SCHOOL OF MEDICINE • DEPARTMENT OF MEDICINE

Introduction/Overview

The rotation in nuclear cardiology is meant to enable fellows to achieve the knowledge, skills, and attitudes of competent cardiovascular specialists in the interpretation of nuclear myocardial perfusion images acquired during exercise and pharmacologic stress testing. Fellows are expected to gain proficiency in the diagnosis and management of critical cardiac conditions. Learning occurs through hands-on, supervised clinical experiences, reading studies side-by-side with attending nuclear medicine physicians, and attend divisional and departmental conferences. Attending physicians are expected to reinforce the understanding of the etiology, pathogenesis, clinical presentation, and natural history of cardiovascular diseases diagnosed and evaluated by nuclear cardiology. Trainees are expected to develop their skills in clinical problem solving, diagnosis, therapy, interviewing, communication and interpersonal skills, and in navigating system issues impacting inpatient care.

The rotation should enhance fellows understanding of the diagnosis and risk stratification of acute cardiac conditions. The fellow will play an integral role in the education of their co-fellows. The fellow is expected to contribute to monthly teaching conferences both by selecting cases to present and discuss as well as by bringing in appropriate literature to review. Senior fellows are expected to demonstrate increased clinical leadership.

The fellow is expected to be involved intimately in patient care and be familiar with the results of procedures, and to review the actual tests as appropriate, including correlation with cardiac catheterization results. Appropriate utilization of the health system resources is particularly important in the Section of Nuclear Imaging. The fellow is expected, when feasible, to come in early to evaluate studies ordered for that day, in order to fully participate in decisions regarding additional testing, care, and triage. Fellows are expected to communicate effectively with house staff, nursing staff, referring physicians, other cardiovascular specialists, and other members of the health care team.

All fellows are expected to progress in the six ACGME Competencies. The nuclear cardiology rotation is particularly well-suited for practice-based learning and improvement as well as for understanding a systems-based perspective. Senior fellows, in conjunction with attending staff, are expected to choose one relevant focused area of nuclear cardiology and endeavor to evaluate and/or improve the overall quality in that area.

Principle Teaching Methods

Direct Supervision of Diagnostic Testing
The fellow provides supervision of all patients undergoing exercise and pharmacologic stress testing by being immediately available within the Nuclear Imaging Section while patients are undergoing stress testing. The attending physician provides supervision to all members of the team via direct patient care. The team includes radiology residents and a cardiovascular fellow.

Case-Based Learning
Daily interpretation of nuclear cardiology studies
Attending physicians are expected to teach during study interpretation in addition to discussing routine patient management; teaching time should average 4 - 5 hours per week. The fellow is expected to take a leadership and teaching role during study interpretation commensurate with his/her experience and knowledge. The expectation is that fellow leadership and teaching will progress during the training period.

Clinical Content

Patient Characteristics
The mix of patients is typical for a nuclear cardiology program in a tertiary hospital and includes patients with myocardial infarction, unstable angina, congestive heart failure, cardiogenic shock, and severe valvular disease.

Procedures
Fellows have the opportunity to learn procedures under the direct supervision of attendings and qualified fellows (fellows who have documented satisfactory competency in these procedures), including single- and dual-isotope nuclear myocardial perfusion imaging (MPI), gated blood pool (MUGA) scans, and positron emission tomography (PET).

Principle Educational Material Used

Fellows have 24-hour access to the Core Library located in the hospital. Computer access to literature searching, on line journals, Up-to-Date, and textbooks is available. Fellows are expected to be proficient in obtaining requisite information on pathophysiology from standard textbooks and the medical literature. Current therapeutics should be guided by the medical literature with particular weight given to clinical guidelines and consensus statements issued by the American College of Cardiology, the American Heart Association, and similar professional bodies.

Methods used in Evaluation and Performance

A competency-based evaluation matrix for written evaluations is to be completed at the end of the nuclear cardiology rotation by the attending using the www.myevaluations.com system. Attending evaluations are sent electronically to the fellow upon completion and are available for review by the fellows on-line and at the time of their semi-annual evaluation/counseling meetings. In addition to a written evaluation, the attending physician is to give verbal feedback. Fellows complete written evaluations of the attending, which are anonymous. Fellows complete a written rotation evaluation with specific attention to the learning objectives. 360-degree feedback is accomplished via written feedback from nursing personnel and certified nuclear medicine technologists (CNMTs). Duty-hour compliance is monitored by the Program Director.

Level of Supervision by Faculty
All fellows are supervised by the attending of record according to the institutional policy on attending supervision that is included in our departmental policies.

Objectives by PGY Year

The attending physician is immediately available through paging and speaks regularly with the radiology residents and cardiovascular fellow. Fellows and attending physicians are available, usually within 30 minutes, for assistance with patient evaluation and for interpretation of studies. Attending physicians must document their involvement in the evaluation of patients’ studies daily. As there are only two one-month blocks of Nuclear Medicine training, the expectations, objectives and goals are similar for junior and senior fellows (and may occur in the same year).