Cardiovascular Disease Fellowship

About the Program

Quick Facts

2021 Recruitment Timeline

We have adapted our usual application and interview procedures to meet the challenge of the COVID-19 pandemic.

  • The application deadline through ERAS is July 20, 2021

  • We will extend invitations for interviews the week of August 23, 2021

  • Our virtual interview dates are September 13, 20, 27, and October 5, 11 and 13, 2021. We will be holding 2 half days sessions for each of these dates.

  • New fellows will begin training on July 1, 2022.

History

The University of Iowa Cardiovascular Disease Fellowship Training Program was established in 1966. Over 250 fellows have graduated from the program and have become leading clinicians, educators, scientists, and administrators throughout the United States and the world. The program is certified by the Accreditation Council for Graduate Medical Education (ACGME). The Abboud Cardiovascular Research Center has the longest funded cardiovascular NIH T32 training grant, which supports research training for clinical and postdoctoral fellows.

Mission Statement and Aims

As a premier academic medical center in the Midwest, we help our trainees to develop the skills that they will need to shape the future of cardiovascular medicine though leadership in clinical care, scientific investigation, education, administration, and public health at the regional, national, and international levels.

To achieve this mission, we aim to provide academically and clinically rigorous training in general cardiology as well as advanced training in clinical cardiology subspecialties. Our fellows will continue to develop the basic and clinical knowledge, procedural skills, clinical judgment, professionalism and interpersonal skills, and abilities necessary to be outstanding cardiovascular clinicians, investigators, educators, and administrators. They will also learn how to continue to develop these skills through the course of a long career, as required of leaders in cardiovascular medicine. The curriculum is designed to provide broad clinical exposure in acute and chronic cardiovascular care in the inpatient and outpatient settings, as well as extensive experience in non-invasive and invasive cardiac procedures. Clinical training is provided at an integrated clinical cardiovascular center, the Heart and Vascular Center and the University of Iowa Stead Family Children's Hospital, within the University of Iowa Hospitals and Clinics, and at the Iowa City Veterans Affairs Health System.

Because of the role of our fellows as future leaders in diverse fields, we also aim to facilitate scholarly activity at the world-renowned Abboud Cardiovascular Research Center or in other divisions, departments, colleges, or research centers at the University of Iowa. We also closely collaborate with other colleges at the University of Iowa, including the College of Public Health and the Tippie College of Business, allowing our fellows to obtain graduate degrees, including Master of Clinical Investigation, Master of Public Health, Master of Health Administration, and Master of Business Administration. In addition, the Fellows as Clinician Educators (FACE) Program is designed to introduce future clinician-educators to a set of skills that will be useful in their careers. The program presents concepts of educational design and research, lecture development, evaluation, observation and feedback.

Our philosophy is to provide flexibility so that each fellow can individualize her or his training to meet future career goals.

Duration

We offer a three-year traditional track which includes two years of clinical training and one year of scholarly activity (research training or graduate degree education), and a four-year scholarly track which includes two years of clinical training and two years of scholarly activity. We strongly encourage applications from candidates interested in the four-year scholarly track geared towards training as physician-scientists to become future leaders in academic cardiovascular medicine. We welcome six to seven new fellows each year.

Further subspecialty training is available in Interventional Cardiology, Clinical Cardiac Electrophysiology, Advanced Heart Failure and Transplant Cardiology, and Advanced Cardiac Imaging . In addition, extended research training may be available for exceptionally promising physician-scientists.


Learn more about graduate medical education at the University of Iowa:

 

Training Structure

We offer a three-year traditional track which includes two years of clinical training and one year of scholarly activity (research training or graduate degree education), and a four-year scholarly track which includes two years of clinical training and two years of scholarly activity. The organization of the training program is flexible, and is tailored to individual fellow’s goals and interests. However, all fellows must complete the following core rotations in compliance with guidelines from the American Board of Internal Medicine (ABIM), the Accreditation Council on Graduate Medical Education (ACGME), and the American College of Cardiology Revised Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training 4 (COCATS 4) in order to achieve excellence in academic cardiology and eligibility for board certification. All fellows will achieve level 1 certifications outlined in COCATS 4 after completing core rotations, but almost all fellows will choose to achieve level 2 certifications in certain areas using elective blocks.

Clinical training is provided at an integrated clinical cardiovascular center, the Heart and Vascular Center, within the University of Iowa Hospitals and Clinics and at the Iowa City Veterans Affairs Health System. The University of Iowa Hospitals and Clinics is owned by the university, and has integrated leadership with the University of Iowa Carver College of Medicine. It has 811 beds, admits approximately 37,000 patients each year, offers both primary and quaternary care services, has over 1,700 faculty physicians, and has over 15,000 staff. Forbes Magazine ranked The University of Iowa Hospitals and Clinics as the seventh best employer in the health care industry. The Iowa City Veterans Affairs Health System is located adjacent to the university, and shares the same faculty as the University of Iowa Hospitals and Clinics.

Core Rotations

Rotation 4-week blocks
Adult Congenital Heart Disease 1
Cardiac Catheterization 4
Consultations 2
Cardiac CT and MRI 1
Cardiovascular Intensive Care 2
Echocardiography 3
Electrophysiology 2
Heart Failure and Transplant 2
Nuclear Cardiology and Stress Testing 2
Vascular Medicine 1
VA Inpatient Service 1


Fellows will also have two “flex” rotations, during which they will be able to select experiences in outpatient clinics, imaging, or research. However, during these rotations, they will be available to cover for unexpected absences by fellows on certain other services.

Elective Rotations and Scholarly Activity

Fellows will have four blocks to schedule elective rotations. They may use these electives for additional clinical training to achieve level 2 certifications in selected areas, or they may use these electives for scholarly activity. Fellows must request clinical electives in February of the prior academic year to be scheduled into the rotation calendar. Generally, this elective time will be available in the second and the third years.

Fellows in the three-year traditional track will receive six blocks dedicated for scholarly activity, generally in their second and third years. Fellows in the four-year scholarly track will receive 18 blocks dedicated for scholarly activity, generally in their second, third, and fourth years, and they may also use their elective and flex time for scholarly activity. In some cases, specialized research training may occur prior to clinical training as a part of the fellowship training program.

Scholarly activity may involve basic, translational, clinical, or population science research at the world-renowned Abboud Cardiovascular Research Center or in other divisions, departments, colleges, or research centers at the University of Iowa. The Abboud Cardiovascular Research Center has the longest funded cardiovascular NIH T32 training grant, which supports research training for clinical and postdoctoral fellows. We also closely collaborate with other colleges at the University of Iowa, including the College of Public Health and the Tippie College of Business, allowing our fellows to obtain graduate degrees, including Master of Clinical Investigation, Master of Public Health, Master of Health Administration, and Master of Business Administration.

Fellows with an interest in education have ample opportunities to lead didactic teaching sessions. Fellows are expected to give didactic lectures at catheterization conferences, echocardiography conferences, clinical conference lecture series (cardiology grand rounds), board review lecture series, and morbidity and mortality conferences. Fellows participate in teaching part of the electrocardiography course material to medical students under the direction of Dr. Donald Brown, and have the opportunity to teach in other sessions in the undergraduate medical curriculum. In addition, fellows are involved in direct clinical teaching of medical residents on the inpatient cardiology services (cardiovascular intensive care unit, heart failure service ,and consultations service) and assist in the early training of new cardiology fellows. The Fellows as Clinician Educators (FACE) Program is designed to introduce future clinician-educators to a set of skills that will be useful in their careers. The program presents concepts of educational design and research, lecture development, evaluation, observation and feedback. At the conclusion of the program, FACE participants are required to develop a teaching portfolio.

Clinics

Throughout all years of training, fellows maintain half-day continuity clinics alternating every week between the Heart and Vascular Center within the University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Health System.

Call Duties

Each weeknight and weekend day, there is one fellow on call in house for the cardiovascular intensive care unit (CVICU night float) and one fellow on call from home for all other cardiology services at the University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Health System. Over the course of the entire fellowship program, each fellow is responsible for approximately 40 CVICU night float calls and 70 home calls for a total of 110 calls. CVICU calls are covered by more senior fellows, who also provide backup for the more junior fellows who are on home call. Fellows who are on dedicated scholarly time are generally exempt from call duties.

Conferences

Several conferences take place throughout the week, and a repeating core curriculum lecture series is completed each year. In addition, a journal club is held weekly and provides a forum for critical review of the literature and debate of current topics in cardiology. Support is provided for fellows to attend at least two national or international conferences during their fellowship, in addition to conferences at which they are presenting their research.

Vacation

Fellows receive three weeks of paid vacation each academic year, which they make take together as one three-week segment, or as a combination of a one- and a two-week segment. Vacation time is requested in February of the prior academic year and is scheduled into the rotation calendar.

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 Iowa Board of Medical Examiners.

Procedure Certification

Certification levels are defined by COCATS 3 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 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 twice a year to be reviewed by the program director during the fellow’s biannual evaluation.

Conferences

A wide breadth of conferences is offered every weekday through the academic year. Since the start of the COVID-19 pandemic, all conferences have moved to live online presentations. In-person conferences will resume when safe.

Weekly Conferences:

Monday

Electrocardiogram Teaching Conference - 7:00-8:00am
Fundamentals of electrocardiographic interpretation and arrhythmia evaluation are covered.

Cardiology Grand Rounds - 12:00 noon – 1:00 pm
Each fellow is assigned one conference each year to present an emerging clinical topic or to present her or his research data. The remainder of Cardiology Grand Rounds are presented by preeminent external speakers from around the world and University of Iowa faculty. Lunch is provided.

Work-in-Progress Research Conference (WIP) - 4:00 pm – 5:00 pm
In conjunction with the Abboud Cardiovascular Research Center, fellows and other trainees present their research data to a wide audience of clinical and non-clinical faculty, clinical and postdoctoral fellows, undergraduate, medical, and graduate students, and staff.

Tuesday

Advanced Imaging Conference - 12:00 noon – 1:00 pm
The acquisition and interpretation of nuclear cardiology, cardiac CT, and cardiac MRI studies are discussed by imaging faculty. Recent interesting cases and newly published papers are presented by imaging faculty and fellows.

Wednesday

Echocardiography Conference - 8:00 am – 9:00 am
The acquisition and interpretation of transthoracic and transesophageal echocardiograms are discussed. Recent interesting cases and newly published papers are presented. The conference is attended by imaging faculty, fellows, and sonographers.

Core Curriculum Conference - 12:00 noon – 1:00 pm
Core material in cardiovascular disease is presented by faculty members who are experts in the topic. The lectures are repeated every year, allowing for reinforcement of core knowledge that is tested on board certification examinations. Lunch is provided.

Thursday

Interventional Core Conference - 7:00 am – 8:00 am
Fellows on the cardiac catheterization services are assigned on a rotating basis to coordinate the presentation of catheterization-based topics. Breakfast is provided.

Internal Medicine Grand Rounds - 12:00 noon – 1:00 pm
Preeminent external speakers from around the world and Department of Internal Medicine faculty lecture to the combined department and its subspecialty divisions on a wide variety of topics across all specialties and address several interdisciplinary topics (for example, genetics, quality of care, patient safety, reduction of medical errors, and ethics in medicine). CME and MOC credit is available for faculty, and lunch is provided.

Interdisciplinary Fellows Core Conference - 1:00 pm – 2:00 pm

Friday

Electrophysiology Case Conference - 7:00 am – 8:00 am
This conference is conducted by the electrophysiology faculty and the subspecialty electrophysiology fellow. Interesting cases, intracardiac electrophysiological tracings, and basic electrophysiology topics are discussed in this conference.

Interventional, Electrophysiology, and Acute Cardiac Care Journal Club - 12:00 noon – 1:00 pm
Fellows and faculty members present noteworthy newly published papers. The article to be presented is at the discretion of the presenter. Lunch is provided.

Other Conferences

Board Review
This conference is arranged by the Chief Fellow. ACCSAP is reviewed, and food is provided. This conference generally takes place once a week.

Morbidity / Mortality Conference
One morbidity and mortality conference is presented by the senior fellows. The attendance of the responsible faculty member is required for this conference. In addition, fellows are encouraged to attend morbidity and mortality conferences related to cardiovascular disease organized by the Department of Internal Medicine.


Conference content will address the following areas:

1. Basic science

  1. Cardiovascular anatomy
  2. Cardiovascular physiology
  3. Cardiovascular metabolism
  4. Molecular biology of the cardiovascular system
  5. Cardiovascular genetics
  6. Cardiovascular pharmacology
  7. Cardiovascular pathology

2. Prevention of cardiovascular disease

  1. Epidemiology and biostatistics
  2. Risk factors
  3. Lipid disorders

3. Evaluation and management

  1. Coronary artery disease and its complications
  2. Arrhythmias
  3. Hypertension
  4. Cardiomyopathy
  5. Valvular heart disease
  6. Pericardial disease
  7. Pulmonary heart disease
  8. Peripheral vascular disease
  9. Cerebrovascular disease
  10. Heart disease in pregnancy
  11. Adult congenital heart disease
  12. Complications of therapy

4. Management

  1. Acute and chronic congestive heart failure
  2. Acute myocardial infarction and other acute ischemic syndromes
  3. Acute and chronic arrhythmias
  4. Preoperative and postoperative patients
  5. Cardiac transplant patients

Rotations

Rotations at the University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Health System are described briefly below. The links provide additional details of the specific curriculum for each rotation, including the overall purpose, the fellow responsibilities and specific duties, the method of supervision, the learning objectives, patient characteristics, mix of diseases encountered, types of clinical encounters and procedures performed, teaching methods, evaluation methods, and a bibliography.

Adult Congenital Heart Disease (ACHD)

This rotation is organized in collaboration with faculty members from pediatric cardiology at the University of Iowa Stead Family Children's Hospital, which is part of the University of Iowa Hospitals and Clinics, who are board-certified in adult congenital heart disease (ACHD). This rotation provides comprehensive exposure to the diagnosis, assessment and management of outpatient presentations of most forms of congenital heart disease commonly encountered in adults. Fellows participate in ACHD clinics, imaging and cardiac catheterization of adult patients with congenital heart disease, and combined medical-surgical conferences to review adult patients being considered for surgery.

Cardiac Catheterization

At least two general cardiology fellows are assigned to the cardiac catheterization laboratories each block, and they divide their effort daily between the cardiac catheterization laboratories at the University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Health System. Fellows evaluate all patients referred for cardiac catheterization and review them with the faculty member prior to performing any procedure. All invasive cardiac procedures are performed under the direct supervision of an invasive or interventional attending cardiologist. Fellows gain an understanding of coronary anatomy and hemodynamics and acquire the technical, cognitive and motor skills required to gain venous and arterial access and to perform coronary angiography, ventriculography, pericardiocentesis, and endomyocardial biopsies. Fellows become familiar with the indications for and the risks and the benefits of these procedures. Knowledge of comorbid factors that increase the risk of a procedure are acquired. Fellows become familiar with the pharmacology of medications used for conscious sedation, contraindications for their use, their side effects, and monitoring of sedation. Fellows learn to recognize and to treat complications of these procedures.

Cardiac Electrophysiology (EP) Procedure Elective

The purpose of the elective rotation is to gain an understanding of the anatomy, physiology, pharmacology and technology central to the field of cardiac electrophysiology, to acquire a deeper knowledge of patient presentations and diagnostic testing, and to develop the technical, cognitive and motor skills required to gain the venous and arterial access needed to perform device implantations and catheter studies, to place intracardiac catheters, and to understand intracardiac electrograms.  It is important to emphasize that the rotation is not designed to develop full clinical competence in device implantation and EP study/ablation, but rather to develop skills and knowledge in this field that will serve as a foundation for further training in an EP fellowship program, or to support future practice in cardiology that will intersect with EP.

Consultations

Fellows are exposed to complex cardiovascular problems encountered in a quaternary care hospital (University of Iowa Hospitals and Clinics), including the medical services, as well as on surgery, gynecology, psychiatry, and neurology services, in the intensive care units, in the emergency department, and in pregnant patients. The patient population includes men and women of all adult ages and of varied ethnic and socioeconomic background. Special populations include patients with transplanted organs. Consultations often are for diagnosis and management of chest pain, unexplained dyspnea, and dysrhythmias or syncope, and for preoperative cardiac risk evaluation or perioperative cardiac management. Initial consultation and inpatient follow-up are included. The fellow has primary responsibility for all patients referred to the service, under the supervision of the faculty member. Medical residents assist the fellow and are primarily responsible for a subgroup of patients on the service. The fellow supervises the medical residents in this capacity and reports directly to the faculty member. The faculty member conducts rounds daily with all members of the consultation team (fellow, medical residents, and students). Thus, during this rotation, the fellow is expected to acquire skills related to the clinical management of complex cardiovascular problems, and to develop supervisory and teaching skills.

Cardiac CT and MRI

Fellows become familiar with cardiac MRI and cardiac and vascular CT studies performed at the University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Health System. Studies are reviewed with faculty in a centralized multimodality reading room in the Heart and Vascular Center. Advanced training in cardiac CT and MRI are offered for fellows who select cardiac imaging as their major career focus. The fellowship will allocate 12 months to this training, either as a component of the individual fellow’s scholarly and elective blocks, or as an additional year of training following completion of 36 months general cardiology fellowship. Each fellow will assume graduated responsibility for completion of CT or MRI studies, including patient selection, image acquisition, image analysis, data reporting, and consultation with the referring physician. In addition, each fellow who selects this career path will engage in at least one research project that is centered on advanced imaging. COCATS 4 certification at our institution requires demonstration of independence in all aspects of clinical CT or MRI, and at least one peer-reviewed publication.

Cardiovascular Intensive Care

Fellows receive comprehensive training in the evaluation and management of common cardiovascular disorders and other life-threatening illnesses that may present with cardiovascular manifestations. Common clinical problems include acute coronary syndromes, cardiac arrest, cardiogenic shock, cardiac dysrhythmias, congestive heart failure, valvular heart disease, myocardial and pericardial heart disease, and aortic and hypertensive emergencies. Fellows become proficient in the performance and interpretation of several cardiac procedures including, but not limited to, pulmonary artery catheter placement, temporary venous pacemaker insertion, intra-aortic balloon pump management, and elective cardioversion. Review and integration of laboratory, radiographic, hemodynamic, and cardiac diagnostic studies is emphasized. A strong mentoring relationship with faculty is developed and emphasizes leadership skills for managing a healthcare team. In the cardiovascular intensive care unit (CVICU) at the University of Iowa Hospitals and Clinics, medical residents are primarily responsible for all patients. The fellow is responsible for supervising the residents assigned to the CVICU and assists in the management of the patients. A dedicated CVICU faculty member oversees all aspects of the fellow’s duties and conducts twice daily rounds with the fellow. The fellow is jointly responsible with the faculty member for core curriculum teaching as required for the education of medical residents, including didactic lectures and daily teaching on patient care issues.

Echocardiography

Fellows acquire the necessary expertise to perform and to interpret transthoracic, transesophageal, and stress echocardiography studies that are routinely encountered in the practice of cardiology, including the evaluation of patients with general cardiac disorders such as heart failure, coronary artery disease, valvular disorders, pericardial diseases, and cardiac masses. Fellows personally perform at least two transthoracic echocardiographic studies with the sonographers each day. Fellows pre-read at least 10 studies each day, and then formally read all studies performed during the day with the faculty member in a centralized multimodality reading room in the Heart and Vascular Center. Fellows participate in performing contrast echocardiography or amyl nitrite studies and transesophageal echocardiograms, as well as supervising, performing and interpreting exercise and dobutamine echocardiography studies. Fellows learn the indications, limitations, and risks of procedures such as transthoracic echocardiography, transesophageal echocardiography, stress echocardiography, sedation, and echocardiographic contrast. Fellows gain an understanding of the anatomy and physiology of a broad variety of cardiac disorders.

Electrophysiology

Fellows acquire knowledge and experience in the diagnosis and the management of arrhythmias, the indications and the limitations of electrophysiologic studies, the appropriate use of antiarrhythmic agents and defibrillator devices, the use of noninvasive and invasive techniques to assess patients with arrhythmias, and pacemaker and implantable cardioverter defibrillator (ICD) management and interrogation. The fellow is the point of contact for the electrophysiology consultations service at University of Iowa Hospitals and Clinics. This service includes all inpatient and most outpatient consultations from other clinics and the emergency department. The fellow conducts daily rounds on all electrophysiology inpatients and communicates management plans to the patient’s primary team. The fellow evaluates patients in the electrophysiology clinic. The fellow assists the faculty member during procedures such as interrogation of devices or cardioversions. The fellow participates in performing and interpreting Holter monitor studies, event recorders, exercise stress tests for dysrhythmia management, tilt table tests, and signal-averaged electrocardiograms.

Heart Failure and Transplant

Fellows gain extensive experience in the diagnosis and management of patients with acute and chronic congestive heart failure and an introductory experience to cardiac transplantation in both the inpatient and the outpatient settings. The primary responsibilities of fellows are to manage a busy inpatient care team at the University of Iowa Hospitals and Clinics under the supervision of the faculty member, to complete inpatient consultations with faculty oversight, and to teach medical students and residents on the rotation. In addition, fellows perform central line placements, pulmonary artery catheterizations, vasodilator challenges, and endomyocardial biopsies; manage heart failure and pulmonary hypertension in an outpatient clinic setting; participate in review of cardiac biopsies; supervise and interpret cardiopulmonary exercise tests; and gain familiarity with ultrafiltration. Fellows also perform outpatient invasive procedures and evaluate patients in the heart failure clinic under the direct supervision of the faculty member.

Nuclear Cardiology and Stress Testing

Fellows learn about the indications, the performance, the interpretation, and the limitations of diagnostic nuclear cardiology and stress testing. Fellows are expected to understand the basic principles of radioisotopes, myocardial perfusion imaging, and multigated acquisition (MUGA) scans, and gain skills required to interpret studies independently. Fellows are given primary responsibility to perform stress tests, under direct supervision of a faculty member or a specially trained exercise physiology professional. Fellows are instructed in the complementary roles of myocardial perfusion and left ventricular function in patient assessment and management, the interpretation of stress testing following myocardial infarction to identify high-risk patients and to prescribe appropriate exercise regimens for cardiovascular rehabilitation, the role of stress testing in preoperative cardiac risk assessment, and the value and limitations of stress test results in patient diagnosis, prognostication, and clinical management. Studies that are performed routinely include maximal and submaximal exercise tests, pharmacologic tests with dobutamine or regadenoson, and MUGA scans. Fellows pre-read all stress electrocardiograms and imaging studies in preparation for the afternoon reading session with the faculty member in a centralized multimodality reading room in the Heart and Vascular Center.

Vascular Medicine

Fellows perform and become familiar with non-invasive assessments of peripheral vascular disease using ultrasound methods with the assistance of vascular laboratory technicians. A full range of noninvasive tests is available in the Vascular Laboratory at the Heart and Vascular Center including:

  • Peripheral arterial disease (PAD)
    • Doppler arterial exams of the legs or arms (physiologic testing)
    • Duplex ultrasound scan of the extremity arteries
  • Cerebrovascular disease
    • Carotid artery duplex scan
  • Deep venous thrombosis (DVT)
    • Venous duplex scan of the arms or legs
    • Inferior vena cava (IVC) scan
  • Renal artery disease
    • Renal artery duplex scan
    • Duplex scan of the renal veins
  • Aneurysms
    • Aortic duplex scan
    • Duplex scan of peripheral arteries

Fellows attend clinics with faculty in the Vascular Surgery Clinic at the Heart and Vascular Center. Fellows also receive didactic lectures in peripheral vascular disease at core curriculum conference and during the weekly clinical conference of the Division of Vascular Surgery.

VA Inpatient Service

Fellows receive broad exposure to a wide variety of common and rare cardiovascular disorders in the inpatient setting at the Iowa City Veterans Affairs Health System. Fellows have primary responsibility for all patients referred to the service under the supervision of one faculty member dedicated to this rotation. Fellows provide cardiology consultation on inpatients, including preoperative and perioperative patients and critically ill cardiac patients. Teaching by the faculty members occurs daily on attending rounds and is supplemented as needed for urgent consultations. The faculty member reviews the detailed consultations prepared by the fellow, provides bedside teaching of clinical history and cardiac examination skills, and reviews noninvasive and invasive studies with the fellow, including electrocardiograms. Fellows also interpret all electrocardiograms, Holter monitors, and event monitors performed on outpatients or inpatients.

VA Outpatient Cardiology

Purpose:

This rotation provides exposure to general cardiology in an outpatient setting. 
The purpose of this rotation is to acquire expertise and proficiency in the management of outpatient cardiovascular issues in a patient population with common cardiovascular diseases like coronary artery disease, valvular heart disease, peripheral vascular disease, heart failure, arrhythmias and preoperative evaluation. Fellows will gain experience in ECG interpretation, performance and interpretation of exercise and pharmacologic stress testing, and performance and interpretation of transthoracic echocardiograms. Fellows will also perform transesophageal echocardiograms and elective cardioversions. 

Responsibility / Specific Duties:

The fellow has primary responsibility for all patients referred to the service, under the supervision of one faculty member dedicated to this rotation. This rotation also provides the opportunity and time to acquire expertise in nuclear cardiology (half day every afternoon on all weekdays) on studies performed at the VA and basic training in cardiac CT.

When responding to a request for consultation, the trainee is expected to provide comprehensive evaluation of the patient’s cardiovascular illness in a prompt and concise manner, formulate a prioritized differential diagnosis, and outline the evaluation. The trainee is expected to document the evaluation and management plan in the patient’s electronic medical record. The trainee should communicate the evaluation in a clear and concise manner to the requesting physician and provide adequate follow up. Interactions with colleagues and allied personnel should be conscientious, respectful, responsible, punctual and appropriate. The trainee must exhibit humanistic qualities when interacting with patients and their families and demonstrate integrity, respect and compassion.

Outpatient consultations for patients referred from other services and other VA hospitals are provided week day mornings each week. Patients are scheduled by the physician assistant’s and are seen in the 8E office area. Patients are seen separately by the PA’s and the outpatient fellow. The fellow is responsible for personally reviewing all cardiology studies for the patients evaluated in clinic.

The VA outpatient fellow is expected in the VA clinic on 8E at 8am except on those days where there is a morning conference (e.g. Thursday 8-9am echo conference and Wednesday 7:30 to 8:30 am cardiology grand rounds/clinical conference). Fellows are expected to evaluate no more than 5 patients (typically no more than 3 new patients) until noon. After 1 pm, the VA outpatient rotation is dedicated to non-invasive cardiology. Fellows are expected to participate in the performance and interpretation of nuclear cardiology studies (typically from 2:00pm – 3:30pm), CT coronary angiograms and also review echo studies done in the VA echo lab. Fellows are required to maintain a detailed procedure log. The fellow will perform and interpret GXTs at the VA and follow up the abnormal results as appropriate. The VA outpatient fellow is responsible for interpretation of all Holter monitor studies and will read half of all ECGs for the day. The other half of the ECG reading is to be shared with the VA inpatient fellow.

Supervision:

The fellow is expected to discuss all cases with the supervising VA cardiology staff. However, complex cath cases and EP cases maybe directly discussed with cath lab and EP staff. All discussed cases must be documented in the VA electronic chart (CPRS) with the name of the attending physician.

Learning Objectives:

  1. Obtain training in the concepts and practice of effective outpatient cardiac consultation. This includes:< >Improving skills for acquiring a detailed and accurate history and physical examination. (A, B)Improving skills for insightful review of laboratory data. (A, B)Obtain training in review of noninvasive and invasive cardiac tests and incorporation of the test results into the context of the patient’s cardiac presentation. (A, B)Obtain training in placing the cardiac findings in the patient’s overall medical context. (A, B)Obtain training in formulation of a broad differential diagnosis with focus on the most likely diagnosis. (A, B)Obtain training in formulation of an effective treatment plan. (A, B)Gain experience in providing support of the proposed diagnosis and treatment plan by citation of relevant clinical studies and guidelines. (B, C)Gain experience in effective communication and interaction with referring physicians. (D, E)Gain exposure to a broad range of cardiac conditions through individual outpatient consultations and supplemental reading. (A, B)
  2. Gain training in guideline-based preoperative cardiac risk assessment and effective preoperative risk reduction. (B, C)
  3. Obtain training in ECG interpretation. (B)
  4. Obtain training in exercise and pharmacologic stress testing performance and interpretation. (B)
  5. Obtain training in performing elective cardioversions and in understanding the indications, contraindications, and risks of the procedure. (B)
  6. Gain an appreciation for the role of the staff members in the non-invasive labs, including the technicians, nurses, and administrative staff. (D, E, F)

Level Specific Goals and Objectives:

Junior Fellows (first year fellows)

Every patient will be staffed with the faculty in a timely fashion. The faculty will then review the history and physical findings with the fellow as well as any pertinent laboratory studies. The fellow will then formulate a plan and generate a note in the medical record. These findings will then be communicated with the patient and health care team.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

Patient Characteristics / Mix of Diseases / Types of Clinical Encounters:

At the VAMC, most patients presenting to the non-invasive labs for cardiac procedures and those presenting to the outpatient consult clinic are adult males from a variety of ethnic backgrounds. Fellows will evaluate patients in the outpatient clinic setting and will perform exercise treadmills, and elective cardioversions. Fellows will also evaluate patients pre and post procedure. Cardiac conditions encountered will include chronic coronary disease, congestive heart failure, valvular heart disease, and dysrhythmias.

Teaching Methods:

Teaching occurs by a variety of methods on this rotation.

  1. Direct teaching related to technical skills occurs during the performance of elective cardioversions.
  2. The supervising physician will overread fellow interpretation of stress ECGs, and TTEs and offer constructive criticism and further instruction. Attendings will read echos directly with the fellow and provide didactic teaching during the reading sessions.
  3. The supervising physician will review the detailed consult notes written by the fellow on all patients seen in clinic. The attending cardiologist provides constructive suggestions for acquisition of additional relevant clinical information, alternate interpretations of the data presented, recommendations for additional diagnostic considerations, and additional treatment considerations. The attending cardiologist reviews the noninvasive and invasive study results performed on the consult patients with the fellow.

Evaluation:

  1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
  2. The fellow’s progress will be reviewed verbally at mid-rotation.
  3. A standard fellow evaluation form will be completed by the VAMC attending cardiologists who worked with the fellow during the course of the month at the end of the rotation.
  4. The final evaluation will be based on the fulfillment of the rotation objectives as determined by
    1. Personal observation during interaction with the fellow.
    2. Evidence of literature review related to individual patients seen in the consult clinic or related to the various procedures performed during the month.
    3. Evidence of a thorough and accurate patient history and physical examination for each consult patient seen in clinic and evidence of an appropriate directed history and physical examination for each patient referred for procedures requiring pre-procedure evaluation.
    4. Accuracy in interpretation of invasive and non-invasive tests for the consult patient, with good insight into the role of those test results in arriving at an appropriate differential diagnosis and treatment plan.
    5. Performance of the fellow in arriving at a broad, appropriate differential diagnosis, with focus on a most likely diagnosis.
    6. Use of literature and guidelines to develop appropriate treatment plans.
    7. Improved accuracy in interpretation of ECGs, stress ECGs, and TTEs.
    8. Progression of technical skills in performing TTEs and TEEs.
    9. Feedback from the support staff in the non-invasive, ECG lab and nurse managers.

VA Inpatient Cardiology

Purpose:

The purpose of this rotation is to provide broad exposure to the cardiology fellow to a wide variety of common and rare cardiovascular disorders in the inpatient setting. The fellow has primary responsibility for all patients referred to the service, under the supervision of one faculty member dedicated to this rotation.

The goals and objectives of this rotation are:

  1. to gain experience in providing cardiology consultation on inpatients, including providing prompt response, assessment of all clinical data (especially ECG monitoring), differential diagnosis, outlined evaluation and interpretation of evaluations, and follow-up of prescribed therapies.
  2. to work closely with the assigned cardiology staff, which provides opportunity for detailed discussion of treatment plans and demonstration of characteristics and qualities to deliver quality care.
  3. to develop proficiency in inpatient consultative cardiology including pre-operative and peri-operative evaluation.
  4. to develop proficiency in intensive care consultation on critically ill cardiac patients utilizing invasive and non-invasive tests and interventions.
  5. to encourage and develop humanistic care of inpatients

The structure and purpose of the consult service is similar to the UIHC consult service except that medical students may pursue a cardiology elective rotation and may occasionally participate as members of the cardiology consult team. The VA inpatient fellow is responsible for reviewing all cardiac tests requested on the patients including ECG, Holter monitor studies, nuclear and echo studies, interrogating pacemakers and reviewing invasive studies such as cardiac catheterization. The cardiology fellow on this rotation serves as a cardiology consultant to patients admitted to the intensive care unit and to other medical and surgical services. The critical care staff physician serves as the primary physician for patients in the intensive care unit at the VA medical center. However, all cardiology consultations are reviewed with the assigned cardiology staff physician whose has the final authority for all recommendations made by the cardiology consult service.

Responsibility / Specific Duties:

The VA inpatient fellow is responsible for all inpatient and Urgent Care Clinic cardiology consults between 8:00 am and 5:00 PM Monday through Fridays. If there is an ICU patient on the service or floor patients with active cardiac problems, the fellow should come in on one of the weekend days to round on that patient. Usually, it suffices for the VA inpatient fellow to come in on one of the weekend days after deciding with the VA staff. The VA fellow is required to take at least one day of the weekend off every week. The VA inpatient fellow is expected to evaluate any urgent consult as soon as possible. This includes performing a history and physical examination and reviewing all diagnostic test results, laboratory data, and progress notes. The fellow then formulates a differential diagnosis and treatment plan and offers any urgent recommendations immediately. The fellow presents the urgent consultation to the attending cardiologist as soon as is necessary for optimal patient care.

All consultations on patients in the Intensive Care Unit or wards must be reviewed with a staff cardiologist. This interaction should be documented by entering the staff physician’s name as the supervising physician and naming the staff as a cosigner on the note. In most cases, patients should be discussed with the designated consultation cardiology staff, but may, at the discretion of the fellow/general cardiology staff physician be discussed with the cardiac catheterization staff, electrophysiology service staff or other cardiology staff with particular expertise depending on the nature of the problem. Daily follow up of inpatients should continue as long as the patient’s cardiology problem is active. Daily review of Consult Service patients with the designated staff is expected. Night (5:00 PM to 8:00 AM) hours and weekend coverage of the inpatient service will be provided by the F1 call fellow. Patients that require follow up on the weekend or are unstable should be indicated to the fellow on F1 call. Cardiology consultation for VA patients on other services will also be provided by the Fellow (F1) on call after 5pm. The fellow is encouraged to participate in the VA daily ICU rounds (at 8am) conducted by a critical care MICU staff physician. The fellow is expected to be available for all ICU procedures for cardiology patients and those on the neurology team, internal medicine team and, if requested, the surgical team. The fellow may participate in the procedure (including insertion of temporary pacemakers and Swan-Ganz catheters, electrical cardioversions, etc.).The fellow is expected to read half of all VA EKG’s daily. Holter monitor studies are to be read by the VA outpatient fellow. The fellow is expected to meet with the Cardiology staff daily for review of patients and clinical teaching. Requests for inter-hospital patient transfers may be evaluated by the fellow, but acceptance of a patient in transfer must be done only by the Medical Officer of the Day (MOD). Eligibility for VA care should be verified through the admitting MOD and AOD before elective patient transfer. The inpatient fellow maybe requested to assist the outpatient fellow as needed. Concerns regarding VA Cardiology services should be discussed with the chief of cardiology service at the VA and the fellowship program director.

Supervision:

All cardiac consultations are reviewed in detail with the supervising cardiologist with attention to patient and diagnosis-based teaching of the fellow. In addition to clinical review, the attending cardiologist reviews the progress of the fellow in providing appropriate communication and collaboration with the requesting service. This most importantly includes review of the written consultation documented in the chart. The fellow’s teaching and learning skills are reviewed on rounds and constructive suggestions are made. The attending cardiologist reviews cardiac invasive and non-invasive tests on cardiac consult patients with the fellow on attending rounds.

Learning Objectives:

  1. Obtain training in the concepts and practice of effective inpatient cardiac consultation. This includes:< >Improving skills for acquiring a detailed and accurate history and physical examination. (A, B)Improving skills for insightful review of laboratory data. (A, B)Obtain training in review of noninvasive and invasive cardiac tests and incorporation of the test results into the context of the patient’s cardiac presentation. (A, B)Obtain training in placing the cardiac findings in the patient’s overall medical context. (A)Obtain training in formulation of a broad differential diagnosis with focus on the most likely diagnosis. (A, B)Obtain training in formulation of an effective treatment plan. (A, B)Gain experience in providing support of the proposed diagnosis and treatment plan by citation of relevant clinical studies and guidelines. (B, C)Gain experience in effective communication and interaction with referring physicians. (D, E)Obtain training in organizing a consultative service, including effective prioritization based on acuity of patients’ clinical problems. (A)
  2. Gain exposure to a broad range of cardiac conditions through individual patient consultations, supplemental reading, and formal didactic presentations on rounds. (A, B)
  3. Gain training in guideline-based preoperative cardiac risk assessment and effective preoperative risk reduction. (A, B, C)
  4. Learn to assist physicians on other services in the management of cardiac emergencies. (D, E, F)

Level Specific Goals and Objectives:

Junior Fellows (first year fellows)

Every patient will be staffed with the faculty in a timely fashion. The faculty will then review the history and physical findings with the fellow as well as any pertinent laboratory studies. The fellow will then formulate a plan and generate a note in the medical record. These findings will then be communicated with the patient and health care team.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

Teaching Methods:

Teaching by the attending cardiologist occurs daily on attending rounds and is supplemented as needed for urgent consultations. The attending physician reviews the detailed consult presentations prepared by the fellow. The attending cardiologist provides constructive suggestions for acquisition of additional relevant clinical information, alternate interpretations of the data presented, recommendations for additional diagnostic considerations, and additional treatment considerations. The attending cardiologist reviews noninvasive and invasive studies with the fellow, including ECGs. The attending cardiologist provides bedside teaching of clinical history and cardiac examination skills.

Evaluation:

  1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
  2. The fellow’s progress will be reviewed verbally at mid-rotation.
  3. A standard electronic fellow evaluation form will be completed by the attending cardiologist at the end of the rotation.
  4. The attending cardiologist’s final evaluation will be based on the fulfillment of the rotation objectives as determined by:
    1. Personal observation during interaction with the fellow.
    2. Evidence of literature review related to the individual consult patient.
    3. Evidence of a thorough and accurate patient history and physical examination for each consult.
    4. Accuracy in interpretation of invasive and non-invasive tests for the consult patient, with good insight into the role of those test results in arriving at an appropriate differential diagnosis and treatment plan.
    5. Performance of the fellow in arrival at a broad, appropriate differential diagnosis, with focus on a most likely diagnosis.
    6. Use of literature and guidelines to develop appropriate treatment plans.
    7. Improved accuracy in interpretation of electrocardiograms.
    8. Evidence of effective written and oral communication with referring physicians.
    9. Evidence of effective patient follow-up following initial consultation.
    10. Feedback from other consult team members and referring physicians.

VA Cardiac Catheterization Laboratory

Purpose:

The purpose of the rotation is to gain an understanding of coronary anatomy and hemodynamics and to acquire the technical, cognitive and motor skills required to gain venous and arterial access and to perform coronary angiography.

 The trainee will develop and be expected to demonstrate expertise in the following aspects related to the procedure including:

  1. Understanding the appropriateness of procedure. The trainee should understand the indications for right and left heart catheterization, right ventricular endocardial biopsy, and be able to estimate the risk and benefit of procedures performed. Knowledge of co-morbid factors that increase the risk of a procedure should be demonstrated.
  2. Obtaining informed consent. The trainees should communicate the risk and benefits of a procedure in a manner that is understood by the patient and address questions raised by the patient. In situations where the patient cannot give informed consent, the trainee should obtain consent from appropriate sources.
  3. Administering anesthesia. The trainee should demonstrate knowledge of the pharmacology of medications used for conscious sedation, contraindications for their use, side effects, and the treatment of side effects. The trainee should develop the skills to make the patient comfortable during an examination, follow the degree of sedation, and recognize and treat complications. The trainee should develop skills in obtaining vascular access to the internal jugular, subclavian and femoral veins as well as the femoral artery and brachial artery.
  4. Coronary angiography and ventriculography. The trainee should develop skill in the injection of contrast material for angiography; recognize the potential complications of the use of x-ray contrast material. The trainee should develop a high level of competence in the interpretation of hemodynamic data and angiographic data.
  5. Pericardiocentesis. The trainee should be able to understand the indications and potential risks of cardiac pericardiocentesis. He should demonstrate skill in performing the procedure.
  6. Evaluating and treating complications. The trainee should have full knowledge of the potential complications of the procedures of diagnostic catheterization, the mechanisms for monitoring complications when suspected, and full knowledge of the appropriate treatment of these complications.
  7. Right ventricular endocardial biopsy. The trainee should have full understanding of the indications for diagnostic endocardial biopsy and should have skill in performing this procedure both from the internal jugular and femoral venous approach. The trainee should have understanding of the potential complications and be prepared for emergent pericardiocentesis should complications arise.

Responsibility/Specific Duties:

During the first two years of training the fellow will aim to acquire the cognitive and motor skills to perform left and right heart catheterization. A minimum of six months is dedicated to this area, four at UIHC and two at the VA. In addition, during the two months of inpatient CVICU rotations, the CVICU fellow will participate in invasive procedures on patients admitted or transferred to the CVICU. All procedures are performed under the direct supervision of an attending. The fellow is also expected to learn the indications for coronary intervention and post-intervention management. Fellows with an interest in interventional cardiology will be offered advanced training in this field. Overall, the cardiac catheterization laboratory experience will prepare most fellows for level 2 certification (8 months cardiac catheterization laboratory experience and at least 300 invasive diagnostic procedures).

Duties and responsibilities include the following:

  1. The fellow will evaluate all outpatients referred for cardiac catheterization. The fellow will see all inpatients referred for cardiac catheterization on the ward or unit to which the patient is admitted.
  2. The fellow will evaluate each patient prior to performing any invasive procedure. This evaluation will include reviewing all pertinent paperwork (H&P, labs, non-invasive studies, etc), perform a focused physical exam, ensure informed consent properly obtained, and answer any questions from the patient or family members.
  3. The fellow will discuss cases with the cath lab attending.
  4. The fellow will arrive at least 30 minutes before the first scheduled case in order to greet the first patient and review any outstanding lab data or answer any last minute questions.
  5. The fellow will perform all cath lab procedures under the supervision of the cath lab attending physician.
  6. The fellow will complete the post-procedure paperwork (post-cath orders, brief note for chart, dictate the formal cath report, etc).
  7. The fellow will call the house staff with results and to discuss any pertinent management issues and will inform the appropriate inpatient or outpatient cardiology fellow or physician assistant of any complication or complicated management issues.
  8. The fellow will see all outpatients in the Cath Lab recovery area prior to discharge to perform a post-procedure groin check, review results, and answer any questions. Post-cath inpatients must be seen by the end of the procedure day for a post-procedure groin check.
  9. The fellow will prepare a case for presentation at the weekly Cath Conference.
  10. The fellow may assist the interventional staff with PCI cases if needed.
  11. The fellow will maintain a complete and accurate log of all procedures performed.
  12. The fellow will screen all outpatient referrals for cardiac catheterization and enter orders for the procedure if appropriate.

Supervision:

The fellow will review all cases with the cath lab attending prior to performing any procedure. All invasive cardiac procedures will be performed under the direct supervision of an invasive or interventional attending cardiologist.

Learning Objectives:

  1. Learn the indications and contraindications of cath lab procedures. (B)
  2. Learn to recognize and treat immediate cath lab complications. (A, B)
  3. Become proficient in the technical aspects of coronary and peripheral angiography, right and left heart catheterization, pericardiocentesis, and temporary pacemaker placement. (B)
  4. Learn the indications for and gain exposure to coronary PTCA and stenting. (B)
  5. Learn and understand the protocols for correct performance and interpretation of invasive hemodynamic studies, including dobutamine valve studies, intracardiac shunt assessment, pericardial tamponade, and restrictive versus constrictive physiology. (B)
  6. Learn proper radiation safety. (B)
  7. Develop an academic approach to the proper utilization of invasive cardiac testing. (A, B, C)
  8. Gain an appreciation for the role of the Cath Lab staff members, including the technicians, nurses, and administrative staff. (D, E, F)
  9. Progress toward the specific training requirements for the desired level of certification as outlined by COCATS 3. (B) 
    < >It is important to emphasize that the actual number of procedures required to accomplish clinical competence in cardiac catheterization is somewhat arbitrary, because there is individual variation in cognitive, analytical, and manual-dexterity skills. The listed numbers are therefore the minimum requirements anticipated to properly train the average cardiology fellow, and individual fellows may be required to perform additional procedures as determined by the Cath Lab supervising physician.Minimum training standards for cardiac catheterization are as follows:Training LevelCumulative DurationCumulative Number of Cases PerformedI4100II6
    300

    Patient Characteristics / Mix of Diseases / Types of Clinical Encounters:

    At the VAMC, the patient population that presents for cath lab procedures consists mostly of adult males from various ethnic and socioeconomic backgrounds. Patients presenting to the Cath Lab for procedures have a variety of cardiac disorders, including coronary artery disease, valvular heart disease, congestive heart failure, and pericardial disease. Clinical encounters include pre-procedure evaluations in the ambulatory surgery unit and on the inpatient wards, performing the requested procedure, and providing any immediate post-procedure follow-up. Procedures performed include left and right heart catheterization, coronary and peripheral angiography, percutaneous peripheral and coronary intervention, pericardiocentesis, and temporary pacemaker placement.

    Teaching Methods:

    The fellow will review each patient’s history and planned procedure with the attending. The attending will supervise the fellow during the procedure, and the fellow will assume progressive levels of responsibility as his or her skill level improves. The attending will review all procedure data with the fellow after the procedure is completed.

    Evaluation:

    1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
    2. The fellow’s progress will be reviewed verbally mid-rotation.
    3. A standard fellow evaluation form will be completed by the attending at the end of the rotation.
    4. The final evaluation by the supervising physician will be based on the fulfillment of the rotation objectives as determined by: 
      a. Personal observation during interaction with the fellow while performing Cath Lab procedures.
      b. Evidence of literature reviews appropriate for the individual patient and topic.
      c. Evidence of ability to perform appropriate pre-procedure evaluation.
      d. Evidence of ability to properly select patients for testing.
      e. Competent performance of cardiac procedures relative to the fellow’s level of training.
      f. Correct interpretation of procedure data obtained.Evidence of ability to provide appropriate post-procedure care.
      g. Feedback from Cath Lab staff members, other healthcare providers, and patients.www.cardiosource.com

Resources:

University of Iowa Hardin Medical Library (Medline, Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)

www.cardiosource.com

Baim and Grossman’s Cardiac Catheterization, Angiography, and Intervention (7th edition)

Kern’s The Cardiac Catheterization Handbook (4th edition)

UI Hospitals & Clinics Cardiology Consults

Purpose:

This rotation provides broad exposure to a wide variety of clinical disorders in cardiology. The purpose of this rotation is to expose the fellow to cardiology problems encountered in a tertiary care hospital, which includes complex cardiology problems on the medical services, as well as exposure to the cardiology problems which may arise in surgical, gynecologic, psychiatric, neurologic patients and cardiac illnesses in pregnancy as well as patients presenting to the emergency room. The fellow is expected to develop expertise in preoperative evaluation and perioperative cardiac management. Consultative services are provided for all clinical services at UI Hospitals & Clinics with the exception of pediatrics. The fellow has primary responsibility for all patients referred to the service, under the supervision of the faculty. When a medical resident or residents are assigned to this service, the resident assists the fellow and will be primarily responsible for a subgroup of patients on the service. The fellow will supervise the medical resident in this capacity and report directly to the attending. The attending will make rounds daily with all members of the consult team (fellow, medical residents, and students). Thus, during this rotation, the cardiology fellow is expected to acquire skills related to the clinical management of complex cardiology problems, as well as develop supervisory and teaching skills in the context of working with medical residents or students. It is further expected that the fellow’s skills will progress over time and during subsequent rotations on this service.

Responsibilities/Specific Duties:

The fellow is expected to be involved with all patients on the UI Hospitals & Clinics Inpatient Consult Service and chest pain center patients admitted by the ER physicians. The fellow will see consults with the residents and medical students on the team and discuss patients with the consult attending physician. For non-urgent consultations, the fellow assigns the initial consult workup to a resident or student on the UI Hospitals & Clinics Consult Service. Relative to the resident, the fellow then reviews the initial consultation workup with the resident, takes a focused history and physical examination, reviews all diagnostic tests, laboratory data, and progress notes, and assists, if needed, in the presentation of the consult patient to the attending cardiologist on daily rounds. For the student, the complete history and physical examination are completed either by the fellow or by the resident with review as above by the fellow. The fellow performs the evaluation of patients for whom the consult is urgent. This includes a history and physical examination, review of diagnostic test results, laboratory data, and progress notes. The fellow formulates a differential diagnosis and treatment plan. The fellow presents the urgent consultation to the attending cardiologist as soon as possible, or if appropriate, on daily consultation rounds. The fellow assists with teaching for residents and students on the UI Hospitals & Clinics Consult Service. This typically consists of providing information related to individual consult patients and participation in teaching on daily attending rounds. In addition, the fellow participates in the presentation of didactic core cardiology topics that are required for the residents and students on the UI Hospitals & Clinics Consult Service. In general, the fellow will alternate with the resident in terms of initial evaluation of all consults. When the resident is unavailable (e.g. in clinic), the fellow will evaluate all consults patients. In general, all consults will be seen and staffed on the same day the consult is called. The fellow is expected to evaluate all on the patients seen by the consult team. UI Hospitals & Clinics consult fellow and staff physician provide consultation for Emergency Room chest pain unit. These patients are staffed with the UI Hospitals & Clinics consult staff. Usually, patients admitted to the CP unit need not be examined the same night if you are called after 10pm unless the ER physicians specifically request a consultation. These patients are to be seen early the next morning. Weekend CP patients treadmill coverage is provided by CHAMPS (cardiac rehabilitation service). The Consult Fellow must communicate with the F1 fellow on call the previous night to determine if there are any pending consults or patients requiring immediate follow-up. Similarly, the Consult Fellow must call the F1 fellow taking call after 5pm and review any critically ill patients that may require follow up consultation over night. Weekend cardiology consult coverage is provided by the on-call cardiology fellow. The staff physician coverage for the UI Hospitals & Clinics consult service on the weekend is provided by the cardiology staff on the attending directed service.

Supervision:

  1. All cardiac consultations are reviewed in detail with the attending cardiologist with attention to patient and diagnosis based teaching of the fellow.
  2. In addition to clinical review, the attending cardiologist reviews the progress of the fellow in providing appropriate communication and collaboration with the requesting service.
  3. The attending cardiologist provides teaching of electrocardiographic interpretation.
  4. The fellow’s teaching and learning skills are reviewed on rounds and constructive suggestions are made.
  5. The attending cardiologist reviews cardiac invasive and non-invasive tests on cardiac consult patients with the fellow and other team members on attending rounds.

Learning Objectives:

  1. Obtain training in the concepts and practice of effective cardiac consultation. This includes:< >Improving skills for acquiring a detailed and accurate history and physical examination. (A, B)Improving skills for insightful review of laboratory data. (A, B)Obtain training in review of noninvasive and invasive cardiac tests and incorporation of the test results into the context of the patient’s cardiac presentation. (A, B)Obtain training in placing the cardiac findings in the patient’s overall medical context. (A, B)Obtain training in formulation of a broad differential diagnosis with focus on the most likely diagnosis. (A, B)Obtain training in formulation of an effective treatment plan. (A, B)Gain experience in providing support of the proposed diagnosis and treatment plan by citation of relevant clinical studies and guidelines. (B, C)Gain experience in effective communication and interaction with referring physicians. (D, E, F)Obtain training in electrocardiographic interpretation. (B)
  2. Obtain training in organizing a consultative service, including effective prioritization based on acuity of patients’ clinical problems. (A, B, C)
  3. Gain exposure to a broad range of cardiac conditions through individual patient consultations, supplemental reading, and formal didactic presentations on rounds. (A, B)
  4. Gain training in guideline-based preoperative cardiac risk assessment and effective preoperative risk reduction. (B, C)
  5. Learn to assist physicians on other services in the management of cardiac emergencies. (D, E, F)
  6. Gain experience in proper coding and billing. (E, F)

Level Specific Goals and Objectives:

Junior Fellows (first year fellows)

Every patient will be staffed with the faculty in a timely fashion. The faculty will then review the history and physical findings with the fellow as well as any pertinent laboratory studies. The fellow will then formulate a plan and generate a note in the medical record. These findings will then be communicated with the patient and health care team.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:

Training occurs at University of Iowa Hospitals & Clinics. The patient population includes men and women of all adult ages and of varied ethnic and socioeconomic background. The population includes patients from a primary care base and tertiary referral patients and emergency room patients. Special populations include patients with transplanted organs, acute and chronic neurologic disease, surgical patients, and patients in intensive care units. Clinical encounters consist of inpatient cardiac consultations. Consultations often are for diagnosis and management of chest pain, unexplained dyspnea, dysrhythmias or syncope, and for preoperative cardiac risk evaluation or perioperative cardiac management. Initial consultation and inpatient follow-up are included.

Teaching Methods:

Teaching by the attending cardiologist occurs daily on attending rounds and is supplemented as needed for urgent consultations. The attending physician reviews the detailed consult presentations prepared by the fellow, as well as the presentations by residents or students that have been directed by the fellow. The attending cardiologist provides constructive suggestions for acquisition of additional relevant clinical information, alternate interpretations of the data presented, recommendations for additional diagnostic considerations, and additional treatment considerations. The attending cardiologist reviews noninvasive and invasive studies with the fellow. The attending physician reviews electrocardiograms interpreted by the fellow and provides appropriate feedback for the accurate interpretation of ECG. The attending cardiologist provides bedside teaching of clinical history and cardiac examination skills. In addition to didactic teaching on rounds, the attending cardiologist may assign didactic talks and literature review to the house staff and students to assure that a broad range of cardiac topics are reviewed during the course of the rotation.

Evaluation:

  1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
  2. The fellow’s progress will be reviewed verbally at mid-rotation.
  3. A standard electronic fellow evaluation form will be completed by the attending cardiologist at the end of the rotation.
  4. The attending cardiologist’s final evaluation will be based on the fulfillment of the rotation objectives as determined by:< >Personal observation during interaction with the fellow.Evidence of literature review related to the individual consult patient.Evidence of a thorough and accurate patient history and physical examination for each consult.Accuracy in interpretation of invasive and non-invasive tests for the consult patient, with good insight into the role of those test results in arriving at an appropriate differential diagnosis and treatment plan.Performance of the fellow in arrival at a broad, appropriate differential diagnosis, with focus on a most likely diagnosis.Use of literature and guidelines to develop appropriate treatment plans.Improved accuracy in interpretation of electrocardiograms.Evidence of effective written and oral communication with referring physicians.Evidence of effective teaching of residents and students.Evidence of effective patient follow-up following initial consultation.Feedback from other consult team members and referring physicians.University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
  5. Chou’s Electrocardiography in Clinical Practice (6th edition) Surawicz B and Knilans T
  6. Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
  7. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation - Executive Summary (Circulation. 2006; 114:700-752.)
  8. ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy; JACC Vol. 47, 2006
  9. Perioperative Practice: Time to Throttle Back; Annals of Internal Medicine 152:47-51, January 5, 2010.
  10. www.cardiosource.com

UI Hospitals & Clinics CVICU

Purpose:

The overall purpose of the CVICU rotation is to provide trainees with a comprehensive training experience in the evaluation and management of common cardiac disorders as well as training experience in evaluation and management of other life threatening illnesses that may present with cardiovascular manifestation. This intensive training experience is designed to expose the trainee to both acute presentations of cardiac dysfunction and ensure that the fellow acquires the necessary clinical and procedural skills to care for cardiac disorders routinely encountered in the practice of cardiology. Each cardiology fellow will rotate on the CVICU service for two months during the course of their fellowship. On this rotation, the fellow will learn how to evaluate and manage patients with acute coronary syndromes, including cardiac arrest and cardiogenic shock, cardiac dysrhythmias, congestive heart failure, valvular heart disease, myocardial and pericardial heart disease, and aortic and hypertensive emergencies.Fellows will be introduced to and become proficient in the performance and interpretation of a number of cardiac procedures including, but not limited to, pulmonary artery catheter placement, temporary venous pacemaker insertion, intra-aortic balloon pumps management, and elective cardioversion. Review and integration of laboratory, radiographic, hemodynamic, and cardiac diagnostic studies will be emphasized during this clinical rotation. During this rotation the development of a strong mentoring relationship with clinical faculty is developed and emphasizes leadership skills for managing a healthcare team.

Responsibility/Specific Duties:

In the CVICU, medical residents are primarily responsible for all patients. The fellow is responsible for supervising the house-staff teams assigned to the CVICU and assists in the management of the CVICU patients. The fellow is responsible for those patients admitted to the CVICU who are admitted under the care of the cardiology faculty physician. The CVICU fellow will coordinate management of such patients under the direction of that faculty member. A dedicated CVICU attending physician will oversee all aspects of the fellow’s duties and will make twice daily rounds with the fellow. Teaching rounds are held daily with all members of the CVICU team. The fellow will pre-round on any critically ill patients and discuss significant patient management issues from overnight with the post-call team. The fellow will actively assist the house staff with management of critically ill patients and will be readily available to answer any questions regarding patient management throughout the day. The fellow, together with the attending, will be jointly responsible for core curriculum teaching as required for the education of the house staff. This will include didactic lectures as well as daily teaching on patient care related issues. The fellow will supervise the performance of all invasive procedures performed by house staff on cardiology inpatients in the CVICU. Weeknight and weekend call responsibilities are outlined in the section on call. All critically ill patients and any issues that need follow-up overnight will be checked out in a detailed manner to the on-call fellow. It is the responsibility of the CVICU to be intimately involved in the management of the CVICU patients. The CVICU fellow should be aware at all times of the status and treatment plan of these patients. The CVICU fellow should also be aware of the status and plan for the CHF/TXP service patients, although most of the fellow responsibilities for these patients will fall to the CHF/TXP fellow.

Supervision:

The attending physician, fellow, and house staff will provide a team-based, patient-centered approach toward patient care and teaching as it relates to the etiology, pathogenesis, clinical presentation, natural history, and treatment of the various general cardiac disorders seen on this service. The fellow will be responsible for the day to day management of the CVICU as set forth during daily morning rounds. The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, and review and confirm the fellow’s notes. As appropriate, the attending will review and supplement the fellow’s teaching of the other members of the team. The attending may assign readings or other learning activities as necessary. The attending will supervise the fellow during invasive procedures based on the level of the fellow’s skills.

Learning Objectives:

  1. Obtain comprehensive training in inpatient management of cardiac disorders including: acute myocardial infarction and acute coronary syndromes, cardiac dysrhythmias including all forms of conduction block, acute and chronic congestive heart failure, valvular heart disease, myocardial and pericardial disease, and adult congenital cardiac disease. Additionally, acute aortic syndromes, hypertensive emergencies, pulmonary hypertension, peripheral and extracranial cerebrovascular disease are commonly managed on this service. (A, B)
  2. Evaluate patients in the CVICU who may have cardiac disorders by taking a thorough problem-directed history, performing a careful physical examination, and generating a differential diagnosis and plan of care. (A, B, F)
  3. Gain basic understanding of the indications, use limitations, and complications of cardiac diagnostic studies. (A, B)
  4. Gain basic training and experience in the use of pharmacologic and non-pharmacologic options for treating acute and chronic coronary ischemic syndromes, CHF, dysrhythmias, cardiogenic shock, valvular heart disease, adult congenital heart disease, peripheral vascular disease, and extracranial cerebrovascular disease. (A, B)
  5. Understand the indications, risks, and benefits of thrombolytic therapy, diagnostic cardiac catheterization, PCI, CABG, valve surgery, percutaneous valvuloplasty, cardiac pacemakers, ICDs, resynchronization devices, IABPs, pulmonary artery catheters, elective cardioversion, PFO/ASD closure, peripheral vascular stenting, and carotid stenting. (A, B)
  6. Learn when to request appropriate cardiology subspecialty, vascular surgery, and cardiothoracic surgery consultation. (B, F)
  7. Learn to recognize and manage cardiac emergencies. (A, B)
  8. Explain the etiology, pathogenesis, clinical presentation, and natural history of major cardiac disorders including MI, CHF, atrial and ventricular dysrhythmias, heart block, hypertensive emergencies, acute aortic emergencies, acute and chronic myocardial and pericardial disease states. (A, B)
  9. Practice integrative, patient-centered, team-based medical care, incorporating evidenced based therapies and “best practices,” as outlined by ACC and AHA practice guidelines. (A, B, C, F)
  10. Review all cardiac studies directly related to patient care activities to increase learning opportunities and enhance clinical and integrative skill sets. (A, B)
  11. Gain an appreciation for the role of the ancillary staff members, including the nurses, clerical staff, lab and x-ray technicians, pharmacy staff, social workers, and chaplains. (D, E, F)

Level Specific Goals and Objectives:

Junior Fellows (first year fellows)

Every cardiovascular patient in the CVICU will be primarily managed by the fellow with close faculty supervision as part of a team with internal medicine residents. The fellows will initially assess patients admitted to the service. The faculty will review the history and physical findings with the team as well as any pertinent laboratory studies. The team will then formulate a plan with the faculty. The fellow will perform any necessary procedures in the care of the patient (arterial lines, central venous access, bedside echocardiograms, cardioversions, intubations). The fellow may also be involved in procedures performed in the catheterization lab.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:

Training occurs at University of Iowa Hospitals & Clinics and provides a wide range of pathology and a diverse patient population. Both men of women of all adult ages and of various ethnic backgrounds are seen. Clinical encounters are primarily centered on evaluations of critically ill patients in the emergency room, other inpatient units and patient transferred from community hospitals to the CVICU. Performance of invasive procedures is common and includes hemodynamic monitoring catheters (pulmonary artery catheters, arterial lines, and central venous lines), intra-aortic balloon pumps, temporary venous pacemakers, elective and emergent cardioversions, and intubations.

Teaching Methods:

The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, review and confirm the fellow’s notes, and review and supplement the fellow’s teaching of other members of the team. The attending may assign readings or other learning activities. The attending will supervise the fellow in the performance of procedures. The fellow will assume progressive levels of responsibility for patient care and procedure performance under the supervision of the attending.

Evaluation:

  1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
  2. The fellow’s progress will be reviewed verbally mid-rotation.
  3. A standard fellow evaluation form will be completed by the supervising physician at the end of the rotation.
  4. The final evaluation will be based on the fulfillment of the rotation objectives as determined by:< >Personal observation during interaction with the fellow.Evidence of extensive literature reviews appropriate for the individual patient and topic.Ability to construct a logical management plan.Inclusion of appropriate physical examination.Appropriateness of use of diagnostic tests.Correct interpretation of diagnostic tests.Appropriate selection of pharmacologic and non-pharmacologic therapies.Competent performance of cardiac procedures relative to the fellow’s level of training.Appropriate follow-up.Feedback from other team members, other healthcare providers, and patients.University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
  5. www.cardiosource.com
  6. Heart Disease: A Textbook of Cardiovascular Medicine (9th ed) Eugene Braunwald, editor

UI Hospitals & Clinics Cardiomyopathy / Heart Failure / Transplant

Purpose:

The overall purpose of the Cardiomyopathy, Heart Failure and Transplant rotation is to provide trainees with extensive experience in the diagnosis and management of patients with acute and chronic congestive heart failure and to provide an introductory experience to cardiac transplantation.

Each cardiology fellow will rotate on this service for 2 months during the course of their fellowship. On this rotation, the fellow will learn how to evaluate and manage patients with heart failure related disorders in both the inpatient and outpatient setting. The fellow will also be introduced to the performance of common procedures performed on heart failure and cardiac transplant patients, such as right heart catheterization and RV biopsy.

Responsibilities/Specific Duties:

The overall duties and responsibilities on this rotation include:

  1. Primary: Manage a busy inpatient care team under the supervision of the cardiomyopathy, transplant faculty; complete inpatient consultations with faculty oversight and teach medical students and residents on the clinical rotation.
  2. Secondary: Perform central line placement, pulmonary artery catheterization, vasodilator challenge, and endomyocardial biopsy; manage heart failure and pulmonary hypertension in an outpatient clinic setting; participate in clinical trial enrollment and subject treatment; participate in review of cardiac biopsies; supervise and interpret Cardiopulmonary Exercise Tests and again gain familiarity with ultrafiltration.
    Training will include predominantly in the inpatient setting on the inpatient heart failure/ transplant service. Fellows will also perform outpatient invasive procedures and evaluate patients in the heart failure clinic under the direct supervision of the attending on the heart failure/transplant service.

The fellow is the point of contact for the Congestive Heart Failure/Transplant service at UIHC Monday through Friday from 8 am to 5 pm and on every other weekend. The CHF/TXP fellow will also be responsible for the management of all CHF/TXP patients admitted to the CCU service. On weekends, the CHF/TXP patients are seen by the cardiology fellow on service. The fellow receives and reviews all Congestive Heart Failure/Transplant inpatients in the ICU and on the inpatient service (non intensive care unit) from other services, performs the initial evaluation, reviews all pertinent laboratory data and related test results, develops an initial management strategy, presents the patient to the Congestive Heart Failure/Transplant attending, The fellow will work closely with the Internal Medicine residents or others involved in the care of CHF/TXP patients. The fellow will teach and supervise these team members and assist them in patient presentation. The fellow will conduct daily rounds on all Congestive Heart Failure/Transplant inpatients and will review each patient with the Congestive Heart Failure/Transplant attending physician during the morning rounds. The fellow will attend Congestive Heart Failure/Transplant Meetings. The fellow will assist the Congestive Heart Failure/Transplant attending during procedures performed in the Cath Lab or on the wards and will progress to higher levels of participation as the fellow’s skill level allows. Fellows will participate in cardio-pulmonary exercise testing and receive training to develop expertise in physical rehabilitation for patients with heart failure. The fellow will communicate the patient’s study information to the house staff post-procedure, write a procedure note, and do the appropriate post-procedure checks (x-ray, operative site, labs, etc).

Supervision:

The staff physician and fellow will care for patients as a team to facilitate patient care and teaching as it relates to the etiology, pathogenesis, clinical presentation, natural history, and the treatments of the various Congestive Heart Failure/Transplant disorders seen. The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, and review and supplement the fellow’s teaching of other members of the team. The attending may assign readings or other learning activities as necessary. The attending will supervise the fellow during invasive procedures based on the level of the fellow’s skills.

Objectives:

The objectives of this rotation are as follows:

  1. Learn to diagnose and treat acute, decompensated heart failure and cardiogenic shock; chronic heart failure decompensation in patients with both systolic and diastolic heart failure; decompensated pulmonary hypertension; common complications of heart transplantation; common complications of ventricular assist device insertion (A, B)
  2. Understand the indications and contraindications for the following advanced heart failure and pulmonary hypertension therapies including biventricular pacing; cardiac transplantation; ventricular assist device implantation; pulmonary vasodilators; lung and heart-lung transplantation (A, B)
  3. Improve general inpatient management skills in critical care, telemetry, and consultation settings by developing critical thinking and clinical analysis; developing a comprehensive approach to diagnosis; practicing evidenced based medicine and to develop procedural skills in right heart catheterizations, placement of central venous lines and peripheral arterial lines. (A, B, F)
  4. Learn to appreciate and use a multidisciplinary team in the treatment of cardiomyopathy and pulmonary hypertension by overseeing residents and work with an integrated care team of doctors, nurses (team and floor), nurse practitioners, nutritionists, social workers, pharmacists (A, D, E, F)
  5. Learn common outpatient management strategies and treatment guidelines for heart failure and pulmonary hypertension (A, B)
  6. Become knowledgeable of and participate in clinical trials (A, B, C)
  7. Understand the salient features of allograft rejection, myocarditis, infection, and other pathology on cardiac biopsies (A, B)
  8. Develop teaching skills via didactic and clinical opportunities with residents and students by encourage critical thinking and clinical analysis; encouraging a comprehensive approach to diagnosis and encouraging evidenced based thinking (C, D, E, F)
  9. Fellows who desire additional training in management of cardiomyopathy and cardiac transplantation may spend an additional year to acquire the necessary clinical skill and develop investigative research skills (A, B)
  10. Become familiar with the current medical literature as it relates to CHF and cardiac transplantation to help facilitate the practice of evidence-based management of CHF and post-transplant patients. (C)

Level Specific Goals and Objectives:

Junior Fellows (first year fellows)

Every patient on the CHF/TXP service will be primarily managed by the fellow with close faculty supervision as part of a team of hospitalists, nurse practitioners, and the CHF subspecialty fellow. The fellows will initially assess patients admitted to the service. The faculty will review the history and physical findings with the team as well as any pertinent laboratory studies. The team will then formulate a plan with the faculty. The fellow may also be involved in procedures performed in the catheterization lab (right heart catheterization, biopsies, coronary angiography).

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:

Training occurs at University of Iowa Hospitals & Clinics and provides experience in a wide range of cardiac pathology in a diverse patient population. Both men and women of all adult ages and of various ethnic backgrounds are seen. Clinical encounters include predominantly inpatient consultation, outpatient consultation in the heart failure clinic, and peri-procedural care. Both non-invasive and invasive procedures are performed, including the interpretation of ECGs, cardiopulmonary stress testing, right heart catheterization, and RV biopsy.

Teaching Methods:

The supervising physician will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, review and review and supplement the fellow’s teaching of other members of the team. The attending physician may assign readings or other learning activities. The attending will supervise the fellow in the performance of procedures. The fellow will assume progressive levels of responsibility for patient care and procedure performance under the supervision of the attending.

Evaluation:

  1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
  2. The fellow’s progress will be reviewed verbally mid-rotation.
  3. A standard fellow evaluation form will be completed by the attending at the end of the rotation.
  4. The final evaluation by the supervising physician will be based on the fulfillment of the rotation objectives as determined by:
    1. Personal observation during interaction with the fellow.
    2. Evidence of extensive literature reviews appropriate for the individual patient and topic.
    3. Ability to construct a logical management plan.
    4. Inclusion of appropriate physical examination.
    5. Appropriateness of use of diagnostic tests.
    6. Correct interpretation of diagnostic tests.
    7. Appropriate selection of pharmacologic and non-pharmacologic therapies.
    8. Competent performance of cardiac procedures relative to the fellow’s level of training.
    9. Appropriate follow-up.
    10. Feedback from other team members, other healthcare providers, and patients.

Resources:

  • University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
  • www.cardiosource.com
  • Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
  • www.hfsa.org

 

UI Hospitals & Clinics Cardiac Catheterization Laboratory

Purpose:

The purpose of the rotation is to gain an understanding of coronary anatomy and hemodynamics and to acquire the technical, cognitive and motor skills required to gain venous and arterial access and to perform coronary angiography.

The trainee will develop and be expected to demonstrate expertise in the following aspects related to the procedure including:

  1. Understanding the appropriateness of procedure. The trainee should understand the indications for right and left heart catheterization, right ventricular endocardial biopsy, and be able to estimate the risk and benefit of procedures performed. Knowledge of comorbid factors that increase the risk of a procedure should be demonstrated.
  2. Obtaining informed consent. The trainees should communicate the risk and benefits of a procedure in a manner that is understood by the patient and address questions raised by the patient. In situations where the patient cannot give informed consent, the trainee should obtain consent from appropriate sources.
  3. Administering anesthesia. The trainee should demonstrate knowledge of the pharmacology of medications used for conscious sedation, contraindications for their use, side effects, and the treatment of side effects. The trainee should develop the skills to make the patient comfortable during an examination, follow the degree of sedation, and recognize and treat complications. The trainee should develop skills in obtaining vascular access to the internal jugular, subclavian and femoral veins as well as the femoral artery and brachial artery.
  4. Coronary angiography and ventriculography. The trainee should develop skill in the injection of contrast material for angiography; recognize the potential complications of the use of x-ray contrast material. The trainee should develop a high level of competence in the interpretation of hemodynamic data and angiographic data.
  5. Pericardiocentesis. The trainee should be able to understand the indications and potential risks of cardiac pericardiocentesis. He should demonstrate skill in performing the procedure.
  6. Evaluating and treating complications. The trainee should have full knowledge of the potential complications of the procedures of diagnostic catheterization, the mechanisms for monitoring complications when suspected, and full knowledge of the appropriate treatment of these complications.
  7. Right ventricular endocardial biopsy. The trainee should have full understanding of the indications for diagnostic endocardial biopsy and should have skill in performing this procedure both from the internal jugular and femoral venous approach. The trainee should have understanding of the potential complications and be prepared for emergent pericardiocentesis should complications arise.

Responsibility/Specific Duties:

During the first two years of training the fellow will aim to acquire the cognitive and motor skills to perform left and right heart catheterization. A minimum of six months is dedicated to this area, four at University of Iowa Hospitals & Clinics and two at the VA. In addition during the two months of inpatient CVICU rotations, the CVICU fellow will participate in invasive procedures on patients admitted or transferred to the CVICU. All procedures are performed under the direct supervision of an attending. The fellow is also expected to learn the indications for coronary intervention and post-intervention management. Fellows with an interest in interventional cardiology will be offered advanced training in this field. Overall, the cardiac catheterization laboratory experience will prepare most fellows for level 2 certification (8 months cardiac catheterization laboratory experience and at least 300 invasive diagnostic procedures)
Duties and responsibilities include the following:

  1. The fellow will evaluate the inpatients or outpatients referred for cardiac catheterization and complete the pre-cath work up. The fellow will see all inpatients referred for cardiac catheterization on the ward or unit to which the patient is admitted.
  2. The fellow will evaluate each patient prior to performing any invasive procedure. This evaluation will include reviewing all pertinent paperwork (H&P, labs, non-invasive studies, etc), perform a focused physical exam, ensure informed consent properly obtained, and answer any questions from the patient or family members.
  3. The fellow will discuss cases with the cath lab attending
  4. The fellow will arrive at least 30 minutes before the first scheduled case in order to review any outstanding lab data or answer any last minute questions.
  5. The fellow will perform all cath lab procedures under the supervision of the cath lab attending physician
  6. The fellow will complete the post-procedure paperwork (post-cath orders, brief note for chart, dictate the formal cath report, etc).
  7. The fellow will call the house staff and the responsible cardiology fellow (on the consult, CVICU or CHF service) with results and to discuss any pertinent management issues or complications.
  8. The fellow will perform a post-procedure groin check, review results, and answer any questions that the patient or their family members may have related to the procedure. Post-cath inpatients must be seen by the end of the procedure day for a post-procedure groin check.
  9. The fellow will prepare a case for presentation at the weekly Cath Conference.
  10. The fellow may assist the interventional staff with PCI cases if needed.
  11. The fellow will maintain a complete and accurate log of all procedures performed.
  12. The fellow will screen all outpatient referrals for cardiac catheterization and enter orders for the procedure if appropriate.

Supervision:

The fellow will review all cases with the cath lab attending prior to performing any procedure. All invasive cardiac procedures will be performed under the direct supervision of an invasive or interventional attending cardiologist.

Learning Objectives:

  1. Learn the indications and contraindications of cath lab procedures. (B)
  2. Learn to recognize and treat immediate cath lab complications. (A, B)
  3. Become proficient in the technical aspects of coronary and peripheral angiography, right and left heart catheterization, pericardiocentesis, and temporary pacemaker placement. (B)
  4. Learn the indications for and gain exposure to coronary PTCA and stenting. (B)
  5. Learn and understand the protocols for correct performance and interpretation of invasive hemodynamic studies, including dobutamine valve studies, intracardiac shunt assessment, pericardial tamponade, and restrictive versus constrictive physiology. (B)
  6. earn proper radiation safety. (B)
  7. Develop an academic approach to the proper utilization of invasive cardiac testing. (A, B, C)
  8. Gain an appreciation for the role of the Cath Lab staff members, including the technicians, nurses, and administrative staff. (D, E, F)
  9. Progress toward the specific training requirements for the desired level of certification as outlined by COCATS 3. (B)

It is important to emphasize that the actual number of procedures required to accomplish clinical competence in cardiac catheterization is somewhat arbitrary, because there is individual variation in cognitive, analytical, and manual-dexterity skills. The listed numbers are therefore the minimum requirements anticipated to properly train the average cardiology fellow, and individual fellows may be required to perform additional procedures as determined by the Cath Lab supervising physician. Minimum training standards for cardiac catheterization are as follows:

Level Specific Goals & Objectives:

Junior Fellows (first year fellows)

Junior fellows will perform history and physical examinations on all patients who are to undergo cardiac catheterization. They will obtain informed consent on the patients and review the case with the cardiac catheterization faculty in an effort to plan for the procedure. They will obtain vascular access and emphasis will be given to the technical aspect of the procedure with the catheterization staff. They will perform coronary artery contrast injection while the staff performs panning.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence and will expand emphasis to the panning of cases with junior fellows and/or staff.

CATS Training Requirements for Diagnostic Cardiac Catheterization

Training Level Cumulative Duration  Cumulative Number of Cases Performed
I 4 100
II 8 300

 

Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:

At University of Iowa Hospitals & Clinics, the patient population that presents for cath lab procedures consists of male and female patients from various ethnic and socioeconomic backgrounds. Patients presenting to the Cath Lab for procedures have a variety of cardiac disorders, including coronary artery disease, valvular heart disease, congestive heart failure, and pericardial disease. Clinical encounters include pre-procedure evaluations in the ambulatory surgery unit and on the inpatient wards, performing the requested procedure, and providing any immediate post-procedure follow-up. Procedures performed include left and right heart catheterization, coronary and peripheral angiography, percutaneous peripheral and coronary intervention, pericardiocentesis, and temporary pacemaker placement.

Teaching Methods:

The fellow will review each patient’s history and planned procedure with the attending. The attending will supervise the fellow during the procedure, and the fellow will assume progressive levels of responsibility as his or her skill level improves. The attending will review all procedure data with the fellow after the procedure is completed. Fellows on the cardiac cath rotation are expected to attend the weekly cardiac cath conference and also present cases at the joint TCV – cardiac cath conference.

Evaluation:

  1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
  2. The fellow’s progress will be reviewed verbally mid-rotation.
  3. A standard fellow evaluation form will be completed by the attending at the end of the rotation.
  4. The final evaluation by the supervising physician will be based on the fulfillment of the rotation objectives as determined by:
  5. Personal observation during interaction with the fellow while performing Cath Lab procedures.
    1. Evidence of literature reviews appropriate for the individual patient and topic.
    2. Evidence of ability to perform appropriate pre-procedure evaluation.
    3. Evidence of ability to properly select patients for testing.
    4. Competent performance of cardiac procedures relative to the fellow’s level of training.
    5. Correct interpretation of procedure data obtained.
    6. Evidence of ability to provide appropriate post-procedure care.
    7. Feedback from Cath Lab staff members, other healthcare providers, and patients.

Resources:

  • University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
  • www.cardiosource.com
  • Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
  • Baim and Grossman’s Cardiac Catheterization, Angiography, and Intervention (7th edition)
  • The Cardiac Catheterization Handbook; Morton Kern (4th edition)
  • www.scai.org

 

UI Hospitals & Clinics Echocardiography

Purpose:

The overall purpose of the echocardiography rotation is to provide trainees with a general overview of all aspects of cardiac echocardiography and to ensure fellows acquire the necessary expertise required to perform and interpret transthoracic, transesophageal, and stress echocardiography studies which are routinely encountered in the practice of cardiology.

Each cardiology fellow will rotate on the University of Iowa Hospitals & Clinics echocardiography service for at least three months during the course of their fellowship. On this rotation, the fellow will learn principles of echocardiography as pertains to the evaluation and management of patients with general cardiac disorders such as heart failure, coronary artery disease, valvular disorders, pericardial diseases, and cardiac masses.

Responsibility/Specific Duties:

  1. The fellow is the point of contact for all echocardiography services at UI Hospitals & Clinics.
  2. Fellows should generally arrive at the lab by 8:00 am (or immediately following morning conference) Monday through Friday and is expected to stay until all studies are read by the attending cardiologist. Weekend echo coverage is provided by the on-call fellows.
  3. Fellows will perform at least 2 transthoracic echocardiographic studies with the sonographers each day. These studies are to be performed and recorded as if the fellow is the sonographer, and the performing fellow should be identified in the study information section. The echo fellow should pre-read all scans performed.
  4. Fellows will pre-read as many echocardiograms performed in the lab during the course of the day as possible (at least 10 studies / day)
  5. Fellows will formally read the echocardiograms with the attending cardiologist every day.
  6. Fellows will review all TEE requests and assist in scheduling the procedure in a timely fashion. The fellow will notify the attending immediately if a TEE is deemed urgent.
  7. Fellows are encouraged to oversee and attend all stress echo procedures in the echo lab during which time they will become acquainted with the performance and interpretation of transthoracic studies.
  8. Fellows will attend to all emergencies encountered in the Echo Lab during routine TTEs, TEEs, or stress echocardiograms.
  9. The echo fellow is expected to remain in the general vicinity of the Echo Lab throughout the day and is expected to notify the lab staff if there are any conflicting schedules including vacation.
  10. Fellows should be available and participate in performing contrast echocardiography or amyl nitrite studies, as well as supervising, performing and interpreting exercise and dobutamine echo studies. The echo lab serves as a good venue to acquire the necessary skills in exercise testing as a part of the exercise stress echocardiography laboratory studies.
  11. Fellows are responsible for screening all inpatient transesophageal echocardiograms for appropriate indications and contraindications and for preparing both inpatients and outpatients referred for this procedure. The specific responsibilities include: obtaining consent to perform the TEE, assessing the indications and safety of the procedure, reviewing any pertinent pre-procedure data (e.g., labs or TTE), and discussing the case with the echo attending for that day. The pre-requisite to performing TEE’s is to perform and document 25 esophageal intubations under supervision. All fellows must perform and record at least 30 transthoracic echos prior to being eligible to participate in transesophageal echos
  12. The echo fellow will attend the weekly echo conference and may be asked to perform a mini review of a topic based on an interesting case seen during their rotation through the echo lab.
  13. The fellow will keep a log of all the TTEs, TEEs, and stress echos performed and interpreted during the course of the rotation. This log will be reviewed by the program director during the biannual review.
  14. The fellow is expected to interpret and sign all EKG’s in the echo box daily. These EKG’s are located in the EKG lab and are to be completed by 10:00 am.

Supervision:

The UI Hospitals & Clinics echo fellows will pre-read or simultaneously read studies with the staff physician. This will facilitate patient care and teaching as it relates to the etiology, pathogenesis, clinical presentation, natural history, and the treatment of various cardiac disorders. The attending will review and constructively critique the fellow’s interpretations of all TTE, TEE, and stress echo studies. The attending will review and constructively critique the fellow’s performance of TTE. The attending will directly supervise the fellow’s performance of all TEE procedures. The attending will provide didactic sessions on basic concepts in echocardiography and may assign readings or other learning activities as necessary.

Learning Objectives:

  1. Obtain training in the principles and methods of echocardiography as related to patients with a variety of cardiovascular diseases. (B)
  2. Become proficient in obtaining adequate two-dimensional echocardiographic images with complete spectral and color Doppler data as is routinely acquired. This includes learning proper transducer manipulation and ultrasound system adjustments. Mastering correct transducer manipulation is critical to obtaining optimal image quality and optimal Doppler flow velocity signals. Fellows are expected to acquire a working knowledge of ultrasound instrument settings, such as transducer frequency, harmonics, mechanical index, depth, gain, time-gain-compensation, dynamic range, filtering, velocity scale manipulations, and the display of received signals. (B)
  3. Gain an understanding that becoming skilled in the performance of TTEs facilitates the physician's understanding of optimal echocardiographic data acquisition and technical quality and this knowledge adds to proper interpretation and diagnostic accuracy of studies. (B, C)
  4. Acquire skill in the various techniques of echocardiography including 2D imaging, color-flow Doppler, and both pulse-wave and continuous-wave spectral Doppler. (B)
  5. Learn the indications and limitations of transthoracic echocardiography. (B)
  6. Become proficient with the use of echo contrast and its various indications and uses. (B)
  7. Become proficient in performing and interpreting transesophageal echocardiograms and learn the indications, limitations, and risks of the procedure. (B)
  8. Learn the elements of safe administration of conscious sedation. (A, B)
  9. Become proficient in the interpretation of stress echocardiograms and learn the indications, limitations, and risks of the procedure. (B)
  10. Acquire basic knowledge of ultrasound physics. (B)
  11. Understand the proper use and maintenance of echo equipment. (B, F)
  12. Gain exposure to a broad range of acute and chronic cardiovascular problems through direct patient imaging and through formal and informal didactic teaching sessions. (B)
  13. Gain a better understanding of the anatomy and physiology associated with a broad variety of cardiac disorders. (B)
  14. Learn to use acquired echo data to assess intracardiac pressures and hemodynamics. (B)
  15. Learn to use acquired echo data to detect and quantify cardiac valvular stenosis and regurgitation as well as other abnormal flow states, such as intracardiac shunts. (B)
  16. Learn to communicate echocardiographic findings at a level appropriate for patients, family members, and members of the health care team. (D, E, F)
  17. Gain an appreciation for the role of the members of the echo lab staff, including the sonographers, nurses, and administrative staff. (D, E, F)
  18. Learn to generate accurate, thorough yet efficient, and understandable echo reports which clearly answer the question being asked. (D, E, F)
  19. Learn to coordinate with other cardiology services (e.g., EP for TEE cardioversions, the Cath Lab for PFO/ASD closures or pericardiocentesis, CHF/TXP service for donor echo studies, etc) and thereby gain an understanding of how the health care delivery system can be used to the maximal benefit for patients. (F)
  20. Learn to coordinate Echo Lab procedures with other medical and surgical services and thereby gain an understanding of how the health care delivery system can be used to the maximal benefit of patients. (F)
  21. Gain hands on scanning experience by interacting with sonographers that will lead to the ability to perform high quality scans with measure to provide good echo lab quality control. (D, E, F)
  22. Complete the specific training requirements for the desired level of certification as outlined by COCATS 3 and the American Society of Echocardiography. (B)< >It is important to emphasize that the numbers of examinations refer to comprehensive two-dimensional and Doppler echocardiographic studies that are diagnostic, complete, and quantitatively accurate.The actual number of procedures required to accomplish clinical competence in echocardiographic procedures is somewhat arbitrary, because there is individual variation in cognitive, analytical, and manual-dexterity skills. The listed numbers are therefore the minimum requirements anticipated to properly train the average cardiology fellow, and individual fellows may be required to perform additional studies as determined by the echo lab staff physicianMinimum training standards for transthoracic echocardiography are as follows:Training LevelCumulative DurationCumulative Number of
    Cases PerformedCumulative Number of 
    Cases InterpretedI375150II6150300III12300750


    All fellows are required to fulfill criteria for Level Criteria for Level I training. In addition, fellows are encouraged to perform 50 supervised TEE studies and 100 exercise echo and dobutamine echo studies.

    Level Specific Goals and Objectives:

    Junior Fellows (first year fellows)

    Fellows will pre-read echocardiograms and enter their preliminary findings in Excelera. They will then review these studies with the staffing physician. Fellows may be requested to monitor the stress portion of the exercise stress echocardiography studies. Each study will then be reviewed by the fellow with the staff. Findings will then be communicated with the referring physician. Fellows will share responsibility for assisting with Saturday TEE studies on Stroke Unit patients. These procedures are performed in the CVICU at 10 AM on an as needed basis. Fellows will keep a log of patient studies reviewed and performed.

    Senior Fellows (second year fellows and above)

    In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

    Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:

    Both men and women of all adult ages and various ethnic backgrounds undergo echo Lab procedures. Patients presenting to the Echo Lab have a variety of cardiac disorders, including coronary artery disease, valvular heart disease, congestive heart failure, and pericardial disease. Procedures performed include the acquisition and interpretation of transthoracic, transesophageal, and exercise and pharmacologic stress echocardiograms. Clinical encounters include brief pre-procedure evaluations on the inpatient wards and in the Echo Lab prior to performing TEEs, performing the requested procedure, and providing any immediate post-procedure follow-up.

    Teaching Methods:

    The attending will review the fellow’s performance and interpretation of echocardiographic studies and provide constructive feedback including discussion of accurate interpretation. There will be daily echo reading sessions that will focus on interpretive skills and will cover the range of echo topics in brief case-directed teaching sessions. The attending may assign readings or other learning activities. The attending will directly supervise the fellow in the performance of TEEs. The fellow will assume progressive levels of responsibility for patient care and procedure performance under the supervision of the attending. A weekly didactic and case-based echo conference will be conducted by one of the echocardiography attending with active participation and presentation by the echo fellow.

    Evaluation:

    1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
    2. The fellow’s progress will be reviewed verbally mid-rotation.
    3. A standard fellow evaluation form will be completed by the attending at the end of the rotation.
    4. The attending’s final evaluation will be based on the fulfillment of the rotation objectives as determined by:
      1. Personal observation during interaction with the fellow in echo reading sessions and in the performance of echo procedures.
      2. Evidence of extensive literature reviews appropriate for the individual patient and topic.
      3. Progressive improvement in the ability to adequately acquire TTE data.
      4. Progressive improvement in the ability to safely and properly perform TEEs.
      5. Progressive improvement in the ability to correctly interpret TTEs, TEEs, and stress echocardiograms.
      6. Participation at Echo Conference.
      7. Feedback from other team members, other healthcare providers (sonographers, echo lab administrative personnel, and patients).

Resources:

  • University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
  • www.cardiosource.com
  • Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
  • Otto’s Textbook of Clinical Echocardiography (4th edition)
  • Feigenbaum’s Echocardiography (7th edition)
  • The Echo Manual by Oh et al (3rd edition)
  • www.asecho.org

UI Hospitals & Clinics Nuclear Cardiology/Stress Testing

Purpose:

The purpose of this rotation is for the fellow to acquire knowledge about the indications, the performance, interpretation and limitations of diagnostic nuclear cardiology and stress testing. Fellows are expected to understand the basic principles of radioisotopes and myocardial perfusion imaging and gain skills required to independently interpret nuclear perfusion studies. Each cardiology fellow will spend at least 2 months in the nuclear cardiology laboratory; one month is at University of Iowa Hospitals & Clinics and the other month is completed during the afternoons on the VA outpatient cardiology service.
Extensive experience with nuclear cardiology and stress testing are provided during the outpatient consults rotation at the Iowa City VAMC and during the nuclear cardiology rotation at University of Iowa Hospitals & Clinics. The fellow is directly responsible to the attending of the exercise/nuclear lab for all components of this rotation. The fellow will be given primary responsibility to perform stress tests, under direct supervision of an attending or a specially trained exercise physiology professional. Fellows will be instructed in the interpretation of stress testing following myocardial infarction for the purpose of identifying high risk patients and prescribing appropriate exercise regimens for cardiovascular rehabilitation.

Stress Testing:

The studies performed will include maximal and sub maximal exercise tests as well as pharmacologic tests with dobutamine, or regadenoson. The fellow will become familiar with exercise physiology and will learn the essentials of preparation for exercise testing (skin preparation, electrode placement, etc) and know the clinical importance of the study findings. Fellows will also be instructed in the interpretation of stress testing for the purpose of identifying high risk patients and for prescribing appropriate exercise regimens for cardiac rehabilitation. In addition to the nuclear cardiology laboratory, exercise testing and dobutamine stress testing is performed in the UI Hospitals & Clinics exercise treadmill laboratory, echocardiography laboratory and the VA medical center nuclear laboratory and echocardiography laboratory.

Responsibilities/Specific Duties:

  1. The fellow will work with the Nuclear Exercise Laboratory staff to assess the accurate selection of stress for the patient and can be reasonably expected to answer the clinical question.
  2. The UI Hospitals & Clinics Nuclear fellow will supervise the exercise stress tests with the nuclear laboratory physician assistant. Other exercise stress testing objectives are met during the UI Hospitals & Clinics echo lab rotation (for performance of exercise and dobutamine stress echocardiography) and during the VA outpatient rotation (for performance and interpretation of exercise stress test
  3. The UI Hospitals & Clinics Nuclear fellow will be present in the lab most of the morning to supervise and interpret stress tests, perform tracer injections when possible. In the afternoon, the UI Hospitals & Clinics Nuclear fellow will interpret perfusion images. On the VA outpatient rotation, the VA outpatient fellow is expected to interpret studies with the VA nuclear medicine staff physician.
  4. The fellows should read all stress electrocardiograms and nuclear perfusion imaging studies in preparation for the afternoon reading session with the attending cardiologist.
  5. The UI Hospitals & Clinics nuclear cardiology fellow, VA outpatient fellow and VA cath fellow identify nuclear cardiology studies to be presented at the Advanced Cardiac Imaging Conference.

Supervision:

The attending physician will review with the fellow the appropriateness of test selection at the time of the afternoon reading session. Suggestions for improvement in test selection will be made when appropriate and the rationale and literature basis for an alternative test selection will be discussed. The attending physician will interpret the exercise electrocardiograms and exercise and rest nuclear scans with the fellow each day. Changes in interpretation compared to the fellow’s preliminary interpretation will be discussed, incorporating literature based principles. Staff physicians from cardiology and nuclear medicine will review the myocardial perfusion studies with the fellow in the Advanced Cardiac Imaging conference.

Learning Objectives:

The overall basic objectives of this rotation include understanding the principles of myocardial perfusion and blood flow, factors determining flow, coronary flow regulation, vasoreactivity, coronary flow reserve, regional flow differences, and flow variability; understand the principles of radioactivity, radioactive decay, radionuclide production, radionuclide generators, photon interactions with matter, and radiation detectors; develop a basic understanding of the instrumentation, techniques, and principles involved in nuclear imaging, including collimation, resolution, contrast, localization, noise, SPECT, PET, image reconstitution methods, and attenuation and scatter correction; become familiar with the various methods of stress testing (treadmill, upright and reclining bicycle, pharmacologic), including indications, exclusions, safety, and technique and understand the advantages, disadvantages, and differences between various protocols for image acquisition; understand the differences between the various radioisotopes used in nuclear cardiology, including their energy, half lives, and organs of elimination and gain a proper understanding of the value of perfusion imaging in the diagnosis, prognosis, and management of patients with coronary artery disease.

The specific objectives are:

  1. Obtain training in the principles of noninvasive detection and prognostic assessment of patients with known or suspected coronary artery disease. (A, B)
  2. Gain an understanding of the risks and benefits of various stress testing modalities. (A, B)
  3. Gain an understanding of the implications of various pharmacologic agents on stress test accuracy. (A, B)
  4. Gain training in safely conducting stress tests. Learn to recognize and manage emergencies arising in the course of stress testing. (A, B)
  5. Gain skills in the interpretation of exercise electrocardiograms and stress and rest nuclear cardiac tests. (B)
  6. Gain understanding of nuclear methods for measurement of left ventricular function and the complimentary roles of myocardial perfusion and left ventricular function in patient assessment and management. (B)
  7. Gain understanding of the role of stress testing in preoperative cardiac risk assessment, using published series and guidelines. (B, C)
  8. Gain understanding of the value and limitations of stress test results in the assessment of patient diagnosis and prognosis, and in clinical management. (A, B)
  9. Gain an appreciation for the role of the staff members in the non-invasive lab, including the technicians, nurses, and administrative staff. (D, E, F).
  10. Learn to generate an accurate and easily understood report for stress tests and nuclear perfusion studies. (D)

Each fellow is expected to perform and interpret over the 2 year period a minimum of 80 hours of nuclear cardiology study interpretation during the two month training period in Nuclear Cardiology, which fulfills level 1 ACC guidelines for training. These studies include SPECT and planar myocardial perfusion imaging, gated blood pool studies, and PET perfusion and viability studies. The fellow will participate in daily readout sessions with the attending physician from nuclear medicine or cardiology responsible for the interpretation of the studies. Level 2 training may be attained in nuclear cardiology upon completion of fellowship by spending four to six months in the nuclear cardiology laboratory and by interpreting at least 300 studies including 40 hands on cases studies with direct patient experience. In order to obtain a nuclear license, fellows are required to take mandatory physics courses. These didactic sessions may be undertaken at the University of Iowa or through commercial vendors targeted to providing the didactic courses in an intensive two - four week period.

Level Specific Goals and Objectives:

Junior Fellows (first year fellows)

Fellows may be requested to monitor the stress portion of the stress myocardial perfusion imaging studies. Each study will then be reviewed by the fellow before the patient leaves the testing area to assure safety for the patient. High risk scan findings will be communicated with the reading staff physician as well as the referring physician. Fellows will review all scans with the staffing physicians and generate a report in the medical record. Fellows will keep a log of patient studies reviewed and performed.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.

Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:

The training in Nuclear Cardiology is based at UI Hospitals & Clinics for one month and half-day afternoon during the VA outpatient rotation for 2 months. In addition, fellows may choose to undertake additional training in nuclear cardiology during their elective rotations. Training based at UI Hospitals & Clinics includes men and women of all adult ages, with a wide range of body habitus and medical co-morbidities, and varied ethnic and socioeconomic backgrounds. Although the majority of patients present with chronic or subacute symptoms, many patients present from the Emergency Department after acute myocardial infarction has been excluded and the patient’s presenting symptoms have been stabilized. Most patients are referred for evaluation of chest pain or exertional dyspnea, but a significant proportion of patients are referred for preoperative cardiac risk assessment, assessment of myocardial viability, or assessment of known or suspected arrhythmias. Diagnostic test options include exercise electrocardiography, exercise and rest myocardial perfusion imaging, pharmacologic coronary vasodilation stress, and inotropic (dobutamine) stress tests. The training in Nuclear Cardiology at the VA includes predominantly male patients with a wide variety of cardiovascular disorders or cardiovascular risk factors.

Teaching Methods:

Nuclear cardiology studies are formally read each day in the late afternoon. The attending physician will review the studies read by the fellow (baseline ECG, stress ECG, and perfusion imaging) and offer constructive criticism and further instruction as needed. In addition to study interpretation, didactic lectures covering the basics of nuclear cardiology are given during the core curriculum conference series and during the Advanced Cardiac Imaging conference.

Evaluation:

  1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
  2. A standard fellow evaluation form is completed by the attending at the end of the rotation.
  3. The attending physician’s final evaluation is based on fulfillment of the rotation objectives as determined by:
    1. Personal observation during interaction with the fellow.
    2. Evidence of a growing knowledge base in exercise testing and nuclear cardiology over the course of the rotation.
    3. Ability to identify appropriate versus inappropriate test selections.
    4. Accuracy of exercise electrocardiogram interpretation.
    5. Accuracy of nuclear cardiology test interpretation, including interpretation in the Advanced Cardiac Imaging conference.
    6. Appropriate handling of any patient emergencies.
    7. Feedback from ECG monitoring technicians, nurses, and nuclear medicine technologists in the Exercise Nuclear Laboratory.

Resources:

  • University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
  • www.cardiosource.com
  • Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
  • www.asnc.org
  • Nuclear Cardiac Imaging: Principles and Applications textbook (4th edition) Ami E. Iskandrian, Editor
  • Nuclear Cardiology: Practical Applications (2nd edition) Gary Heller and Robert Hendel Editors

UI Hospitals & Clinics Electrophysiology

Purpose:

The overall purpose of the EP rotation is to provide trainees with a general overview of all aspects of cardiac electrophysiology and to ensure fellows acquire the necessary expertise required to manage the electrophysiology disorders routinely encountered in the practice of cardiology. A minimum of 2 months is dedicated to this area and should include 10 elective cardioversions, fulfilling level 1 ACC guidelines for training. During this rotation, the fellow will work under the supervision of electrophysiology attending physician and interact with the subspecialty electrophysiology fellows. The fellows are expected to acquire knowledge and experience in the diagnosis and management of arrhythmias, the indications and limitations of electrophysiologic studies, the appropriate use of antiarrhythmic agents and defibrillator devices, understand noninvasive and invasive techniques used to assess patients with arrhythmias and become acquainted with the basics of pacemaker/ICD management and device interrogation.

Responsibility/Specific Duties:

  1. The University of Iowa Hospitals & Clinics general cardiology fellow rotating on the EP service is the point of contact for the EP consult service at UI Hospitals & Clinics; this service includes all inpatient and most outpatient consults such as from other clinics and emergency department. EP consults at the VAMC are performed by the VA outpatient and inpatient fellows under the supervision of the EP staff physician designated to the VA.
  2. The UI Hospitals & Clinics fellow receives and reviews all EP inpatient consults, performs the initial evaluation within one hour of being called, reviews all pertinent laboratory data and related test results, develops an initial management strategy, presents the patient to the EP attending as soon as feasible, and writes the final consult. The fellow will communicate to the consulting team caring for the patient and the EP attending will communicate with the requesting attending.
  3. The fellow will conduct daily rounds on all EP inpatients and communicate management plans to the patient’s primary team. The fellow will review each patient with the EP attending and write an appropriate follow up consult progress note.
  4. The fellows will evaluate patients in the EP consult clinic, held daily at 2:00 p.m., or as instructed by the EP staff physician.
  5. The fellow will be supervised by the EP fellow or EP attending for all device interrogation/programming of inpatients and outpatients. However, the fellow will be the primary agent for all OR reprogramming as proscribed and supervised by the EP attending working days from 0730-1700.
  6. The fellow will assist the EP attending during procedures such as interrogation of devices or cardioversions performed on the wards or in the EP lab and will progress to higher levels of participation including performance of EP studies as the fellow’s skill level allows. The fellow will communicate patient study information to the house staff post-procedure and do the appropriate post-procedure checks (x-ray, operative site, labs, etc).
  7. The fellow will participate, perform and/or interpret Holter monitor studies, event recorders, exercise stress tests for dysrhythmia management, tilt table tests, and signal-averaged ECGs.
  8. The fellow is responsible to present selected cases, with guidance of the attending, at the Friday EP patient care conference at 7:15 a.m.

Supervision:

The attending physician and fellow will care for patients as a team to facilitate patient care and teaching as it relates to the etiology, pathogenesis, clinical presentation, natural history, and the treatments of the various electrophysiology disorders seen. The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, review and confirm the fellow’s notes, and review and supplement the fellow’s teaching of other members of the team. The attending may assign readings or other learning activities as necessary. The attending will supervise the fellow during invasive procedures based on the level of the fellow’s skills.

Learning Objectives:

  1. Obtain basic training in the concepts of clinical cardiac electrophysiology, including: normal physiology of the cardiac conduction system, pathophysiology of brady dysrhythmias and tachy dysrhythmias, and mechanisms of AV block. (A, B)
  2. Gain basic understanding of the indications, use limitations, and complications of diagnostic EP studies and radiofrequency ablation therapy. (A, B)
  3. Gain basic training and experience in the use of pharmacologic and non-pharmacologic options for treating cardiac dysrhythmias. (A, B)
  4. Gain basic training in the indications, interpretation, and clinical application of ECG interpretation, ambulatory electrocardiography (Holter) monitoring, event recorders, exercise testing for dysrhythmia assessment, tilt table testing, signal-averaged ECG, and implantable loop recorders. (A, B)
  5. Gain basic training in the fundamentals of cardiac pacing, recognition of normal and abnormal pacer function, knowledge of temporary pacing and permanent pacing, knowledge of pacing modes and the general approach to programming, surveillance, and troubleshooting of pacemakers and implantable cardioverter-defibrillators (ICDs). (A, B)
  6. Understand the indications for cardiac pacemakers, ICDs, and resynchronization devices. (A, B)
  7. Gain basic training in the insertion of temporary pacemakers and the indications and techniques for elective and emergent DC cardioversion. (A, B)
  8. Gain basic training in arterial and venous access for the placement of catheters and performance of EP studies. (A, B)
  9. Evaluate patients in both the inpatient and outpatient setting who may have an electrophysiology disorder by taking a thorough problem-directed history, performing a careful physical examination, and generating a differential diagnosis and plan of care. (A, B)
  10. Provide follow-up care for both inpatient and outpatient consult patients to assess success and adverse effects of treatment, including anti dysrhythmic agents. (A, B)
  11. Explain the etiology, pathogenesis, clinical presentation, and natural history of major EP disorders, including syncope, brady dysrhythmias, tachy dysrhythmias, and sudden cardiac death. (B)
  12. Learn to choose appropriate EP related diagnostic tests. (A, B)
  13. Learn to recognize and manage EP emergencies. (A, B)
  14. Gain an appreciation for the role of the staff members in the electrophysiology laboratory, including technicians, nurses, and administrative staff. (D, E, F)
  15. Learn to generate a comprehensive written consultation carefully explaining the diagnosis and management plan for patient’s with EP disorders. (D, E, F)

Level Specific Goals and Objectives:

Junior Fellows (first year fellows)

Junior fellows will perform history and physical examinations on all patients on whom they are consulted. Findings will then be reviewed with the EP staff and a plan will be generated as well as a note for the electronic medical record. Fellows will obtain informed consent on the patients who are to undergo electrophysiology study/procedures and review the case with the electrophysiology faculty. They will obtain vascular access and emphasis will be given to the technical aspect of the procedure with the electrophysiology staff. They will also perform ICD/device interrogation at the direction of the EP staff and EP subspecialty fellows.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence and will expand emphasis to the performance of electrophysiology testing/procedures with EP staff.

Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:

Training occurs at both UI Hospitals & Clinics and the VAMC providing a wide range of pathology and a diverse patient population. Both men and women of all adult ages and of various ethnic backgrounds are seen. Clinical encounters including inpatient consultation, outpatient consultations, and peri-procedural care. Both non-invasive and invasive procedures are performed, including the interpretation of ECGs, Holter monitors, event monitors, exercise testing for dysrhythmia management, tilt table testing, and signal-averaged ECGs as well as the participation in performing temporary and permanent pacemaker placement, ICD and cardiac resynchronization device placement, DC cardioversion, diagnostic EP studies, radiofrequency ablation, loop recorder implantation, and trans-septal catheterization.

Teaching Methods:

The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, review and confirm the fellow’s notes, and review and supplement the fellow’s teaching of other members of the team. The attending may assign readings or other learning activities. The attending will supervise the fellow in the performance of procedures. The fellow will assume progressive levels of responsibility for patient care and procedure performance under the supervision of the attending.

Evaluation:

  1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
  2. The fellow’s progress will be reviewed verbally mid-rotation.
  3. A standard fellow evaluation form will be completed by the attending at the end of the rotation.
  4. The final evaluation of the staff physician will be based on the fulfillment of the rotation objectives as determined by:
    1. Personal observation during interaction with the fellow.
    2. Evidence of extensive literature reviews appropriate for the individual patient and topic.
    3. Ability to construct a logical management plan.
    4. Inclusion of appropriate physical examination.
    5. Appropriateness of use of diagnostic tests.
    6. Correct interpretation of diagnostic tests.
    7. Appropriate selection of pharmacologic and non-pharmacologic therapies.
    8. Competent performance of cardiac procedures relative to the fellow’s level of training.
    9. Appropriate follow-up.
    10. Feedback from other team members, other healthcare providers, and patients.

Resources:

  • University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Heart Rhythm and Medline)
  • www.cardiosource.com
  • Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
  • Fogoros’ Electrophysiologic Testing 4th Ed
  • Zipes and Jalife’s Cardiac Electrophysiology: From Cell to Bedside (most recent edition)
  • Epstein AE, et al, ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. J Am Coll Cardiol 2008 May 27;51(21):e1-62.

UI Hospitals & Clinics Adult Congenital Heart Disease

During the research year (usually the second year of fellowship), fellows attend the Adults with Congenital Heart Disease clinic every eight weeks over a twelve month period. Working with faculty from Pediatric Cardiology, this rotation provides a comprehensive exposure to the diagnosis, assessment and management of outpatient presentations of most forms of congenital heart disease commonly encountered in adults. Resources include textbooks: Perloff’s Congenital Heart Disease in Adults and Perloff’s “The Clinical Recognition of Congenital Heart Disease”.

UI Hospitals & Clinics Cardiac CT and MRI

The goals of the cardiology fellowship program trainee are to acquire Level 1 training in cardiac MRI and cardiac CT which focuses on basic understanding and familiarity with these newer cardiac imaging modalities. This is accomplished by reviewing the ACC-SAP in Cardiac MRI and CT and attending the core curriculum lecture series geared to cardiac CT and MRI. Cardiac MRI studies maybe reviewed at the workstation in Radiology or in the UI Hospitals & Clinics echocardiography laboratory. Cardiac CT studies maybe reviewed at the workstation in Radiology or the workstation installed in the Cardiology Division in the Cardiac Catheterization laboratory film review area. Fellows will be expected to participate in the performance and interpretation of cardiac CT studies during the VA outpatient and inpatient blocks and occasionally on the UI Hospitals & Clinics consult and echocardiography laboratory rotations. Fellows are encouraged to participate in the performance and interpretation of Cardiac MRI studies during their UI Hospitals & Clinics echocardiography laboratory rotation. Level 1 training in cardiac CT and MRI includes mentored interpretation of 50 cases.

Advanced training in CT and MRI are offered for fellows who select cardiac imaging as their major career focus. The fellowship will allocate 12 months’ fellow effort to this training, either as a component of the individual fellow’s academic/research block, or as an additional year of training following completion of 36 months in the Cardiovascular Diseases fellowship. Each fellow will assume graduated responsibility for completion of CT or MRI studies, including patient selection, image acquisition, image analysis, data reporting and consultation with the referring physician. In addition, each fellow who selects this career path will engage in at least one research project that is centered on advanced imaging. COCATS 3 certification at our institution requires demonstration of independence in all aspects of clinical CT or MRI and, in addition, requires at least one peer review publication.

UI Hospitals & Clinics Cardiac Electrophysiology (EP) Procedure Elective

Recommended for: general cardiology fellows interested or potentially interested in pursuing advanced training in cardiac electrophysiology (EP) after cardiology fellowship, and those fellows who will have a future practice that intersects heavily with EP. Prerequisite: at least one core EP consultation service rotation.

Purpose:

The purpose of the elective rotation is to gain an understanding of the anatomy, physiology, pharmacology and technology central to the field of cardiac electrophysiology, to acquire a deeper knowledge of patient presentations and diagnostic testing, and to develop the technical, cognitive and motor skills required to gain the venous and arterial access needed to perform device implantations and catheter studies, to place intracardiac catheters, and to understand intracardiac electrograms.  It is important to emphasize that the rotation is not designed to develop full clinical competence in device implantation and EP study/ablation, but rather to develop skills and knowledge in this field that will serve as a foundation for further training in an EP fellowship program, or to support future practice in cardiology that will intersect with EP. 

The rotation will generally consist of

  1. Performance of procedures 1:1 with an EP faculty in the laboratory at the Iowa City Veterans Affairs (VA) Health System.
  2. Performance of procedures 1:1 with an EP faculty at the University of Iowa Hospitals and Clinics (UIHC) facilities (Adult EP lab, Pediatric EP lab, OR, minor procedure) on days/cases when the subspecialty EP fellow(s) are in clinic or otherwise not available
  3. Performance of procedures in the UIHC facilities as the second assistant when the subspecialty EP fellow is present
  4. Opportunities to train 1:1 with device company representatives and our nurse specialists on pacemaker/ICD interrogations and reprogramming
  5. Participation in Advanced EP conference

In the EP lab, the trainee will develop and be expected to demonstrate expertise in the following aspects related to EP procedures, including:

  1. Understand the indications for the procedure, its appropriateness, and alternatives. The trainee should understand the indications for various modes of pacing, transvenous vs. subcutaneous ICD implantation, and various types of electrophysiology studies and ablations. The trainee should be able to estimate the risk and benefit of the various procedures being performed and comorbid factors that may increase the risk of the procedure or require special approaches.
  2. Obtaining informed consent. The trainees should be able to communicate the general details of the procedures, their risks and benefits, in a way that is understood by the patient and be able to address questions raised by the patient. In situations where the patient cannot give informed consent, the trainee should obtain consent from appropriate sources.
  3. Administering anesthesia. The trainee should demonstrate knowledge of the pharmacology of medications used for conscious and deep sedation, contraindications for their use, side effects and appropriate treatment for side effects. The trainee should develop the skills to make the patient comfortable during the procedures, follow the degree of sedation, and recognize and treat complications.
  4. Device implantation. The trainee should develop skills in establishing and maintaining a high level of sterility, performing venograms, skin incisions, obtaining axillary, subclavian or cephalic vein access, obtaining hemostasis with electrocautery, inserting sheaths, inserting electrodes into appropriate intracardiac locations, attaching pacing devices, suturing/closing incisions, and performing/interpreting pacemaker/ICD implant testing.
  5. Electrophysiology studies/ablations: The trainee should develop skills in obtaining vascular access to the femoral veins and femoral arteries, placing electrodes in appropriate intracardiac locations, use and interpretation of intracardiac echocardiography, and performing transseptal punctures. Trainees should also develop skills in pacing maneuvers, interpreting intracardiac electrograms, development and interpretation of 3D mapping, and performance of ablation.
  6. Safety. Trainees should gain skill in the proper use of fluoroscopy and methods to limit its use. Trainees should have full knowledge of the potential safety issues relevant to both the patient and to the staff, and how to recognize and treat/avoid such complications.
  7. Drug studies. Trainees should understand the pharmacology of provocative drug studies and the channelopathies or arrhythmia disorders they are designed to uncover.
  8. Understand indications for tilt table testing, how the test is performed, its interpretation and limitations.

Responsibilities/Specific Duties:

  1. The fellow will attend Advanced EP conference on Thursday mornings.
  2. The fellow will be in the EP facilities at the Iowa City Veterans Affairs Health System or University of Iowa Hospitals and Clinics where they will take part in the work up and performance of procedures scheduled for the day, as well as last-minute add-ons. Specific duties for procedures include:
    1. Evaluate inpatients and outpatients referred for procedures and complete the H&P and consent paperwork and pre-procedure orders.
    2. Evaluate each patient prior to performing any invasive procedure. This includes reviewing history, labs, studies and talking to the patient and family to answer questions.
    3. Discuss each patient and their procedure with the attending performing the procedure.
    4. Assist in the performance of the procedure under the supervision of the attending. The trainee will have progressive increase in the extent of maneuvers they may perform during the procedure depending on the progress of their skills.
    5. Complete post-procedure paperwork including procedure note, and orders. For inpatients, the trainee will contact the team to update them on the procedural outcome and plans.
    6. The trainee will assist with the evaluation and discharge of patients after their procedures.
    7. The trainee will keep a log of their procedures in MedHub.

Supervision:

The fellow will review all cases with the EP attending prior to performing any procedure. All invasive procedures will be performed under the direct supervision of an EP attending. Procedures may not start until the attending is physically present in the EP lab or control room.

Learning Objectives:

  1. Learn the indications and contraindications of EP lab procedures.
  2. Learn to recognize and treat immediate complications.
  3. Become proficient in the technical aspects of vascular access, device implantation and EP studies.
  4. Learn the indications for and gain exposure to ablation and 3D mapping.
  5. Learn and understand the protocols for correct performance and interpretation of pacing maneuvers.
  6. Learn proper radiation safety.
  7. Develop an academic approach to the proper utilization of invasive electrophysiology testing.
  8. Understand the roles and responsibilities of various cath lab staff members including radiation technologists, nurses and device company representatives and technical support.

Teaching methods:

The trainee will review each patient’s history and planned procedure with the attending. The attending will supervise the fellow during the procedure, and the fellow will assume progressive levels of responsibility as his or her skill level improves. The attending will review all procedure data with the fellow after the procedure is completed. Fellows are expected to attend weekly Advanced EP conference.

Evaluation:

The goals and objectives for the rotation will be communicated at the beginning of the rotation. A standard fellow evaluation form will be completed by the attending(s) at the end of the rotation. The final evaluation by the supervising physician will be based on fulfillment of the rotation objectives as determined by: personal observation during interaction with the fellow while performing procedures, evidence of literature reviews appropriate for the individual patient and topic, evidence of progress in skill development commensurate with the fellow’s level of training, correct interpretation of procedure data, ability to provide appropriate post-procedure care, feedback from EP lab staff members, other healthcare providers and patients.

UI Hospitals & Clinics Vascular Medicine

The goals of this training are to perform and become familiar with non-invasive assessments of peripheral vascular disease utilizing Doppler ultrasound. Fellows will evaluate patients with the assistance of vascular laboratory technicians. Trainees will have a hands-on experience in assessing patients with vascular disease using various modalities outlined below. A full range of noninvasive tests is available in the Vascular Laboratory including tests for: Peripheral Arterial Disease (PAD) - Doppler arterial exams of the legs or arms (Physiologic testing), duplex ultrasound scan of the extremity arteries; Cerebrovascular Disease - Carotid artery duplex scan; Deep Venous Thrombosis (DVT) - venous duplex scan of the arms or legs and inferior vena cava (IVC) scan; Renal Artery Disease - Renal artery duplex scan and duplex scan of the renal veins; Aortic Aneurysms - aortic duplex scan, duplex scan of peripheral arteries for aneurysms.

Fellows will be required to attend one half-day per week sessions each week for the entire month of the stress/nuclear medicine rotation. These sessions will occur on a morning that does not interfere with continuity clinic. The same weekday morning session will be followed for the remainder of the month. Besides the allocated time in the vascular medicine laboratory, fellows are expected to learn skills in the diagnosis, assessment and management of peripheral vascular disease in the patient population seen in the University of Iowa Hospitals & Clinics cardiology and VAMC continuity clinics. Fellows will also receive didactic lectures in peripheral vascular disease at core curriculum conference and during the weekly divisional clinical conference

Continuity Clinic

Fellows develop skills as consultant cardiologists in the outpatient setting and to learn to address chronic cardiovascular disease management issues on a longitudinal basis. The clinics provide exposure to outpatient cardiology practice, including both consultative and continuity experiences, and provide a means for clinical follow-up of patients recently discharged from the hospital. This experience provides an opportunity to follow and manage patients for a full three years in an outpatient setting. Fellows participate in a half-day continuity clinic once a week, alternating each week between the Heart and Vascular Center at the University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Health System. Fellows see an average of two or three new patients and three to five return patients. Fellows are directly responsible for care of the patients to which they have been assigned. Fellows perform the initial evaluation, formulate a plan of care, and present the case to the faculty member. Fellows are responsible for ordering and following up on all appropriate studies. At the Iowa City Veterans Affairs Health System, one faculty member is present full-time during the clinic to supervise fellows. At the University of Iowa Hospitals and Clinics, each fellow works with a single faculty member in general cardiology or a subspecialty for a period of six months, providing a unique view of the practice patterns of a given faculty member. Clinic assignments are made based on fellow preferences and allocation by chief fellow and the fellowship program director.

The patient population at the Iowa City Veterans Affairs Health System currently includes mostly adult men, whereas the patient population at the University of Iowa Hospitals and Clinics includes both adult men and women. Patients are referred to the Iowa City Veterans Affairs Health System clinic for a wide variety of reasons including routine management of common cardiovascular problems, preoperative evaluations before non-cardiac surgery, evaluations for potential revascularization procedures (surgical and interventional), post-revascularization follow-up, follow-up of recently discharged patients, and referrals for complex cardiovascular problems. Both primary cardiac care and tertiary, consultative evaluations are provided on a routine basis at the University of Iowa Hospitals and Clinics clinic. The cost effectiveness of various options in treating outpatient cardiovascular disease is discussed between the faculty member and the fellows. Clinical follow-up of patient outcomes is used for quality assessment with discussions focused toward quality improvement. Fellows are instructed on relevant issues of risk management as pertaining to patients with cardiovascular disease.

Scholarly Activity

We envision that our fellows will shape the future of cardiovascular medicine though leadership in clinical care, scientific investigation, education, public health, and administration at the regional, national, and international levels. Because of the role of our fellows as future leaders in diverse fields, we expect all fellows to engage in substantive scholarly activity tailored to their long-term career goals. This aspect of training may involve basic, translational, clinical, or population science research, or the pursuit of a graduate degree or a certificate in fields such as public health, health administration, business administration, or education. We offer a three-year traditional track which includes two years of clinical training and one year of scholarly activity, and a four-year scholarly track which includes two years of clinical training and two years of scholarly activity. In addition, extended research training may be available for exceptionally promising physician-scientists. The program makes scholarship a high priority and strongly encourages presentation of original research at a national meeting, completion of original research which is published in a peer reviewed journal, or completion of a graduate degree, as a requirement for completing the training program.

First-year fellows meet regularly with the division director, the program director, and the associate program director for research to explore options for scholarly activity and mentorship congruent with their interests and career goals. By the spring of their first year, they are expected to have identified their research or educational projects and begun preparing to launch these projects. All first-year fellows present their proposed projects to the faculty and the fellows at a retreat in the spring. Scheduling of scholarly time in the second, third, and/or fourth year is established following discussion with the program director and the mentor so as to maximize the likelihood of productivity and success.

The University of Iowa has multiple NIH T32 training grants that support research training for clinical and postdoctoral fellows, including the longest funded cardiovascular NIH T32 training grant at the Abboud Cardiovascular Research Center. Nevertheless, most fellows, especially those embarking on basic or translational science research projects, are expected to submit an external grant application to support their research effort, for example to the American Heart Association or to the NIH. This is an important learning exercise in terms of formulating a hypothesis, learning the tools necessary to answer a significant question, and critically analyzing the pertinent literature.

In conjunction with the Abboud Cardiovascular Research Center, fellows and other trainees present their research data to a wide audience of clinical and non-clinical faculty, clinical and postdoctoral fellows, undergraduate, medical, and graduate students, and staff. Each fellow is assigned one cardiology grand rounds presentation each year that may be used to present her or his research data. Fellows are encouraged to present their research at national meetings, including those of the American Heart Association, the American College of Cardiology, and other major national and international societies.

Examples of Research Opportunities

The University of Iowa is a top 10 public university in terms of biomedical research funding.

Abboud Cardiovascular Research Center

The Abboud Cardiovascular Research Center (ACRC)is led by Barry London, MD, PhD, who is also Director of the Division of Cardiovascular Medicine, and is comprised of nearly 200 researchers. A remarkable feature of the center has been the multiplicity of faculty leadership that has led the center's research program development and mentoring in a spirit of independence infused with shared ideals, common goals, and collegial interaction. The center has modeled a culture of collaboration, team research and mentoring that has been emulated across the university campus and has been adopted by most successful academic research institutions. Interdisciplinary research and training are the rule, not the exception. Basic research at the ACRC is the wellspring from which translation and innovation flow. In line with the deep tradition at the University of Iowa, the center fosters new collaborative partnerships among programs, investigators, and cores, both within and outside the university in areas such as drug, device, and biotech development. Recent activities on that front include partnerships with the Institute of Molecular Medicine at Beijing University, China, and the Institute for Molecular and Translational Cardiology, University of Heidelberg, Germany. The center has trained over 1,000 pre- and post-doctoral students, received over $500 million in research funding, and currently has over $10 million extramural research funding per year. It has the longest funded cardiovascular NIH T32 training grant in the United States.

Active areas of research include:

  • Atherosclerosis and vascular biology
  • Bioengineering
  • Cardiac computerized tomography
  • Cardiac electrophysiology and electropharmacology
  • Cardiac hypertrophy and failure
  • Cardiac nuclear imaging
  • Clinical trials
  • Control of cerebral circulation
  • Control of circulation in heart failure
  • Cardiac metabolism
  • Cardiomyopathies, muscular dystrophies, and heart failure
  • Cardio-oncology
  • Cardiovascular genetics and development
  • CT imaging
  • Cystic fibrosis, pulmonary hypertension, and other lung diseases
  • Coronary physiology
  • Defibrillation
  • Echocardiography
  • Genetics
  • Gene transfer
  • Hypertension
  • Humoral control of circulation
  • Inflammation
  • Integrative neurobiology and sensory signals in cardiovascular regulation
  • Ion channels, calcium handling, and arrhythmias
  • Lipid biochemistry
  • Magnetic resonance imaging
  • Mechanisms of hypertension
  • Molecular biology and genetics
  • Myocardial function in physiological and pathologic states
  • Neurogenic control of circulation
  • Parasympathetic & adrenergic mechanisms
  • Valve disease
  • Vascular endothelium and smooth muscle

Fraternal Order of Eagles Diabetes Research Center

The Fraternal Order of Eagles Diabetes Research Center (FOEDRC) was established in 2008 through a partnership between the University of Iowa and the Fraternal Order of Eagles, who founded the FOEDRC with a $25 million gift. The donation was matched by $25 million from the UI to provide state of the art research facilities and research / administrative support for the FOEDRC. The FOEDRC has rapidly risen in prominence through innovative vision and leadership, recruitment and support of superlatively creative diabetes scientists, world-class facilities and research environment, and institutional support. In 2015, the FOEDRC moved into 20,000 square feet of newly built advanced research space stocked with state-of-the-art biomedical research equipment.

Paul D. Wellstone Muscular Dystrophy Cooperative Research Center

The major theme of the University of Iowa Paul D. Wellstone Muscular Dystrophy Cooperative Research Center (MDSRC) is to translate research discoveries on the structure and function of dystroglycan into clinical applications for the diagnosis and treatment of patients with dystroglycan-related muscular dystrophy. The overall goal is to explore therapeutic strategies for the treatment of various muscular dystrophies arising from the abnormal processing of dystroglycan (dystroglycanopathies).

Institute for Clinical and Translational Science

The Institute for Clinical and Translational Science (ICTS) is a home for clinical and translational science, that leverages infrastructure that includes a highly functional Clinical Research Unit. Its training program has strong foundational lectures and coursework in scientific design, statistics, regulatory science and other skills. It has incorporated successful programs from other CTSA hubs and has focused on flexible formats including online education. The program places a strong emphasis on mentoring, and planning for how to translate science to practice through business models and policy change. 

Examples of Graduate Degrees and Certificates

College of Public Health

Tippie College of Business

Fellows as Clinician Educators (FACE) Program

Internal Medicine subspecialties increasingly are training faculty and fellows who will fill a significant need in medical schools – clinical faculty who are interested in teaching. The clinician-educator academic track was introduced at the University of Iowa in recognition of this trend. Training for these positions involves acquiring a different set of skills and approaches than those traditionally provided to trainees interested in a clinical or physician-scientist career. The Faculty/Fellows as Clinician Educators (FACE) Program addresses the needs of faculty/fellows interested in a clinician-educator career. The goal of the FACE Program is to introduce clinician-educators to a knowledge base and skill set that will be useful in their careers. The FACE Program is offered to General Internal Medicine faculty physicians (hospitalists) and internal medicine fellows who have been identified by their program directors as having a high interest in being a clinical educator. The program presents concepts of clinical teaching skills, observation and feedback, small group teaching, and interactive lecture development. The division director or fellowship program directors must allow protected time for faculty/fellows to participate in course activities. In addition, participants should have opportunities for clinical teaching while participating in FACE.

Institutional Training Grants

The University of Iowa has multiple NIH T32 training grants that support research training for clinical and postdoctoral fellows. Some examples relevant to cardiovascular medicine and science are listed below.

Fellows as Clinician Educators (FACE)

The Fellows as Clinician Educators (FACE) Program is designed to introduce future clinician-educators to a set of skills which may be of use in their career. The program presents concepts of educational design and research, lecture development, evaluation, observation and feedback. At the conclusion of the program, FACE participants are required to develop a teaching portfolio.

Learn more about FACE

Interdisciplinary Fellowship Conference

Below is an example of the Dapartment of Internal Medicine Common Curriculum Schedule. It is shared between Fellows from all divisions of the Department.

PDF icon20-21 Fellows Conference Master Schedule.pdf

How to Apply

Applications are only accepted through the Electronic Residency Application System(ERAS).

The deadline for ERAS applications is July 20.

US residents should contact their Dean's Office or ERAS at https://students-residents.aamc.org/training-residency-fellowship/applying-fellowships-eras/.

International residents should contact the ECFMG at www.ecfmg.org/eras/index.html.

All applicants must also register with the National Resident Matching Program:www.nrmp.org (Phone: 202-828-0566).

Positions are available for fellows who wish to obtain clinical and research training in cardiovascular diseases beginning July 1 next year. The cardiology fellowship program is three to four years in duration depending on the candidate’s interest in subspecialty training, research, or other scholarly activity. We strongly encourage applications from candidates interested in a four-year fellowship position geared towards training as physician-scientists to become future leaders in academic cardiovascular medicine. We provide broad-based clinical experiences in cardiovascular medicine at our teaching sites , the University of Iowa Hospitals and Clinics (including the Heart and Vascular Center and the University of Iowa Stead Family Children's Hospital) and the Iowa City Veterans Affairs Health System. Clinical training is provided in cardiac catheterization, coronary angiography, electrocardiography, clinical cardiac electrophysiology, echocardiography, cardiac radionuclide imaging, cardiac magnetic resonance imaging, cardiac computed tomography, stress testing, adult congenital heart disease, vascular medicine, outpatient cardiology, and cardiology consultation.

Depending on the interests of the applicant, basic research training is provided in the broad areas of cardiovascular physiology, biochemistry, pharmacology, electrophysiology, molecular biology, and genetics. Research is conducted at several different levels, including studies on patients or normal subjects, on animal models, and at cellular and molecular levels. Opportunities for translational, clinical, and population science research projects are also available. Faculty in the Division of Cardiovascular Medicine apply their expertise in the laboratory to the solution of specific problems. The interaction of investigators provides an optimal environment for training of young investigators and the emergence of new ideas and new directions in research. The fellowship also provides opportunity for research training with scientists in other departments who are involved in research programs within the interdisciplinary Abboud Cardiovascular Research Center. This experience is integrated with clinical training in preparation for an academic career. Research conferences and seminars are held regularly. The research experience may vary from six months to 24 months, depending on research interests. We strongly encourage applicants interested in applying for a four-year fellowship program for training as academic physician-scientists to mention their objective clearly in the personal statement. Research opportunities for cardiovascular fellows include:

  • Atherosclerosis and vascular biology
  • Bioengineering
  • Cardiac computerized tomography
  • Cardiac electrophysiology and electropharmacology
  • Cardiac hypertrophy and failure
  • Cardiac nuclear imaging
  • Clinical trials
  • Control of cerebral circulation
  • Control of circulation in heart failure
  • Cardiac metabolism
  • Cardiomyopathies, muscular dystrophies, and heart failure
  • Cardio-oncology
  • Cardiovascular genetics and development
  • CT imaging
  • Cystic fibrosis, pulmonary hypertension, and other lung diseases
  • Coronary physiology
  • Defibrillation
  • Echocardiography
  • Genetics
  • Gene transfer
  • Hypertension
  • Humoral control of circulation
  • Inflammation
  • Integrative neurobiology and sensory signals in cardiovascular regulation
  • Ion channels, calcium handling, and arrhythmias
  • Lipid biochemistry
  • Magnetic resonance imaging
  • Mechanisms of hypertension
  • Molecular biology and genetics
  • Myocardial function in physiological and pathologic states
  • Neurogenic control of circulation
  • Parasympathetic & adrenergic mechanisms
  • Valve disease
  • Vascular endothelium and smooth muscle

Prerequisites are an MD or DO degree and completion of an approved[AF1] [BCJ2]  residency in internal medicine. Approved residency programs are accredited by the ACGME, approved by the AOA, accredited by the Royal College of Physicians and Surgeons of Canada (RCPSC), or accredited by ACGME International (ACGME-I). Appointments are made on an annual basis, with a starting date of July 1. The stipend is dependent on years of training.

Please note that all information listed below will be required by the August 11 deadline.
Completed applications are reviewed by our faculty, and we invite for interview those individuals whose credentials suggest that they will have good potential to be offered an appointment. Applicants with a J-1 or H-1B visa and high scores and research publications will be considered for our fellowship program. If you are selected for an interview, we will send you a letter of invitation. Interviews will take place in September-October.

A complete ERAS application includes:

  • Curriculum vitae
  • Statement of the applicant's long-term career goal and field of interest
  • Dean's letter
  • Three current letters of recommendation
  • Applicant's transcripts for USMLE Steps 1, 2, and 3
  • Medical school transcript
  • Publications and manuscripts, if applicable, can be listed in the summary sheet and CV sections of the ERAS application. Applicants selected for interview may be asked to forward reprints of published articles, and copy of published or submitted manuscripts.
  • Reprints of published articles, copy of published or submitted manuscripts (if applicable)
  • A recent photograph of applicant must accompany application

Application Deadline

The deadline for applications is July 20.

Selected candidates for the interview process will be notified by the first part of September.


2021 Recruitment Timeline

  • We have adapted our usual application and interview procedures to meet the challenge of the COVID-19 pandemic.
  • The application deadline through ERAS is July 20, 2021
  • We will extend invitations for interviews the week of August 23, 2021
  • Our virtual interview dates are September 13, 20, 27, and October 5, 11 and 13, 2021. We will be holding 2 half days sessions for each of these dates.
  • New fellows will begin training on July 1, 2022.

Board Certification

Medical specialty certification in the United States is a voluntary process which serves multiple purposes for the trainee and the public.

Certification is

  • one mission of the training program to produce trainees who meet board eligibility criteria;
  • distinguishes a physician as someone with a distinct level of expertise;
  • provides more opportunities when applying for employment;
  • presents resources and tools by the ABMS;
  • a commitment to life-long improvement for providing the best patient care; and
  • elevates physicians into the ranks of doctors committed to the highest standards of healthcare.

For more information visit the American Board of Internal Medicine for specifics on board certification requirements.

Eligibility 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. Most fellowship trainees are usually 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 Iowa Board of Medical Examiners.

Interview Information

  • The application deadline through ERAS is July 20, 2021
  • We will extend invitations for interviews the week of August 23, 2021

Our virtual interview dates are September 13, 20, 27, and October 5, 11 and 13, 2021. We will be holding 2 half days sessions for each of these dates.

Interviews will be conducted individually with 4-6 of our faculty members, including the program director, the associate program directors, and the division director, for approximately 20-25 minutes each. Applicants will also have an opportunity to speak with our fellows informally following the faculty interviews. We plan to use Zoom as our interview platform.

Our People

A Message from the Program Director

One of the most gratifying aspects of being at the University of Iowa is the opportunity to work with stellar clinical and postdoctoral fellows and medical, graduate, and undergraduate students, and to contribute to their development into thought leaders in clinical medicine, education, research, administration, and public health.

With access to state-of-the art clinical and research facilities and world-renowned faculty, our fellows have had all the resources to excel during their general cardiology and subspecialty training and in their subsequent careers.

We are thrilled that you are considering joining our program, our university, and our city. We all look forward to meeting you.

 

Ferhaan Ahmad, MD, PhD
Director, Cardiovascular Disease Fellowship Program
Director, Cardiovascular Genetics Program
Associate Professor of Internal Medicine

Phone: 319-384-8001
Email: ferhaan-ahmad@uiowa.edu

Program Leadership

 

Barry London, MD, PhD
Director, Division of Cardiovascular Medicine
Director, Abboud Cardiovascular Research Center
Professor and Potter Lambert Chair in Internal Medicine

Phone: 319-356-2750
Email: barry-london@uiowa.edu

 

Milena Gebska, MD, PhD
Associate Director, Cardiovascular Disease Fellowship Program
Clinical Associate Professor of Internal Medicine - Cardiovascular Medicine

Email: milena-gebska@uiowa.edu

 

Kaikobad Irani, MD
Associate Director, Cardiovascular Disease Fellowship Program
Professor of Internal Medicine

Email: kaikobad-irani@uiowa.edu

 

Kimberly Delcour, DO
Assistant Director, Cardiovascular Disease Fellowship Program
Clinical Assistant Professor of Internal Medicine

Email: kimberly-delcour@uiowa.edu

 

Sidakpal Panaich, MBBS
Assistant Director, Cardiovascular Disease Fellowship Program
Clinical Assistant Professor of Internal Medicine

Email: sidakpal-panaich@uiowa.edu

Contact Us

Cari Harland
Cardiology Fellowship
Department of Internal Medicine - E316-1 GH
The University of Iowa Carver College of Medicine
200 Hawkins Drive
Iowa City, IA 52242-1009
Phone: 319-384-8001
Fax: 319-353-6343
email: cari-harland@uiowa.edu

Denise Floerchinger
Internal Medicine Fellowship Program Administrator

Phone: 319-356-2732
Email: denise-floerchinger@uiowa.edu

Current Cardiovascular Disease Fellows

First Year Fellows

Michael Arustamyan

 

Michael Arustamyan, DO
Medical School: Lake Erie College of Osteopathic Medicine
Residency: Cleveland Clinic


Eric Heller

 

Eric Heller, MD
Medical School: University of Iowa
Residency: University of Iowa


Suvasin Lakshmanan

 

Suvasini Lakshmanan, MBBS
Medical School: Jawaharlal Institute
Residency: University of Massachusetts


Paul Lee

 

Paul Lee, MD
Medical School: Virginia Commonwealth University
Residency: University of Colorado


Farhad Sami

 

Farhad Sami, MBBS
Medical School: Services Institute of Medical Sciences
Residency: University of Kansas


Giselle Statz

 

Giselle Statz, MD
Medical School: Loyola University
Residency: University of Iowa


2nd Year Fellows

 

Thor Bjarnason, MD, PhD
Medical School: University of Iceland
Residency: University of Iowa


 

Nick Isom, MD
Medical School: University of Oklahoma
Residency: University of Kansas


 

Arooj Khan, MBBS
Medical School: Allama Iqbal Medical College
Residency: Cleveland Clinic


 

Nagalakshmi Nagarajan, MD
Medical School: University of Texas Health Sciences Center-Houston
Residency: University of Iowa


 

Vikram Sharma, MBBS
Medical School: Seth G.S. Medical College
Residency: Cleveland Clinic


 

Wasawat Vutthikraivit, MD
Medical School: Ramathibodi Hospital Faculty of Medicine
Residency: Texas Tech University


Third Year Fellows

 

Derek Eshun, MBChB
Medical School: Kwame Nkrumah University of Science & Technology School of Medical Sciences
Residency: Meharry Medical College


 

Corina Iorgoveanu, MD
Medical School: Universitatea de Medicina si Farmacie Carol Davila
Residency: University of Connecticut Health Center


 

Jai Parekh, MBBS
Medical School: B.J. Medical College, Pune, India
Residency: Creighton University School of Medicine


 

Tyler Rasmussen, MD, PhD
Medical School: University of Iowa
Residency: University of Iowa


 

Doosup Shin, MD
Medical School: Korea University College of Medicine
Residency: University of South Florida College of Medicine


 

Ahmed Zaghloul, MBBCh
Medical School: Ain Shams University Faculty of Medicine
Residency: University of Connecticut


 

Jin Zhao, MB, PhD
Medical School: China Medical University
Residency: University of Maryland Medical Center Midtown


Fourth Year Fellow

 

Colin Burnett, MD
Medical School: University of Iowa
Residency: University of Iowa

Current Faculty

The Department of Internal Medicine has a faculty of nearly 300 professionals whose clinical, teaching, and research expertise spans the entire discipline of medicine.

Cardiovascular Medicine Division Faculty

Department Faculty (alphabetical listing)

Chair, Department of Internal Medicine

Isabella Grumbach, MD, PhD
Interim Chair and DEO, Department of Internal Medicine
Kate Daum Endowed Professor
Professor of Medicine – Cardiovascular Medicine
Professor of Radiation Oncology