Cardiovascular Disease Fellowship

There is no dedicated Acute Service Lecture Series. A majority of the lecture series will have content pertinent to this rotation and curriculum. Specific inpatient topic reviews will occur as a part of:

• Multidisciplinary Case Conference
• Core Conference
• Journal Club

The acute service rotation overlaps extensively with almost all areas of cardiovascular training and promotes competency across many of the designated training goals as outlined in COCATS 4.

In addition to supplementing the learning experience in other areas, the acute service rotation, along with the consult rotation and ambulatory rotations, is designed to provide the trainee with Level I competency in the following areas:

• Training in Ambulatory, Consultative, and Longitudinal Care (Task Force 1)
• Training in Preventative Cardiovascular Medicine (Task Force 2)

Specific curricular milestones relevant to the acute service (and overlapping with consult service and ambulatory rotations), as they relate to the Core Competencies promulgated by the ACGME, are adopted as outlined in the COCATS 4 Task Force 1 and Task Force 2 documents. They are included, with the appropriate associated Evaluation Methods for fellows, as a separate document referenced by all associated rotations.

Based on the 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.

• Be present and prepared for daily rounds, typically starting at 8:30 a.m.
• Daily triage, evaluation, continuing care, and disposition planning of patients admitted to the acute cardiology service including:
  • Evaluation and triage of new patients from the emergency department, consultative service, and outpatient clinics.
  • Review and confirm patient assessments performed by medicine residents and fellow coverage from night and weekend admissions.
  • When necessary, perform an exam and document pertinent findings or decisions to supplement the resident’s comprehensive history and physical.
  • Review and confirm pertinent lab data, diagnostic testing, prior interventions/surgical history.
  • Assess for high acuity or unstable clinical scenarios through daily sign out and indirect assessment. See and examine high acuity patients before rounds.
• Develop an individualized diagnostic and management plan for testing and treatment based on the current ACC/AHA guidelines and other accepted literature regarding evidence based and standard practice as it pertains to each patient. Be cognizant of indications to withhold or adjust standard treatment.
• Review the history, physical examination, testing and/or treatment plans with the house staff and attending physician.
  • When the presentation is provided by residents or medical students (most common), provide supplementary information as necessary.
  • Present the patient as needed and based on the discretion of the fellow and attending.
• Assist in the coordination of efficient scheduling of inpatient testing, such as coronary angiography, percutaneous coronary intervention, right heart catheterization, TTE/TEE, electrocardioversion, and stress testing.
• Ensure effective communication with the Intensive Care Team when patients are in the HVICCU.
• Communicate the provisional diagnosis, recommendations, test results and plan of care with the patient and/or family in addition to potential complications associated with recommended testing or treatment.
• Provide education to the patient and/or family about their disease process.
• Serve as a team leader and role model for the acute service team:
  • Distribute patient care responsibilities to members of the care team to promote education and efficient care, being cognizant of their level of training. Engage individuals in care under the fellow’s direct supervision to promote learning when they are not ready for independence in a given area.
  • Review patient care plans and provide direct and indirect supervision to residents and medical students.
  • Provide education to the residents, medical students and other acute service team members.
  • Attend, supervise, or perform any necessary bedside procedures based on the skill level of associated house staff team members.
  • Maintain professional interactions and high quality communication with all members of the care team.

Fellows are required to attend the weekly PACHD conference on Tuesdays from 3 to 5 p.m. while on the ACHD rotation. They are also encouraged to attend the Pediatric Surgical conference on Thursdays from 7:30 to 8:30 a.m.

ACHD focused didactics will also occur as a part of the following conference series:

• Multidisciplinary Case Conference
• Core Conference
• ECHO Conference
• MRI Conference

The Adult Congenital Heart Disease rotation and associated training is designed to provide the fellow, within the standard three-year program, Level I competency in ACHD:

• COCATS Level I: (one month experience minimum)
  • Completion of four-week clinical ACHD rotation (detailed above)
  • Exposure to management of ACHD inpatients throughout 3-year training
  • Attending ACHD didactics (occurring throughout several educational schedules); at least six hours of didactic attendance required
  • Exposure to following diagnostic modalities of ACHD patients (ECG, echocardiogram, nuclear perfusion scans, cardiac MRI and CT)
  • Review and understand consensus-based ACHD care guidelines

The goal of Level I training is to provide the graduating Cardiovascular Disease fellow with sufficient knowledge and experience to manage patients with simple congenital heart lesions and the perspective to determine which patients need referral to an ACHD specialist.

There is no Level II training curriculum or qualifying examination in ACHD.

COCATS Level III training requires experience beyond a three-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. Penn State Health offers a subspecialty Level III training program which can be applied for following general cardiology fellowship.

Specific curricular milestones for Adult Congenital Heart Disease, as they relate to the Core Competencies promulgated by the ACGME, are adopted as outlined in the COCATS 4 Task Force 14 document. They are included in this curriculum with the appropriate associated Evaluation Methods for fellows.

Based on the 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.

Mandatory expectations

• Participate in outpatient clinic three days each week.
  • Obtain clinic schedule assignments from Pam Henderson prior to starting the rotation.
• Round on ACHD inpatients and provide inpatient consultative services on new or established ACHD patients.
• Attend weekly PACHD conference on Tuesday from 3 to 5 p.m.
• Fellow will present cases recently seen in-house or in clinic and review appropriate data with the faculty.
• Read ACHD Echocardiograms at least a half-day a week (when not in clinic or ACHD rounds).
  • It is expected that at the end of three years of fellowship, 25 ACHD echocardiograms will have been interpreted.

Optional expectations

• Participate in the Pediatric Surgical Conference Thursday morning 7:30 to 8:30 a.m.
• Participate in Cardiac MRI and TEEs of ACHD patients when scheduling permits (Cardiac MRIs predominantly performed on Tuesdays).
  • This is considered of high importance (mandatory) for fellows who desire advanced imaging: Level II MRI and/or Level III ECHO.

There is no dedicated Ambulatory Lecture Series. A majority of the lecture series will have content pertinent to this rotation and curriculum. Specific outpatient topic reviews will occur as a part of:

• Core Conference
• Echo Conference
• Nuclear Conference

The ambulatory clinics overlap extensively with almost all areas of cardiovascular training and promotes competency across many of the designated training goals as outlined in COCATS 4.

In addition to supplementing the learning experience in other areas, the ambulatory clinics, along with the consult service and acute service rotations, are designed to provide the trainee with Level I competency in the following areas:

• Training in Ambulatory, Consultative, and Longitudinal Care (Task Force 1)
• Training in Preventative Cardiovascular Medicine (Task Force 2)

Specific curricular milestones relevant to the acute service (and overlapping with the consult service and acute service rotations), as they relate to the Core Competencies promulgated by the ACGME, are adopted as outlined in the COCATS 4 Task Force 1 and Task Force 2 documents. They are included, with the appropriate associated Evaluation Methods for fellows, as a separate document referenced by all associated rotations.

Based on the 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.

• Be present and prepared for all assigned outpatient clinics.
  • All fellows will have approximately one-half clinic day per week on average.
  • There is no ambulatory clinic during the consult service rotation.
  • Clinics will alternate between a local cardiology clinic with a faculty preceptor and the Lebanon VA clinic.
• Local Penn State Health clinic: Fellows’ Clinic with Dr. Leaman
  • • Thursday afternoons in I.O. Silver clinic.

  Fellows will be assigned a half day clinic schedule comprising new patients and return visits.

• Local Penn State Health clinic: Shared with a core clinical faculty
  • Fellows will be assigned to work with a faculty cardiologist during their scheduled clinic for a half-day.
  • Fellow responsibility for patients should be discussed with their preceptor.
• Lebanon VA clinic
  • Wednesday and Friday mornings in the cardiac clinic (fourth floor, Building 21) of the Lebanon VA hospital.
  • Fellows will be assigned a half-day clinic schedule comprising new patients and return visits.
• At all clinics the fellows are expected to:
  • See the patient at the arranged time and date.
  • Review the reason for the consult or visit.
  • Review the history of present illness or and pertinent medical, social, and family history.
  • Review and confirm pertinent lab data, diagnostic testing, and prior interventions/surgical history.
  • Develop an individualized diagnostic and management plan for testing and treatment based on the current ACC/AHA guidelines and other accepted literature regarding evidence based and standard practice as it pertains to each patient.
    • Be cognizant of indications to withhold or adjust standard treatment.
  • Define a plan for short-term or routine follow-up when necessary.
  • Present the history, physical examination, differential diagnoses, assessment, and plan to their clinic preceptor.
  • Prepare appropriate documentation of the visit (outpatient letter or visit summary).
  • Communicate the provisional diagnosis, recommendations, test results and plan of care with the patient and/or family in addition to potential complications associated with recommended testing or treatment.
  • Provide education to the patient and/or family about their disease process, lifestyle modification, risk factor modification, suggested treatment options, and prognosis as appropriate.
  • Maintain professional interactions and high quality communication with all members of the clinic team and staff.

The cardiac catheterization rotation and associated training is designed to provide the fellow, within the standard three-year program, two potential levels of COCATS training:

• COCATS Level I: (four months experience minimum)
  • All fellows are expected to achieve COCATS Level I training during the fellowship.
  • Trainee should participate in minimum of 100 diagnostic procedures.
  • At least 50 of these should involve coronary angiography and 25 should involve hemodynamic assessment of valvular, myocardial, pericardial, or congenital disease.

• COCATS Level II: (6 months experience minimum)
  • All fellows have the opportunity to achieve COCATS Level II training during the fellowship program.
  • Participation in the performance of 300 diagnostic catheterization procedures.

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 Health 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 the curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested time frame in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship.

• Attend the Cardiac Catheterization conferences throughout the year.
  • When assigned, prepare a topic or case review for presentation during Cardiac Cath conference.
• Track participation in performing cardiac catheterization procedures.
• Participate in the weekly Structural Heart Disease (SHD) multidisciplinary meetings.
• Observe five (5) each of TAVR and Mitraclip cases in second and/or third year of training.
• The following specific responsibilities pertain to all fellows during the rotation:
  • See and evaluate the patient prior to the planned procedure.
  • Review and understand the indication for each planned procedure.
  • Complete the History and Physical (H&P) note for the first patient of the day.
    • Subsequent H&Ps may be written by the CRNP or PA, but the fellow is expected to help with additional review, examination, and documentation when available or necessary.
    • Know pertinent details of each patient on whom you expect to perform a procedure regardless of who completed the H&P.
  • Obtain informed consent from the patient or their designated representative.
    • Review the procedure along with its indication, risks, benefits, and alternatives.
  • Discuss the indications, history, examination, prior cardiac work-up, and planned procedure strategy with the designated faculty prior to each case.
  • Discuss appropriate use criteria (AUC) for diagnostic catheterization, pertaining to the case.
    • When indicated, discuss the AUC for coronary revascularization.
  • Participate in the planned procedure in a manner commensurate with the fellow’s current level of experience under the direct guidance of the involved faculty.
  • Participate in analyzing the angiographic and hemodynamic data obtained during the procedure.
  • Participate in discussion on formulation of treatment plan.
  • Preparation and completion of the procedure report.
    • To be completed as timely as possible, no later than the end of the day.
  • Communicate procedural findings and/or testing results to the referring team.
  • Explain procedural findings and/or testing results, along with any new recommendations or plans to the patient or their designated representative.
  • Assess the patient post procedure, including evaluation and treatment of any complications related to the procedure.

The cardiac CT portion of the Vascular/Imaging rotation and associated training are designed to provide the fellow, within the standard three year program, one potential level of COCATS training:

• COCATS Level I: (one month experience minimum)
  • All fellows are expected to achieve COCATS Level I training within the first two years of fellowship.

COCATS Level II training requires a minimum of three 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 fellowship leadership to see if arrangements external to Penn State can be made.

COCATS Level III training requires experience beyond a three-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. Penn State Health does not offer subspecialty training in cardiac CT.

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 the curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested time frame in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship.

• Attend and participate in the monthly Multimodality Imaging conferences throughout the year.
• Discuss upcoming/planned cardiac CT cases with the responsible faculty member.
• Review planned cardiac CT cases for clinical background and medical history prior to the cardiac CT study.
  • Evaluate the appropriateness of the study and anticipated clinical data.
  • Review prior CT studies and/or other imaging modalities.
  • Discuss planned protocol with the responsible faculty.
• Attend planned cardiac CT studies when possible.
• Observe and/or participate in the measurement and interpretation of the cardiac CT studies under the guidance of the interpreting faculty member.
• Independent review of cardiac CT materials.
• Refer to and follow the Vascular/Imaging Rotation Schedule for recommended schedules. Due to the current structure of cardiac CT at the institution, availability and timing of cardiac CT studies may not be predictable. Independent learning will comprise a significant portion of the fellows’ exposure to cardiac CT. Interested fellows are encouraged to proactively seek out hands-on opportunities.

The cardiac MRI portion of the Vascular/Imaging rotation and associated training are designed to provide the fellow, within the standard three-year program, one potential level of COCATS training:

• COCATS Level I: (one month experience minimum)

• • All fellows are expected to achieve COCATS Level I training within the first two years of fellowship.

COCATS Level II training requires a minimum of three months of dedicated training in cardiac MRI. At the current time, Level II training is not available during the standard fellowship. Fellows who wish to achieve Level II in cardiac MRI should discuss this with fellowship leadership to see if arrangements external to Penn State can be made.

COCATS Level III training requires experience beyond a three-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. Penn State Health 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 the curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested time frame in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship.

• Attend and participate in the monthly Multimodality Imaging conferences throughout the year.
• Review planned cardiac MRI cases for clinical background and medical history prior to the cardiac MRI study.
  • Evaluate the appropriateness of the study and anticipated clinical data.
  • Review prior CMR studies and/or other imaging modalities.
  • Discuss planned protocol with the responsible faculty.
• Attend the Tuesday morning cardiac MRI acquisitions.
  • Scheduled adult cardiac MRI cases are on Tuesdays from 8:30 a.m. to 2:30 p.m.
• Observe and/or participate in the measurement and interpretation of the cardiac MRI studies under the guidance of the interpreting faculty member.
• Refer to and follow the Vascular/Imaging Rotation Schedule.

There is no dedicated Consult Service Lecture Series. A majority of the lecture series will have content pertinent to this rotation and curriculum. Specific inpatient topic reviews will occur as a part of:

• Multidisciplinary Case Conference
• Core Conference
• Journal Club

The consult service rotation overlaps extensively with almost all areas of cardiovascular training and promotes competency across many of the designated training goals as outlined in COCATS 4.

In addition to supplementing the learning experience in other areas, the consult service rotation, along with the acute service rotation and ambulatory rotations, is designed to provide the trainee with Level I competency in the following areas:

• Training in Ambulatory, Consultative, and Longitudinal Care (Task Force 1)
• Training in Preventative Cardiovascular Medicine (Task Force 2)

Specific curricular milestones relevant to the consult service (and overlapping with acute service and ambulatory rotations), as they relate to the Core Competencies promulgated by the ACGME, are adopted as outlined in the COCATS 4 Task Force 1 and Task Force 2 documents. They are included, with the appropriate associated Evaluation Methods for fellows, as a separate document referenced by all associated rotations.

Based on the 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.

• Be present and prepared for daily rounds. Timing of rounds is typically at least twice a day in the morning and afternoon. However, variation is common and rounds will be coordinating between the fellow and on call faculty for the consult service team.
• Evaluation, continuing care, and cardiovascular disposition planning of patients in the emergency room and admitted to non-cardiology services when a cardiology consultation is requested. This includes:
  • Timely response to all new consults. When necessary, multiple requests are to be triaged by the fellow with the assistance of the on call faculty as needed.
  • Distribute new consults and/or daily follow-up to residents and students on the consult service, being cognizant of their level of training and the acuity of the request.
  • Review and confirm patient assessments performed by medicine residents and fellow coverage from night and weekend consults.
  • Review and confirm pertinent lab data, diagnostic testing, prior interventions/surgical history.
  • Maintain a functional knowledge of all patients being followed by the consult service, even if they are being seen routinely by a resident or study.
• Develop an individualized diagnostic and management plan for testing and treatment based on the current ACC/AHA guidelines and other accepted literature regarding evidence based and standard practice as it pertains to each patient. Be cognizant of indications to withhold or adjust standard treatment.
• Present the history, physical examination, testing and/or treatment plans to the attending physician.
  • When the presentation is provided by residents or medical students, provide supplementary information as necessary.
• Provide clear documentation of the cardiac assessment and plan with attention to any specific questions raised by the requesting team. All recommendations for new consults and significant daily updates should be communicated directed to the primary team with a phone call or face-to-face conversation.
• Communicate the provisional diagnosis, recommendations, test results and plan of care with the patient and/or family in addition to potential complications associated with recommended testing or treatment.
• Provide education to the patient and/or family about their disease process.
• Triage any “1, 2” pages (from outside calls) which may be directed to the inpatient consult team during the day. This often involves answering questions or providing basic recommendations by phone and facilitating communication or follow-up with the appropriate associated provider or their clinic staff.
• Serve as a team leader and role model for the consult service team.
  • Review patient care plans and directly supervise residents and medical students.
  • Provide education to the residents, medical students and other consult service team members.
  • Maintain professional interactions and high quality communication with all members of the consult team, the primary service team, and the interdisciplinary care team.
• Provide daily sign out on consult patients to the on-call cardiology fellow on a daily basis.

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 I (two months experience minimum)
  • All fellows are expected to achieve COCATS Level I training during the fellowship.
  • Experience will come during dedicated rotation and frequent ICU level rounds while on all inpatient service rotations.

COCATS Level III training requires experience beyond a three-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. At the present time, Penn State Health 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 the curriculum and rotation schedule a fellow may achieve these milestones ahead or behind the suggested time frame in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship.

• Five consecutive weekdays, 12-hour shifts.
• Attend 7 a.m. and 7 p.m. ICU handoff rounds.
• Round with Intensivist team and act as a liaison between the Cardiology and Intensivist teams and assist in decision-making.
• Provide cardiology consultation on patients in the ICU, as requested.
• Responsible for consult note on cardiology consult patients and rounding with appropriate cardiology attending.
• Assist in the scheduling of cardiac procedures in HVICU patients (cath lab, TEE).
• Teach the ICU staff about cardiology topics.
• Assist in procedures performed in the HVICU (PA catheter and art line placements, IABP placement, TEE, ECMO).
• Participate in end-of-life issues, family discussions and meetings.

The echocardiography rotation and associated training are designed to provide the trainee, within the standard three-year program, three potential levels of COCATS training:

• COCATS Level I: (three months experience minimum)
  • All fellows are expected to achieve COCATS Level I training within the first 2 years of fellowship.
    • Minimum number of TTE examinations performed/interpreted: 75/150
• COCATS Level II: (six months experience minimum)
  • Required to perform and interpret echocardiographic studies independently in practice.
  • All fellows are expected to achieve COCATS Level II training during the fellowship.
    • Minimum number of TTE examinations performed/interpreted: 150/300
    • Minimum number of SE/DSE examinations interpreted: 100
    • Minimum number of TEE examinations performed & interpreted: 50
      • A minimum of 100 TEEs is strongly recommended.
  • Many fellows will achieve this in time to take the NBE Certification Exam in their third year of fellowship.

• COCATS Level III: (nine month experience minimum)
  • Interested fellows must discuss the opportunity to achieve COCATS Level III training during the general fellowship with the echo lab director. This will include (but is not limited to):
    • More intensive exposure to and experience with all areas of echocardiography including:
      • Echo Lab Administration
      • Quality Improvement
      • Advanced Echo Modalities/Techniques
      • Echo Focused Teaching
    • Minimum number of TTE examinations performed/interpreted: 300/750
    • Although not formally outlined in COCATS, a substantially higher number of stress echoes and TEEs is also anticipated for those fellows who desire to attain Level III training.
  • This decision should be made before the beginning of the third year of training to ensure proper preparation of the schedule and training experience.

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 the curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested time frame in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship.

• Attend and participate in the echocardiography conference series throughout the year.
  • When assigned, prepare a topic or case review for presentation during Echocardiography conference.
• Track participation in performing and interpreting studies.
  • Separate tracking of TTEs, stress echoes, and TEEs is required.
  • Studies performed or interpreted during conferences and while not on the echocardiography rotation should also be tracked.
• Be present in the echo lab area throughout the working day to maximize education and learning from direct experience, faculty supervision, and focused teaching. This includes:
  • Be available to answer the phones and field questions from sonographers, staff, and referring providers.
  • Assist with the evaluation and management of critical findings, patient complaints, and test complications.

• • Prepare comprehensive preliminary reads on transthoracic, exercise stress, and dobutamine stress echocardiographic studies.

• Provide preliminary interpretation of the resting and stress ECGs for all stress echoes.

• • Supervise stress echocardiogram exams when required.
    • All fellows are expected to directly supervise at least 10 stress echoes.
  • When necessary, contact ordering physicians directly with significantly abnormal or unexpected findings (such as abnormal stress test, cardiac tamponade, or new diagnosis severe aortic stenosis).
  • Learn the appropriate technique for ultrasound contrast preparation and administration including agitated saline and microbubble contrast.
    • Assist with preparation and administration of ultrasound contrast when nursing is not available.
• One fellow in the lab must be assigned to transesophageal echocardiography studies on a daily basis. This responsibility should not be assigned to first-year fellows during their first two months in the lab. The following responsibilities pertain to TEE:
  • There should be one upper-year fellow assigned and available to cover TEE each day.
    • When more than one qualified fellow is available on the rotation, the fellows are responsible for arranging daily coverage assignments.
  • Carry the TEE pager (3335) or have this forwarded to the fellow’s individual pager.
    • If forwarded, this forward should be removed at the end of the day.
  • Review each request for a TEE to determine appropriateness.
  • Review patient history, physical, and prior studies.
  • Understand and evaluate any potential contraindications for a TEE procedure.
  • Discuss each case with the supervising faculty before arranging or performing the study.
  • When appropriate arrange for TEE with anesthesia.
  • Be aware of the risk and benefits of sedation and of the TEE and provide informed consent to the patient or surrogate.
  • Administer moderate conscious sedation and perform the TEE under the direct guidance and supervision of the TEE attending.
  • Communicate results of the study to the patient and/or family.
  • Contact the referring provider with results when appropriate.
  • When there are no TEEs to perform, or all TEE responsibility for the day is completed, the TEE fellow should continue all other general responsibilities for the echo lab as outlined.
• Senior fellows are encouraged to participate in the orientation, supervision, and guidance of new first-year fellows in the echo lab.
• Fellows on call will also be expected to triage, perform, interpret, and communicate results from STAT TTE and TEE studies requested during nights and weekends while sonographer coverage is not available.
  • An on call echo faculty will always be available for TEEs and as back-up for TTEs.
  • Please refer to addendum for additional information.
• Fellows who desire Level III Training should discuss additional expectations with the Echo Lab Director.

The electrophysiology rotation and associated training is designed to provide the trainee, within the standard three-year program, two potential levels of COCATS training.

• COCATS Level I: (two months experience minimum)
  • All fellows are expected to achieve COCATS Level I training within the standard three-year training program.
    • Minimum number of procedure involvement:
      • Electrocardioversions: 20
      • Temporary pacemakers: 5

• COCATS Level II:(six months experience minimum)
  • Interested fellows must discuss the opportunity to achieve COCATS Level II training during general fellowship with a member of the EP faculty. This will include (but is not limited to):
    • Requisite number of EP rotations.
    • Minimum number of device interrogations/programming: 100 (25 remote)
    • Arranging additional EP focused outpatient clinic exposure
  • It is anticipated this level of training will be pursued by fellows who desire to move on to Level III subspecialty training in electrophysiology or who intend a career in an area with limited access to EP specialists.

COCATS Level III training requires experience beyond a three-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. Penn State Health 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 the 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.

• Attend and participate in the electrophysiology conference series throughout the year.
  • When assigned, prepare a topic or case review for presentation during electrophysiology conference.
• Track participation in at least the following procedures:
  • Temporary Pacemaker Placement
  • Electrocardioversion (ECV)
    • Temporary Pacemakers and ECVs performed while not on EP rotation should also be tracked.
• Daily availability to see new EP consults and write an appropriate consult note, present pertinent data to the assigned EP faculty, communicate recommendations and provide longitudinal follow-up to the referring team as appropriate.
• In addition to daily assistance with EP consults the fellow is expected to participate in AT LEAST one of the following activities on a daily basis:
  • Observe and participate in electrocardioversions, electrophysiology studies, ablations, and device implantations in the EP lab.
    • The minimum numbers for participation in temporary pacemakers and ECVs are outlined, but observing all the procedures at least once is encouraged.
    • Check with EP lab staff about procedure availability on a daily basis
  • Review and provide preliminary interpretation for exercise ECG testing.
    • Performed on most days.
    • Contact person: Rich Bradford (or any exercise physiologist)
  • Review and provide preliminary interpretation for ambulatory ECG monitoring (Holter monitors)
    • Performed in Lumedex
  • Observe and participate in device interrogations and programming in the outpatient device clinic and on the inpatient units.
    • Shadowing an EP technologist during the rotation is strongly encouraged. With appropriate training, fellows should perform their own interrogations
    • Outpatient appointments occur every Monday, Wednesday, and Friday in the Device Clinic; Tuesday and Thursdays are telephonic interrogation and potentially not as useful for the fellows’ experience.
  • Observe and participate in tilt table testing
    • This occurs every other Monday morning in the Non-Invasive Lab (Stress Lab 1)
    • Contact person: Barbara Bentz, CRNP (pager 2853)
  • Attend outpatient EP clinic with an EP faculty member for one half-day per week.
    • This will occur on Fridays at Nyes Road clinic with Drs. Samii and Hussain
    • The fellowship coordinator will confirm these dates with you two weeks before the start of the rotation so new patient visits can be specifically assigned for the fellow to see with EP faculty supervision.

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 educational opportunities.

The heart failure service rotation is designed to provide the trainee, within the standard three-year program, two potential levels of COCATS training:

• COCATS Level I: (two months experience minimum)
  • All fellows are expected to achieve COCATS Level I training within the first two years of fellowship.
• COCATS Level II:  (four months experience minimum)
  • Interested fellows must discuss the opportunity to achieve COCATS Level II training during the general fellowship with a member of the CHF faculty. This will include (but is not limited to):
    • The requisite minimum number of CHF service rotations.
    • Arranging CHF focused outpatient clinic exposure during the 3^rd year of fellowship.
    • Dedicated experience in right heart catheterization and biopsies with CHF faculty.
    • CHF Focused Teaching.
  • It is anticipated this level of training will be pursued by fellows who desire to move on to Level III subspecialty training in heart failure or who intend a career in an area with limited access to CHF specialists.

COCATS Level III training requires experience beyond a three-year fellowship and by definition cannot be obtained during the general fellowship in cardiovascular disease. At the present time, Penn State Health 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 the curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested time frame in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship.

• Daily triage, evaluation, continuing care and disposition of patients admitted to the general cardiology heart failure service including:
  • Evaluation and triage of new patients from the emergency department and consultative service.
  • Review and confirm patient assessments performed by medicine resident and fellow coverage from night and weekend admissions.
  • On admitted patients a history and physical is performed to supplement the admitting resident’s comprehensive history and physical as needed.
• Develop an evidence-based, individualized diagnostic and management plan for testing and treatment based on the current ACC/AHA, HFSA or ISHLT guidelines as it pertains to each patient.
• Present the history, physical examination, testing and/or treatment plans to the attending physician.
  • When the presentation is provided by residents or medical students, provide supplementary information as necessary.
• Communicate the provisional diagnosis, recommendations, test results and plan of care with the patient and/or family in addition to potential complications associated with recommended testing or treatment.
• Provide education to the patient and/or family about their disease process.
• Serve as a team leader and role model for the heart failure service team.
  • Attend, supervise or perform any necessary bedside procedures based on the skill level of associated house staff team members.
  • Review patient care plans and directly supervise residents and medical students.
  • Provide education to the residents, medical students and other heart failure team members.
• Serve as a liaison between the heart failure team and other services that may be providing non-cardiac treatment for heart failure patients.
• Assist in the management of patients who are undergoing evaluation for or who have had cardiac transplantation in conjunction with designated transplant coordinators.
• Attend weekly Transplant/VAD meeting.

The nuclear cardiology rotation and associated training is designed to provide the trainee, within the standard three year program, two potential levels of COCATS training.

• COCATS Level I: (two months experience minimum)
  • All fellows are expected to achieve COCATS Level I training within the first two years of fellowship.
    • Minimum number of nuclear cardiology studies: 100
• COCATS Level II: (four months experience minimum)
  • All fellows have the opportunity to achieve COCATS Level II training during the fellowship program.
    • Minimum number of nuclear cardiology studies: 300
  • Required to perform and interpret nuclear cardiology studies independently in practice.
  • Many or all can achieve this in time to take the CBNC Board Exam in their third year of fellowship.
    • An external radiation safety training course is required to fulfill the NRC requirement for Classroom and Laboratory Training and sit for the CBNC Board Exam.

COCATS Level III training requires experience beyond a three-year fellowship and by definition cannot be obtained during general fellowship in cardiovascular disease. At the present time, Penn State Health 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 the curriculum and rotation schedule a fellow may achieve these milestones ahead or behind the suggested time frame in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship.

• Attend the Nuclear Cardiology and Nuclear/Cath Correlate Conferences throughout the year.
  • When assigned, prepare cases for the Nuclear/Cath Correlate Conferences with appropriate correlations to coronary angiography and other imaging modalities.
  • When assigned, prepare one topic review for Nuclear Cardiology Conference during second and third year of fellowship.
• Track participation in performing and interpreting cases.
  • Studies performed or interpreted during conferences and while not on the nuclear cardiology rotation should also be tracked.
• Daily supervision of nuclear stress testing (at the Medical Center) including:
  • Documentation of the reason for the stress test.
  • Obtain an appropriate history and physical (H&P) to ensure the test can safely and appropriately be performed.
  • Oversee the performance of the stress test with the clinical nurse in nuclear radiology.
  • Review and provide preliminary interpretation of the resting and stress ECGs (at the Medical Center).
  • Attend the daily afternoon reading session held jointly with Nuclear Radiology.
  • Review and provide preliminary interpretation of the nuclear imaging results (at the Medical Center and those performed at satellite locations).
• Communicate with the patient as necessary during the time surrounding their testing.
• Communicate abnormal test results to requesting/ordering physicians.
• Participate in the following activities under the guidance of a nuclear cardiology technician and/or health physicist:
  • Radiopharmaceutical Handling and Dose Preparation.
    • Performed at 6 a.m. on all weekdays.
    • Must notify nuclear technologist at least 24 to 48 hours in advance.
  • Image Acquisition and Processing.
    • Performed throughout the morning on all weekdays.
    • May ask nuclear technologist to participate on a daily basis.

• Dedicated Health Physics Experience.
  • Performed one-on-one with the Health Physics Department.
  • Can be done in a single day or broken up over two to four days.
  • Can be done at any time, but is recommended in the second or third year before taking boards.
  • Must be set up in advance.

The research rotation, along with longitudinal effort occurring concomitantly with other training, is designed to provide the trainee, within the standard three-year program, training that meets or exceeds COCATS Level I expectations.

• COCATS Level I:
  • Trainees should establish a relationship with a research mentor and devote six to 12 months to one or more scholarly activities or cardiac research projects.
  • 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?).

• Advanced training:
  • Trainees preparing for careers in research need an extensive foundation in scientific investigation.
  • These skills can be achieved in combined degree programs including MD/PhD, MD/MPH and MD/MS.
  • Trainees seeking a career in investigative cardiology without an advance degree are encouraged to obtain necessary scientific analytical course work and clinical research experience to promote a productive research career.
    • Graduate level course work is available through the Penn State College of Medicine’s master’s degree program in Public Health Sciences.

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 the curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested time frame in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship.

• 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.
  • After developing clinical questions, research project should be followed until completion.
  • Project results should be written up and submitted for presentation at a cardiovascular conference or publication in a peer reviewed journal.
  • 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.

The vascular portion of the Vascular/Imaging rotation and associated training are designed to provide the fellow, within the standard three-year program, two potential levels of COCATS training:

• COCATS Level I: (two months experience minimum)

• • All fellows are expected to achieve COCATS Level I training within the first two years of fellowship.

• COCATS Level II: (training duration not defined)

• • Interested fellows must discuss the opportunity to achieve COCATS Level II training during general fellowship. This will include:
    • Additional scheduled time (as elective rotation or concomitant with other rotations) in the vascular imaging lab.
    • To sit for the Physician’s Vascular Interpretation Examination requires interpretation of a minimum of 500 total vascular studies across the vascular testing areas.

COCATS Level III training requires experience beyond a three-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 the curriculum and rotation schedule, a fellow may achieve these milestones ahead or behind the suggested time frame in the COCATS 4 document. All Level I milestones represent minimum expectations during general fellowship.

• Attend Vascular Laboratory reading sessions with on Tuesday afternoons and Thursday mornings.
  • Participate in the review and interpretation of peripheral vascular studies.
• Attend weekly Vascular lectures during rotation on Thursday mornings at 8 a.m.
  • Schedule to be confirmed at the start of the rotation.
• Attend outpatient clinic to shadow and participate in the evaluation and treatment of patients with peripheral vasculature disease.
• Track reading of peripheral vascular studies for documentation.
  • New Innovations is the preferred method of tracking.
• Refer to and follow the Vascular/Imaging Rotation Schedule.
• Notify the respective faculty of expected attendance or, if unable to attend the scheduled sessions, notify as a courtesy for their involvement in the program.