Cardiology Fellowship Manual Goals & Objectives -Exercise Physiology- 1 P a g e
Pediatric Cardiology Fellowship EXERCISE PHYSIOLOGY Goals & Objectives Introduction/Purpose The goal of the exercise rotation is to introduce fellows to the field of exercise science. Fellows will study the pre-procedure indication issues i.e. the physiologic questions that lead to the decision to recommend the diagnostic evaluation compared to subjective historical data. The fellows will learn the basic process and techniques used to collect the data including basic skills in rhythm evaluation, blood pressure assessments and metabolic measurements. The risks and benefits associated with stress testing will be understood. The fellow will complete the rotation with knowledge of normal and abnormal physiologic response to exercise and an understanding of longitudinal exercise evaluations. Faculty Supervisor(s)/Preceptor(s): Fletcher/Erickson/Kugler/Thomas/Yetman Admin Assistant or Office Contact: Priscilla Phillips Length of Rotation Concomitant with ACHD/HF and EP rotations during 1 st -3 rd year, Fellows will participate until they have been involved with 25 complete exercise evaluations during the 3 years of fellowship. Of the 25 total studies, ten studies should include supervision of exercise. Location: Pediatric and Adult Congenital Exercise Laboratory, Children s Hospital & Medical Center Prerequisites Vacation/time off is allowed during rotation. The fellow must submit the dates through the appropriate channels in accordance with the policies of the fellowship. General Responsibilities and Expectations Exercise Lab Hours: 0730 1630. During the rotation, the fellow will be responsible to participate in most scheduled cases, with the exception being required clinical and educational fellowship activities. Weekly/monthly didactic schedules Fellows will be required to attend all required lectures and conferences. Special exceptions may be made to participate in rare or exceptional procedures, as long as the fellow is maintaining attendance at well above the minimum level described in the fellowship policies, including time missed for vacation/time-off. The exercise rotation includes attendance at weekly care conference and requires attendance at quarterly exercise lectures.. 2 P a g e
Night or weekend call. Fellows will continue to perform call as scheduled on evenings, weekends and holidays as dictated by the overall fellowship schedule. Fellows will not be required to come in on off-hours and weekends for exercise procedures. Vacation If the fellow takes vacation/time-off during the rotation, it is the fellow s responsibility to read about topics covered. Fundamental to the rotation are responsibilities relevant to clinical service, medical records documentation and conferencing. These include (but are not limited to) the following (Patient Care, PC; Interpersonal & Communication Skills, IPCS; Systems-Based Practice, SBP; Medical Knowledge, MK; Professionalism, P): Educational Responsibilities and Expectations Obtain reading materials required for the rotation. This will include introductory chapters from the standard texts, as well as procedure specific literature. (MK; SBP) Read required material and be prepared to discuss. (MK; SBP) Patient specific materials must be read and discussed before each procedure. This will include a review of the patient s history, the goals specific to that procedure. (PC; MK; SBP; IPCS) Complete and submit rotation experience and faculty evaluations. (SBP) Submit a total list of procedures performed. (SBP) Minimum required procedures for the 3 year fellowship: (PC; MK; SBP; IPCS) o At least 25 exercise evaluations of which at least 20will include metabolic assessment component. Instructional Resources Journal Club (Exercise topics will be discussed as part of the overall journal club experience. There will not be a specific formal exercise rotation journal review conference.) Required Reading and Viewing References Textbooks: Exercise Gas Exchange In Heart Disease ed. K Wasserman Exercise Physiology: Energy, nutrition and human performance eds. McCardle WD, Katch FI, Katch VL. Articles: Rhodes J, Ubeda Tikkanen A, Jenkins K. Exercise Testing and Training in Children With Congenital Heart Disease Circulation 2010; 122: 1957-1967. doi: 10.1161/CIRCULATIONAHA.110.958025 3 P a g e
. Johnson JT, Yetman AT. Cardiopulmonary exercise testing in adults with congenital heart disease. Progress in Pediatric Cardiology 2012; 34:47-52. Paridon et al. Clinical stress testing in the pediatric age group. Circulation 2006; 113:1905-1920 Standard cardiology and exercise textbooks, classic articles, journal and manuscripts on newer techniques and procedures. Optional Reading and Viewing Educational Goals and Objectives Patient Care Patient focused, compassionate and effective care is delivered at all times in the exercise laboratory. By the end of the exercise experience, the pediatric cardiology fellow will be able to: Discuss principles and practice of exercise science as applied to specific congenital and acquired heart disease issues. Correctly interpret metabolic data derived from the exercise study. Perform diagnostic exercise evaluations. Follow safe practice guidelines for exercise. Medical Knowledge Exercise involves patient specific knowledge, hemodynamic and physiologic principles, equipment and technique ability and limitations, and safety regimens regarding both bike and treadmill studies. By the end of this rotation, the pediatric cardiology fellow will be able to: Properly identify a patient who would benefit from exercise evaluation with complete rationale/explanation. Encapsulate the methods to acquire data that will optimize useful information and simultaneously limit the patient s exposure to risk. 1. Demonstrate the ability to use the scientific method and the deductive reasoning process. 2. Demonstrates an understanding of the pathophysiology of cardiopulmonary exercise. 1. Maintain and improve upon Goals for Medical Knowledge. 2. Demonstrate understanding of the pathophysiology of exercise in complex forms of congenital heart disease. 4 P a g e
3. Demonstrate understanding of indications for, appropriate procedures, and risk of stress testing. 1. Maintain and improve upon & 2 Goals for Medical Knowledge. 2. Demonstrate advanced knowledge of abnormal cardiac anatomy and associations with exercise findings. 3. Demonstrate a comprehensive understanding of the various types of exercise evaluations. Practice-based Learning and Improvement The fellow will be required to investigate, evaluate, and improve their own practice, and appraise and assimilate scientific evidence. By the end of this rotation, the pediatric cardiology fellow will be able to: Utilize evidence-based medicine to formulate a systematic method for patient evaluation and treatment with exercise techniques. Search, interpret and discuss online and written resources for literature relevant to specific patient presentations and procedures. Stay current with pediatric and congenital cardiac disease exercise literature and technology. Analyze their experience, and help design their rotation to optimize exposure and improve practice and performance. 1. Demonstrate the ability to use information technology and feedback to improve the practitioner s fund of knowledge and technical skills and provide a better care to patients. 2. Identify knowledge deficiencies and acts to improve upon them. 1. Maintain and improve upon Goals for Practice-Based Learning and Improvement. 2. Systematically review and present data for cardiac care conference with appropriately directed evidence-based discussion and critique. 1. Maintain and improve upon & 2 Goals for Practice- Based Learning and Improvement. 2. Apply knowledge of study design and statistical methods to the appraisal of clinical studies and their impact upon patient care. 5 P a g e
3. Assist and supervise junior fellows in performance critiques and quality improvement conferences. Interpersonal and Communication Skills The exercise laboratory requires very effective communication. This includes the referring cardiologists, the team performing the procedure, the primary care provider and the discussion post procedure of the data collected and questions left unanswered. Effective exchange of information is critical. By the end of this rotation, the pediatric cardiology fellow will be able to: Receive a referral and properly interpret the reason for the referral, with an analysis of the required information (both present and missing). Use and develop effective communication skills (verbal, nonverbal, and listening) with the patient and family as well as other members of the healthcare team. Work with the exercise team before during and after the procedure to be an effective team member and provide the patient with the highest level of care. 1. Communicate with patients and their families in easily understood and culture-sensitive language. 2. Work effectively as a member of a professional group. 3. Maintain comprehensive, timely, and legible medical records. 1. Maintain and improve upon Goals for Interpersonal and Communication Skills. 2. Take leadership of the exercise evaluation and ensure accurate communication amongst members of the team. 3. Demonstrate the basic ability to effectively communicate to patients and families exercise physiology in patients with congenital heart disease. 1. Maintain and improve upon &2 Goals for Interpersonal and Communication Skills. 2. Complete all medical records in a timely, succinct fashion, including inpatient notes. 3. Demonstrate proficiency in effectively communicating all types of defects to patients and families in a culturally sensitive and understandable manner. Professionalism Professional responsibility, adherence to ethical principles and conduct, and sensitivity to patients are essential qualities in a quality physician. Throughout this rotation, the pediatric cardiology fellow will be expected to: Display a professional attitude in appearance, communication, dependability, promptness, and work ethic. 6 P a g e
Demonstrate integrity, honesty, and empathy. Adhere to patient confidentiality. Respect patient s autonomy and diversity. 1. Maintain professional demeanor in communication with patients, parents and caregivers. 2. Maintain respect for patient privacy and confidentiality. 1. Maintain and improve upon Goals for Professionalism. 2. Demonstrate patient ownership and assumes primary responsibility for care. 1. Maintain and improve upon & 2 Goals for Professionalism. 2. Demonstrate sensitivity and responsiveness to patients culture, age, gender, and disabilities. 3. Maintain professional demeanor in communication with patient care teams and referring physicians System-based Practice The fellow will need to develop an understanding and appreciation of the necessary relationships to provide quality exercise services within the system given limitations in resources and allocation. By the end of this rotation, the pediatric cardiology fellow will be able to: Understand and be able to discuss the basics of charges and reimbursement. Identify cost effective measures, potential waste, and limitations to providing high quality care without compromising quality. Coordinate care effectively with other specialties to limit excess utilization, unnecessary or duplicate testing and other sources of waste. 1. Practice cost-effective health care and resource allocation that does not compromise quality of care 2. Understand the finances involved in the exercise laboratory; this includes the hospital, equipment, personnel as well as professional billing and charges 1. Maintain and improve upon Goals for Systems-Based Practice. 2. Effectively integrate cardiac and noncardiac medical issues into comprehensive patient plan. 7 P a g e
3. Understand the finances involved in the exercise laboratory; this includes the hospital, equipment, personnel as well as professional billing and charges 1. Maintain and improve upon & 2 Goals for Systems- Based Practice. 2. Identify and evaluate a quality-improvement project within the division. 3. Demonstrate understanding of the contribution of systems issues to medical error and prevention. 4. Understand the finances involved in the exercise laboratory; this includes the hospital, equipment, personnel as well as professional billing and charges Work Product The rotation is designed with both exposure and core competency completion requirements. During the course of this rotation, pediatric cardiology fellow will: Log procedures performed as they occur. Methods of Evaluation and Feedback Subjective assessment of the fellow s performance and the quality of the rotation experience will be documented with evaluation forms. These will include: Assessment of written patient documents for completeness and accuracy. Patient documents include procedure notes, exercise reports, pre-procedural history and physicals. Assessment of the understanding of data in oral presentations pre and post procedure in conferences, individual discussions and in family discussions. Assessment of the independent study that the fellow performed over the course of the rotation to understand the diseases and physiology presented and better their overall knowledge base. Assessment of the fellow s medical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism, and systembased practice The standard evaluation form will be used and discussed with the fellow at quarterly intervals and during the semi-annual meeting with the program director. The fellow will submit a rotation experience evaluation using the standard rotation evaluation form. 8 P a g e