Advanced Specialist Training (AST) Programme in Cardiology

I. Definition Cardiology is a medical subspecialty concerned with the prevention, diagnosis, management, and rehabilitation of patients with diseases of the cardiovascular system. A cardiologist is a specialist who is an expert in the diagnosis and management of all aspects of cardiovascular disease. II. II.1. Advanced Specialist Training (AST) Programme in Cardiology Eligibility To be eligible for the AST programme, applicants must have completed Basic Specialist Training (BST) or its equivalent, and obtained : a) Master of Medicine in Internal Medicine (MMed(Int Med)), or b) Member of Royal College of Physicians, UK (MRCP(UK)), or c) Member of Royal College of Physicians, Ireland (MRCPI). Applicants who have passed the Part I examination for the Fellowship of the Royal Australasian College of Physicians (FRACP) may be admitted by the Cardiology Specialist Training Committee (STC) on a case-by-case basis. II.2. Duration The duration of the programme is three years, and consists of the following areas of training: a) Basic Cardiology Training (24 months) b) Advanced Cardiology Training (12 months) a) Basic Cardiology Training - The duration for basic cardiology training is 24 months. - Trainees are required to fulfil postings for 7 subspecialties areas. - The 7 sub-specialities are: i. Coronary Care ii. Echocardiography iii. Nuclear cardiology iv. Cardiac catheterization / Intervention v. Electrophysiology / Pacing vi. Ambulatory Cardiology/ Cardiac rehabilitation / Preventive Cardiology vii. Clinical Cardiology (ward work) - The duration for each of the five major postings (namely, Coronary Care, Echocardiography, Nuclear Cardiology and Cardiac catheterization / Intervention, and Clinical Cardiology Ward Work) is 4 months. Electrophysiology / Pacing, Ambulatory Cardiology, Cardiac Rehabilitation, Preventive Cardiology may be combined together to form the last 4-month posting. Alternatively, any of the minor 1

postings could be combined with one of the major postings (eg Ambulatory Cardiology with Nuclear Cardiology) during any of the 5 major postings, and the final 4 months may be spent doing an elective posting chosen by the trainee, or have the posting assigned by the supervisor/head of Department. - During training rotations, trainees are expected to spend up to 60% of their time during regular hours performing service work for the department. - There will be no examination at the end of the basic cardiology training. Entry into the Advanced Cardiology Training will be automatically granted, provided that trainees were deemed to have completed all postings in a satisfactory manner by their Supervisors and/or Head of Department. b) Advanced Cardiology Training - The duration for Advanced Training is 12 months, after successful completion of the Basic Cardiology Training. - Trainees may concentrate on any of the sub-speciality areas in adult cardiology, including those not included in the Basic Cardiology Training (eg research, Adult Congenital Heart Disease). This part of the training may be done in Singapore or overseas. For overseas training, requests have to be made to the Cardiology STC through the supervisor and Head of Department of the trainee s parent institution. Trainees may only leave for overseas training after the Cardiology STC has granted permission. Towards the end of the Advanced Cardiology Training, trainees will be required to submit a report certifying satisfactory completion of training from the supervisor, as well as the logbook, with proper entries, to the Cardiology STC. These will be evaluated before trainees may be allowed to sit for the FAMS exit examinations. III. Objectives of Training Upon completion of the cardiology training programme, the cardiologist will be able to function as a specialist in the essential roles and key competencies: medical expert/clinical decision maker, communicator, collaborator, manager, health advocate, scholar, and professional. The graduate cardiologist will have achieved the following general educational objectives and be able to: Provide competent, comprehensive and evidence based diagnosis and management for patients with cardiovascular disorders. Counsel patients and the broader community on prevention and rehabilitation of diseases of the cardiovascular system. Communicate effectively and compassionately with patients and their families Communicate constructively and effectively with other physicians (especially referring physicians) and other health care professionals. 2

Function as a member of the health care team and coordinate the team as appropriate. Contribute to the education of students, other physicians, other health care professionals, and patients and their families. Posses the necessary technical skills for basic diagnostic and treatment procedures for patients with cardiovascular diseases. Maintain complete and accurate medical records. Be able to undertake accurate self-appraisal, develop a personal continuing education strategy and pursue lifelong mastery of cardiology. Be able to critically evaluate the cardiology literature and apply pertinent information to patient management. During the cardiology training program, the advanced trainee must undertake a broad range of practical clinical experiences including acute and chronic cardiac care, ambulatory care, prevention and rehabilitation; attend a programme of formal education activities; and have exposure to and involvement with research activities. The advanced trainee must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to adult cardiology. In addition, all trainees must demonstrate an ability to incorporate gender, cultural and ethnic perspectives in research methodology, data presentation and analysis. The advanced trainee must assume graduated responsibility for clinical decision making and patient care and be able to function as an independent clinical decision maker at graduation. IV. AST Cardiology - Training Requirements The educational objectives detail the knowledge, skills and attitudes essential in the training of the cardiologist: IV.1. Content of Training Programme Medical Expert / Clinical Decision Maker General Requirements Demonstrate diagnostic and therapeutic skills for ethical and effective patient care. Access and apply relevant information to clinical practice. Demonstrate effective consultation services with respect to patient care, education and legal opinions. Specific Requirements 3

Cardiologists are experts in all aspects of the diagnosis and management of cardiovascular disease. The cardiologist should be able to practice contemporary, evidence-based, cost effective medicine and avoid unnecessary or harmful investigations or management. The cardiologist has specific technical skills in diagnostic and therapeutic cardiovascular procedures. The cardiologist must be able to provide care and services to diverse communities. Graduated advanced trainee must demonstrate the appropriate knowledge, skills and attitudes relating to gender, culture and ethnicity, and must understand the importance of these perspectives in research methodology, data presentation and analysis. The advanced trainee will demonstrate the following knowledge and skills necessary for excellent patient care: a) The knowledge to acquire is spelt out in the syllabus section below. It encompasses the major disease processes encountered in cardiology. Objectives are listed once in the most appropriate category. Each section includes specific domains of knowledge, and clinical problems that should be mastered by the graduate cardiologist. For each clinical problem the graduate cardiologist is able to perform a complete and accurate cardiovascular history and physical examination, formulate appropriate differential and provisional diagnoses, develop an appropriate plan of investigation and interpret the results, develop a therapeutic plan, develop a plan of secondary prevention and demonstrate appropriate clinical judgement including consideration of such factors as: the patient s age and other health status; risks, benefits, and costs of diagnostic and therapeutic strategies; and alternative management approaches. Where the term pharmacology is used, it refers to mechanisms of action, clinically relevant pharmacokinetics, indications, contraindications and adverse effects. b) Skills Graduate cardiologists are expected to possess the following skill sets: 1. Expertise in obtaining the complete cardiovascular history and assessment 2. Mastery of all aspects of the cardiovascular examination including carotid and peripheral arterial assessment, jugular veins, precordium, auscultation and systemic manifestations of cardiovascular disease. 4

IV.2. Syllabus 3. Problem solving and clinical decision making, including the ability to correlate, evaluate and prioritize information acquired by clinical assessment; formulate an appropriate problem list; and develop and implement a diagnostic and therapeutic plan using appropriate knowledge derived from clinical appraisal of relevant literature. 4. Technical skills: i. The graduate cardiologist must understand the indications, contraindications, complications and interpretation and have the expertise in performing the following: electrocardiogram (ECG), exercise stress testing, Holter monitoring, pericardiocentesis, temporary transvenous pacing, hemodynamic monitoring (arterial line and Swan-Ganz catheter) and electrical cardioversion. ii. The advanced trainee will understand the indications, contraindications, complications and interpretation, and have the experience of performing the following techniques: cardiac catheterisation and angiography, echocardiography (transthoracic and trans-oesophageal studies), percutaneous coronary interventions, invasive diagnostic electrophysiologic studies, nuclear imaging techniques, temporary and permanent pacemaker insertion, and intra-aortic balloon counterpulsation. iii. Other skills Consultation and communication skills, including the ability to present clear and pertinent assessments and recommendations in written and verbal form; participate constructively as part of a team with other physicians and health professionals; ensure appropriate follow-up and reassessment of the patient s progress and ensure maintenance of appropriate records. The list below should be used as a guide for training, and for preparation of the final exit examination. While it is not exhaustive in listing every single domains of knowledge and clinical problems relating to each heading, it would very much provide the Advanced Trainees with an idea of what is expected at the conclusion of the training programme. a) Coronary Heart Disease Normal coronary anatomy Physiology of normal and abnormal coronary blood flow Normal and abnormal endothelial function Pathogenesis of atherosclerosis Risk factors for atherosclerosis and their management 5

Pathophysiology of acute coronary syndromes Non-atherosclerotic causes of ischemia and infarction Diagnostic techniques for coronary disease, including their sensitivity and specificity Pharmacology of anti-ischemic, antiplatelet, anticoagulant, thrombolytic and lipid-lowering agents Revascularization procedures; percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG), their indications, contraindications and benefits. Gender differences important in the diagnosis and management of coronary artery disease. Ethnic differences important in the incidence of coronary artery disease. Clinical problems Chest pain acute and chronic Chronic stable angina Acute coronary syndromes Acute myocardial infarction including complications Hypotension / shock Post-myocardial infarction management Asymptomatic coronary artery disease. b) Valvular Heart Disease Normal valve structure and function Pathology of valvular disease Pathophysiology and hemodynamics of valvular stenosis and regurgitation Diagnostic techniques Valve surgery: indications, timing, outcome Prosthetic valves: types, complications, natural history Acute and chronic mitral regurgitation Mitral valve prolapse Acute and chronic aortic regurgitation Aortic stenosis Mitral stenosis Tricuspid valve disease Endocarditis: diagnosis, treatment and prophylaxis Rheumatic fever: diagnosis and prophylaxis Patients with prosthetic valves: management and follow-up 6

c) Congenital Heart Disease - Basic cardiac embryology - Intracardiac shunting: hemodynamics, pathophysiologic effects - Congenital lesions in which survival to adulthood is likely - Congenital lesions in which post-operative survival to adulthood is likely. Atrial septal defect Ventricular septal defect Patent ductus arteriosus Coarctation of the aorta Congenital coronary anomalies Eisenmenger s syndrome Cyanotic congenital heart disease in the adult Ebstein s Anomaly, Tetralogy of Fallot d) Congestive Heart Failure Physiology of normal and abnormal ventricular systolic and diastolic function Hemodynamic abnormalities in heart failure Neurohormonal abnormalities in congestive heart failure Ventricular remodelling Etiology, prognosis and natural history of congestive heart failure Diagnosis and investigation for patients with congestive heart failure Pharmacology device therapy and surgery in patients with congestive heart failure. Chronic congestive heart failure Acute exacerbation of congestive heart failure Congestive heart failure in the patients with coronary artery disease Dilated cardiomyopathy Myocarditis Hypertrophic cardiomyopathy: obstructive and non-obstructive Restrictive cardiomyopathy Cardiac transplantation: indications, contraindications, prognosis, management of the post-transplant patients. 7

e) Hypertension Definition Diagnoses Effect of hypertension on target organs and their management Effect of treatment on mortality and complications Secondary causes: screening, diagnosis and management Pharmacology of antihypertensive agents The newly diagnosed patient with hypertension Chronic hypertension Hypertensive urgencies and emergencies Early onset and resistant hypertensives f) Pulmonary Vascular Disease Normal pulmonary vascular physiology Hemodynamics of pulmonary hypertension Natural history of primary and secondary pulmonary vascular diseases Measurement and investigations Pharmacology of pulmonary vasodilator agents, and other treatment modality Pulmonary embolism Primary pulmonary hypertension: natural history, diagnosis and management Secondary causes of pulmonary hypertension: etiology, diagnosis and management g) Pericardial Disease Pericardium: normal anatomy and function Effect of pericardial disease on cardiac hemodynamics and function Pathology and treatment of pericardial diseases 8

Pericarditis: acute, chronic and relapsing Post-cardiotomy syndrome Pericardial effusion Pericardial tamponade Pericardial constriction h) Aortic, Cerebrovascular and Peripheral Vascular Disease Cerebrovascular disease: etiology and risk factors, presentations, cardiac causes of stroke and transient ischemic attach (TIA), treatment options Aortic disease: pathology, etiology, evaluation and treatment Peripheral vascular disease: risk factors, clinical presentations, treatment options Aortic dissection: diagnosis, medical management, indications for surgery and follow-up Aortic aneurysms: diagnosis, investigation, prognosis, treatment including medical, indications for endovascular stenting and surgery Acute peripheral arterial occlusion: principles of diagnosis and management Claudication: principles of diagnosis and management Stroke and transient ischemic attack: principles of diagnosis and management Management of patients with combined cardiac disease and carotid or peripheral vascular disease i) Acute Cardiac Care Hemodynamics: normal and abnormal systemic and pulmonary flows, pressures and resistances Ventilation in patients with primary cardiac disease: indications, principles of management Pharmacology of inotropes, vasopressors, vasodilators Systemic and non-cardiac complications in the critically ill patient Acute pulmonary edema 9

Cardiogenic shock Cardiac arrest Recurrent ventricular arrhythmias ( electrical storm ) j) Electrophysiology Normal cellular electrophysiology Normal sinoauricular (SA) node, auriculoventricular (AV) node, and conducting system function Mechanisms of arrhythmogenesis Mechanisms of conduction abnormalities Pharmacology of antiarrhythmic agents Temporary and permanent cardiac pacing: techniques, indications and follow-up Antitachycardia devices Invasive electrophysiology studies: indications, techniques, complications Invasive ablative techniques for tachyarrhythmias: indications, complications Palpitations Syncope Resuscitated sudden death Supraventricular tachyarrhythmias Atrial fibrillation Wolff-Parkinson-White syndrome Ventricular tachyarrhythmias Bradyarrhythmias k) Pregnancy in Patients with Cardiovascular Disease - Normal cardiovascular physiologic changes in pregnancy and their effect in patients with heart disease - Use of cardiovascular drugs in pregnancy High-risk cardiac lesions in pregnancy (cyanotic congenital heart disease, pulmonary hypertension, cardiomyopathy and congestive heart failure, Marfan's syndrome, valvular obstruction) Common congenital and valvular diseases 10

Patients with prosthetic valves Arrhythmias Hypertension l) Cardiac imaging Indications, contraindications of various form of cardiac imaging modalities Preparation for tests Interpretation of results Limitation of test Choosing of one test over another Assessment of patients with ischaemic heart disease Assessment of patients for cardiac transplant EBCT for screening of coronary atherosclerosis and risk stratification Functional test (eg exercise radionuclide test) or Imaging for anatomy (eg Multi-Slice CT) for screening Initial and following up evaluation for patients with acute aortic dissection The future of non-invasive cardiac imaging m) Other topics Perioperative evaluation and management of the patient with cardiovascular disease undergoing noncardiac surgery Cardiac trauma: diagnosis and management Cardiac tumours: diagnosis, natural history, management Cardiac complications of systemic diseases Inherited cardiac diseases: Marfans, Hypertrophic Cardiomyopathy etc IV.3. Special Areas of Training a) Communicator General Requirements Establish therapeutic relationships with patients and families Obtain and synthesize relevant history from patients, families and their communities. Listen effectively. Discuss appropriate information with patients and families and the health care team. 11

Specific Requirements To provide the best possible care the cardiologist must establish effective relationships with patients, families, other physicians and other health professionals. Communication skills are essential to obtain a history from and convey information to patients and families and to establish a relationship characterized by trust, understanding and compassion. The advanced trainee will demonstrate the ability to: Listen carefully, obtain and synthesize relevant history from patients and families. Present relevant information clearly, concisely and accurately, in written and verbal format and maintain appropriate records. Educate patients, families and other health professionals in formal and informal settings with regard to the patient s condition, management, risk factors and secondary prevention. Demonstrate caring, empathy, understanding and confidentiality. Understand the impact of such factors as age, gender, disability, ethnocultural background and socio-economic background on the patient s history, relationships and ability to comply with a therapeutic program. Identify and discuss end-of-life issues with the patient and family, demonstrating compassion, respect and understanding. b) Collaborator General Requirements Consult effectively with other physicians and health care professionals Contribute effectively to other interdisciplinary team activities Specific Requirements Cardiologists work in partnerships with other health professionals involved in the care of their patients and it is essential for cardiologists to collaborate effectively with a multidisciplinary team of health care workers. The advanced trainee will demonstrate the ability to: Consult with other physicians and other health care professionals, and to understand their roles and contributions. Contribute effectively and constructively to multidisciplinary team activities, contribute to team development, and recognize areas of expertise and value opinions of other team members. c) Manager General Requirements Utilize resources effectively to balance patient care, learning needs and outside resources. 12

Allocate finite health care resources wisely. Work effectively and efficiently in a health care organization. Utilize information technology to optimise patient care, life-long learning and other activities. Specific Requirements Cardiologists function as manager when they make practice decisions involving co-workers, resources and policies. Cardiologists must priortize and execute tasks, work effectively with colleagues and make appropriate decisions regarding the location of finite health care resources. Cardiologists frequently assume positions of leadership in the health care system. The advanced trainee will demonstrate: Practice and time management skills including punctuality, planning, prioritisation and triage skills. Understanding of the advantages and disadvantages of health care in a variety of setting, including hospitals, ambulatory care clinics, offices, homecare and chronic care and rehabilitation facilities. Understanding of the cost and cost-effectiveness of therapeutic and preventive health programs, and the ability to make appropriate decisions based on evidence of benefit to the patient and population served. Understanding of quality assurance and quality improvement programs and the ability to develop appropriate programs in their areas of responsibility. The ability to use information technology as an important tool in optimal patient management. The ability to organize and coordinate the work of the health care team as a patient s most responsible physician. d) Health Advocate General Requirements Identify the important determinants of health affecting patients. Contribute effectively to improved health of patients and communities. Recognize and respond to those issues where advocacy is appropriate. Specific Requirements Cardiologists have an important role in advocating health promotion for individual patients, their practice populations, and the broader community. Health advocacy is undertaken by individual cardiologists and their professional organizations. The advanced trainee will: 13

Be able to identify the biologic, psychosocial, environmental, and economic determinants of health, utilize this information in a management and prevention plan, and ensure that the patient accesses appropriate health and social services in the management of individual patients. Be able to identify patient groups at risk of cardiovascular disease and its complications within a practice population and apply available knowledge regarding primary and secondary prevention. Identify issues and opportunities for contributing to the improvement of cardiovascular health in the broader community. e) Scholar General Requirements Implement and monitor a personal continuing education strategy. Critically appraise sources of medical information. Facilitate learning of patients, housestaff/students and other health professionals. Contribute to developments of new knowledge. Specific Requirements Cardiologists undertake a lifelong pursuit of mastery of cardiology, and have the responsibility for ongoing self-directed learning. They contribute to the education of students, patients, and colleagues and contribute to research, its appraisal and application. The advanced trainee will: Be able to develop and utilize a self-directed continuing education strategy. Know and be able to apply the principles of critical appraisal to sources of medical information. Know and apply the evidence based standards of care to cardiovascular diseases. Understand the importance of ongoing research in cardiovascular disease, will participate and contribute to clinical and/or basic research, and will demonstrate a questioning and inquisitive approach to medical information. Contribute to the education of students, patients and other health professionals. f) Professional General Requirements Deliver highest quality care with integrity, honesty and compassion. Exhibit appropriate personal and interpersonal professional behaviours. Practice medicine ethically consistent with obligations of a physician. 14

Specific Requirements Cardiologists have a unique role in society as professionals dedicated to improving the cardiovascular health of patients in their communities. Cardiologists are committed to the highest standards of excellence in clinical care and ethical conduct, and are committed to acting with integrity, honesty and compassion. The advanced trainee will: Understand and apply the basic principles of medical ethics including: informed consent, advanced directives, research ethics, patient autonomy, and justice. Understand the nature of professional interpersonal relationships and boundaries with patients, co-workers, and students. Understand legal and professional obligations that apply to cardiology including preparation of timely and accurate medical-legal reports, responses to regulatory bodies, notification of coroners, and substitute decision making. V. FAMS Exit Examination V.1. Introduction a) The FAMS Exit Examinations are held twice a year, at the end of April and October. b) The Panel of Examiners is appointed by the Joint Committee for Specialist Training (JCST), with recommendations from the Cardiology Specialist Training Committee. c) Candidates will only be eligible to sit for the Exit Examination upon successful completion of all the sub-specialty postings during the Advanced Specialist Training (AST) period. d) Candidates who fail the Exit Examination will be recommended to undergo further training in area(s) to be decided by Examination Committee and/or STC Cardiology before they re-sit for the Exit Examination in 6 months time. V.2. Examination Format The Cardiology STC has recommended the following assessment criterias: a) The format for the exit examination consists of 2 components, Paper 1 on MCQ and Paper 2 on Data Interpretation. b) A candidate would be deemed to have failed the exit examination if he/she fails the Paper 1 Examination. Candidates may only proceed to sit for Paper 2 Examination if he/she passes the Paper 1 Examination 15

c) Candidates are required to secure passes in both the Paper 1 and 2 Examinations in order to obtain an overall pass in the exit examination. d) Candidates sitting for exit reassessments will have to undergo both parts of the exit examination, even if they had passed the Paper 1 Examination during an earlier assessment. The Paper 1 Examination score obtained during an earlier examination will not be carried forward. e) If a candidate fails to satisfy the panel of examiners during the Exit Examination, he/she may be recommended to fulfil an additional six months of training before sitting for an exit reassessment. V.3. Details of the Exit Examination Components a) Written Examination The written examination is designed to test the overall knowledge (i.e. breadth and depth) on adult cardiology. This segment comprises the following: 1. Multiple Choice Questions (MCQs) i There will be 60 MCQs of 4 statements with True or False answers (i.e. 240 True or False statements) for the paper, covering all areas of the syllabus. ii. Candidates will have 2 hours (120 minutes) to complete the paper. iii. Candidates need only to offer a true or false answer for each statement. NO marks will be deducted for wrong answers. Passing mark is set at 75%, but the STC has the discretion to adjust the passing mark for each examination as it deems fit 2. Data interpretation i. Data interpretation segment will begin only after the answer for the MCQ session is submitted. ii. Twenty questions will be set for this hundred (100) minute segment of the examination. iii. Data interpretation of the following areas is tested: - ECG - Echocardiography - Nuclear Cardiology - Electrophysiology Tracings - CxR - Cardiac hemodynamics - Images related to coronary angiography / intervention or cardiac catheterization iv. Generally one or more images / tracings will be shown for each question. Candidates will be asked to make diagnosis, offer differential diagnosis, provide reason(s) for doing so, naming the abnormalities, suggest further investigations, or 16

suggest treatment plan. Answers are expected to be short and precise. v. Passing mark is set at 75%. However, the STC has the discretion to adjust the passing mark for each examination as it deems fit V.4 End of training assessments a. As stated in V.1, candidates can only sit for the Exit Examination after they have successfully completed the AST Programme (3 years). b. While there are no marks awarded during the assessments for each posting, candidates must be given a satisfactory report by his/her supervisor during each individual postings in order to be deemed to have successfully completed the particular three-month rotation. c. Trainees are required to repeat the particular posting(s) if they failed to obtain a satisfactory report. This infers that the training period might be extended beyond three years. d. It is mandatory for a trainee who is repeating a posting to be supervised by a different supervisor from the earlier posting. If this is not feasible in the parent institution, arrangements have to be made for him/her to be attached to another hospital for the repeat training period, at the parent hospital s budget. VI. Specialist Accreditation with the Ministry of Health Having satisfied the panel of Exit Examiners, candidates will be informed in writing by the Academy of Medicine of their successes at the Exit Examinations. They may then proceed to apply for Specialist Accreditation with the Ministry of Health with the letter from the Academy of Medicine substantiating the successful completion of Advanced Specialist Training. VII. Sub-Specialty Board of Examination STC Cardiology has recommended that no further examination in areas of subspecialty will be held locally for cardiologist to practice in a chosen subspecialty of cardiology. However, the specialist needs to provide evidence / documentation on having undergone training in the sub-specialty when requested to do so by relevant authority. For specialist accreditation of overseas-trained cardiologists, following recommendations from the Cardiology STC, the Specialist Accreditation Board (MOH) may register applicants with any of the following foreign exit qualifications as specialists: 17

(a) FRACP (Cardiology) (b) American Board of IM (Cardiology) (c) MRCP(UK) & CCST (Cardiology) (d) FRCPS Can(Cardiology) Last updated on 8 Aug 2006 18