Four electrophysiology physicians and one physician assistant provide clinical services on the cardiac arrhythmia service. Staff physicians rotate on a weekly basis through three areas of clinical responsibility: invasive laboratory procedures, ward patient care, and outpatient clinic care. Service meetings and conferences are held daily to coordinate care and provide teaching to fellows. As part of their training, fellows are required to keep a procedure log and fellowship portfolio.
Invasive Laboratory Procedures
The laboratory staff physician supervises all invasive procedures and is responsible for the care of all patients undergoing procedures in the electrophysiology (EP) laboratory. In addition, the laboratory physician provides teaching and guidance for the fellows on the interpretation of electrophysiologic data derived from all procedures performed in the laboratory.
A cardiac electrophysiology fellow serves as first operator for all EP laboratory procedures in conjunction with the laboratory staff physician. Fellows see all patients scheduled for laboratory procedures prior to their arrival in the laboratory. Part of the fellow’s role is to explain to the patient the rationale for the procedure as well as the risks involved. As part of this preprocedure evaluation, the fellow ensures that the appropriate orders are written and consent forms signed. After all laboratory procedures are completed, the fellow writes postprocedure orders (and admitting orders if necessary), and completes the computerized report under the supervision of the staff physician.
The fellow visits the patient on the floor and ensures that no complications referable to the procedure have occurred. After pacemaker implantation, the implanting fellow also performs a pacemaker system evaluation in conjunction with either the staff physician or physician assistant. After all procedures in which subclavian or jugular vessels have been cannulated, and after all pacemaker and transvenous defibrillator implants, the fellow who performed the procedure personally views the post-procedure chest radiograph to exclude relevant abnormalities.
The inpatient staff physician makes daily rounds with a physician assistant and an electrophysiology fellow, and assumes responsibility for the clinical care of all inpatients on the arrhythmia service. He or she coordinates the admission and discharge of inpatients with their referring physicians. The inpatient physician sees all consults in conjunction with an electrophysiology fellow and schedules procedures in the laboratory as indicated. Physician assistants, acting under the supervision of the ward attending physician, are responsible for admission and discharge orders as well as for documenting admission and follow-up notes in the medical record.
Physician assistants dictate discharge summaries for editing and signature by the staff physician. The staff physician is responsible for contacting referring physicians and ensuring that follow-up arrangements for discharged patients are satisfactory. Patients on the electrophysiology service who are in an intensive care setting are on the house staff service. An electrophysiology fellow, in conjunction with the attending physician, is responsible for liaison regarding the daily care of these patients, as the physician assistants will not ordinarily be involved.
The staff physician responsible for the outpatient clinic sees all outpatient consults for the arrhythmia service. In addition, he or she supervises all noninvasive testing (signal averaging and tilt-table testing) as well as the pacemaker and ICD clinics. Pacemaker and defibrillator clinics are held daily, and fellows are expected to attend on a regular basis. Fellows have a dedicated arrhythmia consultation and continuity clinic weekly for one half-day session. Fellows perform interrogation and troubleshooting of all pacemakers and defibrillators using the standard programming and ECG tools available as well as occasional radiography. The findings and management plans are discussed with the outpatient staff physician. Fellows also see urgent consults and perform outpatient preoperative evaluations under the supervision of the staff physician.
Procedure Log and Fellowship Portfolio
The cardiac electrophysiology fellow is responsible for maintaining a personal log of all procedures performed in and out of the laboratory; such procedures should include both invasive and noninvasive testing. Collected data should include patient name and medical record number, date and type of procedure, indication(s), complications, and name of supervising faculty physician. This log should be complete and accurate; it is evaluated by the program director, who certifies its authenticity.
In addition, fellows are responsible for compiling a portfolio of their written material produced during the fellowship. This includes copies of inpatient and outpatient consultation notes and reports of invasive and noninvasive procedures, as well as all teaching materials prepared for departmental and institutional conferences. At the end of the fellowship, this portfolio becomes part of the fellow’s permanent record, from which future credentialing recommendations are made.