SCHOOL OF MEDICINE • DEPARTMENT OF MEDICINE

Introduction/Overview

The rotation in the Echocardiography laboratory is designed to enable fellows to achieve the knowledge, skills and attitudes of competent cardiologists needed to properly apply the echocardiographic methods (transthoracic [TTE], Real-time three-dimensional transesophageal [TEE], and stress echo [SE]) used in the care of patients with known or suspected cardiovascular conditions. Learning occurs through hands on, supervised clinical procedures, daily reading sessions, and divisional and departmental conferences. In addition to interpretation of images, attending physicians are expected to reinforce the findings of the study to an understanding of the etiology, pathogenesis, clinical presentation and natural history of cardiovascular diseases. Fellows begin learning to perform TEE from their FIRST year of the fellowship under supervision and develop excellent technical skills quickly.

Fellowship training in echocardiography includes instruction in the physical principles and instrumentation of ultrasound and cardiovascular anatomy, physiology and pathophysiology both in regard to the cardiovascular system in general and in relationship to the echocardiographic examination in particular.

Fellows rotating through echocardiography at all levels are responsible for leading the weekly echocardiography conference under the supervision of the echocardiography director. They are expected to discuss interesting and educational cases for review with the Echocardiography Director prior to the conference and to prepare a short didactic review complimenting case studies. The goal of the conference is to expose fellows the myriad echocardiographic aspects of cardiovascular disease. The curriculum detailed below will be covered by these didactic presentations in addition to core lectures in echocardiography, echo study review, and clinical conferences.

Appropriate utilization of the health system resources is particularly important in the echo laboratory; this is highlighted by the recent development of appropriateness criteria by the ACC and related imaging Societies. In addition to understanding these guidelines and integrating with other imaging technologies, the fellow is expected, when feasible, to review relevant studies in patients referred for stress echo and TEE, to evaluate medical complaints in patients in the laboratory, and to participate in decisions regarding additional testing, care, and triage. Finally, fellows are expected to communicate effectively with house staff, nursing staff, referring physicians, other cardiologists, and other members of the health care team.

The echocardiography laboratory is committed to providing exceptional clinical service 24/7. In this regard, the on-call schedule applies to sonographers, fellows and echocardiography attendings. Fellow call is dictated by the Night Float and weekend call schedules. Studies performed while on-call should be stored for review the next working day with the echo attending. A note detailing the preliminary findings should be written on any patient receiving an echocardiogram after-hours.

It is recognized that ultrasound is an evolving technology with an expanding list of methods and clinical indications. The core cardiology training symposium (COCATS) has defined three levels of expertise. The cardiology program at UH will provide Level 2 training for all cardiology fellows; Level 3 training is available but optional. Level 2 training provides the candidate the necessary knowledge and experience to be capable of performing and interpreting an echocardiographic examination (M-mode, 2D, TEE, exercise and pharmacologic stress echo) independently under the supervision of a laboratory director. This requires a minimum of: 150 TTE performed/300 supervised interpretations, 25 TEE intubations/50 supervised studies, 100 supervised stress echos, and 20 contrast studies. The third level of expertise requires additional training and will enable the trainee to direct an echocardiography laboratory, as well as perform various special ultrasound procedures, such as 3D echo, myocardial perfusion imaging, and myocardial strain echocardiography.

The Echocardiography Laboratory at Case Medical Center is a full-service, ICAEL-accredited multi-vendor laboratory performing over 10,000 TTEs, over 600 TEEs, and over 800 SEs. Newer techniques (e.g. myocardial strain imaging, 3D TEE, 3D strain) are used routinely. System-wide integration of studies and interpretation on HeartLabs facilitates second opinions, ensures timely study interpretation, and assists quality assurance. There are nine ongoing clinical studies in the laboratory.

 

Principle Teaching Methods

Direct Supervision of Patient Care
The attending physician provides supervision to all members of the team via direct patient care; this involves performing and interpreting TEE and stress echos and interpretation of TTE studies. Hands-on scanning is performed under the instruction and supervision of senior sonographers.

Case-Based Learning
Selected TTE, TEE, and stress echos are used for in-depth discussions examining the clinical context of the echocardiographic study. Clinical data, previous echocardiograms, angiograms, CMR and CT studies, and pathology are analyzed when available. These teaching sessions are seamlessly integrated into reading sessions and are analogous to daily attending walk rounds.

Didactics
The curriculum in echocardiography is formally presented in The Core Curriculum and the Echo conference; other venues include Divisional and Departmental conferences.

 

Clinical Content

Patient Characteristics
The mix of patients referred for an echocardiographic study are typical for a tertiary hospital and offers a wide range of pathologies from a broad racial, ethnic, and socioeconomic population.

Procedures
Fellows learn TEE and stress echocardiography under the direct supervision of attendings. Advanced techniques, such as 3D echo and strain rate imaging are routinely employed.

 

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, echo image data bases, Up-to-Date, and textbooks are available on all wards. 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 the American Society of Echocardiography.

 

Methods used in Evaluation and Performance

A competency-based evaluation matrix for written evaluations is to be completed at the end of the CICU rotation by the attending using the www.myevaluations.com system. Attendings 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 provides verbal feedback. Fellows complete written, anonymous evaluations of the attending. Fellows complete a written rotation evaluation with specific attention to the learning objectives. 360 degree feedback is accomplished via written feedback from the Chief Sonographer. Duty hour compliance is monitored by the Program Director.

 

Objectives by PGY Year

While both first and second year fellows rotate through the laboratory, expectations and independence vary by level of training. Fellowship is a continuous process of professional and academic growth, with each individual progressing at a somewhat different pace and along a unique path. First year fellows should spend mornings scanning with the sonographers during their first month and should become familiar with the procedures for recording, storing, and retrieving images. Initially, the trainee interprets the echocardiogram with the attending, and as the fellow progresses, studies are read independently and subsequently reviewed with the attending. Senior fellows, as they obtain sophistication, judgment, and knowledge, should take a prominent/leadership role in guiding education and patient care. Every cardiology fellow should be exposed to and familiar with the clinical performance, interpretation, strengths and limitations of TTE, TEE and stress echocardiography, and their multiple clinical applications. All fellows are expected to progress in the six ACGME Competencies.