SCHOOL OF MEDICINE • DEPARTMENT OF MEDICINE

Introduction/Overview

The rotation on the clinical electrophysiology pacing service is to enable fellows to achieve the knowledge, skill, and competence of cardiologists in the evaluation and management of patients with cardiac arrhythmias. Learning occurs through hands on, supervised clinical experiences, bedside teaching, attending rounds, participation in procedures, and bi-weekly electrophysiology (EP) conferences.

Attending physicians are expected to reinforce the fellow’s understanding of the etiology, pathogenesis, and clinical presentation of cardiac arrhythmias. Trainees are expected to develop skills in arrhythmia recognition, diagnosis, and utilize evidence-based medicine in the management of these patients. The fellow should be able to recognize and treat arrhythmia emergencies. In addition, the fellow will participate in interviewing patients, enhance and develop their communication and interpersonal skills, and navigate system issues impacting patient care.

The fellow will participate in the education of the house staff. The fellow is expected to contribute to rounds by bringing appropriate relevant medical literature for the house staff as well as providing a preliminary management plan. Senior fellows are expected to demonstrate increased clinical leadership as well as familiarity with published guidelines.

Appropriate utilization of the health system resources is of utmost importance in the management of patients with cardiac devices and/or a history of previous arrhythmia. The fellow is expected to gather information prior to attending rounds. Being familiar with previous device evaluations, anti-arrhythmic drug use, results of diagnostic tests and review of telemetry prior to rounds will allow the fellow to participate fully in management recommendations.

The fellow is expected to communicate effectively with the patient, patient’s family, house staff, nursing staff, referring physicians, and the electrophysiology laboratory personnel. All fellows are expected to progress in the six ACGME competencies.

Principle Teaching Methods

Direct Supervision of Patient Care
The attending physician provides supervision to all members of the cardiac arrhythmia service. The service includes a cardiology fellow or a cardiac electrophysiology fellow and a clinical nurse practitioner. The fellow will provide additional supervision to the nurse practitioner and any rotating medical students or residents.

Case-Based Learning
Attending physicians are expected to teach during team rounds in addition to discussing routine patient management; teaching time will average 5 hours a week. The fellow is expected to take a leadership and teaching role on rounds commensurate with his/her experience and knowledge. The expectation is that the fellow leadership and teaching will progress during training.

Clinical Content

Patient characteristics
The mix of patients includes consultative care for patients with arrhythmias admitted to any location within the hospital, including cardiac intensive care unit, medical intensive care unit, surgical intensive care unit, operating suites, recovery room, emergency room, patients on telemetry units, and patients on the general medical and surgical units. In addition the fellow will participate in the care of cardiac arrhythmia patients admitted to an inpatient electrophysiology service comprised of patients initiating anti-arrhythmic drugs, patients with device complications, or patients with a primary arrhythmia diagnosis.

Procedures
The fellow will learn to perform device interrogation and reprogramming under the direct supervision of the attending physician and/or cardiac device nurse. The fellow will attend procedures in the cardiac electrophysiology laboratory. The fellow will have opportunity to participate in device implantation and radiofrequency ablation.

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, and textbooks is 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 emphasis given to clinical guidelines and consensus statements issued by the American College of Cardiology, American Heart Association, and the Heart Rhythm Society.

Methods used in Evaluation and Performance

A competency-based evaluation matrix for written evaluations is to be completed at the end of the Cardiac Electrophysiology rotation by the attending using the www.myevaluations.com system. The evaluations are sent electronically to the fellows upon completion and are available for review by the fellows. In addition to a written evaluation, the attending is to give verbal feedback. Fellows complete written evaluations of the attending which are anonymous. Feedback is also solicited via written feedback from nursing personnel.

Objectives by PGY Year

The Fellow is expected to assume responsibility for the initial evaluation and management of the patients referred for EP Consultation. With the assistance of the attending physician (who is always available for emergent consultation), fellows are responsible for formulating a diagnostic and therapeutic plan. Attending physicians document their involvement in the evaluation and management of patients.

Graded Responsibilities

While the general responsibilities for all years of fellowship are the same, the expectations and independence increase with each successive year 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 (e.g. first year clinical fellows may have completed an EP fellowship). First year fellows are expected to discuss in detail consultations with the attending while patients are actively followed. Second year fellows are expected to have a comfortable handle on management, and to discuss patients with an eye to subtleties of management and future plans. Senior fellows are expected to have facile handling of complex cases, as well as a sophisticated and maturing clinical judgment.  Thus, the expectation is that the leadership and teaching roles will progress during training.