Rotations/Curriculum - Cardiology Fellowship

Clinical and laboratory rotations ensure that the trainee is exposed to an extremely broad range of common and uncommon disease entities. Over the course of their training, fellows complete rotations in the following areas:

In addition to this clinical training, fellows are allotted time for research, educational conferences, and ambulatory care experience.

Inpatient Consultative Cardiology

The clinical (CCU and consult) rotations provide an opportunity for the fellow to acquire experience in the evaluation and management of a broad range of acute and chronic cardiovascular diseases, including myocardial infarction, unstable angina, chronic coronary artery disease, congestive heart failure, arrhythmias, lipid disorders, hypertension, peripheral vascular disease, valvular heart disease, cardiomyopathy and pulmonary heart disease. The fellow is expected to consider the etiology, pathogenesis, clinical presentation, and natural history of the condition encountered. The fellow directly observes, manages and judges the effectiveness and complications of therapeutic regimens.

The cardiology fellow is responsible for all cardiac admissions to the Coronary Care Unit (CCU) during the clinical rotation. The clinical fellow sees consultations from the Emergency Room, Ambulatory Surgery (for preoperative consultations), Recovery Room, the Medical / Surgical Intensive Care Units, and the general medical and surgical services. As the cardiology fellows are responsible for admitting and following all acutely ill patients with cardiac conditions, they have the opportunity to observe and manage patients at the onset of presentation and the period of initial stabilization, and they respond to complications as they arise. Fellows continue to follow selected patients following transfer out of the CCU and participate in the decision making following stabilization of the acute illness. In cases in which the particular patients' problems are no longer relevant to the fellow's learning experience, he or she may sign off the case so that the rotation is not burdensome. In selected cases, the fellow may arrange for long-term follow-up in his or her outpatient clinic. By doing so, the fellow has the opportunity to assume responsibility for the patient from initial acute presentation to discharge and beyond.

In this busy clinical rotation, fellows are paired with a supervising cardiology staff member. The purpose of this experience is to "learn by doing," through hands-on exposure to a wide variety of cardiovascular disorders. While all cases are eventually reviewed under the direct supervision of an attending cardiologist, fellows are expected to assume progressively increasing responsibility in the formulation of management plans and decisions throughout their training that is commensurate with their experience and ability at the time. As fellows gain consultant level expertise, they play a greater role in the teaching of medical students and residents, and in providing appropriate references to the literature.

Invasive Cardiology Rotation

The Cardiac Catheterization/ Interventional Laboratory at Lahey Clinic is a high-volume, state-of-the-art lab that offers a full service of invasive diagnostic and percutaneous interventions, such as coronary angioplasty and stenting, balloon valvuloplasty, and peripheral vascular disease interventions.

The lab sees a high volume of patients derived from both the Lahey system and outside cardiologists referring patients for tertiary care. Consequently, all trainees have ample opportunity to gain exposure to adult patients with acute and chronic cardiovascular disorders, including coronary artery disease and valvular, pericardial, and cardiomyopathic heart disease.

During these rotations, trainees develop a clear understanding of the indications, limitations and complications of cardiac catheterization; learn the pathophysiologic basis of cardiovascular disorders; acquire skill in interpretation of hemodynamic findings; and learn the medical and surgical implications of the angiographic and hemodynamic findings.

The nature of experience within the invasive rotations is marked by progressively increasing responsibilities by the trainee. Trainees are expected to progressively gain manual dexterity skills as well as enhance their judgment and interpretative skills through an "apprenticeship" model, where a staff member interacts and supervises the fellow on a one-to-one basis. Fellows initially observe, then assist, then perform the various procedures. The pace of this transformation is commensurate with the fellow's experience and ability at the time. A staff cardiologist is present in the lab at all times during all procedures. Typically, hands-on supervision is given until such time as a fellow develops a reasonable level of confidence. At that point, the supervision becomes more observational unless a specific problem arises.

Electrocardiography and Nuclear Rotation

This is a combined noninvasive rotation. The fellow spends approximately equal time in the ECG and nuclear laboratories. During this rotation the fellow's responsibilities include interpretation of selected ECG tracings, exercise tests, ambulatory monitor studies, and nuclear scans, which are then reviewed by the attending cardiologist.

A relatively unique feature of our program is that the majority of exercise stress tests are performed by an experienced cardiovascular technician, trained in exercise physiology and stress testing, under the general supervision of an attending cardiologist. The fellow's presence is not required during testing. This system significantly reduces the fellow's burden from potentially excessive exercise test witnessing, and allows the fellow to focus on refining electrocardiography and nuclear interpretive skills. The fellows do supervise all pharmacologic nuclear scans and selected exercise studies, usually at the request of the referring physician or ECG technician. This commonly relates to patients with recent acute ischemic syndrome or potentially unstable arrhythmia.

Electrocardiography, Exercise Testing, and Ambulatory ECG: Electrocardiography is a basic tool used by a variety of physicians from different disciplines, in the diagnosis of all forms of heart disease. A cardiology subspecialist should develop the highest level of expertise in recognition of patterns and arrhythmias encountered in both common as well as uncommon disease states. The educational objective of this rotation is to enable the fellow to confidently identify normal variants and abnormal findings, and to understand the accuracy, limitations and clinical implications of such findings. The fellow is exposed to the differences among the varying exercise protocols, with maximal, symptom-limited, and heart rate-limited tests, and develops an understanding of exercise physiology, expected heart rate, and blood pressure response to exercise.

Echocardiography: The fellow develops proficiency in the interpretation of exercise testing, and just as important, develops an awareness of the sensitivity and specificity of findings. Furthermore, the fellow develops an appreciation for the impact of certain confounding variables (such as conduction abnormalities on the resting ECG) on the accuracy of exercise test results and the role of various imaging techniques in those circumstances.

Nuclear Cardiology: Training in nuclear cardiology allows the fellow to become familiar with the fundamentals of nuclear imaging, including myocardial perfusion imaging and radionuclide angiography. The fellow also becomes familiar with the specific characteristics, practical advantages and disadvantages, and cost differences among the various commonly used isotopes, including Thallium and Sestamibi. The fellow should understand the pharmacological basis of commonly used stress agents such as dipyridamole.

The fellow becomes thoroughly familiar with the indications for exercise and pharmacological stress nuclear perfusion studies, and the diagnostic and prognostic implications of the test results. Correlations between nuclear data and clinical information and coronary anatomic findings, if available, are emphasized to maximize learning experience.

The fellow becomes familiar with the variety of techniques used in myocardial perfusion studies used for diagnosis of ischemic and viable myocardium, including exercise and redistribution, rest or reinjection studies using qualitative and quantitative techniques, and the difference between planar and single photon emission computed tomography (SPECT).

Echocardiography Rotation

The echocardiography laboratory at Lahey Clinic is a high-volume laboratory that plays a central role in the diagnosis of a wide variety of cardiovascular conditions in the ambulatory, inpatient, critical care and intraoperative settings. The lab provides complete transthoracic studies (M-mode, two-dimensional imaging, and Doppler) as well as special procedures such as transesophageal, exercise and pharmacologic stress echocardiography. The wide scope of this exposure provides fellows with the opportunity to attain rich experience to acquire the necessary skill and expertise to become proficient in this subspecialty.

The emphasis in this rotation is on integrated comprehension of cardiovascular anatomy, physiology, pathophysiology and hemodynamics. The fellow develops an appreciation for the three-dimensional cardiac structural relationships and its depiction using two-dimensional imaging planes. As the echo examination is an operator-dependent technique, it is imperative that the trainee initially gains "hands on" experience with performance and interpretation of studies. As the trainee gains exposure and experience, he or she is able to recognize limitations of the technique, confounding artifacts, and is able to derive appropriate qualitative and quantitative data leading to accurate diagnostic interpretation.

With increasing experience, the fellow can master skills of interpretation of transthoracic and transesophageal echocardiograms, including technically difficult studies, challenging hemodynamic problems, and congenital heart disease cases.

Transesophageal Training: A relatively unique feature of the fellowship program is that fellows have the opportunity to participate and develop proficiency in TEE simultaneously with transthoracic echoes throughout the three years of training. After gaining experience in instrumentation and basic cardiac anatomy, the fellow is able to observe, and then participate in, the transesophageal echo performance with staff members starting in their first year of training. All studies are supervised by a staff member. As the trainee gains experience, he or she is able to perform a complete examination with progressively less input from the attending physician.

Stress Echocardiography: Stress echocardiography has emerged as a powerful diagnostic and prognostic imaging modality for the management of patients with ischemic heart disease. Yet the accuracy of results is highly dependent on operator and interpreter skill. Wall motion assessment is acknowledged to be one of the most difficult skills to master. To ensure homogeneity and accuracy of the technique, the American Society of Echocardiography developed guidelines and recommendations for training in performance and interpretation of stress echocardiography, which include the supervised interpretation of at least 100 stress echo studies. The high volume of stress echocardiography at Lahey Clinic provides an ideal setting for those who wish to acquire this skill during the second and third years of training.

Electrophysiology Rotation

The Cardiac Electrophysiology Service at Lahey Clinic provides a complete range of services in a dedicated state-of-the-art lab. Services include intracardiac electrophysiologic studies, catheter ablation therapy of cardiac arrhythmias, pacemaker implantation (including biventricular applications) and follow-up in a dedicated pacemaker clinic setting, and cardioverter defibrillator implantation and follow-up.

This rotation is designed for cardiology trainees to acquire knowledge and expertise in the diagnosis and management of bradyarrhythmias and tachy-arrhythmias. The fellow is exposed to noninvasive and invasive techniques related to the diagnosis and management of patients with cardiac arrhythmias, including ambulatory ECG monitoring, event recorders, exercise testing for arrhythmia management, and tilt table testing. The cardiology trainee learns about the pharmacologic and nonpharmacologic therapeutic options and appropriate use of antiarrhythmic therapy, including pharmacology, pharmacokinetics, drug interactions, and side effects such as proarrhythmic potential.

The level of proficiency needed to independently perform intracardiac electrophysiology testing and implant permanent pacemakers requires a dedicated fourth year of training as defined by the ABIM and NASPE. Accordingly, the emphasis of the EP rotation for the clinical cardiology fellow is not necessarily directed towards complete and independent performance of these procedures. The clinical cardiology fellow is expected, however, to participate and assist in enough of these procedures to gain exposure to some of the technical aspects, and more important, to develop full understanding of the indications and limitations of these procedures. During this rotation the fellow gains first-hand experience as a consultant in arrhythmia management by seeing and following consults directed to the arrhythmia service under the supervision of a staff cardiac electrophysiologist.

Congenital Heart Disease Rotation

The focus of this one-month rotation, which typically takes place during the second year of fellowship, is to provide the fellow with an excellent opportunity to gain experience in a concentrated manner in patients with congenital heart disease.

The fellows gain experience in adult congenital heart disease under the direction of a recognized expert in this field, Dr. Richard Liberthson, who is affiliated with Massachusetts General Hospital. In this setting, the fellow sees a large number of outpatients and, to a lesser extent, inpatients with one-to-one collaboration with Dr. Liberthson. The clinical experience is supplemented with appropriate readings in congenital heart disease textbooks.

Cardiac Transplantation Rotation

A minority of training programs have active programs in cardiac or cardiopulmonary transplantation. Accordingly, fellows may have little hands-on experience in this discipline during most clinical rotations. Yet it is important for cardiovascular fellows to recognize when to refer patients for transplantation and to become familiar with long-term management of these patients.

Fellows rotate for a period of one month during their third year to receive focused exposure in this discipline at an academically-affiliated institution with an active cardiac transplant program. During this rotation, the fellow develops an understanding of appropriate patient selection criteria for cardiac transplantation, preoperative testing and post-transplantation care. Fellows develop an understanding of cardiac transplantation success rates, expected survival, and types of anticipated complications in the short and long term. Fellows also use this opportunity to expand their understanding of pathophysiological mechanisms in outpatient and inpatient management of advanced heart failure, pharmacology of standard and experimental cardiovascular drugs, as well as various ventricular assist devices.