CARDIOLOGY FELLOWSHIP MANUAL

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TABLE OF CONTENTS

EDUCATIONAL PROGRAM……………………………………………………….. 3

Objectives

General Expectations

KEY CLINICAL FACULTY………………………………………………… ………8

FACILITIES AND RESOURCES………………………………….………………….10

SPECIFIC PROGRAM CONTENT………………………………..……………….…12

Rotation Components

Cardiovascular Medicine Inpatient Service

UMC and VA Consultative Service

UMC Outpatient Clinics

VA Outpatient Clinics

UMC Non-Invasive Laboratory & Graphics

UMC Fit for Life/Cardiac Rehab

VA Non-Invasive Laboratory

UMC and VA Invasive Laboratory

EPS and Arrhythmia Service

Research Rotations

Elective Rotation Options

Pediatric Cardiovascular Medicine

VA Nuclear Medicine

Didactic Schedule

Mentoring

Methods of Assessment

INSTITUTIONAL POLICIES………………………………………………………43

Professional Activities Outside the Educational Program

Primary verification of credentials for applicants to residency and fellowship training

programs

ACLS/BLS/PALS Certification

Policy for Educational/Career Counseling

Disciplinary Action Policy For Residents/Fellows

Grievance Policy For Residents/Fellows

Policy To Address Resident Concerns

Institutional Vacation And Leave Policy

Non-Renewal Of A Resident/Fellow

Professional Assistance Policy

Reduction In Size Or Closure Of A Residency Program/Fellowship Supervision Of

Residents And Fellows

Moonlighting - J-1 or H-1B Visa Holders

Resident Work Hours And On-Call Frequency Policy

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Policy to Monitor Residents and Fellows with Prior Issues of

Concern

Duty Hour Policy

Anonymous Evaluation

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CARDIOVASCULAR DISEASES FELLOWSHIP

MANUAL

Educational Program

GOALS AND OBJECTIVES

The Division of Cardiovascular Medicine offers a three-year fellowship training program

in Cardiovascular Diseases. During this time our goal is to produce physicians who

maintain the intellectual curiosity, the concern for patients, and the attention to detail

fostered by Internal Medicine training programs. However, we want to expand

knowledge in the specialty of Cardiovascular Diseases. As specialists in Cardiovascular

Diseases, we strive to acquire a basic core of knowledge of cardiovascular anatomy and

physiology to make an accurate diagnosis and establish an effective treatment plan in

patients with a wide variety of acute and chronic cardiovascular disorders. Furthermore,

we seek to provide opportunities to make new discoveries and observations and to

disseminate this knowledge in oral and written formats.

The first year Cardiovascular Medicine Fellow typically spends 7 months on an inpatient

service - either a Coronary Intensive Care Unit rotation or a Consultative Service. Two

months are usually spent in the Non-Invasive Laboratory and two months are spent in the

Invasive Laboratory. One month is spent on Research. Weekly half day outpatient

continuity clinics are part of the first year experience.

The second and third years are spent tailoring the type of training desired by the fellow

(non-invasive, invasive, or research). Weekly half day outpatient clinics are also part of

the second and third year experience.

At the end of three years, the Cardiovascular Medicine Fellow will spend at least 8

months in the Inpatient (CICU or consultative Service), at least 8 months in the Invasive

Laboratory and at least 4 months in the Non-Invasive Laboratory.

Research opportunities are available to all fellows and are dependent on the type of

research chosen. Fellows may elect to take ½ day per week for the duration of the three

year program for research duties. During that time they are free from clinical

responsibility. Alternatively, fellows may elect to receive protected time for one month at

a time for a maximum of six rotations during their three year fellowship. Fellows are

provided a list of ongoing clinical and basic science projects performed by members of

the Division of Cardiovascular Medicine or other University faculty members. Proposals

suitable for competitive grant funding may be required from certain fellows. Publication

in peer reviewed journals is also expected. Fellows will be expected to meet regularly

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with their mentor and provide regular progress reports.

In addition to these rotations, a number of other conferences are designed to provide

didactic instruction. These include Cardiovascular Medicine Conferences at 7:30 am M-

F, the Departmental M&M conference at Noon on Tuesdays, and Internal Medicine

Grand Rounds at Noon on Thursdays.

GENERAL EXPECTATIONS

1. Attendance and punctuality are required at all Divisional and Departmental functions.

These functions include, but are not limited to rounds, fellows‘ clinics, and conferences.

Except in instances involving emergent patient care, faculty will excuse fellows from

other duties to ensure attendance at these functions.

2. All pages will be answered promptly. Beepers are worn from 8am - 5pm and on call.

During procedures pages should be answered by other fellows or support staff.

3. Interactions with staff, patients, and colleagues are to be courteous and polite at all times.

4. If a fellow is for any reason unable to meet a clinical schedule requirement, he or she is

responsible for identifying a replacement as soon as possible. This applies to consult,

night, weekend, and holiday coverage, procedure and clinic appointments, and conference

presentations. The fellow should report the changes in coverage to the Education

Coordinator in writing.

5. Clinics are never canceled except for designated holidays and pre-approved vacation. If a

fellow will be unable to attend clinic as scheduled, he or she must first obtain the

approval of the Director of the fellows‘ Clinic and then arrange alternate coverage.

When canceling a clinic date for anticipated vacation, notify the fellowship

coordinator in writing at least four weeks in advance to the canceled clinic.

The coordinator will notify the proper clinic personnel. No more than two

clinic cancellations for vacation at the University Hospital and no more than

two clinic cancellations for vacation at the VA Hospital. The fellowship

coordinator will track vacation time and number of clinics cancelled for

vacation.

In the rare circumstance when one fellow is substituting for another fellow‘s

duties in clinic, 24 hour notice should be given in writing to the fellowship

coordinator so that the clinic can be notified of the substitutions.

In the event a fellow‘s clinic needs to be overbooked, approval from that

fellow must be obtained prior to overbooking.

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When a fellow has a clinic obligation, he/she must arrange for another fellow

to cover any service until his/her clinic obligation is complete. The clinic

obligation has priority over all other responsibilities that might conflict with

clinic.

All fellow‘s clinic notes must be done electronically (Power Note) using the

Cardiovascular Medicine IM Clinic Note. This note should be used for all

patients, including consults in clinic. (Use the Chest Pain Clinic Notes for the

chest pain follow-up patients from the ED.) All notes need to be completed

the same day as the clinic visit and forwarded to the attending for clinic within

24 hours.

6. The Cardiovascular Medicine faculty attending is ultimately responsible for the

performance of all cardiovascular procedures, including their prompt termination when he

or she deems it necessary. The amount of time and degree of independence allotted a

fellow for the safe and efficacious completion of a procedure will be determined solely by

the faculty attending on a case-by-case basis.

7. Fellows who perform procedures on patients have the responsibility to acquaint the

patient with the steps involved in procedure preparation and performance, inform the

patient of associated risks and obtain the patient‘s signature on a consent form. The

physician obtaining consent must date, time, and sign each form. It is desirable that

fellows who perform a given procedure also obtain informed consent.

8. Fellows performing consultations, procedures, and clinic follow-up visits on patients at

University of Missouri affiliate hospitals must provide prompt follow-up to referring

physicians and to the patient‘s primary physician. Obviously, this is extremely important

to continuity of care and preservation of referral relationships.

9. At the end of each rotation, each fellow will be evaluated by the Cardiovascular Medicine

attending and/or attending faculty from other departments with whom we work closely,

such as pediatrics, nuclear medicine and surgery. The standard American Board of

Internal Medicine evaluation form is used for this purpose and is submitted electronically

through New Innovations. Fellows are evaluated by other health care providers (360

degree evaluations). Fellows will evaluate attendings at the end of each rotation using a

similar format. In addition, every six months, fellows will evaluate individual rotations.

The results of these evaluations are reviewed by the faculty and fellows at least yearly.

10. Requests for vacation time should be made through the fellowship coordinator during the

first week of the year or earlier. (Twenty working days of vacation are permitted

annually. These days may not be carried over into the following year). Approvals from

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the division and fellowship directors are required. Flexibility will be allowed for job

interviewing but this will be considered vacation leave. Fellows should notify the

educational coordinator at least two weeks in advance of absence, please note time

requirements above for clinic cancellations. It is appropriate to notify your faculty

attending in advance of your absence.

11. It is the responsibility of the fellow to notify the education coordinator in the event they

are sick. Ten working days of sick leave are provided per year. (These days may not be

carried over into the following year.) Use of sick leave is permitted for personal or family

illness and/or doctor's appointments. The fellow is responsible for finding coverage of

their service which should be given to the fellowship coordinator in writing (note time

requirement for clinic cancellations). Maternity/Paternity leave is considered as sick

leave. Fellows are eligible for FMLA (Family and Medical Leave Act) as outlined in the

University Policy.

12. It is the fellow‘s responsibility to complete a Notification of Absence form (obtained

from the fellowship office) 2 weeks prior to any absence from the University. This form

will indicate appropriate coverage and must be signed and approved by Program Director

prior to departure. This policy will be strictly enforced and disciplinary action will be

taken in the event of non-compliance.

13. All fellows are encouraged to attend either the American Heart Association or the

American College of Cardiology annual scientific sessions during their training program.

Fellows will be provided with $1,500 of travel funds to attend one AHA or ACC

scientific meeting during their fellowship. Chief Fellow(s) may attend one additional

meeting with the approval of the fellowship director. Third year fellows may travel for

one board review course or specialty course review at their own expense, upon approval

from the fellowship director. This travel is not considered vacation; however, additional

courses, which may be requested, will be considered vacation.

Fellows submitting an abstract for consideration need to first discuss travel funding with

their faculty mentor. If division funds are requested the fellow must have his/her abstract

reviewed by the Program Director and Division Director prior to submission. Funding

must be approved before the abstract is submitted.

The division will cover travel expenses for fellows presenting abstracts at ACC or AHA

annual scientific sessions with the prior approval of the Program Director and Division

Director. Funds for subsidizing travel to meetings must be arranged via the Division

Administrator at least 30 days prior to the meeting. In no case will the division cover

expenses greater than $1,500 per meeting. If fellows obtain unrestricted travel grants

from industry, the funds may be used only to attend major meetings such as AHA, ACC,

and Heart Rhythm Society.

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Upon the fellows return from travel, a request for reimbursement must be submitted to

the division administrator within 30 days. Documentation in the form of receipts must

accompany all reimbursement requests for meals, taxi fare, parking, etc. All travel must

comply with the Department of Internal Medicine‘s and University of Missouri Travel

Guidelines. These policies are available on the departmental intranet.

14. Fellows should not apply to attend a meeting (or submit an abstract to a meeting) unless

they have first discussed with their mentor a funding of their travel, if the abstract is

accepted. In most cases, it will be the responsibility of the mentor to fund the trainees

travel expenses.

15. Each day there are two fellows on call for MU & VA, one for the consults and CCU, and

one for the emergency echocardiograms and cardiac catheterizations. Fellows are on call

approximately 5-7 days in a month. Although the call is taken from home, the fellows

come to the hospital as required. Communication with the attending physician on call is

encouraged.

16. Fellows are expected to keep all licensure current. This would include state license,

ACLS, BLS, staff health requirements and VISA if applicable. Should any licensure or

mandatory testing become delinquent, it is the responsibility of the fellow to renew in an

expedited manner. If licensure is not kept current, the fellow employment contract will

be considered null and void.

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Key Clinical Faculty

Kul Aggarwal, MD, FACC, FACP

Associate Professor of Clinical Medicine

Chief, Cardiovascular Medicine Section, Harry S Truman Memorial Veterans

Hospital

Director, Cardiac Catheterization Laboratories, Harry S Truman Memorial Veterans

Hospital

Martin Alpert, MD

Professor of Internal Medicine

Director of Clinical Cardiovascular Medicine

Dmitri Baklanov, MD, PhD

Assistant Professor of Medicine

Anand Chockalingam, MD

Assistant Professor of Clinical Medicine

Kevin C. Dellsperger, MD, PhD

Marie L. Vorbeck Chair

Professor and Chairman, Department of Internal Medicine

Professor, Department of Medical Pharmacology and Physiology

Thomas P. Dresser, MD, PhD


Chief, Nuclear Medicine Section, Harry S Truman Veterans Hospital

Director, Nuclear Cardiovascular Medicine Training Program

Director, Clinical Support Service Line, Harry S Truman Veterans Hospital

Mary Dohrmann, MD, FACC


Director, Cardiovascular Medicine Clinic

Director, Cardiac Rehabilitation

William P. Fay, MD, FACC, FAHA

J.W. and Lois Winifred Stafford Distinguished Chair in Diabetes and

Cardiovascular Research

Professor of Internal Medicine, Pharmacology & Physiology

Director, Division of Cardiovascular Medicine

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Greg Flaker, MD, FACP, FACC

Brent Parker Professor of Medicine

Program Director, Cardiovascular Disease Fellowship Program

Director, Division of Cardiovascular Medicine Research

Director, Electrophysiology Laboratory, University of Missouri

Saravanan Kuppuswamy, MD


Leonard Politte, MD

Professor of Medicine

Hongmin Sun, PhD

Assistant Professor of Medicine

Richard Weachter, MD


Richard Webel, MD


Director, Cardiac Catheterization Laboratory

Jainbo Wu, PhD

Research Assistant Professor

Gong-Yuan Xie, MD, FACC

Professor of Medicine

Director, Non-Invasive Cardiovascular Medicine & Adult Echocardiography

Cuiha Zhang, MD, PhD

Associate Professor of Internal Medicine

Associate Professor of Medical Pharmacology and Physiology

Associate Professor of Nutritional Sciences

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Facilities and Resources

Cardiovascular Medicine trainees provide inpatient and outpatient care to University

Hospital and Clinics and Harry S Truman Memorial Veterans' Hospital and consult

service coverage to Columbia Regional Hospital.

University Hospital and Clinics: Mid-Missouri‘s leading cardiovascular referral center, University Hospital, admits more

than 1,000 Cardiovascular Medicine patients each year and supports more than 10,000

invasive and non-invasive procedures. The 400 bed hospital is equipped with state-of-

the-art cardiac catheterization facilities providing a wide range of diagnostic and

therapeutic modalities such as coronary angiography, angioplasty, and endomyocardial

biopsy, electrophysiology and hemodynamic studies and placement of coronary stents.

Non-invasive capabilities include Doppler, transesophageal and stress echocardiography,

ambulatory ECG monitoring and exercise testing, nuclear cardiac imaging and stress /

cardiopulmonary exercise testing.

Harry S Truman Veterans Hospital: The Harry S Truman VA Hospital is a 97 bed hospital immediately adjacent to the

University Hospital. The hospital has a progressive Intensive Care Unit, modern cardiac

catheterization facilities and updated non-invasive laboratories to provide up to date

cardiovascular care to veterans from the Midwest. In 2006, University of Missouri

cardiologists performed over 700 invasive cardiovascular procedures at the HSTVAMC. Fellows rotating thru the VA hospital have the following resources available to them:

1. Computer terminals at the VA hospital in the Echo reading room (Room A107) and the

Cath lab room next to reviewing room (Room B131) to look up online resources.

2. Online access to MU as well as VA. VA library facilities are available thru the Main

Page of the VA on every computer. The web address for the library facilities are:

vaww.columbia-mo.med.va.gov/library. They can get online access to several textbooks

and journals

3. VA library. The VA library is situated in the main inpatient building and has the

following hours: staffed Monday to Friday from 8am to 430pm

Afterhours access is available at all times by contacting the VA Police on the first floor.

Columbia Regional Hospital: Columbia Regional Hospital serves Mid-Missouri as a 219-bed full service acute care

facility offering state-of-the-art diagnostic and medical treatment. In 2006, University of

Missouri cardiologists performed over 500 invasive cardiovascular procedures at CRH.

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Fellows Office: Cardiovascular Medicine Fellows will have their own desk, which will be located in

Clinical Support and Education Building CE305. An Education Coordinator is provided

to assist Cardiovascular Medicine Fellows in a variety of clerical needs. Office support is

available to the fellows in preparation for speaking engagements such as lectures,

conferences, and research presentations. Fellows have access to the Otto Lottes Health

Sciences Center Library. In addition, the Division of Cardiovascular Medicine provides

the Cardiovascular Medicine Fellows with a variety of resources including computer

access, a variety of software, and Internet access. The Division has resource books and

journals involving invasive and non-invasive information. Current Board Review tapes

and books are also accessible.

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Specific Program Content

The goals and objectives of each rotation are listed in this manual and are posted on the

Division website. Selected tests or important references from the medical literature which are

recommended reading for each rotation are listed at the end of each section.

CARDIOVASCULAR INPATIENT SERVICE

GOALS and OBJECTIVES:

1. To learn to recognize and treat all aspects of cardiovascular disease in patients who

present to the inpatient Cardiovascular Medicine service.

2. To learn the appropriate use and relative value of various diagnostic tests used in the

evaluation of these patients.

3. To develop a basic knowledge of cardiovascular anatomy, physiology, and recent

literature/guidelines and apply it to each patient in a logical and efficient way to achieve a

good, cost-effective, and evidence-based plan of care.

4. To enhance the internal medicine knowledge base especially as it relates to cardiovascular

disorders and the interplay of other medical problems with the cardiovascular disease

being treated.

5. To maintain the highest degree of empathy possible with patients who are often

frightened and anxious, by maintaining good communication with them, their families,

and with other health care providers.

6. To maintain an inquisitiveness about patient care that fosters self-motivated learning and

searching after answers that may not be obvious.

7. To understand the role of drugs used in acute and chronic cardiovascular diseases, such as

vasoactive, inotropic, antithrombotic, lipid-lowering, antiarrhythmic drugs.

8. To learn the indications for and technique of invasive monitoring in the care of

cardiovascular patients, such as PA catheter insertion and use, IABP use and

troubleshooting, temporary pacing, arterial lines, ultrafiltration catheters, etc.

At the University Hospital this service is usually composed of Cardiovascular Medicine

attending physicians (2/month), a Cardiovascular Medicine Fellow, Medical Residents and

Medical Students. In addition, nurses, dieticians, social workers, and other health care

professionals make rounds on a daily basis in a 16 bed integrated CICU with cardiovascular

medicine and thoracic surgery patients. At the Harry S Truman VA Hospital, this service is

usually composed of a Cardiovascular Medicine attending physician and a Cardiovascular

Medicine Fellow. They are directly responsible for patients admitted in CICU. For patients on

the floor, they provide consultative services.

Patients in the Cardiovascular Medicine Inpatient Rotation include:

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Patients who present to the Emergency Room with chest pain and are thought to

have acute myocardial infarction, intermediate coronary syndrome or unstable

angina.

Patients who are hemodynamically unstable and need intensive monitoring and/or

Swan Ganz catheterization or other invasive procedures for management.

Patients who present with acute heart failure or shock syndromes requiring

intensive care unit management.

Patients with symptomatic brady or tachyarrhythmias who are unstable or at risk

of instability who need intravenous antiarrhythmics or are in need of temporary

pacemakers.

Patients who have undergone an interventional procedure including post operative

procedures and require short-term intensive monitoring.

Patients who have predominantly cardiovascular problems who require

mechanical ventilation.

Any other patients, who upon determination of the Cardiovascular Medicine team,

need CICU care for management of hypertensive, valvular, pericardial,

cerebrovascular or congenital heart disease. Patients with heart disease of

pregnancy, cardiac transplant patients, and patients with pulmonary heart disease

including pulmonary embolism may be evaluated in the CICU.

In order to provide one 24-hour period per week free from patient care

responsibilities, VA CCU-Consult fellow and MU CICU fellow will share the

weekend responsibilities for rounds on the above services. Specifically, one

person will make morning rounds with staff in both CCUs on Saturday and other

person on Sunday. This will give both fellows 24 hour period free of direct

patient care responsibilities.

Sometimes VA and MU may not have concurrent holidays. In case of holiday at

VA ONLY, the VA CCU-Consult fellow will cover the service including consults

till 12 noon and subsequently on call person will take over. For holiday in MU

ONLY, the MU-CCU fellow will make CCU rounds as usual and on call will do

the consults from 8:00 am (as on weekends).

For UMC and VA Cardiovascular Medicine inpatient services, the Cardiovascular

Medicine Fellow will:

1. Evaluate all new patients admitted to CICU and Cardiovascular Medicine wards.

2. Write an admission note for all CICU patients, discuss all admissions with the

resident and medical student on service, to develop an appropriate differential

diagnosis, proposed work-up plan, and initiate therapy.

3. Conduct daily ‗work‘ rounds with residents, students, nursing and other health care

personnel in CICU, to include ethical, cost-containment, social issues as well as

medical and discharge planning issues, and triage for transfer out of CICU at the

earliest time each morning.

4. Provide teaching for residents and students.

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5. Provide appropriate supervision of residents and students in procedures such as

insertion of central lines, PA catheters, temporary pacemakers, arterial lines, and

thoracentesis and pericardiocentesis. Preferably, these will be done with the CICU

attending present as well.

6. Provide appropriate triage support for the residents in deciding transfers to and out of

CICU, as well as discharge planning, including discharge medications.

7. Ensure efficient patient flow.

8. Maintain effective, day-by-day communication with patients, their families, and with

nursing personnel, with respect to medical care, diagnosis, medical testing, and

prognosis, especially with critically ill patients.

9. Communicate with referring physicians at the time of referral, significant in-hospital

events, and at discharge.

10. Provide basic and advanced cardiac life support.

11. Evaluate admissions in the ER with attention to triage for appropriate placement in

CICU, step-down, or telemetry.

12. Personally review chest x-rays, EKG‘s, telemetry rhythm strips, coronary angiograms,

echocardiograms, myocardial perfusion scans, and stress tests on patients assigned to

them.

13. Maintain the highest level of professionalism, ethics, and of medical care for each

patient without regard for social, religious, ethnic, or gender differences.

14. Wash hands before and after each patient contact.

15. Ensure communication with any physicians consulted, with expressed appreciation

and due regard for recommendations given, in the best interest of the patient.

16. Maintain open communication with the CICU attending, who will be available for

daily attending rounds, procedures, and at other times deemed necessary for good

patient care.

17. CICU admission notes are to include at minimum a brief history of present illness,

documentation of pertinent cardiovascular physical exam findings, an interpretation

of the admission EKG, and brief assessment and plan. This is forwarded in the

electronic medical record to the attending physician for his or her signature.

18. Daily review of resident progress notes for accuracy in documentation of the ongoing

plans and reassessment as new information becomes available.

19. CICU fellows will care for all patients on the cardiovascular medicine inpatient

service, but in general will not be required to carry a load of more than 12 patients at

one time. If this occurs, he/she may notify the attending physician, who may

redistribute the number of patients supervised by that fellow.

20. Enroll patients in research projects

21. Present patient information at M&M conference or other conferences

Patient who may be in CICU:

Patients who present to the emergency department with chest pain and are thought to have

acute myocardial infarction or acute coronary syndrome.

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Patients who present with acute heart failure or shock syndromes requiring intensive care

unit management

Patients who are hemodynamically unstable and need intensive monitoring or invasive

procedures for management.

Patients with symptomatic brady or tachyarrhythmias who are unstable or at risk of

instability who need intravenous antiarrhythmics or are in need of temporary pacemakers.

Patients who have undergone an interventional procedure including post operative

procedures and require short-term intensive monitoring.

Patients who have predominantly cardiovascular problems who require mechanical

ventilation.

Any other patients, who upon determination of the Cardiovascular Medicine team, need

CICU care for management of hypertensive, valvular, pericardial, cerebrovascular or

congenital heart disease. Patients with heart disease of pregnancy, cardiac transplant

patients, and patients with pulmonary heart disease including pulmonary embolism may be

evaluated in the CICU.

The level of service and the degree of supervision provided will depend on the experience of the

trainee. In general,

First Year Fellows:

History and physical examination of the cardiovascular patient

Developing a differential diagnosis

―Work-up‖ and management plan formulation

Understanding the ethical, legal and cost-containment issues involved in patient care

Right heart cardiac catheterization including indications, placement of Swan Ganz

catheters, hemodynamic monitoring and interpretation of data

Gaining proficiency in the interpretation of EKGs

Assess patients who are candidates for cardiac transplantation

Teaching of Students and Residents

Second Year Fellows:

In addition to skills acquired at the previous level:

Leading discussions on multi-disciplinary rounds


Insertion of temporary transvenous pacemakers

Insertion of and management of intra-aortic balloon counterpulsation devices

Third Year Fellows:


Management of complex cardiovascular problems

Gaining further understanding of the interplay of various disciplines such as Critical Care,

Pulmonary Medicine, Nephrology and Cardiothoracic Surgery in the care of the patient


For these UMC and VA Cardiovascular Medicine Inpatient Services, the Resident will:

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Evaluate new admissions to the CICU and to the Cardiovascular Medicine Ward

Service. This evaluation will include a comprehensive history, physical examination,

diagnosis and an assessment and plan. The plan can be formulated with the help of the

Cardiovascular Fellow. Such evaluation will be documented in the chart of the

patient.

Responsible for writing the admission orders for the patient at the time of admission,

and at the time of transfer from the floor to the CICU or from CICU to the ward.

Additionally, it will be the resident‘s responsibility to write all subsequent orders for

all patients under his/her care.

Responsible for dictating discharge and death summaries in a timely fashion on all

patients under his/her care.

Will coordinate his/her plans for scheduling days off with his/her co-residents on the

rotation and with the fellow.

Closely monitor progress of all patients and promptly bring to the attention of the

fellow any significant change in the condition of any patient under his/her care.

Notify and coordinate with the fellow any invasive procedures such as central venous

line insertion, right heart catheterization, pleural fluid paracentesis, arterial line

insertions, etc., that a patient may need and ensure that the fellow is present during the

procedure.

Attend daily rounds with the Cardiovascular Fellow and with the service attending.

The resident will present all cases to the attending.

Examine all patients assigned to him/her at least once a day and more frequently if

clinical circumstances warrant and write a progress note in the patient‘s medical

record documenting such examination together with an assessment and any changes

in plan.

Responsible for checking all laboratory results such as blood tests, ECG‘s, and x-rays

on his/her patients and acting appropriately upon such results.

Supervise student activities as related to patient care.

Provide teaching to medical students.

For the UMC and VA Cardiovascular Medicine Inpatient Services the Attending will:

Communicate the goals, objectives, expectations and define the teaching structure to

all members of the team including fellows, residents, students and support staff.

Conduct rounds daily at which time each assigned patient is personally interviewed

and examined. Be personally responsible for the conduct of special procedures (e.g.,

cardioversion, Swan Ganz catheter, etc.).

Review patient‘s clinical data and formulate a plan with the house staff for the

management of each patient.

Be available at all times to advise the fellow and the residents on issues related to the

care of all patients on the Cardiovascular Medicine Service. In case the attending

anticipates being unavailable for any period of time, then to make arrangements with

an alternate attending to be available for such support and to notify the team about

such coverage.

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Educate all members of the team including Fellows, Internal Medicine residents,

students and nurses. Such education will be in the form of formal teaching rounds and

will incorporate clinical discussions in addition to addressing legal, ethical and cost-

containment issues. Education in bedside manner, elicitation of history and physical

examination will also be carried out.

Communicate with the patient regularly and with families especially in the case of

critically ill patients.

Be a team leader and role model for all members of the team. Provide effective

feedback and evaluation of fellows, residents and medical students on the rotation.

Provide references for further reading. (Appendix A) Support and encourage

scholarly activities and research projects. Discuss individually at the end of the

rotations strengths, weaknesses and suggestions for improvement.

Be responsive to any special difficulties that fellows or residents may be experiencing

and make efforts to relieve such difficulties.

Provide a list of texts or key articles for reading during the rotation.

UMC AND VA CONSULTATIVE SERVICE


The goals and objectives of the Cardiovascular Medicine Consultation rotation are to

provide expert consultation to inpatients or outpatients with cardiac problems. During this

rotation an emphasis will be placed on

1) understanding the pathophysiology of a wide variety of cardiac conditions and different

treatment options,

2) provide effective therapy for cardiac conditions, and

3) provide continued follow-up and advice to physicians of other services concerning cardiac

patients.

The UMC Consultative service is usually composed of the Cardiovascular Medicine

Attending Physician, a Cardiovascular Fellow, Medical Residents, and Medical Students.

Rounds are conducted at mutually agreeable times. In general, rounds are performed at least

daily except Sundays. A list of patients is generated and, to ensure continuity, checked out to

the faculty or fellow on call on a daily basis, informing the person on call about important

details of each patient. The VA Consultative Service includes the Attending physician and

Cardiovascular Medicine Fellow assigned to the VA Inpatient Service.

Patients evaluated by the Cardiovascular Medicine Consultation Service include:

Patients in the Emergency Room, Outpatient Clinics or Inpatient Services who have

heart failure, chest pain, cardiac arrhythmias, hypertensive, pericardial disease,

valvular, cerebrovascular or congenital heart disease.

Patients who require cardiovascular medicine evaluation prior to surgery.

Patients who are admitted to the hospital for non-cardiac causes, but who require

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cardiovascular follow-up.

Cardiovascular medicine fellow responsibilities for the UMC and VA Consultative Service

include:

Provide a prompt written evaluation and treatment plan on patients referred for

consultation from 8 am to 5 pm Monday - Friday. The ―on call‖ cardiovascular

medicine fellow provides this service during evenings and weekends. At UMC the

clinic note should be dictated on the date of the clinic visit and reviewed for

corrections in Power Chart within 48 hours, then forwarded to the appropriate

attending for final signature.

Discuss the plan with the assigned cardiovascular medicine attending. The dictation

should include a summary of this discussion.

Communicate by written or oral form to the referring and primary care physician. At

UMC all Power Chart notes that are electronically signed will be FAXed to the

referring physician by the division secretary after final signature by the attending.

Discuss evaluation with attending, residents, and students during scheduled consult

rounds.

Evaluate patients for potential admission to the Cardiovascular Medicine Service or

arrange appropriate outpatient follow-up and testing.

Provide teaching to residents and students.

Communicate to physicians the results of the cardiovascular medicine evaluation

including test results and plans for further follow-up.

Interpret ECGs, chest x-rays, stress tests, ambulatory monitors, and other selected

graphic material on a daily basis.

The level of service and the degree of supervision provided will depend on the experience of the

trainee. In general,

First Year Fellows:

Assessment of patients referred for cardiovascular consult focusing on clinical skills

required in the assessment of such patients

Formulate a differential diagnosis and a management recommendation for such patients

Acquire an understanding of the peri-operative assessment of patients undergoing non-

cardiac surgery



Be able to effectively render assessment and recommendations on peri-operative

cardiovascular care of the patient undergoing non-cardiac surgery

Be able to effectively render assessment and recommendations on peri-operative

cardiovascular care of the patient undergoing cardiac surgery especially in the areas of

arrhythmia management, hemodynamics and myocardial ischemia and infarction

Third Year Fellows:

19


Be able to effectively function as a Cardiovascular Consultant

Participate in the teaching of members of disciplines other than Cardiovascular Medicine

Cardiovascular Medicine Attending responsibilities for the UMC and VA Consultative

Services include:

Communicate the goals, objectives, expectations and define the teaching structure to

all members of the team including fellows, residents, and students.

Conduct rounds M-F at which time each assigned patient is personally interviewed

and examined.

Review patient‘s clinical data and the written plan with the Cardiovascular Medicine

Fellow.

Be available M-F 8am - 5 pm to advise the fellow and the residents on issues related

to the care of all patients on the Cardiovascular Medicine Consult Service. After

hours and on weekends an ―on call‖ attending will be available for such support.

Educate all members of the team including Fellows, Internal Medicine residents,

students and nurses. Such education will be in the form of formal teaching rounds and

will incorporate clinical discussions in addition to addressing legal, ethical and cost-

containment issues. Education in bedside manner, elicitation of history and physical

examination will also be carried out.

Communicate with the primary care team regularly.

Be a team leader and role model for all members of the team. Provide effective

feedback and evaluation of fellows, residents and medical students on the rotation.

Provide references for further reading. (Appendix B) Support and encourage

scholarly activities and research projects. Discuss individually at the end of the

rotations strengths, weaknesses and suggestions for improvement.

Be responsive to any special difficulties that fellows or residents may be experiencing

and make efforts to relieve such difficulties.

Faculty will provide a list of key references pertinent to the patient population.

UMC OUTPATIENT CLINICS


The goals and objectives of the outpatient rotation is to develop an appreciation of the

pathophysiologic mechanisms of disease, to develop an understanding of the use of diagnostic

testing, to observe the response of therapy over longitudinal follow-up of patients with

cardiovascular disorders over the 3-year training program with faculty supervision. In

compliance with ACGME requirements for program curriculum section V, subsection F, item 1,

2 and 3, titled ―Ambulatory Medicine‖, the goal of the Cardiovascular Medicine Division is to

provide the facility, faculty, support personnel, patients and supporting services for the fellows to

become competent in evaluating, treating and follow-up care in an outpatient setting in a

longitudinal manner over a three year period of their training. The Cardiovascular Medicine

20

clinics at UMHC and VAH provide the opportunity for ―a single continuity clinic for the entirety

of the fellowship.‖ The clinic scheduling template is designed to meet the ACGME goal of ―four

to eight patients during each ½ day session.‖ The full range of patients with cardiovascular

disease is available for the fellow to evaluate under the supervision of an attending physician at

each clinic.

Volumes of patient: given the ACGME goal of 4 – 8 patients per clinic, the projected

volume per fellow (based on 48 weeks of clinic, UMHC/VAH combined) is 192 minimum, 384

maximum. The Cardiovascular Medicine Fellowship Coordinator currently tracks the patient

volumes

at UMHC/VAH.

Types of patients: no surveillance currently exists for tracking the types of patients seen

by the fellows, although this is easily obtainable. It is recommended that a spread sheet for each

fellow track ICD-9 codes used at the clinic visits. Periodic review would help assess the variety

of each fellow‘s clinic experience.

Oversight: an attending supervises every clinic and evaluates every patient with the

fellow in clinic.

Recommended reading: it is recommended that the fellows are familiar with the

published ACC/AHA guidelines for management of cardiovascular diseases. Additionally,

Braunwald‘s Heart Disease: A Textbook of Cardiovascular Medicine is an important companion

text for in-depth reading.

This requires the Fellows to gain an understanding and skills in:

1. Office organization including the function of receptionist, scheduling, nursing support,

record keeping, dictation, billing procedures and other business aspects of the office.

2. Knowledge of the services available and how to access them such as obtaining consults

from other services, laboratory, radiology, rehabilitation, social services, etc.

3. Understand the patient‘s ability to receive medical care as to travel, financial constraints,

family support, and other personal issues affecting receiving appropriate care.

4. Improve communication skills with the patient and their family in understanding their

illness and the rational the recommended care carefully explaining any side effects or

complications that might occur and the seriousness of the complication as to risk-benefit.

5. Improve skills in time management.

6. Prompt documentation of medical data and communicating this to appropriate people.

7. Develop a thorough understanding of the ICD-9 code and its importance to the patient

and third party carriers.

8. Understand the Resource-Based Relative Value Scale as it applies to services rendered.

21

9. Understand reimbursement policies by private insurance carriers, Medicare, Medicaid and

other financial sources.

10. Skills in appropriate follow-up care coordinated with the care given by the referring

physician and patient‘s ability to receive care. Develop skills communicating with

referring physicians.

Clinics are designed to provide 4-8 patients during each ½ day session.

Monday or Wednesday afternoons from 1:00 pm to 5:00 pm in Medicine Specialty Clinic.

An annual clinic schedule has been made. The Fellow will be assigned to this clinic

every other week, alternating with the VA Outpatient Clinic.

―Special‖ appointments may be arranged on a per patient basis by arrangement with the

clinic staff. Such appointments are usually made for tenuous patients needing earlier than

two week follow-up or for outpatients being seen by the consult fellow. The fellow must

pre-arrange an attending for these special appointments.

VA OUTPATIENT CLINICS GOALS and OBJECTIVES:

This continuity clinic allows longitudinal follow-up of patients with cardiovascular disorders

over the 3-year training program with faculty supervision.

Tuesday and Thursday afternoons from 1:00 pm to 4:00 pm in Cardiovascular

Medicine Clinic on the first floor. An annual clinic schedule has been made. Any

additional changes need to be addressed to the supervising clinic attending. In the

event of a cancellation, there must be a 30 day in advance notice. The Fellow will

be assigned to this continuity clinic every other week, alternating with the UMC

clinic.

VA Pacemaker, ICD Clinic Monday mornings from 9:00 am to 11:00 am in

room A101.

Cardiovascular Medicine Fellow responsibilities for the UMC and VA Outpatient Services

include:

Make every effort to be on time for scheduled appointments. In case of an

emergency, notify the clinic attending of an absence and your substitute for the

clinic.

Provide a written evaluation, including a diagnostic plan and treatment strategy.

At UMC the clinic note should be dictated on the date of the clinic visit and

reviewed for corrections in Power Chart within 48 hours, then forwarded to the

appropriate attending for final signature.

Discuss the plan with the assigned Cardiovascular Medicine attending. The

dictation should include a summary of this discussion.

Communicate by written or oral form to the referring and primary care physician.

22

At UMC all Power Chart notes that are electronically signed will be FAXed to the

referring physician by the division secretary after final signature by the attending.

Personally review diagnostic studies including ECGs, chest x-rays, stress tests,

echocardiograms, ambulatory monitors and cardiac catheterization studies.

Office organization including the function of receptionist, scheduling, nursing

support, record keeping, dictation, billing procedures and other business aspects

of the office.

Knowledge of the services available and how to access them such as obtaining

consults from other services, laboratory, radiology, rehabilitation, social services,

etc.

Cardiovascular Medicine Attending responsibilities for the Outpatient Services include:

Make every effort to provide timely consultation with the Cardiovascular

Medicine Fellow.

Review the patent‘s clinical data and laboratory studies and formulate a treatment

plan with the Cardiovascular Medicine Fellow on each patient.

Review written evaluations and letters to referring physicians and primary care

physicians.

Provide quarterly performance evaluations of each fellow to the division director.

Recommended reading for Outpatient Clinic Rotation: It is recommended that the fellows

are familiar with the published ACC/AHA guidelines for management of cardiovascular

diseases. Additionally, Braunwald‘s Heart Disease: A Textbook of Cardiovascular Medicine is

an important companion text for in-depth reading.

UMC ECHO LABORATORY


The goals and objectives of the UMC and VA echo services are to gain an understanding of the

diagnostic capabilities of echocardiography and Doppler. Specific goals include:

Gain understanding on instrumentation and controls on echo machines

Able to acquire 2-D and Doppler images and store and retrieve them

Able to carry out a comprehensive echocardiographic evaluation of a patient

Understand the indications of echocardiography especially in context of ACC/AHA and

ASE guidelines

Interpret 2-D and Doppler echo and be able to identify structural and hemodynamic

abnormalities

Understand the indications and complications of TEE

Interpret and perform TEE

23

Manage smooth workflow in the echo lab

Provide preliminary readings on studies

Understand the indications of contrast

Understand the principles and application of contrast echo

Understand tissue Doppler and its application ( Strain and strain rate imaging)

Actively participate in Treadmill Stress testing with echocardiography including selection

of digitized image looped immediately post exercise

Pharmacologic stress testing with echocardiography including selection of digitized

image loops immediately post exercise

TEE guided cardioversion

Understand advanced echo: (a) AV optimization (b) Research applications

Be fluent in presentation of case based echocardiography in formal presentations

Formulate Research projects, echo related

Carry out research projects

In the Echo rotation fellows perform and interpret multidimensional echocardiography.

Studies are performed between 8:30 am to 5:00 pm. Emergency procedures are provided

through the ―on call‖ Cardiovascular Medicine fellow and attending. Studies are interpreted

in conjunction with the Non-Invasive Cardiovascular Medicine attending or the Nuclear

Medicine attending. Cardiovascular Medicine fellows are strongly encouraged to attend

conferences in Nuclear Medicine during this rotation. With adequate numbers, certification

for licensure to perform nuclear studies is available. The University echocardiographic

laboratory is fully ICAEL accredited and is a fully digital lab. At the end of the required

rotations, level II certification in echocardiography will be achieved.

Responsibilities of the Cardiovascular Medicine Fellow in the Echo Rotation include:

If the VA Echo Fellow is on vacation, then the fellow assigned to MU Echo Block

rotation will cover.

First Year Fellow:

Understanding the basic principles of 2-D, M-Mode and Doppler echocardiography

Performing and interpreting 2-D, M-Mode and Doppler studies

Performing and interpreting head up tilt studies.

Second Year Fellow:


Performance and interpretation of transesophageal echocardiograms

Performance and interpretation of dobutamine and exercise stress echocardiograms

Performing and interpreting urgent echocardiographic studies while on call

Performing and interpreting head up tilt studies.

Third Year Fellow:


Performance and interpretation of intra-operative transesophageal echocardiograms

Performing and interpreting head up tilt studies

24

Assessment of prosthetic valves

Conducting research

Fellows are responsible for having all echo studies preliminarily read by the end of the

day whenever possible and placed in the Enconcert system under preliminary reports.

If the echo attending cannot be present to overread studies by 6:00 pm the fellows may

leave if they wish, leaving the lab set up in and in orderly fashion so that attending can

read efficiently. However, they should check the finalized reports the next day in the

system to see what differences there were in interpretation. At a time that is suitable to

the staff attending, the fellow can go over those corrections he/she does not clearly

understand.

At the end of the block all fellows should be prepared to perform a transthoracic 2D,

M mode, doppler, and color flow echocardiographic study (TEE and stress echoes of

any type-DSE, etc. are already performed always under the staff supervision) which

will be reviewed and critiqued by the staff physician. The attending also has the

prerogative to make up a brief written test which the fellow will be required to take if

the staff so desires.

The fellows need to attend all educational conferences set out by the division and may

expect to be responsible for presenting at echo conferences interesting studies for

educational QA purposes.

In addition, it should be noted that if a fellow wishes to attend the 7:30 am conference

rather than perform the intra-operative study all he/she needs to do is simply let the

attending know and that will not be a problem. This is also true for the noon

Department of Medicine lectures that occur on Tuesdays and Thursdays. If a fellow

would prefer to perform a study during the 7:30 am - 8:30 am period they may call the

Cardiovascular Medicine Fellowship office and let the secretary know and this will be

an excused absence, followed-up with an e-mail to the fellowship coordinator.

Each individual staff echo attending on rotation may supplement the Echo Fellow‘s

instruction as deemed appropriate as long as it is within reason. (Appendix C)

UMC Fit for Life/Cardiac Rehabilitation Goals and Objectives:

The purpose of the rotation is to provide the fellow with instruction and clinical experience in

cardiovascular rehabilitation.

At the end of the rotation the fellow will be knowledgeable in the following areas:

Acquire knowledge about prevention and rehabilitation of cardiovascular

disease, including coronary disease, valvular disease, congestive heart

failure, peripheral vascular disease

25

Components of Cardiac Rehabilitation Phases 1, 2, 3, and 4

Standards for certification of a cardiac rehabilitation and secondary

prevention program by the American Association of Cardiovascular and

Pulmonary Rehabilitation (AACVPR)

Standards for certification for Chest Pain Center

Documentation requirements for CMS and AACVPR

Reimbursement requirements for CMS

Role of the medical director in cardiac rehabilitation program, including

staff relations, program development, and safety considerations

Setting

Fit for Life is located in GL-20 of the University of Missouri Health Care. Fit for Life

offers the following programs:

Cardiac rehabilitation (post-MI, post-CABG, post-PCI, post-valvular

surgery)

Heart failure rehabilitation

Pulmonary rehabilitation

Peripheral Artery Disease Rehabilitation

Bariatric Rehabilitation

Stayfit Wellness

Freedom from Smoking

Rotation

Basic: All fellows in Cardiovascular Medicine will rotate through Fit for Life ½ day per

week during their MU Non-Invasive Lab (non-Echo) rotation.

Elective: Fellows may elect an additional month rotation in Fit for Life. An individual

program of study will be coordinated with the supervisor and medical director of Fit for Life at

least one month in advance of this elective.

Responsibilities

The fellow will meet with the supervisor and/or medical director of Fit for Life at the start

of their MU Non-Invasive Lab (non-Echo) rotation to coordinate the ½ day per week

commitment to Fit for Life.

During the rotation the fellow will participate in the following:

New patient intake (including pre-test, 6-minute walk test, screening

examination, and planning rehabilitation program)

Inpatient rehabilitation consultation rounds

Exercise with patients in phase 2 and 3 rehabilitation

Patient education programs (e.g., smoking cessation counselling)

Read the recommended chapters provided in the Fit for Life resource

library

Recommended reading

26

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR).

Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 4th ed. Champaign:

Human Kinetics, 2004.

Chp. 1 – Integration of Cardiac Rehabilitation and Secondary Prevention

Chp. 2 – Cardiac Rehabilitation Cointinuum of Care

Chp. 3 – Emergence of Nutrition and Plant-based Diets in the Treatment

and Prevention of Cardiovascular Disease

Chp. 4 – Cardiac Rehabilitation in the Inpatient and Transitional Settings

Chp. 8 – Modifiable Cardiovascular Disease Risk Factors

Chp. 9 – Special Considerations

Chp. 10 – Administrative Considerations

American College of Sports Medicine. Resource Manual for Guidelines for Exercise

Teating and Prescription, 5th ed. Leonard A. Kaminsky et al, editors. Philadelphia: Lippincott

Williams & Wilkins, 2005.

Chp. 3 – Exercise Physiology

Chp. 4 – Physiologic Effects of Aging and Deconditioning

Chp. 9 – Relationship of nutrition to Chronic Diseases

Chp. 22 – Cardiopulmonary Adaptations to Exercise

Chp. 27 – Applied Exercise Programming

Chp. 31 – Exercise Training in Patients in Cardiovascular Disease

Chp. 41 – Factors Associated with Regular Physical Activity Participation

Chp. 42 – Behavioral Strategies to Enhance Physical Activity Participation

Chp. 45 – Exercise Program Professionals and Related Staff

Chp. 46 – Health and Fitness Program Development and Operation

Chp. 47 – Clinical Exercise Program Development and Operations

Chp. 48 – Financial Considerations

Chp. 49 – Policies and Procedures for Program Safety and Compliance

Chp. 50 – Legal Considerations

American College of Sports Medicine. Guidelines for Exercise Testing and Prescription,

7th ed. Mitchell H. Whaley et al, editors. Philadelphia: Lippincott Williams & Wilkins, 2005.

Chp. 2 – Preparticipation Health Screening and Risk Stratification

Section III – Exercise Prescription

1. Chp. 7 – General Principles of Exercise Prescription

2. Chp. 8 – Exercise Prescription Modifications for Cardiac Patients

3. Chp. 9 – Other Clinical Conditions Influencing Exercise

Prescription

4. Chp. 10 – Exercise Testing and Prescription for Children and

Elderly People

27

VA NON-INVASIVE LABORATORY


The goals and objectives of the VA non-invasive rotation is similar to the UMC Echo and

Graphics rotation.

The Cardiovascular Medicine fellow will perform/interpret echocardiogram, tilt tests. If

VA echo fellow is on vacation, echo fellow from the University Hospital will cover his

responsibilities. VA Treadmills are covered by VA Nuclear Fellow. If there is no VA

Nuclear fellow for a particular rotation, the default coverage for treadmills VA Echo

fellow, followed by VA CCU/consult fellow. EKGs, Holter, Event Monitors at VA are

the responsibility of VA CCU/Consult Fellow.

The Echo Fellow at MU/VA should take note of next day‘s first start OR TEEs, inform

the responsible attending, and review the indication for TEE and previous

noninvasive/invasive studies pertinent to that patient.

UMC AND VA INVASIVE LABORATORY


The goals and objectives of training in the invasive laboratory include:

Hemodynamic assessment – recording of pressures in the cardiac chambers and the

vascular tree.

Determination of cardiac function, evaluation of shunts, and valvular disease.

Angiography to evaluate the presence of vascular obstruction or other abnormalities,

contractile function the left ventricle, and valvular lesions.

Therapeutic procedures such as pericardiocentesis, intraaortic balloon pumping,

endomyocardial biopsies, and temporary transvenous pacemaker insertion.

Fellows will receive training in right and left heart catheterization, coronary angiography,

interventional Cardiovascular Medicine, endocardial biopsy, pericardiocentesis, and intra-

aortic balloon couterpulsation. Procedures are scheduled from 8:30 am to 4:00 pm.

Emergency procedures are arranged by the "on call" Cardiovascular Medicine fellow and

attending.

Responsibilities of Cardiovascular Medicine Fellow on Invasive Lab Rotation are:

During cardiac catheterization rotations the fellow is expected to be present in the

catheterization laboratory for the entire work day, unless assigned to clinic, and report to the

Charge Person in the cath lab regarding the case assignment and other functions (exposure to

X-ray and other equipment operation, QA and troubleshooting, as well as the catheter

inventory management is included in the cath lab experience). The fellows are expected to

know the patients and perform a relevant cardiovascular physical exam, including their

vascular access sites prior to the admission of the patient to the laboratory, and be physically

present with the assigned patient the entire time the patient is in the room. The fellows will

28

master the catheterization skills progressively over the course of 3 years and are expected to

perform several diagnostic catheterizations with the attending present but not scrubbed during

their last rotation. Fellows will interpret studies, generate a report in conjunction with the

attending physician, and arrange appropriate follow-up. Fellows will generate a discharge

summary for outpatients undergoing catheterization studies.

In taking part in these UMC and VA rotations, the fellow will be able to meet minimum

performance and interpretation guidelines including:

The level of service provided is dependent upon the experience of the trainee. In general,

First Year Fellow:

Learning vascular access

Achieving hemostasis, sheath removal

Setting up pressure manifolds or Acist device

Learning basic hand washing techniques, gowning and gloving

Maintaining sterility in cardiac catheterization lab

Performing diagnostic coronary angiography and left ventriculography

Performing and interpreting right heart catheterization

Understanding basics of interventional Cardiovascular Medicine especially indications

for interventional procedures and selection of patients for surgical referral

Hemodynamics and valve area calculations

Assessment of severity of lesion stenosis

Interpretation of coronary and peripheral angiograms

Second and Third Year Fellows:


Assisting in percutaneous transluminal coronary angioplasties

Assisting in intra-coronary stent placements

Insertion and care of intra-aortic balloon counterpulsation devices

Perform endomyocardial biopsies

Take calls for emergent cardiac catheterization laboratory procedures

Assisting in other interventional procedures such as rotablations, directional coronary

atherectomies, laser angioplasties, and thrombectomy

Assisting in balloon valvuloplasties

Taking call for emergent call cardiac catheterization laboratory procedures

Learning techniques of lesion assessments including ―setting up‖ angiographic views,

analyzing lesions with quantitative coronary angiography

Planning interventional strategies

Assisting in intra-coronary doppler flow studies and pressure wire measurements

Assisting in the performance and interpretation of intravascular and intracrdiac

ultrasound studies

Assisting in the performance of peripheral interventional procedures, PFO and ASD

closures

29

EPS AND ARRHYTHMIA SERVICE GOALS and OBJECTIVES:

The goals and objectives of the EP and Arrhythmia service is to provide special instruction in the

diagnosis and treatment of patients with cardiac arrhythmias. An emphasis will be on

understanding the pathophysiologic mechanisms of disease, the usefulness of specialized

diagnostic and therapeutic procedures, and an appreciation of the long term challenges faced in

follow-up of patients with cardiac arrhythmias.

One fellow is assigned to EP rotation and is responsible for EP procedures at UMC and VA. EP

studies at VA are scheduled on Fridays. If EP fellow is occupied with procedures at UMC, the

Cath Lab fellow in VA will cover for him. Selected references are enclosed (Appendix D).

Responsibilities of Cardiovascular Medicine Fellow on EP rotation include:

ICU Clinic

Care of EP patients

Communication with Dr. Greg Flaker and Dr. Rich Weachter when need identified and

the night before a scheduled procedure

Assigned to cath lab for all EP procedures

First Year Fellow:

Understanding basics of EPS through didactics

Follow-up of patients with permanent pacemakers/ICD‘s

Second and Third Year Fellows:


1. Follow-up of patients with permanent pacemakers/ICD‘s

2. Basic electrophysiologic studies including vascular access, positioning of catheters,

evaluation of Sinus node recovery time, programmed stimulation and mapping techniques

3. Implantation and follow-up of permanent pacemakers

4. Assisting in the follow-up of ICDs

5. Assisting in radiofrequency ablation procedures

6. Assisting in implantation of ICDs

Recommended Reading for EP rotation:

EP Textbooks

1. Ellenbogen KA, Kay GN, Wilkoff BL. Clinical Cardiac Pacing and Defibrillation. 2 ed.

Philadelphia: W.B. Saunders, 2000

2. Hayes DL, Lloyd MA, Friedman RA. Cardiac Pacing and Defibrillation: A Clinical

Approach. Mount Kisco, NY: Futura, 2000.

3. Josephson M. Clinical cardiac electrophysiology techniques and interpretations. 3rd

edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2002.

http://www.amazon.com/gp/product/0721676839/qid=1144267365/sr=2-1/ref=pd_bbs_b_2_1/104-1782477-9071110?s=books&v=glance&n=283155


http://www.amazon.com/gp/product/087993462X/qid=1144267473/sr=1-1/ref=sr_1_1/104-1782477-9071110?s=books&v=glance&n=283155

http://www.amazon.com/gp/product/087993462X/qid=1144267473/sr=1-1/ref=sr_1_1/104-1782477-9071110?s=books&v=glance&n=283155

http://www.amazon.com/gp/product/0812112016/qid=1144330183/sr=1-1/ref=sr_1_1/104-1782477-9071110?s=books&v=glance&n=283155


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4. Kowey P, Naccarelli GV. Atrial Fibrillation. New York: Marcel Dekker 2005.

5. Zipes DP, Haissaguerre M. Catheter Ablation of Arrhytmias. 2 ed. New York: Futura

2002.

6. Fogoros R. Electrophysiologic testing. 3rd edition. Malden, MA: Blackwell Science, 1999.

Other Books

1. Ellenbogen, KA, and Wood,MA. Cardiac Pacing and ICDs, third edition. Malden MA:

Blackwell Science, Inc.

2. Barold SS, Stroobandt RX, Sinnaeve AF, Cardiac Pacemakers Step by Step: An Illustrated

Guide. Mount Kisco, NY: Futura, 2004.

3. Grubb BP and Olshansky B. Syncope: Mechanisms and Management. 2nd

Edition. Malden,

MA: Blackwell Publishing 2005.

Defibrillation

1. Kadish A, Dyer A, Daubert JP, Quigg R, Estes NA, Anderson KP, Calkins H, Hoch D,

Goldberger J, Shalaby A, Sanders WE, Schaechter A, Levine JH. Defibrillators in Non-

Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators. Prophylactic

defibrillator implantation in patients with nonischemic dilated cardiomyopathy. New England

Journal of Medicine. 350(21):2151-8, 2004.

2. Bristow MR. Saxon LA. Boehmer J. Krueger S. Kass DA. De Marco T. Carson P. DiCarlo L.

DeMets D. White BG. DeVries DW. Feldman AM. Comparison of Medical Therapy, Pacing,

and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization

therapy with or without an implantable defibrillator in advanced chronic heart failure. New

England Journal of Medicine. 350(21):2140-50, 2004.

3. Wathen MS, Sweeney MO, DeGroot PJ, Stark AJ, Koehler JL, Chisner MB, Machado C,

Adkisson WO. PainFREE Investigators. Shock reduction using antitachycardia pacing for

spontaneous rapid ventricular tachycardia in patients with coronary artery disease.

Circulation. 104(7):796-801, 2001.

4. Moss AJ, Hall WJ, Cannom DS, Daubert JP, Higgins SL, Klein H, Levine, JH, Saksena S,

Waldo AL, Wilber D, Brown MW, Heo M. Improved survival with an implanted defibrillator

in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter

Automatic Defibrillator Implantation Trial Investigators. New England Journal of Medicine

1996; 335(26):1933-1940.

5. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, Daubert JP, Higgins SL.

Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced

ejection fraction. New England Journal of Medicine 2002; 346(12): 877-883.

6. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients

resuscitated from near-fatal ventricular arrhythmias. The Antiarrhythmics versus Implantable

Defibrillators (AVID) Investigators. New England Journal of Medicine 1997; 337(22): 1576-

1583.

7. Causes of death in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial.

Journal of the American College of Cardiovascular Medicine 1999; 34(5): 1552-1559.

8. Domanski MJ, Saksena S, Epstein AE, Hallstrom AP, Brodsky MA, Kim S, Lancaster S.






http://content.nejm.org/cgi/content/short/350/21/2151










http://circ.ahajournals.org/cgi/content/full/104/7/796
















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Relative effectiveness of the implantable cardioverter-defibrillator and antiarrhythmic drugs

in patients with varying degrees of left ventricular dysfunction who have survived malignant

ventricular arrhythmias. AVID Investigators. Antiarrhythmics Versus Implantable

Defibrillators. Journal of the American College of Cardiovascular Medicine 1999; 34(4):

1090-1095.

9. Schron EB, Exner DV, Yao Q, Jenkins LS, Steinberg JS, Cook JR, Kutalek SP, Friedman PL,

Bubien RS, Page RL, Powell J. Quality of life in the antiarrhythmics versus implantable

defibrillators trial: impact of therapy and influence of adverse symptoms and defibrillator

shocks. Circulation 2002; 105(5): 589-594.

10. Larsen G, Hallstrom A, McAnulty J, Pinski S, Olarte A, Sullivan S, Brodsky M, Powell J.

Cost-effectiveness of the implantable cardioverter-defibrillator versus antiarrhythmic drugs in

survivors of serious ventricular tachyarrhythmias: results of the Antiarrhythmics Versus

Implantable. Circulation 2002; 105(17): 2049-2057.

11. Lee KL, Hafley G, Fisher JD, Gold MR, Prystowsky EN, Talajic M, Josephson ME, Packer

DL, Buxton AE, Multicenter Unsustained Tachycardia Trial Investigators. Effect of

implantable defibrillators on arrhythmic events and mortality in the multicenter unsustained

tachycardia trial. Circulation 2002; 106(2): 233-238.

12. Buxton AE, Lee KL, DiCarlo L, Echt DS, Fisher JD, Greer GS, Josephson ME, Packer D,

Prystowsky EN, Talajic M. Nonsustained ventricular tachycardia in coronary artery disease:

relation to inducible sustained ventricular tachycardia. MUSTT Investigators. Annals of

Internal Medicine 1996; 125(1): 35-39.

13. Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G. A randomized

study of the prevention of sudden death in patients with coronary artery disease. New

England Journal of Medicine 1999; 341(25): 1882-1890.

14. Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G. A randomized

study of the prevention of sudden death in patients with coronary artery disease. Multicenter

Unsustained Tachycardia Trial Investigators. New England Journal of Medicine 1999;

341(25): 1882-1890.

15. Buxton AE, Lee KL, DiCarlo L, Gold MR, Greer GS, Prystowsky EN, O'Toole MF, Tang A,

Fisher JD, Coromilas J, Talajic M, Hafley G. Electrophysiologic testing to identify patients

with coronary artery disease who are at risk for sudden death. Multicenter Unsustained

Tachycardia Trial Investigators. New England Journal of Medicine 2000; 342(26): 1937-

1945.

16. Maron BJ, Shen WK, Link MS, Epstein AE, Almquist AK, Daubert JP, Bardy GH, Favale S,

Rea RF, Boriani G, Estes NA, III, Spirito P. Efficacy of implantable cardioverter-

defibrillators for the prevention of sudden death in patients with hypertrophic

cardiomyopathy. New England Journal of Medicine 2000; 342(6): 365-373.

17. Gardy GH, Lee KL, Mark DB, Poole JE, et al. Amiodarone or an implantable cardioverter—

defibrillator for congestive heart failure. New Engl J Med 2005;352(3):225-237.

18. Solomon Sd, Zelenkofske S, McMurray JJV, Finn PV, et al. Sudden death in patients with

myocardial infarction and left ventricular dysfunction, heart failure, or both. New Engl J

Med 2005;352(25):2581-2640.

19. Hohnloser SH, Kuck KH, Roberts RS, et al. Prophylactic use of an implantable cardioverter-













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defibrillator after acute myocardial infarction. New Engl J Med 2004;351(24):2481-2488.

20. Gillis AM. Prophylactic implantable cardioverter-defibrillators after myocardial infarction –

not for everyone. New Engl J Med 2004(24):2540-2542.

21. Kadish A, Dyer A, Daubert JP, Quigg R, et al. Prophylactic defibrillator implantation in

patients with nonischemic dilated cardiomyopathy. New Engl J Med 2004;350(21):2151-

2158.

Pacing

1. Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA, Kerber RE,

Naccarelli GV, Schoenfeld MH, Silka MJ, Winters SL, Gibbons RJ, Antman EM, Alpert JS,

Gregoratos G, Hiratzka LF, Faxon DP, Jacobs AK, Fuster V, Smith SC, Jr., Committee M,

Task FM. ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac

Pacemakers and Antiarrhythmia Devices: Summary Article: A Report of the American

College of Cardiovascular Medicine/American Heart Association Task Force on Practice

Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines).

Circulation 2002; 106(16): 2145-2161.

2. Ellenbogen KA. Cardiac Pacing. Cardiovascular Medicine Clinics 18, 1-239. 2000.

3. Josephson ME, Maloney JD, Barold SS, Flowers NC, Goldschlager NF, Hayes DL et al.

Guidelines for training in adult cardiovascular medicine. Core Cardiovascular Medicine

Training Symposium (COCATS). Task Force 6: training in specialized electrophysiology,

cardiac pacing and arrhythmia management. Journal of the American College of

Cardiovascular Medicine 1995; 25(l): 23-26.

4. Connolly SJ, Sheldon R, Roberts RS, Gent M. The North American Vasovagal Pacemaker

Study (VPS). A randomized trial of permanent cardiac pacing for the prevention of vasovagal

syncope. Journal of the American College of Cardiovascular Medicine 1999; 33(1): 16-20.

5. Sutton R. Guidelines for pacemaker follow up. Report of a British Pacing and

Electrophysiology Group (BPEG). Heart 1996; 76(5): 458-460.

6. Connolly SJ, Kerr CR, Gent M, Roberts RS, Yusuf S, Gillis AM, Sami MH, Talajic M, Tang

AS, Klein GJ, Lau C, Newman DM. Effects of physiologic pacing versus ventricular pacing

on the risk of stroke and death due to cardiovascular causes. Canadian Trial of Physiologic

Pacing Investigators. New England Journal of Medicine 2000; 342(19): 1385-1391.

7. Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R, Marinchak RA, Flaker G.

Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. New England Journal

of Medicine 2002; 346(24): 1854-1862.

8. Goldschlager N, Epstein A, Friedman P, Gang E, Krol R, Olshansky B, North American

Society of Pacing and Electrophysiology (NASPE) Practice Guideline Committee.

Environmental and drug effects on patients with pacemakers and implantable

cardioverter/defibrillators: a practical guide to patient treatment. Archives of Internal

Medicine. 161(5):649-55, 2001.

9. Lamas GA. Ellenbogen KA. Evidence base for pacemaker mode selection: from physiology

to randomized trials. Circulation. 109(4):443-51, 2004.

10. The DAVID Trial Investigators. Dual-chamber pacing or ventricular backup in patients with

an implantable defibrillator. JAMA 2002;288(24):3115-3123.









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Biventricular Pacing

1. Ellenbogen KA, Kay GN, Wilkoff BL (eds.), Device Therapy for Congestive Heart Failure

Elsevier Science, Philadelphia, Pennsylvania, 2004.

2. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, Kocovic DZ, Packer

M. Cardiac resynchronization in chronic heart failure. New England Journal of Medicine

2002; 346(24): 1845-1853.

3. Cazeau S, Leclercq C, Lavergne T, Walker S, Varma C, Linde C, Garrigue S, Kappenberger

L, Haywood GA, Santini M, Bailleul C, Daubert JC, Multisite Stimulation iC. Effects of

multisite biventricular pacing in patients with heart failure and intraventricular conduction

delay. New England Journal of Medicine 2001; 344(12): 873-880.

4. Kuhlkamp V, The I. Initial experience with an implantable cardioverter-defibrillator

incorporating cardiac resynchronization therapy. Journal of the American College of

Cardiovascular Medicine 2002; 39(5): 790-797.

5. Lozano I, Bocchiardo M, Achtelik M, Gaita F, Trappe HJ, Daoud E, Hummel J, Duby C.

Impact of biventricular pacing on mortality in a randomized crossover study of patients with

heart failure and ventricular arrhythmias. Pacing & Clinical Electrophysiology 2000; 23(11

Pt 2): 1711-1712.

6. Saxon LA, De Marco T, Schafer J, Chatterjee K, Kumar UN, Foster E, VIGOR C. Effects of

long-term biventricular stimulation for resynchronization on echocardiographic measures of

remodeling. Circulation 2002; 105(11): 1304-1310.

7. Stellbrink C, Breithardt OA, Franke A, Sack S, Bakker P, Auricchio A, Pochet T, Salo R.

Impact of cardiac resynchronization therapy using hemodynamically optimized pacing on left

ventricular remodeling in patients with congestive heart failure and ventricular conduction

disturbances. Journal of the American College of Cardiovascular Medicine 2001; 38(7):

1957-1965.

8. Bradley DJ, Bradley EA, Baughman KL, Berger RD, et al. Cardiac resynchronization and

death from progressive heart failure: A Meta-analysis of randomized controlled trials.

JAMA 2003;289(6):730-740.

9. Cleland JGF, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on

morbidity and mortality in heart failure. New Engl J Med 2005;352:Cleland1-Cleland 11.

Lead Extraction

1. Love CJ, Wilkoff BL, Byrd CL, Belott P, Brinker J, Fearnot NE, Friedman RA, Furman S,

Goode LB, Hayes DL, Kawanishi DT, Parsonnet V, Reiser C, Van AR. Recommendations

for Extraction of Chronically Implanted Transvenous Pacing and Defibrillator Leads:

Indications, Facilities, Training. Pacing and Clinical Electrophysiology 2000;(23).

2. Wilkoff BL, Byrd CL, Love CJ, Hayes DL, Sellers TD, Schaerf R, Parsonnet V, Epstein LM.

Pacemaker lead extraction with the laser sheath: results of the pacing lead extraction with the

excimer sheath (PLEXES) trial. Journal of the American College of Cardiovascular

Medicine 1999; 33(6): 1671-1676.

3. Kay GN, Brinker JA, Kawanishi DT, Love CJ, Lloyd MA, Reeves RC, Pioger G, Overland

MK, Ensign LG, Grunkemeier GL. The Risks of Spontaneous Injury and Extraction of an

Active Fixation Pacemaker Lead: Report of the Accufix Multicenter Clinical Study and

World-Wide Registry. Circulation 1999; 100: 2344-2352.










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4. Byrd CL, Wilkoff BL, Love CJ, Sellers TD, Reiser C. Clinical study of the laser sheath for

lead extraction: the total experience in the United States. PACE 2002; 25(5): 804-808.

Syncope

1. Stickberger SA, Benson DW, Biaggioni I, Callans DJ, et al. AHA/ACCF Scientific

Statement on the Evaluation of Syncope: From the American Heart Association Councils on

Clinical Cardiovascular Medicine, Cardiovascular Nursing, Cardiovascular Disease in the Y

oung, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working

Group; and the American College of Cardiovascular Medicine foundation: In Collaboration

with the Heart Rhythm Society: Endorsed by the American Autonomic Society. Circ

2006;113:316-327.

2. Soteriades ES, Evans JC, Larson MG, Chen MH, et al. Incidence and prognosis of syncope.

New Engl J Med 2002;347(12):878-885.

3. Manolis AS, Linzer M, Salen D, Estes NAM. Syncope: current diagnostic evaluation and

management. Ann Int Med 1990;112(11):850-863.

4. Grubb, BP. Neurocardiogenic Syncope. New Engl J Med 2005;352(10):1004-1010.

5. Kapoor WN. Syncope. New Engl J Med 2000;343(25):1856-1862.

RESEARCH ROTATIONS


The goals and objectives of the Research rotation is to discover new knowledge and to translate

this knowledge into the practice of Cardiovascular Medicine.

Research rotations are required. Cardiovascular Medicine fellows are encouraged to take part in

clinical trials. Duties include review and understanding of research protocols, recruitment of

patients into studies, and follow-up of patients within protocol guidelines. In addition, blocks of

1-3 months of research time are available with selected members of the Cardiovascular Medicine

and University Faculty. Fellows should meet regularly with their mentors regarding their

progress in research.

The amount of research is dependent upon the experience of the trainee. In general,

First Year Fellows:

Researching topics of presentation with the help of assigned mentors

Presentation of researched topics in Conference formats

Critically analyzing journal articles of relevance to Cardiovascular Diseases and

presenting such analyses in the form of Journal Club presentations

Preparing and presenting topics/case reports/ research studies of importance to Internal

Medicine at the regional and National meetings of the American College of Physicians

and other organizations in Internal Medicine

Attending the National Annual Scientific Sessions of the American Heart Association/

American College of Cardiovascular Medicine

Identifying areas of potential research, including participation in clinical trials

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Further refining research and presentation skills by acquiring the ability to present with

clarity, complex topics and controversial topics in Internal Medicine and Cardiovascular

Medicine in Conference format

Participating in ongoing clinical and basic science research protocols of the Division of

Cardiovascular Medicine



Third Year Fellows:



Preparing and submitting for publication manuscripts on original research conducted

Formulate research plans for a future career in Cardiovascular Medicine

Fellows need to notify the fellowship coordinator 1 week prior to research rotation in writing

regarding who they will be working with.

ELECTIVE ROTATION OPTIONS

PEDIATRIC CARDIOLOGY

Elective rotations are available in conjunctive with pediatric cardiologists. This experience will

provide exposure to congenital heart disease and other pediatric conditions. The rotation

includes outpatient clinics and participation in invasive and non-invasive studies.

VA NUCLEAR MEDICINE ROTATION

This is an elective rotation. The fellow may actually be on a research rotation while on this

block, too. This block will have coverage only 6 to 8 rotations (out of 13) per year.

Treadmills/CPX treadmills will routinely begin at 10:00am.

During this rotation, interpretation of nuclear studies including myocardial perfusion imaging,

pharmacologic stress testing, first pass and gated radionuclide angiography will be performed. A

basic knowledge of radiation safety, use of radiopharmaceuticals, and acquisition and processing

of nuclear medicine images is gained.

NUCLEAR CARDIOLOGY TRAINING

The purpose of the Nuclear Cardiology Training Modules is to give training to Fellows in

Cardiovascular Medicine to meet the requirements for licensure in Nuclear Cardiology. This

training is intended to be a component toward eligibility to take the Certification Examination in

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Nuclear Cardiology (CBNC) as well as to meet the requirements defined in 10CFR35.290 and

35.390 for becoming an authorized user of radiopharmaceuticals.

Each of the modules is 1-3 hours in length and consists of the following types of learning: a)

reading from selected texts, b) WEB-based reading and homework problems, c) classroom

lectures, and d) exams. The schedule for examinations is as follows: a) for every 3 hours of

learning a 20 minute exam is given, b) for every 15 hours of learning a 1 hour exam is given, and

c) for every 45 hours of learning a 90 minute exam is given. A passing score of 80% is required.

ADVANCED NUCLEAR CARDIOLOGY TRAINING-LEVEL 2 (4-6 MONTHS).

This training will give the trainee the qualifications to become an authorized user of

radiopharmaceuticals as defined by the Nuclear Regulatory Commission (NRC) in CFR 35.290

or 35.390. A total of 700 hours is required. A minimum of 500 hours is spent in the Nuclear

Medicine Clinic in supervised clinical work. A minimum of 300 cases in nuclear cardiology are

interpreted under supervision of a preceptor, and a minimum of 100 of these cases have

correlations with coronary angiogram data. The trainee will become competent in all aspects of

performing myocardial perfusion imaging: patient management, data acquisition/processing, and

interpretation. Additional training of up to 200 hours is obtained through a series of lectures,

readings, and electronic media (Web-based; learning CD‘s), and examinations. The areas of

training include radiation physics, radiation biology, instrumentation, radiopharmaceuticals

(handling, preparation, dosing, patient injection), and radiation safety

Nuclear Cardiology Learning Objectives

Clinical training in Nuclear Cardiology involves working under a physician preceptor and

mastery of the following areas:

1) Evaluating consultation requests for cardiac studies and choosing the proper diagnostic

procedure.

2) Selecting the proper imaging protocol and supervising the procedure.

3) Understand the procedure for formulation of radiopharmaceutical from Mo-99/Tc-99m eluant,

and the proper dose preparation using the dose calibrator.

4) Safe handling of radiopharmaceutical and proper technique for injecting patients.

5) Using proper protocol (treadmill, adenosine, or dobutamine) for inducing increased coronary

flow for Myocardial Perfusion Imaging.

6) Acquiring images with gamma camera and processing data.

7) Interpreting images in order to evaluate myocardial perfusion.

8) Recognition of artifacts that affect perfusion images.

9) Preparation of final reports.

10) Correlation of findings from myocardial perfusion images and cardiac catheterization.

Recommended Reading for Nuclear Cardiology Rotation:

Basic Science of Nuclear Medicine, CD-ROM, 22 lessons, Society of Nuclear Medicine,

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2001.

Nuclear Medicine Self-Study Program III, Topic 5: Myocardial Perfusion Scintigraphy-

Technical Aspects; Topic 6: Myocardial Perfusion Scintigraphy-Clinical Aspects, Society

of Nuclear Medicine, 2001, Editor: Elias Botvinick M.D.

Iskandrian AE and Verani MS, Nuclear Cardiac Imaging, Principles and Applications, 3rd

edition, 2003, Oxford University Press, 511p.

DePuey EG, Garcia EV, and Berman DS editors, Cardiac SPECT Imaging, 2nd

edition,

2001, Lippincott Williams and Wilkins, 349p.

DIDACTIC SCHEDULE

The important education mission of the Division of Cardiovascular Medicine is additionally

achieved through our daily morning conferences.

CARDIOVASCULAR MEDICINE CONFERENCES

Cardiovascular Medicine Conferences are held daily from 7:30am to 8:30am in the Clinical

Support & Education Building (CE313) Conference Room. A variety of topics are covered and

attendance is mandatory given that these sessions form an integral component of the training

experience and upon which board eligibility is based. The Division requires at least 67%

attendance to conferences to be board eligible.

Service assignment determines which fellow has primary responsibility for the conference. The

conference material must be planned in concert with the responsible faculty member identified.

This includes the availability of handouts, projectors, and slides, and the coordination with

contributing departments or divisions. Fellows typically are responsible for 5-6 major conference

per year.

Conferences will be held in the Clinical Support & Education Building (CE313) Conference

Room.

The fellows attendance at the Conferences will be recorded by their signing the Attendance List.

This is necessary for documenting the educational experience provided by the Division and for

recommending board eligibility.

The success of the fellow‘s conference will be graded by the faculty in Cardiovascular Medicine

using the attached document. This document will be used to determine the trainees‘ level of

performance and again relates to the Divisions‘ recommending board eligibility.

38

Monday and Tuesday: Core Curriculum/Graphics Conferences

Core Curriculum:

Review of a major Cardiovascular Medicine topic by faculty or fellow. Early in the academic

year a general review occurs. Later in the year more focused topics are presented. Topics

included include:

cardiocirculatory physiology and metabloism

cardiovascular pharmacology

heart failure

myocardial infarction and coronary artery disease

valvular heart disease

pericardial disease

hypertension

lipid abnormalities

congenital heart disease

Cardiovascular risk factors

heart disease in pregnancy

principles of cardiovascular rehabilitation

cardiovascular pathology

peripheral and cerebral vascular disease

biostatistics

cardiac trauma

cardiovascular epidemiology

pulmonary vascular disease

newer imaging techniques, such as magnetic resonance imaging, fast computerized

tomography, positron emission tomography

ethical issues in clinical practice

Cardiovascular Medicine as it relates to other subspecialties such as thoracic surgery,

nephrology, pulmonary and critical care, etc

cardiovascular diseases in the elderly

molecular biology of the cardiovascular system

cardiac transplantation

Specific Objectives:

1. Understanding cardio-circulatory physiology, cardiovascular pharmacology.

2. Understanding the basic principles of management of common cardiovascular problems

such as acute myocardial infarction, angina pectoris, valvular heart disease,

cardiomyopathies, and congenital heart disease especially in the adult, congestive

heart failure, pericardial disease, endocarditis, and cardiac arrhythmias.

3. Developing an understanding of preventive Cardiovascular Medicine.

4. Discussion of lipid abnormalities, their diagnosis and management.

39

5. Heart disease in pregnancy.

6. Cardiovascular rehabilitation.

7. Cardiovascular pathology including endomyocardial biopsies.

8. Biostatistics.

9. Ethical issues in clinical practice and in research.

10. Cardiovascular Medicine as it relates to other specialties, e.g. pulmonary and critical care,

nephrology, thoracic surgery.

11. Understanding the principles of effective consultation to other services and in particular

peri-operative cardiovascular assessment for non-cardiac surgery.

12. Understanding the indications, contraindications, timing and complications of

cardiothoracic surgical procedures.

Graphics:

Review of selected ECG's, echos, or stress tests other suitable patient material by faculty or

fellow.


1. Understanding the basic principles involved in electrocardiography, signal averaged

electrocardiography, stress testing, echocardiography including stress and

transesophageal echocardiography, cardiopulmonary exercise testing, nuclear

imaging,

2. Understanding cardiac arrhythmias, basics of pacemaker indications, implantation,

follow-up and troubleshooting.

3. Understanding the basics of anti-tachycardia device and drug therapy.

4. Understanding implantation of and follow up of patients with implanted ICDs.

5. Understanding of application of nuclear medicine as it applies to cardiovascular disease.

Indications and interpretation of Radionuclide stress tests, radionuclide

ventriculograms.

6. Principles of intra-operative transesophageal echocardiographic evaluation and

monitoring.

Wednesday: Peer Review Conference with Cardiothoracic Surgery

Challenging cases involving both services are presented by fellows or residents.


1. Present clinical cases of relevance to Cardiovascular Medicine to Cardiothoracic

surgery.

2. Basic principles of right and left cardiac catheterization, hemodynamics, assessment of

40

patients with valvular heart disease, intra-coronary ultrasound and doppler flow studies,

coronary interventions including PTCA, intra-coronary stent placements, DCA,

rotablation, intra-aortic balloon counterpulsation devices.

3. Invite comments and discussion of differential diagnosis and management plans on such

a patient from the fellows and faculty in the Division of Cardiovascular Medicine and

members of the Cardiothoracic Surgery Department.

4. Discuss in detail a particular aspect of the clinical problem based on such a case. This

would include a comprehensive review of literature as applies to that issue.

5. Enhance presentation and public speaking skills.

6. Address cost-effectiveness, legal and ethical issues as relate to the case being presented.

7. Review protocols developed for Cardiovascular Medicine and Cardiothoracic Surgeons.

1st Wednesday: CT Surgery presents.

2nd Wednesday: Topic review with/without clinical cases.

3rd & 4th Wednesday: Cardiovascular Medicine cath fellows present.

Thursday:

Cardiovascular Medicine Grand Rounds

New and exciting cardiovascular topics are presented by Cardiovascular Medicine faculty, basic

science faculty, or visiting professors.

Friday: Clinical Conference/Research Conference

Clinical Conference:

This conference is often in a morbidity and mortality format with a case presentation and a

review of literature.


1. Presentation of clinical cases with a critical analysis of management and

complications together with a review of the literature as it pertains to the

particular disease process or complication.

2. Discuss and present issues related to the practice of Internal Medicine as well as

issues related to cardiovascular diseases.

3. Address legal, ethical and cost-containment issues as related to the particular

problem.

4. Addressing quality assurance issues related to specific instances of management and

formulating suggestions for future improvement and monitoring as recommended

by the QA committee of the Division of Cardiovascular Medicine or the

Department of Internal Medicine.

Research (monthly):

Faculty/fellow research projects are presented ranging from works in progress to

completed and published manuscripts. The focus is on design, statistical analysis, and

interpretations of results.


1. Review of fellow/faculty research projects

2. Biostatistics or epidemiology lectures

Journal Club (monthly): Recent articles reviewed by 1 or 2 fellows.


1. Learning debating techniques.

2. Effective rationalization of decisions.

3. Review of current literature

4. Critique research in the field

5. Learning of issues where clear consensus is lacking in the field of Cardiovascular

Medicine and arguments for and against differing viewpoints.

6. Being aware of the latest developments and current thinking and evolution of

knowledge in a particular disease state or syndrome

Information and experience in cultural, social, family, behavioral, ethical, and economic

issues such as confidentiality of information, indications of life support systems, and

allocation of limited resources are addressed at multiple levels within the organization of

the school of medicine. At the beginning of each academic year, the Associate Dean for

Education conducts a mandatory seminar for all trainees on diverse aspects of cultural,

psychosocial, and economic issues related both to patient care and to the interaction with

medical and paramedical personnel. Within the Division of Cardiovascular Medicine,

issues such as confidentiality of information, life support systems, and its social and

economic impact are addressed by a research specialist, the individual faculty during

rounds, and during the weekly morbidity and mortality conference and clinical cardiology

conference. In view of the continuous restructuring of medical care resources that the

United States is experiencing, the faculty of the Division of Cardiovascular Medicine

considers very important to educate and advise the trainees on the emerging role of

primary care providers and its consequent impact on academic and private Cardiovascular

Medicine and other subspecialties. In this regard, the trainees and faculty are also

encouraged to attend seminars on these issues that are annually provided at the national

meetings of the American College of Cardiovascular Medicine and the American Heart

Association.

DEPARTMENT OF MEDICINE CONFERENCES

Medical Grand Rounds (weekly, Thursday noon)

The goal is to Acquire knowledge on a particular topic of interest to a practicing Internal

Medicine Specialist. This usually is an area where there have been important advances in

understanding of the pathophysiology, diagnostic methods or management and are

presented by experts in the field who may be members of the Faculty at University of

Missouri-Columbia or invited Faculty from other institutions in the United States.

Medicine M&M

The goal is to participate in discussion of morbidity and mortality of selected cases in

Internal Medicine. These are often discussions in clincopathologic conference format and

are designed to educate participants in correct management of specific problems and to

recognize complications and to learn about pathology associated with such disease

processes as seen on biopsy or autopsy.

MENTORING

Each fellow will be assigned a faculty mentor. The faculty mentor will assist the fellow

in career plans, coordinate conference presentations, help with research projects, and

provide guidance in any number of other areas during the fellowship program.

METHODS OF ASSESSMENT, EFFECTIVENESS, AND RESULTS

The Cardiovascular Medicine Fellow‘s acquired body of knowledge, skills in physical

examination and communication, technical proficiency, professional attitudes and

humanistic qualities within the clinical setting are evaluated monthly by the faculty

assigned to the same rotation as the fellow or by each faculty working in the cardiac

catheterization laboratories. The written records of the evaluation based on the standard

ABIM form are maintained in each of the trainee‘s files. Trainees will be given oral

feedback on individual basis by the faculty at the end of the rotation. At the end of each

rotation the laboratory secretary / unit clerk will provide the number of procedures

performed by the trainees, signed by the fellows and endorsed by the faculty.

A semiannual review by all faculty will identify strengths and weaknesses of the fellow.

This assessment will be provided to the Fellowship Director who will incorporate the

evaluation into the fellow‘s file. A semiannual evaluation with an oral and written

assessment is provided by the Program Director with the opportunity to comment on

areas of disagreement.

At the end of each rotation the fellows are required to anonymously and candidly evaluate

the individual faculty‘s teaching ability, clinical knowledge and scholarly activity as well

as the program as a whole. These evaluations are reviewed by the program and division

director of Cardiovascular Medicine, and appropriate feedback and counseling of the

faculty is provided as a group and individually by the division‘s director. Appropriate

discussion for the program‘s planning and improvement is conducted in the quarterly

fellowship review by the division of Cardiovascular Medicine‘s faculty.

INSTITUTIONAL POLICIES

Professional Activities Outside the Educational Program

Policy: The ACGME requires that the institution assure that each training program

maintain a policy that specifies moonlighting conditions, whether

moonlighting by Housestaff within that program is allowed or is not, and

that this policy be referenced in each trainee contract.

Purpose: To provide an institutional policy that guides and provides a basis upon

which programs will add their specific policy. To inform and protect

Housestaff who choose to moonlight while training at the University of

Missouri-Columbia, Health Sciences Center.

Definitions:

Housestaff: Residents and fellows are physicians in training for Board certification.

Housestaff are required to have a temporary or permanent Missouri medical license and

are provided University Physician malpractice insurance during official training activities.

Hospital funding for this training is primarily from Federal funds-Medicare DME, IME

or VA. Billing, directly or indirectly, for services during such training hours is illegal

(double-dipping). Excluded from this definition are fellows or chief residents with a

faculty appointment and a departmental salary.

Internal Supervised Resident Activity (ISRA): Elective resident participation in patient

care within their residency program and license that exceeds ACGME requirements.

ISRA includes an additional stipend but must be voluntary, on the University Hospitals

and Clinics campuses and rendered under GME Oversight Committee approval with the

same faculty supervision, attending billing, and documentation rules, and at a level of

clinical responsibility as is true for the resident‘s training requirements. Activity falling

outside any of these requirements is moonlighting. A resident may voluntarily choose to

participate in this elective responsibility upon successful completion of the PGY1 year.

Moonlighting: Medical practice/work done by Housestaff outside of his/her training

program.

Information:

Standards applicable to Moonlighting:

· Any resident/fellow wishing to moonlight must receive approval to do so from

their program director. Moonlighting must be approved by the Department

Chairman and Program Director of the training program and these individuals

should assure that moonlighting is not detrimental to training in any significant

way.

· Moonlighting is generally done for compensation, through contract income or

other perks.

· While moonlighting, housestaff are officially attending physicians, not

Housestaff.

· Moonlighters, since they are attending physicians, must, before they begin moonlighting,

hold permanent licenses – Missouri medical, Federal narcotics (DEA) and State narcotics

(BNDD). They must have medical staff privileges and malpractice coverage for the patient

care they will provide.

· Moonlighting can be medical practice outside of the training program, but within a

University of Missouri Health Sciences Center location or under a University of Missouri

contract. In this situation, the University of Missouri Health Sciences Center provides for

malpractice coverage and any related legal representation. A permanent State license and

Medical Staff privileging and credentialing are still necessary. HCFA also requires that, for

inhouse moonlighting, the training institution must have a contract with each resident

that specifies the moonlighting is separate from ACGME training and done under: a

regular state license and for HCFA approved medical services.

A resident/fellow moonlighting at any health care entity which is not a part of the University

of Missouri Health Sciences Center requires that arrangements be made between the

moonlighter and the health care entity for malpractice coverage and related legal

representation. The moonlighter is operating independent of the University and must assume

no such coverage exists unless these arrangements have been completed.

· Moonlighters are subject to all local, state, and federal laws that apply to attendings when

and where they moonlight. This includes, but is not limited to, COBRA laws. HCFA does

not allow moonlighters to bill for any inpatient services. Only emergency center and other

out-patient care may be billed.

· Moonlighting must comply with Visa guidelines. Certain VISAs do not allow work outside

the training program.

8. Each program must create a policy that complies with this Health Sciences Center Institutional

Policy and place this and the institutional policy in their program manual. Programs may choose to

permit, not permit, or limit moonlighting.

9. Program policy should require that moonlighting will not interfere with Housestaff training

responsibilities/schedules as well as stipulate consequences for Housestaff who do not comply with

the training program policy.

10. Programs which approve moonlighting for Housestaff are responsible for assuring that physicians

have training about all state and legal responsibilities of practicing physicians including COBRA

11. Hospital-wide orientation will include COBRA and information residents need to know about

moonlighting.

GMEOC Approval: 6/15/99

Dean Approval: 6/24/99 Revisions approved: 5/2/00

UNIVERSITY OF MISSOURI - HEALTH SCIENCES CENTER

PRIMARY VERIFICATION OF CREDENTIALS FOR APPLICANTS

TO RESIDENCY AND FELLOWSHIP TRAINING PROGRAMS

Programs must select applicants on the basis of preparedness, ability, credentials, communication skills

and personal qualities like motivation and integrity. Discrimination by gender, race, color, national

origin and disability is prohibited. Restrictive covenants are not permitted.

Each program director must be certain each resident/fellow candidate meets all ACGME, general

Missouri State Licensing Board criteria and immigration requirements before accepting the individual

into the program. The acceptance of unqualified candidates can lead to withdrawal of

certification by the ACGME. The primary verification process consists of the following activities:

New US Graduates

1. Application for residency/fellowship through the Electronic Residency Application Service

(ERAS) serves as primary verification. (Minimum documents required: graduate of MD or DO

medical school in the US or Canada which is accredited by LCMF or AOA respectively;

medical school transcript, Dean‘s letter; United States Medical Licensing Examination

(USMLE) Step 1 and 2 scores; reference letters) or:

2. Completion of the Universal Residency Application with the above stated documents attached.

Transcripts must be verified with the school.

Foreign-Born and International Medical Graduates (IMG: a physician whose basic medical degree is

conferred by a medical school located outside the US, Canada or Puerto Rico) must:

1. Hold J-1 visa (exchange visitor) H-1B visa (temporary worker), immigrant visa or ―green card‖ or

an Immigration and Naturalization Service (INS) issued or approved work permit if not a US

citizen.

2. Have a full unrestricted license to practice medicine in a US licensing jurisdiction or hold an

Educational Commission for Foreign Medical Graduates (ECFMG) Standard Certificate, which is a

prerequisite to practice medicine in the US and is an eligibility requirement to take Step 3 of the

USMLE. A Standard ECFMG Certificate is issued to an applicant who meets the examination

requirements, fulfills the medical education credentialing requirement and clears their financial

account with ECFMG. This Certificate is considered valid if the ―valid through‖ dates of the

English test and CSA is not later than the program start date. In order for an applicant to obtain

permanent validation of the Certificate, ECFMG must receive documentation from an official of

the program confirming the applicant‘s entry to the program, at which time, ECFMG will provide a

―valid indefinitely‖ sticker to the holder of the Certificate.

Residents Entering a Program After Completing Preliminary Year at Another Institution - In addition

to the requirements of A or B of this policy, requires a:

1. Letter from the program director of the resident‘s preliminary year program indicating he/she has

successfully completed the preliminary year of training.

Physicians Entering a Fellowship - In addition to the requirements of A or B of this policy, requires a:

1. Letter from the program director of the resident‘s previous program indicating he/she successfully

completed the residency program.

2. Verification that the completed residency program is accredited and meets the ACGME

requirements for entry into that particular fellowship.

3. Reference letter from the Hospital where the physician previously practiced and a National

Practitioners Data Bank (NPDB) query, if the fellowship start date is not immediately after

residency completion.

Restrictive Covenants

ACGME accredited residencies must not require residents to sign

POLICY

Required ACLS/BLS/PALS Certification All residents/fellows who have direct contact with patients must maintain active certification in

BLS and ACLS. This includes all training programs with the exception of Pathology.

Child Health, Family Practice and Med/Peds training physicians must maintain PALS

certification.

POLICY FOR EDUCATIONAL/

CAREER COUNSELING

Occasionally, a residency program director will request that a resident receive evaluation and

counseling for a problem they are having. This is usually done by members of the UMC

Psychiatry Department, although a program director may request evaluation by someone outside

the department or outside the University. The following guidelines should be followed.

3. The request for evaluation must be in writing from the program director with a general

statement of the reason for the request.

4. The evaluator will keep a record of the encounter(s) but not as part of the resident‘s

medical record. Appropriate confidentiality will be maintained.

5. The evaluator will update the program director regarding the resident‘s progress. At the

outset, the resident will be informed that the program director will receive updates from

the evaluator. The resident will discuss with the evaluator what information will be

shared to maintain confidentiality.

6. If a mental health disorder or substance abuse is found during the course of evaluation or

counseling, appropriate referral to the health care system will be made. All University

and State of Missouri requirements for reporting must be followed.

7. The requesting department is responsible for the cost of the evaluation and counseling. If

referral is made to the health care system, the resident‘s insurance will be billed, and the

resident will be responsible for any other expenses (just as with any other medical

condition).

DISCIPLINARY ACTION POLICY

FOR RESIDENTS/FELLOWS

Resident physicians are subject to disciplinary actions including oral reprimands, written

reprimands, suspensions and discharge for misconduct or for performance which does not meet

acceptable standards.

Suspension Without Pay or Termination

Before a resident physician may be suspended without pay or terminated prior to the specified

ending date of his or her appointment, the resident physician should be provided in writing with

findings which the University believes support the proposed suspension without pay, or the

termination.

That written notice will be provided by the residency program director and will include details

concerning the findings of misconduct or the performance deficiencies. In addition, the written

notice will inform the resident physician that if he or she disagrees with such findings and desires

to contest the proposed disciplinary suspension or termination, he or she must inform the

residency program director in writing within ten (10) days of receipt of the written notice.

After receiving notice that the resident physician disagrees with such allegations and desires to

contest the proposed disciplinary suspension or termination, the residency program director will

schedule a meeting with the resident physician so that he or she will have an opportunity to

present information in support of his or her position regarding the findings.

After discussing the issues with the resident, the residency program director shall decide whether

(1) to impose the disciplinary suspension without pay or the termination which had been

contemplated, (2) to impose some lesser degree of discipline or (3) that the resident physician

should receive no discipline. That decision shall be communicated to the resident physician in

writing as soon as possible.

If the resident physician is dissatisfied with the decision of the residency program director, he or

she may, within ten (10) days of receipt of such written decision, file a grievance in accordance

procedures outlined in the Grievance Policy.

References

1. Collected Rules & Regulations, University of Missouri, Academic Grievances: Section

370.010

2. Collected Rules & Regulations, University of Missouri, Grievance Procedure for

Administrative, Service and Support Staff: Section 380.010

3. Collected Rules & Regulations, University of Missouri, Discrimination Grievance Procedure

for Students: Section 390.010

GRIEVANCE POLICY FOR

RESIDENTS/FELLOWS

For purposes of this policy, a grievance is defined as an allegation that:

1. There has been a violation, a misinterpretation, an arbitrary, or discriminatory application

of University policy, regulation or procedure which applies personally to the resident

physician, relating to the privileges, responsibilities, or terms and conditions of the

residency training program including academic or other disciplinary actions or the

employment of the resident physician; or

2. The resident physician has been discriminated against on the basis of race, color, religion,

sex, national origin, age, disability, or status as a Vietnam era veteran.

Filing a Grievance

A resident physician who has a grievance shall initiate action by filing a signed, written account

of the grievance with the program director within thirty (30) days after the occurrence of the

event out of which the grievance has arisen. The program director shall respond to the grievance

in writing within thirty (30) days after receipt of the written grievance.

Grievance Appeals

Should the resident physician be dissatisfied with the response of the program director, he/she

may, within ten (10) days after receipt of such response, submit a written appeal to the

Associate/Assistant Dean of the School of Medicine having responsibility over graduate medical

education. Upon receipt of the written appeal, the Associate/Assistant Dean shall arrange a

meeting with the resident physician and with the involved residency program director to discuss

the allegations and the response. In an effort to reach a fair decision on the grievance, the

Associate/Assistant Dean may elect to meet with others having knowledge of the circumstances

giving rise to the grievance, including those identified by the resident physician or the residency

program director. Upon completion of the Associate/Assistant Dean‘s consideration of the

appeal, the Associate/Assistant Dean shall provide a written decision to the resident physician

and to the residency program director.

Appeal to the Dean

If the resident physician is dissatisfied with the decision of the Associate/Assistant Dean, he/she

may, within ten (10) days after receipt of such written decision, submit a written appeal to the

Dean of the School of Medicine who shall decide whether the previous decision shall be

affirmed, reversed or modified. In reaching that decision, the Dean may ask to meet with the

resident physician, but is not required to do so; may utilize the services of an ad hoc advisory

committee, appointed by the Dean, but is not required to do so; and may consult with the

program director and faculty with whom the resident physician worked, but is not required to do

so. The resident physician shall have no right of appeal from the Dean‘s decision, but may

request that the Chancellor exercise his or her discretion to review the Dean‘s decision.

(Also see the University of Missouri Employee Grievance Policy: 380.010 GRIEVANCE PROCEDURE FOR

ADMINISTRATIVE, SERVICE & SUPPORT STAFF)

POLICY TO ADDRESS RESIDENT CONCERNS

Purpose: The ACGME requires that the Housestaff have assurance of an educational

environment in which to raise and resolve issues without fear of intimidation or

retaliation. This policy outlines a process by which residents can address concerns in

a confidential and protected manner.

The Housestaff representatives to the GME Oversight Committee will give a monthly

report of resident issues identified during their monthly meetings, or through

communication among resident(s). This report should include, but not be limited to

concerns of residents about fairness of schedules, treatment, workloads, etc.

Concerns will be addressed as needed in a way that excludes and prohibits retaliation

toward any fellow or resident.

Individual resident concerns should be addressed with the following process.

Process: Resolution should be attempted at the most local level. If resolution is not obtained at

this level, the resident or fellow may proceed to the next level as appropriate to the

nature of the concern.

1. Contact the Chief Resident of the Program

2. Contact the Program Director

8. Contact the Department Chair

9. Contact the Housestaff Organization

10. Contact the Assistant Dean for Graduate Medical Education/Associate

Dean for Medical Education

If the issue is not able to be resolved by this informal mechanism, then a formal

grievance may be filed with the Program Director. See Grievance Policy.

INSTITUTIONAL VACATION AND LEAVE POLICY

Purpose: The ACGME requires an Institutional Leave Policy that is known to all Residents.

Each program must have its own vacation and professional leave policy that it makes available to

its residents/fellows before they sign their contracts and that:

· Follows ACGME program requirements.

· Complies with MU‘s Family Leave Policy.

The institution will fund up to one month each year of any combination of vacation and leave for

each resident.

To hold a GME position for their return, residents/fellows must obtain written approval from

their department for leave/vacation that exceeds one month per year. Adverse decisions, as

always, may be appealed through the Policy to Address Resident Concerns, and then as a

grievance.

NON-RENEWAL OF A RESIDENT/FELLOW CONTRACT AT

UNIVERSITY OF MISSOURI HEALTH SCIENCES CENTER

Purpose: To provide a procedure in the event a resident or fellow‘s contract will not be

renewed for the following year.

1. The Program Director must provide a written notice to the resident/fellow indicating that

their contract for the following year will not be renewed. Justification for non-renewal of

the contract must be adequately outlined. This written intent must be given to the

resident/fellow no later than four months prior to the end of the current appointment.

2. If the primary reason for non-renewal of the contract occurs within four months prior to

the end of the current appointment, the Program Director must provide written notice as

early as circumstances will allow, prior to the end of the appointment.

3. The resident/fellow must be allowed to implement the institution‘s grievance procedures,

including those outlined in the Health Sciences Center‘s “Policy to Address Resident

Concerns”.

PROFESSIONAL ASSISTANCE POLICY

Policy: The policy of providing assistance to residents and fellows is delineated for the

following conditions: 1) Mental Health; 2) Physical (Medical) Health; 3) Impaired

Physicians; and 4) Financial. All requests for resource information will be treated

confidentially.

The Associate Dean for Medical Education will be the safety net to help trainees

who feel they cannot get what they need through their Program Director. The

Associate Dean will also be a resource to Program Directors in solving trainee

issues. This individual or designee may be contacted at any time for emergencies.

Purpose: Graduate Medical Education can be a stressful time for residents and fellows. It

is our job to nurture and support our trainees so each is the best person and

physician that he or she can be. The program directors are charged by their

Residency Review Committees (RRCs) to monitor stress, depression, mental

and/or physical illness of their trainees, and to assist in obtaining treatment and/or

identifying methods of counseling. The institution is required by the ACGME to

facilitate resident/fellow access to appropriate and confidential counseling,

medical, and psychological support services. This includes the stipulation of

written policies describing how physician impairment, including substance abuse,

will be handled.

Definitions: Substance Abuse: Use of alcohol or drugs with resulting diminution of ability to

carry out responsibilities in the workplace.

Resident Physicians: Resident or fellow trainees

Impaired Physician: Physician is unable to perform trainee duties, in best

judgment of the Health Sciences Center Physician Health Committee.

General Information: All trainees are enrolled in the University of Missouri group plans for life

insurance, long term disability, and medical benefits. This coverage includes medical treatment

as well as psychiatric counseling and treatment. In addition, the Housestaff Organization has

arranged for additional disability coverage at the individual trainee‘s expense.

Medical/Physical Health

Time off for treatment of medical or physical conditions will be granted in accordance

with the program‘s specifics for medical leave of absence. The trainee may refer to their

training manual for this information or contact their program director.

Emotional/Psychological

Psychological illness such as short term psychological problems of situational distress,

anxiety, or stress, may result in impairing the ability to perform assigned job

responsibilities. Please refer to number 3 above and Attachment A, for information on

actions required by the Medical School. Treatment for such illness is generally covered

by existing health benefits.

Impaired Physicians

Residents or Fellows with substance abuse problems should be aware that the Health

Sciences Center‘s policy is nonpunitive if the treatment plan is adhered to, except as

identified in Attachment A, item B,5 of the ―Substance Abuse Policy for Clinical Faculty

and Resident Physicians,‖ which states that probable cause of impairment due to

substance abuse will result in a report to the Missouri Physician‘s Health Committee

(MPHC) for further investigation and action. In accordance with laws regarding

reporting, the MPHC will be required to report substantiated substance abuse to the

National Practitioner Data Bank.

Also, please reference the University of Missouri policy on drug/alcohol abuse – HR508

―Drug/Alcohol Abuse in the Workplace,‖ University of Missouri, Human Resources

Benefits Manual.

Financial Consultation

Trainees in need of financial advice/counseling are encouraged to make early contact with

the University of Missouri - Columbia Medical School Financial Aid Coordinator. Other

private counseling organizations may be utilized and a list of local organizations is

provided in Attachment B.

Procedure:

Trainee:

Graduate Medical Education trainees should seek professional help on their own

when they feel this is necessary. If this is a medical/physical or

emotional/psychological condition, the trainees primary physician should

be contacted, or the campus Employee Assistance Program may be

contacted at 882-6701 to provide free, confidential evaluation and referral

for any problem - financial, medical, psychological, etc.

Trainees are strongly encouraged, but not required, to inform their Chief Resident

and Program Director of medical illness, emotional or psychiatric illness

when any of these may interfere with professional performance.

Confidentiality will be maintained unless this is not consistent with good

patient care.

Program

Director 1. The Program Director, upon becoming aware of a problem, either through

trainee performance, reports from others, or through communication with

the trainee, should be the first line to help the resident physician resolve

any issues. The Program Director should discuss alternative sources of

counseling and/or other care with the resident physician and assist in

initiating the process for counseling.

2. Program Directors may, at their discretion, seek information about

alternatives for handling medical/physical or emotional/psychological

problems from other sources, such as other Program Directors or the

Graduate Medical Education Office, while maintaining confidentiality.

3. If the determination has been made that the trainee is not able to carry out

assigned responsibilities due to substance abuse and, after discussing the

identified issues with the trainee, the trainee is not willing or able to

correct the problem, the Program Director may temporarily remove the

trainee from the rotation or change the schedule pending expedient

implementation of Attachment A: “Substance Abuse Policy for Clinical

Faculty and Resident Physicians,”. The trainee will continue to receive

pay, fringe benefits, and due process during the impaired physician process

of Attachment A.

Attachment A - Impaired Physician Policy, Clinical Faculty and Resident Physicians

Attachment B - List of Local Counseling Resources.

References:

HR508 ―Drug/Alcohol Abuse in the Workplace,‖ University of Missouri, Human Resources

Benefits Manual.

Housestaff Bylaws, Rules and Regulations

Attachment A

SUBSTANCE ABUSE AND IMPAIRED PHYSICIAN POLICY

UNIVERSITY OF MISSOURI-COLUMBIA SCHOOL OF MEDICINE

HOUSESTAFF PROGRAM

The Dean, University of Missouri-Columbia School of Medicine, has established the following

program to address the issue of substance abuse and impairment by residents /fellows operating

under the auspices of the University of Missouri-Columbia Health Sciences Center. This policy

is similar to that in place for our clinical faculty.

Physicians hold a unique place in society. Professional standards require that persons seeking

care can be assured that their physicians are not impaired by reason of substance abuse or mental

illness. The purpose of this policy is:

A. To assure that patients receiving care from physicians, operating under the

auspices of the University of Missouri-Columbia Health Sciences Center, receive

the highest quality health care from individuals not only well trained and highly

motivated, but unimpaired by reason of substance abuse or mental illness.

B. To assure that individual residents/fellows have access to appropriate health care

and assurance of continued access to employment so long as they comply with

institutional requirements and standards.

A. HEALTH SCIENCES CENTER PHYSICIAN HEALTH COMMITTEE

1. The Health Sciences Center Physician Health Committee will, as needed, be

appointed by the Dean, School of Medicine, to assume responsibility for oversight

of the Health Sciences Center Physician Health Program to address issues of

physician impairment or substance abuse.

2. Membership of the Health Sciences Center Physician Health Committee will

consist of:

a. Two members of the clinical faculty appointed by the Dean, School of

Medicine. Individuals may be reappointed at the discretion of the Dean.

One of these individuals will be designated by the Dean to chair the

committee.

b. One resident physician or clinical fellow appointed by THE DEAN FROM

RECOMMENDATIONS BY the House Staff Organization.

3. The Health Sciences Center Physician Health Committee will meet as often as

necessary to fulfill its obligation.

4. All information presented at meetings of the Health Sciences Center Physician

Health Committee, and all actions of the committee will be considered to be

confidential except as provided herein and except that such information will be

available to the Dean, School of Medicine and otherwise as required by law.

B. RESPONSIBILITIES OF THE HEALTH SCIENCES CENTER PHYSICIAN HEALTH

COMMITTEE.

1. The Health Sciences Center Physician Health Committee will initially establish a

definition of impairment. This definition will be utilized by future committees.

Following its establishment, it must be approved by the Dean, School of

Medicine.

2. It is the responsibility of the Health Sciences Center Physician Health Committee

to receive any admission of substance abuse or mental health problems by a

physician, or allegations of impairment of physicians due to substance abuse or

mental illness.

3. The Health Sciences Center Physicians Health Committee will be responsible for

investigating those allegations. The Committee shall inform the individual in

writing of the allegations and provide him/her an opportunity to respond to the

allegations.

4. The Health Sciences Center Physician Health Committee shall inform the Dean if

the Committee suspects the individual is impaired by substance abuse or mental

illness, and presents potential risk to patients.

5. If probable cause to believe that impairment due to substance abuse is present,

allegations related to possible substance abuse must be reported to the Missouri

Physicians Health Committee for further investigation and action.

6. If there is probable cause to believe that impairment due to mental illness is

present, the Health Sciences Center Physician Health Committee shall require

psychiatric evaluation by a psychiatrist approved by the Health Sciences Center

Physician Health Committee.

7. Upon determination that a resident/fellow is impaired due to substance abuse or

mental illness, the Health Sciences Center Physician Health Committee will notify

the Dean, School of Medicine.

C. PERMISSION TO CONTINUE CLINICAL RESPONSIBILITIES

If the resident/fellow has been removed from clinical responsibilities by the Dean,

permission to resume clinical responsibilities will be granted only with the agreement of

the Health Sciences Center Physician Health Committee and the Dean.

D. CONTINUATION OF FACULTY APPOINTMENT

1. Residents/fellows found to be impaired by reason of substance abuse or mental

illness may not be dismissed from employment prior to full evaluation of their

impairment. They may, however, be removed from clinical responsibility. Full

evaluation of impairment due to substance abuse will be made by the Missouri

Physicians Health Committee. Full evaluation of mental illness will be made by a

licensed psychiatrist approved by the Health Sciences Center Physicians Health

Committee. The allegedly impaired physician may participate in determining the

identity of that physician.

2. Residents/fellows found to be impaired by reason of substance abuse or mental

illness may not be terminated based upon such substance abuse or mental illness

during the term of their contract if they are compliant with the requirements of the

Health Sciences Center Physician Health Committee, and the Missouri Physician

Health Committee.

E. TERMINATION OF APPOINTMENT

1. A resident/fellow who has been found to be non-compliant with the Health

Sciences Center Physician Health Committee or the Missouri Physician Health

Committee will be reported to the Dean, School of Medicine.

2. Noncompliance may be grounds for termination of appointment.

3. Any dismissal shall conform to applicable University procedures.

6/18/91

REVISIONS 2/99

REVISIONS 5/2/00

Attachment B

FINANCIAL ADVICE/COUNSELING RESOURCES

Conway Jones

University of Missouri - Columbia

Medical School Financial Aid Coordinator

MA202 Medical Science Building .................................................................................... 882-2923

FINANCIAL/COUNSELING ORGANIZATIONS - LOCAL

A G Edwards & Sons Inc

2100 Forum Blvd Columbia ................................................................................. 445-7088

American Express Financial

1316 Old Highway 63 S Columbia ....................................................................... 499-4945

American Express Financial Advisors

601 Nifong Columbia ........................................................................................... 499-4880

American Express Financial Advisors Inc.

2710 Forum Blvd Columbia ................................................................................. 446-2744

American Tax Service

311A Bernadette Dr Columbia ............................................................................. 445-8364

David Banks, CFP

2611 Luan Ct Columbia ........................................................................................ 445-4308

Boone County National Bank

Columbia ............................................................................................................... 874-8490

Boone County National Bank Investor Services

Columbia ............................................................................................................... 874-8446

Alan Bunch, LUTCF

Principal Financial Group

401 Vandiver Dr Columbia ................................................................................... 443-3535

Cambria Financial Management Inc

Columbia ............................................................................................................... 817-3180

Casey and Company LLC CPAs

1 E Broadway Columbia ....................................................................................... 442-8427

Consumer Credit Counseling Services of Mid-America

(Staffed, in part, by MU Department of Consumer and Family Economics Students)

205 E. Ash, Columbia ........................................................................................... 443-0303

Dollar-Kuretich Doris Financial Advisor

116 S Jefferson ...................................................................................................... 581-5994

Finance World

601 Business Loop 70 W Columbia ..................................................................... 815-9700

Financial Architects Inc

1000 W Nifong Blvd Columbia ............................................................................ 443-3183

Fundbuilder

4818 Santana Cir Columbia .................................................................................. 815-1055

Kammerich Financial Services

1951 Boone Village Plaza Suite D Boonville ................................................ 660-882-7620

Thomas Lightfoot

1414 Rangeline Columbia ..................................................................................... 874-3888

Lincoln Financial Advisors

601 E Broadway Suite 304 Columbia ................................................................... 443-1654

Merrill Lynch 800-937-0948

2804 Forum Blvd Suite 2 Columbia ..................................................................... 446-7023

Mita Financial Services

1961 Hirst Dr ................................................................................................. 660-263-8096

Money Concepts Financial Planning Center

217 E Jackson Mexico .......................................................................................... 581-4313

Northwestern Mutual Life

The Peter W. Graff District Agency

1900 North Providence Rd Suite 307 ................................................................... 449-2488

Nova Financial

811 Cherry St Columbia ....................................................................................... 874-0434

Principal Financial Group

Betty Schuster, CFP

401 Vandiver Dr., Columbia ................................................................................. 443-0389

Professional Planning Group

Christine Marks, CLU, ChFC

108 E. Green Meadows, Rd. Suite 7

Columbia, MO 65203 ........................................................................................................ 443-8628

Sims & Associates Insurance & Financial Services

4818 Santana Cir Suite B Columbia ..................................................................... 874-4494

Waddell & Reed Inc

1900 North Providence Rd Columbia ................................................................... 875-4494

OTHER COUNSELING SERVICES

Employee Assistance Program ........................................................................................ 882-6701

University Physicians Psychiatry Clinic ........................................................................ 882-2511

REDUCTION IN SIZE OR CLOSURE OF A

RESIDENCY PROGRAM/FELLOWSHIP PROGRAM

AT UMC - HEALTH SCIENCES CENTER

The GMEOC will be asked for recommendations and input when there is a perceived need to

reduce or close a program. The Dean will make final decisions.

Notification, by the Associate Dean responsible for Graduate Medical Education, will be

provided to and input requested from the Department Chairman and Program Director of

any program that is being considered for reduction or closure. Preliminary notice will be

given by the Program Director to residents/fellows in the program of the proposed action,

with the assurances described below.

Residents with commitments from programs that are being downsized or closed will be allowed

to continue until training is completed at the Health Sciences Center. Residents who

decide to leave will be assisted by their program in finding new GME positions.

4. Programs being downsized will continue to take at least one, or the minimum number of

new residents required by the ACGME, each year until the target size is reached, even

though this will delay the downsizing.

5. Notification will be sent to the ACGME, by the Associate Dean responsible for Graduate

Medical Education, indicating intent to reduce or close a program.

6. Residents will be given final notification of the action by the Associate Dean and the

Program Director. This will include the effective date of the reduction or closure.

SUPERVISION OF RESIDENTS AND FELLOWS

(HEREAFTER REFERRED TO AS RESIDENTS)

AT UNIVERSITY OF MISSOURI-COLUMBIA

HEALTH SCIENCES CENTER

Purpose: To set institutional standards for faculty supervision of residents that assures their

education and our compliance with ACGME institutional standards.

Assuring adequate supervision is the responsibility of the program director, department and the

institution.

The following are standards for all MU resident positions, irrespective of where they are training.

These are minimum rules. No program can fall below these standards, but they will be

expanded if:

Documentation (HCFA or PATH) or Medical Staff rules at a given institution exceed these

standards.

An individual program has more stringent RRC requirements for supervision.

The clinical setting where the resident physician is training has additional rules. For example,

the Harry S. Truman Memorial Veterans Hospital Policy is described in: Resident

Supervision, VAH Handbook 1400.1, March 21, 00, available in the Resident

Coordinators Office or at the VA.

The department elects to expand supervision requirements, using the following standards as a

base.

Standards

1. All patient care performed by residents during training will be under the supervision of a

physician faculty member qualified to provide the appropriate level of care. The specifics

of this supervision must be documented in the medical record by the supervising

physician or resident.

2. The supervising physician must be immediately available to the resident in person or by

telephone 24 hours a day during clinical duty. Programs must assure this occurs:

Residents must know which supervising physician is on call and how to reach this

individual.

3. Inpatient supervision: The supervising physician must obtain a comprehensive

presentation for each admission. This must be done within a reasonable time, but always

within 24 hours of admission. The supervising physician must also require the resident to

present the progress of each inpatient daily, including discharge planning. All required

supervision must be documented in the medical record by the resident and/or the

supervising faculty member.

4. Outpatient supervision: The supervising physician must require residents to present each

outpatient‘s history, physical exam and proposed decisions. All required supervision

must be documented in the medical record by the resident and/or the supervising faculty

member.

5. Supervision of consultations: The supervising attending must communicate with the

resident and obtain a presentation of the history, physical exam and proposed decisions

for each referral. This must be done within an appropriate time but no longer than 24

hours after notification of the consultation request. All required supervision must be

documented in the medical record by the resident and/or the supervising faculty member.

6. Supervision of procedures: The supervising faculty physician must be certain that

procedures performed by the resident are warranted, that adequate informed consent has

been obtained and that the resident has appropriate supervision during the procedure to

include sedation. Whenever there is more than minor risk to the patient, the

supervising physician must be present during the key part of the procedure. All required

supervision must be documented in the medical record by the resident and/or the

supervising faculty member.

7. Supervision of emergencies: During emergencies, the resident should provide care for the

patient and notify the supervising physician as soon as possible to present the history,

physical exam and planned decisions. All required supervision must be documented in

the medical record by the resident and/or the supervising faculty member.

8. Common questions:

1. When does the supervising physician have to come in to see a patient? This

would be typical of expected practice, or whenever the resident asks the

supervising physician to be present or whenever HCFA or Medical Staff rules

require this.

2. To whom are faculty responsible to for resident supervision? The program

director, the chair of the department, the GME Oversight Committee and the Dean

of the School of Medicine for educational supervision. The supervising physician

is also responsible for HCFA documentation requirements and Medical Staff

rules.

Approved by the GMEOC: 5/2/00

Health Sciences Center

Policy

Moonlighting - J-1 or H-1B Visa Holders

In the June 30, 1999, Federal Register the USIA (United States Information Agency) outlined

policies regarding moonlighting of non-resident aliens with visas. J-1* visa holders are

prohibited to obtain employment that is not a part of their training program. H-1B** visa holders

are also prohibited from moonlighting unless specifically allowed, as specified, in their visa.

Any resident or fellow in a training program at the University of Missouri who fails to comply

with this regulation is at risk for deportation.

To ensure compliance with this regulation, the following process will be followed:

1. Any resident/fellow wishing to moonlight must receive approval to do so from their program

director. Moonlighting must be approved by the Department Chairman and Program Director

of the training program and these individuals should assure that moonlighting is not

detrimental to training in any significant way. (Please refer to the “Professional Activities

Outside the Educational Program‖ policy of the Health Sciences Center for moonlighting

requirements.)

2. The Department Chairman and/or Program Director must verify visa status. If it is

determined that the resident/fellow wishing to moonlight is a J-1visa holder, the Chairman

and/or Program Director will not allow the resident/fellow to moonlight.

3. If it is determined that the resident/fellow wishing to moonlight is an H-1B visa holder, the

Chairman and/or Program Director must request that the resident/fellow submit his

H-1B visa documents for review by the University of Missouri Legal Counsel to

determine whether the stipulation for outside employment is written in the visa. If

moonlighting is not specifically allowed in the visa, the Chairman and/or Program Director

will not allow the resident/fellow to moonlight.

4. Each program must create a policy that complies with this Health Sciences Center

Institutional Policy and place this and the institutional policy in their program manual.

RESIDENT WORK HOURS AND ON-CALL FREQUENCY

POLICY FOR THE UNIVERSITY OF MISSOURI

Purpose: To set institutional standards for resident duty hours and in-house on-

call frequency that ensure resident duty hours are not excessive

Standards:

1. Resident duty hours should both foster resident education and facilitate

the care of patients. The educational goals of each residency program

and the learning objectives of the residents must not be compromised by

excessive reliance on residents to fulfill institutional service obligations.

However, duty hours must reflect the fact that responsibilities for

continuing patient care are not automatically discharged at specific times.

Programs must ensure that residents are provided appropriate back-up

support when patient care responsibilities are especially prolonged or

difficult.

2. Each residency program must adhere to the duty hours limitations set by

their individual RRC (Residency Review Committees) and the ACGME

institutional requirements as set forth in the Essentials of Accredited

Residencies in Graduate Medical Education: Institutional and Program

Requirements (in: Graduate Medication Education Directory.) The

structuring of duty hours and on-call schedules must focus on the needs of

the patient, continuity of care and the educational needs of the resident.

3. All resident should have, on average, one day out of seven free from

routine clinical duties and in-house educational requirement. *

4. Residents‘ in-house call duties should not average more than every third

night. While on duty in the hospital, residents must be provided adequate and

appropriate food services and sleeping quarters.

Approved by the GMEOC: 4/4/00

* April 2000: The Executive Director of the ACGME Institutional Review

Committee indicated citations are being given if residents do not get one day

(defined as 24 hours) off per week and are on call more than every third night. The

ACGME concept driving this requirement is that medical errors will increase and

education decrease if residents/fellows work more than this, even if they volunteer

to do so. Maximum weekly work hours have been left to individual RRC‘s unless

they are ―very excessive‖.

Policy to Monitor Residents and Fellows with Prior Issues of

Concern

University of Missouri Health Care

Residents and fellows who have any issues of impairment identified by the various

licensing agencies (Board of Healing Arts, DEA, BNDD) will have an appropriate

monitoring and supervision plan developed by the program director.

The plan may be proscribed by or in conjunction with the licensing agency. The plan will

be approved by a subcommittee of the GMEOC authorized to act on the committee‘s

behalf in closed session.

The medical executive committee or chief of staff at any hospital the resident/fellow is

assigned will be notified of the issue and the monitoring plan prior to the resident/fellow

working in that location.

The chair of the GMEOC should be notified as soon as the issue is identified and

preferably before a contract is offered.

Approved by the GMEOC 9/7/04

Revisions approved by GMEOC 10/5/05

Duty Hour Policy

For the

University of Missouri

Purpose: To set institutional standards for resident duty hours and in-house on-call

frequency that ensure resident duty hours are not excessive.

Standards: Resident duty hours should both foster resident education and facilitate the care of

patients. The educational goals of each residency program and the learning

objectives of the residents must not be compromised by excessive reliance on

residents to fulfill institutional service obligations. However, duty hours must

reflect the fact that responsibilities for continuing patient care are not

automatically discharged at specific times. Programs must ensure that residents

are provided appropriate back-up support when patient care responsibilities are

especially prolonged or difficult.

Each residency program must adhere to the duty hour limitations set by their individual RRC

(Residency Review Committees) and the ACGME institutional requirements. The structuring of

duty hours and on-call schedules must focus on the needs of the patient, continuity of care and

the educational needs of the resident.

- Residents are to work no more than 80 hours per week, averaged over a four-week period.

- Call frequency must occur no more often than every third night, averaged over a four-

week period.

- Residents must receive one day (24 hours) off in seven, averaged over a four-week

period.

- There must be a limit of on-call assignments to 24 hours with 6 additional hours for the

transfer of care, educational activities or other non-patient care activities, or as defined by

the specialty‘s RRC.

- Residents must have a minimum rest period of 10 hours between duty periods.

When residents take call from home and are called into the hospital, the time spent in the hospital

must be counted toward the weekly duty hour limit. Additionally, internal moonlighting hours

must also be counted toward the weekly limit.

Revisions approved by the GMEOC 1/6/04

Policy for Processing Anonymous Evaluations

The ACGME requires that faculty members sign evaluations they complete of training

physicians. Programs may elect to have additional health care staff evaluate the training

physician, including peers or other co-workers (i.e., nursing staff, techs). These evaluations

should be kept anonymous from the training physician being evaluated, to the extent possible

under the law. Anonymity may be maintained by having a summary of these evaluations

prepared by the program director or coordinator, which is then placed in the training physician

file. The evaluation instrument itself may be destroyed or, if kept, assurance should be made that

the anonymity of the evaluator will be maintained.

Approved by the Graduate Medical Education Oversight Committee1/3/06

Documents

CARDIOLOGY FELLOWSHIP MANUAL