University of Washington
School of Medicine
Cardiology Fellowship

Educational Objectives

• Patient Care

• Medical Knowledge

• Practice-Based Learning and Improvement

• Interpersonal and Communication Skills

• Professionalism

• Systems-Based Practice

• Close one-on-one attending-fellow provision of patient care in inpatient and outpatient settings, with increasing levels of independence during the training period.

• Direct faculty teaching of cardiovascular procedures including indications, performance and study interpretation. A series of didactic conferences on core cardiovascular knowledge.

• Clinical and research conference presentations.

• Research training under the supervision of a faculty mentor, including submission of a competitive grant application, dedicated research time, journal clubs, training in research methodology and ethics.

• A teaching curriculum that includes training in presentation of clinical cases, writing review articles, written and oral presentation of research data, and teaching medicine residents and medical students.

• Involvement in the quality improvement activities of the Cardiology Division for optimizing our patient care systems and participation in academic and clinical administrative functions of the Division.

• Responsibility for providing continuous care to our patients by implementation of appropriate call schedules and mechanisms for handling unexpected coverage issues.

• Direct one-on-one observation of patient care and procedures.

• Written (online) evaluations for each month-long rotation using the ABIM evaluation form.

• Review of procedure logs.

• Procedural competency evaluations.

• Fellow self-evaluation narratives submitted every 6 months.

• Updated CV including teaching conferences, presentations and publications.

• One on one meetings with each trainee and the Fellowship Director or Associate Director every 6 months (with additional meetings as needed) summarized in a letter.

• Summary letter at completion of training documenting areas of clinical competency, final procedure numbers, average ABIM score, narrative comments on clinical performance and a synopsis of research experience.

• A passing score on the ABIM examination in Cardiovascular Disease.

Inpatient Cardiac Care

• To learn an efficient and accurate diagnostic approach to hospitalized patients with a wide range of cardiac diseases.

• To learn the basics of management of a wide range of acute cardiac diseases.

• To learn inpatient Cardiology consultation and the appropriate role of the consultant.

• To learn participatory and leadership skills as part of a team of professionals.

• To become more sensitive and skilled in interacting with patients and families.

• To develop communication skills with other health care providers, including referring physicians, cardiac surgeons, pharmacists, nurses, and cardiovascular allied health professionals.

Ambulatory Cardiac Care

• To learn the differential diagnosis for common presenting symptoms and signs and appropriate diagnostic testing strategies.

• To learn the appropriate management of cardiac disease in the outpatient setting, including use of diet, pharmacological therapy, exercise, cardiac rehabilitation, and the appropriate timing of surgical or percutaneous interventions.

• To learn cardiac risk factor evaluation and modification in patients with or at risk for cardiac disease, including dietary and other life style modifications, smoking cessation therapy, lipid-lowering therapy, and other effective strategies.

• To learn the appropriate intervals for periodic evaluation and testing of patients with chronic cardiac disease.

• To gain a longitudinal perspective regarding the clinical course of patients with chronic disease.

• To become more sensitive and skilled in interacting with patients and families.

• To improve communication skills with referring physicians and other health care providers.

Electrocardiography and Cardiac Arrhythmias

• To learn the diagnostic approach to and appropriate management of cardiac arrhythmias.

• To learn the indications for, management, risks and follow-up of cardiac pacemakers, implantable defibrillators and cardiac resynchronization devices.

• To learn the indications for, management, risks and follow-up of invasive diagnostic electrophysiologic testing and catheter ablation procedures.

• To gain a basic understanding of device interrogation, threshold and sensing tests and to have the opportunity to evaluate device rhythm events and participate in decision making regarding those events.

• To interpret at least 3,500 12-lead ECGs and at least 150 24-hour ECGs.

• To be competent in the performance and interpretation of stress ECG studies (at least 200 cases)

• To correlate ECG and stress test findings with clinical diagnosis, prognosis, and management.

• To gain competency in performing DC cardioversion (at least 10 cases) and in insertion and management of temporary pacemakers (at least 20 cases).

Echocardiography

• To learn normal and abnormal tomographic cardiac anatomy, physiology, and pathophysiology.

• To comprehend the principles of echocardiographic instrumentation, fluid dynamics, cardiac hemodynamics, and imaging and Doppler artifacts.

• To learn the indications for and limitations of echocardiography

• To achieve competency in the performance and interpretation of transthoracic echocardiography by scanning at least 150 patients and interpreting at least 300 studies.

• To learn the indications and risks of stress echocardiography and transesophageal echocardiography and participate in performing at least 100 stress echo studies, 20 contrast studies, and 50 transesophageal echo studies.

• To correlate data from echocardiographic, physical examination and other diagnostic procedures.

• To clearly articulate for the referring physician the clinical significance of the echocardiographic findings in the context of the patient's specific disease process.

Nuclear Cardiology & Advanced Cardiac Imaging

• To learn the basic operation and quality control of gamma cameras and computers.

• To learn the principles of patient selection, performance, monitoring, interpretation, and reporting of exercise and pharmacological stress testing.

• To learn how to acquire, reconstruct and analyze radionuclide ventriculograms and myocardial perfusion images including both SPECT and PET/CT.

• To perform and interpret at least 300 nuclear cardiology studies, to correlate the results with other clinical parameters, and to assess the impact of the study on subsequent clinical management.

• To learn how to acquire and analyze cardiac magnetic resonance images for assessment of anatomy and function in patients with both congenital and acquired heart disease.

Cardiac Catheterization

• To gain knowledge of normal and abnormal coronary artery anatomy, physiology, and pathology.

• To learn the principles of radiographic image formation, image plane orientation, radiographic instrumentation, and factors that affect image quality.

• To demonstrate knowledge of radiation safety issues and techniques to minimize radiation exposure.

• To learn the relationship of angiographic findings to other clinical parameters, the indications for angiography, and alternate diagnostic approaches.

• To perform and interpret 300 left heart catheterizations with coronary angiography, at least 100 right heart catheterizations, >5 pericardiocentesis and >10 intra-aortic balloon pumps.

• To correlate angiographic and clinical findings and formulate an appropriate therapeutic approach for each patient based on these findings.

• To gain knowledge and experience in the role of interventional cardiology and cardiac surgery and the factors important in the patient selection for these procedures.

Heart failure and Cardiac Transplantation

• To learn the appropriate diagnosis and treatment of heart failure in the acute care setting, including use of invasive hemodynamic monitoring, use of continuous infusion intravenous medications and other acute care treatment options.

• To learn the diagnosis and treatment of chronic heart failure in the outpatient setting.

• To learn in detail the pharmacology of agents used in the treatment of heart failure.

• To learn the indications for heart transplantation, the pre-transplant evaluation protocol, and post-transplant follow-up.

• To learn the indications for ventricular assist device implantation, both pulsatile and continuous flow devices, and to work with the cardiac surgical team to provide longitudinal follow-up for these patients.

Research

• To identify a research problem, critically analyze the relevant literature and formulate a competitive research proposal.

• To learn the benefits of peer review and constructive criticism during all phases of research.

• To learn to formulate a hypothesis, determine whether it is testable, and describe how to test it.

• To learn research methodologies specific to the individual research project.

• To learn the basics of experimental design, including the appropriate use of control groups.

• To understand and apply the concepts of sample size and statistical power to the design of experiments and interpretation of data.

• To learn to collect, organize, and preserve experimental data.

• To learn to analyze experimental and observational data objectively and evaluate the quality, impact and limitations of the data

• To develop skills important in clear organization and presentation of research results

• To learn the strengths and weaknesses of basic, clinical, and health services research techniques.

• To learn responsible conduct of research including general issues of scientific integrity as well as issues specific to the individual research product including animal care requirements, protection of privacy, informed consent, and institutional approval of human investigation.

• To learn to evaluate the risks and benefits of a research project from the points of view of the research subjects and society.

Teaching and Practice Based Learning

• To use recommended textbooks and online resources to develop effective self study methods for continuing medical education.

• To learn effective teaching and presentation skills.

• To remain current regarding the research literature.

• To learn to synthesize information from multiple sources, including print and electronic media.

• To develop an approach to life-long learning.

Areas beyond basic cardiology that require additional training:

• Electrophysiology, including permanent pacer and ICD implantation

• Interventional cardiology

• Nuclear cardiology

• Level III Echocardiography, CHF/Transplant, CT/CMR

CONFERENCES

• Division of Cardiology Grand Rounds on Fridays from (September through June) 7:30 to 8:30 AM. Grand Rounds include at least 1 research conference per month, regular clinical-pathologic correlation conferences, and topics of clinical interest. Each fellow makes at least 1 presentation with other presentations given by Cardiology faculty, faculty from related disciplines, and visiting speakers.

• Cardiology Tutorials on Fridays from 8:45 to 9:45 AM. (All year, with conferences from 7:30 to 9:45 during the summer when Grand Rounds are not held.) These conferences cover the range of topics listed in the ACGME requirements including clinical and research topics. Tutorials are scheduled by the Associate Fellowship Director and the Fellowship Coordinator and are coordinated with systematic readings from a major cardiology textbook.

• Cardiac Clinical Care Conference, weekly, with collaboration of Cardiology, CT-Surgery and Cardiac Anesthesia in these discussion. The cases and background information are presented by the Cardiology Fellows on a rotating schedule.

• Journal Club is a monthly dinner meeting arranged by the Cardiology Fellows. Fellows present recent journal articles of general interest, describing the content of the article and directing a brief discussion of its strengths and weaknesses. All fellows are strongly encouraged to pre-read the selected articles and provide an interactive dialogue on current cardiology topics. Attendings with an interest in the area of the articles are invited to share their perspective and experience.

• Fellows may attend other conferences, such as Vascular Biology Breakfast Club and Medicine Grand Rounds, as their rotations and schedules allow. There is a monthly Congenital Heart Disease conference as well as weekly cardiac imaging conferences and a weekly electrophysiology conference that fellows are encouraged to attend as their schedules permit. Participation in various didactic courses, CME courses and lecture series are encouraged as long as they do not interfere with other required assignments and clinical duties.

• Fellows on VAMC rotations participate in the Friday VAMC Cardiology Conference and fellows on HMC rotations participate in the Friday conferences at HMC.

• Fellows may elect to take the nuclear medicine didactic course, the Department of Medicine biostatistics course or other selected courses.

• Fellows are encouraged to participate in local CME courses, the local Echo Society lectures, and other University conferences and lecture series.

• All fellows attend the Ethics in Medicine lecture series.

• Conferences are regularly scheduled during Grand Rounds or Tutorial on the following topics: OSHA and radiation safety regulations, continuous quality improvement, risk management.

Teaching Curriculum

Specific Teaching Requirements:

• Cardiology/CT Surgery Clinical Conferences: All fellows present clinical cases with presentation of diagnostic studies and a concise review of the relevant literature. This teaching experience is supervised by Dr. Steve Goldberg who provides training in case presentations, effective POWERPoint graphics, and how to lead an interactive discussion. Each fellow presents between 10 and 15 times (30 minutes each).

• Cardiology Grand Rounds: These 1 hour formal presentations provide an opportunity for fellows to present a rigorous review of the literature on a focused topic or present their own research results. Each fellow works with a faculty mentor on selection of a topic, preparation of slides and presentation style. Overall supervision is provided by Dr. Kevin O’Brien. Each fellow presents at Grand Rounds between 1 and 3 times.

• Resident Teaching: Cardiology Fellows provide both bedside teaching and didactic sessions to the Medicine Residents during rotations on inpatient Cardiology at both UWMC and HMC (4 months total). Fellows also teach Family Medicine residents on the Cardiology Consult service at UWMC.

• Medical Student Teaching: All Cardiology Fellows participate in Team Teaching of the small group sessions for the Cardiovascular Core Course (Human Biology 540) for 2nd year Medical Students. These interactive 2 hour sessions occur 3 times a week for one month with the fellow and a faculty member working together on teaching in this format. In addition to teaching skills, this experience provides an intense review of cardiac anatomy, physiology, pharmacology and pathology.

• Cardiology Fellows also provide bedside teaching and didactic sessions for 3rd and 4th year medical students on the Cardiology Consult rotation at UWMC (2 months).

• Cardiology Fellows: All 3rd year Cardiology Fellows will be given a specific assignment, under the supervision of a faculty member, to develop or update teaching material for each clinical rotation (for example, a cardiac cath workbook or echo workshops). This may include QA or developing approaches to measuring competency.

RESEARCH TRAINING

All fellows are expected to conduct substantive research during their fellowship years and publish the results of their work.

Year 1

During the first year, all fellows are expected to identify a faculty mentor with whom they will work and begin discussion of possible research projects. Faculty mentors may be in the Division of Cardiology, but fellows may work with any University of Washington faculty member. Approval to work with a faculty mentor is contingent only on the fellowship committee’s assessment of the excellence of the mentor and the suitability of the project.

Year 2

At the beginning of the second year of fellowship, all fellows present a draft research proposal for discussion by their colleagues. Also, in the second year, all fellows are expected to apply for research fellowship grants either internally (i.e., an existing training grant) or externally. Current institutional training grants support fellows working in basic and applied cardiovascular biology, imaging, health care outcomes, bioengineering, and epidemiology. Fellowship grant applications are typically submitted to the American Heart Association, the American College of Cardiology, the National Institutes of Health, and other professional societies and private agencies.

Year 3

The third year is devoted primarily (50 to 80% time) to research under the guidance of a faculty mentor. Fellows are expected to present interim results at laboratory meetings and cardiology conferences, submit abstracts, and prepare manuscripts for publication. The only clinical duties during the 3rd year are continuity clinic and limited on-call duties.

In addition to the training provided by the research project itself, fellows also receive training in the scientific “survival skills” that are required for success as an independent investigator. These skills include writing manuscripts and grants, speaking, biomedical ethics, financial management, job finding, and mentor ship. Training in these areas is provided by formal courses and by the research mentors on an informal basis.

After Year 3

Fellows who intend to become independent principal investigators in laboratory-based, clinical, or population-based research will extend their research training beyond the third year of fellowship, subject to approval by the research mentor and fellowship director. Research mentors guide fellows whose aptitude and interest for research remain high towards submission of faculty transition grants such as the NIH K08 or K23, and the American Heart Association Scientist Development Grant or Fellow to Faculty Award. The University of Washington is a recipient of a NIH K12 award, which provides up to 5 years of faculty-level salary support and a mentored training environment for fellows who wish to develop a career in clinical research. K12 support is awarded through a competitive process.

Areas of research

Major areas of research that are available to fellows include laboratory-based cardiovascular research, cardiovascular imaging, bioengineering, outcomes research, and epidemiology. An NIH-funded training grant in laboratory-based cardiovascular research is based in the Division and provides opportunities in four areas: signaling and vascular injury, gene and cell therapy, genetics of cardiovascular risk, and biomechanics and bioengineering. Fellows have also pursued research in epidemiology and prevention of cardiovascular disease through the Cardiovascular Health Research Unit, which is a division of General Internal Medicine.

Useful web sites:

Cardiovascular Research Training Grant: /cardweb/research.shtml

Cardiovascular Health Research Unit: http://depts.washington.edu/chru/Research.htm

ITHS KL2 Multidisciplinary Clinical Research Career Development Program:http://www.iths.org/education/kl2

Advanced Cardiology training:

There are two 1-year programs available in the Division of Cardiology: advanced training in Clinical Electrophysiology and advanced training in Interventional Cardiology.

Fellows Ski Day 2006