Curriculum for Adult Cardiovascular Disease Training American University of Beirut Medical Center

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1 1 Curriculum for Adult Cardiovascular Disease Training American University of Beirut Medical Center Core Physician Committee: 1. Samir Alam, M.D., Chair 2. Bernard Abi-Saleh, M.D. 3. Marwan Refaat, M.D. 4. Hussein Ismaeel, M.D. 5. Walid Gharzuddine, M.D. 6. Antoine Abchee, M.D. Clinical competency committee: Program evaluation Committee: 1. Wael AlJaroudi, M.D. 1. Hussein Ismaeel, M.D. 2. Hussein Ismaeel, M.D. 2. Abdallah Rubeiz, M.D. 3. Maurice Khoury, M.D. 3. Cardiology fellow Full-time faculty: 1 Samir Alam, M.D. Chief, Division of Cardiology 2 Wael AlJaroudi, M.D. Director, Cardiovascular Training Program 3 Ziad Ghazzal, M.D. 4 Hadi Skouri, M.D. 5 Abdallah Rubeiz, M.D. 6 Samir Arnaout, M.D. 7 Antoine Abchee, M.D. 8. Maurice Khoury, M.D. 9. Walid Gharzuddine, M.D. 10. Habib Dakik, M.D. 11. Bernard Abi-Saleh, M.D. 12. Marwan Refaat, M.D. 13. Hussein Ismaeel, M.D. Part-time faculty

2 2 1. Jaber Sawaya M.D. 2. Sami Kaedbey M.D. PROGRAM DISCRIPTION American University of Beirut Medical Center Department of Internal Medicine Division of Cardiovascular Diseases Fellowship Training Program P.O. Box: Riad El Solh Beirut, Lebanon Telephone: extension:5420 Fax: Program Director: Wael AlJaroudi, M.D. History/Background: The Cardiovascular Disease Training Program at the American University of Beirut first started in Since the program inception, over 40 individuals have been trained. The program constitutes an integral component of the Department of Internal Medicine at the American University of Beirut. The program is committed to education, research and excellence in patient care. The program covers a wide variety of acute and chronic cardiovascular diseases and prepares the trainee to function independently as cardiovascular specialists. Duration: The Duration of the Cardiovascular Diseases Program is three years with 7 positions ( with the aim in expanding to 9 fellows) over the three year general cardiology training. Comprehensive training in all major aspects of clinical cardiology is combined with training in clinical cardiovascular research. It is the program s responsibility to ensure that the educational resources are adequate to support the number of fellows appointed to the program. Trainees rotate exclusively at the American University of Beirut Medical Center and the Outpatient Department.

3 3 Prerequisite Training/Selection Criteria: All applicants to the Cardiovascular Diseases Fellowship Training Program at the American University of Beirut Medical Center are required to have completed three year internal medicine at well-recognized residency programs. The fellowship program constitutes seven position for the three training years. Two fellows are selected each year with a third fellow every third year (plan to expand to 3 fellows per year and each year). Each applicant should submit an application to the Graduate Medical Education Office with the required documentation: 1- an authenticated copy of the medical school diploma 2- an authenticated copy of the internal medicine diploma 3- a recent Passport size colored photograph of the applicant 4- an official medical school transcript[s],impressed with original medical school seal[s]. 5- a copy of a valid identification card and /or passport 6- A curriculum vita prepared within three months of the application. 7- A minimum of three letters of reference from faculty members from the Internal Medicine Residency program from which the applicant has been trained. These letters of reference must be written in English or be accompanied by certified translations. 8- Score reports on steps in the United States Medical Licensure Examination (IF Applicable) 9- Letter of Intention 10-Score reports of the English Language Proficiency examination from Graduates of schools/residency programs outside the United states other than the American University of Beirut/Lebanese American University. 11-Any other information that the Faculty of Medicine may request in connection with the applicant s credentials. The deadline for submitting applications is the end of February of each academic year. Selections will be completed by mid May of each year at which selected individuals will be informed by our program. The selection process will take place as follows: A review committee will be appointed. This committee includes the program director and two other full time cardiology faculty. The applications will be screened first by the program director and the chief fellow. Based on specific criteria agreed upon by the committee, a decision is made whether to invite the

4 4 applicant to a personal interview. Preference will be given to applicants who choose cardiology fellowship as their first choice. Each applicant will be interviewed by all faculty members who will be sitting in one room and administering questions. A second interview will be one on one with the applicant and the Director, in addition to the chief fellow. Applicants will be scrutinized for adequate clinical experience since graduation from medical school and residency training. Clarification of any gaps will be requested from otherwise competitive applicants. Exceptionally and at the discretion of the program director, applicants unable to visit due to extenuating circumstances will be offered the opportunity to complete a telephone or video-conference interview. Cumulative evaluation scores are developed for each applicant and a rank order is formulated by the committee. The cardiology rank order list is sent to the Graduate Medical Education Committee and sent to the Academic Committee for approval. The final rank list results are announced by the Graduate Medical Education Office. Program Certification: The Cardiovascular Diseases Fellowship Training Program is certified by the Lebanese Ministry of Health and the Lebanese Order of Physicians. Fellowship trainees are not required to be licensed to practice Medicine in Lebanon. GENERAL INFORMATION 1. Mission Statement The mission of the Fellowship Training Program in Cardiovascular Diseases at the American University of Beirut Medical Center is to provide an academically and clinically comprehensive training program in general and clinical cardiology as well as cardiovascular research. The aims of the program are to provide the trainee with the basic and clinical knowledge, procedural skills, clinical judgment, professionalism and interpersonal skills, and abilities necessary to continue to hone these skills through the course of a long career, as required of a leader in cardiovascular medicine. The curriculum is designed to provide a broad clinical exposure in acute and chronic cardiovascular care occurring in the inpatient and outpatient settings, as well as extensive experience in non-invasive and invasive cardiac procedures. Fellowship training will prepare fellows to function as outstanding cardiologists and prepare them to train in various sub specialists.

5 5 Upon completion of this training program, trainees are expected to: understand the pathophysiology of acute and chronic heart disease be clinically experienced in the diagnosis, evaluation and management of patients with acute and chronic heart disease comprehend and have acquired experience in cardiovascular pharmacology have developed an understanding of the indications and contraindications of cardiac procedures and cardiac interventions have acquired knowledge to develop the decision making process that leads to the selection of alternative treatment options be able to recognize and manage treatment related complications have acquired knowledge and expertise in patient education and discharge planning have acquired the necessary skills that are needed to manage acute hemodynamic resuscitation including use of vasoactive agents, use of antiarrhythmic drugs, use of thrombolytic agents, CPR, advanced life support, pericardiocentesis, intra-aortic balloon pump understand and apply the latest methods of heart disease prevention cultivate and maintain a quality approach to patient care based on critical thinking, compassion and dedication promote scholarly research foster excellence in teaching 2. Training Structure Fellowship training occurs over the course of 3 years. All fellows must be intimately involved in a research project during the course of their fellowship. Fellows maintain a half day continuity clinic per week at the Outpatient Department (OPD).Fellows rotate on a variety of inpatient and outpatient services as well as through the invasive and non-invasive

6 6 3. Facilities laboratories. All fellows will achieve level 2 certification in Cath, Echocardiography, and level 1 certifications in other rotations as outlined in COCATS 2. It is the intent of the fellowship administration to individualize training within the framework of ACGME guidelines to optimize each fellow s experience to achieve excellence in academic cardiology. The core clinical training for the program is based on the ACC Revised Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training II (COCATS II) published in 1995 and updated in Training is conducted in compliance with the Accreditation Council for Graduate Medical Education (ACGME) program requirements for general fellowship education in the subspecialties of Internal Medicine and the specific requirements for fellowship education in Cardiovascular Disease. These guidelines were last updated in July 2012 and can be reviewed on the ACGME website ( under the Residency Review Committee tab, and are kindly attached. The hospital which form the core of this program functions are both primary and tertiary care institution. The patients from this institution represent a wide variety of common and rare cardiovascular disorders and provide excellent exposure to all areas of cardiovascular medicine. AUBMC has a CCU with 20 beds, 2 cardiac catheterization laboratories, one of which serve as a electrophysiology (EP) laboratory, an echocardiography laboratory with 5 echocardiography machines (an extra machine has just been purchased) and 2 staff reading per day, ECG and stress testing area, nuclear cardiology perfusion imaging laboratory (managed by Cardiology division with the department of Radiology), advanced cardiac imaging with cardiac CT and cardiac MRI (1.5 and 3.0 T) (managed by Cardiology and Radiology departments), a prevention outpatient clinic (Saturdays), and a congestive heart failure/transplant clinic, hypertensive/vascular medicine, and smoking cessation programs (to be initiated by mid 2013). CURRICULUM

7 7 1. Introduction: The curriculum of the cardiovascular diseases fellowship consists of a variety of clinical experiences and didactic conferences that take place at AUBMC. Fellows rotate on several inpatient services and outpatient services and provide both direct and consultative care. Fellows attend a weekly continuity clinic at the OPD. Procedural skills are gained as fellows rotate through the invasive and non-invasive laboratories at the hospital. Several conferences occur throughout the week, and a core curriculum lecture series that covers the entire cardiology curriculum (Mayo review series) is covered over a two year rotating cycle. Additionally, journal club takes place biweekly and provides a forum to critically review the literature and to debate current topics in cardiology alternating with invasive/noninvasive cardiology cases and case of the month discussions with the expertise and Guidelines update. A cardiology Grand round will take place weekly and presented either by a cardiology faculty, invited speaker or fellows supervised by a preselected faculty member. In addition, advanced ECG lectures will be done once a week and supervised by at least one of the EP attendings, and will cover ECG interpretation (cardiology fellows level) in addition to pacemaker/icd programing, and intracardiac electrocardiogram interpretation. CCU core lecture series have also been initiated. A final aspect of the curriculum involves fellow involvement in teaching. This occurs in several settings, including direct clinical teaching of Internal Medicine residents on the inpatient cardiology services (intensive care unit, and consult service) as well as assisting in the early training of new cardiology fellows. Fellows are expected to give didactic lectures at cath conferences, cardiology clinical conference lecture series (cardiology grand rounds), and morbidity and mortality conference. COCATS 2 (Core Cardiology Training Symposium) is the curriculum guiding document for fellowships in cardiovascular disease. This document consists of the reports of individual task forces which reviewed and made recommendations for training in each of 11 vital areas of cardiovascular disease. A brief description will be given as to how the American University

8 8 of Beirut Fellowship Program in Cardiovascular Disease addresses each Task Force s recommendations. Task Force 1: Training in Clinical Cardiology Extensive training in general clinical cardiology occurs both in the inpatient and outpatient and also in the laboratory and non-laboratory setting. The cardiology fellow is primarily responsible for the management of inpatients with cardiovascular diseases in the Emergency room,coronary care Unit and consult service. Training in procedural skills is acquired at the division facilities described above. Outpatient consults and management of chronic cardiovascular disease takes place in the weekly continuity clinics at the OPD. Fellows do at least 5-6 CCU rotations and 5-6 Consult rotations (10-12 months of clinical cardiology) and meet the COCATS requirements. Task Force 2: Training in Electrocardiography, Ambulatory Electrocardiography, and Exercise Testing Fellows interpret ECG during each of the clinical rotations (stress test, CCU, consults, EP, and ECG conference) and Holter monitor recordings during the EP rotation and ECG conference. Fellows interpret Holter monitor recordings during electrophysiology rotation. Fellows interpret ECG and stress tests on the electrophysiology and Nuclear Cardiology rotations and stress echocardiography during echocardiography rotations. Fellows directly supervise exercise stress tests. These studies are then reviewed by the attending cardiologist. Fellows meet the COCATS requirements and read more than 3500 ECG, perform at least 300 stress tests (level 2), and 150 holters (level 1) Task Force 3: Training in Diagnostic Cardiac Catheterization and Interventional Cardiology All fellows complete months in the cath labs and receive level 2 training in Cath. Fellows receive extensive training in vascular access, left and right heart catheterization, diagnostic coronary angiography, invasive hemodynamics. A monthly Cath Conference is held during which faculty and fellows present teaching case and review angiographic and hemodynamic findings, discuss diagnostic and management issues, review complications and promote discussion of specific cardiology topics pertaining to invasive cardiology.

9 9 Task Force 4: Training in Echocardiography Transthoracic and transesophageal echocardiography training occurs during the Echocardiography laboratory rotation and at any time the fellow will be free. All fellows complete 6 months on these rotations to achieve level 2 certification, and are expected to read 300 studies and perform 150 cases. All fellows receive training in exercise 9treadmill and recently acquired bicycle) stress echocardiography and transesophageal echocardiography after the first month of training in echocardiography. A bi-monthly Echocardiography Conference is held that includes echocardiography case reviews and case specific didactic teaching. A series of lectures in echocardiography is also presented at the core curriculum lecture series. Didactic teaching is also expected during the one-one reading with the attending. Task Force 5: Training in Nuclear Cardiology All fellows complete 2 months in the Nuclear Cardiology Lab, and read with attending. They are expected to learn about radiation safety, handling radioactive material, imaging patients, image processing and interpretation. Lectures in nuclear cardiology are provided at the core curriculum course series. They will achieve level 1 training. Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing, and Arrhythmia Management All fellows complete 2 months on the Electrophysiology (EP) service to achieve Level 1 EP training. The EP service covers all EP consults and procedures. Fellows evaluate inpatient consults; perform device interrogations with dedicated personnel for device interrogation and/or with the EP faculty physician, and are active in the EP lab during procedures such as ablation or device implantation/extraction. Fellows obtain informed consents, explain indications and contraindications of procedures and may assist with procedures performed in the EP laboratory usually during the senior year of training. Also, basic EP topics are addresses during the core curriculum conference series and the advanced ECG conference. Task Force 7: Training in Cardiovascular Research

10 10 The Cardiology Division is active in both clinical and basic science research. All fellows are encouraged to become involved in ongoing research projects. Research is an important and critical component of training in cardiovascular disease. There are several databases that are being build and several projects already in process with fellows being actively involved. The fellows are carefully paired with mentors depending on fellow s research interests. The cardiology fellowship is part of the Research Fellowship Program, and each fellow is expected to have a proposal, mentor, and initiate a research and end up in at least one publication of an original research topic. In the future, we hope to expand the fellowship program to allow each fellow to have dedicated 4 months of research. Task Force 8: Training in Heart Failure and Transplantation. At the time being there is no such rotation. Soon, the Heart Failure outpatient Unit will start and fellows interested will rotate in this unit. Fellows on this service admit and manage patients with decompensated heart failure. Outpatient consults will be performed (in the near future) on patients referred to the heart failure/ transplant clinic for assistance with heart failure management or for consideration of cardiac transplantation. Fellows may perform right heart catheterizations procedures. Task Force 9: Training in the Care of Adult Patients with Congenital Heart Disease There is no specialized Adult Congenital Heart Disease at our center but our fellows will participate in the Pediatric Congenital Heart disease procedures. Additionally, lectures on congenital heart disease and their associated surgical procedures are given as a part of the core curriculum lecture series. In the near future, if we expand the program and number of fellows, we will have the opportunity to offer the fellows a dedicated month in congenital heart disease in collaboration with the pediatric department Task Force 10: Training in Preventive Cardiovascular Medicine In addition to discussing prevention-related issues relevant to individual patients seen on the inpatient services or in the outpatient clinics, dedicated lectures on Preventive Cardiovascular Medicine are provided to the fellows as a part of the core curriculum lecture series. These lectures cover cardiovascular (CV) genetics, clinical epidemiology and biostatistics,

11 11 principles of clinical trials, principles of outcomes research, principles of clinical pharmacology, principles of behavior change and aspects of compliance, and principles of disease management and multidisciplinary system development. The specific content areas defined by the task force are HTN, hyperlipidemia, thrombosis/hypercoagulable states, smoking cessation, cardiac rehabilitation, exercise physiology, nutrition, psychosocial and behavioral aspects of CV disease, metabolic disorders, gender and racial differences as related to CV disease, and population demographics as related to CV disease. Over a rotating two year period, the content areas outlined by this task force are addressed through core curriculum conference series, review of current literature in the journal cub setting, state of the art review and controversial topics in the cardiology grand rounds lecture series. Also, a prevention clinic has recently opened every Saturday morning and fellows will be encouraged to attend. Smoking cessation, nutrition and weight loss programs will also be launched soon and will offer additional resources to the fellows training. Task Force 11: Training in Vascular Medicine and Peripheral Catheterbased Interventions Although a dedicated rotation in Vascular Medicine is currently not available; a vascular medicine/hypertension outpatient clinic is opening soon. Fellows will be encouraged in their spare time to go to the vascular lab and learn how to interpret vascular US (carotids..), attend vascular interventions and surgeries, go to the vascular clinic and have exposure to peripheral vascular disease (arterial and venous) and different aspects of vascular medicine (thrombosis, hypercoaguable states..). We would like to create at least 1 month of such rotation, but currently we are limited by the number of fellows. Procedure Certification: Certification levels are defined by COCATS 2 as follows: Level 1: Basic training required of all trainees to be competent consultant cardiologists. Level 2: Additional training in one or more specialized areas that enables the cardiologist to perform or interpret (or both) specific procedures at an

12 12 intermediate skill level or engage in rendering cardiovascular care in specialized areas. Level 3: Advanced training in a specialized area that enables a cardiologist to perform, interpret, and train others to perform and interpret specific procedures at a high skill level. In general, level 2 certification is required to independently interpret and/or perform a specific cardiac procedure and level 3 certification is required to run a procedure-related laboratory. All fellows are required to maintain detailed documentation of the procedures they perform as described in the Procedure Documentation section of this manual. This procedure log is to be turned in monthly to be reviewed by the program director. There will be quarterly meetings with all the fellows and program director to discuss problems, areas for improvement.. In addition, each fellow will have a biannual evaluation with the program director. A new set of evaluation tailored to each rotation will be implemented and required to be submitted on a monthly basis for each fellow. Also, fellows will be evaluating the attending on a monthly basis. 2. The ACGME Core Competencies This fellowship training program at the American University of Beirut is committed to comply with the following six core competencies, which are detailed by the Accreditation Commission of Graduate Medical Education: Patient Care Medical Knowledge Practice Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems Based Practice Patient Care Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Medical Knowledge

13 13 Fellows must demonstrate knowledge about established and evolving biomedical, clinical, epidemiological and social behavioral sciences, as well as the application of this knowledge to patient care systematically analyze practice, using quality improvement methods, and implement changes with the goal of practice improvement incorporate formative evaluation feedback into daily practice locate, appraise, and assimilate evidence from scientific studies related to their patients health problems use information technology to optimize learning participate in the education of patients, families, students, residents and other health professionals Interpersonal and Communication Skills Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and other health professionals. Fellows are expected to: communicate effectively with patients, families, and the public, a appropriate, across a broad range of socioeconomic and cultural backgrounds; communicate effectively with physicians, other health professionals, and health related agencies; work effectively as a member or leader of a health care team or other professional group; act in a consultative role to other physicians and health professionals maintain comprehensive, timely, and legible medical records Professionalism Fellows must demonstrate a commitment to carrying out professional responsibilities, an adherence to ethical principles, and sensitivity to patients of diverse backgrounds. Fellows are expected to demonstrate: compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self interest; respect for patient privacy and autonomy; accountability to patients, society and the profession; and

14 14 sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities and sexual orientation Systems Based Practice Fellows must, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Fellows are expected to: work effectively in various health care delivery settings and systems coordinate patient care within the health care system incorporate considerations of cost awareness and risk benefit analysis in patient and/or population-based care advocate for quality patient care and optimal patient care systems work in inter-professional teams to enhance patient safety and improve patient care quality participate in identifying system errors and in implementing potential systems solutions 3. Rotations The clinical rotations are divided as follows: 1st year 2nd year 3rd year Cath 4months 3 months 3 months Echo 2 months 2 months 2 months EP 1 months 1 months 2months Nuclear 0 months 1 month 1 month Consult 2 months 2 month 1 month

15 15 CCU 2 months 2 month 1 month Research/elective 0 months 0 month 1 month Vacation 1 month 1 month 1 month First year fellows F1a & F1b& F1c Second year fellows F2a & 2b Third year fellows F3a & F3b The specific curriculum for each rotation of the cardiovascular disease fellowship is summarized in Appendix I. For each rotation, the overall purpose, the fellow responsibilities and specific duties, method of supervision, learning objectives, patient characteristics, mix of diseases encountered, types of clinical encounters and procedures performed, teaching methods, and evaluation methods will be described. (See Appendix I) Faculty June- July July- Aug Aug- Sep Sep- Oct Oct- Nov Nov- Dec Dec-Jan Jan-Feb Feb- March March- April F3a Echo LHC LHC Echo Elective EP LHC consult CCU EP Vacation nuclear F3b LHC Consult CCU LHC Echo Elective EP nuclear EP LHC Echo Vacation F2a CCU nuclear consult EP LHC Echo CCU LHC consult Vacation LHC Echo F2b consult CCU nuclear Echo EP LHC consult CCU LHC Echo Vacation LHC F1a LHC EP Echo LHC consult CCU LHC vacation echo LHC consult CCU F1b Echo LHC EP CCU LHC consult Echo LHC vacation CCU LHC consult F1a EP Echo LHC consult CCU LHC vacation Echo LHC consult CCU LHC Supervision by faculty members is expected throughout the academic year and during all aspects of the educational experiences. The cardiology trainee April- May May- June

16 16 and the supervising cardiology faculty must carry out each component of patient care jointly. There is a faculty call schedule that can be accessed through the intranet. The majority of key clinical faculty must be involved in scholarship defined as one of the following: a) the scholarship of discovery, as evidenced by peer-reviewed funding or by publication of original research in a peer reviewed journal; b) the scholarship of dissemination, as evidenced by review articles or chapters in textbooks; c) the scholarship of application, as evidenced by the publication or presentation of, for example, case reports or clinical series at local, regional, or national professional and scientific society meetings Faculty members: Include the Chief of Cardiology and the Cardiology Training Program Director, who are full-time faculty of the Department of Medicine of the American University of Beirut, are American Board Certified and have extensive experience in General Cardiology. there is a total of 13 full time faculty members dedicated to the Cardiology training program throughout the year participate in all aspects of academic activities including conferences, national meetings, educational courses and activities designed to enhance their teaching effectiveness assist in the preparation of the written curriculum and the general administration of the training program provide appropriate supervision throughout the clinical and technical experience of the trainee and assist in monitoring stress as well as nurture the attributes and qualities of a well rounded physician are always available for immediate feedback, advice, support and counseling Clinical Experience

17 17 The trainee is given the responsibility to care for acute and chronically ill patients throughout the length of hospitalization, under the supervision of faculty members in Cardiology Care of patients includes all intensive care settings (emergency department, coronary care unit, medical intensive care unit and post surgical intensive care units) Pre procedure evaluation and planning are conducted with the supervising faculty member Cognitive knowledge and critical decision making should be acquired throughout the training process in areas that include: randomized clinical trials, short and long term benefits, strengths and limitations of different treatment modalities The trainee will be actively involved in patient education, including risk factor modification and discharge planning The trainee will acquire an understanding in cardiovascular rehabilitation The trainee will develop experience in providing consultation services and communicating with members of other health care teams Each trainee will participate in the out patient follow up cardiology clinic one half day each week, and is expected to evaluate at least one new patient and two return patients under the supervision of a faculty member Patient mix for in-patients and ambulatory settings: adult patients including geriatrics, both sexes and all races Fellows will evaluate rotation, faculty members, residents (monthly), peers/self/training program (biannually) in a 360 degree evaluation system ( see appendix II ) Technical experience and other skills Fellows must have formal instruction, clinical experience, and must demonstrate competence in the performance of the following: elective cardioversion; insertion and management of temporary pacemakers, including transvenous and transcutaneous; programming and follow-up surveillance of permanent pacemakers bedside right heart catheterization; right and left heart catheterization including coronary arteriography (fellows must participate in a minimum of 100 catheterizations.);

18 18 exercise stress testing; fellows must perform a minimum of 50 stress ECG tests; echocardiography (fellows must perform a minimum of 150 and interpret a minimum of 300 studies, including transesophageal cardiac studies). chest x-rays; electrocardiograms; a minimum of 3500 electrocardiograms; ambulatory ECG recordings; a minimum of 150 ambulatory ECG recordings; radionuclide studies of myocardial function and perfusion. intracardiac electrophysiologic studies; intra-aortic balloon counterpulsation; percutaneous transluminal coronary angioplasty and other interventional procedures; programming and follow-up surveillance of ICDs; pericardiocentesis. Didactic Curriculum Basic topics: o Cardiovascular anatomy, physiology and metabolism o Molecular biology of the cardiovascular system o Cardiovascular pharmacology and complications of therapy o Cardiovascular pathology Prevention of cardiovascular disease: o Epidemiology and biostatistics o Risk factors modification o Lipid disorders Diagnosis, evaluation and management of patients with: o Acute and chronic ischemic heart disease Acute myocardial infarction Acute coronary syndrome o Acute and chronic heart failure Cardiomyopathy o Arrhythmias o Hypertension, o Valvular heart disease,

19 19 o Pulmonary heart disease, o Peripheral vascular disease, o Infections and inflammatory heart disease o Adult congenital heart disease. o Pericardial disease o Cerebrovascular disease o Heart disease in pregnancy Management of: o Pre-operative and post-operative patients o Cardiopulmonary arrest Diagnostic techniques, including: o ECG o MRI, PET o Nuclear cardiology o Echocardiography and doppler o Cardiac catheterization o Pacemaker interrogation Conferences Weekly cardiology grand round: clinical topics, clinical research, basic science research, morbidity and mortality. (Wednesday noon). Speakers will include Cardiology faculty, Cardiology fellows and invited faculty. Weekly cardiology conference: journal club, case reviews invasive/noninvasive and Guidelines updates (Tuesday 5:30 pm) Presented by Cardiology fellows Combined cardiology and cardiothoracic surgery conference. (One per trimester) Core lecture series (didactic curriculum) presented mainly by cardiology fellows (Wednesday 7:30 AM) Advanced ECG conference (Thursday 5:30 PM) Clinical cardiology research conference: progress report on research projects and proposal of new projects (One per trimester) Internal Medicine grand round (Tuesday noon) Fellows are expected to all conferences (mandatory unless there are emergencies and sick patients)

20 20 In-service examination The ACC in-service examination will be administered on October 15 th and 16 th (4-6 hrs) under the supervision of the NBME, each year for all fellows (mandatory) Research Trainees are required to complete at least one research project during the fellowship including preparation of a manuscript for submission to a peer reviewed journal Trainees will participate in the enrollment of patients in clinical trials Trainees are required to submit abstracts to scientific meetings Protected time for research is currently limited given the number of fellows. However, the fellows in general have been proactive with several research and publications in the pipeline(see Appendix III) Fellows will meet on a regular basis with the mentors and at least once a month with Dr Marwan Refaat who will be in charge of the cardiology research program and will follow-up on the fellows progress. Teaching Trainees will make presentations at conferences, journal clubs research and national meetings Trainees will be responsible for teaching nurses, medical and other students rotating on the different services Duty Hours in the Learning and Working Environment (See Appendix IV) The program is committed to and be responsible for promoting patient safety and trainees well being. Faculty and fellows should be educated to recognize the signs of fatigue and sleep deprivation. Duty hours must be limited to 80 hours per week, averaged over a four week period, inclusive of all in house call activities, including moonlighting Fellows are provided with 1 day in 7 that is free from all educational and clinical responsibilities, averaged over a 4 week period, inclusive

21 21 of call. (One day is defined as 1 continuous 24 hour period free from all clinical, educational, and administrative duties.) Adequate time for rest and personal activities is provided, which consists of a 10 hour time period provided between all daily duty periods Vacation and Attendance of National Meetings A total of 4 weeks of vacation will be given during each academic year. House Staff Policies The Cardiovascular Training Program follows all the rules and regulations outlined in the Policies and Procedures of the American University of Beirut Medical Center. GENERAL FELLOWSHIP RESPONSIBILITIES Responsibilities specific to individual rotations are described in each rotation s curriculum. General responsibilities that apply to the daily performance of fellowship duties will be listed in this section. 1. In general, daily work hours are from 8:00 am to 5:00 pm Monday through Friday. Obviously, work hours will vary based on the required duties of each rotation. Fellows on inpatient services with early morning rounds will need to arrive at a time that allows adequate preparation for rounds. Fellows on procedure rotations are expected to arrive in time to evaluate the patient prior to starting the planned procedure. 2. Fellows will provide timely, safe, and effective care for all patients he/she is responsible for. 3. Fellows will document all patient care in the medical record in a timely fashion. 4. Fellows will attend scheduled cardiology teaching conferences and initial attendance documentation sheet. 5. Fellows will review each rotation s curriculum with the attending at the beginning of the month and strive to achieve the outlined goals and objectives.

22 6. Fellows will keep an accurate and up-to-date procedure log. This log will be reviewed at each 6 month evaluation with the program director. 7. Fellows will review the call schedule and perform all call duties as scheduled. If fellows switch call, responsible staff must be notified. 8. Fellows are expected to carry their pagers at all times while on duty and to respond to pages in a timely fashion. 9. Fellows are expected to supervise and teach all house staff members on his/her team. 10. Fellows are expected to communicate with the attending physician, house staff members of the team, the patient, and family members as frequently as is necessary to facilitate excellent patient care. This includes discussing urgent issues that arise on call with the on-call attending. 11. Fellows will check out all critically ill patients, pending test results, and other pertinent information to the on-call fellow prior to leaving for the day. 12. Fellows will comply with the program s duty hour guidelines and report any problems with compliance to the program director. This includes not exceeding duty hours due to excessive moonlighting. 13. Fellows will notify the Chief Fellow (third year fellow) of any unplanned absence in order to ensure that continuity clinics are cancelled and rescheduled appropriately and that rotation/call duties are covered. Coverage for scheduled vacation and conferences is pre-arranged at the beginning of the year. 14. Fellows will conduct themselves in a professional manner at all times and will treat all others, including colleagues, faculty, residents, medical students, ancillary staff, referring health care providers, and patients and their families, with the utmost respect. 15. Fellows will develop a personal self-study program that is guided by the fellowship curriculum. 16. Fellows will adhere to all AUBMC GME-related policies. 17. Fellows will adhere to all AUBMC institutional policies. 18. Fellows will complete all rotation, faculty, and program evaluations in an honest, constructive, and timely fashion. 19. Fellows will comply with the licensure requirements of the Lebanese Law. 20. Fellows will comply with all state and federal laws governing the practice of medicine. 21. Fellows will abide by the institutional order writing policy. 22

23 23 CALL DUTIES RESPONSABILITIES 1. Call begins at 5 pm and ends at 8 am on weekdays. Saturday and Sunday call is from 8 am to 8 am. 2. Each day there is one fellow on in-house call. Interventional call is covered by the third year fellow if he is not on in-house call. 3. Each day will have an assigned attending on call to discuss consults. Two attending are on call for the consult and ER/CCU services. Another attending will be assigned to cover echo call (TEEs), and one interventional attending will be on call to cover the cath lab who maybe the same on CCU?ER or consult services. The attending call schedule will be published at the beginning of each month. 5. The official daily and yearly call schedule is posted on the internet. Any call changes should be marked on this schedule, and the hospital operator of the appropriate facility should be notified. 6. A call room is available on the 6 th floor of the General Hospital for fellows on general cardiology call. 7. Fellows will see all urgent consults on call and page the responsible attending to discuss the plan of care. 8. Fellows will provide assistance to the CCU residents Fellows are expected to come in to see any critically ill patient. 9. Fellows will assist with vascular access, PA catheter placement, elective cardioversion, and transthoracic echocardiography as needed. Once an individual fellow has received the requisite training and has been deemed competent in performing these procedures, he/she may perform the procedures without a senior level fellow or attending directly present. The results of procedures are discussed and reviewed with the appropriate attending. Advanced procedures, including diagnostic cardiac catheterization, transvenous pacemaker placement, coronary angiography, and TEE are performed only under direct supervision of the attending. 10. The fellows on call Saturday and Sunday will follow-up with new consults and any existing consults from the week. They are also responsible for all EP consults, urgent TTEs, rounding with the attending on consults, and taking overnight call. 11. always there is a second call fellow in case of any procedure that cannot be done by the first year fellow

24 24 Division of Cardiovascular Diseases Fellows Coverage Policy The coverage policy has been developed to allow for continuous patient care without any disruptions due to emergency situations. The protocol for coverage has several features to allow for adequate coverage in all situations. Fellows requiring coverage on an immediate basis must themselves be involved in an emergent, unforeseeable incident that could not have been otherwise prevented. These events will require the requesting fellow to contact the program director or associate program director in person or via phone and discuss the specifics of the coverage options. When the decision has been made by the program director to grant coverage, the name of the available coverage fellow will be provided. For situations where the requesting fellow is incapable of contacting the coverage fellow, the program/associate program director will assist. Otherwise, it is then the responsibility of the fellow who is requesting coverage to contact the coverage fellow either in person or via phone and discuss the specifics of the coverage requirements. Also, it is the responsibility of the fellow requiring coverage to provide full details regarding pertinent patient care issues either over the phone or via to the covering fellow. The pool of fellows available to cover will depend on the time of day coverage is required and the rotations from where fellows can be withdrawn. A hierarchial system has been developed to determine the order of coverage. The order of coverage will be first, the nuclear/ep fellow, second, the echo fellow (if there are two echo fellows), and third, the CCU/Research fellow. Fellows maybe pulled from these services Monday-Friday from 8am to 5pm when coverage is required. For the rare circumstance where coverage is required on nights or weekends and the back-up fellow is ill, coverage will have to be provided by the second call fellow. Finally, to keep the coverage system equitable for all those involved, all coverage s will be documented on a spreadsheet for future reference. Most importantly, the payback system will be tracked for all coverage issues except for vacation and conference coverage. The above policies are meant to serve as guidelines to be as fair as possible to all fellows. Minor adjustments in the enforcement of the above policies will be at the discretion of the fellowship program director. Issues of concern with regard to this policy may be periodically reviewed and refined to suit the needs of the fellowship program. Curriculum for Cardiovascular Disease Training Program American University of Beirut January 2013 AlJaroudi/Ghazzal 24

25 25 PROCEDURE DOCUMENTATION Fellows are required to keep a detailed procedure log. An updated log is to be presented to the program director for review at the biannual fellow evaluation. 1. The following procedures require documentation: -ECG interpretation (patient identification information not required) -elective cardioversion -temporary transvenous pacemaker insertion -programming and surveillance of permanent pacemakers and ICDs -right heart catheterization -left heart catheterization, including coronary angiography -peripheral angiography and aortography -exercise and pharmacologic stress testing -transthoracic echocardiogram (2D and Doppler) acquisition and interpretation -transesophageal echocardiograms -stress echocardiograms -ambulatory ECG recording (Holter) interpretation -radionuclide studies of myocardial function and perfusion interpretation -pericardiocentesis -intra-aortic balloon pump placement 2. Specialized procedures requiring extra training: -percutaneous cardiovascular interventions -intravascular ultrasound (IVUS) -intracardiac EP studies -permanent pacemaker/icd placement 3. Documentation must include the procedure performed, patient s name and medical record number, date of the procedure, attending cardiologist, indication for the procedure, results, and any complications. Curriculum for Cardiovascular Disease Training Program American University of Beirut January 2013 AlJaroudi/Ghazzal 25