with respect to teaching 4. Contribute to the development, dissemination, and translation of new knowledge and practices 4.1. Describe the principles of research and scholarly inquiry 4.2. Describe the principles of research ethics 4.3. Pose a scholarly question 4.4. Conduct a systematic search for evidence 4.5. Select and apply appropriate methods to address the question 4.6. Disseminate the findings of a study by presentation or publication G. Professional As Professionals, Cardiologists are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behavior. Key and Enabling Competencies: Cardiologists are able to 1. Demonstrate a commitment to their patients, profession, and society through ethical practice 1.1. Exhibit appropriate professional behaviors in practice, including honesty, integrity, commitment, compassion, respect and altruism Understand the nature of professional interpersonal relationships and boundaries with patients, coworkers, and students 1.2. Demonstrate a commitment to delivering the highest quality care and maintenance of competence 1.3. Recognize and appropriately respond to ethical issues encountered in practice 1.4. Manage conflicts of interest 1.5. Recognize the principles and limits of patient confidentiality as defined by professional practice standards and the law 1.6. Maintain appropriate relations with patients

23 2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation 2.1. Demonstrate knowledge and an understanding of the professional, legal and ethical codes of practice 2.2. Fulfill the regulatory and legal obligations required of current practice 2.3. Demonstrate accountability to professional regulatory bodies 2.4. Recognize and respond to others unprofessional behaviors in practice 2.5. Participate in peer review 3. Demonstrate a commitment to physician health and sustainable practice 3.1. Balance personal and professional priorities to ensure personal health and a sustainable practice 3.2. Strive to heighten personal and professional awareness and insight 3.3. Recognize other professionals in need and respond appropriately ROTATION SPECIFIC OBJECTIVES AND SKILLS Within the Cardiology training program there are a specific set of goals, knowledge, technical and professional skills for each rotation. Rotation-specific objectives provide guidance and direction for the performance of the rotation, and it is upon the attainment of such skills that the end of rotation evaluation will be based. Rotationspecific skills, and evaluations for the residents are as follows: :

24 Rotation Specific Objectives and Skills: Coronary Care Unit The Coronary Care Unit provides the cardiology resident with exposure to the assessment and management of patients with acute cardiac illness, focusing on patients with coronary artery disease, acute coronary syndromes and congestive heart failure. Specific goals and objectives include: Fundamental Skills/Knowledge 1. Understanding of the basic and clinical science and pathophysiology of the acute coronary syndromes 2. Diagnosis of the acute coronary syndromes and their complications, including skills in history, physical exam, ECG interpretation, biochemical diagnosis, and use of ancillary testing 3. Management of acute coronary syndromes, including use of appropriate pharmacologic agents, and indications for invasive monitoring, intraaortic balloon pump and coronary angiography 4. Understanding of the pathophysiology of decompensated heart failure and cardiogenic shock 5. Management of congestive heart failure and cardiogenic shock including appropriate pharmacologic agents and indications for intraaortic balloon pump insertion 6. Understanding of pathophysiology and treatment of common heart rhythm disturbances that occur in the CCU, including heart blocks and tachyarrhythmias Technical Skills 1. Arterial cannulation, radial and femoral 2. Central venous cannulation and PA line insertion 3. Temporary pacing including transvenous (atrial and ventricular), transcutaneous, overdrive and burst pacing 4. Intra-aortic balloon insertion and usage 5. Mechanical ventilation 6. 2D echocardiography in emergent situations 7. Pericardiocentesis 8. Electrical cardioversion Professional Skills 1. Ability to manage a CICU, including bed utilization.

25 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Rotation : Coronary Care Unit Base Hospital: Level of Training: Report Covers Period: Location: Program Director or Supervisor(s): A. Medical Expert Understanding of the basic and clinical science and pathophysiology of the acute coronary syndromes 2. Diagnosis of the acute coronary syndromes and their complications, including skills in history, physical exam, ECG interpretation, biochemical diagnosis, and use of ancillary testing 3. Management of acute coronary syndromes, including use of appropriate pharmacologic agents, and indications for invasive monitoring, intra-aortic balloon pump and coronary 4. angiography Understanding of the pathophysiology of decompensated heart failure and cardiogenic shock 5. Management of congestive heart failure and cardiogenic shock including appropriate pharmacologic agents and indications for intra-aortic balloon pump insertion 6. Understanding of pathophysiology and treatment of common heart rhythm disturbances that occur in the CCU, including heart blocks and tachy-arrhythmias B. Communicator Appropriate progress notes; transfer and discharge summaries 2. Appropriate communication with consultation junior medical, nursing and allied health care staff 3. Appropriate communication with patients 4. Appropriate communication with patient families 5. establishes therapeutic relationships with patients/families 6. delivers understandable information to patients/families 7. provides effective counseling to patients/ families 8. maintains professional relationships with other health care providers 9. provides clear and complete records & reports (including oral reports) C. Collaborator works effectively in a team environment 2. Ability to work with allied health care staff 3. Ability to work with nursing staff 4. Ability to work with attending and junior medical staff 5. consults effectively with other physicians and other health care providers D. Manager manages time effectively 2. Appropriate use of bed resources for new emergencies 3. Appropriate use of valuable second or third line therapeutic agents

26 4. Appropriate transfer of patients from critical units to maintain bed availability 5. allocates health care resources effectively 6. utilizes information technology effectively 7. works effectively in a health care organization 8. practices evidence-based medicine E. Health Advocate is attentive to preventive measures 2. Adequate patient education on compliance and role of medications 3. Adequate patient education on compliance and role of medications 4. is attentive to issues of public policy for health 5. recognizes important social, environmental and biological determinants of health 6. demonstrates concern that patients have access to appropriate supports, information and services 7. offers advocacy on behalf of patients at practice and general population levels F. Scholar 1. attends and contributes to rounds, seminars and other learning events 2. appropriately discussed present selected topics as requested 3. adequate ability to search literature 4. adequate effort to increase knowledge base 5. accepts and acts on constructive feedback 6. reads around patient cases and takes an evidence-based approach to management problems 7. contributes to the education of patients, house staff/students, and other health professionals 8. contributes to the development of new knowledge G. Professional recognizes limitations and seeks advice and consultation when needed 2. understands the professional, legal and ethical obligations of physicians 3. delivers evidence based care with integrity, honesty and compassion 4. demonstrates appropriate insight into own strengths and weaknesses 5. exercises initiative within limits of knowledge and training 6. discharges duties and assignments responsibly and in a timely and ethical manner 7. reports facts accurately, including own errors 8. maintains appropriate boundaries in work and learning situations 9. espects diversity of race, age, gender, disability, intelligence and socio-economic status H. ROTATION SPECIFIC CRITERIA Technical Skills Arterial cannulation, radial and femoral 2. Central venous cannulation and PA line insertion 3. Temporary pacing including transvenous (atrial and ventricular), transcutaneous, overdrive and burst pacing/ 4. Intra-aortic balloon insertion and usage 5. Mechanical ventilation 6. 2D echocardiography in emergent situations

27 7. Pericardiocentesis 8. Electrical cardioversion Professional Skills Ability to manage a CICU, including bed utilization. I. Overall Competence PROCEDURAL TRAINING DURING ROTATION: Number of central venous lines performed by trainee Number of PA lines performed by trainee Number of IABP insertions performed by trainee Number of TTVP insertions performed by trainee Number of Pericardiocenteses performed by trainee Number of arterial lines inserted by trainee Number of cardioversions performed by trainee General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

28 Rotation Specific Objectives and Skills: Cardiac Catheterization Laboratory Experience in all aspects of diagnostic cardiac catheterization in patients with ischemic, valvular and adult congenital heart disease, including the pre- and post- procedural assessment of the patient, interpretation and preparation of a procedure report will be provided to residents with the following objectives and goals: Fundamental Skills/Knowledge 1. Understands the role of coronary angiography in the management of acute coronary syndromes and chronic stable angina. 2. Understands the role of right and left heart catheterization in the diagnosis, assessment and management of acute and chronic valvular and other congenital and acquired hemodynamic conditions. 3. Understands the decision-making process regarding coronary revascularization and the different revascularization options (CABG, PCI). 4. Understands the decision making process surrounding the timing of valve replacement or repair, and timing and choice (Surgery, catheter based) of closure of shunts and repair of other congenital or acquired anomalies. 5. Ability to correlate clinical findings on physical examination of the patient with the angiographic and hemodynamic findings at the time of catheterization. 6. Understands radiation protection issues as they pertain to the catheterization laboratory. 7. Knows potential complications, and their management, of diagnostic and interventional cardiac catheterization procedures. Technical Skills 1. Arterial puncture, arterial cannulation and sheath placement, including flushing. 2. Techniques of and performance of catheter exchanges. 3. Selective intubation of left and right coronary arteries. 4. Selective intubation of saphenous vein bypass grafts and left and right internal mammary arteries. 5. Injection of contrast by hand. 6. Performance of left ventricular and aortic angiography by power injection. 7. Techniques of right heart catheterization. 8. Specialized procedures (i.e. shunt run, insertion of an intra-aortic balloon pump). 9. Safe performance of image acquisition. 10. Removal of intra-arterial sheath, achievement of hemostasis and management of complications of sheath removal.

29 Interpretive Skills 1. Understands coronary anatomy, its variations and anomalies. 2. Ability to characterize and assess coronary flow, collaterals and to describe lesion morphology. 3. Ability to interpret left ventriculography, assess left ventricular function and valvular regurgitation. 4. Understands the hemodynamics of AS, AI, MS, MR, LV dysfunction and congenital heart disease. 5. Understands the oximetry of shunts. 6. Ability to calculate cardiac output and mitral and aortic valve areas.

30 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Cardiac Catheterization Laboratory Covers Period: Location: Program Director or Supervisor(s): Base hospital: level of training: A. Medical Expert Understand the clinical presentation, natural history and prognosis of ischemic heart disease 2. Know the rationale of the pharmacotherapy available in the treatment of angina and unstable coronary syndromes in the Cardiac Catheterization Laboratory 3. Know the indications for cardiac catheterization and percutaneous and surgical revascularization 4. Understand the importance of secondary prevention strategy in the management of ischemic heart disease 5. Know indications for urgent catheterization and intervention in unstable coronary syndromes 6. Know the indications for urgent cardiac catheterization for left ventricular dysfunction, valvular heart disease and infective endocarditis 7. Demonstrate diagnostic skills at the bedside which allow accurate diagnosis and assessment of underlying cardiac pathology 8. Know potential complications and management of cardiac catheterization, pacemaker insertion and coronary intervention 9. Demonstrate confidence in obtaining arterial hemostasis following arterial sheath removal and the ability to deal with complications of arterial cannulation 10. Understands the role of coronary angiography in the management of acute coronary syndromes and chronic stable angina. 11. Understands the role of right and left heart catheterization in the diagnosis, assessment and management of acute and chronic valvular and other congenital and acquired hemodynamic conditions. 12. Understands the decision-making process regarding coronary revascularization and the different revascularization options (CABG, PCI). 13. Understands the decision making process surrounding the timing of valve replacement or repair, and timing and choice (Surgery, catheter based) of closure of shunts and repair of other congenital or acquired anomalies. 14. Knows potential complications, and their management, of diagnostic and interventional cardiac catheterization procedures. 15. Understands radiation protection issues as they pertain to the catheterization laboratory. 16. Ability to correlate clinical findings on physical examination of the patient with the angiographic and hemodynamic findings at the time of catheterization. 17. Demonstrate the confidence to perform right heart catheterization, pericardial centesis and transvenous pacemakers

31 18. Know the indications for cardiac catheterization and appropriate timing for surgical intervention of various forms of valvular, coronary, congenital and pericardial diseases 19. Understand the clinical presentations, natural histories and prognosis of various forms of valvular heart disease, congenital heart disease as well as pericardial disease based on hemodynamic findings B. Communicator Obtain and synthesize relevant history from patients and their families 2. Be able to inform the patient and their family about their cardiac condition, its prognosis, management and plans for follow-up 3. Be able to write consultation and discharge letters to referring physicians including angiographic findings and recommendation 1. establishes therapeutic relationships with patients/families 4. delivers understandable information to patients/families 5. provides effective counseling to patients/ families 6. maintains professional relationships with other health care providers 7. Write a report of the procedure results on the chart C. Collaborator consults effectively with other physicians and other health care providers 2. works effectively in a team environment 3. Identify social rehabilitative and dietetic concerns with patients and consult appropriate allied healthcare professionals 4. Collaborate with other members of the healthcare team, attending physician, nurses, cardiopulmonary and x-ray technicians in the Cardiac Catheterization Laboratory including junior house staff 5. Work appropriately with nurses in the Pre Admission, Day Unit and Wards prior to cardiac catheterization D. Manager manages time effectively 2. Utilizes catheterization laboratory equipment and time in an efficient manner 3. Respects and adheres to both the laboratory schedule and the patients needs for a timely examination 4. Understands the indications and contraindications of cardiac catheterization 5. allocates health care resources effectively 6. utilizes information technology effectively 7. works effectively in a health care organization 8. practices evidence-based medicine E. Health Advocate 1. is attentive to preventive measures Help patients identify risk factors and implement strategies to for secondary prevention 3. Understand the importance of measurements of outcomes for invasive procedures 4. Help understand the triage system for patients undergoing invasive testing 5. is attentive to issues of public policy for health 6. recognizes important social, environmental and biological determinants of health 7. demonstrates concern that patients have access to appropriate

32 supports, information and services 8. offers advocacy on behalf of patients at practice and general population levels F. Scholar Recognize gaps in knowledge base 2. attends and contributes to rounds, seminars and other learning events 3. Develop skills to consult the literature and attending staff to fill knowledge gaps 4. Provide instruction to other healthcare professionals including referring physicians on the results of the hemodynamic testing 5. accepts and acts on constructive feedback 6. reads around patient cases and takes an evidence-based approach to management problems 7. contributes to the education of patients, house staff/students, and other health professionals 8. contributes to the development of new knowledge G. Professional Deliver care with integrity, honesty and compassion 2. Understand the professional, legal and ethical codes to which physicians are bound 3. recognizes limitations and seeks advice and consultation when needed 4. exercises initiative within limits of knowledge and training 5. discharges duties and assignments responsibly and in a timely and ethical manner 6. reports facts accurately, including own errors 7. maintains appropriate boundaries in work and learning situations 8. respects diversity of race, age, gender, disability, intelligence and socio-economic status H. Rotation Specific Criteria Technical Skills Arterial puncture, arterial cannulation and sheath placement, including flushing. 2. Techniques of and performance of catheter exchanges. 3. Selective intubation of left and right coronary arteries. 4. Selective intubation of saphenous vein bypass grafts and left and right internal mammary arteries. 5. Injection of contrast by hand. 6. Performance of left ventricular and aortic angiography by power injection. 7. Techniques of right heart catheterization. 8. Specialized procedures (i.e. shunt run, insertion of an intra-aortic balloon pump). 9. Safe performance of image acquisition. 10. Removal of intra-arterial sheath, achievement of hemostasis and management of complications of sheath removal. Interpretive Skills Understands coronary anatomy, its variations and anomalies. 2. Ability to characterize and assess coronary flow, collaterals and to describe lesion morphology. 3. Ability to interpret left ventriculography, assess left ventricular function and valvular regurgitation. 4. Understands the hemodynamics of AS, AI, MS, MR, LV dysfunction and congenital heart disease.

33 5. Understands the oximetry of shunts. 6. Ability to calculate cardiac output and mitral and aortic valve areas. I. Overall Competence PROCEDURAL TRAINING DURING ROTATION: Number of left heart catheterizations performed by trainee Number of right heart catheterizations performed by trainee Number of coronary angiograms ± PCI performed by trainee Number of IABP insertions by trainee General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

34 Rotation Specific Objectives and Skills: Echocardiography The principles and practices of the performance and interpretation of M-mode, 2-D and Doppler echocardiography, including the opportunity for an introduction to transesophageal echocardiography are provided to all residents with the following goals and objectives: Fundamental Skills/Knowledge 1. Understanding of indications for echocardiography and its role in the diagnosis, assessment and management of acquired and congenital heart disease. 2. Understanding of normal cardiac anatomy and blood flow and pathological changes in cardiac anatomy and blood flow due to acquired and congenital heart disease. 3. Understanding of the physical principles of echocardiographic image formation and blood flow velocity measurements with colour flow Doppler. 4. Ability to correlate echocardiographic findings with cardiac auscultation and differential diagnosis. 5. Understanding of the role of echocardiography in acute cardiac care. 6. Understanding of the indications for transesophageal echocardiography and for stress echocardiography 7. Understanding of the limitations of echocardiography and diagnostic alternatives to echocardiography. Technical Skills 1. Technical proficiency with operation of ultrasonograph and all the controls affecting the quality of the received signals. 2. Ability to position and direct ultrasound transducer and obtain a complete standard examination including all desired tomographic images and Doppler flow velocity signals. 3. Ability to distinguish between an adequate and an inadequate echocardiographic examination. 4. Ability to perform quantitative analysis of the echocardiographic study and to produce a written report. 5. Proper use and care of equipment.

35 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Rotation: Echocardiography Report Covers Period: Location: Program Director or Supervisor(s): Base Hospital: Training Level: A. Medical Expert Understanding of indications for echocardiography and its role in the diagnosis, assessment and management of acquired and congenital heart disease. 2. Understanding of normal cardiac anatomy and blood flow and pathological changes in cardiac anatomy and blood flow due to acquired and congenital heart disease. 3. Understanding of the physical principles of echocardiographic image formation and blood flow velocity measurements with colour flow Doppler. 4. Ability to correlate echocardiographic findings with cardiac auscultation and differential diagnosis. 5. Understanding of the role of echocardiography in acute cardiac care. 6. Understanding of the indications for transesophageal echocardiography and for stress echocardiography 7. Understanding of the limitations of echocardiography and diagnostic alternatives to echocardiography. B. Communicator Develop a good patient relationship during the examination with appropriate attention to comfort 2. Interpret from the requisition the relevant questions to be answered by the echocardiographic examination 3. Communicate the results of the examination to the patient and the referring physician 4. delivers understandable information to patients/families 5. provides effective counseling to patients/ families 6. maintains professional relationships with other health care providers 7. Develop a report of all salient echocardiographic features C. Collaborator Work closely with the staff in the echocardiographic department including technologists 2. Work with the staff cardiologists in an effective and professional manner 3. Work with other physicians and allied health care professionals when performing echocardiographic examinations 4. consults effectively with other physicians and other health care providers D. Manager manages time effectively and utilizes the echocardiographic equipment and time in an efficient manner 2. Respects and adheres to both the laboratory schedule and the patients

36 needs for a timely examination 3. Understands the indications and contraindications for cardiac echo 4. allocates health care resources effectively 5. utilizes information technology effectively 6. works effectively in a health care organization 7. practices evidence-based medicine E. Health Advocate is attentive to preventive measures 2. uses echocardiography to help patients understand their cardiovascular illness 3. uses the information from echocardiography to help patients modify cardiac risk factors 4. understands the role of echocardiography in diagnosing cardiovascular disease 5. is attentive to issues of public policy for health 6. recognizes important social, environmental and biological determinants of health 7. demonstrates concern that patients have access to appropriate supports, information and services 8. offers advocacy on behalf of patients at practice and general population levels F. Scholar 1. attends and contributes to rounds, seminars and other learning events 2. understands knowledge gaps in technical and interpret skills in echocardiography 3. accepts and acts on constructive feedback 4. participate in rounds and presentations of echocardiographic topics 5. Assists in the teaching of more junior house staff in the technical and interpretive skills of echocardiography 6. critically reads the literature on topics related to echocardiography 7. reads around patient cases and takes an evidence-based approach to management problems 8. contributes to the education of patients, house staff/students, and other health professionals 9. contributes to the development of new knowledge G. Professional 1. Interact with patients coming to the Echocardiography Laboratory with integrity, honesty and compassion 2. recognizes limitations and seeks advice and consultation when needed 3. Work with other physicians and allied healthcare professionals in a appropriate and professional manner 4. exercises initiative within limits of knowledge and training 5. discharges duties and assignments responsibly and in a timely and ethical manner 6. reports facts accurately, including own errors 7. maintains appropriate boundaries in work and learning situations 8. respects diversity of race, age, gender, disability, intelligence and socio-economic status H. Rotation Specific Criteria Technical Skills 1. Technical proficiency with operation of ultrasonograph and all the controls affecting the quality of the received signals. 37

37 2. Ability to position and direct ultrasound transducer and obtain a complete standard examination including all desired tomographic images and Doppler flow velocity signals. 3. Ability to distinguish between an adequate and an inadequate echocardiographic examination. 4. Ability to perform quantitative analysis of the echocardiographic study and to produce a written report. 5. Proper use and care of equipment. I. Overall Competence PROCEDURAL TRAINING: Number of studies (transthoracic 2D-echo/Doppler) performed by trainee during rotation Number of studies (transthoracic 2D-echo/Doppler) interpreted by trainee during rotation Number of reading sessions attended by trainee Other training during rotation (TEE, stress echo) General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

38 Rotation Specific Objectives and Skills: Electrophysiology The training in the approach to and the management of patients with a wide range of disturbances of cardiac rhythm, including pacemaker and defibrillator assessment and follow-up with the following goals and objectives: Fundamental Skills/Knowledge 1. Understanding of basic and clinical science of cellular electrophysiology as well as an understanding of the pathophysiology of common electrophysiologic problems 2. Diagnosis and management of complex arrhythmias and use of ancillary testing. Knowledge of available pharmacologic and non-pharmacologic approaches to management 3. Understanding of indications and techniques for invasive EP testing and appropriate interpretation of results. Basic knowledge of cath-lab based mapping and ablation 4. Knowledge of the indications, types and technique of permanent pacemaker implantation. 5. Programming of single and dual chamber pacemakers and defibrillators. Ability to troubleshoot commonly encountered pacemaker and defibrillator problems 6. Management of emergency situations with specific reference to emergency management of arrhythmias 7. Understanding of ancillary testing and procedures such as tilt-table testing, intraoperative mapping 8. Interpretation of 12-lead EKG, Holter monitoring, and exercise stress testing Technical Skills 1. Arterial and venous cannulation, femoral 2. Placement of catheters for EPS - CS, His bundle etc 3. Temporary pacing including transvenous (atrial and ventricular), transcutaneous, overdrive and burst pacing 4. Electrical cardioversion

39 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Cardiac Electrophysiology Report Covers Period: Location: Program Director or Supervisor(s): Base Hospital: Training Level: A. Medical Expert Understands the clinical presentation, natural history & prognosis of the cardiac arrhythmias and conduction disturbances 2. Understanding of basic and clinical science of cellular electrophysiology as well as an understanding of the pathophysiology of common electrophysiologic problems 3. Diagnosis and management of complex arrhythmias and use of ancillary testing. Knowledge of available pharmacologic and nonpharmacologic approaches to management 4. Understanding of indications and techniques for invasive EP testing and appropriate interpretation of results. Basic knowledge of cath-lab based mapping and ablation 5. Programming of single and dual chamber pacemakers and defibrillators. Ability to troubleshoot commonly encountered pacemaker and defibrillator problems 6. Is able to determine the mechanism of SVT from ECG recordings and is able to differentiate wide QRS tachycardia from the ECG 7. Understands the pathogenesis of cardiac arrhythmias including primary electrophysiology abnormalities and secondary causes of rhythm disturbances 8. Knows the causes of syncope. Knows the diagnostic work up & management of patients with syncope 9. Knows the pharmacology of anti-arrhythmic drugs 10. Understands the concept of pro-arrhythmia 11. Knows the immediate management of symptomatic bradyarrhythmias and is able to insert a temporary pacemaker when required 12. Understands the mechanisms and long term management of paroxysmal SVT, atrial fibrillation and atrial flutter 13.!Knows the diagnostic work up and management of patients with VT (non-sustained and sustained) and ventricular fibrillation / cardiac arrest 14. Knows the indications for and appropriate follow-up of pacemakers and anti-tachycardia devices 15. Knows the immediate care of atrial fibrillation, SVT, VT and ventricular fibrillation 16. Management of emergency situations with specific reference to emergency management of arrhythmias 17. Understanding of ancillary testing and procedures such as tilt-table testing, intra-operative mapping 18. Interpretation of 12-lead EKG, Holter monitoring, and exercise stress testing

40 B. Communicator establishes therapeutic relationships with patients/families 2. Is able to inform the patient and their families about their problem, its prognosis, management and plans for follow up 3. Keeps the health care team informed as to the management plan for each patient 4. Is able to write consultation / discharge letters to referring physicians 5. delivers understandable information to patients/families 6. provides effective counseling to patients/ families 7. maintains professional relationships with other health care providers 8. provides clear and complete records & reports (including oral reports) C. Collaborator works effectively in a team environment 2. Participates in the performance of an EP study 3. consults effectively with other physicians and other health care providers D. Manager manages time effectively 2. understands and applies cost-effective strategies in assessing and treating patients with arrhythmias 3. appropriately manages time in seeing patients in the clinic and in consultation in the hospital 4. allocates health care resources effectively 5. utilizes information technology effectively 6. works effectively in a health care organization 7. practices evidence-based medicine E. Health Advocate is attentive to preventive measures 2. identify and address cardiac risk factors 3. identify and educate patients with inherited arrhythmias 4. provide vocational counseling for patients with complex and lifethreatening arrhythmias 5. is attentive to issues of public policy for health 6. recognizes important social, environmental and biological determinants of health 7. demonstrates concern that patients have access to appropriate supports, information and services 8. offers advocacy on behalf of patients at practice and general population levels F. Scholar attends and contributes to rounds, seminars and other learning events 2. recognizes gaps in knowledge regarding patient problems and develops strategies to fill the gap through reading and consulting other members of the health care team 3. accepts and acts on constructive feedback 4. reads around patient cases and takes an evidence-based approach to management problems 5. contributes to the education of patients, house staff/students, and other health professionals 6. contributes to the development of new knowledge

41 G. Professional - carries out duties in a professional manner delivers care with integrity, honesty and compassion 2. understands the professional, legal and ethical codes to which physicians are bound 3. recognizes limitations and seeks advice and consultation when needed 4. exercises initiative within limits of knowledge and training 5. discharges duties and assignments responsibly and in a timely and ethical manner 6. reports facts accurately, including own errors 7. maintains appropriate boundaries in work and learning situations 8. respects diversity of race, age, gender, disability, intelligence and socio-economic status ROTATION SPECIFIC CRITERIA B. Technical Skills Arterial and venous cannulation, femoral 2. Placement of catheters for EPS - CS, His bundle etc 3. Temporary pacing including transvenous (atrial and ventricular), transcutaneous, overdrive and burst pacing 4. Electrical cardioversion I. Overall Competence PROCEDURAL TRAINING DURING ROTATION: Number of EKGs interpreted by trainee Number of Holter monitors interpreted by trainee Number of invasive EP studies attended by trainee Number of cardioversions performed by trainee General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

42 General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

43 Rotation-Specific Objectives and Skills: Nuclear Cardiology Training in the principles of nuclear medicine as they relate to cardiovascular diagnosis leading to a basic proficiency in the performance and interpretation of nuclear cardiology investigations with the following goals and objectives: Fundamental Skills/Knowledge 1. Understanding of indications for nuclear perfusion and angiographic studies and their role in the diagnosis, assessment and management of acquired and congenital heart disease. 2. Understanding of normal cardiac anatomy and blood flow and pathological changes in cardiac anatomy and blood flow due to acquired and congenital heart disease. 3. Understanding of the physical principles of radioisotopes in cardiovascular imaging. 4. Ability to correlate nuclear findings with clinical presentation. 5. Understanding of the role of nuclear imaging in management of patients with coronary artery disease. 6. Awareness of issues of safe handling of radionuclides. 7. Understanding of the limitations of nuclear studies and diagnostic alternatives. Technical Skills 1. Technical proficiency with performance of exercise and pharmacologic stress testing and interpretation of stress EKGs. 2. Interpretative skills and ability to appreciate pitfalls in diagnosis 3. Ability to distinguish between an adequate and an inadequate examination. 4. Ability to perform quantitative analysis of the study and to produce a written report. 5. Proper use and care of equipment.

44 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Rotation: Nuclear Cardiology Base Hospital: Level of training: Report Covers Period: Location: Program Director or Supervisor(s): A. Medical Expert Understanding of indications for nuclear perfusion and angiographic studies and their role in the diagnosis, assessment and management of acquired and congenital heart disease. 2. Understanding of normal cardiac anatomy and blood flow and pathological changes in cardiac anatomy and blood flow due to acquired and congenital heart disease. 3. Understanding of the physical principles of radioisotopes in cardiovascular imaging. 4. Ability to correlate nuclear findings with clinical presentation. 5. Understanding of the role of nuclear imaging in management of patients with coronary artery disease. 6. Awareness of issues of safe handling of radionuclides. 7. Understanding of the limitations of nuclear studies and diagnostic alternatives. B. Communicator Establishes therapeutic relationships with patients/families 2. Communicates well with patients, families and team members 3. Understands and implements accurate informal consent for procedures 4. Delivers understandable information to patients/families 5. Communicates results to referring physician in a clear and instructive manner 6. Maintains professional relationships with other health care providers 7. Provides clear and complete records & reports (including oral reports) C. Collaborator works effectively in a team environment 2. Respects opinions of all allied health professionals and team members 3. consults effectively with other physicians and other health care providers D. Manager 1. Uses pretest screening to assess cost effectiveness of testing and makes appropriate plans for ongoing follow up keeping in mind cost effectiveness of all investigations 2. Manages time effectively 3. Allocates health care resources effectively

45 4. Utilizes information technology effectively

46 5. Works effectively in a health care organization 6. Practices evidence-based medicine E. Health Advocate is attentive to preventive measures 2. Assess all cardiovascular risks in pre-test assessment 3. Includes lifestyle and risk factor modification in exercise prescription 4. is attentive to issues of public policy for health 5. recognizes important social, environmental and biological determinants of health 6. demonstrates concern that patients have access to appropriate supports, information and services 7. offers advocacy on behalf of patients at practice and general population levels F. Scholar attends and contributes to rounds, seminars and other learning events 2. collaborates with ongoing research involving the Nuclear/PET Laboratory 3. Continues ongoing research efforts 4. accepts and acts on constructive feedback 5. reads around patient cases and takes an evidence-based approach to management problems 6. contributes to the education of patients, house staff/students, and other health professionals 7. contributes to the development of new knowledge G. Professional recognizes limitations and seeks advice and consultation when needed 2. exhibits appropriate personal and interpersonal behavior respecting the rights and dignities of patients and their families and the expertise and opinion of the health care workers 3. practices medicine in an ethically responsible manner 4. delivers the highest quality care with integrity, honesty and compassion 5. exercises initiative within limits of knowledge and training 6. discharges duties and assignments responsibly and in a timely and ethical manner 7. reports facts accurately, including own errors 8. maintains appropriate boundaries in work and learning situations 9. respects diversity of race, age, gender, disability, intelligence and socio-economic status H. ROTATION SPECIFIC CRITERIA TECHNICAL SKILLS Technical proficiency with performance of exercise and pharmacologic stress testing and interpretation of stress EKGs. 2. Interpretative skills and ability to appreciate pitfalls in diagnosis 3. Ability to distinguish between an adequate and an inadequate examination. 4. Ability to perform quantitative analysis of the study and to produce a written report. 5. Proper use and care of equipment. I. Overall Competence

47 Procedural Training during rotation Number of studies (exercise and pharmacologic stress tests) performed by trainee during rotation Number of studies (perfusion and angiographic) interpreted by trainee during rotation Number of reading sessions attended by trainee General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

48 Rotation Specific Objectives and Skills: Consultative Cardiology The core clinical rotations of Cardiology Ward/Consults and outpatient Cardiology provides the resident the opportunity to assess inpatients with a variety of cardiologic disorders and to provide consultations in both an inpatient and outpatient setting which encompass the following goals and objectives: Fundamental Skills/Knowledge 1. Understanding of the pathophysiology of the acute coronary syndromes 2. Diagnosis of the acute cardiac syndromes and their complications, including skills in history, physical exam, ECG interpretation, biochemical diagnosis, and use of ancillary testing 3. Management of acute coronary syndromes, including use of appropriate pharmacologic agents, indications for invasive monitoring, and coronary angiography 4. Understanding of the pathophysiology of congestive heart failure 5. Management of congestive heart failure including appropriate pharmacologic agents and indications for cardiac transplantation 6. Understanding of pathophysiology and treatment of common heart rhythm disturbances (including heart blocks bradyarrhythmias and tachyarrhythmias, and their treatments). 7. Understanding of the indications for pacemaker insertion (both temporary and permanent) 8. Skills in cardiac physical diagnosis 9. Skills in electrocardiographic interpretation 10. Understanding of the management strategies of the patient post myocardial infarction 11. Understanding of the role and issues surrounding secondary prevention in patients with coronary artery disease 12. Understanding of common valvular disorders (aortic, mitral, tricuspid, pulmonic stenosis and insufficiency) 13. Understanding of common adult congenital heart disorders (ASD, VSD, Tetralogy of Fallot) Technical Skills 1. Ability to perform a 12-lead ECG

49 Rotation Specific Objectives and Skills: Advanced Cardiac Imaging (CT/MRI) Recent advancements in CT and MR imaging have led to an explosion of interest and utilization of these techniques to evaluate various aspects of cardiovascular anatomy and cardiovascular and cardiothoracic physiology and diseases. Given the increasing availability and use of these techniques, familiarity with the indications, benefits and limitations of these techniques is important for any cardiologist and residents in-training. The collaborative interaction with both Radiology and Cardiology departments is an important feature of the program; it combines the strengths of faculty with different training backgrounds to provide a balanced perspective on the utilization. Instruction will be performed under the direction of expert faculty in the Cardiac Imaging Section during the performance and interpretation of cardiovascular studies. Fellows will participate in study supervision, image acquisition, data post-processing, image interpretation, and preparation of the final report Fundamental Skills/Knowledge 1. Learn the indications for, and the practical application and interpretation of state-of-the-art cardiovascular and cardiothoracic imaging, using CT and MR. 2. Gain knowledge of CT and MR physics. 3. Residents will learn in-depth knowledge of normal and pathologic cardiovascular and cardiothoracic anatomy, and the physiology of acquired and congenital heart disease, cardiothoracic diseases, and vascular diseases of the aorta. 4. In addition, the fellow should be able to compare the CT/MR with other cardiovascular imaging technologies including echocardiography, nuclear cardiology and invasive x-ray angiography. Technical Skills 1. Scanning principles related to cardiovascular and cardiothoracic imaging protocols, 2. Basic ECG interpretation skills as applicable to imaging protocols. 3. Contrast agents used for safe and optimal imaging. 4. Interpretative skills for reading clinical cardiovascular and cardiothoracic imaging studies, including data post-processing tools for analysis

50 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Rotation: Cardiac CT/MRI Base Hospital: Level of training Report Covers Period: Location: Program Director or Supervisor(s): A. Medical Expert Understanding of indications for cardiac CT/ MRI and their role in the diagnosis, assessment and management of acquired and congenital heart disease. 2. Understanding of normal cardiac anatomy and pathological changes in cardiac anatomy due to acquired and congenital heart disease. 3. Understanding of the physical principles of CT/MRI in cardiovascular imaging. 4. Ability to CT/MRI findings with clinical presentation. 5. Understanding of CT/ MRI in management of patients with coronary artery disease and congenital heart disease 6. Understanding the safety issues and contraindication related to contrast m 7. Understanding of the limitations of CT/MRI and diagnostic alternatives. B. Communicator Establishes therapeutic relationships with patients/families 2. Communicates well with patients, families and team members 3. Understands and implements accurate informal consent for procedures 4. Delivers understandable information to patients/families 5. Communicates results to referring physician in a clear and instructive manner 6. Maintains professional relationships with other health care providers 7. Provides clear and complete records & reports (including oral reports) C. Collaborator works effectively in a team environment 2. Respects opinions of all allied health professionals and team members 3. consults effectively with other physicians and other health care providers D. Manager 1. Uses pretest screening to assess cost effectiveness of testing and makes appropriate plans for ongoing follow up keeping in mind cost effectiveness of all investigations 2. Manages time effectively 3. Allocates health care resources effectively

51 4. Utilizes information technology effectively

52 5. Works effectively in a health care organization 6. Practices evidence-based medicine E. Health Advocate is attentive to preventive measures 2. Assess all cardiovascular risks in pre-test assessment 3. is attentive to issues of public policy for health 4. recognizes important social, environmental and biological determinants of health 5. demonstrates concern that patients have access to appropriate supports, information and services 6. offers advocacy on behalf of patients at practice and general population levels F. Scholar attends and contributes to rounds, seminars and other learning events 2. collaborates with ongoing research involving the CT/MRI 3. Continues ongoing research efforts 4. accepts and acts on constructive feedback 5. reads around patient cases and takes an evidence-based approach to management problems 6. contributes to the education of patients, house staff/students, and other health professionals 7. contributes to the development of new knowledge G. Professional recognizes limitations and seeks advice and consultation when Needed 2. exhibits appropriate personal and interpersonal behavior respecting the rights and dignities of patients and their families and the expertise and opinion of the health care workers 3. practices medicine in an ethically responsible manner 4. delivers the highest quality care with integrity, honesty and compassion 5. exercises initiative within limits of knowledge and training 6. discharges duties and assignments responsibly and in a timely and ethical manner 7. reports facts accurately, including own errors 8. maintains appropriate boundaries in work and learning situations 9. respects diversity of race, age, gender, disability, intelligence and socio-economic status H. ROTATION SPECIFIC CRITERIA TECHNICAL SKILLS Technical proficiency with performance of CT/MRI protocols 2. Interpretative skills and ability to appreciate pitfalls in diagnosis 3. Ability to distinguish between an adequate and an inadequate examination. 4. Ability to perform quantitative analysis of the study and to produce a written report. 5. Proper use and care of equipment. I. Overall Competence

53 Procedural Training during rotation Number of studies (CT/MRI tests) performed by trainee during rotation Number of studies (CT/MRI) interpreted by trainee during rotation Number of reading sessions attended by trainee General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Signature of evaluator: Date:

54 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Rotation: Consultation Report Covers Period: Location: Program Director or Supervisor(s): Hospital: Level of training: A. Medical Expert Elicit a history that is accurate, concise and relevant to the patient s potential cardiac problems in the context of other medical problems that maybe present 2. Diagnosis of the acute cardiac syndromes and their complications, including skills in history, physical exam, ECG interpretation, biochemical diagnosis, and use of ancillary testing 3. Management of acute coronary syndromes, including use of appropriate pharmacologic agents, indications for invasive monitoring, and coronary angiography 4. Collect and organize previous relevant cardiological investigations 5. Formulate and prioritize a problem list with emphasis on the relative role of the cardiac problems to other problems 6. Initiate further investigations in a cost effective, ethical and useful manner with emphasis on acquiring information that will influence treatment and outcomes 7. Understanding of the indications for pacemaker insertion (both temporary and permanent) 8. Elicit a history that is accurate, concise and relevant to the patient s potential cardiac problems in the context of other medical problems that maybe present 9. Recognize and manage post-operative complications including acute coronary syndromes, arrhythmias and congestive heart failure 10. Develop a management plan for the cardiac problems that take into account the possible effects on other compromised systems 11. Be able to investigate and estimate the cardiac risks in non-cardiac surgery and initiate strategies to reduce those risks 12. Understanding of common valvular disorders (aortic, mitral, tricuspid, pulmonic stenosis and insufficiency) 13. Understanding of common adult congenital heart disorders (ASD, VSD, Tetralogy of Fallot) B. Communicator Communicates appropriately with patients 2. Communicate with other medical, nursing and allied healthcare staff 3. Ensure proper communication to the primary care team by written and spoken word regarding the cardiac management plan and how it effects other problems and changes in the overall patient s condition 4. establishes therapeutic relationships with patients/families 5. delivers understandable information to patients/families 6. provides effective counseling to patients/ families

55 7. maintains professional relationships with other health care providers 8. provides clear and complete records & reports (including oral reports) 9. Discuss the cardiac problems with the patient and their family and how it relates to their overall care and specifically the role that cardiology is planning in their care 10. Recognize when the cardiology problem is the primary issue in the patient s care and arrange appropriate investigations and care including transfer to a cardiac unit C. Collaborator Work closely with attending and other medical staff 2. Work closely with nursing and allied health staff 3. Develop a management plan for the cardiac condition for patients in collaboration with members of the primary health care team 4. Coordinate the care of complex medical and surgical patients with the referring service including the organization of investigations and other cardiac therapies 5. Participate in inter-disciplinary meetings respecting the opinion of others and their expertise being cognizant of the consultative process D. Manager Use scarce resources appropriately 2. Learn cost effectiveness of valuable second and third line agents 3. Organizes schedule to see new consults and review previous consults in time efficient manner 4. Organizes and utilizes appropriate testing, especially pre-operative evaluation 5. Understands cost-effectiveness of testing and treating complex patients with multi-system disease 6. manages time effectively 7. allocates health care resources effectively 8. utilizes information technology effectively 9. works effectively in a health care organization 10. practices evidence-based medicine E. Health Advocate educate patients on healthy behaviours 2. educate patients on compliance and future risk issues 3. review risk factors and risk factor modification with patient and patient s family 4. encourage public policies to promote health 5. is attentive to preventive measures 6. is attentive to issues of public policy for health 7. recognizes important social, environmental and biological determinants of health 8. demonstrates concern that patients have access to appropriate supports, information and services 9. offers advocacy on behalf of patients at practice and general population levels F. Scholar Recognize the interplay of the cardiovascular system with other systems in health and disease and expand knowledge in those areas that overlap 2. Teach more junior staff / clerks

56 3. Develop expertise in the assessment of risk of life threatening cardiac conditions in non-life threatening non-cardiac surgery 4. Contribute knowledge independently learn to the consultative process 5. attends and contributes to rounds, seminars and other learning events 6. accepts and acts on constructive feedback 7. reads around patient cases and takes an evidence-based approach to management problems 8. contributes to the education of patients, house staff/students, and other health professionals 9. contributes to the development of new knowledge G. Professional Deliver evidence based care with integrity, honesty and compassion 2. Understand the professional, legal and ethical codes to which physicians are bound 3. Develop appropriate patient-doctor relationship 4. recognizes limitations and seeks advice and consultation when needed 5. exercises initiative within limits of knowledge and training 6. discharges duties and assignments responsibly and in a timely and ethical manner 7. reports facts accurately, including own errors 8. maintains appropriate boundaries in work and learning situations 9. respects diversity of race, age, gender, disability, intelligence and socio-economic status Technical Skills Ability to perform a 12-lead ECG General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

57 Rotation Specific Objectives and Skills: CARDIOLOGY WARD Rotation Objectives: To develop the appropriate level of clinical skills (history taking and physical examination), interpretative and technical skills distinct to the subspecialty of Cardiology so as to function as a consultant on the General Cardiology ward (under the supervision of the cardiology attending staff). Goals: 1. To develop strong decision-making skills in the management of cardiac patients, especially in the following areas: (1) diagnostic/prognostic investigations; (2) selection of medical/interventional/surgical treatment; (3) collaboration with other colleagues in Cardiology (Electrophysiology, Cardiac Transplantation/Heart Failure Service, Congenital Cardiology, Hypertrophic Cardiomyopathy); (4) seeking appropriate consultation requests from other subspecialties; (5) admission/discharge planning 2. To demonstrate leadership skills in managing a General Cardiology Inpatient Unit which specializes in tertiary and quaternary care referrals 3. To work, collaborate, supervise and contribute to the ongoing education of the Acute Care Nurse Practioners (ACNP s) 4. To effectively manage the allocation of in-patient Cardiology beds and to work closely with the nurse in charge, ACNP in charge for the week, to determine the appropriate allocation of in-patient beds 5. To work in partnership with nurses and other health care professionals (Pharmacy, Home Care, Physiotherapy, Occupational Therapy, Social Work) involved in the care of patients as part of the health care team 6. To develop effective written communication skills appropriate to a Cardiology consultant, including writing appropriate notes in the medical chart and overseeing the completed discharge summary for all in-patients admitted to the General Cardiology ward 7. To develop the ability to communicate in a timely, effective, and compassionate manner towards patients and their families

58 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Rotation: Cardiology Ward Report Covers Period: Location: Program Director or Supervisor(s): Hospital: Training Level: A. Medical Expert Understanding of the pathophysiology of the acute coronary syndromes 2. Diagnosis of the acute cardiac syndromes and their complications, including skills in history, physical exam, ECG interpretation, biochemical diagnosis, and use of ancillary testing 3. Management of acute coronary syndromes, including use of appropriate pharmacologic agents, indications for invasive monitoring, and coronary angiography 4. Understanding of the pathophysiology of congestive heart failure 5. Management of congestive heart failure including appropriate pharmacologic agents and indications for cardiac transplantation 6. Understanding of pathophysiology and treatment of common heart rhythm disturbances (including heart blocks bradyarrhythmias and tachyarrhythmias, and their treatments). 7. Understanding of the indications for pacemaker insertion (both temporary and permanent) 8. Skills in cardiac physical diagnosis 9. Skills in electrocardiographic interpretation 10. Understanding of the management strategies of the patient post myocardial infarction 11. Understanding of the role and issues surrounding secondary prevention in patients with coronary artery disease 12. Understanding of common valvular disorders (aortic, mitral, tricuspid, pulmonic stenosis and insufficiency) 13. Understanding of common adult congenital heart disorders (ASD, VSD, Tetralogy of Fallot) B. Communicator Communicates appropriately with patients 2. Communicate with other medical, nursing and allied healthcare staff 3. Prepare concise discharge and transfer summaries with all relevant information 4. establishes therapeutic relationships with patients/families 5. delivers understandable information to patients/families 6. provides effective counseling to patients/ families 7. maintains professional relationships with other health care providers 8. provides clear and complete records & reports (including oral reports) C. Collaborator Work closely with attending and other medical staff 2. Work closely with nursing and allied health staff

59 D. Manager Use scarce resources appropriately 2. Learn cost effectiveness of valuable second and third line agents 3. Mange bed availability to admit new patients 4. manages time effectively 5. allocates health care resources effectively 6. utilizes information technology effectively 7. works effectively in a health care organization 8. practices evidence-based medicine E. Health Advocate educate patients on healthy behaviours 2. educate patients on compliance and future risk issues 3. review risk factors and risk factor modification with patient and patient s family 4. encourage public policies to promote health 5. is attentive to preventive measures 6. is attentive to issues of public policy for health 7. recognizes important social, environmental and biological determinants of health 8. demonstrates concern that patients have access to appropriate supports, information and services 9. offers advocacy on behalf of patients at practice and general population levels F. Scholar Increase knowledge base 2. Teach more junior staff / clerks 3. attends and contributes to rounds, seminars and other learning events 4. accepts and acts on constructive feedback 5. reads around patient cases and takes an evidence-based approach to management problems 6. contributes to the education of patients, house staff/students, and other health professionals 7. contributes to the development of new knowledge G. Professional Deliver evidence based care with integrity, honesty and compassion 2. Understand the professional, legal and ethical codes to which physicians are bound 3. Develop appropriate patient-doctor relationship 4. recognizes limitations and seeks advice and consultation when needed 5. exercises initiative within limits of knowledge and training 6. discharges duties and assignments responsibly and in a timely and ethical manner 7. reports facts accurately, including own errors 8. maintains appropriate boundaries in work and learning situations 9. respects diversity of race, age, gender, disability, intelligence and socio-economic status Technical Skills Ability to perform a 12-lead ECG

60 General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

61 Heart Failure/Cardiac Transplantation The Heart Failure and Transplant Service is a clinical service comprising both heart failure and transplant patients conducted at the University Health Network. Residents rotating throughout the service are directly responsible for the transplant patients and consult for the heart failure patients. Residents rotate through the outpatient Heart Failure Service, the Heart Transplant Clinic and when able and available, the Cardiac Amyloid Clinic. Fundamental Skills/Knowledge 1. Understanding of the pathophysiology of congestive heart failure 2. Management of congestive heart failure including appropriate pharmacologic agents and indications for cardiac transplantation 3. To act as a consultant to inpatient heart failure patients 4. To develop an understanding for the outpatient management of advanced heart failure, including indications for admission, management of medical therapy, up-titration and initiation of evidence-based therapies 5. To understand the indications, and contraindications for cardiac transplantation and ventricular assist device therapy 6. To gain an experience in cardiac transplantation, its indications, outcomes and complications 7. To develop skills in the cardiac physical diagnosis of heart failure patients

62 IN-TRAINING EVALUATION REPORT Name: Base Hospital: Rotation: Heart Failure/Transplantation Training level: Report Covers Period: Location: Program Director or Supervisor(s): A. Medical Expert basic science knowledge 2. clinical knowledge 3. data-gathering (e.g. history & physical) 4. choice & use of ancillary tests (e.g. laboratory tests) 5. soundness of judgment & clinical decisions 6. performance under emergency conditions 7. self-assessment ability (insight) B. Communicator establishes therapeutic relationships with patients/families 2. delivers understandable information to patients/families 3. provides effective counseling to patients/ families 4. maintains professional relationships with other health care providers 5. provides clear and complete records & reports (including oral reports) C. Collaborator works effectively in a team environment 2. consults effectively with other physicians and other health care providers D. Manager manages time effectively 2. allocates health care resources effectively 3. utilizes information technology effectively 4. works effectively in a health care organization 5. practices evidence-based medicine E. Health Advocate is attentive to preventive measures 2. is attentive to issues of public policy for health 3. recognizes important social, environmental and biological determinants of health 4. demonstrates concern that patients have access to appropriate supports, information and services 5. offers advocacy on behalf of patients at practice and general population levels F. Scholar - resident will develop a plan for self-improvement attends and contributes to rounds, seminars and other learning events 2. accepts and acts on constructive feedback 3. reads around patient cases and takes an evidence-based approach to management problems 4. contributes to the education of patients, house staff/students, and other health professionals 5. contributes to the development of new knowledge

63 G. Professional - carries out duties in a professional manner recognizes limitations and seeks advice and consultation when needed 2. exercises initiative within limits of knowledge and training 3. discharges duties and assignments responsibly and in a timely and ethical manner 4. reports facts accurately, including own errors 5. maintains appropriate boundaries in work and learning situations 6. respects diversity of race, age, gender, disability, intelligence and socio-economic status H. Rotation Specific Criteria Understanding of the pathophysiology of congestive heart failure 2. Management of congestive heart failure including appropriate pharmacologic agents and indications for cardiac transplantation 3. To develop an understanding for the outpatient management of advanced heart failure, including indications for admission, management of medical therapy, up-titration and initiation of evidence-based therapies 4. To understand the indications, and contraindications for cardiac transplantation and ventricular assist device therapy I. Overall Competence General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

64 Rotation Specific Objectives and Skills: Congenital Cardiology All residents will be provided exposure to the assessment and management of pediatric patients with congenital heart disease, the natural history of these lesions, and the assessment and management of adult patients with congenital heart disease with the following goals and objectives: Fundamental Skills/Knowledge 1. Understanding of the common adult congenital heart disorders (ASD, VSD, Tetralogy of Fallot). 2. Diagnosis of the patient with adult congenital heart disease including skills in history, physical exam, ECG interpretation, other radiographic interpretation (CXR/MRI), and use of ancillary testing 3. Management of the patient with adult congenital heart disease, including use of appropriate pharmacologic agents, indications for surgical intervention, percutaneous intervention and coronary angiography 4. Understanding of the common surgical procedures in patients with congenital heart disease. 5. Understanding of the indications for pacemaker insertion, and electrophysiologic interventions. 5. Skills in cardiac physical diagnosis 6. Skills in electrocardiographic interpretation as it pertains to patients with congenital heart disease 7. Skills in echocardiographic interpretation as it pertains to patients with congenital heart disease

65 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Base Hospital: Rotation: Congenital Heart Disease Level of Training: Report Covers period: Location: Program Director or Supervisor(s): A. Medical Expert Understand cardiac embryology and the embryonic development of the cardiovascular system 2. Understanding of the common adult congenital heart disorders (ASD, VSD, Tetralogy of Fallot). 3. Diagnosis of the patient with adult congenital heart disease including skills in history, physical exam, ECG interpretation, other radiographic interpretation (CXR/MRI), and use of ancillary testing 4. Management of the patient with adult congenital heart disease, including use of appropriate pharmacologic agents, indications for surgical intervention, percutaneous intervention and coronary angiography 5. Understanding of the common surgical procedures in patients with congenital heart disease. 6. Understanding of the indications for pacemaker insertion, and electrophysiologic interventions. 7. Skills in cardiac physical diagnosis 8. Develop and approach to the common clinical conditions related to congenital conditions, i.e. congestive heart failure, cyanotic heart disease, common pediatric arrhythmias 9. Understand the effects of congenital heart disease and development 10. Understand the effects of common congenital cardiac conditions in pregnancy 11. Skills in electrocardiographic interpretation as it pertains to patients with congenital heart disease 12. Skills in echocardiographic interpretation as it pertains to patients with congenital heart disease B. Communicator Learn to be able to obtain a history of patients and their families as this is particularly important in the pediatric population 2. Understand the effects of congenital heart disease on the family 3. establishes therapeutic relationships with patients/families 4. delivers understandable information to patients/families 5. provides effective counseling to patients/ families 6. maintains professional relationships with other health care providers 7. Educate patients on their cardiac conditions & provide appropriate advice 8. Communicate effectively with the numerous healthcare professionals involved in patients with complex 9. congenital heart disease 10. Provide expert opinion to referring physicians on patients with

66 congenital heart disease 11. provides clear and complete records & reports (including oral reports) C. Collaborator work effectively with other physicians involved in patient care 2. works effectively in a team environment 3. consults effectively with other physicians and other health care providers D. Manager manages time effectively 2. allocates health care resources effectively & uses diagnostic investigations in a clinically efficient and cost effective manner 3. utilizes information technology effectively 4. works effectively in a health care organization 5. practices evidence-based medicine E. Health Advocate Educate parents and children of the effects of congenital cardiac conditions 2. Promote heart healthy lifestyle 3. Provide vocational counseling considering the cardiac condition 4. is attentive to preventive measures 5. is attentive to issues of public policy for health 6. recognizes important social, environmental and biological determinants of health 7. demonstrates concern that patients have access to appropriate supports, information and services 8. offers advocacy on behalf of patients at practice and general population levels F. Scholar Develop a life time ability for personal education 2. Learn to research uncommon cardiac conditions utilizing modern search techniques 3. attends and contributes to rounds, seminars and other learning events 4. accepts and acts on constructive feedback 5. reads around patient cases and takes an evidence-based approach to management problems 6. contributes to the education of patients, house staff/students, and other health professionals 7. contributes to the development of new knowledge G. Professional Deliver the highest quality health care with integrity, honesty and compassion 2. Exhibit appropriate personal and intrapersonal professional behaviors 3. Practice medicine ethically consistent with the obligations of a physician 4. recognizes limitations and seeks advice and consultation when needed 5. exercises initiative within limits of knowledge and training

67 6. discharges duties and assignments responsibly and in a timely and ethical manner 7. reports facts accurately, including own errors 8. maintains appropriate boundaries in work and learning situations 9. respects diversity of race, age, gender, disability, intelligence and socio-economic status H. Rotation Specific Criteria Understanding of the common adult congenital heart disorders 2. Diagnosis of the patient with adult congenital heart disease including skills in history, physical exam, ECG interpretation, other radiographic interpretation (CXR/MRI), and use of ancillary testing 3. Management of the patient with adult congenital heart disease, including use of appropriate pharmacologic agents, indications for surgical intervention, percutaneous intervention and coronary angiography 4. surgical intervention, percutaneous intervention and coronary angiography I. Overall Competence PROCEDURAL TRAINING: Number of adult congenital heart disease studies (transthoracic 2D-echo/Doppler) performed by trainee during rotation Number of adult congenital heart disease studies (transthoracic 2D-echo/Doppler) interpreted by trainee during rotation Number of reading sessions attended by trainee Other training during rotation (TEE, cardiac catheterization interventional procedures) General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement.

68 N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

69 Rotation Specific Objectives and Skills: Research Residents will be expected to complete a research project including a completed written manuscript within the 3-year training program. Residents will be expected to participate in the Faculty of Medicine Research Day each year. Residents will be expected to present their interim research results to their peers and Divisional staff during the first 2 years of the training program. In their final year they will be expected to present at the Faculty of Medicine Research Day, an oral abstract, which will be judged along with their submitted, completed manuscript in the spirit of a Young Investigator s Competition. Goals and objectives of this rotation include: Fundamental Skills 1. Understand the appropriate application of research methodologies to address questions of basic or clinical interest applicable to the understanding of cardiovascular disease. 2. Appreciate what is involved to develop, participate in, and complete a clinical or basic science research project. 3. Synthesize and present research findings in a scientific forum to an audience of peers and faculty. 4. Be able to critically appraise research findings and appropriately apply them to clinical practice. 5. To develop an appreciation for the scientific method. 6. To complete and submit a scientific manuscript.

70 IN-TRAINING EVALUATION REPORT (Cardiology) Name: Rotation: Research Hospital: Training level: Report Covers Period: Location: Program Director or Supervisor(s): A. Medical Expert Understands different types of research, ethical issues, legal issues, and statistic knowledge to design a research project, develop rationale/access feasibility of proposal. Able to critically appraise the literature. B. Communicator Has written up research proposal, ethics, submission and consent forms as required Has written interim research reports. Has presented data in oral, abstract or manuscript form. Has presented at peer-reviewed meetings. Has presented at Ursula Bangs Research Day Has completed a written manuscript of the work. C. Collaborator Collaborates with all heath care professionals and basic scientists involved in research. D. Manager Learn skills of setting a budget for proposed or ongoing research. Learn time management skills to balance research with ongoing clinical commitments. E. Health Advocate Evaluate research initiatives with patient s best interests in mind. Evaluate all research initiatives with ethics principles as a primary basis. F. Scholar Has learned basic skills including literature searching and grant proposal writing skills. G. Professional Conduct all research with primary objectives of maintaining highest degree of professional conduct. Develop insights into present personal strengths and weakness in the research arena. Understand ethical codes of behavior.

71 General Comments: Provide a general impression of the trainee's development during this rotation, including general competence, motivation and consultant skills. Please emphasize strengths and areas that require improvement. N.B. I certify that I have read all parts of this in-training evaluation report and I have discussed it with my evaluator(s). Signature of trainee: Date: Signature of evaluator: Date:

72 Elective Rotations The goals and objectives of the program are also achieved by undertaking rotations of an elective nature. Rotations may include Congestive Heart Failure/Cardiac Transplantation, Cardiac Surgery, Cardiac Pathology, and a Community Cardiology Elective rotation. Goals and objectives for the elective rotations will be based upon the nature and scope of area studied. Community Cardiology Residents may elect to partake in elective opportunities in the community to provide an understanding of a typical cardiology practice in a non-academic environment (could be in private sector). Fundamental Skills/Knowledge 1. Understanding of the diagnosis and management of cardiac disorders in the community setting. 2. Understanding of the practice of cardiology in community setting AMBULATORY CARE REQUIREMENTS Residents are required to attend longitudinal ambulatory care clinics as part of the requirements of training as mandated by the program It is the expectation of the training program that residents will attend and participate in longitudinal clinics during each year of training.

73 TRAINING PROGRAM STRUCTURE Resources Four major hospitals /centers are involved in the training program: Chest Disease Hospital, Sabah Al-Ahmad Cardiac Center, Al-Dabous Cardiac Center and Mubarak Al-Kabeer Hospital. The residents within the cardiology program rotate across the four institutions to get exposure to different expertise and resources available at the four sites. Some centers may provide unique services and exposure to different population of patient s that may not be readily available in other centers. Residents are exposed to state-of-the art acute coronary care units, non-invasive cardiac diagnostics including echocardiography, stress testing and nuclear imaging, Cardiac CT and MRI, invasive cardiology like cardiac catheterization, and percutaneous intervention, specialized Electrophysiology laboratories, and ambulatory care cardiology. For some resources or services that are not available, like cardiac rehabilitation and cardiac transplantation, arrangements are made for residents to have those rotations done elsewhere abroad. Resources: CDH SACC DCC Mubarak H. CCU Catheterization Lab X Primary PCI X X EP Service X Non Invasive lab Echocardiography/holter/ETT/ABPM Nuclear Cardiology CT/MRI Limited X X X Cardiovascular surgery X Congenital heart disease X X X Heart failure/cardiac transplantation X X HF only X service Cardiac Rehabilitation Limited X X X Research Ambulatory Care

74 Clinical Tutors: There are clinical tutors assigned specifically to participate in the teaching and educational aspect of the program either clinical sessions or formal lecturing etc. according to the program agenda. The clinical tutor list is provided below: Entry and Examination Eligibility This program is available only to those candidates who have successfully completed four years of training in Kuwait Board in Internal Medicine (and are eligible to sit the Internal Medicine Board examination) or equivelent. The resident has to achieve certification in Internal Medicine (pass the Internal Medicine exam) in order to be eligible to sit the Adult Cardiology certification examination. Additional years of more specialized Cardiology training will not be included in this curriculm.