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.
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.
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”.
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.
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.
Fellows are exposed to complex cardiovascular problems encountered in a quaternary care hospital (University of Iowa Hospitals & 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.
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.
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 & 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.
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.
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 & 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.
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 & 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.
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.
Learn more about the Nuclear Cardiology abd Stress Testing rotation.
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:
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.
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
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.
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.
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”.
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:
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:
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:
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:
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 |
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.
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.
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.
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
In the EP lab, the trainee will develop and be expected to demonstrate expertise in the following aspects related to EP procedures, including:
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.
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.
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.
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.
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.
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.
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 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.
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.
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. Fellows will have the option to obtain additional exposure to ECMO management if they wish during their CVICU rotations.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
The overall duties and responsibilities on this rotation include:
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).
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.
The objectives of this rotation are as follows:
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.
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.
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.
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.
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.
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:
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.
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.
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.
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.
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
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:
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.
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.
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.
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 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.