The goal of each rotation of the cardiovascular disease training program is to obtain a vast exposure to cardiovascular disease states, and to achieve the ability to diagnose these disease states through the integration of clinical skill, and both invasive and non invasive testing. Finally, by integrating this information, treatment and management strategies of these disease states is stressed.
The Cardiovascular Disease Fellowship is structured to assure exposure to all areas of Cardiology, both clinical and procedural, with the expectation that fellows achieve competency in these areas. This goal is achieved through integrated rotations in the in-patient and outpatient setting, along with intensive training in the procedural aspects of cardiac care beginning with simulator training. The rotations allow for exposure to all aspects of cardiovascular disease, allowing for progressive growth and expansion of skills to culminate in the ability to provide care to the cardiac patient independently and without supervision. The structure of the program focuses on the core competencies, as defined by the ACGME, as well as the recommendations for training provided by The American College of Cardiology, and reflects an integrated approach to the continuum of cardiac care.
Patient population: Patients referred to the North Shore-LIJ Health System encompass a wide range of ethnic groups and socioeconomic strata. These patients originate from Eastern Queens, Nassau and Suffolk counties, and may be transferred for tertiary care from any of the North Shore-LIJ Health System affiliate hospitals. These patients range from the well insured with a private physician to the uninsured without prior medical care. Patient encounters range from outpatient management in the cardiology continuity clinic, outpatient vascular medicine clinic, outpatient and inpatient congenital heart disease patients, inpatient consultative and electrophysiology services, primary caregiver in the coronary care unit, procedurally based encounters in the cardiac catheterization lab, echocardiography lab, nuclear cardiology lab and electrophysiology lab.
Written Curriculum: Cardiology is a broad and rapidly changing field and no single curriculum could be considered definitive. Each rotation provides its own written curriculum. This curriculum contains a broad base of literature required for eventual mastery of that rotation. Fellows are taught evidence based medicine with strong emphasis on diagnosis and management according to established ACC/AHA guidelines. In addition, each fellow is supplied with Braunwald’s Heart Disease and receives the Journal of the American College of Cardiology and Circulation through affiliate membership in the American College of Cardiology and the American Heart Association. It is through this combination of curriculum text, a standard cardiology reference text, and late breaking literature that fellows are exposed to the full breadth of cardiovascular disease.
Fellows are expected to independently read the curriculum and recommended texts, and publications with emphasis placed on cases currently being managed. The literature is discussed with the Key Clinical Faculty on the rotation. It is this integration of case management and literature review that is most successful in solidifying a knowledge base. Fellows are encouraged to perform independent literature reviews for case presentations and conferences and share this literature with their peers. The program also utilizes web-based teaching tools including “Cardiosource Plus” from the American College of Cardiology. Most of the curriculum and other educational materials are accessed through a “share drive” which allows for easy modification as new materials become available.
Clinical Training: Fellows present clinical cases in the morning report teaching conference and receive educational feedback from both attending physicians and peer fellows. These case presentations include clinical assessments, electrocardiography and arrhythmia evaluation, and evaluation of hemodynamic and imaging data. Fellows round with attending physicians on the CCU, heart failure, congenital heart disease, consultative and electrophysiology services. During these rotations, fellows receive one-on-one instruction and feedback in history taking, physical examination and inpatient management of cardiac disease. In the cardiology continuity clinic, fellows present cases to the attending supervising the clinic and have an opportunity to provide care in a longitudinal manner for a group of patients. During the CCU and clinic rotations the fellow directs a team of residents, interns and medical students. He/she is responsible for organization of rounds, assisting the attending physician with the education of the residents, and supervising the residents. On all clinical rotations, integration with nursing staff, social workers, physical therapists, nutritionists, and other allied health professionals is an important educational priority.
Training Locations: Our fellows rotate monthly on either the campus at Long Island Jewish (LIJ) Medical Center, New Hyde Park, NY, or at North Shore University Hospital, Manhasset, NY. In addition, second and third year fellows are offered rotations at Huntington Hospital and Nassau University Medical Center.
Ambulatory Practice: All fellows participate in our ambulatory practice each week. The fellows’ practice is supervised by an attending full time cardiologist and staffed by a patient care associate and technical support staff. Patients are drawn from inpatient referrals from the cardiology and medicine services, as well as referrals from outpatient clinics. Fellows learn management of outpatient disease states, primary and secondary cardiac preventive medicine, test selection and interpretation and the decisions regarding need for hospitalization. The use of the electronic medical record has facilitated the continuity of care. Each patient is assigned to a fellow who will continue to follow the patient as an outpatient or inpatient for the entire three years of training.
Rotation Schedule: Cardiovascular disease fellows rotate through these rotations at both North Shore University and LIJ Medical Center. The time allotment per rotation fulfills requirements for fellowship subspecialty training in Cardiology and enables the fellows to reach volume requirements towards certification in procedures, as recommended by both the ACGME and The American College of Cardiology.
Fellows rotate through each of the following cardiac subspecialties:
- Coronary Care Unit
- Clinical Consultation Service
- Cardiac Catherization Laboratory
- Echocardiographic Laboratory
- Nuclear Cardiology Laboratory
- Electrophysiologic Laboratory
- Congestive Heart Failure
- Cardiac CT/MR
- Vascular Medicine
- Congenital Heart Disease
- Nassau University Medical Center CCU
- Huntington Hospital private practice
Supervision Policy: Fellows are carefully supervised in all aspects of fellowship training.
On Call Supervision: At all times first and second year fellows on call are supervised by a senior fellow as well as four attending physicians. These attending physicians represent the interventional, echocardiography, electrophysiology and clinical consult services. Fellows are expected to evaluate patients and determine treatment plans after discussing cases with the appropriate service attending. The attending physician and the senior backup fellow perform diagnostic and therapeutic procedures. During the weekend, fellows round with the clinical consult attendings who evaluate patients with the fellow in a similar fashion to the weekday rounds.
Procedural Supervision: Fellows are supervised in all procedurally based rotations. Fellow advancement to independent performance of procedures is based upon established ACC/AHA guidelines for procedures as determined by attending physicians who must certify fellows based upon clinical and procedural competency. Computer databases at both North Shore University Hospital and LIJ Medical Center document procedural volume. Fellows receive formal feedback with regard to procedural competence as part of each post rotational evaluation. A log of procedures which fellows are credentialed to perform independently as well as under supervision is maintained and reviewed with fellows.
- Left and right heart catheterization
- Percutaneous intervention
- Intraaortic balloon pump
- Transthoracic echocardiography
- Transesophageal echocardiography
- Stress Echocardiography
- Intra-operative echocardiography
- Transvenous pacemaker
- Tilt table testing
- DC cardioversion and defibrillation
- Pacemaker and defibrillator interrogation
- Electrocardiograms and Holter monitor interpretation
- Invasive programmed electrophysiologic stimulation and ablation
- Exercise testing
- Pharmacologic stress testing
- Use of radionuclide pharmaceuticals as adjunct to stress testing
Conferences: Fellows are required to attend all cardiology conferences at the hospital where they are rotating. Fellows are assigned conferences as a part of their educational and teaching responsibilities. The conference schedule includes but is not limited to:
- Morning teaching conference (Monday through Friday)
- Journal Club
- Fellows Conference
- Fellows’ Forum
- Core Curriculum
- Grand Rounds
- Morbidity and Mortality Conference
- Board Review
- Subspecialty Noon Conference
- Nuclear Medicine
Evaluation of Fellows: Fellows are evaluated formally by attending physicians, patients, secretaries, and other health care professionals for each block rotation addressing the six core competencies. Criteria for evaluations are in compliance with the ACGME. These evaluation criteria include patient care, medical knowledge, practice based learning, interpersonal and communication skills, professionalism, and systems based practice as part of their overall clinical competence as a subspecialist in cardiovascular disease. Procedural skills are evaluated in detail in appropriate rotations by a separate evaluation process. The program directors and each fellow review these evaluations in order to give the fellow feedback on their performance. Summative evaluations of the fellows are prepared semi-annually and at the conclusion of the training program. The program uses New Innovation software for the evaluation process and compliments it with paper multi source evaluations. The simulation center (Patient Safety Institute) is used as part of the evaluation process.