CURRICULUM FOR FELLOWSHIP IN CARDIOVASCULAR DISEASES UNIVERSITY OF OKLAHOMA HEALTH SCIENCES CENTER TABLE OF CONTENTS

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1 CURRCULUM FOR FELLOWSHP N CARDOVASCULAR DSEASES UNVERSTY OF OKLAHOMA HEALTH SCENCES CENTER TABLE OF CONTENTS. Educational Program... 3 a. Core (General) Competencies... 3 b. Evaluation Curriculum for Fellowship in Cardiovascular Diseases... 4 a. Objectives... 4 A. Clinical Experience... 4 B. Technical & Other Skills... 5 C. Formal nstruction... 5 D. Research Experience... 6 b. Description of Rotations... 7 A. Coronary Care Unit... 7 B. Consult Service C. Echocardiography D. Heart Station & Stress Testing E. Cardiac Catheterization Laboratories F. Pacing Rotation for General Cardiology (Non-EP) Fellows G. Fellow Research H. Cardiology Fellows Clinic Cardiac Rehabilitation J. Nuclear Cardiology K. Heart Failure Rotation L. EKG Reading (Heart Station and Dedicated EKG Reading Assignment) M. Vascular Medicine N. Pediatric Cardiology/Adult Congenital Heart Disease O. Cardiothoracic Surgery P. EP Ablation Q. EP Consult c. General Learning Objectives Resources Available a. Training Sites b. Teaching Conferences V. Relationship of Core Competencies and Educational Objectives to Teaching Conferences V. Teaching Plan for Specific Learning Objectives... 52

2 V. Procedure Skills V a. List of Procedures V b. Documentation of Procedures V. Reading List Recommendations V. Outline for ncorporating Core Competencies into Cardiology Fellows Rotation X. Core Cardiovascular Training Statement (COCATS-4) Competency Tables Approved by faculty and fellow representatives June

3 . EDUCATONAL PROGRAM a. Core or General Competencies Six areas of core or general competencies are required as outlined by ACGME: 1. Patient Care Demonstrating compassionate, appropriate and effective for the treatment of health problems and promotion of heath 2. Medical Knowledge Understanding established and evolving biomedical, clinical and cognate sciences and application of this knowledge to patient care 3. Practice-based Learning and mprovement Engaging in investigation and evaluation of one s own patient care, appraisal and assimilation of scientific evidence and improvements in patient care 4. nterpersonal and Communication Skills Acquiring skills in effective information exchange and teaming with patients, their families and other health professionals 5. Professionalism Manifesting through a commitment to carrying out professional responsibilities, adhering to ethical principles and sensitivity to diverse patient population 6. Systems-Based Practice Following actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value Training of cardiology fellows will incorporate the above ACGME principles. b. Evaluation Evaluation of fellows will be done through: Monthly, end of rotation written evaluations by the attending physician Formative evaluation after individual procedure by supervising faculty Evaluations by nurses, case managers, students (if applicable) and patients that are part of the multisource feedback Yearly formal written in-training examination Observation of clinical procedures by a faculty member (proctored procedures) End of training summative evaluation by program director Evaluation of the teaching program will be done through: ABM pass rate and specific performance data from the examination Feedback about the teaching program and faculty from the fellows after rotations Feedback from on-line survey of graduating fellows (done by GME office) Feedback from the yearly on-line ACGME Resident (fellow) survey Feedback from the yearly on-line ACGME Faculty survey 3

4 . CURRCULUM FOR FELLOWSHP N CARDOVASCULAR DSEASES a. Objectives The objective of the cardiology fellowship program is to provide training and experience in the evaluation and management of a variety of acute and chronic cardiovascular conditions. ncluded in this list are: chronic coronary artery disease congestive heart failure acute coronary syndromes acute myocardial infarction arrhythmias lipid disorders and prevention hypertension cardiomyopathy valvular heart disease pulmonary heart disease vascular disease infectious and inflammatory heart disease adult congenital heart disease acute care cardiology out-patient and ambulatory cardiology The training and experience acquired during the training will be sufficient for the level of the specialist. The training will be aimed at acquiring both the knowledge base as well as technological skills. Pathophysiology, pathogenesis, natural history, and diagnosis will be stressed. The goal of the training program is to provide opportunities for the fellows to develop clinical competence in the field of adult cardiology. A. Clinical Experience 1. Patient Population Clinical experience includes opportunities to observe, manage and judge the effectiveness of therapeutic programs in patients with a wide variety of adult cardiovascular disorders on both an inpatient and an outpatient basis. The fellow will be given opportunities to assume continuing and progressively more independent responsibility for both acute and chronically ill patients to learn the natural history of cardiovascular disease. 2. Ambulatory Medicine Continuing care experience in the ambulatory care setting will occur at two 1/2 day clinics each week during the 36 months of training. 3. npatient Care There will at least 8 months of non-laboratory clinical practice activities (e.g., consultations, CCU, PCCU, clinical electives in Thoracic Surgery and Pediatric Cardiology). 4

5 4. Special Clinical Experience There will be a minimum of 24 months of clinical training, including inpatient and special rotations: a. Minimum of four (4) months of cardiac catheterization b. Minimum of four (4) months of noninvasive cardiac evaluations including, exercise stress test, ECG interpretation, ambulatory ECG recording, echocardiography, and nuclear cardiology c. Two (2) months electrophysiology and pacemaker follow-up B. Technical and Other Skills 1. Training program will provide experience for the fellow in the performance and interpretation of: a. History and physical examination b. Cardiopulmonary resuscitation and advanced cardiac life support c. Elective cardioversion d. Bedside right heart catheterization e. nsertion and management of temporary pacemakers f. Over 100 right and left heart catheterizations including coronary arteriography g. Over 50 exercise stress tests h. Over 150 echocardiography studies and interpretation 2. Training program will provide experience for the fellow with performance and/or interpretation of: a. Pericardiocentesis b. Programming and follow-up of permanent pacemakers c. ntracardiac electrophysiologic studies d. ntra-aortic balloon counterpulsation 3. Training program will provide experience for fellows in the interpretation of: a. Chest x-rays b. Electrocardiogram c. Ambulatory ECG recording d. Radionuclide studies of myocardial function and perfusion C. Formal nstruction Training program will provide instruction and knowledge in: 1. Basic science including a. Cardiovascular anatomy b. Cardiovascular physiology c. Cardiovascular metabolism d. Molecular biology of the cardiovascular system e. Cardiovascular pharmacology f. Cardiovascular pathology 2. Prevention of cardiovascular disease including a. Epidemiology and biostatistics b. Risk factors c. Lipid disorders 5

6 3. Evaluation and management of patients with a. Coronary artery disease and its manifestations and complications b. Arrhythmias c. Hypertension d. Cardiomyopathy e. Valvular heart disease f. Pericardial disease g. Pulmonary heart disease h. Peripheral vascular disease i. Cerebrovascular disease j. Heart disease in pregnancy k. Adult congenital heart disease l. Complications of therapy 4. Management of a. Acute and chronic congestive heart failure b. Acute myocardial infarction and other acute ischemic syndromes c. Acute and chronic arrhythmias d. Preoperative and postoperative patients e. Cardiac transplant patients 5. Diagnostic techniques including a. Magnetic resonance imaging b. Computed tomography c. Positron emission tomography D. Research/Scholarly Activity Experience Research/Scholarly activity is a required component of fellowship training. ACGME requires meaningful research experience for the cardiology fellow. Fellow will be expected to have completed a research or scholarly project and presented the results locally and/or nationally and written a manuscript based on the project. 6

7 b. Description of the Rotations & Evaluation of Various Levels of Entrustment A. Coronary Care Unit Educational Goals and Associated Curricular Competencies: 1. Understand the assessment and management of acute ischemic syndromes (STEM and Non- STEM ACS). (Core competencies: Patient Care, Medical Knowledge, nterpersonal Skills, Professionalism) 2. Understand the assessment and management of hemodynamic instability. (Core competencies: Patient Care, Medical Knowledge, nterpersonal Skills, Professionalism) 3. Develop the skills needed to use the noninvasive laboratory and the cardiac catheterization laboratory in the most cost effective and appropriate manner. (Core competencies: Patient Care, Medical Knowledge, Systems Based Practice) 4. Understand the indications and comparative merits of catheter based revascularization vs. surgical revascularization in various forms of ischemic and valvular heart disease. (Core competencies: Patient Care, Medical Knowledge) 5. Understand the indication, monitoring and trouble shooting of intra-aortic balloon pump and other mechanical circulatory devices, pulmonary artery catheters and temporary pacemakers. (Core competencies: Patient Care, Medical Knowledge, Systems Based Practice) 6. Understand the emergency management of various types of tachy- and bradyarrhythmias. (Core competencies: Patient Care, Medical Knowledge) 7. Learn interdisciplinary and team management of cardiovascular patients and transitions of care. (Core competencies: Patient Care, nterpersonal Skills, and System Based Practice) Fellow Responsibilities: First Year Fellow (OUMC CCU): 1. Assist on "work round" with the housestaff on the CCU and PCCU patients in predominantly an advisory role. 2. Discuss potential management problems with the attending early in the day, including decisions to perform invasive procedures. 3. nteract with the cardiac catheterization team, cardiac surgery team and the stress & echo lab to organize care of patients as well as interpretation of new diagnostic information. 4. Act as liaison between the CCU and cardiology attending and referral sources of patient admissions to ensure smooth flow. 7

8 5. Review angiograms and echocardiograms with housestaff and attending on cardiology inpatients. Correlate angiographic and clinical findings and discuss the impact of angiographic findings on patient management with attending and housestaff. 6. Function as a teacher for the ward team. Structure of the ward team is as follows: Attending physician in charge, CCU fellow, resident, intern, physician assistant, pharmacist (Pharm.D), case manager, social worker. Residents report to the fellow and the fellow reports to the attending. 7. Oversee safe and effective patient hand off processes and transitions of care as per hospital and university directives. Second Year & Third Year Fellow (DVA Med Center): 1. Assist on "work round" with the housestaff on the CCU and PCCU patients in predominantly an advisory role. 2. Discuss potential management problems with the attending early in the day, including decisions to perform invasive procedures. 3. nteract with the cardiac catheterization team, cardiac surgery team and the stress & echo lab to organize care of patients as well as interpretation of new diagnostic information. 4. Act as liaison between the CCU and cardiology attending and referral sources of patient admissions to ensure smooth flow. 5. Review angiograms and echocardiograms with housestaff and attending on cardiology inpatients. Correlate angiographic and clinical findings and discuss the impact of angiographic findings on patient management with attending and housestaff. 6. Function as a teacher for the ward team. Structure of the ward team is as follows: Attending physician in charge, CCU fellow, resident, intern, physician assistant, pharmacist (Pharm. D), case manager, social worker. Residents report to the fellow and the fellow reports to the attending 8. Oversee safe and effective patient hand off processes and transitions of care as per hospital and university directives. 7. Be aware of the procedures that CCU fellow is credentialed to perform (Bedside Swan Ganz catheterization, temporary pacemaker insertion, bedside emergency transthoracic echocardiography. Fellow Assignments: OU Medical Center, Coronary ntensive Care Unit DVA Medical Center, Coronary ntensive Care Unit Mix of Diseases and Patient Characteristics: Acute ischemic syndromes Acute myocardial infarction Arrhythmias (supraventricular and ventricular) 8

9 Teaching Methods: Sudden cardiac death Hypotensive syndromes Bradyarrhythmias Congestive heart failure Chest pain syndromes Pericardial effusion and tamponade Ward rounds Didactic lectures Case Conference and Clinical Morbidity and Mortality Conference (Wednesdays) Monthly quality improvement meeting (fourth Monday) Procedure Skills to be Acquired and Documented: Pulmonary artery catheterization Temporary transvenous pacing Cardioversion nteraction with the nternal Medicine/Family Medicine Resident and Responsibilities of the CCU resident: 1. Assess patients admitted to the CCU and cardiology wards (including data collection, physical examination, write ups, test ordering, assessment of information from tests); discuss patient information with the cardiology fellow and subsequently the cardiology attending) 2. Prepare for daily ward rounds 3. Discharge patients and ensure safe transitions of care 4. Respond as appropriate to code blue during day time 5. Respond to calls from Emergency Department for consultations and patient dispositions 6. Direct the patient hand off process to ensure safety and completeness 7. Serve as the immediate supervisor and resource for the internal medicine or family medicine resident assigned to the team. Faculty Supervision: CCU attending will make ward rounds daily with the ward team and supervise performance of the CCU fellow. CCU attending will provide the overview of the rotation as well as feedback at the end of the rotation. A written formal evaluation that incorporates the 6 core competencies as well as specific competencies involved in the rotation will be generated. Any procedure logs generated will require the attending s signature. 9

10 Suggested Reading: Textbook of Cardiovascular Medicine, Editor: Eric J. Topol, Lippincott-Raven Heart Disease: A Textbook of Cardiovascular Medicine, Editor: Eugene Braunwald, W.B.Suanders Company Hurst s The Heart, Editors: Schlant, Alexander, McGraw-Hill, nc Mayo Clinic Cardiology Board Review (DVD) series ACCF Cardiology Board Review series Method of Evaluation: End of rotation written evaluation by faculty Multisource Feedback Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. Procedures Approved in the CCU for Cardiology Fellows: Procedures P1 P2 P3 P4 P5 P6 P7 Faculty Arterial Puncture & Cannulation. S S S A A A A A Cardiac Pacemaker (Transvenous) S S S A A A A A Cardioversion (Elective) S S S A A A A A Echocardiography A A A A A ECG nterpretation (ncluding ETT) S S S A A A A A Endotracheal ntubation S S S A A A A A Paracentesis, Abdominal S S S A A A A A Pericardiocentesis (non-emergent) S S S S A A A A Placement of ABP S A A A A Respirator Management S S S A A A A A Subclavian Puncture/nternal Jugular Line S S S A A A A A Swan-Ganz Catheterization S S S A A A A A Thoracentesis S S S A A A A A Thrombolytic Therapy S S S A A A A A Transesophageal Echo S S S S S S A A S = Only with Supervision A= Approved P4- first year fellow P5- second year fellow P6- third year fellow P7- fourth year fellow 10

11 Core Competencies (Education and Evaluation) during this rotation: Competency Methodology for Methodology for Education/Training Testing/Evaluation 1. Patient Care CCU Rounds (bedside) Global rating Unit Consults CCU Case Monthly M & M Conference Conference Presentation M & M Presentations Multisource feedback 2. Medical Knowledge CCU Rounds (bedside) Global rating Unit Consults CCU Case Conference Presentation Multisource feedback 3. Practice-based Learning & CCU Rounds (bedside) Global Rating mprovement Unit Consults Multisource feedback Monthly QA Conference 4. nterpersonal & CCU Rounds (bedside) Global Rating Communication Skills Unit Consults Multisource feedback 5. Professionalism CCU Rounds (bedside) Global Rating Unit Consults Multisource feedback 6. System based Practice CCU Rounds Global Rating Unit Consults Multisource feedback Handouts about how to access services 11

12 ACC CMC Template Evaluation Tool for Cardiovascular ntensive Care Unit Rotation No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Ready for Unsupervised Critical Deficiencies Early Learner Advancing-mproving Practice Aspirational 1 Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures. M-CCC-MK1, MK2, MK3, MK4, MK7, MK13 Has rudimentary knowledge of the pathophysiology, diagnosis, and management of patients with acute coronary syndrome, cardiogenic shock, and common arrhythmias. Has a basic understanding of the pathophysiology and management of acute coronary syndromes. Recognizes some forms of shock and is able to initiate therapies with guidance. Requires assistance in the interpretation of hemodynamic data. Recognizes common atrial and ventricular arrhythmias. Recognizes and manages most types of acute coronary syndromes. Knows the pathophysiology and differential diagnosis of shock. Able to interpret most hemodynamic data and appropriately use inotropes and pressors. Knows the indications for mechanical circulatory assist devices. dentifies and manages common atrial and ventricular arrhythmias. Recognizes and manages acute coronary syndromes. Knows the pathophysiology, differential diagnosis, and management of shock. Accurately interprets hemodynamic data and appropriately uses inotropes and pressors. Knows the indications for mechanical circulatory assist devices. dentifies and manages complex atrial and ventricular arrhythmias. Serves as a resource to cardiologists and other healthcare providers on the management of critically ill patients with cardiovascular disease. 2 Patient Care and Procedural Skills PC1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC2: Develops and achieves comprehensive management plan for each patient. PC3: Manages patients with progressive responsibility and independence. PC4a: Demonstrates skill in performing and interpreting invasive procedures. M-CCC-PC1, PC2, PC3, PC8, PC9, PC10, PC12, PC15 Does not recognize the symptoms or signs associated with acute coronary syndromes, shock, and other common cardiovascular emergencies. Lacks skills to insert hemodynamic monitoring devices and requires complete supervision in the interpretation of hemodynamic data. Unable to identify and treat common arrhythmias. Needs assistance with the management of most patients with acute coronary syndromes, shock, and other common cardiovascular emergencies. Requires supervision for the insertion and interpretation of invasive hemodynamic monitoring devices. Able to initiate therapy for common arrhythmias. Able to identify and manage most patients with acute coronary syndromes and associated complications. Able to identify and manage patients with shock and appropriately use indicated medical and mechanical therapies, in most cases. Has skill to insert and manage invasive monitoring with minimal assistance. Able to manage common unstable arrhythmias. Able to manage patients with acute myocardial infarction and any associated rhythm, conduction, or mechanical complication. Able to manage patients with all forms of shock and appropriately use pressors, inotropic agents, and mechanical support. Able to manage life threatening arrhythmias. Able to place and manage arterial, central venous, and pulmonary artery catheters and temporary transvenous pacemakers. Demonstrates skills necessary to manage critically ill patients with a broad range of cardiovascular diseases and associated complications. s a leader and educator for training others in critical care cardiology.

13 Systems-Based 3 Practice SBP1: Works effectively within an interprofessional team. SBP3: dentifies forces that impact the cost of health care, and advocates for and practices costeffective care. SBP4: Transitions patients effectively within and across health delivery systems. M-CCC-SBP1, SBP2, SBP3, SBP4, SBP5 Does not interact effectively with other members of the health care team. Does not engage in quality improvement and safety measures. Does not assist with transitions of care. Engages in discussion with team members when directly approached, but does not actively seek input from others. Able to initiate transitions of care with supervision. Recognizes importance of quality improvement and safety measures. Actively engages members of the critical care team and associated consultants in collaborative decisionmaking. Able to tranistion patients between care settings with minimal assistance. Participates in quality improvement and safety initiatives. Efficiently coordinates activities of the critical care team to provide optimal care. Active participant in quality improvement and safety initiatives. Able to effectively transition patients between care settings. Viewed by the critical care team as a leader in delivery of high quality care. Leads others in quality improvement initiatives. 4 Practice-Based Learning and mprovement PBL1: Monitors practice with a goal for improvement. PBL2: Learns and improves via performance audit. PBL3: Learns and improves via feedback. PBL4: Learns and improves at the point of care. M-CCC-PBL1 Unwilling or unable to selfreflect upon one's practice or performance. Does not accept feedback well. Consistently misses opportunities for learning and self-improvement. Sometimes defensive when receiving feedback. Acts on some, but not all, opportunities for learning and self-improvement. Accepts feedback well. Regularly reflects upon one's performance, and consistently acts on those reflections to promote improvement. Actively seeks feedback on performance and incorporates changes into his or her practice. Actively and independently engages in selfimprovement and learning activities. 5 nterpersonal and Communication Skills CS1: Communicates effectively with patients and caregivers. CS2: Communicates effectively in interprofessional teams (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel). CS3: Appropriate utilization and completion of healthcare records. M-CCC-CS1, CS2 Does not complete notes in a timely fashion. Does not communicate effectively with patients and members of the healthcare team. Unable to initiate end-oflife discussions with patients or family. Requires reminders to complete notes. Engages in discussion with patients and team members, but requires guidance. nitiates end of life discussions with patients and families with assistance. Consistently completes documentation in a timely fashion. Engages patients and team members in discussion of healthcare decisions. Able to discuss end-of-life decisions with patients and family. Completes documentation Demonstrates ability to act concisely, accurately, and in as role model in providing timely fashion. Actively and reporting all elements engages patients and team of patient care. Able to lead members in healthcare end-of-life discussions with decisions. patients and families. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-CCC-PROF1, PROF2, PROF4 Lacks sensitivity to patients' Exhibits inconsistent needs. Not consistently sensitivity and respect respectful when interacting when interacting with with patients, staff, and patients, staff, and peers. peers. Does not accept Requires reminders to responsibility for tasks. follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

14 b. Description of the Rotations B. Consult Service Educational Goals and Associated Competencies: 1. Understand the role of cardiologist as a consultant when complex cardiac disease is encountered in surgical, obstetric or general medicine practice. (Core Competencies: Patient care, medical knowledge, professionalism, practice based learning and improvement and system based practice) 2. Gain an increased understanding of clinical diagnosis and management of cardiovascular disease in the inpatient and outpatient settings. (Core competencies: Patient care, medical knowledge, system based practice) Fellow Responsibilities: Second and Third Year Fellows: 1. Evaluate consult patients and discuss their management with the cardiology attending. Follow the patients until cardiac problems are stable and discuss the management with the attending daily. 2. Evaluate and help with the disposition of the patients seen in the Emergency Department 3. Organize special procedures for the consult patients with the cath lab, echo lab, and EP lab whenever necessary. 4. Oversee nuclear stress tests as needed. Fellow Assignments: OU Medical Center consults are covered by the consult fellow assigned to OUMC. DVA Medical Center consults are covered by the VA-CCU fellow. Mix of Diseases and Patient Characteristics: Acute ischemic syndromes Acute myocardial infarction Arrhythmias (supraventricular and ventricular) Sudden cardiac death Hypotensive syndromes Bradyarrhythmias Congestive heart failure Chest pain syndromes Pericardial effusion and tamponade 12

15 Teaching Methods: Rounds Reading assignments Procedural Skills to be acquired & procedure logs to be maintained: NA Faculty Supervision: Consult service attending will make ward rounds daily with the ward team and supervise performance of the fellow. Attending will provide the overview of the rotation as well as feedback at the end of the rotation. A written formal evaluation that incorporates the 6 core competencies will be generated nteraction with the nternal Medicine Resident & Responsibilities of the nternal Medicine Resident on the Consult Service (VA only): 1. Assess patients referred for cardiology consult; discuss patients with the cardiology fellow and cardiology attending 2. Provide supervision and teaching to the residents assigned to the consult service 3. Supervise stress tests, tilt table tests at VAMC and OUMC (ad hoc and optional) 4. Cardiology fellow is the immediate supervisor and resource for the internal medicine resident assigned to the team. Fellow also provides supervision and teach fourth year medical students whenever they are present in the team. Suggested Reading: Heart Disease: A Textbook of Cardiovascular Medicine, Editor: Eugene Braunwald, W.B.Suanders Company Hurst s The Heart, Editors: Schlant, Alexander, McGraw-Hill, nc Mayo Clinic Cardiology Review (DVD) series Method of Evaluation: End of rotation written evaluation by faculty. Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 13

16 ACC CMC Template Evaluation Tool for Cardiology Consult Service Rotation DM No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational 1 Medical Knowledge MK1: Possesses the scientific, socioeconomic, and behavioral knowledge required to provide care for common medical conditions and basic preventive care. MK2: Consistently interprets basic diagnostic tests accurately, Lacks foundational knowledge regarding the clinical manifestions of common cardiovascular conditions including acute coronary syndromes, stable ischemic heart disease, heart failure syndromes, valvular disease, vascular syndromes, perioperative risk assessment, and M-SCHEM-MK3, MK4, MK9, MK14; M-VALV-cardiovascular diseases MK2, MK5, MK14 associated with pregnancy. Minimally understands the role of the cardiovascular consultant in the management of various types of cariovascular diseases (including acute coronary syndromes, stable ischemic heart disease, heart failure syndromes, arrythmias, perioperative cardiac care). Shows improving understanding of the pathophysiology the common cardiovascular conditions (including acute coronary syndromes, stable ischemic heart disease, heart failure syndromes, arrhythmias, and perioperative cardiac care). Shows sustained ability to adequately evaluate and provide guideline-based management of various types of cariovascular diseases (including acute coronary syndromes, stable ischemic heart disease, heart failure syndromes, arrhythmias, and perioperative cardiac care). Understands subtle nuances in interpreting physical findings, test results, and providing evidence-based collaborative care. 2 Patient Care and Procedural Skills PC1: Consistently acquires accurate and relevant histories. PC2: Consistently develops appropriate care plans, recognizes situations requiring urgent or emergency care. M-SCHEM-PC1, PC3, PC7, PC10; M-VALV- PC1, PC2, PC4, PC9 Fails to recognize clinical manifestations of significant acute and chronic heart disease. Fails to provide guidelinerecommended therapies. Fails to work harmoniously with those seeking consults. Fails to recognize own skill limitations. Possesses partial skills needed to safely assess and initiate treatment for a variety of acute and chronic cardiac conditions. nterprets basic diagnostic tests. Possesses insufficent skills to work collaboratively. s inattentive to patient safety and comfort, cost, effective care, and quality of care. Shows improving ability to evaluate and develop treatment plans for most common cardiac diagnoses. Provides appropriate guidance to transitions of care. Works effectively with consulting physicians and services. Consistently and effectively performs clinical assessment and develops evidence-based treatment plans. Consistently recognizes appropriate indications and contraindications to diagnostic testing therapies. Recognizes opportunities to improve quality and safety of patient care. Demonstrates skills necessary to evaluate complicated pathology. Effectively manages patients who were not successfully managed by others. Sets outstanding example of professionalism. 3 Systems-Based Practice SBP1: Works effectively within an interprofessional team (e.g. peers, consultants, nursing, ancillary professionals, and other support personnel). M-SCHEM-SBP1, SBP2; M-VALV-SBP1, SBP2 Frequently fails to work effectively within the patient care team, act as a patient advicate and effectively and safely transition care. Engages in discussion when Actively engages members directly approached, but of the care team in does not actively seek input collaborative decisionmaking. from others. Efficiently coordinates activities of patent care process including transitions of care. Provides team-based optimal care. Viewed by patient care team as a leader in delivery of high-quality care.

17 Practice-Based Learning and 4 mprovement PBL1: Monitors practice with a goal for improvement. M-SCHEM-PBL2; M-VALV-PBL2 Unwilling to self-reflect Consistently misses upon one's own practice or opportunities for learning performance. and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance, and consistently acts on those reflections to promote improvement. Actively and independently engages in selfimprovement and learning activities. 5 nterpersonal and Communication Skills CS1: Communicates effectively with patients and caregivers. CS2: Communicates effectively in interprofessional teams (e.g. with peers, consultants, nursing, ancillary professionals, and other support personnel). CS3: Appropriate utilization and completion of healthcare records. M-SCHEM-CS1, CS2; M-VALV-CS1 Does not enter test results and interpretations into health record. nconsistently enters test results and interpretations into health record. Consistently enters test results and interpretations into health record. Provides effective and prompt test results and interpretations to physicians. Demonstrates ability to act as role model to provide comprehensive, succinct, patient-specific test results to clinicians. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and M-SCHEM-PROF1, PROF2, PROF3; M-VALVethical behavior in professional conduct. PROF1, PROF2 Lacks sensitivity to patients' needs. s disrespectful when interacting with patients, staff, and peers. Does not accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

18 b. Description of the Rotations C. Echocardiography Educational Goals and Associated Competencies: 1. Selects patients for echocardiography (initial and follow-up) based on accepted current guidelines. (Core Competencies: Medical Knowledge, Patient Care) 2. Performs comprehensive analysis and reporting of TTEs. (Core Competencies: Medical Knowledge, Patient Care) 3. Performs TEEs, conducts comprehensive analysis and reporting of TEEs; understands and follows contraindications to esophageal intubation and moderate/conscious sedation. (Core Competencies: Medical Knowledge, Patient Care) 4. Performs stress echocardiography, conducts comprehensive analysis and reporting of stress echocardiograms. (Core Competencies: Medical Knowledge, Patient Care) 5. Applies Appropriate Use Criteria (AUC) and other guidelines based principles to patient selection for echocardiography. (Core Competencies: Medical Knowledge, Patient Care) 6. Understands the role, cost comparison and relative value of competing technologies (cardiac CT, cardiac MR and nuclear studies). (Core Competencies: Medical Knowledge, Patient Care) 7. Understands the basic troubleshooting of the echocardiography machine and maintenance of the TEE probe. (Core Competencies: Professionalism, Practice-Based Learning and mprovement) Fellow Responsibilities: First Year Fellow: 1. Perform 150 echocardiograms under the supervision of a qualified sonographer (RDMS or RDCS) and/or the attending echocardiographer. Goals of hands-on training are: ---Understanding of the tomographic cardiac anatomy and the 3D relationship of different tomographic image planes. ---Understanding of basic image and flow acquisition parameters and the effect of instrumentation settings on data quality. ---Recognition and avoidance of ultrasound artifacts. 2. nterpret 300 echocardiograms under the supervision of an appropriately qualified physician. 3. Perform stress (exercise and pharmacologic) echocardiograms and participate in their interpretation. 14

19 4. Correlate echocardiographic findings with physical examination findings and other clinical data. nteract with referring physicians when echocardiograms are requested and when further interpretation of echocardiographic results is needed. 5. Read a standard textbook on echocardiography and study other recommended articles. 6. Prepare and help present cases as needed at the weekly echocardiography conference. 7. Communicate with referring physicians any critical information as necessary. 8. Work effectively with the echo lab team to ensure patient safety and an error free care operation. Second and Third Year Fellow: 1. Participate in the evaluation, preparation and performance of patients undergoing transesophageal echocardiograms. 2. Correlate echocardiographic findings with physical examination findings and other clinical data. nteract with referring physicians when echocardiograms are requested and when further interpretation of echocardiographic results is needed. 3. Continue to read a standard textbook on echocardiography and study other recommended articles. 4. Prepare and help present cases as needed at the weekly echocardiography conference. 5. Communicate critical information with referring physicians as needed. 6. Work effectively with the echo lab team to ensure patient safety and an error free care operation Fellow Assignments: OUMC Echo Lab DVA Medical Center Echo Lab Mix of Disease and Patient Characteristics: Coronary artery disease (acute and chronic) Valvular heart disease Pulmonary heart disease Hypertensive heart disease Congenital heart disease Prosthetic valve surgery Pericardial disease Traumatic heart disease Aortic disease Heart Failure 15

20 Faculty Supervision and Method of Evaluation: Echo faculty will provide guidance and supervision in patient care issues. They will also supervise reading of the echocardiographic studies. Faculty will provide formative feedback after each procedure (debriefing). Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. Teaching Methods: Scanning at the bedside (transthoracic, stress and transesophageal echo) Reading of echocardiographic studies Formative feedback after TEEs Didactic instruction in the weekly echocardiography conferences (Thursdays 7.30 to 8.30 am) Suggested Reading: The Echo Manual, by Jae K. Oh, James B. Seward and A. Jamil Tajik, Lippincott Williams & Wilkins 2007 Graded Responsibilities and Performance mprovement in Echocardiography: Entrustable Professional Activities in Echocardiography at the end of Training: 1. Selects patients for echocardiography (initial and follow-up) based on accepted current guidelines 2. Performs comprehensive analysis and reporting of TTEs 3. Performs TEEs, conducts comprehensive analysis and reporting of TEEs; understands and follows contraindications to esophageal intubation and moderate/ conscious sedation 4. Performs stress echocardiography, conducts comprehensive analysis and reporting of stress echocardiograms 5. Understands the role, cost comparison and relative value of competing technologies (cardiac CT, cardiac MR and nuclear studies) 6. Understands basic trouble shooting of the echocardiography machine and maintenance of the TEE probe Milestones: Approximate Time 1. Pre-reads correctly critical TTE findings First year a. Tamponade 2 years b. LV dysfunction and wall motion abnormalities 1-2 years c. Cardiac masses First year d. Acute RV failure 1-2 years e. Aortic dissection 2-3 years f. Severe valvular lesions 2-3 years 2. Performs esophageal intubation safely 2 years 3. Performs TEEs and obtains standard views correctly 2-3 years 4. Performs and pre-reads stress echocardiograms correctly 2 years Milestones: 1. Develops concept of three dimensional cardiac anatomy First year 2. Selects patients for TTE based on current guidelines First year 3. Understands typical findings in tamponade, LV dysfunction, 1-2 years cardiac masses, acute RV strain, severe valvular lesions 16

21 Assessment of development of Landmarks and Milestones: 1. Monthly assessment (formative) 2. Observation (direct) 3. n-training evaluation (once a year) 4. Proctored procedures Echo board examinations (National Board of Echocardiography): Administered in July each year Please obtain prior approval and guidance from Program Director Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 17

22 ACC CMC Template Evaluation Tool for Echocardiography Rotation DM No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational 1 Medical Knowledge MK2: Knowledge of diagnostic testing and procedures. M-MAG-ECHO-MK2, MK7, MK8, MK9, MK10, MK11, MK13, MK15, MK16, MK17 Lacks foundational knowledge regarding the appropriate indications for echocardiographic examinations. Minimally understands the role of echocardiography in assessing patients with a variety of cardiac problems. Understands the key echocardiographic findings for the most common cardiac problems. Understands the basic acquisition parameters and views needed to obtain a limited examination. Consistently understands the key echocardiographic findings for a wide spectrum of cardiac problems. Understands the basic acquisition parameters and views needed to obtain a comprehensive examination. Understands subtle nuances in interpreting test results. Pursues knowledge of emerging techniques in echocardiography. 2 Patient Care and Procedural Skills PC4b: Demonstrates skill in performing and interpreting noninvasive procedures and/or testing. M-MAG-ECHO-PC1, PC2, PC3 Fails to know when performing certain echocardiographic examinations is unsafe. Attempts to perform examinations without appropriate supervision. Possesses partial skills needed to safely perform and interpret basic TTE examinations. Possesses insufficient skills to perform and interpret TEE examinations. s inattentive to patient safety and comfort. Can safely perform and interpret basic TTE examinations. Possesses partial skills needed to perform and interpret TEE examinations. nconsistently recognizes appropriate indications and/or high-risk findings in all settings. Consistently and effectively performs and interprets TTE and TEE examinations. Consistently recognizes appropriate indications and contraindications to echocardiographic examinations. Recognizes high-risk findings and artifacts. Demonstrates skills necessary to interpret, teach, and supervise others in the performance of advanced echocardiography. 3 Systems-Based Practice SBP1: Works effectively within an interprofessional team. M-MAG-ECHO-SBP1 Frequently requires reminders from laboratory staff to complete responsibilities. Engages in discussion when directly approached, but does not actively seek input from others. Actively engages members of the laboratory staff in collaborative decisionmaking. Efficiently coordinates activities of the echocardiographic laboratory team to optimize care. Viewed by the echocardiographic laboratory team as a leader in delivery of high-quality care. 4 Practice-Based Learning and mprovement PBL1: Monitors practice with a goal for improvement. M-MAG-ECHO-PBL1 Unwilling to reflect upon one's own practice or performance. Consistently misses oportunities for learning and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance, and consistently acts on those reflections to promote improvement. Actively and independently engages in selfimprovement and learning activities. 5 nterpersonal and Communication Skills CS3: Appropriate utilization and completion of healthcare records. M-MAG-ECHO-CS2 Does not enter test results and interpretations into health record. nconsistently enters test results and interpretations into health record. Consistently enters test results and interpretations into health record. Provides effective and prompt test results and interpretations to physicians. Demonstrates ability to act as a role model to provide comprehensive, succinct, patient-specific, test results to clinicians.

23 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-MAG-ECHO-PROF2 Lacks sensitivity to patients' needs. s disrespectful when interacting with patients, staff, and peers. Does not accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

24 b. Description of the Rotations D. Heart Station & Stress Testing Educational Purpose and Associated Competencies: 1. Understanding of the interpretation of 12-lead electrocardiograms. (Core Competencies: Medical Knowledge) 2. nterpret 24-hour ECG's and rhythm strips. (Core Competencies: Medical Knowledge) 3. Understand indications for performance of exercise treadmill tests and be able to interpret the results. (Core Competencies: Procedure Skills, Professionalism, Systems-Based Practice) 4. Understand the indications, performance and interpretation of tilt table testing. (Core competencies: Medical Knowledge, Procedure Skills, Practice-Based Learning and mprovement, Systems-Based Practice) Fellow Responsibilities: First Year only: 1. Perform scheduled treadmill exercise tests and review the results with an Attending 2. nterpret 24 hour ECGs with review by an Attending on a regularly scheduled basis 3. nterpret ~ 3500 EKGs and discuss the findings with an Attending. 4. Participate and interpret nuclear myocardial perfusion studies and radionuclide ventriculograms (goal: 25 myocardial perfusion studies and 50 RNVs). 5. Observe and perform quality control under the supervision of Nuclear Medicine Technologist (goal: 10 studies) Fellow Assignments: OU Medical Center, Presbyterian Tower Heart Station DVA Medical Center Mix of Diseases and Patient Characteristics: A variety of patients with cardiovascular conditions will be available, including, Acute forms of coronary artery disease Chronic coronary artery disease Arrhythmias Hypertension Cardiomyopathy 18

25 Teaching Methods: Valvular heart disease Pulmonary heart disease nfectious and inflammatory heart disease Adult congenital heart disease Discussion with attending Monthly EKG conferences Reading of nuclear studies daily in Nuclear Medicine Procedural Skills to be Acquired and Documented: Stress testing Adenosine stress testing Holter monitor analysis Tile table testing EKG reading Suggested Reading: Heart Disease: A Textbook of Cardiovascular Medicine, Editor: Eugene Braunwald, W.B.Saunders Company Hurst s The Heart, Editors: Schlant, Alexander, McGraw-Hill, nc Mayo Clinic Cardiology Review (DVD) series The Complete Guide to ECGs. O Keefe JH, Hammill SC, Freed MS, Pogwizd SM. Physician s Press Faculty Supervision and Method of Evaluation: Cardiology faculty will oversee selected EKG readings with the first year fellow. EP faculty will be available as needed for complicated cases. Evaluation of skills will be done by the End of rotation written evaluation by faculty as well as an intraining examination at the end of the year Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 19

26 ACC CMC Template Evaluation Tool for ECG and Stress Testing DM No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Ready for Unsupervised Critical Deficiencies Early Learner Advancing-mproving Practice Aspirational 1 Medical Knowledge MK2: Knowledge of diagnostic testing and procedures. M-TEST-ECG-MK2, MK4, MK5, MK9, MK11; M-TEST-STRESS-MK1, MK3, MK8, MK11 Lacks foundational knowledge regarding the cellular mechanisms that result in the genesis of the surface ECG. Does not know the mechanisms of common ECG abnormalities. Lacks foundational knowledge regarding the appropriate indications for stress testing. Has basic understanding of the cellular mechanisms of the surface ECG. Has knowledge of common arrhythmias, conduction disorders, and clinical disorders. Knows some indications and contraindications for stress testing. Understands the cellular mechanisms of the surface ECG. Has knowledge of characteristic patterns and mechanisms of most arrhythmias, conduction disorders, and clinical disorders. Understands most of the indications, limitations, and contraindications for stress testing. Knows the underlying cellular/ionic mechanisms of surface ECG. Knows the characteristic patterns and mechanisms of common arrhythmias, conduction disease, and clinical disorders. Knows the indications, limitations, and contraindications for exercise stress testing. Knows findings associated with a poor prognosis. Demonstrates knowledge necessary to interpret ECGs, continuous and event monitors, and all forms of stress testing. s a leader and educator for others training in ECG and stress testing interpretation. 2 Patient Care and Procedural Skills PC4b: Demonstrates skill in performing and interpreting noninvasive procedures and/or testing. M-TEST-ECG-PC2, PC3, PC4, PC5, PC6, PC7, PC8, PC9, PC10; M-TEST-STRESS-PC1, PC3, PC4 Requires complete supervision in the selection of clinically appropriate stress tests. Unable to interpret ECGs, continuous and event monitors, and stress tests. Possesses skills to interpret uncomplicated ECGs and stress tests. Requires guidance in selecting appropriate stress tests for individual patients. Recognizes some high-risk features of stress testing. Can accurately interpret most ECGs, continuous and event monitors, and stress tests. Recognizes appropriate indications and contraindications to stress testing. Can identify highrisk findings of stress testing in most settings. Accurately interprets ECGs, contiuous and event monitors, and stress tests. Consistently recognizes appropriate indications, limitations, and contraindications to stress testing. Skill to utilize stress test findings in the risk assessment and management of patients. Demonstrates skills necessary to teach and supervise others in the interpretation of ECGs, continuous and event monitors, and stress testing.

27 Systems-Based 3 Practice SBP1: Works effectively within an interprofessional team. SBP3: dentifies forces that impact the cost of health care, and advocates for and practices cost-effective care. M-TEST-ECG-SBP1; M-TEST-STRESS-SBP1, SBP2 Unable to apply appropriate use criteria or cost considerations in the selection of stress testing. s not an active member of the ECG and stress test laboratory team. nteracts with the laboratory staff but is not an active member. Able to apply appropriate use criteria and cost considerations in the indications for stress testing with supervision. Actively engages members of the laboratory staff in collaborative decisionmaking regarding appropriate use of stress testing. Able to retrieve and utilize ECG tracings in electronic data systems. ncorporates appropriate use criteria and cost considerations in the selection of stress tests. Effectively leads and coordinates the exercise Viewed by the ECG and test interprofessional team stress test laboratory team to ensure safe and efficient as a leader in delivery of care. high-quality care. 4 Practice-Based Learning and mprovement PBL1: Monitors practice with a goal for improvement. M-TEST-ECG-PBL1; M-TEST-STRESS-PBL1 Unwilling to reflect upon one's own practice or performance. Consistently misses oportunities for learning and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance, and consistently acts on those reflections to promote improvement. Actively and independently engages in selfimprovement and learning activities. 5 nterpersonal and Communication Skills CS1: Communicates effectively with patients and caregivers. CS2: Communicates effectively in interprofessional teams. CS3: Appropriate utilization and completion of healthcare records. M-TEST-ECG-CS1; M-TEST-STRESS-CMR- CS1, CS2 Does not enter test results and interpretations into health record. Does not communicate test results effectively to patients or healthcare providers. nconsistently enters test results and interpretations into health record. Communicates test results to patients and healthcare providers with guidance. Consistently enters test results and interpretations into health record. Able to communicate test results to patients and healthcare providers with minimal guidance. Provides effective and prompt test results and interpretations to healthcare providers and patients. Demonstrates ability to act as a role model to provide comprehensive, succinct, patient-specific test results to healthcare providers and patients. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team. PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and M-TEST-ECG-PROF1, PROF2; M-TESTethical behavior in professional conduct. STRESS-PROF1, PROF2 Lacks sensitivity to patients' needs. s disrespectful when interacting with patients, staff, and peers. Does not accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

28 b. Description of the Rotations E. Cardiac Catheterization Laboratories Educational Purpose and Associated Competencies: Fellow Duties: 1. Understand normal and abnormal coronary artery anatomy, physiology and pathology. (Core competencies: Medical Knowledge, Patient Care) 2. Understand the principles of radiographic image formation, image planes relative to cardiac anatomy, radiographic instrumentation and factors that affect image quality. (Core competencies: Medical Knowledge, Patient Care, Systems-Based Practice) 3. Understand radiation safety issues and techniques to minimize radiation exposure. (Core competencies: Medical Knowledge, Patient Care) 4. Understand the relationship of angiographic findings to other clinical parameters, indication for angiography and alternate diagnostic approaches. (Core competencies: Medical Knowledge, Patient Care, Professionalism, Systems-Based Practice) 5. Perform and interpret left and right heart catheterization, pericardiocentesis, and placement of intra-aortic balloon pump & temporary pacemakers and other invasive procedures used in the diagnosis and management of cardiovascular disease. (Core competencies: Medical Knowledge, Patient Care, Systems-Based Practice, Practice- Based Learning and mprovement) 6. ncorporate patient safety and prevention of errors in daily practice. (Core competencies: Patient Care, Professionalism) 7. Work effectively within the multi-disciplinary team. (Core competencies: Systems-Based Practice, Professionalism, nterpersonal and Communication Skills) First Year: 1. Evaluate and perform assessment of all patients scheduled for cath lab procedures the following day. Obtain informed consent and "sign up" the patient. 2. Apply the Appropriate Use Criteria (AUC) to patient selection. 3. Discuss with the cath attending cath patients scheduled for the following day and formulate a plan of action during the procedure. 4. Perform and report at least 100 procedures. Discuss the hemodynasmic and angiographic with the cath attending and generate full reports within 24 hours. 5. Follow up evaluation of the patient after cath in the evening of cath as well as next morning to look for complications. 20

29 6. Communicate with the coronary care unit team or referring physicians for effective hand off and transition of care. 7. Present patients and cath data in the cath conference. Present assigned didactic topics in the cath conference. 8. Observe and participate in interventional procedures. Second Year: 1. n concert with the first year fellow evaluate and perform assessment of all patients scheduled for cath lab procedures the following day. 2. Discuss the patient for cath the following day with the first year fellow (if involved) the cath attending and formulate the plan of action during the procedure. 3. Perform and maintain log book for all procedures performed. Discuss the hemodynasmic and angiographic with the cath attending and generate full reports within 24 hours. 4. Follow up evaluation of the patient after cath in the evening of cath as well as next morning to look for complications. 5. Communicate with the coronary care unit team or referring physicians for effective hand off and transition of care. 6. Present patients and cath data in the cath conference. Present assigned didactic topics in the cath conference. 7. Observe and participate in interventional procedures. Third Year: 1. Collaborate with the first/second year fellow in evaluating and perform assessment of all patients scheduled for cath lab procedures the following day or same day for outpatients. The third year fellow should be a source of education to the junior fellows. 2. Discuss the patient for cath the following day with the junior fellows and the catch attending and formulate the plan of action during the procedure. 3. Perform and maintain logbook of all procedures. Discuss the hemodynamic and angiographic findings with the cath attending and generate full reports within 24 hours. 4. n conjunction with the junior fellows ensure follow up evaluation of the patient after cath in the evening of cath as well as next morning to look for complications is performed. 5. Communicate with the coronary care unit team or referring physicians for effective hand off and transition of care. 6. Present patients and cath data in the cath conference. Present assigned didactic topics in the cath conference. 7. Observe and participate in interventional procedures 21

30 Fellow Assignments: OU Medical Center, Cath Lab DVA Medical Center, Cath Lab Mix of Diseases and Patient Characteristics: Coronary artery disease (acute and chronic) Valvular heart disease Pulmonary heart disease Hypertensive heart disease Congenital heart disease Status- post Prosthetic valve surgery Pericardial disease Post-cardiac transplantation status Teaching Methods: During cath procedures (proctoring) During reporting of cath studies Tuesday morning cath conference Procedural skills to be acquired and documented: Right heart catheterization Left heart catheterization Coronary arteriography Pericardiocentesis Balloon pump insertion Myocardial biopsy Temporary pacemaker insertion Suggested Reading: Cardiac Catheterization, Angiography, and ntervention. William Grossman, Donald S. Baim. Lea & Febiger Hemodynamic Rounds (Paperback) by Morton J. Kern. Wiley-Liss The Cardiac Catheterization Handbook (4th Edition) (Paperback) by Morton J. Kern. Mosby Attending Supervision and Method of Evaluation: End of rotation evaluation by faculty Formative evaluation and feedback by faculty after a heart catheterization procedure End of year in training examination Proctored LHC at the end of fellowship training Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 22

31 nteraction between Cardiology Fellow and the nterventional Cardiology Fellow and Line of Supervision: 1. The nterventional fellow collaborates with the first/second or third year fellow on the catheterization rotation in evaluating and performing assessment of all patients scheduled for cath lab procedures the following day or same day for outpatients. The interventional fellow is a valuable supplemental source of education to the junior fellows. 2. The nterventional fellow discusses the patient for cath the following day with the junior fellows and the cath attending and formulates the plan of action both for pretreatment strategies and formulates a therapeutic plan during the procedure. 3. n conjunction with the junior fellows the nterventional fellow ensures follow up evaluation of the patient after cath in the evening of cath as well as next morning to look for complications and report these in accordance with ACC guidelines to the cath lab secretaries. This is to allow appropriate performance improvement. 4. nterventional fellow maintains a collegial, mentoring working relationship with the cardiovascular fellows. nterventional fellow is not permitted to ask cardiovascular fellows for coverage of his/her duties at any time. 23

32 ACC CMC Template Evaluation Tool for Catheterization Lab Rotation DM No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational 1 Medical Knowledge MK2: Knowledge of diagnostic testing and procedures. M-NV/NT-MK1, MK2, MK3, MK4, MK5, MK6, MK7, MK8, MK9 Has rudimentary knowledge of normal coronary and valve anatiomy, and cardiovascular hemodynamics. Lacks foundational knowledge of the appropriate indications for cardiac catherization. Recognizes normal coronary anatomy, LV function, and hemodynamics. Requires assistance with interpretation and clinical management of common coronary, ventricular, and hemodynamic pathology. Correctly identifies and understands clinical management of common coronary, ventricular, and hemodynamic abnormalities. Requires assistance with performance, interpretation, and clinical management of complex disease. Consistently understands the key anatomical and hemodynamic findings for a Understands subtle wide spectrum of cardiac nuances in interpreting test problems. Appropriately results. Pursues knowledge applies this information to of emerging techniques in the clinical management of the cardiac catheterization the patient. laboratory. Patient Care or 2 Procedural Skills PC 1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC 3: Manages patients with progressive responsibility and independence. PC4a: Demonstrates skill in performing and interpreting invasive procedures. M-NV/NT-PC1, PC2, PC3, PC4, PC5, PC8 Fails to know the indications, risks, and benefits of cardiac catherization. Attempts to perform the procedure or parts of the procedure without appropriate supervision. Possesses partial skills to safely perform and interpret uncomplicated coronary angiography, ventriculography, and hemodynamic measurements. s inattentive to patient safety and comfort. Can safely perform and interpret uncomplicated coronary angiograms, ventriculograms, and hemodynamic measurements. Possesses partial skills needed to perform these procedures and interpret results in patients with complex pathology. Recognizes most high-risk findings in all settings and is able to manage common complications that occur during, or as a result of, the procedure. Consistently and effectively performs and interprets all aspects of the cardiac catheterization procedure. Consistently recognizes appropriate indications and individual patient risks. Demonstrates skill Recognizes normal variants. necessary to interpret, s able to manage teach, and supervise others complications that occur in the performance of all during, or as a result of, the skills involved in the cardiac procedure. catheterization procedure. Systems-Based 3 Practice SBP1: Works effectively within an interprofessional team. M-NV/NT-SBP1 Frequently requires reminders from laboratory staff to complete responsbilities. Engages in discussion when directly approached but does not actively seek input from others. Actively engages members of the laboratory staff in collaborative decisionmaking. Efficiently coordinates activities of the cardiac catheterization laboratory team to optimize care. Viewed by cardiac catheterization laboratory team as a leader in delivery of high-quality care. Practice-Based Learning and 4 mprovement PBL1: Monitors practice with a goal for improvement. M-NV/NT-PBL1 Unwilling to self-reflect upon one's practice or performance. Consistently misses oportunities for learning and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance and consistently acts on those reflections to promote improvement. Actively and independently engages in selfimprovement and learning activities.

33 nterpersonal and Communication 5 Skills CS3: Appropriate utilization and completion of healthcare records. M-NV/NT-CS2, CS3 Does not enter test results and interpretations into health record. nconsistently enters test results and interpretations into health record. Consistently enters test results and interpretations into health record. Provides effective and prompt test results and interpretations to physicians. Demonstrates ability to act as role model to provide comprehensive, succinct, patient-specific, test results to clinicians. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-NV/NT-PROF3 Lacks sensitivity to patients' needs. s disrespectful when interacting with patients, staff, and peers. Does not accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

34 b. Description of the Rotations F. Pacing Rotation for General Cardiology (Non-EP) Fellows Educational Goals and Associated Competencies: 1. Understand the basic principles involved in pacing (definitions, modes of pacing, thresholds and output, impedance, various modes of pacing). (Core competencies: Medical Knowledge, Patient Care, Systems-Based Practice, Professionalism) 2. Understand the current indications of temporary and permanent pacing. (Core competencies: Medical Knowledge, Patient Care) 3. Understand the principles of pacemaker and CED interrogation. (Core competencies: Medical Knowledge, Patient Care, Procedure Skills) 4. Know how to interrogate and program CEDs. (Core competencies: Medical Knowledge, Patient Care, Procedure Skills) 5. Be able to assess the patient with permanent pacemaker and CED during outpatient followup. (Core competencies: Medical Knowledge, Patient Care, Procedure Skills) 6. Be able to assess complications of permanent pacemakers and CEDs. (Core competencies: Medical Knowledge, Patient Care, Professionalism, Procedure Skills) Fellow Responsibilities: Second year and third year: 1. Fellow will assess patients referred for consultation to the pacing service and discuss management plans with the pacing attending. 2. Fellow will scrub in on pacemaker implantation procedures. 3. Fellow will work with the pacemaker service nurse/pa and attending to learn pacemaker programming and troubleshooting. 4. Fellow will participate in the follow-up of patients with permanent pacemakers. Fellow Assignments: OU Medical Center DVA Medical Center Mix of Diseases and Patient Characteristics: Patients with symptomatic bradycardia Patients with pacemakers 24

35 Teaching Methods: Bedside instruction regarding pacemaker and CED programming (proctoring) Cath lab instruction during pacemaker and CED implantation Procedural skills to be acquired: Pacemaker (CED) programming Troubleshooting of pacemakers and CEDs Suggested Reading: Cardiac Pacing. Kenneth A. Ellenbogen, Blackwell Science Method of Evaluation: End of rotation written evaluation by faculty. Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 25

36 ACC CMC Template Evaluation Tool for Pacing and Electrophysiology Rotation No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 DM Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational 1 Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures. M-ARR-MK2, MK3, MK5, MK6, MK9, MK10, MK13, MK14, MK18 Has rudimentary Knows the basic knowledge of mechanisms leading to arrhythmia production. May not fully understand the pathophysiology and approach to evaluation and assessment of patients with atrial fibrillation and flutter. Lacks foundational knowledge of the appropriate assessment and management of ventricular arrhythmias and heart blocks. mechanisms of arrhythmia genesis. Understands the pathophysiology and approach to evaluation and management of atrial fibrillation and flutter, including assessment of stroke risk antocoagulation strategies. Understands the management of ventricular tachyarrhythmias. Knows the indications for the placement of a permanent pacemaker and CD. Correctly identifies the risk stratification and management of sudden cardiac death, predisposition, and significance of cardiac arrhythmias in adult congenital heart disease and pre-excitation neurocardiogenic syncope. Understands clinical management of common coronary, ventricular, and hemodynamic abnormalities. Understands the appropriate use and monitoring of antiarrhythmic drugs. Consistently understands the mechanisms and clinical implications of findings for a wide spectrum of arrhythmias, including ventricular preexcitation. Knows the basic principles involved in programming and interrogating implanted devices. Appropriately applies this information to the clinical management of patients. Understands subtle nuances in the application and interpretion of tests used for the assessment of patients with cardiac arrhythmias and implantable devices. Pursues knowledge including changing guidelines and newer technology used in management of patients with tachy- and bradyarrhythmias. Patient Care or 2 Procedural Skills PC 1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC 3: Manages patients with progressive responsibility and independence. PC4a: Demonstrates skill in performing and interpreting invasive procedures. M-ARR-PC1, PC2, PC3, PC4, PC6, PC8, PC9, PC11, PC13, PC 21 Fails to know the appropriate evaluation and management of patients with palpitations or syncope. Fails to provide guideline-based treatment plans for patients with tachy- or bradyarrhythmias. Does not know the risk assessment and secondary prevention approaches in patients susceptible to cardiac arrest. Possesses partial skills to appropriately manage patients with tachy- and brady-arrhyhmias, elective cardioversion, and temporary pacing. Knows the appropriate selection and monitoring of patients for antiarrhythmic drug therapy. Possesses partial skills needed to manage patients with complicated tachy- and bradyarrhythmias. Performs adequate guideline-based selection of patients for implantable devices and cardiac resynchronization therapy. Consistently and effectively evaluates and manages patients with palpitations, syncope, supraventricular tachyarrhythmias, atrial fibrillation and flutter, ventricular tachyarrhythmias, and symptomatic bradycardias. Possesses the necessary skills in cardioversion and defibrillation, temporary pacing, and risk assessment of patients for secondary prevention of sudden cardiac death. Possesses skills to integrate information provided by electrophysiologic consultation. Demonstrates the skills necessary to interpret, teach, and supervise others in the management of patients with cardiac rhythm disorders. Functions as a resource for patients with complicated cardiac arrhythmia problems or implantable device issues.

37 3 Systems-Based Practice SBP1: Works effectively within an interprofessional team. M-ARR-SBP1, SBP3 Fails to work harmoniously within an interprofessional team. Does not incorportate risk-benefit considerations in diagnostic and therapeutic decisions. Does not practice high value care. Engages in respectful discussions, actively eliciting input from other team members. Demonstrates an awareness of the value of technical and nursing staff input. Actively engages team members in collaborative decision-making. Demonstrates thorough, appropriate actions and discussions in which team members' input is valued. Efficiently coordinates patient care within an interdisciplinary team. Appropriately includes team members' perspectives in care decisions. Provides high value care with awarenes of current healthcare disparities within certain patient populations. Viewed by the patient care team as a leader in delivery of high quality, high value, evidence-based care. Practice-Based Learning 4 and mprovement PBL1: Monitors practice with a goal for improvement. M-ARR-PBL1, PBL2 Unwilling to self-reflect upon one's practice or performance. Consistently misses oportunities for learning and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance and consistently acts on those reflections to promote improvement. Actively and independently engages in selfimprovement and learning activities. nterpersonal and 5 Communication Skills CS3: Appropriate utilization and completion of healthcare records. M-ARR-CS1, CS2 Does not effectively and appropriately interact with patients, families, and the healthcare team. nconsistently involves patients. nconsistently seeks other team members' suggestions while developing treatment plans. Demonstrates ability to engage the patient, as well as the patient care team, and incorporate their suggestions and priorities in the treatment plan. Communicates effectively with, and educates, patients and families across the cultural, ethnic, and socioeconomic backgrounds. Demonstrates ability to act as a role model in providing comprehensive, patientcentered, compassionate communications to patients, families, hospital staff, and peers. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-ARR-PROF1, PROF2; M-HF-PROF2 Lacks occasional sensitivity to patients' needs. s occasionally disrespectful when interacting with patients, staff, and peers. Does not consistently accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Consistently exhibits Has respectful interactions with professional behavior with patients and is sensitive to their patients, staff, and peers. needs. Exhibits professional Accepts responsibility for behavior in most settings when assigned tasks. interacting with staff and peers. Demonstrates appropriate Rarely requires reminders to sensitivities to end-of-life follow through on tasks. care decisions. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

38 b. Description of the Rotations G. Fellow Research and Scholarly Activities Educational Objectives: Research and scholarly activities are required components of fellowship training. ACGME requires meaningful research experience for the cardiology fellow. Fellow will be expected to have completed a small research project during the first year of fellowship (e.g. a case report) and presented the results at the Stewart Wolf Housestaff Research Day, Cardiology Fellows Research Day and/or ACC/ACP Oklahoma Chapter meetings. Fellow will be expected to conduct a larger research project during the second and third years. This will lead to presentation at a national scientific meeting and a manuscript. Educational Goals and Associated Competencies: 1. Understand the basics of research methodology. (Core Competencies: Medical Knowledge, Practice-Based Learning and mprovement) 2. Write up a new project or continue an ongoing prospective or retrospective study. (Core Competencies: Medical Knowledge, Practice-Based Learning and mprovement) 3. Work towards writing a manuscript based on the research project, and also work on improving skills in writing manuscripts. (Core Competencies: Medical Knowledge, Practice-Based Learning and mprovement) Fellow Responsibilities and Expectations: 1. Fellow will work with a research mentor and develop a project for investigation. (Core competencies: Medical knowledge) 2. Fellow will acquire, analyze and present data from the research project. (Core competencies: medical knowledge) 3. Fellow will present data from research project at the housestaff research day of OUHSC. (Core competencies: Medical knowledge) 4. Fellow will write a paper based on the research project. (Core competencies: Medical knowledge, professionalism) 5. Fellow will develop an understanding of the basic concepts of research methodology. (Core competencies: Medical knowledge) First Year Fellow: Work towards completing a case report Second and Third Year Fellow: Write a project description, present at the research conference, obtain RB approval, collect and analyze data and prepare abstract and manuscript. 26

39 Fellows Assignment: Each fellow will have a research mentor who would advise the fellow at various stages of the research project and facilitate the completion of the project. The fellow will present the research proposal at the fellow s research conference. At the completion of the study, fellow will present the data again at the fellow s research conference. There will be a total of three to six months of research time available during fellowship training. Research months might run concurrent with another lighter rotation. Method of evaluation: End of rotation written evaluation by faculty. Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. Suggested Reading: Designing Clinical Research by Hulley SB, Cummings SR, Browner WS, Grady D, Hearst N, Newman TB. Lippincott Williams & Wilkins Publishers 27

40 ACC CMC Template Evaluation Tool for Cardiovascular Research and Scholarly Activity No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 DM Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational 1 Medical Knowledge MK1: Posseses clinical knowledge. MK3: Scholarship. M-RES-MK3, MK4, MK5, MK6 Has rudimentary knowledge of statistical principles. Does not know how to develop a study hypothesis and plan a study capable of answering the study's question. Performs appropriate evaluation of research publications, including a determination of the validity of the study findings and applicability to various patient populations. Demonstrates improving ability to formulate meaningful research questions and methodology. Understands how to find resources available for conducting research. Consistently understands the principles of epidemiology and outcomes evaluation. Knows the basic principles of biostatistics. Knows principles involved in hypothesis formation, hypothesis testability, and statistical power achievability. Understands indepth,9 finer points involved in research methodology. Serves as a resource to others regarding details of research and scholarly activity. Patient Care or Procedural 2 Skills PC1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC3: Manages patients with progressive responsibility and independence. PC4a: Demonstrates skill in performing and interpreting invasive procedures. M-RES-PC1, PC2, PC3, PC4 Fails to understand how to analyze research studies for strength of evidence supporting study results. Does not appropriately protect patients' interests during informed consent. Shows minimal level of Does not know the skills required for creating methods for developing a appropriate research meaningful research questions. Able to apply question or designing a evidence from research study to investigate the studies to patient care in research question. most situations. Demonstates improving ability to critically apply scientific evidence to patient care. Shows greater skills in assuring patient safety and rights in research participation. Consistently and effectively reviews published research. Considers quality of evidence when making clinical decisions. Applies principles of biomedical ethics to human subjects research. Appropriately obtrains informed consent. Assures patient welfare and security of clinical data used for research. Demonstrates skills necessary to interpret, teach, and supervise others in the performance of research and scholarly projects. Serves as a mentor and/or collaborator in research projects. 3 Systems-Based Practice SBP1: Works effectively within an interprofessional team. M-RES-SBP1, SBP2 Does not know the basic principles involved in interacting with national registries and the institutional review board. Demonstrates early skills in interacting with national registries and institutional review boards. Actively engages with national registries and shows improving skills in interacting with institutional review boards. Efficiently interacts with institutional review boards to facilitate research and scholarly acivities. Effectively accesses and utilizes national registries. Viewed by peers and faculty as a resource regarding questions about accessing national registries for research and interacting with institutional review boards.

41 Practice-Based Learning and 4 mprovement PBL1: Monitors practice with a goal for improvement. M-RES-PBL1, PBL2 Unwilling to self-reflect upon one's performance. Consistently misses oportunities for learning and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance and consistently acts on those reflections to promote Actively and independently improvement. engages in selfimprovement and learning Appropriately integrates emerging medical evidence. activities. nterpersonal and 5 Communication Skills CS2: Comunicates effectively in interprofessional teams (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel). M-RES-CS1, CS2 Does not know how to present research data in a clear and concise fashion. Shows rudimentary skills in presenting research data Consistently provides good during journal clubs. Does presentations at journal not consistently discuss the clubs. Shows improving impact of a research study abilities to make formal on direct patient care. research presentations. Provides an effective presentation of study results during formal presentations. Communicates the impact of research findings on clinical care through venues such as journal clubs. Demonstrates the ability to act as a role model to provide comprehensive, succinct presentations of research study findings. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-RES-PROF1, PROF2, PROF3 Lacks sensitivity to patients' needs. s disrespectful when interacting with patients, staff, and peers. Does not accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Has respectful and ethical interactions with patients. Exhibits professional behavior in most settings when interacting with staff and peers. Consistently exhibits sensitivity to patient autonomy and safety in research. Practices with integrity in matters related to relationships with industry. nteracts respectfully with ancillary staff. Serves as a role model for others with respect to professional interactions with patients, staff, and peers. Conducts oneself with a high level of integrity in all research endeavors.

42 b. Description of the Rotations H. Cardiology Fellows Ambulatory Clinics Educational Goals and Associated Competencies: 1. Understand the management of outpatient cardiac patients. (Core competencies: Medical Knowledge, Patient Care, Systems-Based Practice, Practice- Based Learning and mprovement, Professionalism, nterpersonal and Communication Skills) 2. Understand the outpatient assessment, formulation of diagnostic testing and therapy procedures. (Core competencies: Medical Knowledge, Patient Care, Systems-Based Practice, Practice- Based Learning and mprovement) 3. Know how to effectively coordinate care between inpatient and outpatient services. (Core competencies: Medical Knowledge, Patient Care, Systems-Based Practice, Practice- Based Learning and mprovement, Professionalism) Educational Purpose and Associated Competencies: Clinic experience offers the fellows an opportunity to evaluate patients with cardiac disease after the acute phase of illness is over and to acquire experience with the assessment and management of chronic cardiac conditions. This experience will cover patients with multiple types of clinical problems including Coronary artery disease Valvular heart disease Hypertensive heart disease Congestive heart failure Adult congenital heart disease Suspected heart disease in patients with cardiac risk factors Risk factor modification Pre-operative evaluation of patients with heart disease Clinic Description: There will be two half-day clinics, one each at the OU Medical Center and DVA Medical Center. Each clinic will run from 1:00 pm through 4:00 pm. Fellows are excused from the OUMC Clinic during their CCU rotations. OUMC Fellow Clinic: Location 6 th Floor, Tuesdays DVA Medical Center Fellow Clinic: Location 5 th Floor, Thursdays Fellows will have clinic assignments during each year of fellowship. Fellow Responsibilities: OU Medical Center Clinic: Fellow will assess, investigate and treat a panel of patients during the threeyear fellowship training. Fellow will be responsible for the management of cardiac problems of these patients, including follow-up of the results of tests and responding to patient phone calls. 28

43 DVA Medical Center Clinic: Patients are seen on consults from primary care or surgery clinics. Fellow is responsible for assessment and treatment of patients assigned to the clinic. Once therapy is initiated and patient is stabilized, patients are referred back to their primary care providers. Fellow is responsible for the supervision of residents and medical students if assigned to the clinic. All VA requirements regarding patient access to clinic as well documentation of faculty supervision must be complied with. Attending Supervision: There are 3 faculty members assigned to the clinic. Faculty member will be available for the fellows for consultation and discussion of treatment issues. Faculty input and concurrence with treatment plans is to be documented in the chart for all new patients and those established patients undergoing cardiac catheterization and revascularization procedures. Please also refer to the general supervision principles for the fellowship in this document. Mix of diseases and patient characteristics: A variety of patients with chronic cardiovascular conditions will be available, including Chronic coronary artery disease Congestive heart failure Arrhythmias Lipid disorders Hypertension Cardiomyopathy Valvular heart disease Pulmonary heart disease nfectious and inflammatory heart disease Adult congenital heart disease Teaching Methods: Evaluation: Procedures: None Discussion with attending Chart stimulated recall. Written evaluation will be generated at six-monthly intervals. Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. Suggested Reading: Textbook of Cardiovascular Medicine, Editor: Eric J. Topol, Lippincott-Raven Heart Disease: A Textbook of Cardiovascular Medicine, Editor: Eugene Braunwald, W.B.Saunders Company Hurst s The Heart, Editors: Schlant, Alexander, McGraw-Hill, nc 29

44 ACC CMC Template Evaluation Tool for Ambulatory Clinics Rotation DM No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Ready for Unsupervised Critical Deficiencies Early Learner Advancing-mproving Practice Aspirational 1 Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures. M-AMB-MK1, MK3, MK4, MK5, MK6, MK7, MK9, MK13, MK15, MK17, MK18 Has rudimentary knowledge of indications for diagnostic testing. Fails to apply Appropriate Use Criteria and high value considerations to treatment plans. Has limited understanding of guidelinedirected medical therapy. nconsistently applies guideline-directed principles to diagnostic testing and developing trreatment plans. Requires assistance with interpretation and clinical management of common cardiovascular diseases. Correctly identifies and understands clinical management of common cardiovascular disorders. Requires minimal assistance with clinical management of complex cardiovascular disorders. Consistently understands the manifestations of a wide spectrum of cardiac problems. Appropriately applies this information to the clinical management of the patient. Understands subtle nuances in interpreting physical diagnostic clues and test results. Pursues knowledge of new evidence and guidelines. Patient Care and 2 Procedural Skills PC1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC3: Manages patients with progressive responsibility and independence. M-AMB-PC1, PC2, PC3, PC4, PC5, PC8, PC10, PC11 Fails to recognize the signs and symptoms of common cardiovascular diseases. Performs inadequate examination and assessement. Fails to develop comprehensive, evidence-based treatment plans. Provides inadequate follow-up to patients. Possesses partial skills to conduct effective patient assessment. s inattentive to patient safety and comfort. Develops incomplete treatment plans and provides treatment that is not consistent with guideline-directed medical therapy. Can safely perform clinical assessments and interpret uncomplicated data in common cardiovascular disorders. Recognizes most high-risk findings in all clinical settings and is able to manage complications of common cardiovascular disorders. Consistently and effectively performs clinical assessments and interprets diagnostic tests to develop guideline-directed medical therapy in common cardiovascular disorders. Demonstrates skills Consistently recognizes appropriate indications of testing and therapy and individual patient risks. s able to assess and manage complications of common cardiovascular disorders and their therapies. necessary to interpret, teach, and supervise others in the evaluation and management of a variety of cardiovascular disorders including uncommon conditions. Diagnoses and manages rare diagnoses. Systems-Based 3 Practice SBP1: Works effectively within an interprofessional team. SBP3: dentifies forces that impact the cost of health care, and advocates for and practices costeffective care. SBP4: Transitions patients effectively within and across health delivery systems. M-AMB-SBP1, SBP2, SBP4 Fails to provide continuity of care. Has inadequate skills in coordinating transitions of care. Engages in discussion when directly approached, but does not actively seek input from others. Actively engages members of the patient care team in collaborative decisionmaking. Efficiently coordinates transitions of care. Works diligently in improving patient safety and error prevention. Functions as a role model and leader in delivery of high-quality, safe, effective and high-value care. Practice-Based Learning and 4 mprovement PBL1: Monitors practice with a goal for improvement. M-AMB-PBL2, PBL3 Fails to incorporate clinical performance data to improve self learning and system processes. Consistently misses oportunities for learning and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance and consistently acts on those reflections to promote improvement. Actively and independently engages in selfimprovement and learning activities.

45 nterpersonal and Communication 5 Skills CS3: Appropriate utilization and completion of healthcare records. M-AMB-CS1, CS2, CS3 Does not communicate effectively and in a timely manner with patients and families. Does not involve patients and families in shared decision making. Does not engage in balanced decision making. nconsistently communicates test results and assessments with patients and families. Does not provide sufficient, balanced information to patients to enable shared decision making. Consistently communicates effectively and respectfully with patients and families. Provides unbiased, balanced information to patients. Provides effective and prompt information about test results and interpretations to patients and referring physicians. Presents balanced treatment options to patients. Demonstrates ability to act as a role model by providing comprehensive, succinct, patient specific test results to clinicians. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-AMB-PROF1, PROF2, PROF3, PROF4 Lacks sensitivity to patients' needs. s disrespectful when interacting with patients, staff, and peers. Does not accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

46 b. Description of the Rotations. Cardiac Rehabilitation Educational Purpose and Associated Core Competencies: Fellow will be expected to acquire the following skills during rotations in the Cardiac Rehabilitation Service: 1. dentification and assessment of patients with cardiovascular diseases who are candidates for cardiac rehabilitation. (Core competencies: Medical knowledge, patient care, procedure skills) 2. Understanding the principles of inpatient and outpatient cardiac rehabilitation. (Core competencies: Medical knowledge, patient care) 3. Risk stratification and control of risk factors patients with cardiovascular disease. (Core competencies: Medical knowledge, patient care, practice based learning) 4. Developing exercise program prescriptions for patients with cardiovascular disease. (Core competencies: Medical knowledge, patient care, system based care, procedure skills) 5. Assessing the progress of patients while in the cardiac rehabilitation program. (Core competencies: Medical knowledge, patient care) Fellow Responsibilities: First Year Only: 1. Rounds in the cardiac rehabilitation unit at the VA Medical Center and OUMC along with the cardiac rehabilitation nurse 2. Assess progress of patients with the physician director 3. Formulate exercise prescriptions for the patients 4. Serve s a resource for problems that may arise with patients Mix of Diseases and Patient Characteristics: Post-coronary intervention patients Post-myocardial infarction patient Patients with chronic forms of coronary artery disease Teaching Methods: Rounds Reading assignments 30

47 Procedural skills: Stress testing Exercise prescription writing Suggested Reading: Advances in Cardiopulmonary Rehabilitation, editors Jean Jobin, Francois Maltais, Pierre LeBlanc, Clermont Simard. Published by Human Kinetics Psychosocial nterventions for Cardiopulmonary Patients. Wayne M. Sotile. Published by Human Kinetics Clinical Cardiac Rehabilitation: A Cardiologist s Guide. Editors Fredric J. Pashkow, William A. Defoe. Published by William & Wilkins Guidelines for Cardiac Rehabilitation Programs by American Association of Cardiovascular and Pulmonary Rehabilitation. Published by Human Kinetics Cardiac Rehabilitation. Published by US Department of Health and Human Services Method of Evaluation: End of rotation written evaluation by faculty. Contact: Ruthie Gunter ruthie.gunter@va.gov Faculty supervisor: Dr. Udho Thadani 31

48 b. Description of the Rotations J. Nuclear Cardiology Educational Goals and Associated Competencies: Nuclear cardiology rotation is aimed at providing the fellow an overview of the common diagnostic tests using nuclear isotopes. This included myocardial perfusion imaging, estimation of ventricular ejection fraction by nuclear ventriculography and infarct imaging. Fellows will acquire the following skills: 1. Understand the basics of physics of nuclear isotopes and principles of nuclear safety. (Core competencies: Medical Knowledge, Systems-Based Care) 2. dentify patients who are appropriate candidates for nuclear cardiology studies. (Core competencies: Medical Knowledge, Patient Care, Practice-Based Learning and mprovement) 3. Evaluate abnormalities seen on nuclear cardiac studies. (Core competencies: Medical Knowledge, Patient Care) Fellow Responsibilities: 1. Evaluate the appropriateness (AUC) of the stress test ordered and assess the ability of the patient to undergo the test referred for nuclear cardiac stress testing. 2. Supervise the nuclear stress testing including tests performed utilizing adenosine, dobutamine or exercise. 3. nterpret nuclear stress tests under direct supervision of an appropriately qualified attending physician. 4. Attend the lectures and conferences regarding Nuclear Cardiology offered during the rotation. Mix of Disease and Patient Characteristics: Patients with chest pain from the clinic, in patient service or ER Post myocardial infarction of revascularization patient with ischemia Patients with unexplained systolic dysfunction Teaching Methods: Reading studies with nuclear medicine faculty Directed reading Yearly lecture series on nuclear physics Procedure Skills: Myocardial perfusion imaging Nuclear ventriculography 32

49 Suggested Reading: Essential Nuclear Medicine Physics by Powsner and Powsner Nuclear case studies (under education and online education links) Method of Evaluation: Written evaluation at the end of the rotation. Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 33

50 ACC CMC Template Evaluation Tool for Nuclear Cardiology Rotation No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Ready for Unsupervised Critical Deficiencies Early Learner Advancing-mproving Practice Aspirational 1 Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures. M-MAG-NC-MK1, MK2, MK3, MK4, MK6, MK9, MK10 Has rudimentary knowledge of radiation safety, myocardial perfusion imaging and selection of appropriate selection of stress test modaltiies. Lacks foundational knowledge in cost effective and guideline based selection of nuclear cardiology tests. Has a basic understanding of the various tests used in the assessment of myocardial ischemia, ventricular function and myocardial viability. Recognizes some of the abnromalities involved in nuclear studies and their relevance to clinical deicsion making. Understands the appropriate indications for different ypes of nuclear cardiology tests, shows improving understanding of the appropriate choice of different modalities of stress testing and application of test results to patient care. Knows the appropriate indications of nuclear cardiology techniques in the evaluation of myocardial ischemia, ventricular function and myocardial viability in patients with known or suspected ischemic, valvular or myocardial diseases. Knows the comparitive merits and weaknesses of other imaging modalities in the evaluation of mycardial ischemia, ventricular function and myocardial viability Serves as a resource to cardiologists and other health care providers on nuclear cardiology techniques and the relative strengths and weaknesses of the other imaging modalities. Knows principles of radiation safety and how to minimize radiation exposure Patient Care and 2 Procedural Skills PC1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC2: Develops and achieves comprehensive management plan for each patient. PC3: Manages patients with progressive responsibility and independence. PC4b: Demonstrates skill in performing and interpreting M-MAG-NC-PC1, PC3; M-SCHEM-PC2, PC4, noninvasive procedures and/or testing. PC5 Does not appropriately select imaging studies or integrate findings from perfusion studies to patient care. Does not know findings in high-risk patients. Able to identify the appropriate nuclear imaging modality in most patients with heart disease. Unable to appropriately integrate findings from nuclear imaging studies in all patient care decisions. Able to identify the implications of abnormal findings on nuclear imaging regarding patient care decisions. Able to evaluate and select patients appropriately for nuclear imaging studies. Able to integrate findings from perfusion imaging studies and ventriculographic studies with clinical and other test results appropriately. Able to interpret and integrate stress-rest perfusion studies and radionuclide ventriculographic studies in patient care decisions. Demonstrates skills necessary to perform stress-rest perfusion studies and ventriculographic studies. Serves as a resource for interpretation of complicated studies and nuances of nuclear cardiology tests. 3 Systems Based Practice SBP1: Works effectively within an interprofessional team. SBP3: dentifies forces that impact the cost of health care, and advocates for and practices costeffective care. SBP4: Transitions patients effectively within and across health delivery systems. M-MAG-NC-SBP1, SBP2, SBP3 PBL1: Monitors practice with a goal for improvement. PBL2: Learns and improves via performance audit. PBL3: Learns and improves via Practice Based Learning feedback. PBL4: Learns and improves at the point 4 and mprovement of care. M-MAG-NC-PBL1 Does not interact harmoniously with other members of the healthcare team. Does not acknowledge importance of high value, cost effective care. Unwilling to self-reflect upon one's own practice or performance. Does not accept feedback well. Engages in discussion with team members when directly approached, but does not actively seek input from others. Recognizes importance of high value, cost effective care. Consistently misses opportunities for learning and self-improvement. Can be defensive when receiving feedback. Actively engages members of the nuclear laboratory, incorporating high value care principles in most patients. Acts on some, but not all, opportunities for learning and self-improvement. Accepts feedback well. Works efficiently and effectively with the nuclear laboratory staff, incorporating risk-benefit and high value care considerations. Regularly reflects upon one's performance and consistently acts on those reflections to promote improvement. Actively seeks feedback on performance and incorporates changes into his or her practice. Viewed by peers and technical staff as a leader in delivery of high quality care and cost effective care. Participates and leads others in laboratory safety and quality improvement initiatives. Actively and independently engages in selfimprovement and learning activities.

51 nterpersonal and 5 Communication Skills CS1: Communicates effectively with patients and caregivers. CS2: Communicates effectively in interprofessional teams (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel). CS3: Appropriate utilization and completion of healthcare records. M-MAG-NC-CS1, CS2 Does not complete reports in a timely fashion. Does not communicate effectively with patients and members of the healthcare team. Requires reminders to complete reports. Engages in discussion with patients and team members but requires guidance. Consistently completes documentation in a timely fashion. Actively engages patients and team members in discussion of healthcare decisions. Completes documentation concisely, accurately, and in timely fashion. nforms promptly test results and interpretations to physicians. Demonstrates ability to act as role models to provide comprehensive patientspecific test results to clinicians. 6 Professionalism PRO1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PRO2: Accepts responsibility and follows through on tasks. PRO3: Responds to each patient's unique characteristics and needs. PRO4: Exhibits integrity and ethical behavior in professional conduct. M-MAG-NC-PROF1, PROF2 Lacks sensitivity to patients' needs. s not Exhibits inconsistent always respectful when sensitivity and respect interacting with patients, when interacting with staff, and peers. Does patients, staff, and peers. not accept responsibility Requires reminders to for tasks. follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

52 b. Description of the Rotations K. Heart Failure Rotation Educational Goals and Associated Competencies: 1. Understand the pathophysiology, etiology and prevalence of heart failure (Core competencies: Medical Knowledge, Patient Care, System Based Practice) 2. Assess the role of devices (CD, pacing and resynchronization) in heart failure (Core competencies: Medical Knowledge, Patient Care, System Based Practice, Professionalism) 3. Understand the role of drug therapy of acute decompensated and chronic heart failure (Core competencies: Medical Knowledge, Patient Care, System Based Practice) 4. Know the importance of end-of-life issues (Core competencies: Medical Knowledge, Patient Care, System Based Practice, Professionalism) Fellow Responsibilities: First Year: 1. Attend Heart Failure Clinic at OU Physicians Heart Lung Vascular (HLV) Clinics twice a week. Fellow Assignment: OU Medical Center OU Physicians Mix of Diseases and Patient Characteristics: Chronic heart failure Patients with CD, CRT and CEDs Teaching Methods: Clinic rounds Reading assignments Weekly case conference (Tuesday noon) Procedural Skills to be Acquired and Documented: CED (Pacemaker & CD) interrogation and follow up Evaluation: End of the rotation written evaluation by the attending Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 34

53 ACC CMC Template Evaluation Tool for Heart Failure Rotation DM No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational 1 Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures. M-HF-MK1, MK2, MK3, MK4, MK7, MK8, MK10, MK11, MK12, MK13 Has rudimentary knowledge of the pathophysiology, natural history, and physical examination findings in patients with heart failure. Lacks foundational knowledge of the testing and medications used in the diagnosis and management of heart failure. Has a basic understanding of the pathophysiology and management of heart failure. Knows common symptoms and physical examination findings in HF patients. Recognizes common complications associated with heart failure. Understands the pathophysiology, natural history, and management of most forms of heart failure. Understands the indications for advanced HF care, including mechanical circulatory support and transplant. Recognizes common complications associated with heart failure. Knows the pathophysiology, differential diagnosis, and management of heart failure. Able to recognize and manage common complications associated with heart failure. Knows the indications for mechanical circulatory assist devices and transplantation. Serves as a resource to cardiologists and other healthcare providers on the management of heart failure patients. 2 Patient Care and Procedural Skills PC1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC2: Develops and achieves comprehensive management plan for each patient. PC3: Manages patients with M-HF-PC1, PC2, PC4, PC5, PC7, PC9, PC11, progressive responsibility and independence. PC12, PC16 Does not recognize the symptoms or signs associated with heart failure. Does not know the role of noninvasive and invasive testing in the assessment and management of heart failure patients. Cannot manage common heart failure complications. Able to identify patients with heart failure, but requires supervision in their evaluation and management. Knows the type of noninvasive and invasive testing used to assess patients with heart failure but is unable to consistently use this data in their management. Able to identify and manage most patients with acute and chronic heart failure. Understands the role of noninvasive and invasive testing in the assessment and management of most heart failure patients. Recognizes and manages common complications associated with heart failure. Able to evaluate and manage patients with acute and chronic heart failure. Appropriately selects and incorporates data from diagnostic and laboratory testing in the evaluation and management of heart failure patients. dentifies patients that are appropriate for advanced heart failure management and devices. Demonstrates skills necessary to manage and consult on all forms of heart failure. s skilled in the selection and management of patients appropriate for transplant and assist devices. 3 Systems-Based Practice SBP1: Works effectively within an interprofessional team. SBP3: dentifies forces that impact the cost of health care, and advocates for and practices cost-effective care. SBP4: Transitions patients effectively within and across health delivery systems. M-HF-SBP1, SBP2, SBP4, SBP5 Does not interact with other members of the health care team. Does not acknowledge the importance of cost effective care. Does not assist with transitions of care. Engages in discussion with team members when directly approached, but does not actively seek input from others. Recognizes the importance of cost effective care. Actively engages members of the heart failure team in collaborative decisionmaking. Able to tranistion patients between care settings with minimal Efficiently coordinates assistance. Makes cost activities of the heart effective decisions failure team to provide regarding patient care. cost effective, optimal care. Viewed by the heart failure team as a leader in delivery of high quality and cost effective care. Leads others in quality improvement initiatives.

54 Practice-Based Learning and 4 mprovement PBL1: Monitors practice with a goal for improvement. PBL2: Learns and improves via performance audit. PBL3: Learns and improves via feedback. PBL4: Learns and improves at the point of care. M-HF-PBL1 Unwilling to self-reflect upon one's practice or performance. Does not accept feedback well. Consistently misses opportunities for learning Acts on some, but not all, and self-improvement. Can opportunities for learning be defensive when and self-improvement. receiving feedback. Accepts feedback well. Regularly reflects upon one's performance, and consistently acts on those reflections to promote improvement. Actively seeks feedback on performance and incorporates changes into his or her practice. Actively and independently engages in selfimprovement and learning activities. 5 nterpersonal and Communication Skills CS1: Communicates effectively with patients and caregivers. CS2: Communicates effectively in interprofessional teams (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel). CS3: Appropriate utilization and completion of healthcare records. M-HF-CS1, CS2 Does not complete notes in a timely fashion. Does not communicate effectively with patients and members of the healthcare team. Requires reminders to complete notes. Engages in discussion with patients and team members, but requires guidance. Consistently completes documentation in a timely fashion. Engages patients and team members in discussion of healthcare decisions. Accurately completes documentation in a concise and timely fashion. Actively engages patients and team members in healthcare decisions. Demonstrates ability to act as a role model in providing and reporting all elements of patient care. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-HF-PROF3 Lacks sensitivity to patients' needs. s not always respectful when interacting with patients, staff, and peers. Does not accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

55 b. Description of the Rotations L. EKG Reading (Heart Station & Dedicated EKG Reading Assignment) Educational Goals and Associated Competencies: 1. Understand the common abnormalities seen on 12 lead EKG (chamber enlargement, hypertrophy, acute myocardial infarction, atrial arrhythmias, ventricular arrhythmias, paced rhythms). (Core competencies: Medical Knowledge, Patient Care) 2. Understand the indications for ambulatory EKG monitoring (Holter monitoring). (Core competencies: Medical Knowledge, Patient Care) 3. Review abnormalities seen on ambulatory EKG monitoring. (Core competencies: Medical Knowledge, Patient Care) Fellow Responsibilities: First Year Fellow Over-read EKGs at VAMC Participate in Holter monitor reading with second or third year fellows Select EKGs from OUMC and VAMC for monthly EKG conference Second & Third Year Fellows Over-read EKGs at VAMC Review selected complicated EKGs with VA attending Read Holter monitors at VAMC Select EKGs from VAMC for monthly EKG conference Fellow Assignment: OU Medical Center DVA Medical Center Teaching Methods: Sit down EKG reading session Monthly EKG conferences Directed reading Procedural Skills to be Acquired and Documented: EKG reading Ambulatory EKG reading Evaluation: End of the rotation written evaluation by the attending Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 35

56 Suggested Reading: The Complete Guide to ECGs. Authors: James H. O'Keefe; Stephen Hammill SBN-13: SBN-10: Publisher: Physicians Press Format: Paperback, 512 pages 36

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59 b. Description of the Rotations M. Vascular Medicine Educational Goals and Associated Competencies: 1. Gain knowledge to differentiate the clinical presentation and management of acute versus chronic peripheral vascular diseases including arterial, venous and lymphatic disorders. (Core competencies: Medical Knowledge, Patient Care) 2. Gain knowledge on various anticoagulants used in the short and long-term management of patients with deep venous thrombosis, pulmonary embolism. (Core competencies: Medical Knowledge, Patient Care) 3. Understand basic principles of anatomical and physiological vascular testing for venous arterial disease. (Core competencies: Medical Knowledge, Patient Care) Description The objectives of this rotation are to provide experience in the understanding, diagnosis, and treatment of peripheral arterial, venous, and lymphatic disorders. This is to be accomplished by participation in clinics, consultations, vascular laboratory activities, reading the core curriculum, and vascular conference. Core Curriculum Attached is a pdf to be read during this one-month rotation. Other reading materials are available. Before the rotation The fellows will receive an with information regarding the rotation, and they are required to do a pre- test evaluation before starting the rotation. Outpatient Care Active participation in the VA Vascular Clinic and in the Vascular Clinic is expected. The VA Clinic convenes each Monday at 1:00 p.m. on 7E. The Fellow s Vascular Clinic convenes the first and second Wednesday of each month at 1:00 p.m. at PPB, sixth floor. Each patient s hospital and vascular lab studies are reviewed, and then each patient is interviewed, examined, and discussed with an attending physician to determine the appropriately formulated treatment plan. Occasionally, you may be asked to see patients in the faculty practice clinic at the OU Physicians / HLV clinic Consult Service Each medicine or cardiology fellow will be expected to see vascular medicine consults (all hospitals). Consult requests are made by paging the Vascular Medicine fellow (pager ), who will relay the request to the appropriate resident or fellow. They are responsible for initiating the patient contact for chart review, interview, examination, vascular laboratory and x-ray review, and presentation to the attending physician with a formulated diagnostic and treatment plan. As well, the resident or fellow is responsible for maintaining adequate follow-up, with further diagnostic and treatment suggestions during the remainder of the inpatient s stay, including appropriate discharge referrals to the respective vascular clinics, and presenting the data to the attending physician. The residents and fellows are expected to round with the attending every day, the time will be determined by the attending. 37

60 Vascular Laboratory Activity The medicine resident or cardiology fellow is expected to develop an understanding of what each vascular lab study is used for and generally how it works. Observing actual studies is strongly encouraged. The common studies performed in the vascular laboratories are: a. Lower extremity arterial physiologic study (LEA) with or without exercise b. Upper extremity arterial physiologic study (UEA) c. Venous duplex scan (ultrasound plus Doppler of lower and upper extremities) d. Venous reflux or valvular insufficiency e. Carotid duplex scan f. Temperature studies: vasospasm study in upper or lower extremities g. Visceral arterial studies h. Arterial duplex studies of the upper or lower extremities. Weekly Vascular Conference This conference convenes each Wednesday at 7:00 a.m. in the Basic Sciences Education Building, Room 272, and provides a forum to present a variety of specific vascular cases, with discussion among members of the General Surgery, Radiology Special Procedures, nterventional Cardiology, and Vascular Medicine staff. Appropriate vascular laboratory and x-ray reports are to be submitted for inclusion in the Vascular Conference case agenda. Occasionally, a five to 10 minute didactic presentation at the end of a Vascular Conference is expected. Possible topics are to be discussed with the appropriate staff. Conferences: Rotating fellows and residents are expected to attend our conferences and prepare an article for the journal club. Vascular seminar: (Second Friday, monthly, SEC, Level 1, East Boardroom/12:00-1:00) maging conference: (First Friday, monthly, SEC, Level B, Conf Rm D/ 12:00-1:00) Thrombosis conferen(fourth Friday, monthly, SEC, Level 1 East Boardroom/ 12:00-1:00) Journal club: (Fourth Wednesday, monthly, WP 3010 Cardiology Conf Rm/ 1:00-2:00 p.m. Post test: Before the end of the rotation the residents and fellow are expected to contact Dr. Casanegra to arrange for a date and time of the post-test exam, which is administered at a time of mutual convenience. Conclusion For questions or concerns, contact Heidi Childers, extension Evaluation: End of the rotation written evaluation by the attending Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 38

61 ACC CMC Template Evaluation Tool for Vascular Medicine Rotation No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational DM Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures M-VASC-MK1, MK2, MK3, MK5, MK6, MK12, MK15, MK16, MK22, MK26 Does not know the anatomy of peripheral arterial and venous system, does not know the causes and clinical epidemiology of PVD. Does not know the pathphysiology of deep venous thrombosis. Does not know the indications Know the pathology, for screening of abdominal aortic aneurysms. Does not know the indications and contraindications, and clinical pharmacology of drugs used to treat thrombotic disorders. pathophysiology, and differential diagnosis of peripheral artery diseases, including atherosclerotic, thrombotic, vasculitic, fibromuscular, vasospastic, and atheroembolic causes. Know the methods and indications to assess subclinical atherosclerosis (including coronary calcification, carotid intimamedia thickness, and anklebrachial index). Know indications and risks for surgical and percutaneous interventional treatments for PVD and the expected outcomes. Know the indications for CT and MR angiography in patients with suspected vascular disease. Be able to instruct others in both the examination and interpretation of vascular imaging studies in all disease states. Be able to serve as a resource for cardiologists on the management of patients with vascular disease. 2 Patient Care and Procedural Skills PC1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC2: Develops and achieves comprehensive management plan for each patient. PC3: Manages patients with progressive responsibility and independence. PC4b: Demonstrates skill in performing and interpreting non-invasive procedures and/or testing PC5: Requests and provides consultative care. M-VASC-PC1, PC2, PC3, PC5, PC6, PC9, PC12, PC20 Unable to perform physical examination of arterial and venous system. Does not know how to elicit clinical features of acute limb ischemia and how to use diagnostic testing to assess and manage patients with suspected vascular disease. Able to identify patients at risk for, or with, venous thrombosis and/or thromboembolism. Able to accurately assess clinical features of acute limb ischemia. Able to appropriately manage risk factors in patients with arterial disease. Able to appropriately utilize noninvasive screening for abdominal aortic aneurysm. Able to interpret and integrate clinical findings and testing results in the evaluation and management of most patients with PVD. Able to interpret limb segmental blood pressure measurements, pulse volume recordings, and treadmill vascular exercise tests. Able to diagnose and manage acute limb ischemia. Able to interpret and integrate clinical findings and testing results in the evaluation and management of patients with PVD. Demonstrates skills necessary to interpret duplex ultrasound tests for carotid disease, abdominal aortic aneurysm, peripheral artery disease, renal artery disease, and venous disease. Able to instruct others in both the examination and interpretation of vascular imaging studies in all disease states. Able to determine when assessment for subclinical atherosclerosis may be indicated, and to select appropriate tests. 3 Systems-Based Practice SBP1: Works effectively within an interprofessional team. SBP3: dentifies forces that impact the cost of health care, and advocates for and practices cost-effective care. M-VASC-SBP1, SBP2, SBP4 Does not interact with other members of the health care team. Does not acknowledge importance of cost effective care. Does not know when to refer Works effectively with patients for consultative laboratory staff services. (multidisciplinary team). Correctly incorporates appropriate use criteria (AUC) into clinical practice. Participates in laboratory quality improvement initiatives. Able to lead functioning operations as a Laboratory Director or in a similar leadership capacity. Viewed by colleagues as a leader in high value care.

62 Practice Based Learning and 4 mprovement PBL1: Monitors practice with a goal for improvement. PBL2: Learns and improves via performance audit. PBL3: Learns and improves via feedback. PBL4: Learns and improves at the point of care. M-VASC-PBL1, PBL2 Unwilling to self-reflect upon one's own practice or performance. Does not accept feedback well. Consistently misses oportunities for learning and self-improvement. Can be defensive when receiving feedback. Understands that the perceptions of others are important, even when different from his or her own. Actively seeks feedback from multiple sources, as well as spontaneously selfevaluating performance. Applies insights from other activities to self-reflection related to current activity. 5 nterpersonal and Communication Skills CS1: Communicates effectively with patients and caregivers. CS2: Communicates effectively in interprofessional teams (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel). CS3: Appropriate utilization and completion of health care records. M-VASC-CS1, CS2 Does not complete notes and test reports in the health record. Does not communicate information to other healthcare providers. nconsistently completes notes and reports in the health record. Does not consistently relay important patient information directly to other healthcare providers. Consistently completes notes and test reports in the health record. Contacts ordering provider directly Spontaneously selfevaluates with abnormal results. performance. Demonstrates ability to act as a role model by providing comprehensive and timely patient notes and test reports. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team. PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-VASC-PROF1, PROF3 Exhibits inconsistent Lacks sensitivity to patient's sensitivity and respect needs. s not always when interacting with respectful when interacting patients, staff, and peers. with patients, staff, and Requires reminders to peers. Does not accept follow through on tasks. responsibility for tasks. May avoid some tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings. Rarely requires reminders to follow through on tasks. Demonstrates professional behavior in all activities. Accepts responsibility for assigned tasks. Effectively coaches others to develop and maintain professional behavior.

63 b. Description of the Rotations N. Pediatric Cardiology Rotation/Adult Congenital Heart Disease Educational Goals and Associated Competencies: 1. Gain knowledge of hemodynamics in patients with various types of congenital heart disease, by invasive and echocardiographic methods. (Core competencies: Medical Knowledge, Patient Care) 2. Gain knowledge about types of surgical procedures performed for the different types of congenital heart disease. (Core competencies: Medical Knowledge, Patient Care) Fellow Responsibilities: These will be determined by the pediatric cardiology faculty and could include attending the clinic, reading TTEs, scrubbing in the cath lab and self study of interesting case files. Teaching Methods: Didactic session, patient care rounds, reading diagnostic studies Procedure Skills to be attained: None Evaluation: End of rotation evaluation by pediatric cardiology attending Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. 39

64 ACC CMC Template Evaluation Tool for Simple Adult Congenital Heart Disease (atrial septal defects, ventricular septal defects, patent ductus arteriosus, pulmonary stenosis, bicuspid aortic valve, coarctation) DM No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 Ready for Unsupervised Critical Deficiencies Early Learner Advancing-mproving Practice Aspirational 1 Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures. M-ACHD(S)-MK1, MK2, MK3, MK6, MK7, MK9 Lacks foundational knowledge regarding the pathophysiology, diagnosis and management of simple ACHD. Has rudimentary knowledge of simple ACHD defects. Has basic understanding of symptoms, clinical examination, and ECG findings associated with ACHD. Knows most aspects of the anatomy, pathophysiology, and natural history of simple ACHD and associated complcations. Knows indications for endocarditis prophylaxis. Understands most indications for referral to ACHD clinics. Knows the anatomy, pathophysiology, and natural history of simple ACHD defects and associated complications. Recognizes the symptoms, physical examination, and ECG findings associated with these defects. Knows the indications for referral to ACHD clinics. Demonstrates knowledge necessary to manage patients with a broad range of ACHD and associated complications. s a leader and educator for others training in ACHD. 2 Patient Care and Procedural Skills PC1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC2: Develops and achieves comprehensive management plan for each patient. PC3: Manages patients with progressive responsibility and independence. M-ACHD(S)-PC1, PC2, PC7 Able to obtain history and perform physical examination in patients with simple ACHD but information collected is incomplete. Unable to integrate test results with Requires complete clinical findings. Has basic supervision to evaluate and understanding of the manage patients with management of patients simple ACHD. with simple ACHD. Can perform complete history and physical examination on patients with simple ACHD. Able to integrating most laboratory and imaging data with Able to evaluate and clinical findings. Requires minimal assistance with the management of patients with simple ACHD. mange patients with simple ACHD, including common complications and timing of surgical intervention. Demonstrates skills necessary to teach and supervise others in the evaluation and management of patients with simple ACHD. 3 Systems-Based Practice SBP1: Works effectively within an interprofessional team. SBP3: dentifies forces that impact the cost of health care, and advocates for and practices cost-effective care. M-ACHD(S)-SBP1, SBP2 Does not recognize the importance of collaboration with ACHD Center for optimal management of patients with congenital disease. Recognizes importance of collaborating with ACHD Center when managing patients with congenital heart disease but requires guidance to provide longitudinal care. Collaborates with ACHD Center in the management of patients with congenital heart disease. Able to provide longitudinal and costeffective care of patients with congenital disease in collaboration with an ACHD Center. Viewed as a leader in providing high quality and cost-effective care in the management of ACHD patients. 4 Practice-Based Learning and mprovement PBL1: Monitors practice with a goal for improvement. PBL2: Learns and improves via performance audit. PBL3: Learns and improves via feedback. M-ACHD(S)-PBL1, PBL2 Unwilling to reflect upon Consistently misses one's own practice or performance. Does not accept feedback well. Does not audit professional activities. oportunities for learning and self-improvement. Accepts feedback but does not use it to improve professional performance. Acts on some, but not all, opportunities for learning and self-improvement. Accepts feedback well and uses it to improve professional performance. Engages in activities to audit one's performance. Accepts and consistently acts on feedback to promote improvement. Develops activities that assist with selfimprovement and learning. Viewed as a leader in education.

65 nterpersonal and Communication 5 Skills CS1: Communicates effectively with patients and caregivers. CS2: Communicates effectively in interprofessional teams (e.g., with peers, consultants, nursing, ancillary professionals, and other support personnel). CS3: Appropriate utilization and completion of healthcare records. M-ACHD(S)-CS1, CS2 Does not communicate effectively with patients or members of the healthcare team. Does not complete medical record in a timely fashion. Requires some guidance when interacting with patients and members of the healthcare team. Able to complete medical record with instruction. Communicates well with patients and members of the healthcare team. Usually completes medical records in a timely fashion. Leads discussion with patients and families. Actively engaged with all members of the healthcare team. Medical records are always completed accurately and in a timely fashion. Demonstrates ability to act as a role model when communicating with patients, families, and members of the healthcare team. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteris+c5tics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-ACHD(S)-PROF1 Lacks sensitivity to patients' needs. s disrespectful when interacting with patients, staff, and peers. Does not accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

66 b. Description of the Rotations O. Cardiothoracic Surgery Rotation Educational Goals and Associated Competencies: 1. Gain knowledge about the steps of coronary artery bypass grafting and valvular surgical procedures. (Core competencies: Medical Knowledge, Patient Care) 2. Gain knowledge about cardiopulmonary bypass and cold cardioplegia and understand their pros and cons. (Core competencies: Medical Knowledge, Patient Care) Fellow Responsibilities: These will be determined by the CT Surgery attending and may include patient clinic assignment, scrubbing in the OR and follow up of post-op patients Teaching Methods: Bedside teaching during ward rounds Procedure Skills to be attained: None Evaluation: End of rotation written evaluation Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. Suggested Reading: Braunwald s Text book in Cardiology 40

67 ACC CMC Template Evaluation Tool for Cardiothoracic Surgery Rotation No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 DM Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational 1 Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures. M-SCHEM-MK16, MK18; M-VALV-MK14, MK16; M-PER-MK10; M-VASC-MK26; M-HF- MK13 Has rudimentary knowledge of appropriate indications for surgical treatment of ischemic, valvular, vascular, and pericardial diseases. Knows the basic pathophysiology and approach to management of patients with ischemic, valvular, vascular, and pericardial diseases with respect to surgical treatment options. Correctly identifies patients who would benefit from cardiothoracic surgery referral for management of ischemic, valvular, vascular, and pericardial diseases. Consistently understands the clinical implications of findings for a wide spectrum of cardiac patients eligible for surgical treatment of ischemic, valvular, pericardial, and other diseases. Knows the guideline-based treatment in post-surgical patients during the early and late phases after cardiac surgery. Considers STS risk scores in management decisions. Applies clinical guidelinebased surgical therapies to complicated patients with ischemic, valvular, and pericardial disease. Understands subtle nuances in the clinical presentation and assessment of post-cardiac surgery patients. Patient Care or 2 Procedural Skills PC1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC3: Manages patients with progressive responsibility and independence. PC4a: Demonstrates skill in performing and M-SCHEM-PC7; M-VALV-PC8, PC9; M-PERinterpreting invasive procedures. PC3; M-PER-M8 Fails to recognize appropriate evaluation methods and selection process for surgical treatment of ischemic, valvular, vascular, and pericardial diseases. Possesses partial skills to appropriately select patients for surgical treatment of ischemic, valvular, and pericardial diseases. Possesses partial skills required for evaluation and management of postcardiac surgery complications. Possesses partial skills needed to manage patients with post-cardiac surgery low output states. Consistently and effectively evaluates and selects patients with ischemic, valvular, pericardial, and vascular diseases for appropriate surgical procedures. Possesses the necessary skills for Demonstrates skill diagnosis and management of post-cardiac surgery complications, including low output states and cardiac arrhythmias. necessary to interpret, teach, and supervise others in the management of patients with post-cardiac surgery complications. Systems-Based 3 Practice SBP1: Works effectively within an interprofessional team. M-SCHEM-SBP2; M-VALV-SBP1, SBP2 Fails to work harmoniously within an interprofessional Engages in respectful team. Does not incorporate discussion while actively risk-benefit considerations eliciting input from team in diagnostic and members. Demonstrates therapeutic decisions. Does awareness of the value of not practice high value input from technical staff care. and nursing staff. Actively engages team members in collaborative decision-making. Demonstrates appropriately through actions and discussions that team members' input is valued. Efficiently coordinates patient care within an interdisciplinary team. Appropriately includes team members' perspectives in care decisions. Provides high value care with awareness of current disparities in care in certain patient populations. Viewed by the patient care team as a leader in delivery of high quality, high value, evidence-based care.

68 Practice-Based Learning and 4 mprovement PBL1: Monitors practice with a goal for improvement. M-SCHEM-PBL, PBL2; M-VALV-PBL1 Unwilling to self-reflect upon one's practice or performance. Consistently misses oportunities for learning and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance and consistently acts on those reflections to promote improvement. Actively and independently engages in selfimprovement and learning activities. nterpersonal and 5 Communication Skills CS3: Appropriate utilization and completion of healthcare records. M-SCHEM-CS1; M-VASC-CS1 Does not effectively and appropriately interact with patients, families, and the healthcare team. nconsistently involves patients. nconsistently seeks other team members' suggestions while developing treatment plans. Demonstrates ability to engage the patient, as well as patient care team, and to incorporate their suggestions and priorities in the treatment plan. Effectively educates and communicates with patients and families from various cultural, ethnic and socioeconomic backgrounds. Works effectively with the Heart Team in managing patients with ischemic and valvular heart disease. Demonstrates ability to act as role model in providing comprehensive, patientcentered, comapssionate communications to patients, families, hospial staff and peers. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-SCHEM-PROF1, PROF2, PROF3; M-VALV- PROF 1 Lacks occasional sensitivity to patients' needs. s occasionally disrespectful when interacting with patients, staff, and peers. Does not consistently accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Has respectful interactions with patients and is sensitive to their needs. Exhibits professional behavior in most settings when interacting with staff and peers. Rarely requires reminders to follow through on tasks. Consistently exhibits professional behavior with patients, staff, and peers. Accepts responsibility for assigned tasks. Demonstrates appropriate sensivities to end-of-life care decisions. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

69 b. Description of the Rotations P. EP Ablation Rotation Educational Goals and Associated Competencies: 1. Gain knowledge of indications of ablation of various arrhythmias. (Core competencies: Medical Knowledge, Patient Care) 2. Gain basic knowledge about various types of ablative procedures including radiofrequency and cryotherapy. (Core competencies: Medical Knowledge, Patient Care) 3. Gain basic knowledge of the sites of ablation in various types of atrial and ventricular arrhythmias. (Core competencies: Medical Knowledge, Patient Care) Fellow Responsibilities: 1. Observe each of the following case types: a. Supraventricular tachycardia (AVNRT, AVRT) b. Atrial fibrillation c. Ventricular tachycardia 2. Observe and assist with patient care pre and post procedures 3. Attend Wednesday afternoon arrhythmia and device clinics, 1pm a. 1 st, 2 nd, 3 rd Wednesdays are at the VA, 5 th floor b. 4 th Wednesday is at PPOB, 6 th floor Procedure Skills to be attained: 1. Obtain venous and arterial access, if attending of the case allows. 2. Learn to interpret basic intracardiac EGMs for possible general board questions a. Ventricular tachycardia b. Complete heart block c. nfra-hisian block 3. Understanding basic EP lab pacing maneuvers used to differentiate tachycardia mechanisms a. Entrainment methods b. Para-Hisian testing c. Pace mapping/ activation mapping Evaluation Methods: 1. Written evaluation by the attending at the end of the month. 2. Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. Suggested Reading: 1. Cardiac Electrophysiology: A visual guide for nurses, techs, and fellows. Purves P et al. 41

70 ACC CMC Template Evaluation Tool for Pacing and Electrophysiology Rotation No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 DM Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational 1 Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures. M-ARR-MK2, MK3, MK5, MK6, MK9, MK10, MK13, MK14, MK18 Has rudimentary Knows the basic knowledge of mechanisms leading to arrhythmia production. May not fully understand the pathophysiology and approach to evaluation and assessment of patients with atrial fibrillation and flutter. Lacks foundational knowledge of the appropriate assessment and management of ventricular arrhythmias and heart blocks. mechanisms of arrhythmia genesis. Understands the pathophysiology and approach to evaluation and management of atrial fibrillation and flutter, including assessment of stroke risk antocoagulation strategies. Understands the management of ventricular tachyarrhythmias. Knows the indications for the placement of a permanent pacemaker and CD. Correctly identifies the risk stratification and management of sudden cardiac death, predisposition, and significance of cardiac arrhythmias in adult congenital heart disease and pre-excitation neurocardiogenic syncope. Understands clinical management of common coronary, ventricular, and hemodynamic abnormalities. Understands the appropriate use and monitoring of antiarrhythmic drugs. Consistently understands the mechanisms and clinical implications of findings for a wide spectrum of arrhythmias, including ventricular preexcitation. Knows the basic principles involved in programming and interrogating implanted devices. Appropriately applies this information to the clinical management of patients. Understands subtle nuances in the application and interpretion of tests used for the assessment of patients with cardiac arrhythmias and implantable devices. Pursues knowledge including changing guidelines and newer technology used in management of patients with tachy- and bradyarrhythmias. Patient Care or 2 Procedural Skills PC 1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC 3: Manages patients with progressive responsibility and independence. PC4a: Demonstrates skill in performing and interpreting invasive procedures. M-ARR-PC1, PC2, PC3, PC4, PC6, PC8, PC9, PC11, PC13, PC 21 Fails to know the appropriate evaluation and management of patients with palpitations or syncope. Fails to provide guideline-based treatment plans for patients with tachy- or bradyarrhythmias. Does not know the risk assessment and secondary prevention approaches in patients susceptible to cardiac arrest. Possesses partial skills to appropriately manage patients with tachy- and brady-arrhyhmias, elective cardioversion, and temporary pacing. Knows the appropriate selection and monitoring of patients for antiarrhythmic drug therapy. Possesses partial skills needed to manage patients with complicated tachy- and bradyarrhythmias. Performs adequate guideline-based selection of patients for implantable devices and cardiac resynchronization therapy. Consistently and effectively evaluates and manages patients with palpitations, syncope, supraventricular tachyarrhythmias, atrial fibrillation and flutter, ventricular tachyarrhythmias, and symptomatic bradycardias. Possesses the necessary skills in cardioversion and defibrillation, temporary pacing, and risk assessment of patients for secondary prevention of sudden cardiac death. Possesses skills to integrate information provided by electrophysiologic consultation. Demonstrates the skills necessary to interpret, teach, and supervise others in the management of patients with cardiac rhythm disorders. Functions as a resource for patients with complicated cardiac arrhythmia problems or implantable device issues.

71 3 Systems-Based Practice SBP1: Works effectively within an interprofessional team. M-ARR-SBP1, SBP3 Fails to work harmoniously within an interprofessional team. Does not incorportate risk-benefit considerations in diagnostic and therapeutic decisions. Does not practice high value care. Engages in respectful discussions, actively eliciting input from other team members. Demonstrates an awareness of the value of technical and nursing staff input. Actively engages team members in collaborative decision-making. Demonstrates thorough, appropriate actions and discussions in which team members' input is valued. Efficiently coordinates patient care within an interdisciplinary team. Appropriately includes team members' perspectives in care decisions. Provides high value care with awarenes of current healthcare disparities within certain patient populations. Viewed by the patient care team as a leader in delivery of high quality, high value, evidence-based care. Practice-Based Learning 4 and mprovement PBL1: Monitors practice with a goal for improvement. M-ARR-PBL1, PBL2 Unwilling to self-reflect upon one's practice or performance. Consistently misses oportunities for learning and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance and consistently acts on those reflections to promote improvement. Actively and independently engages in selfimprovement and learning activities. nterpersonal and 5 Communication Skills CS3: Appropriate utilization and completion of healthcare records. M-ARR-CS1, CS2 Does not effectively and appropriately interact with patients, families, and the healthcare team. nconsistently involves patients. nconsistently seeks other team members' suggestions while developing treatment plans. Demonstrates ability to engage the patient, as well as the patient care team, and incorporate their suggestions and priorities in the treatment plan. Communicates effectively with, and educates, patients and families across the cultural, ethnic, and socioeconomic backgrounds. Demonstrates ability to act as a role model in providing comprehensive, patientcentered, compassionate communications to patients, families, hospital staff, and peers. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-ARR-PROF1, PROF2; M-HF-PROF2 Lacks occasional sensitivity to patients' needs. s occasionally disrespectful when interacting with patients, staff, and peers. Does not consistently accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Consistently exhibits Has respectful interactions with professional behavior with patients and is sensitive to their patients, staff, and peers. needs. Exhibits professional Accepts responsibility for behavior in most settings when assigned tasks. interacting with staff and peers. Demonstrates appropriate Rarely requires reminders to sensitivities to end-of-life follow through on tasks. care decisions. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

72 b. Description of the Rotations Q. EP Consult Rotation Educational Goals and Associated Competencies: 1. Understand how to differentiate features of various atrial and ventricular tachy and brady arrhythmias. (Core competencies: Medical Knowledge, Patient Care) 2. Gain knowledge regarding the indications, contra-indications, and mechanism of actions of various anti-arrhythmic drugs. (Core competencies: Medical Knowledge, Patient Care) 3. Gain skills to interrogate pacemakers and implantable cardioverter-defibrillators. (Core competencies: Medical Knowledge, Patient Care) Fellow Responsibilities: 1. See and present inpatient consults to arrhythmia or pacing attending. 2. Attend Wednesday afternoon arrhythmia and device clinics, 1pm a. 1 st, 2 nd, 3 rd Wednesdays are at the VA, 5 th floor b. 4 th Wednesday are at PPOB, 6 th floor Teaching Methods: 1. Attending and Fellow review of patient care plan in the clinic. 2. Attending and Fellow review of patient care plan in the hospitals (for consults). 3. Didactic lectures, Wednesday 8am, 6 th floor Children s Hospital, Heart Rhythm nstitute, Webster Laboratory. Procedure Skills to be attained: 1. CED interrogation and troubleshooting. 2. Assist with cardioversions. Evaluation: 1. Written evaluation by the attending at the end of the month. 2. Please refer to the attached evaluation tool that will be utilized by the faculty for this rotation. Suggested Reading: 1. Cardiac Electrophysiology: A visual guide for nurses, techs, and fellows. Purves P et al. 42

73 ACC CMC Template Evaluation Tool for Pacing and Electrophysiology Rotation No. Competency Area Reporting Milestones Subcompetency Link to COCATS 4 Curricular Milestones Level 1 Level 2 Level 3 Level 4 Level 5 DM Critical Deficiencies Early Learner Advancing-mproving Ready for Unsupervised Practice Aspirational 1 Medical Knowledge MK1: Possesses clinical knowledge. MK2: Knowledge of diagnostic testing and procedures. M-ARR-MK2, MK3, MK5, MK6, MK9, MK10, MK13, MK14, MK18 Has rudimentary Knows the basic knowledge of mechanisms leading to arrhythmia production. May not fully understand the pathophysiology and approach to evaluation and assessment of patients with atrial fibrillation and flutter. Lacks foundational knowledge of the appropriate assessment and management of ventricular arrhythmias and heart blocks. mechanisms of arrhythmia genesis. Understands the pathophysiology and approach to evaluation and management of atrial fibrillation and flutter, including assessment of stroke risk antocoagulation strategies. Understands the management of ventricular tachyarrhythmias. Knows the indications for the placement of a permanent pacemaker and CD. Correctly identifies the risk stratification and management of sudden cardiac death, predisposition, and significance of cardiac arrhythmias in adult congenital heart disease and pre-excitation neurocardiogenic syncope. Understands clinical management of common coronary, ventricular, and hemodynamic abnormalities. Understands the appropriate use and monitoring of antiarrhythmic drugs. Consistently understands the mechanisms and clinical implications of findings for a wide spectrum of arrhythmias, including ventricular preexcitation. Knows the basic principles involved in programming and interrogating implanted devices. Appropriately applies this information to the clinical management of patients. Understands subtle nuances in the application and interpretion of tests used for the assessment of patients with cardiac arrhythmias and implantable devices. Pursues knowledge including changing guidelines and newer technology used in management of patients with tachy- and bradyarrhythmias. Patient Care or 2 Procedural Skills PC 1: Gathers and synthesizes essential and accurate information to define each patient's clinical problem(s). PC 3: Manages patients with progressive responsibility and independence. PC4a: Demonstrates skill in performing and interpreting invasive procedures. M-ARR-PC1, PC2, PC3, PC4, PC6, PC8, PC9, PC11, PC13, PC 21 Fails to know the appropriate evaluation and management of patients with palpitations or syncope. Fails to provide guideline-based treatment plans for patients with tachy- or bradyarrhythmias. Does not know the risk assessment and secondary prevention approaches in patients susceptible to cardiac arrest. Possesses partial skills to appropriately manage patients with tachy- and brady-arrhyhmias, elective cardioversion, and temporary pacing. Knows the appropriate selection and monitoring of patients for antiarrhythmic drug therapy. Possesses partial skills needed to manage patients with complicated tachy- and bradyarrhythmias. Performs adequate guideline-based selection of patients for implantable devices and cardiac resynchronization therapy. Consistently and effectively evaluates and manages patients with palpitations, syncope, supraventricular tachyarrhythmias, atrial fibrillation and flutter, ventricular tachyarrhythmias, and symptomatic bradycardias. Possesses the necessary skills in cardioversion and defibrillation, temporary pacing, and risk assessment of patients for secondary prevention of sudden cardiac death. Possesses skills to integrate information provided by electrophysiologic consultation. Demonstrates the skills necessary to interpret, teach, and supervise others in the management of patients with cardiac rhythm disorders. Functions as a resource for patients with complicated cardiac arrhythmia problems or implantable device issues.

74 3 Systems-Based Practice SBP1: Works effectively within an interprofessional team. M-ARR-SBP1, SBP3 Fails to work harmoniously within an interprofessional team. Does not incorportate risk-benefit considerations in diagnostic and therapeutic decisions. Does not practice high value care. Engages in respectful discussions, actively eliciting input from other team members. Demonstrates an awareness of the value of technical and nursing staff input. Actively engages team members in collaborative decision-making. Demonstrates thorough, appropriate actions and discussions in which team members' input is valued. Efficiently coordinates patient care within an interdisciplinary team. Appropriately includes team members' perspectives in care decisions. Provides high value care with awarenes of current healthcare disparities within certain patient populations. Viewed by the patient care team as a leader in delivery of high quality, high value, evidence-based care. Practice-Based Learning 4 and mprovement PBL1: Monitors practice with a goal for improvement. M-ARR-PBL1, PBL2 Unwilling to self-reflect upon one's practice or performance. Consistently misses oportunities for learning and self-improvement. Acts on some, but not all, opportunities for learning and self-improvement. Regularly reflects upon one's performance and consistently acts on those reflections to promote improvement. Actively and independently engages in selfimprovement and learning activities. nterpersonal and 5 Communication Skills CS3: Appropriate utilization and completion of healthcare records. M-ARR-CS1, CS2 Does not effectively and appropriately interact with patients, families, and the healthcare team. nconsistently involves patients. nconsistently seeks other team members' suggestions while developing treatment plans. Demonstrates ability to engage the patient, as well as the patient care team, and incorporate their suggestions and priorities in the treatment plan. Communicates effectively with, and educates, patients and families across the cultural, ethnic, and socioeconomic backgrounds. Demonstrates ability to act as a role model in providing comprehensive, patientcentered, compassionate communications to patients, families, hospital staff, and peers. 6 Professionalism PROF1: Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e.g., peers, consultants, nursing, ancillary professionals, and support personnel). PROF2: Accepts responsibility and follows through on tasks. PROF3: Responds to each patient's unique characteristics and needs. PROF4: Exhibits integrity and ethical behavior in professional conduct. M-ARR-PROF1, PROF2; M-HF-PROF2 Lacks occasional sensitivity to patients' needs. s occasionally disrespectful when interacting with patients, staff, and peers. Does not consistently accept responsibility for tasks. Exhibits inconsistent sensitivity and respect when interacting with patients, staff, and peers. Requires reminders to follow through on tasks. Consistently exhibits Has respectful interactions with professional behavior with patients and is sensitive to their patients, staff, and peers. needs. Exhibits professional Accepts responsibility for behavior in most settings when assigned tasks. interacting with staff and peers. Demonstrates appropriate Rarely requires reminders to sensitivities to end-of-life follow through on tasks. care decisions. Serves as a role model for others with respect to professional interactions with patients, staff, and peers.

75 c. General Learning Objectives: The following is a list of learning objectives during cardiology fellowship training. OBJECTVE 1: TAKES A HSTORY Description of objective: Demonstrates knowledge necessary to obtain an orderly history on patients suspected of having cardiovascular diseases and recognizes the importance: Dyspnea (resting, exertional, nocturnal, positional) Chest pain (specifically what constitutes typical angina ) Edema Palpitations/arrhythmia Exercise tolerance History of hypertension and treatment History of rheumatic fever History of congenital heart disease History of cardiac murmurs or valvular heart disease Cardiovascular risk factors including family history Presyncope and syncope Claudication Process for attainment of the objective: This learning objective will be attained through bedside teaching on the wards and in the clinics Assessment of learning: Bedside rounds OBJECTVE 2: PERFORMS A PHYSCAL EXAMNATON Description of the objective: Demonstrates knowledge necessary for performing an orderly, systematic and adequate physical examination of patients with cardiovascular problems: A. Arterial system Reports and demonstrates the correct method of measuring arterial blood pressure s familiar with difficulties in measuring arterial blood pressure accurately Variation between extremities, positions and level of extremity: The ascultatory gap Proper cuff size 43

76 s familiar with normal and common findings found by inspection or palpation of the venous and arterial pulses, including the following: B. Examination of the Heart a,c,v waves; visual estimation of venous pressure; hepatojugular reflux effect of inspiration on neck veins pulsus alternans, bisferiens, paradoxus pulse in aortic regurgitation and aortic stenosis Discusses normal and common abnormal findings found by inspection and palpation of the anterior chest, including the following: Right and left ventricular heaves Thrills Understands the events of the cardiac cycle and the genesis of: S1,S2,S3,S4, summation gallop, splitting of S2 (normal and paradoxical) and opening snap nnocent murmurs, including flow murmurs, venous hum and mammary soufflés Murmurs of valvular stenosis and insufficiency Maneuvers that alter murmurs, i.e. Valsalva, squatting, inspiration, expiration Pericardial rubs Mitral valve clicks Artificial valve sounds (normal and abnormal) This learning objective will be attained through bedside teaching on the wards. Assessment of process adequacy: Evaluation t each rotation Min-CEX (proctored bedside examination) OBJECTVE 3: ORDERS OR PERFORMS DAGNOSTC STUDES, NTERPRETS LABORATORY DATA N A REASONABLE, EVDENCE BASED & COST EFFECTVE MANNER Description of the objective: A. Electrocardiography 1. General knowledge of the range of the range of normal variation in QRS,P,ST,T wave indices 44

77 2. Understanding of ECG diagnosis of LVH, left atrial enlargement, infarction patterns both acute and chronic 3. Basic understanding of the diagnostic utility of the ECG in the diagnosis of arrhythmias Process for attaining this objective: This training will be acquired through EKG reading during the CCU and consult rotation Additional resource available for the resident is the daily EKG classes & the monthly EKG conference. B. Chest X-ray 1. General knowledge of normal chest X ray findings 2. Appreciation of abnormalities seen in: CHF Valvular disease Hypertensive disease schemic heart disease Common congenital abnormalities seen in adulthood This training will be done during ward rounds and consult rounds. C. Non-invasive Testing 1. Basic appreciation of the indications for Echocardiographic assessment (transthoracic & transesophageal) including 2D and Doppler echocardiography Ambulatory ECG (Holter) monitoring Exercise testing with and without perfusion scintigraphy; understanding of sensitivity and specificity of test in the diagnosis of coronary artery disease Tomographic imaging techniques including MR and CT Basic concepts will be covered in ward rounds and consult rounds. Further training will be available during in the Echo Labs and stress labs. D. nvasive testing Basic knowledge of the methodology involved in performing coronary angiography, left ventricular hemodynamic assessment and electrophysiological testing. Understanding the indications and risks of invasive diagnostic procedures. occur during ward rounds and attending rounds. Additional exposure is available for interested residents during the consult months. OBJECTVE 4: UNDERSTANDS THE PATHOPHYSOLOGY, NATURAL HSTORY, PRESENTATON, DAGNOSTC WORK UP AND MANAGEMENT OF A. Congestive Heart Failure 45

78 Altered myocardial hemodynamics as well as abnormal neurodendoctrine responses Precipitating causes of worsened CHF Mechanisms and importance of diastolic dysfunction Therapy including relative value/limits of diuretics, digoxin, vasodilators or fluid restriction, inotropic agent therapy B. Coronary Artery Disease Risk factors for coronary artery disease and their modification Differential diagnosis of chest pain Chronic and acute ischemic syndromes (unstable angina and acute M) with emphasis on proper history taking Noninvasive and invasive testing in patients with suspected coronary artery disease Complications in acute post myocardial infarction syndromes such as arrhythmias, sudden death, mechanical lesions, pericarditis and cardiac rupture ndications for coronary arteriography Role of interventional procedures and cardiac surgery in the treatment of coronary artery disease Role of medical management (Thrombolytic drugs, ACE inhibitor drugs, beta blockers, lipid lowering agents) C. Arrhythmias Bradyarrhythmias including various forms of conduction disturbances and AV block, with emphasis on the indications for pacing Tachyarrhythmias including an emphasis on the EKG diagnosis of wide complex Atrial: Atrial tachycardioa/av nodal reentrant tachycardia Atrial fibrillation Atrial flutter Ventricular: 1. Premature ventricular contractions (PVCs) 2. Ventricular tachycardia 3. Torsade de pointes 4. Ventricular fibrillation Pre-excitation syndromes Understanding the importance of catheter ablation techniques in treatment of arrhythmias D. Cardiomyopathy Differential diagnosis and laboratory assessment Treatment including cardiac transplantation Follow up of the post transplant patient E. Valvular heart disease Acute rheumatic fever including diagnostic criteria Aortic stenosis/regurgitation Mitral stenosis/regurgitation Tricuspid stenosis/regurgitation Pulmonary stenosis/regurgitation Mitral valve prolapse 46

79 F. Pericarditis Acute: etiology, symptoms and diagnosis Chronic: including large pericardial effusion, cardiac tamponade and the indications for pericardocentesis Diagnosis and management of constrictive pericarditis G. Cardiac tumors Cardiac involvement in metastatic cancer Myxoma H. Congenital heart disease Diagnosis, history and physical of the adult with congenital heart disease especially for the diagnosis of Atrial septal defect Ventricular septal defect Aortic stenosis Pulmonic stenosis Coarctation of aorta Basic understanding of the adult with partially corrected congenital heart disease and post-op complications of the more common repair procedures, e.g. Transposition of the great vessels Tetralogy of Fallot Ebstein anomaly. Pulmonary heart disease Cor pulmonale Pulmonary embolism Primary pulmonary hypertension J. Cardiac involvement in systemic disease Diabetes mellitus Thyroid disease Obesity Thiamine deficiency Pheochromocytoma Rheumatic diseases including scleroderma, SLE, temporal arteritis, polyarteritis nodosa and rheumatoid arthritis Pulmonary embolism and deep venous thrombosis Arterial emboslim K. Peripheral vascular disease Arteriosclerosis obliterans Aneurysms o Abdominal aortic o Thoracic aortic (including aortic dissection) o Peripheral vascular L. Miscellaneous Cardiac Conditions 47

80 Trauma to heart and great vessels nfectious diseases Viral myocarditis nfectious myocarditis Assessment of pre-operative risk for non-cardiac surgery This training will be accomplished during ward rounds, consult rounds and by didactic lectures. OBJECTVE 5: DEVELOPS TREATMENT PLAN FOR COMMON CARDAC PROBLEMS For each major disease of cardiovascular system, identifies the appropriate therapeutic approach Understands the indications for and can perform the following: Cardiopulmonary resuscitation Emergency cardioversion Carotid massage Central venous pressure catheter insertion This training will be provided during CPR certification, ward responsibilities in the coronary care unit and ward rounds. For each of the treatment and drug types listed below, identifies indications, dose, action mechanism, main effects, adverse reactions, interactions, cost, efficacy and appropriate follow up Digitalis and other inotropic drugs Antiarrhythmic drugs Diuretics Calcium channel blockers Beta blockers Angiotensin-converting enzyme inhibitors Vasodilators Anticoagulants and thrombolytics Antihypertensive agents Lipid lowering agents Rheumatic fever prophylaxis Endocarditis prophylaxis Nitrates nstruction will be provided during ward rounds, clinics and through didactic lecture sessions. nformed, aware and able to participate in and teach to patients, students, medical personnel and colleagues regarding Preventive cardiology Psychological aspects of cardiac disease Behavioral therapy including stress management, risk factor reduction Proper nutrition especially regarding lipid management and obesity Medical cost/benefit including different national systems and medical care rationing Clinical trials, Meta analysis This training will be obtained during ward rounds and clinic rotations. 48

81 . RESOURCES AVALABLE a. Training Sites The spectrum of cardiac pathology available at the two teaching sites OUMC and DVA Medical Center are adequate resources to attain the educational objectives for the cardiology fellows. Moreover, additional teaching material is provided during vascular medicine and heart failure rotations. Ward rounds are conducted daily in the CCU, PCCU and consult teams. Stress laboratory, echocardiographic laboratory and cardiac catheterization laboratory operate daily at all the two teaching sites. For acquisition of physician diagnosis skills, a patient simulator (HARVEY) is available on campus. Access to HARVEY can be obtained through the college of medicine offices. b. Teaching Conferences The general objective of teaching conferences is to help the cardiology fellow develop concepts in cardiac anatomy, physiology, pathophysiology, pharmacology, cardiac catheterization, echocardiography, electrophysiology and preventive cardiology. Lectures help in augmenting knowledge gained in the cath lab, echo lab, ward rounds and clinics, while providing opportunities to discuss topics not routinely discussed during ward rounds or lab activities. Fellows Noon Conference Every Monday Time: 12:00-1:00 pm Location: Samis Education Center, Conference Room D, Level B First Monday: Director s meeting. Second Monday: Electrocardiography Conference. Note: EKG reading skills are essential for the cardiology boards; passing the boards requires passing the EKG component of the examination. Fellow assigned to EKG conference must select EKGs in advance. The coding sheet from the EKG text book by O Keefe should be used for the session in order to acquire expertise in its use for the Board examinations. Fellow will also be assigned a specific EKG topic for a minute in-depth review monthly. Remaining Mondays each month: Board Review sessions. Cardiac Cath/Cardiac Surgery Conference Every Tuesday Time: 7:00-8:30 am Location: Samis Education Center, Conf. Rm. D, Level B Last Tuesday: nterventional Journal Club Cath Morbidity & Mortality Conference Second Monday of Every Month Time: 7:30-8:30 am Location: Cardiology Conference Room, Williams Pavilion, Suite 3010 Wednesday Morning Conference: Time: 7:30-8:30 am Location: Samis Education Center, Conference Room D, Level B 49

82 First Wednesday: CCU case conference (Presenters: CCU Fellows from previous month) Second Wednesday: No conference Third Wednesday: Journal Club Fourth Wednesday: Research Conference Fifth Wednesday: No conference Echo/Nuclear/maging Conference Every Thursday Time: 7:30-8:30 am Location: Samis Education Center, Conference Room D, Level B n addition to review of interesting cases, test sessions for practice using the board exam template will be held. Cardiology Grand Rounds Every Friday Time: 7:30-8:30 am Location: Coussons Conference Center, Everett Tower, Children s Hosp. 2 nd Floor, 2E109 One fellow is assigned to Cardiology Grand Rounds each month. Fellow should discuss a patient with a complex therapeutic decision issue. Vascular Medicine Conference Three Fridays a Month Time: 12:00-1:00 pm First Friday: maging Conference (Samis Center, Conf. Rm. D, Level B) Second Friday: Vascular Seminar (Samis Center, East Board Room, Level 1) Fourth Friday: Thrombosis Conference (Samis Center, East Board Room, Level 1) Nuclear Physics Lectures (not held each week) Time: 12:00-1:00 pm, Varying Wednesdays Location: Watch postings on MedHub and refer to list provided Vascular Surgery Conference Every Wednesday Time: 7:00-8:00 am Location: Basic Sciences Education Building (BSEB), Room 272 Monthly CCU QA Conference Fourth Monday of Each Month Time: 7:30-8:30 am Location: Samis Education Center, Conference Room D, Level B Signing in is required for each conference. A minimum of 75% attendance is required. Fellows must adjust their schedules to attend each teaching session since the goals of these sessions are to educate the fellows, prepare them for taking the boards and groom them for practice cardiology effectively. n case a fellow misses a lecture, the options for making up for the sessions include two. The same topics are covered in the lecture series every two years. A copy of the slide set will be available at the fellowship office. 50

83 V. RELATONSHP OF CORE COMPETENCES AND EDUCATONAL OBJECTVES TO TEACHNG CONFERENCES Educational objectives covered by conferences: Monday noon conference for the fellows: EKG reading (Core competencies: Medical Knowledge) Pathophysiology of heart disease, pharmacology, anatomy, embryology (Core competencies: Medical Knowledge, Practice based learning and improvement, system based practice, procedure skills) Cath & Cardiac Surgery Conference: nvasive testing indications and role of percutaneous coronary interventions and cardiac surgery (Core competencies: Procedure skills, medical knowledge, practice based learning and improvement, system based practice, professionalism) Vascular Conference: Symptoms and signs of peripheral vascular disease, diagnostic tests and interventional and surgical treatment of vascular disease (Core competencies: Medical knowledge, procedure skills, practice based learning and improvement) Echocardiography Conference: ndications and role of echocardiography in various cardiac diseases (Core competencies: Medical Knowledge, procedure skills) CCU Patient Care Conference: Acute coronary care, pharmacology, evidence based cardiac care, quality improvement (Core competencies: Medical Knowledge, patient care, practice based learning and improvement, system based practice, professionalism) Journal Club: New developments in cardiology Evidenced based medicine Critical review of the literature (Core competencies: Medical knowledge, practice based learning and improvement) Fellow s Research Conference: Research methodology Opportunities for residents to participate in research (Core Competencies: Medical Knowledge, practice based learning and improvement) 51

84 V. TEACHNG PLAN FOR SPECFC LEARNNG OBJECTVES Cardiovascular llness Competency Priority Preferred Learning Venues Outpatient Cardiology npatient Wards Didactic Clinic Atrial Arrhythmias 1 Yes Yes Yes Conduction Abnormalities 1 Yes Yes Yes Ventricular Arrhythmias 1 Yes Yes Yes Pacemaker Management 3 Yes (Pacemaker Clinic elective) Congenital Heart Disease 3 Yes (Adult Congenital Heart Clinic elective) Congestive Heart Failure Acute Pulmonary Edema 1 Yes Yes Chronic CHF 1 Yes Yes Yes Coronary Artery Disease Stable Angina 1 Yes Yes Yes Unstable Angina 1 Yes Yes Myocardial nfarction (uncomplicated) 1 Yes Yes Myocardial nfarction (complicated) 1 Yes Yes Myocardial nfarction (follow-up) 1 Yes Yes Yes Post Procedure Care 1 Yes Yes Yes Endocarditis 1 Yes Yes Yes Hypertension Chronic 1 Yes Yes Yes Acute 1 Yes Yes Sec. Hypertension 1 Yes Yes Myocardial Disease Cardiomyopathy 3 Yes Myocarditis 3 Yes Pericardial Disease Acute Pericarditis 1 Yes Yes Yes Pericardial Tamponade 2 Yes Yes Pre-op Evaluation 1 Yes Yes Yes Valvular Disease 1 Yes Yes Yes Vascular Disease Aortic Disease 1 Yes Yes Yes Arterial nsufficiency 1 Yes Yes Yes Chronic Venous Stasis 1 Yes Yes Yes Deep Venous Thrombosis 1 Yes Yes Yes Aneurysm 3 Yes Aortic Dissection 3 Yes Yes Drug Therapy of Cardiac Disease 1 Yes Yes Yes 1 = Direct patient responsibility preferred 2 = Any other form of learning that is centered on a patient 3 = Lectures/seminars/reading suffice 52

85 V. PROCEDURE SKLLS V a. List of Procedures 1. Advanced cardiac life support mandatory Training acquired through ACLS training at the beginning of residency 2. Elective cardioversion Training acquired through formal lectures, during the CCU rotation, EP consult rotation 3. Programming and follow-up surveillance of permanent pacemakers Training acquired through pacing rotation, formal didactic courses offered by Medtronic and during the CCU rotation 4. nsertion of Swan-Ganz (pulmonary artery flotation) catheter Training acquired during CCU rotation and the cath lab rotation 5. nsertion of temporary pacemaker Training acquired during CCU rotation and the cath lab rotation 6. Stress testing Training acquired during echo lab rotation and Heart Station rotations at OUMC and DVA Medical Center 7. Tilt Table Training available during Heart Station Rotation 8. Right and left heart catheterization including coronary arteriography Training acquired during cath lab rotation 9. Echocardiography, including transthoracic echocardiography (performance & interpretation), stress echo, transesophageal cardiac studies 53

86 V b. Documentation of Procedures Objectives: To track all cath lab, echo lab, nuclear lab and EP lab procedures to be assess volume of procedures that fellow participated in and procedural competency. To track complications from procedures To develop log books which will help in certifying competencies of fellows Expectations: Fellow will record procedures through Med-Hub the following procedures: Left and right heart catheterization Myocardial biopsy Pericardiocentesis ntra-aortic balloon counterpulsation Transthoracic Echocardiogram Stress echocardiogram Transesophageal echocardiogram Nuclear stress imaging Temporary pacing Right heart catheterization (bedside) Perclose and other closure devices Peripheral arteriograms EP study Permanent pacemaker implantation Follow-up and programming of permanent pacemakers and other devices (CD) Logs will need the following information for each procedure: Name and D of patient (HPA compliant) ndication for the procedure Nature of procedure Attending supervising the procedure Fellow involvement (first assistant, second assistant etc) in the procedure Complications of the procedure Attending signature Logs need to be completed on MedHub after each rotation for tracking with the signatures of the supervising attending confirming verification. There is no need to document EKGs & ambulatory EKGs. COCATS guidelines will be used to judge levels of competency in each procedure (Levels, and ). 54

87 V. READNG LST RECOMMENDATONS Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, by Eugene Braunwald (Editor), Douglas P. Zipes (Editor), Libby Peter (Editor), Robert Bonow (Editor) Heart, Arteries and Veins by Hurst, J. Willis/ Editor(s): Schlant, Robert C. Mayo Cardiology Board Review Cardiosource for nstitutions teaching material (includes ACCF Board Review, several SAPs) The Mayo Echo Manual by Jae Oh Essential Nuclear Medicine Physics by Powsner and Powsner 2nd edition Nuclear case studies (under education and online education links 55

88 V. OUTLNE FOR NCORPORATNG CORE COMPETENCES NTO ROTATONS Location for Methodology for Competency Training & Evaluation Testing 1. Patient Care CCU Global rating Consult Service n-training Exam ABM exam 360º Evaluation 2. Medical Knowledge CCU Global rating Consult Service n-training Exam Research Rotation ABM exam 3. Practice-based Learning & CCU Global Rating mprovement Consult Service 360º Evaluation Research Rotation 4. nterpersonal & CCU Global Rating Communication Skills Consult Service 360º Evaluation 5. Professionalism CCU Global Rating Consult Service 360º Evaluation 6. System based Practice CCU Global Rating Consult Service 360 º Evaluation 56

89 X. COCATS-4 COMPETENCY TABLES See attached 57

90 ACC 2015 Core Cardiovascular Training Statement (COCATS 4) Competency Tables Revision Date: March 13, 2015