SCIENTIFIC BOARD OF INTERNAL MEDICINE

Saudi Commission for Health Specialties SCIENTIFIC BOARD OF INTERNAL MEDICINE CARDIOLOGY FELLOWSHIP TRAINING PROGRAM nd Revised Edition 148 / 007

TABLE OF CONTENTS PAGE I. INTRODUCTION 1 II. GENERAL SCOPE AND OBJECTIVES III. ADMISSION REQUIREMENTS 3 IV. TRAINING REQUIREMENTS 4 VII. STRUCTURE OF TRAINING PROGRAM 4 VIII. VACATIONS, HOLIDAYS AND ON CALL 13 IX. EVALUATION 14 X. CERTIFICATION 15 XI. APPENDIX 16 TRAINING CENTER

I. INTRODUCTION During the past four decades the speed of progress in diagnostic methodologies and management of patients with cardiac disorders has been most remarkable from the introduction of new cardiac catheterization techniques, using new technologies and modifications on present devices such as the introduction of drug eluting. Stents, intravascular ultrasound and the recent development of easier embolectomy devices, in addition to the advances in non-invasive methods in echocardiography, with transesophageal applications, and marked leaps in the field of electrophysiology. The increased need for patients Saudi Cardiologists to serve the ever increasing number of patient with cardiac problems has simulated the creation of a formal Fellowship Program in Adult Cardiology, under the auspice of the Saudi Board of Internal Medicine. This program is designed to produce fully trained, certified and competent cardiology specialists, both in general context and, for those who elect to pursue further training, in the various subspecialties. 1

II. GENERAL SCOPE The purpose of the Saudi Adult Cardiology Training Program is to provide the enrolled physician with all the necessary training during a period of 3 years towards the acquisition of the Saudi Board in Cardiology. The fellows receive preparation to enable them to provide optimal care and consultation for patients with congenital or acquired cardiovascular disease. The trainee will be certified as an Adult Cardiologist after the successful completion of the training program and passing the required examinations. Objectives: The program shall provide adequate training in : Basic medical sciences (anatomy, physiology, biochemistry, pharmacology). Normal development and embryology of the cardiovascular system. Experience in a broad spectrum of acquired and adult congenital heart diseases, including postsurgical conditions, in chronic disorders as well as acute or emergency situations. Exposure to pathologic conditions ranging from the moderately ill to the seriously ill patient requiring intensive care. Significant experience in, and appreciation of the importance of diagnostic investigate studies.

Clinical cardiology - including patient history and comprehensive physical examination, cardiac cath laboratories, echo laboratories, stress, holter and electrophysiology. Public health and community aspects of cardiology, including primary and secondary prevention and rehabilitation. Development of teaching skills. Exposure to research development and analysis. III. ADMISSION REQUIREMENTS To be admitted to the Saudi Cardiology Sub-specialist training program, an individual must: 1. Possess a Saudi Specialty Certificate in Internal Medicine or its equivalent as approved by the Saudi Commission or have successfully completed the written component of the Saudi Specialty Certificate in Internal Medicine.. Be licensed to practice medicine in Saudi Arabia. 3. Provide written permission from his/her sponsoring institution allowing participation in full time training for the whole program period (3 years). 4. Signature of obligation to abide by the rules and regulations of the Training Program and the Saudi Board. 5. Pass successfully the interview for the particular subspecialty. 6. Provide three letters of recommendation from consultants with whom the candidate has recently worked with. 7. Registration as trainee at the Saudi Council for Health Specialties. 3

IV. TRAINING REQUIREMENTS 1. Training is a full time commitment, trainees shall be enrolled in continuous full time training for the whole period of the program (3 years). Training is to be conducted in institutions accredited for training by the Saudi Board of Internal Medicine and subspecialty of Cardiology. 3. Training shall be comprehensive and includes inpatient, outpatient, cardiac cath, echocardiography and electrophysiology. 4. Trainees shall be actively involved in patient care with gradual progression of responsibility. 5. Trainees shall abide by training regulations and obligations set by the Saudi Board of Internal Medicine. V. STRUCTURE OF THE TRAINING 1. Basic Sciences PROGRAM Instruction will be offered through courses, seminars, lectures, workshops or laboratory experience to provide an appropriate background in basic and fundamental disciplines related to the heart and cardiovascular system, such as embryology, anatomy, physiology, biochemistry, pathology, pharmacology, genetics, molecular biology, bioelectronics and biostatistics. i) The fellow will aim to master through the understanding embryology and anatomy of the normal heart and cardiovascular system any deviations from normal that may occur. 4

ii) Normal and abnormal cardiovascular and cardiopulmonary physiology and metabolism will be taught, as well as fundamentals of cardiovascular pharmacology, including the mechanism of drug action, therapeutic indications and side effects. iii) Each cardiac center should organize a continuous science teaching program including basic clinical cardiology and lectures.. Clinical Practice Apart from the care given within the hospital setting, the fellow will participate in consultations and/or conferences in which the cardiology and cardiac surgical staff evaluate the results of surgery and the patient s cardiac status before discharge from hospital. Included in the program will be primary and secondary prevention of cardiovascular disease and cardiac rehabilitation. A) Cardiology Inpatients, Outpatient Clinics and Consultation The candidate should spend five months in first year, two months in second year and two months in third year of training in these areas for a total period of nine months. i) Building the knowledge, skills and clinical judgement already acquired in general medicine, including a thorough grasp of the concepts of the diagnostic process through history, physical examination and investigation, the fellow will develop the more specific requirements demanded in the management of cardiovascular disorders. 5

ii) The fellow will work in the designated team alongside the residents in daily rounds, teaching rounds, etc., participating in the on call schedules as specified. iii) The fellow will participate in the decisions made concerning a particular patient s management, with increasing levels of independence, but always subject to supervision by the consultant cardiologist. The fellow will prepare management plans for individual patients, including pre and post operative management as deemed appropriate. iv) As on call resident, the fellow will participate in receipt, action and follow up consultation requests from other specialties. v) Fellows will attend the cardiology outpatient clinics as scheduled. With a minimum of one clinic per week spread out over the three-year period of training. Cases will be discussed there with the Consultant Cardiologist. vi) During this period, the candidate will get also his training in ECG, Ambulatory ECG, exercise testing and nuclear cardiology. B) ECG Reporting i) Fellows must become familiar with clinically encountered patterns, wave forms and arrhythmias and their origins, clinical implications and management. This will include the various forms of pacer complexes and the appropriate pacemaker adjustments. ii) Fellows should report a minimum of 4000 ECGs during the period of training. 6

C) Ambulatory ECG i) Reviewing, interpreting and reporting Holter tracings, under supervision of the Consultant Cardiologist. ii) Assessing the relative importance of the Holter tracing in the context of particular cardiovascular conditions, and also the effect of anti-arrhythmic treatment. iii) Presentation of interesting and difficult tracing in the rounds and discussions. iv) The fellow must scan and report at least 150 holter tracings during the period of training. v) The candidate will be involved in taking care of inpatient and outpatient services during this period of time. D) Exercise Testing i) Instructions by the Consultant Cardiologist should be supplemented by self teaching from a basic textbook on the principles of stress ECG, including the various protocols in general use and interpretation of the test including sensitivity and specificity, the safety measures and precautions to be taken and indications for terminating the test. ii) After a period of training of not less than two weeks, independent supervision of stress ECG procedures, interpretation of results, preparation of written reports and presentations at rounds or case discussions shall be implemented. 7

iii) The fellow must perform and report at least 00 stress ECGs after assuming independent supervision of the test. A duly filled in and co-signed log book should be provided. E) Nuclear Cardiology i) Instructions by the Consultant Cardiologist should be supplemented by self teaching from a basic textbook on the principles of nuclear cardiology, including the various protocols in general use and interpretation of results. ii) The following procedures will be studied: Stress thallium/cardiolyte scan Persantin thallium scan Technetium pyrophosphate scan MUGA scan iii) Attend the nuclear cardiology session and read the results under supervision of the Consultant Physicist in Nuclear Cardiology. iv) Correlate results with other investigations to achieve an overall correlation with the clinical condition. v) The fellow must report at least 100 stress / persantin thallium scans during the period of training. F) Coronary Care Unit Duration: Two months each for first, second and third year with a total period of six months. 8

Under supervision, the trainee should experiencei) Routine and on call duties as scheduled ii) Routine management of CCU patients. iii) Management of emergency situations in current patients and also emergency admissions. iv) All aspects of life-support. Fellows must pass the standard level for recognized life support programs. v) invasive procedures and techniques, including Swan-Ganz insertion, arterial line insertion, intra-aortic balloon pump insertion and management, temporary pacemaker insertion and management. G) Cardiac Catheterization Laboratory The total period of time spent in the Cardiac Catheterization Laboratory during the whole period of training shall amount to six months, divided into two months blocks in each training year. The Trainee shall: i) Learn from the Consultant Staff, this will be supplemented by a basic textbook on the principles of cardiac catheterization and angiography, including the various recording techniques, with monthly lectures by cathing and interventional cardiologists. ii) Be familiar with the radiographic machines, haemodynamic equipment and the various functions within the Cath Lab. 9

iii) Review all patients clinically as well as their investigations before the scheduled cardiac catheterization, whether diagnostic or interventional. iv) Attend the procedures, at first as an Assistant and then as the primary operator under supervision. The fellow must perform at least 50 diagnostic right heart catheterization and 50 coronary angiography and 300 ventriculography procedures, as the primary operator under supervision during the whole period of training to achieve recognition as an independent operator. This will be documented in a log book. v) Follow up the patients after the procedures. vi) Learn all the various techniques and radiographic projections utilized across the full range of procedures. vii) Review and interpret the results, both angiographic and haemodynamic, calculating the appropriate heamodynamic values, valve areas, etc. viii) Present appropriate reports for discussion with the Consultant at the Cardiac Catheterization Laboratory or the grand rounds with the cardiac surgeons. Relevant topics should include: a) Right and left sided cardiac catheterization. b) Coronary angiography including vein graft angiography. c) E x p o s u r e t o i n v e r v e n t i o n a l procedures during the third year. 10

H) Echocardiography The total period of time spent in the Echocardiography Laboratory during the whole period of training will amount to six months with a duration of two months in each training year. The trainee shall: i) Learning from basic textbook on the principles of echocardiography, Doppler, Colour Doppler, transthoracic and transesophageal techniques. ii) Receive lectures in anatomy, physiology and pathophysiology of the cardiovascular system. iii) Become familiar with the echo machines and their various functions. iv) Perform Echocardiography in conjunction with the echocardiography consultant and technicians to gain an understanding of the normal and abnormal anatomy and morphology of the heart, and its components, in all the recognized ranges and projections. v) Acquire in the first rotation, the ability to perform full, standard studies in M-mode, -D and Doppler. vi) Attend the echocardiography reading sessions with the consultant cardiologist from the noninvasive laboratory, and present results in the usual forums, including ward rounds with the cardiac surgeons. vii) Be able to perform emergency echocardiography in the second and third year of training. 11

viii) Perform seventy-five studies and interpret at least 300 transthoracic studies including Doppler and colour Doppler during the whole period of training. ix) Assist in and get exposed to transesophageal and Dobutamine stress echocardiographic procedures during the third year. I) Electrophysiology and Cardiac Pacing Duration: One month each year for the second and third years for a total period of two months. Under supervision the trainee shall: i) Perform 0 temporary pacemakers. ii) Perform six cardioversions. iii) Interpret a minimum of 15 basic intracardiac recordings. iv) Assist in and get exposed to diagnostic EPS and ablation procedures. v) Assist in and get exposed to permanent pacemaker / ICD implantation procedures. J) Pediatric Cardiology: In order to expose the trainee to congenital cardiology in respect to clinical and echocardiography investigation in children, the trainee shall spend one month in Pediatric Cardiology. 1

K) Research i) Fellows must become familiar with the principles and methodologies of research. ii) Fellows are encouraged to participate in ongoing research in the Department of Adult Cardiology in two projects during the three years period. iii) Fellows will be encouraged to undertake their own research projects, and submit the results in seminars or publish them in local or international journals. iv) The research work will be assessed by the local director of the training center v) The fellow will be expected to attend outpatient clinic, on calls and consultation clinics while conducting research. L) Elective Period Duration: Two months blocks for the second and third year for a total period of four months. (Can be spent either in echocardiography, cardiac catheterization, electrophysiology, adult congenital, CT/MRI.) On call duties during this period shall be covered as normal. VI. VACATIONS, HOLIDAYS AND ON CALL 1. Fellow are entitled to four weeks vacation annually with a maximum of 10 days for both Eid holidays and emergency leave. 13

. Sick and maternity leave shall be compensated for during or at the end of training. 3. On call duty shall be an average of one every three to four nights (minimum of 7 calls per month, 4 hours per call). Fellows are expected to perform regular duty the day after call and ensure continuity of care for their patients. VII. EVALUATION A. In each year, performance will be monitored and assessed with a written report from the Consultant In Charge of each division, i.e. cardiac cath, echo, stress, etc. B. The candidate will be assessed by the regional supervisory committee at the end of each year with an exam which may include a written or clinical component or both. If the candidate passes the evaluation, then he/she will be promoted to the next level. If the candidate however fails the evaluation he/she will continue with the training program on the same level and will be allowed two attempts within the next year of training program. Should the candidate still fail, he/she will then be dismissed from the program. C. Final examination includes: A. Written examination 1. MCQ. Clinical data interpretation Candidates are required to pass the written examination before sitting for the clinical/oral exams. Candidates who fail the examination are allowed to resit for the exam as specified in the Council General Examinations by-laws. 14

B. Clinical examination may include any or all of the following. C. Oral. a. Long case. b. Short case. All exams are subject to the rules specified in the Council General Examinations by-laws. VIII. CERTIFICATION Upon completion of the required training and passing the final examination, the certificate of the subspecialty in cardiovascular diseases will be conferred upon the candidate. 15

V. Training Center Accreditation Requirements For a hospital to be accredited to offer Fellowship training program in Cardiology or to participate in such training, the following requirements must be fulfilled: 1. Cardiology training must take place only in medical institutions that are accredited by the Saudi Council.. Faculty - APPENDIX 1 Must include a minimum of five full time consultants for a program including Training Director. 3. Facilities and resources - The following are essential for the training program: a) Availability of adequate inpatients and ambulatory care facilities. b) Fully equipped and staffed procedure facilities for both diagnostic and therapeutic purposes in one cardiac cath lab. c) Support services such as diagnostic and interventional radiology unit, emergency services, pathology laboratory. d) A well stocked library with the facility of literature searches. e) Echocardiography, cath lab, holter, nuclear medicine, stress test, pacemaker. f) An inpatient subspecialty service with a minimum of four-bedded CCU and ten-bedded wards. g) Adequate number of paramedical personal 16

TRAINING REQUIREMENTS FOR THE ADULT CARDIOLOGY FELLOWSHIP TRAINING PROGRAM Cardiac Catheterization Echo CCU Wards, Consultation: on OPD, Stress, Nuclear & ECG, Holter Electrophysiology & Cardiac Pacing (EP & P) Elective Holiday Duration of training, month 1st Year nd Year 3rd Year 0 1 1 5 Cumulative duration of training, month 6 6 6 9 0 4 3 1 1 1 Minimal (total) No. of procedures performed (supervised) right heart cath 50 left heart cath 50 75 Central lines Swan Ganz Arterial lines Stress ECG = 00 Temporary pacemaker 0 cardioversion=6 ----- ----- Minimal (total) No. of procedures interpreted (monitored) 300 (including performed procedures) 300 (including the 75 performed procedures) (The performed procedures) ECG=4000 Holter=150 Nuclear scans=100 OPD=Minimum 1/ day/week Basic intra cardiac recordings during EPS=15 ----- ----- Procedures need to get exposed to (assist in performing) PCI Other inverventional procedures TEE Dobutamin stress Echo 3-D Echo Intraaortic balloon pump Adult cardiac surgical ICU Adult congenital heart disease (ACHD) Permanent pacemaker / ICD implantation Diagnostic EPS & ablation Echo Cath EP ACHD Research CT / MRI Others -----