CURRICULUM CARDIOVASCULAR DISEASE FELLOWSHIP PROGRAM

CURRICULUM CARDIOVASCULAR DISEASE FELLOWSHIP PROGRAM Department of Internal Medicine Cardiovascular Disease Fellowship Program 1301 West 18th Street Sioux Falls, SD 57105 Phone: 605-312-2253 Fax: 605-312-2222 Effective Date: March 2011 Last Revision Date: July 22, 2015 1

Sanford USD Medical Center Sioux Falls, South Dakota Program Director Adam Stys, MD Program Coordinator Darla Fjerstad 2

INTRODUCTION TO THE CARDIOVASCULAR DISEASE FELLOWSHIP PROGRAM The Cardiovascular Disease Fellowship Program at Sanford School of Medicine is designed to provide the cardiovascular disease fellows with comprehensive exposure to patients with a variety of cardiovascular conditions and teach them the evaluation and management of these disorders. The fellows will rotate and actively participate in a variety of clinical services located at Sanford USD Medical Center and the Royal C. Johnson Veterans Memorial Medical Center during their 36-month training period. The first 24 months are geared towards providing a solid learning experience in all areas in clinical cardiology and establishing a foundation for a research project(s) with protected research time every year. During the last 12 months of the program, the fellows will concentrate on a specific area(s) of cardiology in which they wish to gain additional expertise, such as interventional cardiology, nuclear cardiology, etc., as well as devote at least one extra month of time to complete a research project(s), with the goal of publication in a peer reviewed journal. The facility provides exposure to inpatient care, ambulatory care, cardiothoracic surgery, interventional cardiac and peripheral vascular laboratories, electrophysiology laboratories with exposure to all types of cardiac ablations, internal cardiac defibrillators and pacemakers as well as full service and state of the art non-invasive cardiovascular laboratories. The fellows, during their non-invasive rotations, will be taught comprehensively on cardiovascular topics, with inclusion of such entities as CT angiography, 3D echocardiography, and cardiac MRI. The Cardiovascular Disease Fellowship Program is going to be reevaluated on an on-going basis by the program faculty and the sponsoring institution, so that it can adapt to changes and advances in clinical cardiology and health care delivery that impact on fellows training. Our goal is to provide state of the art training in a very supportive academic environment. The focus is on maximizing the educational experience in a very fellow friendly environment. Obviously, since patient care comes first, the fellows are expected to fully participate in clinical duties (without which there is not a full educational experience), but the program structure ensures dedicated time for learning and research and provides for a very balanced rest/work schedule. 3

YEARLY SCHEDULE OVERVIEW ROTATIONS FIRST YEAR SECOND YEAR THIRD YEAR Clinical (CICU/consults) 6 months 2 months 2 months Non-invasive cardiac evaluations (Echo/CT/MRI/nuclear/stress testing) 2 months (1 month echo, 1 month nuclear) 3 months (2 month echo, 1 month nuclear) 2 months (1 month echo, 1 month nuclear) Cardiac catheterization laboratory 1 month 2 months 1 month Electrophysiology 0.5 month 1.5 months NA Research 1 month 1 month 1 month Vascular Imaging/Vascular Diseases Elective: Cardiothoracic Surgery, Pediatric Cardiology, Heart Transplant and Heart Failure, or any core rotation NA 0.5 months 0.5 months 1.5 months 2 months 5.5 months Time intervals are approximations and may vary slightly. Elective rotations include cardiovascular surgery, pediatric cardiology, or any of the above core rotations. Clinical rotations are at Sanford USD Medical Center, Sioux Falls, SD. Clinical rotations at the Sanford USD Medical Center consist of CICU and consults service (concurrently). The non-invasive cardiac evaluation rotation consists of concurrent training in echocardiography, cardiac stress testing, nuclear cardiology, cardiac CT, and cardiac MRI. The heart transplant and heart failure rotation is at the Mayo Clinic in Rochester. More details on the fellows rotations can be found in the USD Sanford School of Medicine Cardiovascular Disease Fellows Manual. 4

Cardiovascular Disease Fellowship Program and ACGME Requirements (March 1, 2015) *Performance of right & left heart caths, including coronary arteriography = 300 ACGME requires each fellow to participate in a minimum of 100 *Performance of stress ECG test = 200 ACGME requires 50 *Performance of echocardiography = 100 ACGME requires 75 *Interpretation of echocardiography = 600 ACGME requires 150 *Interpretation of electrocardiograms = 3500 ACGME requires 3500 *Performance of Direct Current Cardioversion = 20 ACGME requires 10 *Interpretation of nuclear cardiology (radionuclide studies to include SPECT myocardial perfusion imaging and ventriculograms) = 300 ACGME requires 100 *Observe the performance and interpretation of transesophageal echo studies = 100 ACGME does not indicate a number *Conscious sedation = Need to certify at Sanford Health ACGME does not indicate a number *Placement & management of temporary transvenous pacemakers = 10 ACGME does not indicate a number *Programming and follow-up surveillance of permanent pacemakers and ICDs = 50 all documented in New Innovations ACGME does not indicate a number *Holter Interpretation/Cardiac Event Recorder Interpretation = 20 *Cardiac MRI = 10 *Cardiac CT = 30 5

OVERVIEW OF TRAINING SITES AND ROTATIONS I Sanford USD Medical Center PATIENT POPULATION: Sanford USD Medical Center provides exposure to a diverse patient population, which includes male and female patients ranging in age from teenagers to the very elderly. The fellow will be exposed to examinations of patients with a wide range of cardiac abnormalities which include but are not limited to: Chronic coronary artery disease, acute coronary syndromes, valvular heart disease, arrhythmias, lipid disorders, hypertension/hypertensive heart disease, pericardial disease, cardiomyopathies, cardiac masses, pulmonary vascular/heart disease and pulmonary embolism, diseases of the great vessels/aorta, peripheral vascular disease, infections and inflammatory heart disease, cardiovascular rehabilitation, congestive heart failure, adult congenital heart disease, and cardiovascular trauma. Fellows will perform the following rotations at this site: Coronary Intensive Care Unit (CICU) Cardiology Consultation Non-Invasive Cardiology (echocardiography, nuclear cardiology, stress testing, cardiac CT, cardiac MRI) Cardiac Electrophysiology Cardiac Catheterization Laboratory Ambulatory Care Clinic Research Pediatric Cardiology Cardiothoracic Surgery Vascular Imaging/Vascular Diseases 6

II Royal C. Johnson Veterans Memorial Medical Center PATIENT POPULATION: Patient characteristics are primarily those of an older, predominantly male population. The fellow will be exposed to examinations of patients with a wide range of cardiac abnormalities which include but are not limited to: Chronic coronary artery disease, acute coronary syndromes, valvular heart disease, arrhythmias, lipid disorders, hypertension/hypertensive heart disease, pericardial disease, cardiomyopathies, cardiac masses, pulmonary vascular/heart disease and pulmonary embolism, diseases of the great vessels/aorta, peripheral vascular disease, infections and inflammatory heart disease, cardiovascular rehabilitation, congestive heart failure, and adult congenital heart disease. Cardiovascular fellows while on call will provide coverage for the VA with their clinical faculty back-up. The clinical experience at the VA, while on-call (call from home) will include cardiology consultations, EKG interpretation and ECHO interpretation. EVALUATIONS: The fellow will be evaluated by faculty at the end of each rotation using an electronic evaluation form that assesses performance in six competency areas including patient care, medical knowledge, interpersonal and communication skills, professionalism, systemsbased practice and practice-based learning. In addition, each rotation has rotation-specific questions that will be used to assess the fellow s performance. A mandatory comment section is also included. Verbal feedback will be given by faculty to the fellow on an ongoing basis during the entire rotation with suggestions for improvement. All evaluation forms will be reviewed by the Program Director with the fellow on a quarterly basis. The fellow will evaluate the faculty and the rotation itself using the electronic NEW INNVOATIONS evaluation forms (system used by the Department of Internal Medicine of Sanford School of Medicine). A 360 degree evaluation will be performed. 7

Sanford USD Medical Center Rotations CORONARY INTENSIVE CARE UNIT Educational Goals: 1. Acquire knowledge of the etiology, pathophysiology, clinical features, diagnostic testing, prognosis, treatment and prevention of cardiac emergencies. 2. Acquire knowledge of cardiac diagnostic procedures and their appropriate application in acutely ill cardiac patients. 3. Learn appropriate cooperative relationships with other specialty consultants and primary care physicians in severely ill cardiac patients. Educational Objectives: 1. The fellow will evaluate and manage critically ill and acutely ill cardiac patients. 2. The fellow will become proficient in cardiopulmonary resuscitation and advanced cardiac life support, elective cardioversion, bedside right heart catheterization, insertion and management of temporary pacemakers (including transvenous), emergency pericardiocentesis, interpretation of electrocardiograms, echocardiograms and chest X-rays in the critical care setting. 3. The fellow will manage patients following invasive cardiac procedures. 4. The fellow will evaluate and manage critically ill patients admitted with advanced left and right sided congestive heart failure, including those with implanted left ventricular assist devices (LVAD). 5. The fellow will care for terminally ill cardiac patients. LEARNING OBJECTIVES - PATIENT CARE 1. Perform adequate history and physical examination of critically ill patients. 2. Select and interpret relevant laboratory and procedural data. 3. Formulate informed diagnostic and appropriate treatment decisions for critically ill cardiac patients. a. Teaching methods: bedside rounds, attending rounds. b. Evaluation methods: attending evaluations, 360 degree evaluations, review of case/procedure logs LEARNING OBJECTIVES - MEDICAL KNOWLEDGE 1. Demonstrate an analytical approach to cardiovascular diseases. 2. Demonstrate and apply knowledge of basic and clinical science knowledge in the diagnosis and treatment of patients with acute coronary syndromes, severe arrhythmias, congestive heart failure, and valvular heart disease. 3. Demonstrate evidence based decision making and commitment to lifelong learning. a. Teaching methods: attending rounds, self study, clinical conferences. b. Evaluation methods: attending evaluations, in-service examination, ECG self assessment modules, 360 degree evaluations. 8

LEARNING OBJECTIVES PRACTICE BASED LEARNING AND IMPROVEMENT 1. Demonstrate the ability to analyze one s own practice experience and recognize limits in one s knowledge and expertise. 2. Assimilate scientific evidence into cardiovascular disease practice. 3. Regularly access on-line information (ACC, AHA, PubMed, Cardiosource, tctmd.com, Medscape, etc). 4. Set learning and improvement goals and identify and perform learning activities. 5. Participate in the education of residents, students and other health care professionals on the CICU service. a. Teaching methods: literature reviews, cardiac websites, journal club, clinical and research conferences. b. Evaluation methods: attending evaluations, fellow s portfolio, conference evaluations, 360 degree evaluations, chart audits. LEARNING OBJECTIVES - INTERPERSONAL AND COMMUNICATION SKILLS 1. Demonstrate effective communication with patients, families, and peers across a broad range of socioeconomic and cultural backgrounds. 2. Communicate effectively with physicians and other health professionals. 3. Demonstrate the ability to counsel patients, families, and peers regarding medical treatment plan. 4. Act in a consultative role to other physicians and health care professionals. a. Teaching methods: bedside rounds, attending rounds, interdisciplinary meetings, conferences. b. Evaluation methods: attending evaluations, 360 degree evaluations, patient satisfaction surveys. LEARNING OBJECTIVES - PROFESSIONALISM 1. Demonstrate responsible, compassionate, respectful treatment of patients, families, staff, and colleagues. 2. Place patient safety and patient medical needs above self-interest. 3. Demonstrate courteous, ethical, and helpful behavior to patients, families, and all members of health care team. 4. Provide prompt and thorough evaluation and treatment when called upon. a. Teaching methods: bedside rounds, attending rounds, interdisciplinary meetings. b. Evaluation methods: attending evaluations, 360 degree evaluations, patient satisfaction surveys, fellow portfolio. LEARNING OBJECTIVES - SYSTEMS BASED PRACTICE 1. Demonstrate awareness of the role of a member of the health care team. 2. Utilize hospital resources effectively. 3. Coordinate patient care with the health care system relevant to cardiovascular pathology. 4. Practice cost-effective medicine. 5. Demonstrate insight as to need to call upon others when needed. 6. Participate in identifying potential system errors and implementing potential systems solutions. a. Teaching methods: interdisciplinary meetings, conferences, feedback sessions with referring physicians, 360 degree evaluations, fellow portfolio. 9

b. Evaluation methods: attending evaluations, 360 degree evaluations, fellow portfolio. Educational Methods: The principal teaching method consists of evaluation of the patient, via history and physical examination and review of studies, independently and then in consultation with the attending cardiologist. The fellow will be supervised and taught by attending cardiologists during daily morning rounds, during procedures, and on a 24 hour basis on all aspects of patient care. The fellow will perform oral and written patient presentations, including a cogent, organized and directed history and physical examination on all patients admitted to the CICU on the teaching service (dedicated eight CICU beds). The fellow will conduct work rounds with the medical house staff on the cardiology intensive care unit rotation. The fellow will interact with consulting physicians and patient family members in a humane, considerate and courteous manner. The fellow will perform right heart catheterization with interpretation of hemodynamic data. The fellow will insert and test temporary pacemaker wires. The fellow will conduct daily review of diagnostic studies including but not exclusive of EKGs, echocardiograms, and cardiac catheterization/angiography data. The fellow will formulate an evidence based diagnostic and therapeutic plan for each patient admitted to the CICU. The fellow will function as an academic leader and role model for house staff, encouraging them to read and review pertinent literature as it relates to the patients on CICU service. The fellow will attend didactic sessions outlined in the monthly cardiology schedule. Educational Content: Mix of Diseases: At Sanford USD Medical Center, the fellow will gain exposure to diseases such as: acute coronary syndromes, congestive heart failure, including cardiogenic pulmonary edema, cardiogenic shock, cardiac arrhythmias, valvular heart disease, hypertensive heart disease, cardiomyopathies, pericardial disease, diseases of the great vessels, pulmonary vascular diseases and pulmonary hypertension, and adult congenital heart disease. Patient Characteristics: Male and female patients that are eighteen years of age and older from a wide socioeconomic and ethnic background. 10

Procedure Skills: Proficiency in cardiopulmonary resuscitation and Advanced Cardiac Life Support, elective and emergent cardioversion, defibrillation, bedside right heart catheterization, insertion and management of temporary pacemakers, bedside echocardiograms (including transesophageal), insertion and management of intra-aortic balloon pumps. Educational Materials: 1. Bonow, Mann, Zipes, Libby, Braunwald s Heart Disease: A Textbook of Cardiovascular Medicine, 8 th edition, 2011 2. Valentin Fuster, Hurst s The Heart, 13 th edition, 2010 3. Mayo Clinic Cardiology Review, 2008 4. Marriot, Practical Electrocardiography, 11th edition, 2007 5. Elkayam, Gleicher, Cardiac Problems in Pregnancy, 3 rd edition, 1998 6. Bojar, Perioperative Cardiac Care, 2008 7. Garcia, Congestive Heart Failure, 2010 8. Perloff: Congenital Heart Disease in Adults, 2008 9. Mayo Clinic Cardiology, 3 rd ed. 10. Greenberg: Management of Heart failure, 2010 11. Cho: Cardiology Intensive Board Review Questions, 2008 12. ACC EKG-SAP 4 13. ACC-SAP 7 14. Journals: JACC, Circulation, American Heart Journal, New England Journal of Medicine 15. Online Resources: Medline, UptoDate, PubMed, MD Consult, ACC/AHA Guidelines Evaluation: Evaluation of fellows: The fellow will be evaluated by faculty at the end of each rotation using an evaluation form that assesses performance in six competency areas including patient care, medical knowledge, interpersonal and communication skills, professionalism, systems based practice and practice based learning. Feedback will be given to the fellow on an ongoing basis during the entire rotation. At the end of the rotation, a written evaluation will be performed and communicated to the fellow. 360 degree evaluations will be performed. Strengths and limitations: Sanford USD Medical Center is a large university medical center that serves as a tertiary care hospital for multiple medical facilities within a 200 mile radius. The Center serves a large multi-ethnic population with a broad spectrum of cardiovascular diseases and covers parts of four states (South Dakota, Minnesota, Nebraska, and Iowa). State of the art treatment facilities are available in the CICU. Heart transplantation is not performed at Sanford USD Medical Center; however the fellows complete a two-week rotation at Mayo Clinic in Rochester to expand their experience in evaluation and management of patients for cardiac transplantation or mechanical assist devices. 11

Teaching Faculty: Richard Clark, MD Orvar Jonsson, MD Marian Petrasko, MD, PhD Scott Pham, MD Christopher Stanton, MD Kelly Steffen, DO Adam Stys, MD Maria Stys, MD Tomasz Stys, MD 12

CARDIOLOGY CONSULTATION Introduction: This rotation provides exposure to a wide variety of clinical disorders in cardiology. The goal of this rotation is to expose the fellow to cardiology problems encountered in a tertiary care hospital, which include complex cardiology cases that arise on the medical service, as well as exposure to the cardiology problems that occur in patients with surgical, gynecologic, and psychiatric illnesses, and in pregnancy. Consultative services are provided for any clinical service at Sanford USD Medical Center, with the exception of pediatrics. The fellow has primary responsibility for all patients referred to the service, under the supervision of the faculty member dedicated to this rotation. It is expected that the fellow s skills will progress over time and during subsequent rotations on this service. Educational Goals: 1. Acquire knowledge of the etiology, pathophysiology, clinical features, diagnostic testing, prognosis, treatment and prevention of cardiac complications in patients admitted with non-cardiac illness. 2. Understand the impact of existing cardiac disorders on the medically and surgically ill patients and their management. 3. Acquire knowledge of cardiac diagnostic procedures and their appropriate and evidence based use in cardiac patients. 4. Enhance the internal medicine knowledge base especially as it related to cardiovascular disorders and the interplay of other medical problems with the cardiovascular disease being treated. 5. Maintain the highest level of professionalism, ethics and empathy with patients and families, by effective communication with the patient, their family, and other health care providers. Educational Objectives: 1. The fellow will perform a comprehensive history and physical examination on patients referred with potential cardiovascular complaints. 2. The fellow will discuss differential diagnoses, plan appropriate diagnostic testing and make evidence based therapeutic decisions based on all available clinical data. Written or electronic documentation of the examination is essential. The fellow will ensure timely and effective communication with any consulting physician. 3. The fellow will perform preoperative cardiac risk assessment and advise appropriate testing and peri-operative management of patients undergoing non-cardiac surgery. 4. The fellow will manage cardiac illnesses in acutely ill medical, surgical, and obstetric patients. 13

LEARNING OBJECTIVES - PATIENT CARE 1. Perform adequate history and physical examination of cardiac patients admitted to medical and surgical services. 2. Select and interpret relevant laboratory and procedural data 3. Formulate informed diagnoses and appropriate treatment decisions for cardiac patients seen on medical and surgical services. a. Teaching methods: bedside rounds, attending rounds. b. Evaluation methods: attending evaluations, 360 degree evaluations, review of case/procedure logs. LEARNING OBJECTIVES - MEDICAL KNOWLEDGE 1. Demonstrate an analytical approach to cardiovascular diseases. 2. Demonstrate and apply clinical science knowledge in the diagnosis and treatment of patients with acute coronary syndromes, arrhythmias, congestive heart failure, and valvular heart disease admitted to the medical and surgical services. 3. Demonstrate evidence based decision making and commitment to lifelong learning. a. Teaching methods: attending rounds, self study, clinical conferences. b. Evaluation methods: attending evaluations, in-service examinations, 360 degree evaluations. LEARNING OBJECTIVES PRACTICE BASED LEARNING AND IMPROVEMENT 1. Demonstrate the ability to analyze one s own practice experience and recognize limits in one s knowledge and expertise. 2. Assimilate scientific evidence into cardiovascular disease practice. 3. Regularly access on-line information (ACC, PubMed, Cardiosource, etc). 4. Set learning and improvement goals and identify and perform learning activities. 5. Participate in the education of other physicians, residents, students and other health professionals on referring services. a. Teaching methods: literature reviews, cardiac websites, journal club, clinical and research conferences. b. Evaluation methods: attending evaluations, fellow portfolio, conference evaluations, 360 degree evaluations, chart audits. LEARNING OBJECTIVES - INTERPERSONAL AND COMMUNICATION SKILLS 1. Demonstrate effective communication with patients, families, and peers across a broad range of socioeconomic and cultural backgrounds. 2. Communicate effectively with physicians and other health professionals to exchange information effectively. 3. Demonstrate the ability to counsel patients, families, and peers regarding medical treatment plans. 4. Act in a consultative role to other physicians and health care professionals. a. Teaching methods: bedside rounds, attending rounds, interdisciplinary meetings, conferences, feedback sessions with referring provider. b. Evaluation methods: attending evaluations, 360 degree evaluations, patient satisfaction surveys. LEARNING OBJECTIVES - PROFESSIONALISM 1. Demonstrate responsible, compassionate, respectful treatment of patients, families, and colleagues. 14

2. Place patient safety and patient medical needs above self-interest. 3. Demonstrate courteous, ethical, and helpful behavior to patients, families, and all members of the health care team. 4. Provide prompt and thorough evaluation and treatment. a. Teaching methods: bedside rounds, attending rounds, interdisciplinary meetings. b. Evaluation methods: attending evaluations, 360 degree evaluations, patient satisfaction surveys, feedback sessions with referring providers, fellow portfolio. LEARNING OBJECTIVES - SYSTEMS BASED PRACTICE 1. Demonstrate awareness of the role of a member of the health care team. 2. Utilize hospital resources effectively. 3. Coordinate patient care with the health care system relevant to cardiovascular pathology. 4. Practice cost-effective medicine. 5. Demonstrate insight as to the need to call upon others when needed. 6. Participate in identifying potential system errors and implementing potential systems solutions. a. Teaching methods: interdisciplinary meetings, conferences, and feedback sessions with referring physicians. b. Evaluation methods: attending evaluations, 360 degree evaluations, fellow portfolio. Types of Clinical Encounters: Sanford USD Medical Center is a large university referral center serving a large multiethnic population with a broad spectrum of cardiovascular diseases. Cardiology consultations from all medical and surgical services and emergency room evaluations will generally be seen first by the fellow and then discussed and reviewed with the faculty attending on the same day. Mix of Diseases: At Sanford USD Medical Center, the fellow will gain exposure to a diverse array of diseases which include but are not limited to: acute coronary syndromes cardiogenic pulmonary edema cardiogenic shock cardiac arrhythmias valvular heart disease hypertensive heart disease cardiomyopathies and heart failure pericardial disease diseases of the great vessels pulmonary vascular diseases and pulmonary hypertension adults with congenital heart disease pregnant patients with cardiovascular disease care of the post-op cardiac surgery patient 15

Patient Characteristics: Male and female patients that are eighteen years of age and older from diverse socioeconomic and ethnic backgrounds admitted with non-cardiac illnesses to medical, surgical, and obstetric floors. Specific Fellow Expectations: The fellow will write or dictate a full consultation note for all new consults. A follow-up note will be written each day until the decision to sign off on the case is made by the fellow and attending cardiologist with agreement from the referring physician. All patients will be formally followed throughout their hospitalization, so that appropriate management of cardiac problems can be performed and adequate outpatient follow-up can be arranged. The fellow will ensure prompt, courteous and informative communication with any referring or consulting physicians regarding recommendations and their rationale. One fellow will be dedicated to this rotation at all times. If a fellow cannot be available during his/her rotation, a replacement will be provided. The fellow will maintain open communication with the consulting attending cardiologist. The fellow will be available for new consultations in the afternoon during weekly continuity clinic. The fellow will assist the attending cardiologist in arranging clinic follow-up for all patients seen on the cardiology consultation service. The fellow will see and follow all service patients who have had cardiac surgery. Close association with and participation in a cardiothoracic surgical program is an essential component of the cardiovascular training program. This includes active participation in the pre- and post-operative management of patients with cardiovascular disease (this is a COCATS requirement). The fellow will see all consults on the day they are received. If there is an arrhythmia issue, the consult fellow will discuss the case with the consult attending, who will then decide the need for a formal EP consult. The fellow will provide teaching and guidance for residents and students. The fellow will review daily the resident progress notes for accuracy and reassessment of new information as it becomes available. The fellow will personally review chest x-rays, ECG s, telemetry strips and trends, coronary angiograms, echocardiograms, myocardial perfusion scans, laboratory and other relevant tests. Level of Fellow Supervision by Faculty: Independent analysis of patient information by the fellow is encouraged. All consultations are reviewed with the fellow by the attending physician. All major clinical decisions are made together by the faculty attending and fellow. It is expected that the fellow s skills will progress over time and during subsequent rotations on this service. As a third year fellow, it is expected that the fellow be able to effectively function as a cardiovascular consultant. 16

Educational Methods: The principal teaching method consists of evaluation of the patient via history and physical examination and review of studies, independently and then in consultation with the attending cardiologist. 1. The fellow will be supervised by the attending cardiologist during daily rounds, procedures and on all aspects of patient care. 2. The fellow will perform oral and written/dictated patient assessment and plans. 3. The fellow will interact with referring and other consulting physicians in a helpful, informative, and courteous manner. 4. The fellow will supervise medical residents and medical students rotating on the service 5. The fellow will review daily diagnostic studies including, but not limited, to EKGs, x-rays, echocardiograms, stress tests, nuclear cardiac perfusion studies and cardiac catheterization data. 6. The fellow will formulate an evidence based diagnostic and therapeutic plan for each patient. 7. The fellow will present cases for clinical conference. The general cardiology consult fellow may be asked to present cases chosen by his/her attending cardiologist for its educational value. The fellow will be expected to present a short review of the pertinent literature with the presentation. 8. The fellow will attend didactic sessions outlined in the monthly cardiology schedule. Procedure Skills: No procedures are performed as part of this rotation; however, the fellow performs various cardiac procedures during on-call hours. Rotating Residents and Medical Students When a medical resident or medical student is assigned to this service, they will assist the fellow and will be primarily responsible for a subgroup of patients on the service. The fellow will supervise them in this capacity. The attending cardiologist will make rounds daily with all members of the consult team (fellow, medical residents, and students). Thus, during this rotation, the cardiology fellow is expected to acquire skills related to the clinical management of complex cardiology problems, as well as to develop supervisory, leadership, and teaching skills. General Structure of the Day: The fellow will be available for the consult service from Monday through Friday, from 8:00 am to 5:00 pm. After 5 pm, all new consult calls will go to the fellow or the attending on call. The fellow will attend morning conferences as usual. The fellow will see all follow-up patients preferably in the morning, and a note will be documented in the chart. 17

The fellow will attend formal rounds that will take place at least once per day with all members of the team. Sign Out: The general consult and on call fellows will be expected to add patients to a general consult list of the teaching service. This list should be available to the consult fellow and attending(s) for a specified period of time. Verbal sign out is encouraged whenever possible. The consult fellow should sign out to the on call fellow for the weekend. Evaluation of Fellows: ACGME core competencies are evaluated monthly by the attending faculty. The fellow will be evaluated by faculty at the end of each rotation using an evaluation form that assesses performance in six competency areas including patient care, medical knowledge, interpersonal and communication skills, professionalism, systems based practice and practice based learning. Fundamental to this training is the provision of the best possible care for each individual patient in a compassionate manner. Feedback will be given to the fellow on an ongoing basis during the rotation by faculty. At the end of the rotation, an evaluation (electronic, using E*Value) will be performed and communicated to the fellow. Teaching Faculty: Only full time teaching faculty will participate in the cardiology inpatient consultation service. Richard Clark, MD Orvar Jonsson, MD Marian Petrasko, MD, PhD Scott Pham, MD Christopher Stanton, MD Kelly Steffen, DO Adam Stys, MD Maria Stys, MD Tomasz Stys, MD Specific Consult Attending Expectations: Communicate goals, objectives, expectations, and define the teaching structure to all members of the team including fellows, residents, and students. Conduct daily rounds in which each patient is personally interviewed and examined. Review the clinical data and formulate a plan with the house staff for the management of each patient. Communicate with the attending physician directly whenever possible and especially after the initial consultation Be available to advise the fellows and residents on issues related to the care of all patients on the cardiology consult service (Mon-Fri from 8am - 5pm). In cases in which the attending anticipates being unavailable for any period of time, arrangements will be made for an alternate attending to be available. Be available after hours and on weekends for such support. 18

Educate all members of the team in the form of formal teaching rounds and involve them in clinical discussions. Demonstrate leadership and function as a role model for all members of the team. Provide effective feedback and evaluation of fellows, residents and medical students on the rotation. Communicate regularly with the primary team taking care of the patient. Support and encourage scholarly activities and research projects. Discuss with each fellow individually at the end of the rotation strengths, weaknesses and suggestions for improvement. Be responsive to any special difficulties that fellows or residents may be experiencing and make an effort to relieve such difficulties. Provide a list of texts or key articles for reading during the rotation (references for further reading in addition to the educational materials). Educational Materials: 1. Bonow, Mann, Zipes, Libby, Braunwald s Heart Disease: A Textbook of Cardiovascular Medicine, 8 th edition, 2011 2. Valentin Fuster, Hurst s The Heart, 13 th edition, 2010 3. Marriot, Practical Electrocardiography, 11th edition, 2007 4. Elkayam, Gleicher, Cardiac Problems in Pregnancy, 3 rd edition, 1998 5. Garcia, Congestive Heart Failure, 2010 6. Perloff: Congenital Heart Disease in Adults, 2008 7. Mayo Clinic Cardiology, 3 rd ed. 8. Greenberg: Management of Heart failure, 2010 9. Cho: Cardiology Intensive Board Review Questions, 2008 10. Constant, Essentials of Bedside Cardiology, 2 nd edition, 2002 11. Bojar: Perioperative Cardiac Care, 2008 12. ACC EKG-SAP 4 13. ACC-SAP 7 14. Journals: JACC, Circulation, American Heart Journal, New England Journal of Medicine 15. Online Resources: Medline, UptoDate, PubMed, MD Consult, ACC/AHA Guidelines-Preoperative Risk Assessment of Non-cardiac surgery; ACC/AHA Guidelines-Valvular Heart Disease. 19

NON-INVASIVE CARDIOLOGY: ECHOCARDIOGRAPHY Educational Goals: 1. Evaluate patients presenting for noninvasive cardiology testing and perform the most appropriate test, to optimize patient care while ensuring their safety. 2. Perform and interpret transthoracic (TTE) and transesophageal (TEE) echocardiograms, including 3D echocardiography, treadmill and pharmacologic stress tests with and without echocardiographic imaging. 3. Learn the appropriate use of echocardiographic contrast agents. 4. Understand the indications, contraindications, strengths and limitations of TEE imaging. 5. Understand the risks, complications, and treatment thereof of conscious sedation for TEE. Educational Objectives: 1. The fellow will understand the fundamental principles, physics, performance, interpretation, strengths and limitations of two-dimensional echocardiographic (including use of intravenous echocardiographic contrast), Doppler, color Doppler, tissue Doppler, and three-dimensional echocardiographic methods. 2. The fellow will understand the principles, indications, contraindications, performance and interpretation of exercise and pharmacologic stress tests with and without echocardiographic imaging. 3. The fellow will acquire knowledge regarding normal and abnormal exercise physiology and pathophysiology. 4. The fellow will evaluate and select patients referred for TEE while ensuring the safe performance of the procedure. 5. The fellow will assess airway risk and the appropriate administration of conscious sedation. 6. The fellow will assess the need for anesthesiology back up in high risk patients. 7. The fellow will perform safe and comfortable esophageal intubations. 8. The fellow will perform and interpret TEE. 9. The fellow will perform intra-operative TEE. 10. The fellow will perform real time evaluation of TEE and the ability to provide assistance to the cardiac surgeon in therapeutic decision making in cardiac surgical patients (intra operative examinations). LEARNING OBJECTIVES - PATIENT CARE 1. Perform and interpret transthoracic and transesophageal echocardiograms. 2. Select and evaluate patients for contrast echocardiography. 3. Perform and evaluate patients presenting for stress echocardiography. 4. Perform and interpret TEE (including intra-operative). 5. Select and evaluate patients for TEE. 6. Formulate an informed diagnosis and appropriate treatment based on echocardiogram or stress echocardiogram findings. a. Teaching methods: procedure room, attending rounds, reading sessions. b. Evaluation methods: attending evaluations, 360 degree evaluations, review of case/procedure logs. 20

LEARNING OBJECTIVES - MEDICAL KNOWLEDGE 1. Demonstrate basic knowledge of the physics and principals of echocardiography, including Doppler echocardiography, color Doppler, tissue Doppler, and TEE. 2. Demonstrate knowledge of the principals and physiology of stress echocardiography, both exercise and pharmacologic. 3. Demonstrate evidence based decision making and commitment to lifelong learning. a. Teaching methods: attending rounds/reading sessions, self study (i.e. ECHO SAP), conferences. b. Evaluation methods: attending evaluations, in-service examinations, 360 degree evaluations. LEARNING OBJECTIVES PRACTICE BASED LEARNING AND IMPROVEMENT 1. Demonstrate the ability to analyze one s own practice experience and recognize the limits of one s knowledge and expertise. 2. Assimilate scientific evidence into echocardiography and stress echocardiography. 3. Regularly access on-line information (ACC, PubMed, Cardiosource, etc). 4. Set learning and improvement goals and identify and perform learning activities. 5. Participate in the education of residents, nurses and echo technologists in the echocardiography laboratory. a. Teaching methods: literature reviews, cardiac websites, journal club, and clinical, research, and conferences. b. Evaluation methods: attending evaluations, fellow portfolio, conference evaluations, 360 degree evaluations, chart audits. LEARNING OBJECTIVES - INTERPERSONAL AND COMMUNICATION SKILLS 1. Demonstrate effective communication with patients, families, and peers across a broad range of socioeconomic and cultural background. 2. Communicate effectively with physicians and other health professionals to exchange information effectively regarding echocardiography and stress echocardiography interpretations. 3. Demonstrate the ability to counsel patients, families, and peers regarding medical treatment plan. 4. Act in a consultative role to other physicians and health care professionals. a. Teaching methods: attending rounds, reading sessions, conferences. b. Evaluation methods: attending evaluations, 360 degree evaluations. LEARNING OBJECTIVES - PROFESSIONALISM 1. Demonstrate responsible, compassionate, respectful treatment of patients, families, and colleagues. 2. Place patient safety and patient medical needs above self-interest. 3. Demonstrate courteous, ethical, and helpful behavior to patients, families, and all members of health care team. 4. Provide prompt and thorough evaluation and interpretation of echocardiogram and stress echocardiogram findings. a. Teaching methods: attending rounds, reading sessions, interdisciplinary meetings. 21

b. Evaluation methods: attending evaluations, 360 degree evaluations, fellow portfolio. LEARNING OBJECTIVES - SYSTEMS BASED PRACTICE 1. Demonstrate awareness of the role of a member of the health care team. 2. Utilize hospital resources effectively. 3. Coordinate patient care with the health care system relevant to echocardiographic or stress findings. 4. Practice cost-effective medicine. 5. Demonstrate insight as to the need to call upon others when needed. 6. Participate in identifying potential system errors and implementing potential systems solutions. a. Teaching methods: interdisciplinary meetings, conferences, and feedback sessions with referring physicians. b. Evaluation methods: attending evaluations, 360 degree evaluations, fellow portfolio. Educational Methods: 1. The fellow will perform and record transthoracic echocardiograms under the supervision of a trained ultrasound technician and/or attending physician. All studies will be reviewed by the faculty cardiology attending with constructive feedback to the fellows. The fellow will document the number of echocardiograms performed by identifying themselves as the performing sonographer in the Sanford USD Medical Center digital echo system (Xcelera). 2. The fellow will perform history and physical examinations and review all data, as it relates to TEE and conscious sedation, with the attending cardiologist. 3. The fellow will perform TEE utilizing the methods of conscious sedation, under the supervision of the attending cardiologist. 4. The fellow will perform intra-operative TEE on patients undergoing cardiac surgery under the supervision of an attending cardiologist. 5. The fellow will review TEE studies performed each day with the cardiology attending. 6. The fellow will supervise the performance of treadmill and pharmacologic stress echocardiographic studies (approximately 10-15 per week). 7. The fellow will review at least 10-20 echocardiographic studies performed by technicians daily with a cardiology attending. 8. The fellow will review EKGs on a daily basis and may be asked to teach basic EKG analysis to medical students and residents. 9. The fellow will participate in didactic lectures presented as part of core curriculum conference series. Clinical conferences will routinely involve review and correlation of the ultrasound studies with clinical history and examinations, nuclear cardiology, and invasive studies (hemodynamics and angiography). 22

Educational Content: Mix of Diseases: The fellow will be exposed to examinations of patients with a wide range of cardiac abnormalities among which will include but not be limited to: valvular heart disease (including evaluation of prosthetic heart valves), ischemic heart disease, pericardial disease, cardiomyopathies, cardiac masses, hypertensive heart disease, pulmonary vascular disease, pulmonary hypertension, diseases of the great vessels/aorta (including aortic dissection), cardiac sources of emboli, congestive heart failure, congenital heart disease, and diagnosis and assessment of response to therapy or complications of endocarditis. Patient Characteristics: Male and female patients that are eighteen years of age and older from a wide socioeconomic and ethnic background. Procedure Skills: As listed above: TTE (including echo contrast studies), TEE, administration of conscious sedation, and stress testing. Evaluation: At the conclusion of the echocardiography rotation, the attending cardiologist will review each fellow in reference to their strengths and weaknesses, fund of knowledge, and technical skills. The fellow will be evaluated using a standardized evaluation form that assesses performance in six competency areas including patient care, medical knowledge, interpersonal and communication skills, professionalism, systems based practice and practice based learning. Additionally, evaluators must answer rotation specific questions for each fellow. Feedback will be given to the fellow on an ongoing basis during the entire rotation. At the end of the rotation, a written evaluation will be performed and communicated to the fellow. Educational Materials: 1. Otto, Textbook of Clinical Echocardiography, 2009 2. Armstrong, Ryan, Feigenbaum s Echocardiography, 7 th edition 2009 3. Perrino, Reeves: Transesophageal Echocardiography, 2007 4. Savage: Perioperative TEE, 2010 5. Grime ID. Robb N. Conscious sedation. The role of Monitoring., SAAD Digest. 13(2):7-16, 1996 6. ACC ECHO-SAP 6 7. Journals: JASE, Journal of the American Society of Nuclear Cardiology, JACC, NEJM 8. Online Resources: Medline, UptoDate, PubMed, MD Consult, ACC/AHA Guidelines, ASE/ASNC guidelines and websites 23

Strengths and Limitations: 1. A large volume non-invasive cardiac imaging laboratory performing approximately 12,000 echocardiograms and approximately 500 transesophageal echocardiographic procedures per year. This offers extensive experience in the performance and interpretations of these tests. 2. The laboratory contains state of the art digital echo equipment for both acquisition as well as on and off line analysis. 3. Intra-operative TEE studies are supported by the active cardiac surgery program. 4. Pediatric echocardiography, three-dimensional echocardiography, and tissue Doppler dyssynchrony evaluation exposure is available. Teaching Faculty: Richard Clark, MD Orvar Jonsson, MD Marian Petrasko, MD, PhD Scott Pham, MD Christopher Stanton, MD Kelly Steffen, DO Adam Stys, MD Maria Stys, MD Tomasz Stys, MD 24

NONINVASIVE CARDIOLOGY: EXERCISE TESTING AND NUCLEAR CARDIOLOGY Educational Goals: 1. Understand the principles, indications, contraindications, limitations, performance and interpretation of exercise and pharmacologic nuclear stress tests and cardiac blood pool imaging studies. 2. Understand the importance of nuclear cardiac imaging in diagnosis and prognosis of various cardiac disorders. Educational Objectives: 1. The fellow will clinically evaluate patients presenting for noninvasive cardiology testing, and perform the most appropriate test, to optimize patient care while ensuring their safety. 2. The fellow will perform and monitor all modalities of nuclear cardiac imaging, including choice of exercise protocols, method of skin preparation and electrode application, blood pressure measurements and monitoring of the patient for adverse signs or symptoms. 3. The fellow will acquire knowledge of normal and abnormal exercise physiology and pathophysiology. 4. The fellow will interpret treadmill and pharmacologic nuclear stress tests and MUGA scans. 5. The fellow will understand the principles and practice of radiation safety. 6. The fellow will interpret nuclear cardiac imaging studies and recognition of artifacts seen in nuclear imaging. 7. The fellow will evaluate the results of nuclear imaging and the role in clinical decision making. LEARNING OBJECTIVES -PATIENT CARE 1. Perform and interpret all forms of exercise and pharmacologic stress testing. 2. Select and evaluate patients for stress and pharmacologic stress testing. 3. Evaluate patients presenting for exercise stress or pharmacologic nuclear stress testing. 4. Formulate informed diagnosis and appropriate treatment based on stress test findings. a. Teaching methods: attending rounds, reading sessions. b. Evaluation methods: attending evaluations, 360 degree evaluations, review of case/procedure logs. LEARNING OBJECTIVES - MEDICAL KNOWLEDGE 1. Demonstrate a basic knowledge of the physics and principals of nuclear perfusion imaging and cardiac gated blood pool studies. 2. Demonstrate knowledge of the principals and physiology of stress testing, both exercise and pharmacologic. 3. Demonstrate evidence based decision making and commitment to lifelong learning. a. Teaching methods: attending rounds, reading sessions, self- study, conferences. 25

b. Evaluation methods: attending evaluations, in-service examinations, 360 degree evaluations. LEARNING OBJECTIVES PRACTICE BASED LEARNING AND IMPROVEMENT 1. Demonstrate the ability to analyze one s own practice experience and recognize limits in one s knowledge and expertise. 2. Assimilate scientific evidence regarding nuclear cardiology and exercise/pharmacologic stress physiology. 3. Regularly access on-line information (ACC, PubMed, Cardiosource, etc). 4. Set learning and improvement goals and identify and perform learning activities. 5. Participate in the education of residents, nurses and nuclear technologists in nuclear cardiology laboratory. a. Teaching methods: literature reviews, cardiology websites, journal club, clinical, research, and noninvasive conferences. b. Evaluation methods: attending evaluations, conference evaluations, 360 degree evaluations, chart audits. LEARNING OBJECTIVES - INTERPERSONAL AND COMMUNICATION SKILLS 1. Demonstrate effective communication with patients, families, and peers across a broad range of socioeconomic and cultural backgrounds. 2. Communicate effectively with physicians and other health professionals to exchange information effectively regarding stress testing results and prognosis. 3. Demonstrate the ability to counsel patients, families, and peers regarding medical treatment plan. 4. Act in a consultative role to other physicians and health care professionals. a. Teaching methods: attending rounds, reading sessions, conferences b. Evaluation methods: attending evaluations LEARNING OBJECTIVES - PROFESSIONALISM 1. Demonstrate responsible, compassionate, respectful treatment of patients, families, and colleagues. 2. Place patient safety and medical needs above self-interest. 3. Demonstrate courteous, ethical, and helpful behavior to patients, families, and all members of health care team. 4. Provide prompt and thorough evaluation and interpretation of stress test or gated blood pool imaging findings. a. Teaching methods: attending rounds/reading sessions, interdisciplinary meetings. b. Evaluation methods: attending evaluations, 360 degree evaluations, fellow portfolio. LEARNING OBJECTIVES - SYSTEMS BASED PRACTICE 1. Demonstrate awareness of the role of a member of the health care team. 2. Utilize hospital resources effectively. 3. Coordinate patient care with the health care system relevant to gated blood pool or stress findings. 4. Practice cost-effective medicine. 5. Demonstrate insight as to the need to call upon others when needed. 6. Participate in identifying potential system errors and implementing potential systems solutions. 26