SCHOOL OF MEDICINE • DEPARTMENT OF MEDICINE

Introduction/Overview

The catheterization laboratory rotation is designed to enable fellows to achieve competence at the level expected of a new practitioner. Fellows will be trained to implement compassionate, appropriate, and effective patient care; establish a solid medical knowledge base; and acquire clinical and technical skills to apply to patient care. The program integrates practice-based learning experiences and fellow involvement in quality improvement programs. The rotation also includes didactic learning in the form of weekly conferences and reviews of scientific literature, in addition to bedside teaching. The fellows will be mentored to effectively communicate information to patients, their families, and other health professionals, and to adhere to high ethical principles. The fellowship also provides a system-based practice experience to involve fellows in the larger healthcare system.

The trainees are expected to develop their skills in clinical problem solving, diagnosis, and implementation of optimal therapeutics. They are also expected to refine their interviewing and interpersonal communication skills to help navigate system issues impacting patient care. The fellow is expected to be intimately involved in patient care and be familiar with the results of diagnostic tests and therapeutic procedures. The fellow is expected to be involved with the pre, post and intra-procedural care to understand the importance of continuity of care. The fellow is expected to review the appropriate literature, provide his/her perspective on clinical management and present at a weekly case-based catheterization conference, which also includes didactic lectures by interventional fellows and faculty. Senior fellows are expected to demonstrate increased clinical leadership and independence in diagnostic catheterization procedures. Fellows are expected to communicate effectively with house staff, nursing staff, technicians, referring physicians, other cardiologists, and other members of the health care team. All fellows are expected to progress in the six AGME Competencies.

The cardiac catheterization laboratory rotations are integrated between University Hospitals Case Medical Center (UHCMC) and Louis B. Stokes VA Medical Center (VA). UHCMC has five state of the art and fully equipped cardiac cath labs and the VA has two. The catheterization laboratory physician staff primarily responsible for fellow training is largely the same at both institutions. Other on site capabilities at both UHCMC and the VA include cardiac ICU, cardiac surgery, clinical electrophysiology, echocardiography, nuclear cardiology, and cardiac imaging using CT and MR techniques.

Attending catheterization laboratory physicians are expected to closely oversee the cardiology fellows’ performance and reinforce their understanding of etiology, pathogenesis, clinical presentation and natural history of cardiovascular diseases.

Principle Teaching Methods

Direct Supervision of Patient Care
The cardiology catheterization laboratory attending provides supervision to the catheterization laboratory team consisting of an interventional fellow, a general cardiology fellow, nursing staff and technicians.

Case-Based Learning/Direct Observation of Procedures
Cardiology fellows perform procedures under the direct supervision of the catheterization laboratory attending who is responsible for pre and post procedure teaching of the fellow as well as intra-procedure education.

The fellow should review all cases with the attending physician before catheterization procedures. This discussion includes review of pathogenesis, diagnostic options, previous diagnoses and test results, potential therapies and review of other medical co morbidities. Attending physicians are expected to review current literature, guide fellow reading targeted at specific patient disease processes or procedures, and discuss routine patient management on a daily basis. Several cases per week should be selected for more in depth literature review and discussed in detail with the attending or presented at an appropriate divisional conference.

Conferences
A variety of conferences have been formulated to optimize the training experience of cardiology fellows in the catheterization laboratory. Fellows are expected to attend the weekly divisional clinical case conference as well as the monthly M&M conference. Cardiology Grand Rounds attendance is also mandated. A number of more focused conferences have been implemented for catheterization laboratory based fellow education. Interventional conference at UHCMC is a weekly 90 minute conference devoted in part to literature reviews of key invasive cardiology topics. The interventional fellows are primarily responsible for these presentations. In-depth case review sessions are also done at these conferences to go over interesting, challenging or problematic cases. Interventional conference at the VA is a joint cardiology/cardiac surgery conference held weekly. Fellows rotating through the catheterization laboratory are expected to attend these conferences since there is great educational merit for general fellows regarding diagnostic catheterization.

Clinical Content

Patient Characteristics
Patient mix at UHCMC is typical for a tertiary academic medical center cardiac catheterization laboratory. A wide spectrum of cases at differing levels of acuity /complexity is encountered. This includes patients with myocardial infarction, stable and unstable angina, heart failure, pulmonary hypertension, peripheral arterial disease, structural and congenital heart disease, cardiogenic shock, valvular disease, aortic dissection, hypertension, hypertrophic cardiomyopathy, arrhythmia, etc. The current catheterization laboratory volume at UHCMC is approximately 2400 cases per year. Patients come from a diverse socio-economic spectrum. The VA provides experience and exposure to a sizable and different patient population which further enhances the fellowship training. Current catheterization laboratory volume at the VA is approximately 1400 cases per year. Fellows typically perform approximately 75-100 diagnostic catheterization procedures during each month that they are in the catheterization laboratory. Fellows spend two months at the VA during their first year of fellowship. Second year fellows spend two months at the UHCMC catheterization laboratory. Third year fellows may elect to spend a month or two at the UHCMC catheterization laboratory.

Procedures
Fellows have the opportunity to learn basic and advanced diagnostic catheterization procedures under the direct supervision of an experienced invasive cardiologist.

Principle Educational Material Used

An array of Invasive Cardiology textbooks is readily available at both UHCMC and VA catheterization laboratories for easy and quick reference. In addition, fellows have access to the libraries located in both hospitals. Computer access for literature searches via on line journals is readily 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, the Heart Failure Society of America, the Society for Coronary Angiography and Intervention, the Heart Rhythm Society and similar professional bodies.

Methods used in Evaluation and Performance

A competency-based evaluation matrix for written evaluations is to be completed regularly by the catheterization laboratory cardiologists who interact with the fellows 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 regular evaluation meetings with the Fellowship Program Director. In addition to a written evaluation, the attending physician is to give verbal feedback. Fellows complete a written rotation evaluation with specific attention to the learning objectives. 360 degree feedback is accomplished via written feedback from technician and nursing personnel in the catheterization laboratories. Duty hour compliance is monitored by the Program Director.

Level of Supervision by Faculty

All catheterization laboratory 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

Catheterization laboratory fellows will be responsible for patients they are performing diagnostic catheterization procedures on. They will work closely with the catheterization laboratory attending to be sure appropriate treatment plans and discharge plans are implemented following the procedure. On occasion, patients may require admission to an in-patient cardiology team. Pertinent clinical information will be given to the accepting attending physician and cardiology fellow by the catheterization laboratory fellow to ensure continuity. Catheterization laboratory fellows have 24-hour a day access to the catheterization laboratory attending to discuss patient management. Catheterization laboratory fellows have no on-call responsibility during the catheterization laboratory rotation.

While both first and second year fellows rotate through the catheterization laboratory, expectations and independence vary by level of training. Specific personal goals and expectations for further development are assessed before the rotation begins. These will be related to the fellow’s learning portfolio, and should take into account the fellows prior performance, degree of competence, comfort and experience. Senior fellows are expected to demonstrate increased clinical leadership in patient care and independence in diagnostic catheterization procedures; moreover, it is expected that senior fellows will not only master the subject content necessary to care for patients with cardiovascular disease, but will also develop a sophistication and maturity of clinical judgment. Thus, fellowship is a continuous process of professional and academic growth, with each individual progressing at a somewhat different pace and along a unique path.