Greenville Hospital System Vascular Medicine Fellowship Program CURRICULUM

Greenville Hospital System Vascular Medicine Fellowship Program CURRICULUM Fellows completing the peripheral vascular medicine fellowship at GHS should expect extensive training in the diseases and conditions listed below to obtain competence to the level of a new practitioner in the ACGME required Core Competencies. The core competency areas include: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-Based Practice. The specific knowledge, skills, behaviors, and attitudes expected during this fellowship are listed in section I Objectives and section II Clinical Competencies. Section III will describe patient characteristics and demographics. Section IV outlines the clinical experience of the fellows and their responsibilities are listed in section V. The expectations and evaluations of the fellows are summarized in section VI. Section VII is a comprehensive outline of the vascular diseases that will be covered during the one year fellowship. Section I Objectives: 1. Patient Care Fellows will be expected to provide patient care that is compassionate, appropriate, and effective for the treatment of health issues related to vascular medicine and to the promotion of good overall health. Fellows must be able to: a. Communicate effectively and demonstrate a caring and respectful behavior during interaction with patients and family. b. Gather essential and accurate information about their patients from the history and physical examination with special emphasis on the arterial, venous, and lymphatic systems. Gather pertinent information from laboratory, non-invasive vascular lab, and radiology sources and well as previous medical records. c. Make informed decisions about diagnostic and therapeutic interventions based upon patient information, patient preferences, clinical judgment, and current standards of evidence. d. Develop and recommend patient management plans. e. Develop and counsel patients and their families regarding primary and secondary prevention strategies. f. Use information technology to support patient care decisions and patient education. 2. Medical Knowledge The fellow will acquire and develop the knowledge base in vascular medicine to become proficient as a vascular internist and enable the fellow to sit for the ABVM general vascular medicine board examination. An extensive introduction to this knowledge base is included in the curriculum outline* listed below. The vascular internist must be able to evaluate and manage common vascular disorders and refer patients appropriately to vascular surgeons, cardiologists, interventionalists, neurologists, etc. The vascular internist plays a primary role in treating venous thromboembolic events and a key role in assisting other physicians in the inpatient and outpatient management of vascular diseases. Physicians completing the one year fellowship will receive an overview of all the diseases listed in the Outline to include diagnosis, differential diagnosis, and management. This knowledge base will be imparted to the fellows through direct patient contact, physician-physician interaction, weekly lectures and reading assignments. 3. Practice-based learning and improvement Fellows must be able to investigate and evaluate their inpatient and outpatient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Fellows are expected to: a. Locate, appraise, and assimilate evidence from scientific studies related to their patient s health problems, with emphasis on vascular related conditions. b. Use information technology to manage information, access on-line medical information, and support their own education. 1

c. Facilitate the learning of any students, residents, fellows, and other health professionals. d. Develop lifelong learning habits of staying current with the pertinent medical literature (analyze and critique) e. Establish a basic library of vascular medicine 4. Interpersonal and communication skills Fellows must be able to demonstrate interpersonal and communication skills that result in effective information exchange. This teaming with patients, families, and other health professionals will result in improved patient care. Fellows are expected to: a. Establish an effective consultative relationship with patients and non-vascular oriented physicians. b. Work effectively with others as a member or leader of a health care team or other professional group in the unique role as a consultant. c. Develop the effective communication skills of a consultant (both written and verbal) with the patient s primary care physician and other treating physicians. 5. Professionalism Fellows must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Fellows are expected to: a. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence in the field of vascular medicine, and on-going professional development. b. Demonstrate a commitment to ethical principles pertaining to the provision or withholding of clinical care, confidentiality, patient information and informed consent. c. Demonstrate sensitivity and responsiveness to patient s cultures, age, gender, disabilities, and personal preferences. 6. Systems-based Practice Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on the system resources to provide care that is of optimal value. Fellows are expected to: a. Practice cost-effective healthcare and resource allocation without compromising good quality of care. b. Advocate for quality patient care and assist patients in dealing with system complexities. c. Know how to partner with healthcare managers and other healthcare providers to assess, coordinate, and improve healthcare and know how these activities can affect system performance. Section II Clinical Competencies: 1. Although the vascular medicine fellowship is largely an intellectual program, the fellows will be exposed to a variety of clinical procedures and depending upon their interest, they may have the opportunity to develop clinical competency in the following areas. At the end of the fellowship, the fellows will be able to: a. Complete a comprehensive vascular examination (arterial, venous, and lymphatic) to complement their routine history and physical. b. Interpret vascular laboratory studies including supine venous duplex, standing venous duplex, carotid duplex, lower extremity arterial exams, upper extremity venous and arterial duplex exams, and abdominal duplex exams (including renal artery exams). c. Perform basic (Level 1 and 2 procedures per GHS credentialing documents) phlebologic procedures including injection sclerotherapy of spider veins and reticular veins, outpatient wound debridement, and micro-incisional phlebectomy of non-truncal varicosities. d. Interventional procedures such as angiography and endovenous laser treatments will be discussed in Section. 2

Section III Patient Characteristics: 1. Fellows will care for male and female patients primarily over the age of 12 who are patients of or are referred for evaluation to the faculty of Vascular Medicine at Greenville Hospital System. Patients may be seen in an inpatient setting at Greenville Memorial Hospital or as an outpatient in a private attending physician office or in the outpatient fellow s clinic. The inpatients will be largely a consultative practice focusing on venous thromboembolic diseases. Fellows will encounter and treat patients from diverse ethnic, educational, and economic backgrounds. Section IV The Clinical Experience: 1. The fellowship will consist of 6 months of inpatient service and 6 months of outpatient experience. a. Inpatient: (6 Months): Fellows (along with any medical students or residents) will round on patients and see any consultations every morning. They will examine the patient and present the case along with any pertinent lab or diagnostic studies to the attending physician. Additional responsibilities will include attending and assisting cases on the endovascular service and interpreting non-invasive vascular lab tests. b. Outpatient: (4 Months): This time will be spent at the Institute for Vascular Health located at the Patewood Medical campus (Building C). Daily exposure and responsibilities will be tailored to maximize patient exposure. Daily clinics will be held in vascular medicine, cardiovascular risk reduction, wound clinic, and vein center. c. Vascular Surgery (1 month): A one month hospital rotation under the guidance of the Institute for Vascular Health s Vascular Surgery department. In-patient management of vascular surgery patients and intra-operative exposure is ensured. d. Elective (1 month): Areas of rotation can include rheumatology, dermatology, hematology, or neurology. We would encourage outside rotations with other vascular medicine programs throughout the country. Elective months are arranged by the fellow, but must be approved by one of the directors. Section V Fellow Responsibilities: 1. Have an attitude for learning and be self-motivated. 2. Be responsible for professional conduct at all times. 3. Seek opportunities to see, experience, and expand upon their education. 4. Review their progress on a quarterly basis and actively resolve any deficiencies in a timely manner. 5. Provide leadership to the weekly journal club, imaging conference, and student/residents on the rotation. 6. Acquire experience to sit for the ABVM general certification examination. 7. Acquire experience in the non-invasive peripheral vascular laboratory to sit for the PVI examination. Section VI Fellow Evaluations: 1. Each month the fellow will be evaluated by the responsible vascular medicine attending for their rotation. The form is to be filled out within two weeks of completion of the rotation. These forms will provide the basis of the fellow s quarterly evaluation with the fellowship director(s). Deficiencies will be identified and a strategy developed between the directors and fellow to resolve any issues. All issues must be resolved to successfully complete the training program. Any remedial efforts be documented and fairly evaluated in the same process. Section VII Curriculum Outline Medical Knowledge Base (See above Section I.2, Medical Knowledge) 1. Arterial Disease Normal i. Normal anatomy and physiology of the cerebrovascular, renal, mesenteric, coronary and peripheral vascular beds. 3

Atherosclerosis i. Pathogenesis of Atherosclerosis 1. Historical Perspectives into the theories of atherosclerosis 2. Current model for the development of the atherosclerotic plaque ii. Risk Factors: Identification and intervention 1. DM a. Define characteristic patterns commonly seen in diabetics. b. Define macro-vascular and micro-vascular lesions. 2. Smoking a. Impact of smoking on atherosclerosis, thromboangiitis obliterans (Beurger s Disease) b. Cessation modalities i. Pharmacologic ii. Non pharmacologic 3. Hypertension - a. Epidemiology b. Pathogenesis c. Current classification d. Diagnosis e. Evaluation of the hypertensive patient f. Treatment i. Life-style modification ii. Pharmacologic therapy g. Hypertensive urgencies and emergencies h. Evaluation of the resistant hypertensive patient and secondary causes of hypertension. i. Renal Artery Stenosis (see elsewhere) 4. Lipid Disorders a. Discuss and Implement the NCEP ATP III guidelines b. Discuss lipoprotein metabolism and its role in the pathogenesis of atherosclerosis c. Therapeutic lifestyle change approach to reduce risk d. Role of lipid disorders in atherosclerotic vascular disease e. Plasma triglycerides and cardiovascular disease f. Review evidence that raising HDL-C, lowering LDL-C, and lowering TG will reduce CV disease. i. Review major trials of primary and secondary prevention of CV Discuss phenotypic classification of dsylipotproteinemias g. Genetic disorders of lipid metabolism h. List secondary dyslipidemias Drug Therapy for dyslipidemia: i. Statins ii. Fibrates iii. Niacin iv. bile acid sequestrants v. newer drugs vi. side effects/interactions of drug therapy i. Cutaneous & eye manifestations of lipid disorders j. Review regression of atherosclerosis k. Diagnose metabolic syndrome and its associated lipoprotein disorders, inflammatory disorders, genetic factors and predisposed ethnic groups l. Manage hypertriglyceridemia and low HDL syndrome m. Pathogenesis and management of obesity n. Role of hormone replacement therapy. 4

o. Discuss LDL and HDL subfractions p. Attempt to implement or introduce a rational algorithm to be used by fellows, physician extenders and support staff. q. PPAR alpha and gamma 5. Miscellaneous (including new novel risk factors) iii. Peripheral Arterial Disease (PAD): 1. Epidemiology and Prognostic of PAD 2. Clinical Evaluation and Vascular Testing 3. Functional implications and the Natural History of PAD. 4. Treatment of PAD Risk Factor Modification a. Tobacco Addiction b. Diabetes c. Hypertension 5. Treatment of PAD Antithrombotic and other pharmacologic modalities. 6. Treatment of PAD exercise therapy and assessing quality of life. 7. Implications of PAD in women. 8. Recognizing moderate PAD and critical limb ischemia (CLI) presentation and management. 9. Treatment modalities in moderate PAD and CLI a. Endovascular therapies, including percutaneous angioplasty, stents, atherectomy i. Surgical treatment of PAD, both claudication and limb salvage 10. Review novel & newer risk factors of PAD including hyperhomocysteinemia, elevated levels of lipoprotein (a), and low levels of HDL-C, low levels of vitamin B-12, elevated levels of fibrinogen and plasminogen activator inhibitor (PAI) levels. 11. Complications of PAD a. Atheroembolism b. Amputation 12. Claudication in the Young Including non-atherosclerotic intermittent claudication. a. Accelerated atherosclerosis b. Extrarenal Fibromuscular Dysplasia c. Vasculitis d. Popliteal Artery Entrapment Syndrome e. Cystic Adventitial Disease f. Arterial Calcification Diseases i. MÖnckeberg s sclerosis ii. Idiopathic infantile arterial calcification (IIAC) iii. Calcifications associated with chronic renal failure iv. Extracranial Cerebrovascular Disease 1. Historical background 2. Normal anatomy and physiology a. Differentiate anterior and posterior circulation 3. Pathophysiology of cerebrovascular disease 4. Clinical Presentations a. Transient Ischemic Attack b. Stroke in Evolution c. Completed stroke d. Reversible Ischemic Neurologic Deficit e. Visual field disturbances, Amaurosis Fugax, retinal artery occlusions 5. Physical Exam 6. Diagnostic testing and imaging modalities 7. Medical Therapy 8. Surgical Interventions 9. Endovascular Interventions 5

v. Coronary 1. Full discussion of CAD is beyond the scope of this curriculum and fellowship. 2. Relationship of CAD to: a. PAD b. Cerebrovascular Disease 3. Peri-operative & cardiac management of the vascular patient vi. Mesenteric- Visceral Ischemic Syndromes 1. Normal anatomy and physiology 2. Common collateral pathways 3. Acute Mesenteric Ischemia a. Diagnostic challenges b. Acute embolic ischemia c. Acute thrombotic ischemia d. Treatment 4. Chronic Mesenteric Ischemia a. Presentation and pathogenesis b. Diagnosis c. Treatment 5. Celiac artery compression syndrome 6. Renal Artery Stenosis a. Atherosclerotic b. Non-atherosclerotic i. Fibrous dysplasia ii. Vasculitis c. Renovascular hypertension i. Diagnostic modalities and suggested work-up ii. Pathogenesis d. Treatment 7. Mesenteric Venous Thrombosis a. See under venous diseases Aneurysmal Disease: i. Definition and classification ii. Natural history and clinical manifestations iii. Abdominal Aortic Aneurysms-Infrainguinal 1. Presentation and Natural history 2. Diagnosis 3. Comorbidities and preoperative evaluation 4. Surgical repair 5. Endovascular repair iv. Thoracic Aorta and suprainguinal abdominal aorta 1. Pathogenesis and classification 2. Indications for treatment 3. Surgical repair 4. Endovascular repair 5. Visceral 6. Miscellaneous (femoral, popliteal, upper extremity, etc.) 2. Venous Disease Anatomy and physiology of the upper and lower extremity veins Venous Thromboembolism i. Acute DVT of lower extremities ii. Upper extremity DVT iii. Pulmonary Embolism iv. Catheter related thrombosis 6

v. Thrombophilias (Hereditary and Acquired) Post-thrombotic Syndrome Chronic Venous Insufficiency i. Venous Stasis Ulcerations Varicose Vein Disease Venous Malformations 3. Lymphedema Anatomy and physiology of the lymphatic system Causes, diagnosis, and management Primary vs. secondary Combined venous & lymphatic malformations 4. Hypertension Essential Hypertension (classification, diagnosis, and treatment) Renovascular Hypertension (diagnosis and treatment) 5. Vasospastic Diseases 6. Miscellaneous Arterial Diseases Thoracic Outlet Syndrome Reflex Sympathetic Dystrophy Erythromyalgia Thromboangiitis Obliterans (Buerger s Disease) Systemic Necrotizing Vasculitis 7. Diabetes Vascular patterns and complications of diabetes Diabetic foot ulcers 8. Hypercoagulable States (Thrombophilias) Principles and practices of thrombolysis, anticoagulation (parenteral and oral). 9. Approach to the swollen limb 10. Approach to vascular diseases of the upper extremity 11. Acute vs. chronic limb ischemia 12. AV malformations, pseudoaneurysms, AV fistulas 13. Vascular manifestations of systemic diseases: Hypertension Smoking Rheumatologic Disorders CRF & dialysis 14. Noninvasive vascular laboratory 7