CARDIOVASCULAR DISEASE FELLOWSHIP PROGRAM Fellows Manual Academic Year Sanford USD Medical Center Sioux Falls, South Dakota

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1 CARDIOVASCULAR DISEASE FELLOWSHIP PROGRAM Fellows Manual Academic Year Sanford USD Medical Center Sioux Falls, South Dakota Updated June 30, 2015

2 Department of Internal Medicine Division of Cardiovascular Disease Fellowship Training Program 1400 West 22 nd Street Sioux Falls, SD Phone: Fax: Program Director Adam Stys, MD Program Coordinator Darla Fjerstad

3 INTRODUCTION Welcome to the Cardiovascular Disease Fellowship Program of the Sanford School of Medicine of The University of South Dakota. You are now entering the most important phase of your professional training. The skills and knowledge you develop during this time will last a lifetime. This manual contains guidelines and policies that apply to the Cardiovascular Disease Fellowship Program. The policies contained within this manual are subject to periodic review by the GME Committee and will be updated to reflect any changes implemented by the Committee. Fellows are responsible for knowing and adhering to the policies and guidelines contained in this manual. When in doubt, fellows are responsible to contact the program coordinator or director. The Sanford School of Medicine University of South Dakota Cardiology Fellowship program prides itself in having developed an appropriate mix of patient care, educational conferences, and professional growth to allow for the development of outstanding clinical and academic cardiologist in an atmosphere of scholarship and collegiality. One must balance the primary obligation to the patient, to deliver excellent medical care, with an obligation to one s own personal development as a physician. To have simply discharged your duties of patient care without at the same time tending to your educational and professional growth as a physician would be to have done only half of your job. It is for this reason that participation and attendance at educational exercises during your fellowship training are as much a requirement as the delivery of the highest quality patient care. You must strive every day to take on the challenge of being the best physician that you can possibly become. We strive to produce the next generation of clinical and academic cardiologists. We encourage each fellow to develop a research plan with their research mentor early in the course of their fellowship so that each research project can be completed during the course of the fellowship. We expect the cardiology fellow must develop not only a strong knowledge base in cardiology but also develop the skills to practice cardiovascular medicine. Each fellow should strive to be patient-centered, caring, empathic, and honest. Finally, a commitment to lifelong learning is essential, so that the process of medical education continues for the rest of each fellow s professional life. Fellowship training is a busy time, with many pressures. We encourage you to tend to all aspects of the job, including your own education and development. The faculty and especially the program director is available whenever needed to help tend to personal problems and to improve your fellowship experience. Do not hesitate to make use of the faculty. Once again, welcome to our fellowship program!

4 Table of Contents INTRODUCTION... 2 DURATION OF PROGRAM... 6 PREREQUISITE TRAINING/SELECTION CRITERIA... 6 PROGRAM CERTIFICATION... 6 GENERAL INFORMATION Mission Statement Training Structure Facilities... 7 CURRICULUM Introduction COCATS ACGME Core Competencies... 8 CONFERENCES REQUIRED ROTATIONS ELECTIVE ROTATIONS EDUCATIONAL GOALS BY YEAR FIRST YEAR FELLOWSHIP TRAINING SECOND YEAR FELLOWSHIP TRAINING THIRD YEAR FELLOWSHIP TRAINING SUPERVISION DELINEATION OF RESPONSIBILITIES GENERAL FELLOWSHIP RESPONSIBILITIES CALL DUTIES ROTATION COVERAGE SCHEDULE CHANGES RESEARCH/PRESENTATIONS EVALUATIONS PROCEDURE DOCUMENTATION CRITERIA FOR ADVANCEMENT DUTY HOURS MOONLIGHTING

5 PAGERS LAB COATS DRESS POLICY SEXUAL HARASSMENT/DATING POLICY PARKING MEALS ID BADGES LIBRARY FACILITIES COMPUTER ACCESS FELLOW OFFICE/MAILBOXES VACATION SICK LEAVE GRIEVANCE PROCEDURE DISCIPLINARY ACTION MISCELLANEOUS RESOURCES INDIVIDUAL PORTFOLIOS CONTRACTS PREAMBLE AND HONOR CODE 43 GME BENEFITS AND POLICIES..46

6 DURATION OF PROGRAM The Duration of the Cardiovascular Diseases Program is three years with 6 accredited positions in the general program emphasizing preparation in academic cardiology. Comprehensive training in all major aspects of clinical cardiology is combined with training in basic and clinical cardiovascular research. Opportunities exist in a variety of research disciplines. PREREQUISITE TRAINING/SELECTION CRITERIA All fellow trainees selected for the Cardiovascular Diseases Fellowship Training Program are required to have completed an accredited three year residency program in internal medicine. Fellowship trainees are selected through the NRMP (National Resident Matching Program). PROGRAM CERTIFICATION The Cardiovascular Diseases Fellowship Training Program is certified by the Accreditation Council for Graduate Medical Education (ACGME). All fellowship trainees are required to be licensed by the South Dakota Board of Osteopathic & Medical Examiners. GENERAL INFORMATION 1. Mission Statement The mission of the Fellowship Training Program in Cardiovascular Diseases is to provide an academically and clinically rigorous training program in general cardiology as well as advanced training in clinical cardiology subspecialties and 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 not only as outstanding cardiologists, but also as either sub specialists in a clinical area or investigators in the field of cardiovascular research. 2. Training Structure Fellowship training occurs over the course of 3 years. Two hospitals participate in this program: the Sanford USD Medical Center and the Sioux Falls VA Medical Center. The training program offers advanced training in clinical subspecialties of cardiology (nuclear cardiology, echocardiography, cardiac

7 catheterization/interventional cardiology, electrophysiology, heart failure) as well as academic research training. All fellows must be intimately involved in a research project during the course of their fellowship. The core clinical training for the program is based on the ACC Revised Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training III (COCATS 3) 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 can be reviewed on the ACGME website ( 3. Facilities Sanford USD Medical Center provides exposure to a diverse patient population, which includes male and female patients ranging in age from teenagers to the very elderly. The fellow will be exposed to examinations of patients with a wide range of cardiac abnormalities which include but are not limited to: Chronic coronary artery disease, acute coronary syndromes, valvular heart disease, arrhythmias, lipi disorders, hypertension/hypertensive heart disease, pericardial disease, cardiomyopathies, cardiac masses, pulmonary vascular/heart disease and pulmonary embolism, diseases of the great vessels/aorta, peripheral vascular disease, infections and inflammatory heart disease, cardiovascular rehabilitation, congestive heart failure, adult congenital heart disease, and cardiovascular trauma. The VA Medical center provides exposure to patients of an older, predominantly male population. The fellow will be exposed to examinations of patients with a wide range of cardiac abnormalities which include but are not limited to: Chronic coronary artery disease, acute coronary syndromes, valvular heart disease, arrhythmias, lipid disorders, hypertension/hypertensive heart disease, pericardial disease, cardiomyopathies, cardiac masses, pulmonary vascular/heart disease and pulmonary embolism, diseases of the great vessels/aorta, peripheral vascular disease, infections and inflammatory heart disease, cardiovascular rehabilitation, congestive heart failure, and adult congenital heart disease. CURRICULUM 1. Introduction The curriculum of the cardiovascular diseases fellowship consists of a variety of clinical experiences and didactic conferences that take place at both Sanford and the VAMC. Fellows rotate on several inpatient services and outpatient services and provide both direct and consultative care. Procedural skills are gained as fellows rotate through the invasive and non-invasive laboratories at both hospitals

8 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 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. 2. COCATS 3 COCATS 3 (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 13 vital areas (see below) of cardiovascular disease. When developing the Fellowship Program curriculum, each of the 13 areas was taken into account. Task Force 1: Training in Clinical Cardiology Task Force 2: Training in Electrocardiography, Ambulatory Electrocardiography, and Exercise Testing Task Force 3: Training in Diagnostic and Interventional Cardiac Catheterization Task Force 4: Training in Echocardiography Task Force 5: Training in Nuclear Cardiology Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing, and Arrhythmia Management Task Force 7: Training in Cardiovascular Research Task Force 8: Training in Heart Failure Task Force 9: Training in the Care of Adult Patients with Congenital Heart Disease Task Force 10: Training in Preventive Cardiovascular Medicine Task Force 11: Training in Vascular Medicine and Peripheral Vascular Catheter-Based Interventions Task Force 12: Training in Advanced Cardiovascular Imaging (CMRI) Task Force 13: Training in Advanced Cardiovascular Imaging (Computed Tomography) 3. ACGME Core Competencies The curriculum is designed to meet the required core competencies as defined by the ACGME. The core competencies that must be demonstrated are: A. PATIENT CARE: Fellows must be able to provide patient care that is compassionate, appropriate, and effective in the treatment of health problems and the promotion of health.

9 B. MEDICAL KNOWLEDGE: Fellows must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. C. PRACTICED-BASED LEARNING AND IMPROVEMENT: Fellows must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. D. INTERPERSONAL AND COMMUNICATION SKILLS: Fellows must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. E. PROFESSIONALISM: Fellows must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. F. SYSTEMS-BASED PRACTICE: Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. The curriculum assures the teaching and assessment of these competencies, and the following listing of general core competency elements applies to all rotations of the fellowship. Core competency-related teaching and assessment that is specific to individual rotations will be identified in the Objectives section of the curriculum for each rotation. PATIENT CARE: 1. Fellows will demonstrate the ability to take a history relevant to cardiovascular diseases and perform a directed cardiovascular physical examination in an adult patient population that includes both men and women and is ethnically diverse. Patient encounters will occur in both the inpatient and outpatient setting, including all cardiac procedure laboratories. 2. Fellows will demonstrate the ability to judiciously order diagnostic tests that are clinically appropriate and cost effective. 3. Fellows will demonstrate the ability to safely perform all invasive diagnostic tests for which they seek certification. In addition to procedure performance, fellows will be expected to demonstrate knowledge of appropriate indications, contraindications, and post-procedure complications specific to each cardiac procedure. 4. Fellows will demonstrate the ability to accurately interpret the results of all invasive and noninvasive diagnostic tests and procedures for which they seek certification.

10 5. Fellows will demonstrate the ability to integrate all social aspects of patient care, including gender sensitivity, cultural diversity, and economic issues. 6. Fellows will demonstrate the ability to provide appropriate follow-up care in both the inpatient and outpatient setting. 7. Fellows will demonstrate the ability to synthesize all history, physical examination, and diagnostic testing information into a well-thought out logical plan of care that is documented in a clearly organized consult or note. 8. Fellows will demonstrate the ability to triage and manage critically ill patients in the on-call setting. 9. Fellows will demonstrate the ability to be patient advocates by utilizing hospital resources, such as social work, consult services, pharmacy services, etc, to help facilitate the best possible patient care. 10. The above elements will be evaluated by direct observation and interaction with the cardiology faculty. MEDICAL KNOWLEDGE: 1. Fellows will assist in conducting rounds on inpatient services and/or present patients directly thereby allowing the supervising attending physician to assess their medical knowledge as it relates to specific patient cases. 2. Fellows will provide periodic didactic teaching sessions for the house staff on inpatient teaching rounds. 3. Fellows are expected to develop a reading system that will facilitate a broad knowledge base of cardiology. This reading system should include major cardiology texts, landmark clinical trials, and current literature published in common cardiology journals. 4. Fellows will present at a variety of weekly conferences. 5. Fellows will give a formal grand rounds lecture. 6. Fellows will present at Journal Club. 7. Fellows will maintain a thorough procedure log to document technical skills training. 8. Fellows are expected to attend teaching conferences that are designed to cover a thorough curriculum in cardiovascular diseases. 9. Each fellow will have the opportunity to attend national meetings. 10. Fellows present patients to the attending and are directly observed while performing invasive procedures.

11 PRACTICE-BASED LEARNING AND IMPROVEMENT: 1. Fellows will learn to use information technology, literature sources, and other available resources to learn to practice evidence-based medicine that is guided by sound medical principles consistent with the standard of care and approved practice guidelines. 2. Fellows will learn to individualize patient management based on the available resources and the circumstances particular to the patient. 3. Fellows must be able to analyze their clinic and rotation experiences and discuss methods for improvement as it relates to patient care, fellow education, and junior house staff education. 4. Fellows must be able to recognize their own limitations in knowledge base and clinical skills and be receptive to life-long learning. 5. Fellows will periodically meet as a group with the program director to discuss identified problems and potential solutions. 6. Fellows must be able to use the medical literature to update their practice methods and improve patient care. 7. Fellows must be able to critically evaluate the medical literature. 8. Fellows approach to and use of the medical literature will be assessed by the supervising staff physician on a given rotation. 9. Fellows will maintain online portfolio in which they are required to document experiences in which they identify their own strengths, deficiencies, and limitations in knowledge. INTERPERSONAL AND COMMUNICATION SKILLS: 1. Fellows will learn to effectively communicate as a consultant cardiologist to the referring health care provider and other members of the health care team. 2. Fellows will learn to communicate a patient s medical diagnosis and potential therapies or procedures in a manner that is easily understood by the patient and his or her family members. 3. Fellows will learn to generate accurate, thorough, and easily understood reports for cardiac procedures. 4. Fellows will learn to listen to and understand patient and family member concerns. 5. Fellows are expected to provide thorough, timely, and legible written consultations in the patient s medical record. 6. These skills will be evaluated by direct observation from the attending physicians as fellows rotate through the clinical services, and the results will be reported via monthly rotation evaluations.

12 PROFESSIONALISM: 1. Fellows are expected to treat patients and their family members, colleagues, house staff, support staff, and administrative staff members with appropriate respect. 2. Fellows are expected to approach patient care with compassion and integrity and to be sensitive to individual patient needs with respect to patients age, gender, culture, and/or disabilities. 3. Fellows are expected to maintain the highest ethical standards including maintaining strict patient confidentiality, ensuring adequate informed consent, adhering to ethical business practice, and informing patients of all practical therapeutic options. 4. Fellows are expected to be committed to excellence and on-going professional development. 5. Fellows are expected to report to work in a timely fashion that provides adequate time to prepare for rounds, instruct junior house staff, and attend to complicated or critically ill patients. 6. Fellows will check out any patient issues that may need attention overnight to the on-call fellow. 7. Professionalism will be evaluated through direct observation by attending physicians and reported via rotation evaluations. 8. Professionalism will be evaluated by support staff members via 360 degree evaluations that will be developed. SYSTEMS-BASED PRACTICE: 1. Fellows will learn to interact professionally in the context of the health care system as a whole and remain sensitive to the role of ancillary services, other health care providers, good business practice, and adherence to high ethical standards. 2. Fellows will learn to work with all members of the health care team (nurses, social workers, pharmacists, etc) to provide the best and most efficient plan of care for all patients. 3. Fellows will specifically learn to integrate various cardiology services and procedures with the medical and surgical services involved in the patient s care. 4. Within cardiology, fellows will learn to integrate the services and procedures provided by the various cardiac disciplines involved in the patient s care. 5. Fellows will learn to partner with a patient s primary care provider in order to ensure that the best possible care is provided to the whole patient. 6. Fellows will learn to practice cost-effective health care while not compromising quality of care.

13 7. Fellows are expected to be strong patient advocates. CONFERENCES The training program provides didactic instruction in the following specified topics, with which each fellow is expected to demonstrate a good understanding. 1. Basic science a. Cardiovascular anatomy b. Cardiovascular physiology c. Cardiovascular metabolism d. Molecular biology of the cardiovascular system e. Cardiovascular pharmacology f. Cardiovascular pathology 2. Prevention of cardiovascular disease a. Epidemiology and biostatistics b. Risk factors c. Lipid disorders 3. Evaluation and management of patients with: a. Coronary artery disease and its manifestations and complications b. Arrhythmias c. Hypertension d. Cardiomyopathy e. Valvular heart disease f. Pericardial disease g. Pulmonary heart disease h. Peripheral vascular disease i. Cerebrovascular disease j. Heart disease in pregnancy

14 k. Adult congenital heart disease l. Complications of therapy 4. Management of: a. Acute and chronic congestive heart failure b. Acute myocardial infarction and other acute ischemic syndromes c. Acute and chronic arrhythmias d. Preoperative and postoperative patients e. Cardiac transplant patients 5. Diagnostic techniques, including: a. Magnetic resonance imaging b. Fast compute tomography c. Positron emission tomography Conferences Schedule: DIDACTIC CLINICAL CONFERENCE EVERY THURSDAY 06:30-07:30 SCI CONFERENCE ROOM NONINVASIVE CARDIAC CASE CONFERENCE FIRST FRIDAY OF EVERY MONTH 07:00-08:00 SCHROEDER AUDITORIUM INVASIVE CARDIOLOGY CASE CONFERENCE 2 ND 5 TH FRIDAY OF EVERY MONTH 07:00-08:00 SCHROEDER AUDITORIUM EKG RECOGNITION & MANAGEMENT 1 ST & 3 RD TUESDAY OF EVERY MONTH 06:00-07:00 MEETING ROOM C

15 INTERNAL MEDICINE GRAND ROUNDS/CARDIOLOGY GRAND ROUNDS EVERY WEDNESDAY 12:00-13:00 HEALTH SCIENCE CENTER, ROOM 106 ELECTROPHYSIOLOGY CONFERENCE 2 ND TUESDAY OF EVERY MONTH 06:00-07:00 MEETING ROOM A 4 TH TUESDAY OF EVERY MONTH 18:00-19:00 LOCATION TBD RESEARCH CONFERENCE 4 TH WEDNESDAY OF EVERY MONTH 06:00-07:00 SCI CONFERENCE ROOM CARDIOLOGY JOURNAL CLUB 2nd MONDAY OF EVERY MONTH 06:30-07:30 SCI CONFERENCE ROOM ADULT STRUCTURAL HEART DISEASE CONFERENCE 1 ST &3 RD THURSDAY OF EVERY MONTH 06:00-07:00 CENTER FOR HEALTH & WELL BEING CONFERENCE ROOM Fellows are expected to participate in case presentations and discussions. Conference attendance is recorded for every conference, and each individual fellow s attendance is included in his/her file. Failure to attend conferences will be mentioned in letters of recommendation written by the Program Director. A 75% attendance is required to advance. REQUIRED ROTATIONS For detailed information regarding goals and objectives of each rotation, please refer to the Cardiovascular Fellowship Curriculum. For precise details of each rotation regarding specific duties, expectations, and responsibilities, please see below (please note: start/end times and rotation specific responsibilities will be the discretion of the supervising physician):

16 1. Clinical rotation/cvicu - Sanford USD Medical Center (SUMC) & Sanford Heart Hospital (SHH) The fellow will start with pre-rounding on teaching service patients and attending to urgent issues that need addressing before the attending rounds. The residents and students assigned to this rotation are required to pre-round with the fellow. The attending rounds typically begin at 08:00 with the entire team: fellow, resident(s), student(s). After rounds, the fellow will participate in consults for the teaching service attending and the clinical faculty on call for that given day. The acute admissions during the day (ER, transfers, etc.) will be worked- up by the fellow and discussed with the faculty on the case. The fellow will be responsible for patient care issues on teaching service with residents and/or students, providing them with feedback and teaching. The procedures required in CVICU, telemetry, or floors on teaching service patients will be performed by the fellow under direct supervision of the attending physician. The fellow will review invasive and noninvasive data of the teaching service patients as it presents throughout the day. The fellow will then discuss it with the attending physician. The day will end at approximately 17:00. The fellow may stay longer if there are patient care issues; however, the attending must approve. The ACGME duty hour rules must not be violated under any circumstances. Teaching service faculty derives from the key clinical faculty (KCF) of the program. A KCF member is assigned for a given week of the rotation. Teaching service patients consist of the KCF patients for the given week and designated patients of the rest of the program faculty (interesting cases that are listed as such by all of clinical faculty). The list of teaching service patients for a given day will be available on a daily basis at 07:00 from nursing staff of the KCF on the teaching service rotation. The primary fellow on this rotation is assigned teaching service KCF patients for rounds. Also, this fellow works with the teaching attending on consults and admissions to the teaching attending service. The primary fellow also works with on-call cardiology attending, participating in his/her consults and admissions (sometimes the teaching attending might also be on-call attending). If there are two Cardiovascular Disease fellows on Clinical Service Rotation at the same time in the month, the Senior Fellow will participate in the Internal Medicine Morning Report every Monday at 09:00 in the Network Conference Room 5405 of the Sanford University Medical Center. If there is a second fellow on this rotation, then the second fellow participates in teaching rounds and participates in consults/admissions for the rest of the faculty (non-teaching service at that time and not on-call). 2. Noninvasive rotation - Sanford Heart Hospital (SHH) & Sanford Cardiovascular Institute (SCI) In general, the fellow will start at In the event of a morning conference, the fellow will begin immediately following the conference. The fellow will begin with pre-reading of echocardiography, nuclear cardiology, Holter, cardiac event recorder, and cardiac CT/MRI studies. This reading will occur in the reading room of Sanford Cardiovascular Clinic (SCI) with the fellow using their individual computer sign-on. The studies assigned to the SCI cardiologist on call that day will be pre-read by the fellow and then discussed with the on call attending during the day. As the attending finalizes the study reports the final feedback will be given to the fellow. As discussed and agreed upon with the Sanford Internal Medicine group, the fellow will pre-read all EKGs from Sanford Hospital that are listed under the Internal Medicine reading attending on for the time frame (usually 2 weeks rotation for the attending). The reading schedule for the Internal Medicine group is available at the fellowship s coordinator office.

17 At approximately 08:00-12:00, the fellow will participate in cardiac stress testing under supervision of the program clinical faculty. The list of tests for a given day is available for the fellow directly from the SHH stress lab. The first 25 stress tests for a given fellow in his/her first year will be dictated by his/her attending; afterwards it is the fellow s duty to dictate a stress test report for any stress test that he/she participates in. At approximately 12:00-14:00, the fellow will start transthoracic echocardiographic scanning of outpatients under supervision of the designated echocardiography technician and faculty in the Sanford Heart Hospital (SHH) echo lab. From 14:00 until 17:00, the fellows will be in the reading rooms of Sanford Cardiovascular Institute for echo/nuclear reading with clinical faculty on call and others. Transesophageal echocardiographic studies (TEE) are performed by the program faculty throughout the day. The fellow is expected to participate in as many studies as possible. The fellows are permitted to attend the TEE, even if it occurs during the stress tests time period. The stress lab staff will arrange for a stress test to be covered by an APP if this was to occur. The TEEs are performed at the Sanford Cardiac Catheterization Laboratory and in the intensive care units of SUMC. The list of TEE studies for the day is available for the fellow on the cath lab schedule in the One Chart computer system. Cardiac CT studies are read with the attending of the day, in the SHH reading rooms. Cardiac MRI studies will be read with Dr. Julie Prescott at her reading station. The fellows will be paged directly by her. The day will end at approximately 17: Continuity Clinic Sanford Cardiovascular Institute (SCI) Each fellow will have a specific day of the week assigned to him/her for continuity clinic which will remain the same for the length of the fellowship. Continuity clinic hours are 08:00 12:00 or 12:00 16:00, one half-day per week, for the duration of the fellowship (except vacation time and out of town electives). The continuity clinic is located at the Sanford Cardiovascular Institute (SCI) clinic site. The KCF will supervise the fellows in the clinic and assign patients to the fellows that require special care, that have great educational value, or that will require long term follow-up. Each half day of continuity clinic will require the fellow to see 4-8 patients (approximately 1-2 new patients and 2-3 follow-up visits). Prior to the attending physician seeing the patient, the fellow will be expected to document the following in the electronic medical record: patient history, physical exam, diagnosis, and treatment plan. The documentation will be discussed between the fellow and attending with the attending physician either approving the fellows documentation or making changes as needed. 4. Invasive cardiology Sanford USD Medical Center (SUMC) & Sanford Heart Hospital (SHH) In general, the fellow will start at 0700 in the cardiac catheterization laboratory (SHH/SUMC) and will follow the schedule of procedures. The schedule will be available the day before. The priority cases for the fellow are KCF and clinical faculty patients. Before a procedure, the fellow will visit with the patient in the cath lab holding area (outpatients) or in the patient s hospital room (inpatients). The fellow will review all pertinent data, examine the patient, discuss the informed consent, and answer the patient s

18 questions. On the first invasive rotation, the fellow will scrub-in with the cath lab staff and assist in the preparation for the procedure (scrubbing, setting up injectors, choosing equipment, etc.). This will give the fellow a comprehensive experience of all aspects of invasive cardiology. The fellow on this rotation will be responsible for case presentations for the invasive cardiology conference at 07:00 on all Fridays of the month, except the first Friday on the month. The day will end at approximately 16:00. The fellow, according to the ACGME progressive responsibility for patient management principle, can eventually order conscious sedation medications for a patient if and when the supervising attending agrees to it. This decision (as other decisions on the fellow s progression of responsibilities in the cath lab, i.e. vascular access, the extent of catheter manipulation, etc.) is at the discretion of the supervising clinical faculty and is made on an individual basis. The clinical faculty will make these determinations after observing and teaching a specific fellow during their Invasive rotation. 5. Cardiac Electrophysiology Sanford USD Medical Center (SUMC) & Sanford Heart Hospital (SHH) In general, the fellow will be expected to begin rounding on the EP patients at 0700 daily. The fellow will then will be with the Electrophysiologist on call for the day. The fellow will be responsible for new consult evaluations and to present a complete plan of care to the attending. The fellow is expected to be present in the EP lab during most of the electrophysiology studies and device implantations. The fellow will also be required to be in the device clinic at least one half day per week. Fellows will be expected to present cases at the Tuesday morning EP conference. By the end of the rotation, the fellow will become familiar with heart rhythm programming for device checks. The day generally ends at 17: Research Cardiovascular Health Research Center The fellow must begin corresponding with their research mentor prior to their rotation. In particular, they must identify a project, and the training and approvals that must be in place. Research labs employ a variety of techniques and approaches, and your effort will vary from lab to lab and by study design; plan on at least one month for new human subjects (IRB) or animal studies (IACUC) protocols. In many cases, simple amendments will require a month. The typical rotation will include 1) background research & study design; 2) specific methodological research and lab specific training by observation; 3) validation of fellow on quantitative accuracy with pilot experiments; 4) execution of primary study; 5) analysis of results; 6) follow-up studies; 7) write up & written report to mentor. Working hours will be determined by study design. Typical projects include weekend and evening hours that should be coordinated with your mentor's team. Clear expectations will facilitate your success. 7. Vascular Imaging/Vascular Disease Sanford USD Medical Center (SUMC) & Sanford Heart Hospital The rotation hours are typically 8:00 am to 5:00 pm. The fellow will interpret vascular studies under the supervision of the interpreting vascular clinical faculty. The fellow s primary responsibility is to the oncall clinical faculty who is responsible for vascular studies interpretation. While on rotation, the fellow is expected to present a vascular case at Imaging Conference. The clinical faculty will call the fellow to discuss the peripheral angiograms and interventions as they are done in the cath lab (participation in

19 these is required on the cath lab rotation). The fellow is expected to evaluate patients and prepare them for the peripheral vascular ultrasound studies, as well as perform them under the supervision of a trained ultrasound technician and attending physician. All studies will be reviewed by the faculty attending who will provide feedback and education to the fellows. The fellow will also review computed tomography peripheral angiograms and magnetic resonance angiograms with the clinical faculty. An exposure to vascular/wound clinic is planned and the fellow will be directed there by the faculty. 8. VA Medical Center Royal C. Johnson Veteran s Administration Medical Center Cardiovascular fellows while on call will provide coverage for the VA with their clinical faculty back-up. The clinical experience at the VA, while on-call (call from home) will include cardiology consultations, EKG interpretation and ECHO interpretation. OFF-SERVICE ROTATIONS For detailed information regarding goals and objectives of each rotation, please refer to the Cardiovascular Fellowship Curriculum. For precise details of each rotation regarding specific duties, expectations, and responsibilities, please see below (please note: start/end times and rotation specific responsibilities will be the discretion of the supervising physician): 1. Pediatric Cardiology Sanford Children s Pediatric Cardiology Clinic The fellow will attend outpatient clinic at Sanford Children s Pediatric Cardiology Clinic, which typically starts at 08:00 on weekdays and runs until approximately 17:00. Rounding will begin at the Sanford Children s Hospital at 0700 and sometimes continue throughout the day. Also, the fellow will participate in inpatient consultations for the Pediatric Cardiology service. Fellow participation in outpatient and inpatient services is required at the discretion of the attending Pediatric Cardiologists. The fellow will attend Pediatric Cardiology team meetings and educational conferences as the schedule permits. Participation in the service after hours and on weekends will be at the discretion of the attending Pediatric Cardiologists, as allowed by the call schedule requirements of the Cardiovascular Fellowship program as well as work hour limitations. 2. Cardiothoracic and Vascular Surgery Sanford USD Medical Center (SUMC) & Sanford Heart Hospital (SHH) The fellow reviews the surgery schedule of Sanford Cardiothoracic Surgery the day before. The fellow starts at 07:30 (reports at Sanford Cardiothoracic Surgery Clinic or Sanford Heart Hospital operating rooms) and finishes the day at 17:30. The fellow is required to participate in the daily hospital rounds, prepare and present patients for hospital consults, evaluate new admissions, assist in cardiothoracic surgery procedures, and participate in outpatient clinic. The fellow is also required to present to the cardiothoracic surgery team the reviewed literature on topics assigned by the cardiothoracic surgery attending. 3. Heart Transplant and Heart Failure Rotation Mayo Clinic in Rochester, Minnesota

20 This option is meant to provide for a unique and important educational experience unavailable at Sanford USD Medical Center. Mayo Clinic shall arrange for a two-week rotation for the Cardiology fellow to obtain Heart Transplant/Heart Failure Observational experience at its clinical site in Rochester, Minnesota. The fellow will gain experience in the evaluation and management of patients for cardiac transplant/vad patients in hospital and clinic settings. The fellow will also learn the appropriate cooperative relationships with other specialty consultants and primary care physicians in heart transplant /VAD patients. 4. Elective Rotations Elective rotations include those listed above; any required rotation may also be chosen as an elective. The Program Director and Program Coordinator will be informed a minimum of 4 weeks in advance of the elective. Elective time is not considered vacation time. Attendance at on-site or off-site elective rotations is mandatory. Failure to demonstrate regular attendance may lead to loss of pay and/or academic credit. Fellows must carry their pagers while on elective rotations. Fellows on elective rotations are required to attend all scheduled conferences. Fellows may do an off-site elective rotation, but this must be approved by the Program Director in advance. This option is meant to provide for a unique and important educational experience unavailable at Sanford USD Medical Center. If a fellow wishes to do an off-site elective rotation, he/she must provide a curriculum, a letter from his/her site director, and a reason why the elective rotation cannot be done at Sanford USD Medical Center. This information is required at least 90 days in advance to ensure that the rotation sponsorship is appropriate, that the rotation meets the Residency Review Committee (RRC) requirements, and that it will allow the fellow to receive the required elective credit needed to sit for the ABIM board exam. At the conclusion of the elective rotation, the fellow must provide a written evaluation by the sponsor. The fellow must also provide a brief report to the GME Committee on what he/she has learned during the elective rotation. Please refer to the Away Rotation GME policy. EDUCATIONAL GOALS BY YEAR The Sanford School of Medicine Cardiovascular Disease Fellowship Program is a three-year program designed to train clinical and academic cardiologists. We are committed to training fellows to assume leadership role in cardiovascular medicine in basic and clinical research and clinical cardiology. The curriculum is organized to provide increasing levels of responsibility for trainees with respect to patient care and procedure performance. Adequate progression through the curriculum is assessed by evaluating each fellow s clinical judgment, clinical skills, medical knowledge, procedural skills, professionalism, communication skills, leadership ability, and continuing scholarship. At all times during their training, fellows are expected to conduct themselves with the highest of ethical standards and are expected to display integrity, honesty, compassion, and respect to all members of the health care team, patients, and patient family members. Fellows should always be strong advocates for all patients under their care and should utilize the health care system to maximize the benefit to each individual patient

21 while respecting the patient s expressed wishes. In the end, the welfare of the patient should be the fellow s primary concern. The specific objectives of the program are to help the Fellow: 1. Develop the knowledge base and the clinical, procedural and interpersonal skills necessary to practice cardiovascular medicine in both inpatient and ambulatory care settings. 2. Develop expertise in caring for patients with a variety of acute and critical cardiovascular illnesses in any hospital settings 3. Develop expertise in caring for patients with cardiovascular diseases in the outpatient setting, through continuity ambulatory care experience. 4. Develop expertise in evaluation and diagnosis of patients presenting with cardiovascular diseases through history, physical examination and appropriate diagnostic testing of a wide range of cardiovascular disease problems. 5. Learn the psychosocial underpinnings of medicine and the skills necessary to deal with psychosocial problems. 6. Develop self-directed learning habits and skills that will enable you to continue professional growth throughout your careers. 7. Develop and produce original research projects in field of interest with goal of peer reviewed publication. 8. Develop and enhance the skills needed to communicate effectively with patients, allied health personnel and peers. 9. Incorporate into practice the core role of patient care, patient safety and patient advocacy, and use these tenets as the underpinnings for all actions and behavior. 10. Develop an interest and skill in teaching others, to perpetuate and strengthen the tradition of mutual teaching and learning in cardiology. Specific curricular goals in each of these areas and for each rotation are outlined in the Cardiology Fellowship Curriculum. Each fellow will be expected to meet specific core competency milestones, as identified and outlined by the ACCF Cardiology Competency Statements.

22 Fellows are expected to gain the skills intrinsic to the practice of cardiovascular medicine. These would include the skills of doctor/patient communication and the ability to establish a meaningful, empathic relationship with patients. The ability to obtain a complete focused medical history and perform an effective, focused physical examination are specific objectives of the fellowship program. In addition, fellows are expected to master procedural skills required to practice cardiology. Further, interpretive skills are expected to be mastered by fellows in the areas of cardiovascular diagnostic studies. Fellows are expected to perform primary interpretation of noninvasive and invasive cardiology procedures and be able to interpret and utilize the reported results of more complex testing. Graduates are expected to maintain high standards of humanistic behavior in their professional lives. They are expected to demonstrate honesty, integrity, and high moral conduct in all professional dealings. They should demonstrate professionalism, respect and compassion for patients, and respect for all staff. In addition, they need to demonstrate open, nonjudgmental approaches to dealing with all patients and all patient complaints. It is the obligation of our training program to ensure that the above goals are met and an appropriate method of evaluation is in place. Fellows are expected to have passed their Internal Medicine Boards in their first year of fellowship. FIRST YEAR FELLOWSHIP TRAINING General: The overall purpose of the first year of training is to provide new fellows with a broad exposure to all aspects of clinical cardiology as well as ample introductory experience to a wide variety of invasive and non-invasive cardiac procedures. Fellows will also be introduced to both clinical and basic science research. By the end of the first year, fellows will be able to evaluate cardiac patients and to initiate care appropriate for a wide variety of acute and chronic cardiac conditions but will not be expected to be experts in either clinical care or procedural skills. The goals for the first year of training are for fellows to be introduced to the full range of cardiovascular disease clinical and research opportunities, identify a specific area of interest and a projected career path, be paired with an appropriate mentor, and to select a research project. Clinical Judgment and Skills: By the end of the first year of fellowship training, fellows should be able to obtain an accurate and complete cardiac history and to perform a thorough but directed cardiac physical examination for patients being evaluated for a wide variety of cardiovascular diseases. During their first year of training, fellows will learn the proper role of the various invasive and non-invasive cardiac procedures and tests. Using the information available from the history, physical examination, and test results, first year fellows should be expected to be able to develop a differential diagnosis and a plan of care for common acute

23 and chronic cardiovascular disease states. Additionally, first year fellows will be expected to identify lifethreatening cardiovascular conditions and emergencies and to be able to initiate prompt therapy. First year fellows will gain experience in understanding the pathophysiologic basis of cardiac conditions. First year fellows should be able to contribute to patient management discussions on rounds in conjunction with the staff physician Medical Knowledge: First year fellows will begin to build the critical knowledge base that will permit them to function as competent well-rounded cardiologists. This knowledge will be acquired by reading current cardiology literature sources and standard textbooks as well as via didactic lecture sessions. Clinical knowledge will be gained in the following areas: coronary artery disease, myocardial diseases and heart failure, congenital heart disease, valvular heart disease, peripheral vascular disease and diseases of the aorta, cardiovascular prevention, hypertension, pericardial diseases, cardiac dysrhythmias and clinical electrophysiology, cardiothoracic surgery, cardiac rehabilitation, and pulmonary hypertension. First year fellows will begin to learn the basic literature related to cardiovascular testing and procedures and will begin to develop interpretive skills. Procedural Skills: First year fellows will learn the indications, contraindications, and potential complications related to each major cardiovascular procedure. First year fellows will also begin to develop a working knowledge of the risk/benefit assessment that must take place prior to performing an invasive cardiac procedure. First year fellows will begin to learn how to safely perform procedures and to interpret the data obtained. These procedures will include electrocardiograms, ambulatory ECG monitoring, transthoracic and transesophageal echocardiograms, cardiac catheterization (hemodynamic and angiographic studies), exercise and pharmacologic stress testing, cardiac CT and MRI, electrical and chemical cardioversion, temporary pacemaker placement, and nuclear cardiac imaging. First year fellows will be instructed in how to properly document procedure findings and will be expected to document a thorough and accurate report on any procedure performed. By the end of the first year, fellows should be expert in the pre-procedural and post-procedural assessment of patients referred for cardiac testing and should participate in the performance of invasive procedures only under the direct supervision of an attending cardiologist. Teaching: First year fellows will be expected to provide teaching to medical students and residents on the basics of common cardiovascular conditions and routine bedside invasive. Teaching methods should include actively participating in case discussions on rounds, conducting brief teaching sessions, and introducing house staff to common cardiology literature sources (journal articles, textbooks, etc). Professionalism: First year fellows are expected to conduct themselves with exemplary professionalism at all times, as evidenced by the display of honesty, integrity, respect, and compassion when caring for patients and

24 interacting with patient families, referring providers, and other members of the health care team. First year fellows will accept responsibility for the care of cardiac patients and will be held accountable for conducting themselves with the highest of ethical standards at all times. Communication Skills: First year fellows will learn how to write a thorough, informative, and instructive cardiac consultation note as well as accurate and detailed procedure notes. First year fellows will learn to verbally communicate effectively with patients, families, and all members of the health care team. Fellows will learn the importance of maintaining complete and accurate medical records easily accessible to referring providers. Leadership: First year fellows should be able to provide guidance for medical students and residents as it relates to routine patient care. First year fellows should be able to participate in management discussions on teaching rounds in conjunction with the service attending. Continuing Scholarship: First year fellows will be expected to develop a reading program that will build the foundation of basic cardiology knowledge necessary to become a competent clinical cardiologist. Fellows will learn the significance of keeping current with the literature in order to be able to adapt their clinical practice as new advances are made. Attendance at journal club will allow the fellows to keep abreast of the current literature. Fellows will improve their ability to critically review the cardiovascular literature and to correctly apply the literature in their clinical practice. Fellows will be introduced to both clinical and basic science research as it applies to cardiovascular diseases in order to help them select their fellowship research project. SECOND YEAR FELLOWSHIP TRAINING General: Second year fellows will continue to build upon the knowledge and skills gained during the first year of training and will begin to focus on their particular area of interest. Second year fellows will be given greater latitude in patient management decisions in the continuity of care clinic. During the second year, the fellow s research project should be well-established, and each second year fellow should be able to present his/her activities at the dedicated research conference. Depending upon the outcome of their research work, some second year fellows may be positioned to submit their findings in abstract form to national or regional scientific meetings. Clinical Judgment and Skills:

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