Professional Documents
Culture Documents
Hershey
Medical Center
Fellowship Handbook
Cardiovascular Disease
2016-2017
I. Cardiology Fellowships Program Information..................................................................................... 1
II. Cardiology Faculty ............................................................................................................................ 2-3
III. 2016-2017 Block Schedule .................................................................................................................. 4
IV. Curriculum .................................................................................................................................... 5-137
a. Cardiovascular Disease Fellowship Overview............................................................................... 5
b. Rotations....................................................................................................................................... 8
c. Conferences .............................................................................................................................. 137
V. Departmental Policies .............................................................................................................. 138-147
a. Selection, Evaluation, Renewal, Promotion, and Dismissal of Fellows .................................... 138
b. Grievance and Due Process ...................................................................................................... 142
c. Supervision ............................................................................................................................... 143
d. General Guidelines for Transitions of Care............................................................................... 144
e. Duty Hours, Call, and Fatigue Management............................................................................. 145
f. Moonlighting ............................................................................................................................ 146
VI. Institutional Graduate Medical Education Policies .................................................................. 148-151
a. Statement of Commitment to GME ......................................................................................... 148
b. Additional Work Policy ............................................................................................................. 148
c. Away Rotation Policy ................................................................................................................ 149
d. C.O.R.E (Culture of Respect in Education) ............................................................................... 150
e. Disaster Policy........................................................................................................................... 150
f. Non-Competition Policy............................................................................................................ 151
g. Physician Impairment & Substance Abuse Policy..................................................................... 151
VII. Benefits .................................................................................................................................... 152-157
a. Annual Fellow Stipend .............................................................................................................. 152
b. Educational Support Fund ........................................................................................................ 152
c. Meetings ................................................................................................................................... 153
d. Insurances ................................................................................................................................. 155
i. Medical, Dental, Vision
ii. Flexible Spending and Health Reimbursement Accounts
iii. Short- and Long-Term Disability
iv. Group Term Life
v. Tuition Reimbursement
vi. Employee Assistance Program
e. Employee Discounts ................................................................................................................. 155
f. Leave of Absence ...................................................................................................................... 156
i. Vacation and CME
ii. Medical/Parental/Family Leave
iii. Personal Leave
iv. Professional Leave
v. Effect of Leave
g. ComPsych Guidance Resources ................................................................................................ 156
h. Meal Allowance ........................................................................................................................ 157
i. Meals On-Call ........................................................................................................................... 157
VIII. Miscellaneous Information ...................................................................................................... 158-172
a. Graduate Medical Education Office ......................................................................................... 158
b. Notary ....................................................................................................................................... 158
c. Parking ...................................................................................................................................... 158
d. ID Badging ................................................................................................................................. 158
e. George T. Harrell Library .......................................................................................................... 158
f. Gift Shop ................................................................................................................................... 158
g. Fitness Center ........................................................................................................................... 159
h. ATM .......................................................................................................................................... 159
i. Mail Services ............................................................................................................................. 159
j. Work-Related Injuries ............................................................................................................... 159
k. Telephone/Pager Instructions .................................................................................................. 159
l. Dictation System Instruction ............................................................................................. 160-162
I. CARDIOLOGY FELLOWSHIPS PROGRAM INFORMATION
Eric Popjes, MD
epopjes@hmc.psu.edu
Conference Rooms
H1154 - Hamilton Conference Room
H1222 - IO Silver Conference Room
Fellow 1 2 3 4 5 6 7 8 9 10 11 12 13
1st Year VP EP CA CA CA E E E E R R CA CA N N C C S S IM IM CHF CHF CHF C EP EP
TA N N CA CA CA CA E E E E R R S S IM IM CHF CHF EP EP C C CA N CHF C
RW EP EP N N CA CA CA CA E E E E CHF CHF CA N IM IM C C S S R R C CHF
BD E E E E EP EP CA CA CA CA N N IM IM S S C C CHF CHF R R C CHF CA N
DF E E E E N N R R CA CA CA CA C C CHF CHF EP EP S S IM IM N CA S S
3rd Year CB E E R CHF E CCU CHF N N N E E E R N CA CCU E EP EP R E ACHD ACHD Elective Elective
MF CA R E CCU CCU E S S N N ACHD ACHD R E EP EP E E E E E E R E Elective Elective
MS N CA EP S ACHD ACHD N EP EP EP N N EP E E R CA CA CCU CCU E E E EP Elective Elective
RM R R CCU E N N EP CHF S CCU CCU EP N R CA N E E E E ACHD ACHD E E Elective Elective
TS CA CA N EP E E E CA CCU CHF R CCU CA N R E E N CA CA CA CA CA CA Elective Elective
Introduction: This overview will describe the program in general, the impact the ACGME Outcomes
have on the fellowship program, expectations of the fellows, the evaluation process, schedule of
conferences and journal club meetings, the quarterly benchmarks each fellow is to obtain, and then
cover specific subjects that the fellow will see during their training or that of which they should have a
thorough knowledge. This document should be reviewed early in the fellowship.
General Program Information: Entry into the adult Cardiovascular Disease fellowship is after
completion of an Internal Medicine residency. Fellows entering the program must be in good standing
and be eligible to sit for Internal Medicine boards. The fellowship is a three-year program. During the
fellowship, fellows will spend time on rotations related to (1) non-invasive methods for evaluating
patients (echo [TTE, TEE, pharmacologic and stress echo], MRI, CT, ECG, EP, nuclear cardiology), (2)
invasive methods for evaluating patients (cardiac catheterization) and (3) diagnosis and treatment of
patients with peripheral vascular disease. Other rotations are more directly related to learning to
diagnosis and treat patients with a wide array of cardiac problems; these rotations are (1) a general
cardiology service, (2) in an HV (heart and vascular) ICU housing patients with medical problems (acute
myocardial infarction, acute coronary syndrome, arrhythmias) and surgical problems (post-op CABG,
valve replacement and/or cardiac transplant, peripheral vascular surgery), and (3) a service designed for
caring for patients with congestive heart failure. Fellows spend a half-day each week in a continuity
clinic, as well as time at the Lebanon VA Medical Center. Fellows also receive training in cardiac
rehabilitation and the management of hyperlipidemia. There is dedicated time set aside for research
and fellows are expected to have at least one manuscript submitted for publication prior to leaving the
program. Fellows will be expected to meet the ACGME program requirement of conducting at least one
Quality Improvement/Patient Safety project. This may be the same project as the publication.
Expectations: Each fellow in the program will be expected to perform at a level commensurate with
his/her training. The fellow will demonstrate that compassionate and appropriate care of the patient is
of first priority, in whatever setting the patient-physician encounter occurs (testing laboratories,
outpatient clinic, hospital). The fellow will be professional in dealing with other physicians and all other
persons caring for patients. The fellow will continually expand his cardiology knowledge base. The fellow
will perform self-assessments on a semi-annual basis to ensure that his/her own practice-based learning
is complete. By the time of completion of the fellowship, the fellow will be expected to have a
comprehensive understanding of Cardiovascular Diseases in the larger context of practicing medicine.
He/she will be equipped to independently diagnosis and treat patients with a wide variety of cardiac and
vascular problems and will have the background to enter subspecialty areas of training.
On a professional level, the fellow will be expected to be on time, appropriately dressed and groomed
for work each day, display a positive attitude and a strong work ethic.
Evaluations: The evaluation process is to ensure that the fellows fulfill the requirements of the
fellowship, specifically related to the six ACGME core competencies,* and are on track to graduate with
the ability to independently practice Cardiovascular Medicine. The formal evaluation process will be
conducted at several levels during the year. It will consist of:
Each of these is applicable to the Cardiovascular Disease fellowship and will be individually evaluated
during the year (see evaluations section). It will be very important for you to review the competencies
and understand their implication to your educational program.
The Curriculum, including overview, training goals and objectives, expectations, supervision,
recommended reading and resources, curricular milestones by level of training, and methods of
evaluation are included for each rotation.
B. ROTATIONS
ROTATION INFORMATION
Name of Rotation CARDIAC CATHETERIZATION
Supervising / Evaluating Charles Chambers, MD; Steven Ettinger, MD; Ian Gilchrist, MD; Mark Kozak, MD;
Faculty Members Pradeep Yadav, MD
Facility / Location Cardiac Catheterization Lab / Hershey Medical Center
Clinical Experience All fellows must have a minimum of 4 months of direct cardiac catheterization
experience. Many fellows (who desire COCATS Level II training) will have a 6-8 months
direct cardiac catheterization experience. Additional elective time for interested
fellows is available.
Further exposure to cardiac catheterization content comprised of, but not limited to,
performing arterial and/or venous access for bedside procedures; correlation of
catheterization results with other multimodality imaging studies; as well as ordering,
review, and clinical correlation of invasive cardiac procedures is anticipated for all
fellows on the following rotations:
Inpatient Acute Service
CHF Service
CCU
Consults
Outpatient Continuity Clinics (HMC and VA)
Nuclear Cardiology
Echocardiography
Didactics Cardiac Cath Lecture Series ; Every other Tuesday @ 7am in Hamilton Conference
Room
Additional cardiac catheterization related cases and topics are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
ECHO Conference (stress/cath correlate)
Nuclear Conference (stress/cath correlate)
Overview
The goal of the cardiac catheterization laboratory rotation is to provide the general cardiology fellow with the requisite
cognitive and technical knowledge of invasive cardiology. This will include pre-procedural, procedural, and post-
procedural planning and management, including the appropriateness of the planned procedure. The general fellow will
learn to perform venous and arterial puncture and sheath placement, coronary angiography, ventriculography, and right
heart catheterization. Furthermore, they will learn the interpretation of hemodynamic data, angiographic data and the
appropriateness for diagnostic catheterization and coronary revascularization. Fellows will learn the fundamentals of
radiation safety as it pertains to the catheterization laboratory. Finally, the fellows will participate in the post-procedure
management of the patients, particularly management of complications. Ultimately the cardiac catheterization
laboratory rotation provides a platform for teaching and learning the core knowledge base of cardiac anatomy,
physiology, pathology and therapeutics that all cardiologists should possess regardless of whether they perform invasive
COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during
general fellowship in cardiovascular disease. Penn State Hershey offers a subspecialty Level III training program which
can be applied for following general cardiology fellowship.
Specific curricular milestones for cardiac catheterization, as they relate to the Core Competencies promulgated by the
ACGME, are adopted as outlined in the COCATS 4 Task Force 10 document. They are included in this curriculum with the
appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow may
achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones
represent minimum expectations during general fellowship.
Vacation/CME Time
Time off for vacation and CME may be requested during this rotation. It is the fellows responsibility to make sure the
minimum required fellow presence is available for this rotation:
The catheterization lab requires the presence of at least one fellow, preferably two fellows.
First year fellows should not be left alone during their first month.
When coverage is required to satisfy these minimum requirements, it is the fellows responsibility to arrange this
coverage and notify any involved faculty. In the event of emergent time off, the chief fellow(s) and program leadership
should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be
submitted through the fellowship coordinator and approved by the fellowship director.
The Cardiac Catheterization Handbook, 6th Ed. Kern, Sorajja, and Lim
Ragosta M. Textbook of Clinical Hemodynamics, 1st Ed. Saunders Inc, Philadelphia, PA, 2008
4. Know the indications for, and clinical pharmacology of, antiplatelet and anticoagulant
drugs, and vasopressor and vasodilator agents, used in the cardiac catheterization I
laboratory.
5. Know normal cardiovascular hemodynamics and the principles and interpretation of
waveforms, pressure, flow, resistance, and cardiac output measurements. I
6. Know the characteristic hemodynamic findings with myocardial, valvular, pericardial, and
pulmonary vascular diseases. I
7. Know the methods to detect and estimate the magnitude of intracardiac and
extracardiac shunts. I
8. Know coronary anatomy, its variations and congenital abnormalities, and its coronary
blood flow physiology. I
9. Know the angiographic features of coronary artery disease and how to assess the
anatomic and physiologic severity. I
10. Know the vascular anatomy and the indications and contraindications for, and
complications of, peripheral vascular angiography. I
11. Know the indications and potential complications of percutaneous coronary, peripheral,
valvular, and structural heart interventions. I
12. Know the indications and contraindications for, and the complications of,
endomyocardial biopsy and pericardiocentesis. I
13. Know the indications for, and the mechanisms of action of, mechanical circulatory
support devices. I
14. Know the indications for, and complications of, vascular access and closure strategies
and devices. I
Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training
Exam
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice
of cardiac catheterization.
Goal Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the
ability to call effectively on other resources in the system to provide optimal healthcare.
Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Locate, appraise, and assimilate information from scientific studies, guidelines, and
registries in order to identify knowledge and performance gaps. I
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
1. Communicate with and educate patients and families across a broad range of
socioeconomic, ethnic, and cultural backgrounds, including obtaining informed consent. I
2. Communicate and work effectively with physicians and other professionals on the
healthcare team regarding procedure findings, treatment plans, and follow-up care I
coordination.
3. Complete procedure records and communicate testing results to physicians and
patients in an effective and timely manner. I
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluation, 360 Reviews
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
Instructions:
ThefollowingevaluationquestionshavebeendevisedusingtheCOCATS4CoreCompetencyComponentsand
CurricularMilestonesforTraininginCardiacCatheterization.TheevaluationscaleismodeledaftertheACGME
Milestonescategories,whicharecompetencybaseddevelopmentaloutcomes(e.g.,knowledge,skills,attitudes,and
performance)thatcanbedemonstratedprogressivelybyresidentsandfellowsfromthebeginningoftheireducation
throughgraduationtotheunsupervisedpracticeoftheirspecialties.
SubjectName
Status
Evaluatedby: EvaluatorName
Status
Employer
Employer
Program
Program
Rotation
EvaluationDates
MEDICALKNOWLEDGE
1* Knowstheindications/contraindicationsandpotentialcomplicationsofcardiaccatheterizationfor
assessmentofcoronary,valvular,myocardial,andbasicadultcongenitalheartdiseases.
1 2 3 4 5
2* Knowstheprinciplesofradiationsafety.
1 2 3 4 5
3* Knowstheuseandcomplicationsofcontrastmediaandtheroleofrenalprotectionmeasures.
1 2 3 4 5
4* Knowstheindicationsfor,andclinicalpharmacologyof,antiplateletandanticoagulantdrugs,and
vasopressorandvasodilatoragents,usedinthecardiaccatheterizationlaboratory.
1 2 3 4 5
5* Knowsnormalcardiovascularhemodynamicsandtheprinciplesandinterpretationofwaveforms,
pressure,flow,resistance,andcardiacoutputmeasurements.
1 2 3 4 5
1 2 3 4 5
7* Knowsthevascularanatomyandtheindicationsandcontraindicationsfor,andcomplicationsof,
peripheralvascularangiography.
1 2 3 4 5
8* Knowstheindicationsandpotentialcomplicationsofpercutaneouscoronary,peripheral,valvular,and
structuralheartinterventions.
1 2 3 4 5
9* Knowstheindicationsandcontraindicationsfor,andthecomplicationsof,endomyocardialbiopsyand
pericardiocentesis.
1 2 3 4 5
10* Knowstheindicationsfor,andthemechanismsofactionof,mechanicalcirculatorysupportdevices.
1 2 3 4 5
11* Knowstheindicationsfor,andcomplicationsof,vascularaccessandclosurestrategiesanddevices.
1 2 3 4 5
PATIENTCAREANDPROCEDURALSKILLS
12* Possessesskillstoperformpreproceduralevaluation,assessappropriateness,obtaininformed
consent,andplanprocedurestrategy.
1 2 3 4 5
1 2 3 4 5
14* Possessesskillstoperformrightheartcatheterization.
1 2 3 4 5
15* Possessesskillstoanalyzehemodynamic,ventriculographic,andangiographicdata,andtointegrate
withclinicalfindingsforpatientmanagement.
1 2 3 4 5
16* Possessesskillstomanagepostproceduralpatients,includingcomplicationsandcoordinationofcare.
1 2 3 4 5
17* Possessesskillstoperformendomyocardialbiopsy.
1 2 3 4 5
18* Possessesskillstoperformpericardiocentesis.
1 2 3 4 5
19* Possessesskillstoperformdiagnosticleftheartcatheterization,ventriculography,andcoronary
angiography.
1 2 3 4 5
1 2 3 4 5
21* Possessesskillstoperformdiagnosticperipheral(excludingcarotid)angiography.
1 2 3 4 5
SYSTEMSBASEDPRACTICE
22* Coordinatescareinaninterdisciplinaryapproachforpatientmanagement,includingtransitionofcare.
1 2 3 4 5
23* Utilizescostawarenessandrisk/benefitanalysisinpatientcare.
1 2 3 4 5
PRACTICEBASEDLEARNINGANDIMPROVEMENT
24* Locates,appraises,andassimilatesinformationfromscientificstudies,guidelines,andregistriesinorder
toidentifyknowledgeandperformancegaps.
1 2 3 4 5
25* Documentsnumberandoutcomesofdiagnosticandtherapeuticprocedures.
1 2 3 4 5
PROFESSIONALISM
1 2 3 4 5
27* Interactsrespectfullywithpatients,families,andallmembersofthehealthcareteam,includingancillary
andsupportstaff.
1 2 3 4 5
INTERPERSONALANDCOMMUNICATIONSKILLS
28* Communicateswithandeducatespatientsandfamiliesacrossabroadrangeofsocioeconomic,ethnic,
andculturalbackgrounds,includingobtaininginformedconsent.
1 2 3 4 5
29* Communicatesandworkseffectivelywithphysiciansandotherprofessionalsonthehealthcareteam
regardingprocedurefindings,treatmentplans,andfollowupcarecoordination.
1 2 3 4 5
30* Completesprocedurerecordsandcommunicatestestingresultstophysiciansandpatientsinan
effectiveandtimelymanner.
1 2 3 4 5
OVERALLASSESSMENT
31* OverallAssessmentofthisfellowontheirCardiacCatheterizationrotation.
1 2 3 4 5
32 Comments:Pleaseusethecommentboxbelowtoofferdetailedstrengthsand/orweaknessesofthis
fellowontheirCardiacCatheterizationrotation.
Yes
No
Comment
34* Wasthisevaluationdiscussedwiththefellowattheendoftherotation?
*ACGMEProgramRequirementV.A.2.a).(1)states"facultymustevaluatefellowperformanceina
timelymannerduringeachrotationanddiscussthisevaluationwitheachfellowatthecompletionofthe
assignment."
Yes
No
OverallComment
ROTATION INFORMATION
Name of Rotation Heart & Vascular Intensive Care Unit (HVICU or CCU)
Supervising / Evaluating CHF Service: Omaima Ali, MD; John Boehmer, MD; Dwight Davis, MD; Eric Popjes, MD;
Faculty Members David Silber, MD
General Cardiology: Eric Chan, MD; Joy Cotton, MD; Andrew Foy, MD; Annick Haouzi,
MD; John Kelleman, MD; Edward Liszka, MD; Michael Pfeiffer, MD; John Field, MD
Anesthesia Intensivists: Octavio Falcucci, MD; Kane High, MD; Amit Prasad, MD; Kai
Singbartl, MD
Facility / Location Heart and Vascular ICU / Hershey Medical Center
Clinical Experience All fellows will have a minimum of 1 month of direct Cardiac Critical Care experience.
Cardiac Critical Care rounds will also occur routinely on all inpatient services. Additional
elective time for interested fellows is available.
Further exposure and overlap experience to Cardiac Critical Care content is anticipated
for all fellows on the following rotations:
Inpatient Acute Service
Heart Failure Service
Inpatient Consults
Cardiac Catheterization
Echocardiography
Electrophysiology
Didactics There is no dedicated Cardiac Critical Care Lecture Series. Cardiac critical care lectures
will occur as a part of the Core Conference Series.
Additional cardiac critical care related cases and topics are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
Echocardiography Conference
Cath Conference
EP Conference
Overview
The cardiac critical care rotation, in conjunction with other inpatient cardiology rotations, provides direct exposure to
the essentials of evaluation and management of patients with acute, life-threatening cardiovascular disease and
conditions. This rotation places an emphasis on, and provides the opportunity for, the cardiology trainee to participate
in interdisciplinary care teams in the critical care environment. The fellow will also achieve competency in appropriate
and safe transitions of care out of the critical care environment to other care teams. The cardiac critical care rotation is
also a component of the fellows exposure to ECG interpretation with routine and urgent evaluation of ECGs across a
variety of scenarios.
CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 21
Training Goals and Objectives
The cardiac critical care rotation is designed to provide the trainee, within the standard three year program, training that
meets or exceeds COCATS Level I expectations.
COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during
general fellowship in cardiovascular disease. At the present time, Penn State Hershey does not offer subspecialty
training in Cardiac Critical Care.
Specific curricular milestones for cardiac critical care as they relate to the Core Competencies promulgated by the
ACGME are adopted from the ACC COCATS 4 Task Force 13 document. They are included in this curriculum with the
appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule a fellow may
achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones
represent minimum expectations during general fellowship.
Vacation/CME Time
It is expected that fellows do NOT request routine time off for vacation or CME during this rotation. In the event of an
urgent or unavoidable absence, coverage should be arranged by the fellow in advance. It is the fellows responsibility to
notify any involved faculty and team members.
In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging
coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship
coordinator and approved by the fellowship director.
3. Know the indications, contraindications, and clinical pharmacology for vasoactive and
inotropic medications used in the treatment of patients with advanced heart failure, I
hypotension, or shock.
4. Know the indications, contraindications, and clinical pharmacology for anticoagulant,
antiplatelet and fibrinolytic agents. I
5. Know the indications for, contraindications to, and clinical pharmacology of agents used
to treat hypertensive urgencies and emergencies. I
6. Know the indications, contraindications, and clinical pharmacology for agents used to
treat pulmonary hypertension, including intravenous, inhalational and oral agents. I
7. Know the indications, contraindications, and clinical pharmacology for agents used to
treat supraventricular and ventricular arrhythmias. I
8. Know the indications for, contraindications to, and risks of catheter-based techniques to
treat supraventricular and ventricular arrhythmias. I
11. Know the differential diagnosis and characteristic laboratory findings of oliguria and
acute kidney injury. I
17. Know the differential diagnosis of heart failure or shock in cardiac transplant patients. I
18. Know the elements of risk scoring systems for the assessment of prognosis in acute
coronary syndrome, advanced heart failure, and pulmonary hypertension, including I
demographics and findings from the clinical examination, electrocardiogram, biomarker
19. Knowi the indications
i h forhuse of
di hypothermia
h d iprotocols
i h and the
d principles
i of post-
resuscitation bundled care. I
20. Know the elements of scoring systems for assessment of the risk of major bleeding in
patients treated with antithrombotic medications. I
Evaluation Methods:
Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice
of cardiac critical care.
1. Skill to manage patients with acute myocardial infarction and any associated rhythm,
conduction, or mechanical complications. I
2. Skill to evaluate and manage acutely unstable cardiac patients by integrating the
findings from clinical, electrocardiographic, telemetry, imaging, and hemodynamic I
assessment and to develop a plan for bedside intervention.
3. Skill to place arterial, central venous, and pulmonary artery catheters and temporary
transvenous pacemakers in sequence with cardiac catheterization laboratory rotations. I
6. Skill to evaluate and manage patients with hemodynamic instability following cardiac
surgery. I
13. Skill to participate in the perioperative care of heart transplant and ventricular assist
device patients, in collaboration with heart failure experts, interventional cardiologists, I
and surgical consultants.
14. Skill to monitor blood pressure and hemodynamic state in patients with continuous flow
left ventricular assist devices, in collaboration with heart failure specialists, I
interventional cardiologists, and/or surgeons.
15. Skill to manage hypertensive urgencies and emergencies. I
16. Skill to manage special populations of critically ill cardiovascular patients including those
with aortic dissection, massive or submassive pulmonary embolism, acute severe
I
valvular regurgitation, and advanced pulmonary hypertension with right ventricular
dysfunction.
17. Skill to manage patients with acute bleeding, including bleeding from vascular access or
spontaneous bleeding. I
20. Skill to utilize risk assessment scoring systems when appropriate in patient management
and counseling. I
21. Skill to identify when further medical care is futile and to counsel families on end-of-life
care. I
22. Skill to coordinate safe and effective transitions of care in collaboration with other
members of the care team. I
Evaluation Methods:
Goal Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the
ability to call effectively on other resources in the system to provide optimal healthcare.
1. Work effectively with all members of the critical care unit team including heart
failure/transplant specialists, electrophysiologists, interventionalists, surgeons,
pulmonary critical care physicians, nephrologists, neurologists, nurses, physicians I
assistants, pharmacists, social workers, and other team members as required.
2. Participate in hospital quality and safety initiatives in the critical care units. I
3. Utilize interdisciplinary input and expertise in comanagement of critically ill patients,
including transitions of care. I
Evaluation Methods:
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Identify knowledge and performance gaps and engage in opportunities to achieve
focused education and performance improvement. I
3. Incorporate appropriate use criteria, risk/benefit analysis, and cost considerations in the
use of testing and treatment. I
Evaluation Methods:
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
1. Work effectively in an interdisciplinary critical coronary care unit environment. I
2. Demonstrate sensitivity to patient preferences and values and end-of-life issues. I
3. Practice within the scope of expertise and technical skills. I
4. Interact respectfully with patients, families, and all members of the healthcare team,
including ancillary and support staff. I
Evaluation Methods:
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
1. Communicate with and educate patients and families across a broad range of cultural,
ethnic, and socioeconomic backgrounds. I
2. Communicate and work effectively with physicians and other professionals on the
healthcare team in the management of critically ill patients and their transition to other I
care environments.
3. Communicate with families with regard to end-of-life decisions with respect to
programming of pacemakers and implantable cardioverter-defibrillators. I
Evaluation Methods:
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
Instructions:
ThefollowingevaluationquestionshavebeendevisedusingtheCOCATS4CoreCompetencyComponentsand
CurricularMilestonesforTraininginCardiacCriticalCare.TheevaluationscaleismodeledaftertheACGMEMilestones
categories,whicharecompetencybaseddevelopmentaloutcomes(e.g.,knowledge,skills,attitudes,andperformance)
thatcanbedemonstratedprogressivelybyresidentsandfellowsfromthebeginningoftheireducationthroughgraduation
totheunsupervisedpracticeoftheirspecialties.
SubjectName
Status
Evaluatedby: EvaluatorName
Status
Employer
Employer
Program
Program
Rotation
EvaluationDates
MEDICALKNOWLEDGE
1* Knowsthepathophysiology,differentialdiagnosis,andcharacteristicclinical,hemodynamic,
radiographic,andlaboratoryfindingsofcardiogenic,hypovolemic,septic,andmixedcirculatoryshock,
andofthesystemicinflammatoryresponsesyndrome.
1 2 3 4 5
2* Knowstheindicationsfor,andcharacteristicfindingswith,bedsideinvasiveandnoninvasive
hemodynamicmonitoring.
1 2 3 4 5
3* Knowstheindications,contraindications,andclinicalpharmacologyforanticoagulant,antiplateletand
fibrinolyticagents.
1 2 3 4 5
4* Knowstheindicationsfor,contraindicationsto,andclinicalpharmacologyofagentsusedtotreat
hypertensiveurgenciesandemergencies,pulmonaryhypertension,andsupraventricularandventricular
arrhythmias.
1 2 3 4 5
1 2 3 4 5
PATIENTCAREANDPROCEDURALSKILLS
6* Possessesskillstomanagepatientswithacutemyocardialinfarctionandanyassociatedrhythm,
conduction,ormechanicalcomplications.
1 2 3 4 5
7* Possessesskillstoevaluateandmanageacutelyunstablecardiacpatientsbyintegratingthefindings
fromclinical,electrocardiographic,telemetry,imaging,andhemodynamicassessmentandtodevelopa
planforbedsideintervention.
1 2 3 4 5
8* Possessesskillstoevaluateandmanagepatientswithhemodynamicinstabilityfollowingcardiacsurgery
andtranscathetervalvetherapy.
1 2 3 4 5
9* Possessesskillstoparticipateintheperioperativecareofhearttransplantandventricularassistdevice
patients,incollaborationwithheartfailureexperts,interventionalcardiologists,andsurgicalconsultants.
1 2 3 4 5
SYSTEMSBASEDPRACTICE
10* Workseffectivelywithallmembersofthecriticalcareunitteam,includingheartfailure/transplant
specialists,electrophysiologists,interventionalists,surgeons,pulmonarycriticalcarephysicians,
nephrologists,neurologists,nurses,physician'sassistants,pharmacists,socialworkers,andotherteam
membersasrequired.
1 2 3 4 5
11* Identifiesknowledgeandperformancegapsandengagesinopportunitiestoachievefocusededucation
andperformanceimprovement.
1 2 3 4 5
12* Incorporatesappropriateusecriteria,risk/benefitanalysis,andcostconsiderationsintheuseoftesting
andtreatment.
1 2 3 4 5
PROFESSIONALISM
13* Workseffectivelyinaninterdisciplinarycriticalcoronarycareunitenvironment.
1 2 3 4 5
14* Demonstratessensitivitytopatientpreferences,values,andendoflifeissues.
1 2 3 4 5
INTERPERSONALANDCOMMUNICATIONSKILLS
15* Communicateswithandeducatespatientsandfamiliesacrossabroadrangeofcultural,ethnic,and
socioeconomicbackgrounds.
1 2 3 4 5
16* Communicatesandworkseffectivelywithphysiciansandotherprofessionalsonthehealthcareteamin
themanagementofcriticallyillpatientsandtheirtransitiontoothercareenvironments.
1 2 3 4 5
17* OverallAssessmentofthisfellowontheirCardiacCriticalCarerotation.
1 2 3 4 5
18 Comments:Pleaseusethecommentboxbelowtoofferdetailedstrengthsand/orweaknessesofthis
fellowontheirCardiacCriticalCarerotation.
19* Isthereanyreasonthisfellowshouldnotmovetothenextlevelofresponsibility?
Yes
No
Comment
20* Wasthisevaluationdiscussedwiththefellowattheendoftherotation?
*ACGMEProgramRequirementV.A.2.a).(1)states"facultymustevaluatefellowperformanceina
timelymannerduringeachrotationanddiscussthisevaluationwitheachfellowatthecompletionofthe
assignment."
Yes
No
OverallComment
ROTATION INFORMATION
Name of Rotation ECHOCARDIOGRAPHY
Supervising / Evaluating Peter Alagona, MD; Omaima Ali, MD; Eric Chan, MD; Joy Cotton, MD; William Davidson,
Faculty Members MD; Andrew Foy, MD; Joseph Gascho, MD; Annick Haouzi, MD; John Kelleman, MD;
Edward Liszka, MD; Urs Leuenberger, MD; Michael Pfeiffer, MD; Eric Popjes, MD
Facility / Location Echo Lab, Inpatient Units, Operating Rooms / Hershey Medical Center
Clinical Experience All fellows will have a minimum of 6 months of direct echocardiography experience.
Additional elective time for interested fellows is available.
Further exposure to echocardiography content comprised of, but not limited to, the
ordering, review, and clinical correlation of echocardiographic studies is anticipated for
all fellows on the following rotations:
Inpatient Acute Service
Heart Failure Service
CCU
Consults
Outpatient Continuity Clinics (HMC and VA)
Didactics Echocardiography Lecture Series Every Tuesday @ 12:30pm in Hamilton Conference
Room (4th Tuesday of each month is multimodality imaging)
Additional echocardiography related cases and topics are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
Overview
The echocardiography rotation is a comprehensive approach to learning the use of cardiac ultrasound imaging to
diagnose and guide treatment of cardiovascular disease. The objective of this rotation is to provide a broad exposure to
the field including an understanding of the fundamentals of cardiac ultrasound imaging and image acquisition, the
approach to obtaining and optimizing images on different ultrasound systems, as well as accurate interpretation of
transthoracic, transesophageal, and stress imaging. Fellows will be trained to perform transthoracic and transesophageal
echocardiograms, learn appropriate supervision of stress echocardiography, and will gain improved understanding on
the appropriate use of echocardiography to diagnose and guide therapy of cardiovascular diseases. The
echocardiography rotations are also a component of the fellows exposure to ECG interpretation and stress testing
(pharmacologic and exercise modalities) with routine review of rest and stress ECGs.
Specific curricular milestones for Echocardiography, as they relate to the Core Competencies promulgated by the
ACGME, are adopted from the COCATS 4 Task Force 5 document. They are included in this curriculum with the
appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow may
achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones
represent minimum expectations during general fellowship.
Vacation/CME Time
Time off for vacation and CME may be requested during this rotation. It is the fellows responsibility to make sure the
minimum required fellow presence is available for this rotation:
The Echocardiography Rotation requires the presence of at least one upper year fellow to cover TEE.
1. Know the physical principles of ultrasound, and the instrumentation used to obtain
I
images.
2. Know the appropriate indications, including the AUC, for: M-mode, 2-dimensional, and 3-
dimensional transthoracic echocardiography; Doppler echocardiography and color flow
imaging; transesophageal echocardiography; tissue Doppler and strain imaging; and I
contrast echocardiography.
3. Know the limitations and potential artifacts of the echocardiographic examination. I
4. Know the standard views included in a comprehensive transthoracic echocardiography. I
5. Know the standard views included in a comprehensive transesophageal
echocardiography. I
6. Know the techniques to quantify cardiac chamber sizes and evaluate left and right
ventricular systolic and diastolic function and hemodynamics. II
11. Know the characteristic findings of basic adult congenital heart disease. II
12. Know the findings of complex/postoperative adult congenital heart disease. III*+
13. Know the techniques to evaluate cardiac masses and suspected endocarditis. II
14. Know the techniques to evaluate diseases of the aorta. II
15. Know the techniques to assess pulmonary artery pressure and diseases of the right
heart. II
16. Know the use and characteristic findings in the evaluation of patients with systemic
diseases involving the heart. II
17. Know the indications for, and the echocardiographic findings in, patients with known or
suspected cardioembolic events. II
Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training
Exam
CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 37
Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice
of echocardiography.
5. Skill to integrate echocardiographic findings with clinical and other testing results in the
evaluation and management of patients. I
Goal Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the
ability to call effectively on other resources in the system to provide optimal healthcare.
Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Identify knowledge and performance gaps and engage in opportunities to achieve
focused education and performance improvement. I
Evaluation Methods: Attending Evaluations, Core Competency Committee, Direct Observation and Feedback, In-Training
Exam, Self-Evaluation
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
1. Know and promote adherence to guidelines and appropriate use criteria. I
2. Interact respectfully with patients, families, and all members of the healthcare team,
including ancillary and support staff. I
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
1. Communicate with and educate patients and families across a broad range of cultural,
ethnic, and socioeconomic backgrounds. II
*Because of its unique and specialized nature, competency in interpreting complex and post-operative congenital heart
disease echocardiography studies will usually require training beyond Level II.
+See definition of Level III training in Section 1.2 of COCATS Task Force 5.
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
When a STAT echocardiogram is requested, the on call cardiology fellow should be called. Indications for STAT
echocardiography generally include but are not limited to the following:
1. Assessment of hemodynamic collapse or cardiogenic shock when other diagnostic modalities have not
elucidated the diagnosis.
2. Assessment of suspected cardiac tamponade when suggested by a clinical history, physical exam or
hemodynamic monitoring.
3. Suspected aortic dissection. Patients with bona fide suspicion for traumatic aortic dissection should be directly
studied by transesophageal echo.
4. Suspected cardiac contusion in the hemodynamically unstable patient or in patients requiring urgent surgical
intervention. Patients with suspected cardiac contusion, who are clinically stable without suspicion of traumatic
aortic dissection, can be studied routinely in the Echo Lab. On the weekends, we request that contusion studies
be performed within 24 hours of request. In addition, the 12 lead EKG should be reviewed at the time the echo
is performed.
5. Evaluation of LV function or valvular heart function in the acutely ill patient requiring urgent percutaneous
coronary revascularization, percutaneous valvuloplasty, or cardiac surgery.
The fellow is expected to contact the cardiology attending on call for TEEs when an after hour STAT TEE is ordered.
Coordination of the TEE should be made with the attending. For STAT transthoracic echoes, the fellow should fill out a
preliminary report on Synapse and communicate the findings verbally or by writing a preliminary note in the chart. The
fellow should discuss any questions with the on call echo attending.
When the patient is clinically unstable, the TEE team should be mobilized without further delay. The echo attending
must be present for all TEEs. The only exception to this policy would be the hemodynamically unstable patient when the
transesophageal echocardiography is an absolute emergency and the fellow has sufficient experience to operate semi-
independently. In this extremely rare situation, the senior cardiology fellow on call should communicate the specifics of
the procedure as soon as it is completed. A TEE attending is always available on call. As with any emergent imaging
study, the results of the study must be fully documented in the progress notes and directly communicated to the
responsible physician.
Instructions:
ThefollowingevaluationquestionshavebeendevisedusingtheCOCATS4CoreCompetencyComponentsand
CurricularMilestonesforTraininginEchocardiography.TheevaluationscaleismodeledaftertheACGMEMilestones
categories,whicharecompetencybaseddevelopmentaloutcomes(e.g.,knowledge,skills,attitudes,andperformance)
thatcanbedemonstratedprogressivelybyresidentsandfellowsfromthebeginningoftheireducationthroughgraduation
totheunsupervisedpracticeoftheirspecialties.
SubjectName
Status
Evaluatedby: EvaluatorName
Status
Employer
Employer
Program
Program
Rotation
EvaluationDates
1* Knowsandpromotesadherencetoguidelinesandappropriateusecriteria.
1 2 3 4 5
2* Possessesskillstoperformandinterpretcomprehensivetransthoracicechocardiographyexam.
1 2 3 4 5
3* Possessesskillstoperformandinterpretcomprehensivetransesophagealechocardiographyexam.
1 2 3 4 5
4* Possessesskillstointerpretstressechocardiography.
1 2 3 4 5
5* Knowsthetechniquestoquantifycardiacchambersizesandevaluateleftandrightventricularsystolic
anddiastolicfunctionandhemodynamics.
1 2 3 4 5
1 2 3 4 5
7* Workseffectivelyandefficientlywiththeechocardiographylaboratorystaff.
1 2 3 4 5
8* Communicatestestingresultstophysiciansandpatientsinaneffectiveandtimelymanner.
1 2 3 4 5
9* Interactsrespectfullywithpatients,families,andallmembersofthehealthcareteam.
1 2 3 4 5
10* Identifiesknowledgeandperformancegapsandengagesinopportunitiestoachievefocusededucation
andperformanceimprovement.
1 2 3 4 5
OVERALLASSESSMENT
11* OverallAssessmentofthisfellowontheirEchocardiographyrotation.
1 2 3 4 5
12 Comments:Pleaseusethecommentboxbelowtoofferdetailedstrengthsand/orweaknessesofthis
fellowontheirEchocardiographyrotation.
13* Isthereanyreasonthisfellowshouldnotmovetothenextlevelofresponsibility?
Yes
No
Comment
CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 42
14* Wasthisevaluationdiscussedwiththefellowattheendoftherotation?
*ACGMEProgramRequirementV.A.2.a).(1)states"facultymustevaluatefellowperformanceina
timelymannerduringeachrotationanddiscussthisevaluationwitheachfellowatthecompletionofthe
assignment."
Yes
No
OverallComment
ROTATION INFORMATION
Name of Rotation ELECTROPHYSIOLOGY
Supervising / Evaluating Mario Gonzalez, MD; Sarah Hussain, MD; Gerald Naccarelli, MD; Soraya Samii, MD;
Faculty Members Deborah Wolbrette, MD
Facility / Location EP Lab, Inpatient Units, Device Clinic / Hershey Medical Center
Clinical Experience All fellows will have a minimum of 2 months of direct electrophysiology experience.
Additional elective time for interested fellows is available.
Additional electrophysiology related cases and topics are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
Overview
The clinical cardiac electrophysiology rotation provides direct exposure to the fundamentals of diagnosis and
management of cardiac arrhythmias and conduction disorders. This includes understanding the mechanisms and
management of arrhythmias required to provide comprehensive patient care. The trainee will participate in
electrophysiology focused consultation and management in the inpatient and outpatient settings; observe and
participate in EP studies, testing, and procedures; and work with appropriate staff on the interrogation and
programming of implanted cardiac devices. The electrophysiology rotation is a key component of the fellows exposure
to ECG interpretation.
COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during
general fellowship in cardiovascular disease. Penn State Hershey offers subspecialty training in Electrophysiology which
can be applied for following general cardiology fellowship.
Specific curricular milestones for electrophysiology as they relate to the Core Competencies promulgated by the ACGME
are adopted from the ACC COCATS 4 Task Force 11 document. They are included in this curriculum with the appropriate
associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule a fellow may achieve these
milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent
minimum expectations during general fellowship.
The availability of several of the activities outlined above for the EP rotation fluctuates on a weekly basis. In general, it is
anticipated the fellow will spend, on a daily basis, the equivalent of a half day seeing and following up on consults as
needed and the equivalent of a half day participating in one of the other recommended or required activities.
Reasonable adjustments will be suggested by faculty when appropriate, but are ultimately the responsibility of the
fellow to maximize their educational opportunities.
Vacation/CME Time
Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless
specified by the involved faculty.
In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging
coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship
coordinator and approved by the fellowship director. It is the fellows responsibility to ensure time off does not
significantly impact or limit total exposure to any given rotation.
Clinical Arrhythmology and Electrophysiology: A Companion to Braunwald's Heart Disease, 2nd Ed, Issa, Miller,
Zipes
Handbook of Cardiac Electrophysiology: A Practical Guide to Invasive EP Studies and Catheter Ablation, 1st Ed,
Murgatroyd, Krahn, Yee, Skanes, Klein
CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 47
CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 48
Core Competency Components and Curricular Milestones for Training in ELECTROPHYSIOLOGY
Medical Knowledge 1st Year 2nd Year 3rd Year
Goal Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral
sciences, as well as the application of this knowledge to patient care.
1. Know the mechanism and characteristics of normal sinus rhythm and of sinus node
dysfunction. I
13. Know the indications and contraindications for permanent pacemaker placement,
cardiac resynchronization therapy, and implantable cardioverter-defibrillator placement. I
14. Know the pathophysiology, differential diagnosis, natural history, and approach to
management of syncope, including neurocardiogenic causes and syncope in athletes. I
18. Know the basic principles of programming and interrogating implanted devices
(permanent pacemakers, implantable cardioverter-defibrillators, cardiac I
resynchronization therapies, and implantable monitors).
Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training
Exam
Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice
of electrophysiology.
13. Skill to integrate the information provided in cardiac electrophysiology consultation, and
reports of procedures and device interrogation, into the overall clinical assessment of I
the patient and plan of management.
14. Skill to perform pacemaker and implantable cardioverter-defibrillator interrogation,
programming, and surveillance. II
16. Skill to perform implantation of implantable loop recorders, interpret results to guide
patient management, and manage complications. II
17. Skill to follow-up, interrogate, and troubleshoot patients with implanted devices
(permanent pacemakers, implantable cardioverter-defibrillators, cardiac II
resynchronization therapies), including remote interrogation.
18. Skill to evaluate and manage patients with cardiac arrest. I
19. Skill to prescribe and interpret the results of electrocardiographic recording devices. I
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Procedure/Activity Logbook
Goal Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the
ability to call effectively on other resources in the system to provide optimal healthcare.
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, 360 Reviews
Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Identify knowledge and performance gaps and engage in opportunities to achieve
focused education and performance improvement. I
2. Utilize decision support tools for accessing guidelines and pharmacologic information at
the point of care. I
Evaluation Methods: Attending Evaluations, Core Competency Committee, Direct Observation and Feedback, In-Training
Exam, Self-Evaluation
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews
CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 51
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
1. Communicate with and educate patients and families across a broad range of cultural,
ethnic, and socioeconomic backgrounds. I
2. Engage in shared decision-making with patients, including decisions regarding options for
diagnosis and treatment. I
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluation, 360 Reviews
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
Instructions:
ThefollowingevaluationquestionshavebeendevisedusingtheCOCATS4CoreCompetencyComponentsand
CurricularMilestonesforTraininginCardiacCatheterization.TheevaluationscaleismodeledaftertheACGME
Milestonescategories,whicharecompetencybaseddevelopmentaloutcomes(e.g.,knowledge,skills,attitudes,and
performance)thatcanbedemonstratedprogressivelybyresidentsandfellowsfromthebeginningoftheireducation
throughgraduationtotheunsupervisedpracticeoftheirspecialties.
SubjectName
Status
Evaluatedby: EvaluatorName
Status
Employer
Employer
Program
Program
Rotation
EvaluationDates
MEDICALKNOWLEDGE
1 Knowsthemechanismandcharacteristicsofnormalsinusrhythmandofsinusnodedysfunction.
1 2 3 4 5
2 Knowsthepathophysiology,differentialdiagnosis,clinicalsignificance,andapproachtomanagementof
atrialfibrillationandflutter,includingtheassessmentofstrokeandbleedingrisk,indicationsof
anticoagulation,andselectionofanticoagulantmedications.
1 2 3 4 5
3* Knowstheriskfactorsforstrokeandforbleedinginpatientswithatrialfibrillationoratrialflutter,aswell
astheindicationsfor,anduseof,anticoagulantmedications.
1 2 3 4 5
4 Knowsthetypes,mechanisms,differentialdiagnosis,clinicalsignificance,andapproachtomanagement
ofatrioventriculardissociationandatrioventricularheartblocks(first,second,andthirddegree).
1 2 3 4 5
1 2 3 4 5
6 Knowstheindicationsandlimitationsofnoninvasivetestinginthediagnosisandmanagementofpatients
witharrhythmias:electrocardiogram,ambulatory,event,implantablelooprecorder,andtilttabletesting.
1 2 3 4 5
7 Knowstheindicationsfor,andlimitationsandcomplicationsof,invasiveelectrophysiologictesting,as
wellascatheterablationforcardiacarrhythmias.
1 2 3 4 5
8 Knowstheindicationsandcontraindicationsforpermanentpacemakerplacement,cardiac
resynchronizationtherapy,andimplantablecardioverterdefibrillatorplacement.
1 2 3 4 5
9 Knowsthepathophysiology,differentialdiagnosis,naturalhistory,andapproachtomanagementof
syncope,includingneurocardiogeniccausesandsyncopeinathletes.
1 2 3 4 5
10 Knowsthepathology,clinicalsignificance,andapproachtoevaluation(includingtheroleofgenetic
testing)andmanagementofinheriteddiseasesthatmaycausecardiacarrhythmiasduetoionchannel
abnormalitiesorstructuralchangesintheheart(includingthelongQTsyndrome,Brugadasyndrome,
arrhythmogenicrightventriculardysplasia,hypertrophicdilatedcardiomyopathy,andmyotonic
dystrophy).
1 2 3 4 5
1 2 3 4 5
PATIENTCAREANDPROCEDURALSKILLS
12 Possessesskillstoevaluateandmanagepatientswithpalpitations.
1 2 3 4 5
13 Possessesskillstoevaluateandmanagepatientswithsyncope.
1 2 3 4 5
14 Possessesskillstoevaluateandmanagepatientswithsupraventriculartachyarrhythmias.
1 2 3 4 5
15 Possessesskillstoevaluateandmanagepatientswithatrialfibrillationandflutter(includingrateand
rhythmcontrolandanticoagulationstrategies).
1 2 3 4 5
16 Possessesskillstoperformelectricalcardioversion.
1 2 3 4 5
1 2 3 4 5
18 Possessesskillstointegratetheinformationprovidedincardiacelectrophysiologyconsultation,and
reportsofproceduresanddeviceinterrogation,intotheoverallclinicalassessmentofthepatientand
planofmanagement.
1 2 3 4 5
19 Possessesskillstoperformpacemakerandimplantablecardioverterdefibrillatorinterrogation,
programming,andsurveillance.
*Pacercliniceducator,pleasecompletethisquestion.
1 2 3 4 5
SYSTEMSBASEDPRACTICE
20 Utilizesaninterdisciplinarycoordinatedapproachforpatientmanagement,includingtransferofcareand
employmentrelatedissues.
1 2 3 4 5
21 Incorporatesrisk/benefitanalysisandcostconsiderationsindiagnosticandtreatmentdecisions.
1 2 3 4 5
PRACTICEBASEDLEARNINGANDIMPROVEMENT
22 Identifiesknowledgeandperformancegapsandengagesinopportunitiestoachievefocusededucation
andperformanceimprovement.
1 2 3 4 5
1 2 3 4 5
PROFESSIONALISM
24 Demonstratessensitivitytopatientpreferencesandendoflifeissues.
1 2 3 4 5
25 Practiceswithinthescopeofexpertiseandtechnicalskills.
*Pacercliniceducator,pleasecompletethisquestion.
1 2 3 4 5
26* Interactsrespectfullywithpatients,families,andallmembersofthehealthcareteam,includingancillary
andsupportstaff.
1 2 3 4 5
INTERPERSONALANDCOMMUNICATIONSKILLS
27 Communicateswithandeducatespatientsandfamiliesacrossabroadrangeofsocioeconomic,ethnic,
andculturalbackgrounds.
1 2 3 4 5
28 Engagesinshareddecisionmakingwithpatients,includingdecisionsregardingoptionsfordiagnosisand
treatment.
1 2 3 4 5
OVERALLASSESSMENT
1 2 3 4 5
30 Comments:Pleaseusethecommentboxbelowtoofferdetailedstrengthsand/orweaknessesofthis
fellowontheirElectrophysiologyrotation.
31* Isthereanyreasonthisfellowshouldnotmovetothenextlevelofresponsibility?
Yes
No
Comment
32* Wasthisevaluationdiscussedwiththefellowattheendoftherotation?
*ACGMEProgramRequirementV.A.2.a).(1)states"facultymustevaluatefellowperformanceina
timelymannerduringeachrotationanddiscussthisevaluationwitheachfellowatthecompletionofthe
assignment."
Yes
No
OverallComment
ROTATION INFORMATION
Name of Rotation HEART FAILURE
Supervising / Evaluating Omaima Ali, MD; John Boehmer, MD; Dwight Davis, MD; Eric Popjes, MD; David Silber,
Faculty Members MD
Facility / Location Inpatient Units / Hershey Medical Center
Clinical Experience All fellows will have a minimum of 2 months of direct heart failure experience.
Additional elective time for interested fellows is available.
Further exposure to Heart Failure content comprised of, but not limited to, acute
inpatient care of heart failure patients, long-term management and follow-up of heart
failure patients, imaging review and clinical correlation is anticipated for all fellows on
the following rotations:
Inpatient Acute Service
CCU
Consults
Outpatient Continuity Clinics (HMC and VA)
Echocardiography
Didactics There is no dedicated Heart Failure Lecture Series. Heart Failure lectures will occur as a
part of the Core Conference Series.
Additional heart failure related cases and topics are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
Echocardiography Conference
Cath Conference
Overview
The heart failure service rotation provides the opportunity to diagnose, evaluate and treat patients who encompass a
broad range of heart failure disorders. This rotation will allow the trainee to acquire the appropriate foundational tools
to care for this unique population including knowledge pertaining to medical management, procedural techniques and
advanced heart failure therapies including mechanical circulatory support. The rotation will also provide exposure to
transplant medicine and management of patients both pre- and post-transplant. The heart failure rotations are also a
component of the fellows exposure to ECG interpretation with routine review of inpatient ECGs.
COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during
the general fellowship in cardiovascular disease. At the present time, Penn State Hershey does not offer subspecialty
training in Heart Failure.
Specific curricular milestones for heart failure as they relate to the Core Competencies promulgated by the ACGME are
adopted from the ACC COCATS 4 Task Force 12 document. They are included in this curriculum with the appropriate
associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule a fellow may achieve these
milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones represent
minimum expectations during general fellowship.
In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging
coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship
coordinator and approved by the fellowship director.
1. Know the pathophysiology, differential diagnosis, stages, and natural history of heart
failure. I
2. Know the characteristic history and physical exam findings, and their limitations, in
evaluation of heart failure syndromes. I
3. Know the pathophysiology of heart failure at the molecular, cellular, organ, and
organismal levels, with emphasis on the roles of neurohormonal activation and left I
ventricular remodeling in disease progression.
4. Know the indications, contraindications, and clinical pharmacology for drugs used for
treatment of heart failure, including adverse effects. I
5. Know the indications, contraindications, and clinical pharmacology for the drugs used for
the treatment of heart failure of all etiologies and degrees of severity and in special II
populations.
6. Know the indications, contraindications, and clinical pharmacology for intravenous,
vasoactive, and inotropic drugs used for cardiovascular support in advanced/refractory I
heart failure.
7. Know the appropriate pharmacologic or nonpharmacologic treatment for the prevention
of heart failure in patients with either pre or established heart failure. I
8. Know the clinical pharmacology and use of immunosuppressive medications and other
interventions in heart transplant patients in the treatment of acute rejection. II
11. Know the management of cardiac arrhythmias in heart failure patients, as well as the
indications and risks of use of implantable cardioverter-defibrillator and cardiac I
resynchronization therapies.
12. Know the indications for referral for cardiac transplantation. I
13. Know the management and diagnostic strategies for populations with heart failure not
due to ischemic heart disease, including infiltrative and restrictive cardiomyopathies, II
inherited cardiomyopathies, and those associated with pregnancy and chemotherapy.
Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training Exam
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice
of heart failure.
1. Skill to evaluate and manage patients with new-onset, chronic, and acute
decompensated heart failure. I
2. Skill to evaluate and manage patients with severe heart failure despite treatment. II
3. Skill to appropriately obtain and incorporate data from the history, laboratory studies,
and imaging modalities in evaluation and management of heart failure patients. I
14. Skill to appropriately utilize initial screening studies to determine patient eligibility for
advanced therapies of individuals cared for at non-transplant / non-ventricular assist
device facilities, in collaboration with Level III-trained individuals, who work at advanced II
therapy sites.
15. Skill to interpret and incorporate results of cardiopulmonary exercise testing into
management of heart failure patients, including physical activity and exercise II
recommendations.
16. Skill to recognize, manage, and seek appropriate consultation for depression or undue
anxiety in heart failure patients as part of their overall care. I
Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback,
Procedure/Activity Logbook
Goal Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the
ability to call effectively on other resources in the system to provide optimal healthcare.
1. Utilize appropriate care settings and teams for various levels and stages of heart failure. I
2. Incorporate risk/benefit analysis and cost considerations in diagnostic and treatment
decisions. I
3. Identify and address financial, cultural, and social barriers to diagnostic and treatment
recommendations. I
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, 360 Reviews
Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Identify knowledge and performance gaps and engage in opportunities to achieve
focused education and performance improvement. I
2. Utilize decision support tools for accessing guidelines and pharmacologic information at
the point of care. II
Evaluation Methods: Attending Evaluations, Core Competency Committee, Direct Observation and Feedback, In-Training
Exam, Self-Evaluation
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
2. Interact respectfully with patients, families, and all members of the healthcare team,
including ancillary and support staff. I
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
1. Communicate with and educate patients and families across a broad range of cultural,
ethnic, and socioeconomic backgrounds. I
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluation, 360 Reviews
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
Instructions:
ThefollowingevaluationquestionshavebeendevisedusingtheCOCATS4CoreCompetencyComponentsand
CurricularMilestonesforTraininginHeartFailure.TheevaluationscaleismodeledaftertheACGMEMilestones
categories,whicharecompetencybaseddevelopmentaloutcomes(e.g.,knowledge,skills,attitudes,andperformance)
thatcanbedemonstratedprogressivelybyresidentsandfellowsfromthebeginningoftheireducationthroughgraduation
totheunsupervisedpracticeoftheirspecialties.
SubjectName
Status
Evaluatedby: EvaluatorName
Status
Employer
Employer
Program
Program
Rotation
EvaluationDates
MEDICALKNOWLEDGE
1* Knowsthepathophysiology,differentialdiagnosis,stages,andnaturalhistoryofheartfailure.
1 2 3 4 5
2* Knowsthecharacteristichistoryandphysicalexamfindings,andtheirlimitations,inevaluationofheart
failuresyndromes.
1 2 3 4 5
3* Knowstheindications,contraindications,andclinicalpharmacologyforthedrugsusedforthetreatment
ofheartfailureofalletiologiesanddegreesofseverityandinspecialpopulations.
1 2 3 4 5
4* Knowsthetypesof,andindicationsfor,mechanicalcirculatorysupport.
1 2 3 4 5
5* Knowstheindicationsforreferralforcardiactransplantation.
1 2 3 4 5
6* Possessesskillstoevaluateandmanagepatientswithnewonset,chronic,andacutedecompensated
heartfailure.
1 2 3 4 5
7* Possessesskillstoappropriatelyobtainandincorporatedatafromthehistory,laboratorystudies,and
imagingmodalitiesinevaluationandmanagementofheartfailurepatients.
1 2 3 4 5
8* Possessesskillstoidentifyappropriatecandidatesforpalliativecareandhospice.
1 2 3 4 5
9* Possessesskillstorecognizeandmanagecomorbiditiesinheartfailurepatients.
1 2 3 4 5
SYSTEMSBASEDPRACTICE
10* Utilizesaninterdisciplinary,coordinated,teamapproachforpatientmanagement,includingcare
transitions,palliativecare,andemploymentrelatedissues.
1 2 3 4 5
PRACTICEBASEDLEARNINGANDIMPROVEMENT
11* Identifiesknowledgeandperformancegapsandengagesinopportunitiestoachievefocusededucation
andperformanceimprovement.
1 2 3 4 5
12* Showscompassionandeffectivemanagementofendoflifeissues,includingfamilymeetingsacrossthe
spectrumofpatientswithheartfailure.
1 2 3 4 5
13* Interactsrespectfullywithpatients,families,andallmembersofthehealthcareteam,includingancillary
andsupportstaff.
1 2 3 4 5
INTERPERSONALANDCOMMUNICATIONSKILLS
14* Communicateswithandeducatespatientsandfamiliesacrossabroadrangeofcultural,ethnic,and
socioeconomicbackgrounds.
1 2 3 4 5
15* Engagesinshareddecisionmakingwithpatients,includingoptionsfordiagnosisandtreatment.
1 2 3 4 5
OVERALLASSESSMENT
16* OverallAssessmentofthisfellowontheirHeartFailurerotation.
1 2 3 4 5
17 Comments:Pleaseusethecommentboxbelowtoofferdetailedstrengthsand/orweaknessesofthis
fellowontheirHeartFailurerotation.
18* Isthereanyreasonthisfellowshouldnotmovetothenextlevelofresponsibility?
Yes
No
Comment
OverallComment
ROTATION INFORMATION
Name of Rotation NUCLEAR CARDIOLOGY
Supervising / Evaluating Charles Chambers, MD; Eric Chan, MD; Edward Liszka, MD; Michael Pfeiffer, MD
Faculty Members
Facility / Location Nuclear Radiology Ground Floor / Hershey Medical Center
Clinical Experience All fellows must have a minimum of 2 months of direct nuclear cardiology experience.
The average experience is 3-4 months. Additional elective time for interested fellows is
available.
Further exposure to nuclear cardiology content comprised of, but not limited to,
ordering, reviewing, and applying results from nuclear cardiology studies is anticipated
for all fellows on the following rotations:
Inpatient Acute Service
CHF Service
Consults
Outpatient Continuity Clinics (HMC and VA)
Didactics Nuclear Lecture Series Every 2nd and 4th Thursday @ 7am in Hamilton Conference
Room
Additional nuclear cardiology related cases and topics are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
Overview
The nuclear cardiology rotation provides direct exposure to the fundamentals of nuclear imaging as they pertain to
cardiovascular disease. This includes the ordering, administration, and interpretation of nuclear cardiology studies in
patients with suspected or known cardiovascular disease. These rotations also include a high level overview of radiation
biology and safety training. Fellows who desire to sit for the CBNC Board Exam and/or obtain Level II status will need to
complete an external course to satisfy the requirements of the NRC. The nuclear cardiology rotations are also a
component of the fellows exposure to ECG interpretation and stress testing (pharmacologic and exercise modalities)
with routine review of rest and stress ECGs.
COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during
general fellowship in cardiovascular disease. At the present time, Penn State Hershey does not offer subspecialty
training in Nuclear Cardiology.
Specific curricular milestones for nuclear cardiology as they relate to the Core Competencies promulgated by the
ACGME are adopted from the ACC COCATS 4 Task Force 6 document. They are included in this curriculum with the
appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule a fellow may
achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones
represent minimum expectations during general fellowship.
Vacation/CME Time
Time off for vacation and CME may be requested during this rotation. It is the fellows responsibility to make sure the
minimum required fellow presence is available for this rotation:
When coverage is required to satisfy these minimum requirements, it is the fellows responsibility to arrange this
coverage and notify any involved faculty. In the event of emergent time off, the chief fellow(s) and program leadership
should be notified to assist in arranging coverage. All requests for time off, regardless of the rotation involved, must be
submitted through the fellowship coordinator and approved by the fellowship director.
The afternoon reading sessions will also be attended and supervised by radiology faculty who will interact with fellows
and provide additional direct feedback for all trainees in the group setting.
Nuclear Cardiology Technical Applications 1st Ed., Heller, Mann, & Hendel
5. Know the principles and use of pretest probability and sequential probability analysis to
assess posttest probability. I
7. Know the protocols for administration of standard perfusion agents and the influence of
the clinical situation on choice of imaging protocol. I
8. Know the quality control issues, how to review raw data, and recognize artifacts. II
9. Know the use of nuclear cardiology in the assessment of ventricular function. I
10. Know the protocols for the use of perfusion imaging to assess myocardial viability. I
11. Know the indications for positron emission testing imaging and use of positron emission
testing tracers. II
Evaluation Methods: Attending Evaluations, Conference Presentations, Direct Observation and Feedback, In-Training
Exam
Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the
promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice of
nuclear cardiology.
1. Skill to select the appropriate imaging study. I
2. Skill to integrate perfusion imaging findings with clinical and other test results in the
evaluation and management of patients. I
Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Identify knowledge and performance gaps and engage in opportunities to achieve
focused education and performance improvement. I
Evaluation Methods: Attending Evaluations, Core Competency Committee, Direct Observation and Feedback, In-Training
Exam, Self-Evaluation
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluations, 360 Reviews
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
1. Communicate effectively and timely with patients, families, and referring physicians. I
2. Communicate test results in a comprehensive and user-friendly manner. II
Evaluation Methods: Attending Evaluations, Direct Observation and Feedback, Self-Evaluation
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
Instructions:
ThefollowingevaluationquestionshavebeendevisedusingtheCOCATS4CoreCompetencyComponentsand
CurricularMilestonesforTraininginNuclearCardiology.TheevaluationscaleismodeledaftertheACGMEMilestones
categories,whicharecompetencybaseddevelopmentaloutcomes(e.g.,knowledge,skills,attitudes,andperformance)
thatcanbedemonstratedprogressivelybyresidentsandfellowsfromthebeginningoftheireducationthroughgraduation
totheunsupervisedpracticeoftheirspecialties.
SubjectName
Status
Evaluatedby: EvaluatorName
Status
Employer
Employer
Program
Program
Rotation
EvaluationDates
1* Knowsandpromotesadherencetoguidelinesandappropriateusecriteriafornuclearcardiologyimaging.
1 2 3 4 5
2* Knowstheindicationsformyocardialperfusionimagingandtheappropriateselectionofexerciseversus
pharmacologicstresstesting.
1 2 3 4 5
3* Knowstheprinciplesofsinglephotonemissioncomputedtomographyacquisitionanddisplay,including
thestandardtomographicplanesandviews.
1 2 3 4 5
4* Knowsthemechanismofpharmacologicstressagents,methodsoftheiradministration,andsafety
issuesinusingtheagents.
1 2 3 4 5
5* Possessesskillstoperformandinterpretgatedstressrestperfusionstudy.
1 2 3 4 5
1 2 3 4 5
7* Communicatestestresultsinacomprehensiveanduserfriendlymanner.
1 2 3 4 5
8* Workseffectivelyandefficientlywiththenuclearlaboratorystaff.
1 2 3 4 5
9* Interactsrespectfullywithpatients,families,andallmembersofthehealthcareteamincludingancillary
andsupportstaff.
1 2 3 4 5
10* Identifiesknowledgeandperformancegapsandengagesinopportunitiestoachievefocusededucation
andperformanceimprovement.
1 2 3 4 5
OVERALLASSESSMENT
11* OverallAssessmentofthisfellowontheirNuclearCardiologyrotation.
1 2 3 4 5
12 Comments:Pleaseusethecommentboxbelowtoofferdetailedstrengthsand/orweaknessesofthis
fellowontheirNuclearCardiologyrotation.
13* Isthereanyreasonthisfellowshouldnotmovetothenextlevelofresponsibility?
Yes
No
Comment
CARDIOVASCULAR DISEASE FELLOWSHIP HANDBOOK - 77
14* Wasthisevaluationdiscussedwiththefellowattheendoftherotation?
*ACGMEProgramRequirementV.A.2.a).(1)states"facultymustevaluatefellowperformanceina
timelymannerduringeachrotationanddiscussthisevaluationwitheachfellowatthecompletionofthe
assignment."
Yes
No
OverallComment
ROTATION INFORMATION
Name of Rotation VASCULAR / IMAGING
Supervising / Evaluating Robert Atnip, MD (Vascular Surgery), David Han, MD (Vascular Surgery)
Faculty Members
Facility / Location Vascular Lab, Outpatient Clinics/ Hershey Medical Center, IO Silver
Clinical Experience All fellows will have 2 months of vascular experience. This will be obtained during the
combined Vascular/Imaging rotation and in aggregate exposure on other rotations.
Additional elective time for interested fellows is available.
Further exposure to vascular content comprised of, but not limited to, the
presentation, evaluation, and management of peripheral vascular disease as well as the
ordering, reviewing, and applying results from multimodality imaging of the central and
peripheral vasculature is anticipated for all fellows on the following rotations:
Inpatient Acute Service
CHF Service
Consults
CCU
Outpatient Continuity Clinics (HMC and VA)
ACHD
Didactics Vascular Imaging Lectures will occur individually during the Vascular/Imaging rotation.
Additional vascular related cases and topics are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
Core Conference
Multimodality Imaging
Overview
The vascular portion of the Vascular/Imaging rotation exposes the fellow to evaluation and management of peripheral
vascular disease. The vascular portion of the rotation experience is designed to emphasize exposure to vascular
ultrasound imaging and outpatient management of peripheral vascular disease. Additional multimodality imaging of
the peripheral vasculature as well as inpatient care of non-coronary cardiovascular disease is anticipated in aggregate
throughout other rotations.
COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during
general fellowship in cardiovascular disease.
Specific curricular milestones for vascular imaging, as they relate to the Core Competencies promulgated by the ACGME,
are adopted as outlined in the COCATS 4 Task Force 9 document. They are included in this curriculum with the
appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow may
achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I milestones
represent minimum expectations during general fellowship.
There is flexible time in this rotation designed to allow for self-directed exposure based on areas of interest and
availability. The following secondary goals can be distributed by the fellow during the rotation based on availability,
need, and their personal interest:
The following template serves as a guideline for expected attendance at planned activities (highlighted) to meet the
primary goals, as well as a proposed schedule of secondary activities.
Vacation/CME Time
Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless
specified by the involved faculty.
In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging
coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship
coordinator and approved by the fellowship director.
2. Know the causes and clinical epidemiology of atherosclerotic peripheral vascular disease,
including the incidence and prevalence, sex and ethnic differences, role of genetics, and I
the influence of traditional risk factors and demographics on outcomes.
5. Know the pathophysiology, causes, and clinical epidemiology of acute aortic syndromes
such as dissection and intramural hematoma. I
6. Know the pathophysiology, causes, and clinical epidemiology of deep vein thrombosis
and pulmonary embolism. I
10. Know the cardinal symptoms and physical findings of peripheral atherosclerotic vascular
diseases, including peripheral artery disease, renal and mesenteric artery disease, I
extracranial cerebrovascular disease, and abdominal aortic aneurysm.
11. Know the cardinal symptoms and physical findings of venous diseases including venous
thromboembolism, chronic venous insufficiency, and varicose veins. I
12. Know the differentiating characteristics between arterial, venous, and neurotrophic
lower extremity ulcers. II
13. Know the natural history and prognosis of deep vein thrombosis and pulmonary
embolism. I
14. Know the natural history and prognosis of peripheral atherosclerotic vascular diseases
including peripheral artery disease, renal and mesenteric artery disease, extracranial I
carotid artery disease, and abdominal aortic aneurysm.
15. Know the indications for noninvasive screening for abdominal aortic aneurysm.
I
16. Know the indications for duplex ultrasound of the peripheral veins and carotid arteries
and for duplex and physiological testing of the peripheral arteries. I
19. Know the appropriate indications and laboratory tests to assess for inherited and
acquired thrombophilia. I
20. Know the appropriate indications and laboratory tests to assess for vasculitis.
I
21. Know the indications, contraindications, risks, clinical pharmacology, and interactions of
drugs used to treat atherosclerotic vascular diseases. I
22. Know the indications, contraindications, risks, clinical pharmacology, and interactions of
drugs used to treat thrombotic disorders. I
23. Know the indications, contraindications, risks, and expected outcomes for thrombolytic
therapy for venous thromboembolism (pulmonary embolism and deep vein thrombosis). I
24. Know the indications and risks for surgical and endovascular treatments for acute aortic
syndromes; and, the expected outcomes. I
25. Know the indications and risks for surgical and endovascular treatments for aortic
aneurysm; and, the expected outcomes. I
26. Know the indications and risks for surgical and endovascular treatments for peripheral
atherosclerotic vascular diseases, including peripheral artery disease, renal and
I
mesenteric artery disease, and extracranial cerebrovascular disease; and the expected
outcomes.
Evaluation Methods: Conference Presentations, Direct Observation and Feedback. In-Training Exam
Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice
of cardiac catheterization.
7. Skill to evaluate and manage acute aortic syndromes including identification of patients
for whom surgical or endovascular therapy is indicated. I
8. Skill to evaluate and manage patients with deep venous thrombosis and pulmonary
embolism, including identification of patients for whom thrombolytic therapy is I
indicated.
9. Skill to perform preoperative risk assessment and manage patients undergoing vascular
surgery. I
10. Skill to evaluate and manage lower extremity peripheral artery disease.
I
Goal Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the
ability to call effectively on other resources in the system to provide optimal healthcare.
1. Practice in a manner that balances appropriate utilization of finite resources with the
net clinical benefit for the individual patient. I
Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Identify knowledge and performance gaps and engage in opportunities to achieve
focused education and performance improvement. I
2. Utilize decision support tools for accessing guidelines and pharmacologic information at
the point of care. I
Evaluation Methods: Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
4. Interact respectfully with patients, families, and all members of the healthcare team,
including ancillary and support staff. I
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
1. Communicate with and educate patients and families across a broad range of cultural,
ethnic, and socioeconomic backgrounds. I
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
ROTATION INFORMATION
Name of Rotation VASCULAR / IMAGING
Supervising / Evaluating Steven Ettinger, MD; Mark Kozak, MD; Michael Pfeiffer, MD
Faculty Members Harjit Singh, MD (Radiology)
Facility / Location Ground Floor CT / Hershey Medical Center
Clinical Experience All fellows will have 1 month of cardiac computed tomography experience. This will be
obtained during the combined Vascular/Imaging rotation and in aggregate exposure on
other rotations. Additional elective time for interested fellows is available.
Further exposure to cardiac computed tomography content comprised of, but not
limited to, ordering, reviewing, and applying results from cardiac CT studies is
anticipated for all fellows on the following rotations:
Inpatient Acute Service
Consult Service
Cath
Outpatient Continuity Clinics (HMC and VA)
Didactics There is no dedicated cardiac CT Lecture Series. Cardiac CT lectures will occur as a part
of the Multimodality Imaging Series on the 4th Tuesday of every month (September
June) @ 12:30pm in Hamilton conference room.
Additional cardiac CT related cases and topics are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
Overview
The cardiac CT portion of the Vascular/Imaging rotation exposes the fellow to the basics of cardiac CT. They will gain
familiarity with clinical indications and appropriate use criteria for cardiac CT. They will also be involved with the
manipulation, interpretation, and application of the data from a cardiac CT study.
COCATS Level II training requires a minimum of 3 months of dedicated training in cardiac CT. At the current time, Level
II training is not available during the standard fellowship. Fellows who wish to achieve Level II in cardiac CT should
discuss this with Dr. Ettinger as well as fellowship leadership to see if arrangements external to Penn State can be made.
Specific curricular milestones for computed tomographic imaging, as they relate to the Core Competencies promulgated
by the ACGME, are adopted as outlined in the COCATS 4 Task Force 7 document. They are included in this curriculum
with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a
fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I
milestones represent minimum expectations during general fellowship.
Vacation/CME Time
Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless
specified by the involved faculty.
In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging
coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship
coordinator and approved by the fellowship director.
Exposure to Cardiac CT
o Check for planned coronary CT studies with Drs. Ettinger or Singh
o Review Cardiac CT planning for structural heart disease cases with Dr. Kozak or Pfeiffer
o Independent study of Cardiac CT review materials
Supplemental ECHO exposure
o First years in the second half of their year can observe TEE under the guidance of the upper year fellow
and can start performing TEEs with the permission of the TEE attending
o Additional time in the ECHO lab as needed
Supplemental Nuclear exposure
o Attend afternoon reading sessions for cardiac SPECT imaging.
o Schedule and perform your required Nuclear Radiation Hands-On Safety training
o Assist with coverage for nuclear studies as needed.
The following template serves as a guideline for expected attendance at planned activities (highlighted) to meet the
primary goals, as well as a proposed schedule of secondary activities.
1. Know the principles of cardiovascular computed tomographic scanning and the scanning
modes. I
2. Know the risks and safety measures for cardiovascular computed tomographic scanning,
including radiation reduction strategies. I
6. Know when to request help with interpretation of difficult studies, such as patients with
complex congenital heart disease. I
Evaluation Methods: Conference Presentations, Direct Observation and Feedback. In-Training Exam
Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice
of cardiac catheterization.
Goal Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the
ability to call effectively on other resources in the system to provide optimal healthcare.
1. Incorporate appropriate use criteria, risk/benefit, and cost considerations in the use of
cardiovascular computed tomography and alternative imaging modalities. I
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Identify knowledge and performance gaps and engage in opportunities to achieve
focused education and performance improvement. I
Evaluation Methods: Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
2. Reliably obtain patient informed consent, ensuring that patients understand the risks
and benefits of, and alternatives to, cardiovascular computed tomographic testing. I
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
ROTATION INFORMATION
Name of Rotation VASCULAR / IMAGING
Supervising / Evaluating John Kelleman, MD; Michael Pfeiffer, MD
Faculty Members Carlos Jamis-Dow, MD (Radiology)
Facility / Location Ground Floor MRI / Hershey Medical Center
Clinical Experience All fellows will have 1 month cardiac magnetic resonance imaging experience. This will
be obtained during the combined Vascular/Imaging rotation and in aggregate exposure
on other rotations. Additional elective time for interested fellows is available.
Further exposure to cardiac magnetic resonance imaging content comprised of, but not
limited to, ordering, reviewing, and applying results from cardiac MRI studies is
anticipated for all fellows on the following rotations:
Inpatient Acute Service
CHF Service
Consults
CCU
Outpatient Continuity Clinics (HMC and VA)
ACHD
Didactics There is no dedicated cardiac MRI Lecture Series. Cardiac MRI lectures will occur as a
part of the Multimodality Imaging Series on the 4th Tuesday of every month
(September June) @ 12:30pm in Hamilton conference Room.
Additional cardiac MRI related cases and topics are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
Overview
The cardiac MRI portion of the Vascular/Imaging rotation exposes the fellow to the basics of cardiac MRI protocols,
acquisition, measurement, and interpretation. Fellows will gain an understanding of clinical indications of cardiac MRI
with attention to published appropriate use criteria. Evaluation of cardiac structure, function, and tissue
characterization will be reviewed. An overview of cardiac MRI physics and general MRI safety will be included in the
training.
COCATS Level III training requires experience beyond a 3-year fellowship and by definition cannot be obtained during
general fellowship in cardiovascular disease. Penn State Hershey does not offer subspecialty training in cardiac MRI.
Specific curricular milestones for magnetic resonance imaging, as they relate to the Core Competencies promulgated by
the ACGME, are adopted as outlined in the COCATS 4 Task Force 8 document. They are included in this curriculum with
the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation schedule, a fellow
may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document. All Level I
milestones represent minimum expectations during general fellowship.
Vacation/CME Time
Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless
specified by the involved faculty.
In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging
coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship
coordinator and approved by the fellowship director.
Exposure to Cardiac CT
o Check for planned coronary CT studies with Drs. Ettinger or Singh
o Review Cardiac CT planning for structural heart disease cases with Dr. Kozak or Pfeiffer
o Independent study of Cardiac CT review materials
Supplemental ECHO exposure
o First years in the second half of their year can observe TEE under the guidance of the upper year fellow
and can start performing TEEs with the permission of the TEE attending
o Additional time in the ECHO lab as needed
Supplemental Nuclear exposure
o Attend afternoon reading sessions for cardiac SPECT imaging.
o Schedule and perform your required Nuclear Radiation Hands-On Safety training
o Assist with coverage for nuclear studies as needed.
The following template serves as a guideline for expected attendance at planned activities (highlighted) to meet the
primary goals, as well as a proposed schedule of secondary activities.
Cardiovascular MRI Tutorial: Lectures and Learning, 1st Ed., Biedermann, Doyle, Yamrozik
3. Know the uses, potential side effects, and contraindications of using gadolinium based
contrast agents in cardiovascular magnetic resonance imaging. I
4. Know the indications for cardiovascular magnetic resonance to assess left and
right heart chamber sizes and function. I
10. Know the cardiovascular magnetic resonance indications to assess diseases of the
pericardium. I
13. Know the cardiovascular magnetic resonance indications for left atrial and
pulmonary vein mapping prior to ablation of atrial fibrillation. I
14. Know the cardiovascular magnetic resonance indications for evaluation of adult
congenital heart disease including identification of coronary artery anomalies. I
15. Know the cardiovascular magnetic resonance indications to detect and evaluate
diseases of the aorta and peripheral arteries. I
Evaluation Methods: Conference Presentations, Direct Observation and Feedback. In-Training Exam
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice
of cardiac catheterization.
Goal Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the
ability to call effectively on other resources in the system to provide optimal healthcare.
Practice-Based Learning and Improvement 1st Year 2nd Year 3rd Year
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Identify knowledge and performance gaps and engage in opportunities to achieve
focused education and performance improvement. I
Evaluation Methods: Core Competency Committee, Direct Observation and Feedback, In-Training Exam, Self-Evaluation
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
1.
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
ROTATION INFORMATION
Name of Rotation RESEARCH
Supervising / Evaluating All Participating Faculty
Faculty Members
Facility / Location Hershey Medical Center and Related Facilities
Clinical Experience All fellows will have a minimum of 3 months of dedicated research time. Additional
elective time for interested fellows is available.
Journal Club Lecture Series; Every 3rd Monday (Exact time and locations TBA)
Additional research related topics and critical review are anticipated as a part of:
Grand Rounds
Multidisciplinary Case Conference
Overview
The research rotation provides the ability for cardiology fellows to directly participate in cardiovascular research and
scholarly activity (CRSA). This includes exposure to conducting research, increasing knowledge of the scientific method
and enhancing the ability to critically evaluate published scientific data. These exposures will allow emerging
cardiologists to adapt their knowledge and practice as new scientific investigations occur.
COCATS Level I:
o Trainees should establish a relationship with a research mentor and devote 6-12 months to 1 or more
scholarly activities or cardiac research projects.
o Trainees are encouraged to develop a quality improvement project to enhance system based practices
that will help him or her throughout their professional careers. This could be part of the research project
mentioned above; however, for it to count as research project it must include a specific research
question (i.e. did a particular QI measure lead to a change in behavior or outcomes?).
Specific curricular milestones for cardiovascular research and scholarly activity, as they relate to the Core Competencies
promulgated by the ACGME, are adopted from the COCATS 4 Task Force 15 document. They are included in this
curriculum with the appropriate associated Evaluation Methods for fellows. Based on our curriculum and rotation
schedule, a fellow may achieve these milestones ahead or behind the suggested timeframe in the COCATS 4 document.
All Level I milestones represent minimum expectations during general fellowship.
Fellow Responsibilities
Trainee should find a faculty member to assist with the development of clinical questions and to oversee the
scientific method as it pertains to cardiovascular research or scholarly activity.
o After developing clinical questions, research project should be followed until completion.
o Project results should be written up and submitted for presentation at a cardiovascular conference or
publication in a peer reviewed journal.
o The minimum research requirement is one project, however it is strongly encouraged to spend
additional time on other cardiovascular research or scholarly activity.
Trainee is encouraged to work on a quality improvement project to enhance patient care and improve systems
based practice.
Become more knowledgeable about the scientific method including hypothesis generation, reading background
literature, developing methods to test hypothesis and examining data to determine if it confirms or denies the
hypothesis.
Develop competency in critically interpreting cardiovascular research literature.
Develop an understanding of the issues concerning scientific integrity and ethical conduct.
Vacation/CME Time
Time off for vacation and CME may be requested during this rotation. Coverage does not need to be arranged unless
specified by the involved faculty. It is the fellows responsibility to ensure time off does not significantly impact or limit
total exposure to any given rotation.
In the event of emergent time off, the chief fellow(s) and program leadership should be notified to assist in arranging
coverage. All requests for time off, regardless of the rotation involved, must be submitted through the fellowship
coordinator and approved by the fellowship director.
Designing Clinical Research 4th Ed., Hully, Cummings, Browner, Grady and Newman
Evaluation Methods: Conference Presentations, Direct Observation and Feedback, In-Training Exam
Patient Care and Procedural Skills 1st Year 2nd Year 3rd Year
Goal Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health. Competently perform all medical, diagnostic, and surgical procedures essential for the practice
of RESEARCH.
1. Skill to review published research data and assess the adequacy of research design, data
analysis, and logical deduction. I
Goal Demonstrate an awareness of and responsiveness to the larger context and system of healthcare, as well as the
ability to call effectively on other resources in the system to provide optimal healthcare.
Goal Demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
1. Identify knowledge and performance gaps and engage in opportunities to achieve
focused education and performance improvement. I
Goal Demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
1. Demonstrate sensitivity to patient autonomy and safety in research. I
2. Practice with integrity in the conduct of research, including understanding issues relating
to relationships with industry. I
Interpersonal and Communication Skills 1st Year 2nd Year 3rd Year
Goal Demonstrate interpersonal and communication skills that result in the effective exchange of information and
collaboration with patients, their families, and health professionals.
1. Communicate with fellow trainees and faculty about cardiovascular science and how this
might impact clinical care (for example, through journal clubs). I
If one wishes to achieve levels II and/or III in a particular rotation, it may require additional elective time. This information
should be relayed to the Chief Fellow for scheduling purposes.
Instructions:
ThefollowingevaluationquestionshavebeendevisedusingtheCOCATS4CoreCompetencyComponentsand
CurricularMilestonesforTraininginCardiacCatheterization.TheevaluationscaleismodeledaftertheACGME
Milestonescategories,whicharecompetencybaseddevelopmentaloutcomes(e.g.,knowledge,skills,attitudes,and
performance)thatcanbedemonstratedprogressivelybyresidentsandfellowsfromthebeginningoftheireducation
throughgraduationtotheunsupervisedpracticeoftheirspecialties.
SubjectName
Status
Evaluatedby: EvaluatorName
Status
Employer
Employer
Program
Program
Rotation
EvaluationDates
MEDICALKNOWLEDGE
1* Knowsthebasicprinciplesofmolecularbiology,genetics,genomics,proteomics,metabolomicsand
pharmacogenomics.
1 2 3 4 5
2* Knowstheprinciplesofepidemiologicalmethods.
1 2 3 4 5
3* Knowstheprinciplesofoutcomesevaluation.
1 2 3 4 5
4* Knowsthebasicprinciplesofbiostatistics.
1 2 3 4 5
5* Knowstheprinciplesunderlyinghypothesisformation,specificgoalsdefinition,hypothesistestability,
andstatisticalpowerachievable.
1 2 3 4 5
6* Possessesskillstoreviewpublishedresearchdataandassesstheadequacyofresearchdesign,data
analysis,andlogicaldeduction.
1 2 3 4 5
7* Possessesskillstointegrateappropriatelyscientificconceptsandresearchadvancesinroutineclinical
encounters.
1 2 3 4 5
8* Possessesskillstoroutinelyassessthequalityofevidenceinclinicaldecisions.
1 2 3 4 5
9* Possessesskillstoapplyprinciplesofbiomedicalethicsastheypertaintohumansubjectresearchinthe
identificationofpatientsaspotentialresearchsubjects,presentationofalternatives,obtaininginformed
consentandassuringthesecurityofclinicaldatausedforresearch.
1 2 3 4 5
SYSTEMSBASEDPRACTICE
10* Effectivelyaccessesandutilizesnationalregistrydataforresearch.
1 2 3 4 5
11* KnowstheroleofandhowtointeractwithInstitutionalReviewBoards.
1 2 3 4 5
PRACTICEBASEDLEARNINGANDIMPROVEMENT
1 2 3 4 5
13* Appropriatelyintegratesneworemergingmedicalevidence.
1 2 3 4 5
PROFESSIONALISM
14* Demonstratessensitivitytopatientautonomyandsafetyinresearch.
1 2 3 4 5
15* Practiceswithintegrityintheconductofresearch,includingunderstandingissuesrelatingto
relationshipswithindustry.
1 2 3 4 5
16* Interactsrespectfullywithancillaryandsupport(research)staff.
1 2 3 4 5
INTERPERSONALANDCOMMUNICATIONSKILLS
17* Communicateswithfellowtraineesandfacultyaboutcardiovascularscienceandhowthismightimpact
clinicalcare(forexample,throughjournalclubs).
1 2 3 4 5
1 2 3 4 5
OVERALLASSESSEMENT
19* OverallAssessmentofthisfellow'sresearch.
1 2 3 4 5
20 Comments:Pleaseusethecommentboxbelowtoofferdetailedstrengthsand/orweaknessesofthis
fellow'sresearch.
21* Isthereanyreasonthisfellowshouldnotmovetothenextlevelofresponsibility?
Yes
No
Comment
22* Wasthisevaluationdiscussedwiththefellowattheendoftherotation?
*ACGMEProgramRequirementV.A.2.a).(1)states"facultymustevaluatefellowperformanceina
timelymannerduringeachrotationanddiscussthisevaluationwitheachfellowatthecompletionofthe
assignment."
Yes
No
OverallComment
Goal: The purpose of this one-month rotation is to provide an introduction to the appropriate care for
adults with congenital heart disease (ACHD). This includes providing appropriate inpatient care for
acutely ill patients, outpatient care for chronic issues related to lifelong cardiovascular disease and
consultation for cardiac and non-cardiac surgery in addition to pregnancy counseling. This introductory
rotation to ACHD will provide the fellow with an infrastructure on which to build more subspecialty
training and to recognize and potentially refer patients to a specialized ACHD clinic from a general
cardiology or other subspecialty cardiology field after graduation.
Fellow Responsibilities/Duties:
The fellow will participate in outpatient clinics with ACHD cardiologists two days each week.
Participation includes obtaining a detailed medical and surgical history, performing a physical exam,
reviewing pertinent imaging and electrocardiographic data, making an assessment and plan of care
and compiling/proofreading letters to the referring physician. At this time, the outpatient clinic
Faculty Supervision: ACHD cardiology patient care by the fellow will be supervised in person or
discussed by phone with the appropriate attending. Consults will be staffed with a cardiology attending
in the Program for Adult Congenital Heart Disease. Fellows care of the ACHD patient will be supervised
by faculty within the Program for Adult Congenital Heart Disease.
The mix of congenital heart disease will vary from simple to complex (as reviewed in ACC/AHA
guidelines for the care of the adult patient with congenital heart disease) with excellent potential for
exposure to various genetic syndromes. There is an appropriate gender mix with a wide span of ages.
The ethnicity of our patient population may vary slightly, including the local Amish population, given
that some congenital heart disease lesions are of genetic origin.
The ACHD fellow may participate in procedures, such as cardiac catheterization, electrical or chemical
cardioversion, imaging (TEE or cardiac MRI) as the time and circumstances permit. In cases where
cardiac catheterization is performed by faculty within the Childrens Heart Group, additional
coordination will be required.
Evaluations: The ACHD fellow will be evaluated by faculty within the Program for Adult Congenital
Heart Disease at the end of the months rotation. Feedback will be given to the fellow verbally and in
writing. The written evaluation is based on the ACGME 6 core competencies. The fellows have taken
part in the design of this rotation and development of the curriculum. They are also given the
opportunity to evaluate the curriculum and rotation. The fellows also confidentially evaluate the
attending cardiologists.
Fellows will also be educated at the weekly conference on Tuesday afternoons. Fellows are encouraged
to review current literature about the particular lesion or the pathophysiologic process that pertains to
the patient who will be discussed and share with the faculty at that meeting. Self-study is a must during
this rotation because of the wide variety and number of congenital heart disease lesions observed in
ACHD; some lesions may not be encountered in only one months time.
Conference Topics: Fellows on the ACHD rotation will have attended conferences pertaining to simple,
moderate and severely complex congenital heart disease in the adult, pre-pregnancy risk assessment,
and multi-modality imaging as parts of their other rotations or general cardiology curriculum lecture
series. Additional Tuesday conference topics will be variable and pertain directly to patient-care, similar
to problem-based learning curricula during medical school. It is imperative the fellow actively
participate in these conferences for further understanding of management of the adult with congenital
heart disease.
Websites
www.achaheart.org: Adult Congenital Heart Association
www.isachd.org: International Society for Adult Congenital Heart Disease
Guidelines
2008 ACC/AHA Guidelines for the Management of Adults with Congenital Heart Disease: a report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation. 2008 Dec 2;118(23):e714-833. Epub 2008 Nov 7.
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and
management of patients with Thoracic Aortic Disease: a report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation.
2010 Apr 6;121(13):e266-369. Epub 2010 Mar 16. Erratum in: Circulation. 2010 Jul 27;122(4):e410.
ASD/PFO:
Attie, F., M. Rosas, et al. (2001). "Surgical treatment for secundum atrial septal defects in patients
>40 years old. A randomized clinical trial." J Am Coll Cardiol 38(7): 2035-42.
Gutierrez-Roelens, I., L. De Roy, et al. (2006). "A novel CSX/NKX2-5 mutation causes autosomal-
dominant AV block: are atrial fibrillation and syncopes part of the phenotype?" Eur J Hum Genet
14(12): 1313-6.
Sachweh, J. S., S. H. Daebritz, et al. (2006). "Hypertensive pulmonary vascular disease in adults with
secundum or sinus venosus atrial septal defect." Ann Thorac Surg 81(1): 207-13.
Meissner, I., B. K. Khandheria, et al. (2006). "Patent foramen ovale: innocent or guilty? Evidence
from a prospective population-based study." J Am Coll Cardiol 47(2): 440-5.
Cabanes, L., J. Coste, et al. (2002). "Interobserver and intraobserver variability in detection of patent
foramen ovale and atrial septal aneurysm with transesophageal echocardiography." J Am Soc
Echocardiogr 15(5): 441-6.
Lamy, C., C. Giannesini, et al. (2002). "Clinical and imaging findings in cryptogenic stroke patients
with and without patent foramen ovale: the PFO-ASA Study. Atrial Septal Aneurysm." Stroke 33(3):
706-11.
Hara, H., R. Virmani, et al. (2005). "Patent foramen ovale: current pathology, pathophysiology, and
clinical status." J Am Coll Cardiol 46(9): 1768-76.
Homma, S., R. L. Sacco, et al. (2002). "Effect of medical treatment in stroke patients with patent
foramen ovale: patent foramen ovale in Cryptogenic Stroke Study." Circulation 105(22): 2625-31.
Pregnancy:
Siu, S. C., M. Sermer, et al. (2001). "Prospective multicenter study of pregnancy outcomes in women
with heart disease." Circulation 104(5): 515-21.
Khairy, P., D. W. Ouyang, et al. (2006). "Pregnancy outcomes in women with congenital heart
disease." Circulation 113(4): 517-24.
Lui, G. K., C. K. Silversides, et al. "Heart rate response during exercise and pregnancy outcome in
women with congenital heart disease." Circulation 123(3): 242-8.
Balint, O. H., S. C. Siu, et al. "Cardiac outcomes after pregnancy in women with congenital heart
disease." Heart 96(20): 1656-61.
Tobler, D., S. M. Fernandes, et al. "Pregnancy outcomes in women with transposition of the great
arteries and arterial switch operation." Am J Cardiol 106(3): 417-20.
Tzemos, N., C. K. Silversides, et al. (2009). "Late cardiac outcomes after pregnancy in women with
congenital aortic stenosis." Am Heart J 157(3): 474-80.
Silversides, C. K., J. M. Colman, et al. (2003). "Early and intermediate-term outcomes of pregnancy
with congenital aortic stenosis." Am J Cardiol 91(11): 1386-9.
Overview: The cardiovascular fellow on the ward rotation will be responsible for the evaluation and
ongoing care of patients admitted to the general cardiology ward service. Specific responsibilities
include:
See new patients admitted to the ward and HVICU (the fellow is not responsible to see all patients;
generally patients with non-critical health issues admitted overnight will be seen by the resident on
call and not by the fellow). For patients that are seen:
Document the indication for admission.
Perform of an appropriate history and physical (H&P) examination.
Review and document, by independent interpretation (when appropriate), all relevant
diagnostic information including ECGs, images including chest x-rays, CT scans, echo-Doppler
data, nuclear images, MRI scans, catheterization lab images, hemodynamic data and other
information..
Review and document relevant biochemical lab data
Define a plan for inpatient care, including testing and treatment.
Base recommendations for testing and treatment on, when available, ACC/AHA guidelines.
Indications for withholding standard treatment and testing must be documented.
Be able to present the history, physical examination and testing and/or treatment plans to the
attending physician; if the presentation is given by a medical student or resident, be able to
provide appropriate information not detailed by the presenter
Communicate to the patient the diagnosis and recommend to the patient of any tests/or and
treatments thought to be appropriate
Discuss in an appropriate manner with the patient the risks and benefits of tests and/or
treatments
Promptly notify the patient of any relevant test results
Education of the patient
As appropriate, about the disease(s)/diagnose(s)
About health measures (such as diet, weight loss, cessation of smoking)
Oversee the residents and medical students on the service in regards to patient care
Provide education to the residents and medical students on the service
Educational Goals: Cardiovascular fellows will acquire the necessary skills to diagnose and manage a
wide spectrum of cardiovascular diseases including but not limited to coronary artery disease, valvular
heart disease, diseases of the myocardium, diseases of the pericardium and congenital heart disease,
cardiac arrhythmias, conduction disorders and syncope. Fellows will develop the necessary skills to
obtain a thorough cardiac history and perform a physical examination. This shall include the evaluation
of normal and abnormal heart sounds, evaluation of heart murmurs, including provocative maneuvers
that accentuate or decrease intensity of murmurs. The fellow will acquire the necessary skills to
recognize the peripheral manifestations of cardiac dysfunctions. The fellow will learn the indications
and contraindications for performing diagnostic studies. Adherence to published appropriateness
criteria for diagnostic tests is expected. In addition, the fellow will become proficient in analyzing
diagnostic data to establish a cardiovascular diagnosis and treatment plan. The fellow will acquire
experience in the clinical analysis of surface and intracardiac ECG recordings, chest radiographs, stress
echo and nuclear images, CT scans, M-mode and 2-D echocardiograms, Doppler and catheter
Training Objectives:
To develop the knowledge and skills required to obtain a proper cardiac history. Specific areas
include, but are not limited to, characterization of chest pain (including the differential diagnosis of
various etiologies of chest pain syndrome based on historical description), dyspnea (with
differentiating cardiac from pulmonary causes of dyspnea), exercise capacity and functional class. In
addition, special emphasis should be paid to medications, medication compliance, dietary habits,
smoking and alcohol consumption as well as other risk factors for cardiac diseases. (Patient Care,
Medical Knowledge, Practice-Based Learning, Interpersonal and Communication Skills)
To become proficient in cardiac physical examination. The complete bedside examination includes
palpation of all pulses, recognition of pulse characteristics, and blood pressure examinations in both
upper and lower extremities, especially when delayed or absent femoral pulses are obtained. The
cardiac resident should also be able to estimate jugular venous pressure as well as characterize
different waves in the neck, detect bruits, examine lung fields, and define the precise location and
characterization of left and right ventricular impulses. Proficiency is required for auscultation of
heart sounds as it relates to intensity, splitting and additional heart sounds such as murmurs, rubs
and clicks. To accurately assess the characterization of murmurs with regard to timing pitch, grade,
maximal intensity and radiation and the effect of provocative maneuvers in eliciting the origin of the
murmur. To recognize the peripheral manifestations of heart dysfunction such as palpable and/or
pulsatile liver, anasarca, ascites, peripheral edema or sacral edema. (Patient Care, Medical
Knowledge)
To accurately assess the presence or absence of congestive heart failure. To evaluate whether
murmurs of valvular heart disease such as mitral regurgitation, mitral stenosis, aortic regurgitation
and tricuspid regurgitation contribute singularly or in combination to the clinical picture of
congestive heart failure. (Patient Care, Medical Knowledge)
To accurately assess the presence or absence of abdominal aneurysms and the presence or absence
of peripheral vascular disease. (Patient Care, Medical Knowledge)
To assess the normal auscultatory findings in pregnant patients and to be able to differentiate
pregnant patients with valvular heart disease or congenital heart disease from physiological heart
sounds of pregnancy. (Patient Care, Medical Knowledge, Practice-Based Learning)
To learn to interpret laboratory data to assist with risk stratification and treatment. (Patient Care,
Medical Knowledge, Systems-Based Practice, Practice-Based Learning)
To learn to assess the risk of and treat adverse cardiac events in the perioperative period for
patients referred for non-cardiac surgery (Patient Care, Medical Knowledge, Systems-Based Practice,
Practice-Based Learning)
To learn about the chronicity and long-term characteristics of various cardiac diagnoses, such as
congestive heart failure, valvar disease (such as aortic stenosis and mitral regurgitation), and chronic
coronary artery disease. (Patient Care, Medical Knowledge, Practice-Based Learning)
To interact in a professional manner with the patient in a compassionate and caring manner; to
demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference,
socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues; to
adhere to principles of confidentiality, scientific/academic integrity and informed consent. (Patient
Care, Communication Skills, Professionalism)
To interact with the health care team including nurses, physician assistants, technicians, social
workers, nutritionists, physical therapists, respiratory therapists as well as other physicians. (Patient
Care, Medical Knowledge, Systems-Based Practice, Interpersonal and Communication Skills,
Professionalism)
Learn how to utilize hospital and community resources for managing cardiac patients in the
outpatient setting. (Systems-Based Practice, Practice-Based Learning, Patient Care and
Interpersonal and Communication Skills)
Access and critically evaluate current medical information and scientific evidence. Use information
technology or other available methodologies to access and manage information, support patient
care decisions and enhance both patient and physician education. (Patient Care, Medical
Knowledge, Systems-Based Practice, Practice-Based Learning and Improvement)
The attending cardiologist on the ward service will serve as a mentor for the fellow. The mentor
student relationship will be utilized as the main teaching method after the fellow has seen and
examined the patient and presented the patients findings and plans to the attending. The fellow is
expected to utilize available scientific research, published guidelines and expert opinion to assist
with decision making and learning.
Evaluation Methods: The attending cardiologist will utilize a standardized evaluation process to assess
the performance of the cardiac resident. A written evaluation of the cardiac fellows performance on the
consultative service will be made each six months by the cardiology attendings assigned to the out-
patient continuity clinic. The cardiology attending will evaluate each fellow according to the ACGME
general competencies including: patient care, medical knowledge, practice-based learning and
improvement, interpersonal and communication skills, professionalism and systems-based practice. In
addition, bedside skills such as obtaining history, physical examination and performance of cardiac
procedures will be evaluated. The fellowship director will meet with each cardiac fellow at the end of
each six month rotation to review the written evaluation. Fellows are required to electronically sign
each evaluation in the New-Innovations program.
Educational Content: On the general cardiology ward service patients may be admitted to a general
cardiology floor, to an area allowing intermediate care monitoring, or to an intensive care unit. Patients
may be referred for admission or may be admitted via the emergency room or outpatient clinic.
Patients with a variety of cardiac disorders including but not limited to coronary artery disease,
hypertension, peripheral vascular disease, hyperlipidemia, valvular heart disease, myocardial and
peripheral disease, endocarditis, pericardial diseases and congenital heart disease will form the service.
Obviously patients of both genders are on the ward service. The age spectrum is from 18 years of age to
occasional patients 100 years of age or more. Patients are of rural or urban background, from a wide
range of socioeconomic groups, and of various ethnic backgrounds.
Overview: The cardiovascular fellow on the consult service will be responsible for the performance and
follow-up of all consultations on patients assigned to the consult attending. Specific responsibilities include:
Educational Goals: Cardiology fellows will acquire the necessary skills to diagnose and manage patients with
coronary artery disease, valvular heart disease, and diseases of the myocardium, pericardium and congenital
heart disease. In addition, fellows will be required to understand, recognize and manage patients with cardiac
arrhythmias, conduction disorders and patients presenting with syncope. They will develop bedside
cardiology skills with emphasis on cardiac history taking, bedside physical examination including evaluation
of normal and abnormal heart sounds, evaluation of heart murmurs, including provocative maneuvers that
accentuate or decrease intensity of murmurs, allowing the cardiac residents to better delineate the origin of
the murmur.
Cardiology fellows will acquire the necessary skills to recognize the peripheral manifestations of cardiac
dysfunction. They will learn the indications and contraindications of diagnostic studies. Adherence to
published appropriateness criteria for diagnostic tests is expected. Fellows will learn to explain the purpose
and nature of procedures and be able to explain what the patient should expect during procedures. The
common complications, incidence, and expected benefits will be learned and explained to patients.
Cardiology fellows will become proficient in analyzing diagnostic data to establish a cardiovascular diagnosis
and treatment plan. Fellows will be expected to review laboratory data including ECGs, chest radiographs,
resting transthoracic and transesophageal echocardiograms, stress echo and nuclear stress tests, and
catheterization images to formulate a patient diagnosis and treatment plan. An understanding of the
limitations of each modality to resolve inconsistent or contradictory findings is expected as the fellow
progresses through training.
To develop the knowledge and skills required to obtain a proper cardiac history. Specific areas include
characterization of chest pain (including the differential diagnosis of various etiologies of chest pain
syndrome based on historical description), dyspnea (with differentiating cardiac from pulmonary causes
of dyspnea), exercise capacity and functional class. In addition, special emphasis should be paid to
medications, medication compliance, dietary habits, smoking and alcohol consumption as well as other
risk factors for cardiac diseases. (Patient Care, Medical Knowledge, Practice-Based Learning,
Interpersonal and Communication Skills)
To become proficient in bedside cardiac physical examination. The complete bedside examination
includes palpation of all pulses, recognition of pulse characteristics, and blood pressure examinations in
both upper and lower extremities, especially when delayed or absent femoral pulses are obtained. The
cardiac resident should also be able to estimate jugular venous pressure as well as characterize different
waves in the neck, detect bruits, examine lung fields, and define the precise location and characterization
of left and right ventricular impulses. Proficiency is required for auscultation of heart sounds as it relates
to intensity, splitting and additional heart sounds such as murmurs, rubs and clicks. To accurately assess
the characterization of murmurs with regard to timing pitch, grade, maximal intensity and radiation and
the effect of provocative maneuvers in eliciting the origin of the murmur. To recognize the peripheral
manifestations of heart dysfunction such as palpable and/or pulsatile liver, anasarca, ascites, peripheral
edema or sacral edema. (Patient Care, Medical Knowledge)
To accurately assess the presence or absence of congestive heart failure and discern the signs of cardiac
tamponade at the bedside. To evaluate whether murmurs of valvular heart disease such as mitral
regurgitation, mitral stenosis, aortic regurgitation and tricuspid regurgitation contribute singularly or in
combination to the clinical picture of congestive heart failure. (Patient Care, Medical Knowledge)
To accurately assess the presence or absence of abdominal aneurysms and the presence or absence of
peripheral vascular disease. (Patient Care, Medical Knowledge)
To assess the normal auscultatory findings in pregnant patients and to be able to differentiate pregnant
patients with valvular heart disease or congenital heart disease from physiological heart sounds of
pregnancy. (Patient Care, Medical Knowledge, Practice-Based Learning)
To become skilled in ECG interpretation of hypertrophy, conduction disturbances, heart block, WPW,
acute infarction versus chronic infarction pattern. In addition to recognizing electrolyte disturbances and
its effect on the ECG, the cardiac resident should be able to accurately interpret supraventricular
arrhythmias, especially with regard to the differentiation of atrial fibrillation, from atrial flutter, re-entrant
supraventricular tachycardia and multifocal atrial tachycardia. To be able to evaluate wide complex
tachycardias and differentiate ventricular tachycardia from supraventricular tachycardia with aberration
or pre-excitation and to recognize the different forms of ventricular tachycardia, monomorphic from
polymorphic and torsade-des-pointes. (Patient Care, Medical Knowledge, Practice-Based Learning)
To learn how to interpret cardiac images (chest X-ray, CT, MRI, nuclear, echo, and angiograms) focusing
on assessment of heart structure and function. (Patient Care, Medical Knowledge, Practice-Based
Learning)
To understand the clinical value of different therapeutic interventions including medical, percutaneous,
and surgical therapies as well as device therapy in the management of all types of adult cardiovascular
disease. (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based Learning,
Interpersonal and Communication Skills)
To interact with the health care team including nurses, physician assistants, technicians, social workers,
nutritionists, physical therapists, respiratory therapists as well as other physicians. (Patient Care, Medical
Knowledge, Systems-Based Practice, Interpersonal and Communication Skills, Professionalism)
Learn how to utilize hospital and community resources for managing cardiac patients in the outpatient
setting. Interact with staff in referring physicians offices, lipid clinics, Coumadin clinics, cardiac
rehabilitation, visiting nursing services (VNA), the OASIS program, and hospice. (Systems-Based Practice,
Practice-Based Learning, Patient Care and Interpersonal and Communication Skills)
Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families and
colleagues. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual
preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional
colleagues. Adhere to principles of confidentiality, scientific/academic integrity and informed consent.
(Patient Care, Professionalism)
Access and critically evaluate current medical information and scientific evidence. Use information
technology or other available methodologies to access and manage information, support patient care
decisions and enhance both patient and physician education. (Patient Care, Medical Knowledge,
Systems-Based Practice, Practice-Based Learning and Improvement)
An attending cardiologist will serve as a mentor for the cardiac resident. The mentor and student
relationship will be utilized as the main teaching method during daily clinical rounds. The resident is
expected to utilize all available scientific research, published guidelines and expert opinion to assist with
decision making and learning.
Discrepant findings on diagnostic data, controversial issues and differences of opinion will be discussed
with the attending cardiologists.
Combined management teaching rounds will be held with the consult fellow and other members of the
consult services (i.e., medical residents and students) The daily teaching round component must occur at
least three times per week for a minimum of 4 1/2 hours per week. Generally, a few cases will be
presented on teaching rounds as a basis for discussion of such points as interpretation of clinical data,
pathophysiology, differential diagnosis, specific management of the patient and the appropriate use of
technology. Teaching rounds must include direct bedside interaction with the patient by the resident
and the scheduled teaching physician.
Evaluation Methods: The attending cardiologist will utilize a standardized evaluation process to assess the
performance of the cardiac resident. A written evaluation of the cardiac fellows performance on the
consultative service will be made at the end of each rotation by the cardiology attending assigned to the
consultative service. At the conclusion of each consultative rotation, the cardiology attending will evaluate
each fellow according to the ACGME general competencies including: patient care, medical knowledge,
practice-based learning and improvement, interpersonal and communication skills, professionalism and
systems-based practice. In addition, bedside skills such as obtaining history, physical examination and
performance of cardiac procedures will be evaluated. The cardiology teaching attending will meet with each
cardiac fellow at the end of the rotation to review the written evaluation. Fellows are required to sign each
evaluation in the presence of the cardiac attending.
Educational Content: The consultation service will provide evaluations and patient care throughout the
hospital including the medical and surgical floors, maternity suites, operation suites, recovery room and in
the emergency department. Patients with a variety of cardiac disorders including coronary artery disease,
hypertension, peripheral vascular disease, hyperlipidemia, valvular heart disease, myocardial and peripheral
disease, endocarditis, pericardial diseases and congenital heart disease will form the case mix for the
consultative service. Each patient is seen on a daily basis and if necessary more frequently and each patient
will be reviewed by an attending cardiologist. Cardiac residents will follow each patient throughout their
hospitalization. Major procedures such as a cardiac catheterization, angioplasty, pericardiocentesis,
cardioversion, tilt table testing, echo Doppler cardiography and stress testing will be performed in the
appropriate laboratories. Emergent evaluations for acute chest pain, respiratory failure and cardiac
arrhythmias will occur at the bedside.
Strengths and Limitations: The strengths of the cardiology consultation service include the large volume and
diversity of cardiac patients. The attending cardiologists are experienced teachers with a strong focus on
bedside teaching. A high volume of noninvasive and invasive procedures are performed by the cardiology
staff. Participation in the hospitals quality improvement programs is strongly encouraged. Clinical research
including involvement in local, national and international clinical trials is ongoing. The cardiac resident is
expected to participate in these activities.
Bibliography:
Carithers, Jr. R L. Liver Transplantation, Vol 6, No 1 AASLD Practice Guidelines, Jan 2000; 122-135.
Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman ST, Nouri S,
Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G Jr., Prevention of Bacterial
Endocarditis. Recommendations by the American Heart Association, Circulation, 1997 Jul 1; 96(1): 358-
66.
Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and
Treatment of High Blood Pressure in Adults (Adult Treatment Panel III), www.nhlbi.nih.gov, 2002.
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and treatment of
High Blood Pressure, JNC 7 Complete Report, American Heart Association 2003, Hypertension
2003;42:1206. www.nhlbi.nih.gov.
Kapoor W. Current Evaluation and Management of Syncope, Circulation. 2002;106:1606-1609.
Instructions:
ThefollowingevaluationscaleismodeledaftertheACGMEMilestonescategories,whicharecompetencybased
developmentaloutcomes(e.g.,knowledge,skills,attitudes,andperformance)thatcanbedemonstratedprogressivelyby
residentsandfellowsfromthebeginningoftheireducationthroughgraduationtotheunsupervisedpracticeoftheir
specialties.
SubjectName
Status
Evaluatedby: EvaluatorName
Status
Employer
Employer
Program
Program
Rotation
EvaluationDates
MEDICALKNOWLEDGE
1* Demonstratesknowledgeofestablishedandevolvingbiomedical,clinical,epidemiological,andsocial
behavioralsciences,aswellastheapplicationofthisknowledgetopatientcare.
1 2 3 4 5
PATIENTCAREANDPROCEDURALSKILLS
2* Providespatientcarethatiscompassionate,appropriate,andeffectiveforthetreatmentofhealth
problemsandthepromotionofhealth.Competentlyperformallmedical,diagnostic,andsurgical
proceduresessentialforpractice.
1 2 3 4 5
SYSTEMBASEDPRACTICE
3* Demonstratesanawarenessofandresponsivenesstothelargercontextandsystemofhealthcare,as
wellastheabilitytocalleffectivelyonotherresourcesinthesystemtoprovideoptimalhealthcare.
1 2 3 4 5
PRACTICEBASEDLEARNINGANDIMPROVEMENT
1 2 3 4 5
PROFESSIONALISM
5* Demonstratesacommitmenttocarryingoutprofessionalresponsibilitiesandadherencetoethical
principles.
1 2 3 4 5
INTERPERSONALANDCOMMUNICATIONSKILLS
6* Demonstratesinterpersonalandcommunicationskillsthatresultintheeffectiveexchangeofinformation
andcollaborationwithpatients,theirfamilies,andhealthprofessionals.
1 2 3 4 5
Comment
OVERALLASSESSMENT
7* OverallAssessmentofthisfellowonthisrotation.
1 2 3 4 5
Comment
8 Comments:Pleaseusethecommentboxbelowtoofferdetailedstrengthsand/orweaknessesofthis
fellowonthisrotation.
9* Isthereanyreasonthisfellowshouldnotmovetothenextlevelofresponsibility?
Yes
No
Comment
OverallComment
Overview: The cardiovascular fellow on the continuity clinic rotation will be responsible for the
evaluation and ongoing care of patients referred to the fellow in the outpatient clinic. Specific
responsibilities include:
Educational Goals: Cardiovascular fellows will acquire the necessary skills to diagnose and manage
patients with coronary artery disease, valvular heart disease, diseases of the myocardium, diseases of
the pericardium and congenital heart disease, cardiac arrhythmias, conduction disorders and syncope.
Fellows will develop cardiology skills with emphasis on cardiac history taking, physical examination
including evaluation of normal and abnormal heart sounds, evaluation of heart murmurs, including
provocative maneuvers that accentuate or decrease intensity of murmurs. The fellow will acquire the
necessary skills to recognize the peripheral manifestations of cardiac dysfunctions. The fellow will learn
the indications and contraindications for performing diagnostic studies. Adherence to published
appropriateness criteria for diagnostic tests is expected. In addition, the fellow will become proficient
in analyzing diagnostic data to establish a cardiovascular diagnosis and treatment plan. The fellow will
acquire experience in the clinical analysis of surface and intracardiac ECG recordings, chest radiographs,
stress echo and nuclear images, CT scans, M-mode and 2-D echocardiograms, Doppler and catheter
hemodynamics, coronary angiography, and contrast ventriculography. Opportunities to review new
imaging modalities including cardiac MRI and 3-D echo will be encouraged.
To develop the knowledge and skills required to obtain a proper cardiac history. Specific areas include
characterization of chest pain (including the differential diagnosis of various etiologies of chest pain
syndrome based on historical description), dyspnea (with differentiating cardiac from pulmonary causes
of dyspnea), exercise capacity and functional class. In addition, special emphasis should be paid to
medications, medication compliance, dietary habits, smoking and alcohol consumption as well as other
risk factors for cardiac diseases. (Patient Care, Medical Knowledge, Practice-Based Learning,
Interpersonal and Communication Skills)
To become proficient in cardiac physical examination. The complete bedside examination includes
palpation of all pulses, recognition of pulse characteristics, and blood pressure examinations in both
upper and lower extremities, especially when delayed or absent femoral pulses are obtained. The
cardiac fellow should also be able to estimate jugular venous pressure as well as characterize different
waves in the neck, detect bruits, examine lung fields, and define the precise location and
characterization of left and right ventricular impulses. Proficiency is required for auscultation of heart
sounds as it relates to intensity, splitting and additional heart sounds such as murmurs, rubs and clicks.
To accurately assess the characterization of murmurs with regard to timing, pitch, grade, maximal
intensity and radiation and the effect of provocative maneuvers in eliciting the origin of the murmur.
To recognize the peripheral manifestations of heart dysfunction such as palpable and/or pulsatile liver,
anasarca, ascites, peripheral edema or sacral edema. (Patient Care, Medical Knowledge)
To accurately assess the presence or absence of congestive heart failure. To evaluate whether
murmurs of valvular heart disease such as mitral regurgitation, mitral stenosis, aortic regurgitation and
tricuspid regurgitation contribute singularly or in combination to the clinical picture of congestive heart
failure. (Patient Care, Medical Knowledge)
To accurately assess the presence or absence of abdominal aneurysms and the presence or absence of
peripheral vascular disease. (Patient Care, Medical Knowledge)
To assess the normal auscultatory findings in pregnant patients and to be able to differentiate pregnant
patients with valvular heart disease or congenital heart disease from physiological heart sounds of
pregnancy. (Patient Care, Medical Knowledge, Practice-Based Learning)
To become skilled in ECG interpretation of hypertrophy, conduction disturbances, heart block, WPW,
acute infarction versus chronic infarction pattern. (Patient Care, Medical Knowledge, Practice-Based
Learning)
To learn how to interpret cardiac images (chest X-ray, CT, MRI, nuclear, echo, and angiograms) focusing
on assessment of heart structure and function. (Patient Care, Medical Knowledge, Practice-Based
Learning)
To learn to interpret laboratory data to assist with risk stratification and treatment. (Patient Care,
Medical Knowledge, Systems-Based Practice, Practice-Based Learning)
To understand the clinical value of different therapeutic interventions including medical, percutaneous,
and surgical therapies as well as device therapy in the management of all types of adult cardiovascular
To learn to assess the risk of adverse cardiac events in the perioperative period for patients referred for
non-cardiac surgery (Patient Care, Medical Knowledge, Systems-Based Practice, Practice-Based
Learning)
To learn about the chronicity and long-term characteristics of various cardiac diagnoses, such as
congestive heart failure, valvar disease (such as aortic stenosis and mitral regurgitation), and chronic
coronary artery disease. (Patient Care, Medical Knowledge, Practice-Based Learning)
To interact with the patient in a compassionate and caring manner; to demonstrate sensitivity and
responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs,
behaviors and disabilities of patients and professional colleagues; to adhere to principles of
confidentiality, scientific/academic integrity and informed consent. (Patient Care, Communication
Skills, Professionalism)
To interact with the health care team including nurses, physician assistants, technicians, social workers,
nutritionists, physical therapists, respiratory therapists as well as other physicians. (Patient Care,
Medical Knowledge, Systems-Based Practice, Interpersonal and Communication Skills,
Professionalism)
To learn how to utilize hospital and community resources for managing cardiac patients in the
outpatient setting. Interact with staff in referring physicians offices, lipid clinics, Coumadin clinics,
cardiac rehabilitation, visiting nursing services (VNA), the OASIS program, and hospice. (Systems-Based
Practice, Practice-Based Learning, Patient Care and Interpersonal and Communication Skills)
To access and critically evaluate current medical information and scientific evidence. Use information
technology or other available methodologies to access and manage information, support patient care
decisions and enhance both patient and physician education. (Patient Care, Medical Knowledge,
Systems-Based Practice, Practice-Based Learning and Improvement)
An attending cardiologist will serve as a mentor for the fellow. The mentorstudent relationship will be
utilized as the main teaching method after the fellow has seen and examined the patient and presented
the patients findings and plans to the attending. The fellow is expected to utilize all available scientific
research, published guidelines and expert opinion to assist with decision making and learning.
Discrepant findings on diagnostic data, controversial issues and differences of opinion will be discussed
with the attending cardiologists. When appropriate the attending will examine the patient and discuss
discrepancies of examination with the fellow.
The attending cardiologist will utilize a standardized evaluation process to assess the performance of
the cardiac fellow. A written evaluation of the cardiac fellows performance on the consultative service
will be made each six months by the cardiology attendings assigned to the out-patient continuity clinic.
The cardiology attending will evaluate each fellow according to the ACGME general competencies
including: patient care, medical knowledge, practice-based learning and improvement, interpersonal
and communication skills, professionalism and systems-based practice. In addition, bedside skills such
as obtaining history, physical examination and performance of cardiac procedures will be evaluated.
The cardiology teaching attending will meet with each cardiac fellow at the end of each six month
rotation to review the written evaluation. Fellows are required to electronically sign each evaluation in
the New-Innovations program.
The cardiology attending will perform a yearly chart review of each fellows work, analyzing
letters/chart entries made about at least three patients. All letters/chart entries for the year for each
patient will be analyzed. An assessment form will be filled out for each patient and the attending will
discuss these forms with the fellow at the time of the attending meets with the fellow. See attached
evaluation form.
Educational Content: The out-patient continuity clinic will provide evaluations and patient care for
patients referred by non-cardiology physicians and from in-hospital units after hospitalizations. Patients
with a variety of cardiac disorders including coronary artery disease, hypertension, peripheral vascular
disease, hyperlipidemia, valvular heart disease, myocardial and peripheral disease, endocarditis,
pericardial diseases and congenital heart disease will form the case mix on this service. Fellows will
follow each patient throughout their three years of training.
Fellows will spend one morning each week in a continuity clinic. Two of these meet in the Outpatient
Clinic on the ground of the Medical Center (UPC1, Suite 600). Two meet at the Lebanon Veterans
Hospital on Lincoln Ave, near Lebanon, PA.
Bibliography:
Abraham W et al: Diagnosis and Management of Heart Failure. In : Hursts The Heart. 12th edit; pp
724-760, 2008.
Mukherjee D, Eagle K: Perioperative evaluation and Management of Patients with Known or
Suspected Cardiovascular Disease Who Undergo Noncardiac Surgery. In : Hursts The Heart. 12th
edit; pp 2007-2020, 2008.
ORourke RA et al: Diagnosis and Management of Patients with Chronic Ischemic Heart Disease. In :
Hursts The Heart. 12th edit; pp 1474-1503, 2008.
Fraker TD, Fihn SD: 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the
for the Management of Patients With Chronic Stable Angina: A Report of the American College of
Physicians/American Heart Association Task Force on Practice Guidelines Writing Group to Develop
the Focused Update of the 2002 Guidelines for the Management of Patients with Chronic Stable
Angina. Circ: 116:2762-2772, 2007.
Instructions:
TheevaluationscaleismodeledaftertheACGMEMilestonescategories,whicharecompetencybaseddevelopmental
outcomes(e.g.,knowledge,skills,attitudes,andperformance)thatcanbedemonstratedprogressivelybyresidentsand
fellowsfromthebeginningoftheireducationthroughgraduationtotheunsupervisedpracticeoftheirspecialties.
SubjectName
Status
Evaluatedby: EvaluatorName
Status
Employer
Employer
Program
Program
Rotation
EvaluationDates
1* Qualityofmedicalknowledgeexhibited.
1 2 3 4 5
2* Appropriatenessofpatientcareexhibited.
1 2 3 4 5
3* Degreeofprofessionalismexhibited.
1 2 3 4 5
4* Qualityofcommunicationtoreferringphysician.
1 2 3 4 5
5* Qualityofthechartdocumentation.
1 2 3 4 5
1 2 3 4 5
7 Comments:Pleaseusethecommentboxbelowtoofferdetailedstrengthsand/orweaknessesofthis
fellowinclinic.
8* Isthereanyreasonthisfellowshouldnotmovetothenextlevelofresponsibility?
Yes
No
Comment
9* Wasthisevaluationdiscussedwiththefellowattheendoftherotation?
*ACGMEProgramRequirementV.A.2.a).(1)states"facultymustevaluatefellowperformanceina
timelymannerduringeachrotationanddiscussthisevaluationwitheachfellowatthecompletionofthe
assignment."
Yes
No
Purpose: This rotation provides exposure to general cardiology in an outpatient setting. The PURPOSE
of this rotation is to acquire expertise and proficiency in the management of outpatient cardiovascular
issues in a patient population with common cardiovascular diseases like coronary artery disease,
valvular heart disease, peripheral vascular disease, heart failure, arrhythmias and preoperative
evaluation. Fellows will gain experience in ECG interpretation, performance and interpretation of
exercise and pharmacological stress testing, and performance and interpretation of transthorasic
echocardiograms. Fellows will also perform transesophageal echocardiograms and elective cardio
versions.
Responsibility/Specific Duties: The fellow has primary responsibility for all patients referred to the
service, under the supervision of one faculty member dedicated to this rotation. This rotation also
provides the opportunity and time to acquire expertise in nuclear cardiology (haft day every Wednesday
and Friday mornings, with one fellows doing a full day of clinic on Wednesday and Fridays) on studies
performed at the VA and basic training in cardiac CT.
When responding to a request for consultation the trainee is expected to provide comprehensive
evaluation of the patients cardiovascular illness in a prompt and concise manner, formulate a prioritized
differential diagnosis, and outline the evaluation. The trainee is expected to document the evaluation
and management plan in the patients electronic medical record. The trainee should communicate the
evaluation in a clear and concise manner to the requesting physician and provide adequate follow up.
Interactions with colleagues and allied personnel should be conscientious, respectful, responsible,
punctual, and appropriate. The trainee must exhibit humanistic qualities when interacting with patients
and their families and demonstrate integrity, respect and compassion.
The VA outpatient fellow is expected in the VA clinic at 8:00 am. Fellows are expected to participate in
the performance and interpretation of nuclear cardiology studies, CT coronary angiograms and also
review echo studies done in the VA echo lab. Fellows are mandated to maintain a detailed procedure
log. The fellows will perform and interpreting GXTs at the VA and following up the abnormal results as
appropriate. The VA outpatient fellow is responsible for interpretation of all Holter monitors and will
read half of all ECGs for the day. The ECG reading is to be shared with the VA attending.
Supervision: The fellow is expected to discuss all cases with the supervising cardiology staff. However,
complex cath cases and EP cases directly discussed with the cath lab and EP staff. All discussed cases
must be documented in the VA electronic chart with the name of the attending physician.
Learning Objectives:
1. Obtain training in the concepts and practice of effective outpatient cardiac consultation. This
includes:
a. Improving skills for acquiring a detailed and accurate history and physical examination. (A,B)
b. Improving skills for insight review of laboratory data. (A,B)
c. Obtain training in review of noninvasive and invasive cardiac tests and incorporation of the test
results into the context of the patients presentation. (A,B)
d. Obtain training in placing the cardiac findings in the patients overall medical context. (A, B)
e. Obtain training in formulation of a broad differential diagnosis with focus on the most likely
diagnosis. (A,B)
f. Obtain training in formulation of an effective treatment plan. (A,B)
Evaluation Methods:
1. The goals and objectives for the rotation will be verbally communicated at the beginning of the
rotation.
2. The fellows progress will be reviewed verbally at mid-rotation.
3. A standard fellow evaluation form will be completed by the VA attending cardiologist who worked
with the fellow during his clinic duties. This will be attained in New Innovations.
4. The final evaluation will be based on the fulfillment of the rotation objectives as determined by:
a. Personal observation during interaction with the fellow.
b. Evidence of literature review related to individual patients seen in the consult clinic.
c. Evidence of a thorough and accurate patient history and physical examination for each consult
patient seen in clinic and evidence of an appropriate directed history and physical examination
for each patient referred for pre-procedure evaluation.
d. Accuracy in interpretation of invasive and non-invasive tests for the consult patient, with good
insight into the role of those test results in arriving at an appropriate differential diagnosis and
treatment plan.
Echo Conference
12:30PM H1154
Echo Conference
12:30PM H1154
Imaging Conference
12PM H1154
Echo Conference
12:30PM H1154
Eligibility of Fellows
It is the policy of The Milton S. Hershey Medical Center and its sponsored residency/fellowship programs
to adhere to the guidelines published by the Accreditation Council on Graduate Medical Education with
respect to the eligibility and selection of fellows. Fellows will be selected for the various programs
based upon their previous records and accomplishments. Eligible applicants will be selected on the
basis of preparedness, ability, aptitude, academic credentials, communications skills, motivation and
integrity. Applicants are selected for interviews by the Program Director or Department Chair based on
the eligibility criteria.
Applicants with one of the following qualifications are eligible for appointment to a Residency Program:
1. Graduate of medical schools in the United States and Canada accredited by the Liaison Committee
on Medical Education (LCME).
2. Graduate of colleges of Osteopathic medicine in the United States accredited by the American
Osteopathic Association (AOA).
3. Graduates of Medical Schools outside the United States and Canada who meet one of the following
qualifications: 1) currently valid certificate for the Educational Commission for Foreign Medical
Graduates or 2) have a full and unrestricted license to practice medicine in a US licensing
jurisdiction.
4. Graduates of medical schools outside the United States who have completed a Fifth Pathway
program.
Candidates who are interviewed are given the Residency Benefit Summary that details the terms and
conditions of employment, stipends and benefits of the residency programs.
Selection of Fellows
Fellows will be selected for the various programs based upon their previous records and
accomplishments. Eligible applicants will be selected on the basis of preparedness, ability, aptitude,
academic credentials, communications skills, motivation and integrity.
All programs, where available, participate in an organized matching program, such as the National
Resident Matching Program (NRMP).
Conditions of Appointment
All fellows must have appropriate licensure from the Pennsylvania State Board of Medicine. It is the
responsibility of the fellow to obtain the appropriate licensure.
The period of appointment shall not exceed twelve (12) months, with renewal being dependent
upon performance and the requirements of the residency program.
Evaluation Procedure
Resident Evaluation
The Clinical Competency Committee (CCC), appointed by the Program Director, will meet semi-annually
to evaluate the fellows. It is the responsibility of the Program Director to advise the fellow of his/her
performance in the program.
Every fellow must be evaluated in a timely manner by the faculty during each rotation. This evaluation
will cover the six core competencies (Patient Care, Medical Knowledge, Practice-based Learning and
Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-based Practice).
Additionally, the CCC will evaluate each fellow based on the specialty-specific Milestones. Each fellow
will meet with the program director at least every six months to review his/her progress.
The results of these evaluations will be kept on file in the fellow's evaluation folder in the Residency
Coordinators office. The fellows evaluation folder will be available for his/her inspection.
Faculty Evaluation
Faculty performance must be evaluated as it relates to the educational program. These evaluations will
include a review of the facultys clinical teaching abilities, commitment to the educational program,
clinical knowledge, professionalism, and scholarly activities. Evaluations will be solicited from the
fellows annually and will be written and confidential. Fellows will also have the opportunity to provide
confidential written evaluations at the end of each rotation.
Program Evaluation
The Program Evaluation Committee (PEC), appointed by the Program Director, will meet at least
annually to plan, develop, implement, and evaluate the educational activities of the program. In
addition, they will review and make recommendations for the curriculum and address areas of non-
compliance with ACGME standards. The PEC will consider the written evaluations by the faculty,
fellows, and others during this process.
The Division has adapted the American Board of Internal Medicines (ABIM) educational milestones to
create overall educational goals and objectives for fellows at each level of training. These milestones
encompass the six core competencies and serve as the basis for performance expectations and
evaluation of fellows. These milestones are distributed to the fellows for their review. Semi-annual
evaluations of the fellows are conducted, and their level of performance in each of the milestones is
assessed, by the Clinical Competency Committee. This is determined by their rotational evaluations and
their scholarly activities. Each fellow meets with the Fellowship Program Director semi-annually to
review their education and clinical progress. At this time, areas of weakness are addressed, and a plan
of remediation is recommended if necessary.
The Department Chair shall give written notice of dismissal. The dismissal notice shall include a
summary of the cause for dismissal and shall advise the resident of the right of appeal provided by this
policy.
Residents must be allowed to implement the institutions grievance and due process policy if they
receive a written notice either of intent not to renew their agreement or intent not to promote them to
the next level of training.
Dismissal of Fellows
A fellow may be dismissed for cause during an appointment period. Examples of cause for dismissal
include, but are not limited to, the following:
A failure of Fellow to meet the performance or conduct standards of the Program.
A violation of the rules and regulations of The Milton S. Hershey Medical Center or a violation of
the directions of the Program Director or of the director or coordinator of the service to which
the Fellow is assigned.
An abuse or assault of any patient.
A refusal of rehabilitation for substance abuse or reported abuse of substances.
Any conduct which is or would be detrimental to The Milton S. Hershey Medical Center
operations, activities or interests.
Deficiencies in maintaining current medical records, including discharge summaries.
Lack of evidence of continuing self-education.
Persistent strife in interpersonal relations.
Lack of progress in developing acceptable clinical judgment.
The Department Chair shall give written notice of dismissal. The dismissal notice shall include a
summary of the cause for dismissal and shall advise the fellow of the right of appeal provided by this
policy.
Upon receipt of an appeal, an Appeal Board will be appointed by the Senior Vice President for Health
Affairs and Dean, consisting of the following: The Senior Associate Dean or Assistant Dean for Medical
Education (presiding), the Medical Director of The Milton S. Hershey Medical Center, a senior fellow in
the same program as the appealing fellow, a fellow designated by the Resident Council, and two senior
members of the teaching faculty.
The Appeal Board shall provide the fellow an opportunity to present oral and written statements by the
fellow and other persons in support of the appeal. The Department Chair, or a designee, shall be
responsible for presenting evidence in support of the dismissal. Specific procedures applicable to the
appeal shall be adopted by the Appeal Board and furnished to the fellow and the Department Chair.
The recommendation of the Appeal Board shall be submitted to the Senior Vice President for Health
Affairs and Dean, who shall have final authority to review the dismissal.
Fellow is encouraged to seek resolution of grievances relating to duties. Grievances means any
difference between Fellow and Medical Center with respect to the interpretation or application of, or
compliance with the provisions of this Agreement. The procedure is as follows:
1. Fellow to Program Director or Department Chair - Fellow with a grievance is urged to first
discuss it with the Program Director or Department Chair to which Fellow may be assigned from
time to time. Issues can best be resolved at this stage and every effort should be made to affect
a mutually agreeable solution.
2. Fellow to Ombudsperson - In situations when the concern relates to the Department Chair or
Program Director, and Fellow believes that it cannot be presented to the Department Chair or
Program Director, Fellow may present the grievance directly to the Ombudsperson for guidance.
3. Fellow to Senior Associate Dean for Medical Education If, after discussion with the
Department Chair or Program Director and Ombudsperson, the grievance is not resolved to the
4. Upon failure to satisfactorily resolve the concern with the ombudsperson or the Senior
Associate Dean for Medical Education, Fellow may request that the concern be brought before
an ad hoc grievance committee. The composition of the committee will be determined by the
degree of concern. For the most severe concern as determined by the Senior Associate Dean for
Medical Education, the committee will be constituted as in the Residency Agreement, section
11.2.4. The committee will investigate the concern(s) by appropriate methods and reach a
decision by simple majority vote. The decision of the committee shall be reached within a
reasonable time period, and be final and binding upon the parties and documented. During the
investigation, Fellow status will remain unchanged unless suspended from clinical duties for
cause.
C. SUPERVISION
In all rotations, fellows are supervised by attending physician faculty. In addition to this policy, lines of
responsibility are further delineated in the curriculum for each cardiology rotation. Fellows are
supervised by an attending physician who has clinical privileges in the area they are supervising. Faculty
schedules assign responsibility for supervision to specific faculty members, as well as on-call
responsibilities, so as to provide fellows with appropriate supervision and consultation. The fellows are
provided with a rapid, reliable system for identifying and communicating with their supervising faculty.
Fellows and faculty members are expected to inform patients of their respective roles in their care.
Fellows are provided with multiple tiers of support in their clinical activities. All patients seen by a
fellow, as an outpatient or inpatient, are reviewed in a timely manner with a faculty member to discuss
diagnosis and treatment plans. During interventional procedures in the cath or echo labs, the staff
cardiologist is present throughout each procedure. All diagnostic studies are reviewed with the
appropriate attending cardiologist. Four to six faculty are on night and weekend call to support the
fellow and clinical activities. During the first six months of the academic year, upper level fellows are on
back-up call for first year fellows. In addition, electrophysiology and interventional fellows provide
support, as needed. Two fellows make hospital rounds on weekends and holidays to dispense the work
load. All incoming fellows will pick a faculty research mentor, or be assigned one.
The supervision of fellows is structured to provide them with progressively increasing responsibility,
commensurate with their level of education, ability, and attainment of milestones. The Program
Director, in conjunction with the Programs Clinical Competency Committee, will make determinations
on advancement of fellows to positions of greater responsibility and conditional independence through
assessment of competencies. In recognition of their progress toward independence, senior fellows can
supervise junior fellows when appropriate.
1. Direct supervision: the supervising physician is physically present with the fellow and patient
2. Indirect supervision with direct supervision immediately available: the supervising physician is
physically within the hospital or other site of patient care, and is immediately available to
provide direct supervision
3. Indirect supervision with direct supervision available: the supervising physician is not physically
present within the hospital or other site of patient care, but is immediately available by means
of telephone and/or electronic modalities, and is available to provide direct supervision
4. Oversight: the supervising physician is available to provide review of procedures/encounters
with feedback provided after care is delivered
The Penn State Hershey Heart and Vascular Institute gives fellows significant, but appropriately well-
supervised latitude in the management of patients and provides a comprehensive experience in
cardiovascular diseases. This enables them to become independent and knowledgeable clinicians, with a
commitment to the life-long learning process that is critical for maintaining professional growth and
competency.
Ideally this sign-out between the fellows must be face to face, but at times this may not be possible
and hence communication over the telephone is also acceptable.
Relevant information regarding patients medical history, presenting complaint, hospital course and
potential issues overnight is expected.
An updated written sign-out on all patients on the Acute Cardiology and CHF services is always
available electronically. This is shared by Internal Medicine residents (who cover IMC and Floor level
patients) and Cardiology fellows (who cover the ICU patients):
It is created in Powerchart (open Powerchart->then open AdHoc under the specific patient->click
on Physician Documentation ->then click on Physician Handoff Communication form).
The sign-outs themselves can be accessed and printed within the Explorer Menu within
Connected by selecting specific patient lists from a pull-down menu (created previously in
Powerchart).
Both the Powerchart and Explorer Menu icons/applications are found within the main Cerner
Connected page-the principal Electronic Medical Record used at Hershey Medical Center.
Information regarding expected hospital transfers must be relayed to the on-call fellow by the
attending who accepted the transfer. The attending should also post a transfer accept note in the
electronic record.
The consult fellow will provide a similar verbal and written handoff on patients followed by their
service.
The overnight fellows will sign out overnight events, new admissions to all the service fellows. If the
service fellow is away for any reason (clinic / day off), relevant information must be signed out to
the attending on service.
If the service fellow has a day off over the weekend, the service attending may choose to directly
sign out to the fellow on call.
Sign-outs will periodically be overseen by supervising attendings. If there is concern about the
hand-off process or a specific fellow is felt to be deficient in the observed hand-offs, it will be
brought to the attention of the fellowship director for review, alteration in this policy, or directed
remediation for the fellow.
Duty Hours:
Fellows must have at least one full 24-hour day out of seven free of all educational and clinical patient
care duties when averaged over four weeks. Moonlighting cannot be done on this free day. After 24-
hour home call on the weekend, the fellow can remain in the hospital up to four hours afterward for
effective transitions of care. On a weekday post-call, the fellow may go home at noon if he or she is
overly fatigued. Duty hours are limited to 80 hours per week averaged over a four-week period,
inclusive of all in-house call activities and all moonlighting. Fellows should have eight hours free of duty
between scheduled duty periods. The demands of home call will be monitored, and scheduling
adjustments will be made as necessary to address excessive service demands and fatigue.
Fellows must log duty hours in New Innovations in a timely manner. This will be monitored by the
Program Director.
Fatigue Management:
Although Cardiology fellows are upper level residents who take home call, the potential for being in the
hospital all or most of the night does exist. For this reason, we have established the following criterion
for calling in a back-up fellow:
We also encourage fellows to go home by noon post-call if they are experiencing signs of fatigue. The
fellows and their attendings are collectively responsible for determining whether they are able to safely
and effectively perform their duties. If another fellow is needed to take over the duties of a fellow for
the rest of the day, the attending may call the chief fellow to find out who is available. In most
instances, a replacement will not be required, or a senior resident on the inpatient team can work
closely with the attending.
Education with regards to recognizing the signs of fatigue is provided by the institution and is mandatory
for fellows. Fatigue mitigation processes are outlined above. The following sleep facilities and safe
transportation options are available:
Non-assigned call rooms are located in the Biomedical Research building, room C1827, and on the
6th floor of the main hospital, room H6311. Fellows should contact the GME office at x5168 for the
access code. The best option is C1518, which can be used as a locked call room.
Capital City Cab is available to transport fellows home as needed. They can be reached at 717-939-
6363.
F. MOONLIGHTING
Moonlighting is permissible only by second and third year fellows, who have completed their first year
of fellowship in good standing, under the following conditions/restrictions:
Weekend Moonlighting:
Fellow can moonlight on Sunday during the day, but not Sunday night
Fellow can moonlight on Sunday, only if they have not moonlighted on Saturday
Fellow must have one weekend day free each week
Failure to comply with the moonlighting policy will result in loss of moonlighting privileges.
The Graduate Medical Education Committee is committed to offer graduate medical education
programs in which physicians in training develop personal, clinical and professional competence under
the guidance and supervision of the faculty and staff. Graduate medical education programs will ensure
the progression of responsibilities through demonstrated clinical experience, knowledge and skill. Penn
State Hershey is committed to and responsible for promoting high quality care, patient safety and
resident well-being, and to providing a supportive educational environment.
This "Statement of Commitment" is supported by the governing authority, the Graduate Medical
Education Committee, administration, the teaching faculty, and medical staff. It is the responsibility of
the Graduate Medical Education Committee to assure that the necessary educational, financial and
human resource provisions are made to support all graduate medical education training programs.
Principles:
1. Each program that wishes to provide compensation for additional work under this policy must
develop their own policy consistent with this policy, institutional policy, ACGME/RRC requirements,
and relevant state/federal law, which provide details of the process for allocating these duties and
the remuneration. This policy should be distributed to the residents and fellows of the program and
be available for their review.
2. Additional Work policies should be used only for brief and selflimited staffing needs.
3. The Graduate Medical Education Committee, via the Graduate Medical Education Office, must be
informed of all instances in which this policy is implemented. This notification must include a
justification for the additional work, a description of the duties and compensation, and the plan for
solving the serviceneed issue.
4. The Graduate Medical Education Committee reserves the right, after review, to terminate any
Additional Work policies felt not to comply with this policy or to otherwise not serve the best
interests of the residents/fellows or the institution.
6. Under no circumstances can a resident or fellow be required or obligated to take on additional work
under this policy.
7. Under no circumstances can a resident or fellow violate ACGME work hour rules by taking on
additional duties.
8. Residents must be a US Citizen or Permanent Resident to be eligible for additional work. (Residents
on J1 or H1B Visa are not eligible for additional work.)
9. Remunerated work hours performed under this policy must be tracked and included as duty hours.
10. The program director must indicate that the resident is in good standing and that this additional
duty will not interfere with their didactic training or educational needs (e.g. this would not be
appropriate for a resident who is on academic probation and needs to spend more time reading).
11. Residents and fellows cannot work outside their scope of practice, i.e. they must be appropriately
supervised by qualified faculty. Fellows can work independently in the area of their qualified
underlying specialty, consistent with hospital policy concerning licensure and privileging.
1. The Application for OffSite Away Elective Rotation must be completed and signed/approved by
the applicants Program Director and the Associate Dean for Graduate Medical Education and DIO
(or his designee). All requests must be received by the Graduate Medical Education Office at least 60
days before the beginning of the rotation to be considered for approval.
2. The preceptor at the outside elective site must provide a letter agreeing to accept the
resident/fellow for the time period requested, agreeing to the stated goals and objectives of the
rotation, and agreeing to complete an evaluation of the residents/fellows performance during the
rotation and to send this evaluation to the residents Program Director.
3. No more than one elective away month may be taken per resident/fellow during their training
period. Programs that require four years or more of residency training may offer one additional
away elective month. Exceptions may be granted by the Designated Institutional Official (DIO).
The Application for Off-Site Away Elective Rotation may be obtained from the Program Coordinator.
All Penn State Hershey Medical Center faculty and staff will conduct themselves in a professional
manner and will contribute to creation of an environment supportive of learning.
We will strive to treat our students and trainees the way we want them to treat everyone - with
dedication, respect, and compassion.
We expect that these policies will continue to be living documents, and that we will continue to
improve and address issues pertaining to respect in our learning environment as they arise.
E. DISASTER POLICY
In the event of a local or national disaster or public health emergency, Penn State Hershey will
continue to provide financial and administrative support for its GME programs through the disaster.
Trainees in ACGME accredited programs are considered essential personnel. In the event of a
disaster, all residents and fellows shall report to work as scheduled unless personally notified by their
supervisor or if reporting to work would put the resident at extreme risk. In the event that such a
disaster or its after effects warrant reduction or closure of a program(s), then the Reduction/Closure
Policy will take effect.
If, because of a disaster, an adequate educational experience cannot be provided for each
resident/clinical fellow the sponsoring institution will:
A. Arrange temporary transfers to other programs/institutions until such time as the
residency/fellowship program can provide an adequate educational experience for each of its
house officers/fellows.
B. Create Emergency GME Affiliation agreements retroactive to the date of the disaster to
incorporate new host hospitals, even if the host hospital is outside the affected area.
D. Inform each transferred resident of the minimum duration of his/her temporary transfer,
and continue to keep each resident informed of the minimum duration. If and when a
The Designated Institutional Official (DIO) will notify the ACGME Institutional Review Committee
Executive Director with information and/or requests for information. When appropriate, the DIO will
contact executive directors of specific residency review committees (RRCs).
Within ten days after the declaration of a disaster, the DIO will contact the ACGME to discuss due
dates that the ACGME will establish for the programs:
1. To submit program reconfigurations to the ACGME and
2. To inform each programs house officers of resident transfer decisions.
The due dates for submission shall be no later than 30 days after the disaster unless other due dates
are approved by the ACGME.
F. NON-COMPETITION POLICY
Penn State Hershey Medical Center, nor any of its ACGMEaccredited programs will require a
resident/fellow to sign a noncompetition guarantee or restrictive covenant.
Program Directors, faculty, and other medical center professionals are encouraged to be observant for
signs of impairment from alcohol, drugs, psychiatric or medical disorders among residents.
When impairment is suspected, the appropriate Program Director or Department Chair should be
informed and should utilize available resources to investigate the situation and take appropriate actions,
including intervention, when warranted.
It is our goal to provide intervention and rehabilitation for impaired residents and to support them
during the process. However, dismissal is possible if the resident refuses such.
Resources available to Program Directors, Department Chairs, faculty, or residents with respect to
impairment include the ComPsych, the Student Mental Health Service, the Department of Psychiatry,
professional counseling services and the Pennsylvania Medical Societys Physicians Health Programs.
Definition: Graduate Medical Education Educational Support Funds (GME ESF) is a specific form of
financial support to help residents and fellows learn about new & developing areas of their field. This
includes activities such as professional conferences, written publications, online programs, and other
media forms.
Procedure
1. During the annual budget process GME ESF funds are approved for each applicable training
program.
2. Allowable GME ESF Fund expenditures for residents and fellows include:
Professional conferences and related travel expenses
Medical books, Professional literature, Medical journals/magazine subscriptions (including
electronic books and subscriptions)
Professional licensing exam fees
Individual membership dues and fees to Professional Organizations/Societies, if the Penn State
Hershey Medical Center does not pay separate organizational membership dues to the same
Professional Organization/Society.
Personal use items related to medical education or patient care activities (e.g., iPads or a tablet
device that is for personal use, and that will be owned by the purchaser). The following
rules/regulations apply:
The reimbursement will be reported as income to the resident/fellow and they will pay
personal income tax on the item (as required by law). They will be reimbursed in their
paycheck and applicable taxes will be deducted. The device is a "common or listed property"
personal device, as classified by the IRS. Their W2 will reflect the reimbursement at the end
of the year.
Residents must have money in their current year CME/ESP/book fund account to purchase
the tablet. The resident may use part of their ESF fund to buy the tablet - and be reimbursed
3. Departments/Employees must follow established Accounts Payable policies & procedures for
payment/reimbursement of GME ESF allowable expenditures. Please reference these policies and
procedures at: Accounts Payable Policies.
C. MEETINGS / TRAVEL
Professional meetings serve a variety of important functions including provision of education about
medical practice, current research, administrative issues and compliance issues. They also offer
excellent opportunities for networking that can be invaluable for choosing future employment. All
fellows are encouraged to attend National meetings such as ACC, AHA, TCT, SCAI, and HRS during their
training. The conference must be within the 48 contiguous states of the United States or Canada,
(Approval by Administration must be given to travel internationally. See Program Coordinator for
special request form).
Fellows planning to submit an abstract for consideration at a meeting need to discuss their research /
abstract (and intended conference) with the research committee before submitting the abstract.
Funding must also be approved prior to abstract submission. Fellows who have travel expenses
associated with attendance for presenting at professional meetings that exceed their Educational
Support Funds are eligible to apply for a Travel Funds grant through Penn State Hershey Heart and
Vascular Institute*.
It is the expectation that fellows planning to travel (as soon as they are aware of the possibility) will
reserve their Educational Support Funds (ESF) for this purpose. The fellow will be required to fund at
least $1,000 of the travel from their ESF before accessing departmental funds**. Fellows may be eligible
for up to $1,000 of departmental funds by completing the Application for Travel Funds for Meeting
Presentation form***.
* The Application for Travel Funds for Presentation at a meeting may be obtained from the Program Coordinator.
*** The request to use departmental funds will be reviewed and approved by the Program Director and The
Research Committee Chair. A fellow is only eligible to use departmental funds one time per academic year.
ALL travel should be planned at least 60 days in advance and coordinated through the Fellowship
Program Coordinator.
D. INSURANCES
We emphasize prevention, wellness, and health choices. We continue to encourage our employees to
make informed decisions as engaged healthcare consumers.
We offer an expansive preventive schedule and lifestyle health management program with incentives.
We have maintained the Health Reimbursement Arrangement (HRA) and included opportunities for you
and your spouse/domestic partner to earn additional financial contributions toward your HRA. You
choose when to use your HRA to pay for medical deductible and coinsurance, further enabling you to
plan and save for tomorrow's healthcare expenses today. (Human Resources - Benefits website)
Complete and detailed information on benefits can be viewed on the Human Resources - Benefits
webpage.
E. EMPLOYEE DISCOUNTS
PSHMC has now partnered with Abenity to offer you not only local discounts but also national offers and
discounts as well. Through the new Abenity discount portal, PSHMC employees can access a
comprehensive group of local and national discounts and offers for hotels, restaurants, movie theaters,
spas, theme parks and more as well as concierge services.
Medical/Parental/Family Leave*: A resident may request a maximum of twelve weeks of family leave.
The first six weeks minus any vacation leave already used will be with full pay and benefits, and will
include any remaining vacation leave for the contract period. The remainder of the twelve weeks will
be without pay; however benefits will be billed at the employee rate. If the period of leave bridges
two consecutive contract periods, the amount of paid and unpaid leave will be allocated
proportionately, including available vacations days.
Personal Leave*: A personal leave may be granted to a resident upon review of the circumstances by
the Program Director. All eligible vacation time for that year must be used during this period. The
period of personal leave time that is not covered by vacation time will be unpaid.
Professional Leave*: A professional leave of absence may be granted to a resident upon review of the
circumstances by the Program Director. All eligible vacation time for the academic year must be used
during this period. The period of professional leave that is not covered by vacation time will be
unpaid.
Effect of Leave: All requirements of the residency training program must be fulfilled prior to the
completion of training. The Program Director is responsible to notify the Resident as to the effect of
leave on their training timeline. Residents may be required to extend their length of training to meet
all residency program requirements. The Residency Review Committee for t h e residency program
and the Residency Program Director determine the length of training and training to be completed
following a leave of absence.
*All requirements of the residents respective Board must be satisfied. Board requirements will take
precedence over institutional leave of absence policies, when applicable. Specific specialty Board
information can be accessed through the PSHMC internet, the Graduate Medical Education office, or the
Program Office. (Institutional Requirements: IV.G.I)
You may contact ComPsych Guidance Resources anytime for confidential assistance.
H. MEAL ALLOWANCE
The Penn State Hershey Graduate Medical Education program will fund a debit card/meal program
for resident physicians.
A. Individual debit card accounts will be established for all Penn State Hershey Medical
Center residents who work in the hospital.
B. The resident accounts will carry a maximum dollar limit of $450.
C. Dollar amounts will be specified for each residency-training program*. Amounts will not be
dependent, nor vary, based on the monthly rotation to which the resident is assigned or the
post-graduate year of the resident.
D. Graduate Medical Education will disburse credit to the individual resident account on a
quarterly basis.
E. The hospital identification (ID) badge of each resident will serve as the actual debit card. If
the resident does not present a valid hospital ID badge, the cafeteria staff will be unable to
charge the resident account.
F. After each purchase utilizing the debit card, the resident will be given a receipt indicating
the balance on their account.
G. The debit card account will be valid at all on-campus Food Services locations.
H. Residents may carry a monetary balance in their account from month-to-month and year-
to-year.
I. Residents will not receive any form of cash payment, in lieu of debit card funds.
J. When a resident terminates from a residency program, all funds are removed from the
resident account.
K. The Food Services Department will maintain records of all resident charges. The charges
will be allocated via interdepartmental transfer on a monthly basis, and paid by the Office
of Graduate Medical Education.
I. MEALS ON-CALL
A refrigerator is available in the back of the cafeteria for your use during overnight call. The refrigerator
can be accessed using your employee ID badge, between the hours of 10 p.m. and 7 a.m.
B. NOTARY
Services of a Notary Public are available in the Graduate Medical Education Office at no charge for
official documents. (Personal documents may be notarized at the discretion of the GME office staff, for
a fee.)
C. PARKING
The Parking Services office is located on the ground floor, room CG608, and can be reached at ext 3713.
All persons that park on campus must register their vehicle. A parking sticker will be issued and it must
be prominently displayed in the rear window of your vehicle. Parking Services will assign you to a
specific lot. You must park in this lot or the Centerview Parking Garage when parking on campus.
For additional information regarding parking, including hours of operation, handicap parking, etc. please
visit their website.
D. ID BADGING
The ID Badging office is located on the ground floor with Parking Services in room CG608. They can be
reached at ext 3548.
Penn State Hershey Medical Center and College of Medicine photo identification badges are issued to all
employees and students at the Hershey Campus. The ID badges include a picture of the employee or
student along with other information such as name, PA Department of Health mandated clinical role
and specified clinical certifications or a student/faculty designation. All students and employees are
required to wear their ID badge while working or conducting other hospital or college-related activities
on campus. You must present your ID badge to Security Officers or to hospital or college leadership
upon request.
For additional information regarding ID badging, including hours of operation, please visit their website.
For additional information, or links to their resources, please visit their website.
F. GIFT SHOPS
The Hospital Gift Shop is located on the first floor of the medical center, across from Starbucks. You will
find a wide selection of gifts, chocolates, fresh flowers and plants, magazines, books, toys, and greeting
cards. There is also Penn State store in the main hallway on the first floor near the Rotunda.
H. ATM
An Automated Teller Machine (ATM) is located in the hospital next to the Starbucks in the Main Hospital
Lobby
I. MAIL SERVICES
The HMC Mailroom is located on the Ground Floor, immediately off of the College of Medicine
elevators. It is open for HMC business from 8:00 am to 4:30 pm, Monday through Friday. Stamps and
other mailing supplies are available for sale at the personal service window between the hours of 11:00
a.m. and 1:15 p.m., Monday through Friday.
J. WORK-RELATED INJURIES
All work related injuries and/or illnesses should be reported immediately to your supervisor. If
treatment is required you should report to Employee Health. In a case of serious injury, the injured
employee can report directly to the Emergency Department. All follow up care will be coordinated
through Employee Health. These injuries/illnesses include percutaneous (needle sticks) or mucosal
exposure to blood/body fluids and exposure to communicable diseases.
K. TELEPHONE/PAGER INSTRUCTIONS
Telephone Instructions:
For calls within the Medical Center complex, dial the four or six digit extension number.
For local calls outside the Medical Center complex, and local toll (717), dial 9 + the seven digit
telephone number.
To call long distance, dial 9 + area code + 7 digit phone number.
Pager Instructions:
USER: Dial access code 4311 on any HMC telephone or 531-4311 from any private or public telephone.
SYSTEM: Please dial the page ID.
USER: Dial ID number of intended party.
SYSTEM: Speaks ID number or spoken name (if recorded). Speaks paging status, then prompts for a call-
back number if appropriate.
Dial the pager ID as you would any phone number. One of two things will happen:
You hear a series of beeps. Enter your call back #, followed by the pound sign, and hang up.
Your page will be answered by a voice prompt message. Follow the instructions given by the
paging company.
**Please remember that your 5-digit Author ID is a confidential password to the Enterprise system.
4 Dictate
2 Rewind a few seconds and play. Press several times to go back further then press 4 to continue recording
8 Forward a few seconds and play. Press several times to go further ahead then press 4 to continue recording
*# Help prompts
3 Rewind
4 Play
5 Fast Forward
7 Go to end of report
# New Patient ID