INTERVENTIONAL CARDIOLOGY FELLOWSHIP PROGRAM CURRICULUM

INTERVENTIONAL CARDIOLOGY FELLOWSHIP PROGRAM CURRICULUM I. Overview The interventional cardiology training program (ICTP) at Penn State Health Milton S. Hershey Medical Center is a one-year training program that is accredited by the Accreditation Council for Graduate Medical Education (ACGME). The program s most recent review by the resident review committee (RRC) of the ACGME was in 2009, and the program was fully accredited through 2012. Future accreditation is through the Next Accreditation System of the ACGME and remains to be scheduled. The program is approved to train one resident (fellow) per year. During the year, the residents will be trained to be practitioners in the discipline of interventional cardiology. The residents will also gain exposure to peripheral vascular angiography and intervention as well as intervention for structural heart disease. The residents will receive their training at the Milton S. Hershey Medical Center, a 600-bed tertiary care hospital providing the full range of cardiovascular services. There are five cardiac catheterization laboratories. Two are used primarily for electrophysiology studies, but are fully equipped to perform all cardiac procedures. One lab is equipped for the performance of peripheral vascular procedures. About 600 cardiac intervention procedures are performed annually. The facilities are located on the first floor, adjacent to the Emergency Department. There is a 15-bed procedure unit located next to the catheterization laboratories; the unit has staffing and equipment to permit overnight care of low-risk patients. Two nurse practitioners work with the interventional cardiology faculty and fellow to facilitate care. The non-invasive cardiology suite and the vascular laboratory are adjacent to the catheterization laboratories. The suites for interventional radiology are one floor below; the Heart and Vascular Intensive Care Unit and Operating Rooms are one floor above. In addition, there is an active cardiac surgery program at the Hershey Medical Center. II. Clinical Faculty Core Faculty Mark Kozak, M.D. Training Program Director Associate Professor of Medicine Steven M. Ettinger, M.D. Previous Program Director Director of Intervention for the Heart and Vascular Institute Professor of Medicine Charles E. Chambers, M.D. Professor of Medicine Page 1 of 10

Ian C. Gilchrist, M.D. Professor of Medicine Pradeep Yadav, M.D. Assistant Professor of Medicine III. Structure of Program The 12-month training program is divided into 12 one-month rotations as follows: Cardiac catheterization laboratory - 8 months Peripheral Intervention - 2 months Research - 1 month Vacation - 1 month Each fellow will also participate in an ambulatory care experience one half-day per week for the entire year. The focus of this experience will be the rapid evaluation of patients with chest pain and positive stress tests as well as post-procedure follow up. A. Cardiac Catheterization Rotation During the cardiac catheterization rotation, the resident will be responsible for the preprocedure evaluation of patients undergoing cardiac catheterization and PCI. (S)he will also perform PCI with the a faculty member. The resident will also be expected to see patients post-procedure to assess for any immediate complications of the procedure. The focus of the resident will be interventional procedures; however, (s)h may be required to participate in diagnostic procedures if it does not conflict with an interventional procedure. B. Peripheral Intervention During the rotation in Peripheral Intervention, the resident will participate in procedures performed at the Hershey Medical Center under direction of the Vascular Surgery service or the Interventional Radiology service. In addition, there will be opportunities for additional procedural volume at affiliated institutions. The resident will participate in both diagnostic and interventional procedures. C. Research All residents will be expected to participate in some form of research, and time will be allotted for this. The resident will be expected to select a topic near the beginning of his/her training, so that the research work will be concurrent with clinical training. One month of protected time will be available for preparation of a manuscript, presentation at meetings, or other efforts. D. Ambulatory Care The resident will see outpatients one half-day per week in the Cardiology clinic, supervised by one of the interventional cardiology faculty members. The purposes of this clinic are to allow for Page 2 of 10

rapid evaluation of patients with chest pain and to provide follow-up care for patients who have had procedures. E. Call As a significant number of interventional procedures are performed emergently, night and weekend call are essential to interventional cardiology training. The resident will take call one in every 3-4 nights and one in every 3-4 weekends. All call is taken from home. Should an emergency require a significant amount of time, the resident will be permitted to depart before noon on the following day. IV. Clinical Training Residents will have been trained (level 2) in diagnostic right and left heart catheterization during their general Cardiovascular Disease fellowship. The resident will begin assisting with interventional procedures at the beginning of the Interventional fellowship. The resident will be expected to evaluate patients scheduled for a planned PCI. Many patients will have been evaluated and had a diagnostic procedure performed by the general Cardiology fellow. If ad hoc intervention follows, the Interventional resident will then enter the case. The resident will discuss the clinical indications for the procedure with the attending faculty member before participating. Additional discussion will include a general approach to the treatment of the specific lesion, choice of anticoagulation therapy for the procedure, and selection of equipment. During the course of the year, the resident will be expected to predict technical challenges and potential complications of the planned procedure. During the first months of the fellowship, the fellow will obtain vascular access and engage the coronary artery with the guiding catheter. (S)he will perform angiography with the goal of displaying the lesion in a projections suitable for the performance of PCI. During the PCI, the fellow will then advance the guidewire across the lesion. Over the course of the year, the resident will learn to guide balloons, stents, and other devices into position while protecting the position of the guidewire. At the end of the procedure, the resident will discuss access site management with the attending and will perform device closure of the access site if applicable. By the end of the year, the resident will be expected to have gained expertise in the following areas: 1. PCI equipment selection a. Guiding catheter b. Coronary guidewires c. Adjunctive devices (IVUS, FFR, etc.) d. Balloon selection e. Stent selection 2. Engagement of the coronary artery with the guiding catheter 3. Angiographic imaging for PCI 4. Guidewire manipulation 5. Balloon angioplasty 6. Coronary stenting 7. Thrombectomy (suction catheters, rheolytic thrombectomy) 8. Rotational atherectomy Page 3 of 10

9. Distal protection (distal occlusion, and filters) 10. Chronic Total Occlusions 11. Vascular closure device selection and use The resident will perform about 400 PCI procedures during the course of the year with a minimum of 250 procedures performed as the primary operator. V. Didactic Training The Heart and Vascular Institute at the Hershey Medical Center has a weekly conference schedule covering all subspecialties of cardiovascular medicine. There are three conferences per week in which the Interventional resident will be expected to participate: Monday Weekly 4:30 P.M. Cardiology Grand Rounds. The topics vary and are presented by both local faculty and outside speakers. Twice per month cases are presented by fellows to permit discussion of management strategies or other aspects of interest. The Interventional group is responsible for about one presentation per month and the resident will be expected to help with the selection and preparation of these presentations. Tuesday 7:00 A.M. Cardiac Catheterization Conference on alternate weeks (Electrophysiology uses the alternate week). The topics of the conference are planned to cover the breadth of problems and techniques relevant to the catheterization laboratory over a two year cycle. One slot per month will be reserved for topics related to Interventional cardiology. Tuesday 8:00 A.M. Vascular Conference. The management of peripheral vascular disease is discussed. This conference is attended by members of the Divisions of Cardiology, Interventional Radiology, and Vascular Surgery. The Interventional Resident will be required to attend during his rotations with the Interventional Radiology Group and will be encouraged to attend at other times. Wednesday 7:00 A.M. Core Cardiology Conference. This conference is part of the General Cardiology Curriculum. The Interventional resident will be expected to attend those conferences covering relevant topics, such as those related to the management of ischemic heart disease. Wednesday 4:00 P.M. Monthly. The cardiac catheterization has a monthly meeting to review procedural data. Aggregate data are reviewed on a quarterly basis. The Hershey Medical Center submits its data to the ACC-NCDR and receives benchmarking data from the ACC-NCDR. This meeting is part of a Continuous Quality Improvement program. The intention is to identify areas for improvement. The other weeks are used to review individual complications and discuss relevant topics, such as door-to-balloon times, hypothermia protocols, etc. The Interventional resident will attend this meeting and participate in Quality Improvements. Thursday 4:00 P.M. Heart and Vascular Institute Conference. This conference is attended by representatives of the Cardiology, Interventional Radiology, Cardiothoracic Surgery, and Vascular Surgery. The format rotates and includes Morbidity and Mortality Conference, Case Presentations, and Lectures. The cardiac catheterization laboratory will present both difficult Page 4 of 10

cases and complications, and the Interventional resident will prepare the presentation with a faculty member. Thursday Monthly 7:00 A.M. Interventional Cardiology Journal Club. Once per month the Interventional cardiology resident and faculty will have a journal club. A topical article(s) will be chosen ahead of the meeting. The Interventional resident will present the study and begin the discussion. VI. Research The Interventional resident will choose a research project at the beginning of the year. As the program is one year, this will likely be part of a program that is conducted by a faculty member. Research work will be conducted in parallel with clinical training. One month of dedicated time is available to complete a project, prepare a manuscript, etc. A resident with an established research interest will be encouraged to continue in this area if feasible. The cardiac catheterization laboratory at the Hershey Medical Center collects data on every patient undergoing a procedure. Some of this data is submitted to the ACC-NCDR. The Interventional resident may choose to test a hypothesis through retrieval of data from one of these data sets. Faculty will be available for assistance, both within the Heart and Vascular Institute and elsewhere in the institution (i.e. Health Evaluation Sciences). Interventional faculty members are investigators in many multi-center clinical trials. The Interventional resident will be expected to be a co-investigator for at least one of these studies. As a co-investigator, the resident will screen, obtain consent, and ensure that the protocol is followed. This experience will give the resident exposure to clinical trials. VII. Systems Based Quality Improvement (QI) As noted above, the catheterization laboratory at the Hershey Medical Center has quarterly meetings to review complications and assess other measures of quality. Each resident will participate with a faculty member in a quality improvement initiative within the cardiac catheterization laboratory. At the present time, several important (QI) initiatives are in progress. These include analysis and reduction of door-to-balloon time for STEMI, drug-eluting stent utilization, prevention of vascular access site complications, and prevention of contrast-induced nephropathy. The resident will meet with their assigned faculty member and review all cases that fall within the purview of their initiative and initiate system and policy modifications that will improve patient care. VIII. Core Curriculum and Self-Learning The ICTP at the Hershey Medical Center will use the curriculum of the Interventional Fellows Institute (IFI) (www.interventionalfellowsinstitute.com), a program sponsored by the Society for Cardiac Angiography and Interventions (SCAI). This valuable on-line resource contains approximately sixty one-hour slide presentations (divided into ten modules) narrated by the foremost thought leaders in interventional cardiology. These presentations cover basic topics in interventional cardiology. The website allows the program director to select which presentations he/she wishes the residents to review and permits the program director to track which Page 5 of 10

presentations the resident has completed. A time-line for completion of modules will be given to the resident at the start of the academic year. Each module also contains a quiz which can be used to assess the medical knowledge of the resident. Concepts in which the resident will be expected to review and have an adequate knowledge base include: A. Basic Science for the Interventional Cardiology 1. Basic Concepts in Atherogenesis 2. Current Concepts of Endovascular Thrombosis 3. Plaque Morphology and Acute Coronary Syndromes B. Cath Lab Basics 1. Radiation Principles and Cath Lab Equipment 2. The Basics of Guide Catheter, Guide Wire, and Balloon Selection 3. Femoral Artery Access and Closure Techniques 4. Contrast Media and Contrast Induced Nephropathy C. Valvular, Structural, and Congenital Heart Disease 1. Cardiac Hemodynamics for the Interventionalist 2. Valvular Heart Disease: Valvuloplasty Techniques 3. Interventional Catheterization for Congenital Heart Disease D. Intracoronary Imaging and Physiology 1. Physiologic Lesion Assessment and Clinical Trial Results (3 modules) 2. IVUS Imaging, Clinical Trial Results, and Applications (2 modules) E. Patient and Lesion Specific Approaches 1. Patient and Lesion Specific PCI Considerations 2. Saphenous Vein Graft Interventions (2 modules) 3. Ostial and Bifurcation Lesions (2 modules) F. Acute Myocardial Infarction and Thrombus 1. Rescue PCI 2. Mechanical Thrombectomy 3. Cardiogenic Shock and Hemodynamic Support G. Anticoagulation in the Catheterization Laboratory 1. Aspirin and Thienopyridines 2. GP IIb/IIIa Inhibitors 3. Heparin and LMWH 4. Direct Antithrombins 5. Monitoring and Complications of Anticoagulation H. Coronary Stenting 1. Balloon Angioplasty and Provisional Stenting 2. Coronary Stenting (2 modules) 3. Sirolimus Eluting Stents: A Comprehensive Review 4. Stent Thrombosis, Timing, Outcome, and Optimization of Pharmacology 5. Drug-Eluting Stent Comparisons I. Coronary Stenting: Drug Eluting Stents 1. In-Stent Restenosis 2. Vascular Brachytherapy J. Advance PCI Techniques and Devices 1. Embolic Protection Page 6 of 10

2. Rotational Atherectomy IX. Self-Assessment The interventional cardiology resident will be required to participate in self-assessment exercises. At the start of the academic year, the program director will distribute a self-assessment quiz based on questions compiled from respected resources including the IFI, www.tctmd.com, and the CathSAP program of the American College of Cardiology (ACC) and the Society for Cardiac Angiography and Interventions. This exercise will allow the resident and the program director to determine areas of weakness and strength and will guide subsequent efforts. A follow up self-assessment examination will be given late in the academic year so that the resident can identify remaining weaknesses and focus self-study on these areas prior to the completion of training. X. Continuing Medical Education Each trainee will have the opportunity to attend one or two conferences designed for interventional fellows: SCAI Interventional Fellows Course CRF Interventional Fellows Course C3 Interventional Cardiac Complications Course Any trainee whose research submission is accepted for presentation will be granted time to travel to the meeting where their work will be presented. XI. Duty Hours The common program requirements of the ACGME state that the in-hospital work week can be no longer than 80 hours and the resident must receive one full day off out of every seven days when averaged over a four-week period. Furthermore, a resident cannot participate in continuous patient care for a period of greater than 24 hours. The ICTP at the Hershey Medical Center is committed to meeting these requirements. The structure of the call schedule and work week makes it highly unlikely that a resident will be in the hospital for greater than 80 hours per week. The frequency of weekend call is one in 3-4 weekends. Therefore, during a given four week period, the resident should get 4-6 full days off per week. All call is taken from home, and the interventional resident will not be the first call physician for most Cardiology patients. Should the unlikely situation arise that a resident has performed 24 consecutive hours of patient care, the resident will be relieved of his/her duties for the remainder of the day, and the program director or other faculty member will assign any remaining patient care duties to a colleague, general Cardiology fellow, or a mid-level provider. The Hershey Medical Center has an on-line program for residents to track duty hours (New Innovations). Any trends towards violation of duty hour policies will be addressed and corrected by the program director. XII. Procedure Logs All procedures performed by a resident can be easily searched using the catheterization laboratory reporting system. However, each resident will be encouraged to keep his/her own Page 7 of 10

procedure log that will allow for easier tracking of procedural specifics (adjunctive devices used, interesting management decisions, complications, etc.). The procedural logs will be reviewed by the program director and the resident during their semi-annual review. XIII. Evaluations At the conclusion of each quarter, each resident will be evaluated by each faculty member. The evaluations will be based on the resident s performance in each of the core competencies during their clinical rotations, research rotations, and ambulatory sessions. The residents will also have an opportunity to evaluate each of the faculty members. The evaluations will be discussed with each resident during their semi-annual evaluation, and goals for improvement will be discussed as well. Urgent issues, however, will be discussed with the resident on an ad hoc basis. The evaluations for each faculty member will be discussed semiannually during faculty meetings. Specific urgent matters pertaining to a faculty member, however, will be addressed by the program director and faculty member on an ad hoc basis. The New Innovations system will be used for evaluation solicitation and management. Semiannually (November and April), the resident will be evaluated using a 360 evaluation tool (Appendix A). The resident will observed during their initial assessment of a PCI patient with attention paid to history and physical, description of procedure and expectations, and obtaining of informed consent. The evaluation will continue into the catheterization laboratory with a focus on procedural planning, procedural skills, and medical decision making. The resident will also be evaluated on their post-procedural management of the patient. During this evaluation, an evaluation will also be solicited from the nurse or nurse practitioner caring for the patient, and if feasible, the patient themselves. A score will be given and the evaluation will be discussed with the resident during their semiannual evaluation. During these time periods as well, evaluation of each resident will be solicited from fellow residents to assess professionalism and an ability to work in an integrated approach to patient care. There will be a semiannual assessment of the program and the ability of the program to meet the goals set out in this document. Specific goals for improvement will be discussed and implemented. These meetings will be documented. XIV. Core Competencies The ACGME has put forth six core competencies that will be developed and evaluated during the course of the training program. The competencies are listed below along with a description of the competency as well as the means to develop and evaluate the competency by the ICTP at HMC. A. Medical Knowledge Definition: Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. Residents are expected to demonstrate and investigatory and analytic thinking approach to clinical situations and know and apply the basic and clinically supportive sciences which are appropriate to their discipline. The residents will have opportunities for medical knowledge development via assignments for focused topic case presentations at the catheterization conference. They will also Page 8 of 10

have the ability to enhance knowledge with required completion of the curriculum outlined by the Interventional Fellows Institute. They will be evaluated on their knowledge during the performance of cases as well as via in-service/self-assessment examinations. B. Patient Care Definition: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to 1. communicate effectively and demonstrate caring and respectful behaviors when interaction with patients and their families 2. gather essential and accurate information about their patients 3. make informed decisions about diagnostic and therapeutic interventions based on patient information, preferences, up-to-date scientific evidence, and clinical judgment 4. Develop and carry out patient management planes 5. counsel and educate patient and their families 6. Use information technology to support patient care decisions and patient education 7. Perform competently all medical and invasive procedures considered essential for the area of practice 8. provide health care services aimed at preventing health problems and maintaining health 9. Work with health care professionals, including those from other disciplines, to provide patient focused care. The residents be observed during their work in the catheterization laboratory and evaluated monthly by the interventional cardiology staff. The bi-annual 360 evaluation will provide feedback for residents regarding this competency. C. Practice based learning and improvement Definition: Residents must be able to evaluate and their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to 1. analyze practice experience and perform practice based improvement activities using a systematic methodology 2. Obtain and use information about their own population of patients and the larger population from which their patients are drawn 3. locate, appraise, and assimilate evidence from scientific studies related to their patients health problems 4. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness 5. Use information technology to manage information, access on-line medical information, and support their own education 6. Facilitate the learning of students and other health care professionals The journal club experience will provide the ideal venue in which to develop and evaluate this competency. The resident s ability to evaluate and incorporate new data into clinical care will be evaluated. Furthermore, participation in research projects and selfassessment examinations will further enhance the development of this competency. D. Systems based practice Definition: residents must demonstrate an awareness of and responsiveness to the larger context of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to 1. know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources 2. practice cost-effective health care and resource allocation that do not compromise the quality of care 3. Advocate for quality patient care and assist patients in dealing with system complexities 4. partner with health care managers and health care providers to assess and coordinate The resident will be expected to participate in one systems initiative for improvement of quality of care within the catheterization laboratory (i.e. prevention of vascular complications, improvement of door to balloon times, prevention of contrast induced nephropathy). The resident will be evaluated on their participation in this initiative as well as their implementation of practice parameters to improve quality of care. Page 9 of 10

E. Professionalism Definition: residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse population. Residents are expected to 1. demonstrate respect, compassion, and integrity 2. demonstrate a commitment to ethical principles 3. demonstrate sensitivity and responsiveness to patients culture, age, gender, and disabilities Professionalism is a difficult competency to teach, but one that the faculty of the HMC ICTP hope to develop by example. The trainees will be evaluated monthly on this competency and in more detail during the biannual 360 evaluation. F. Interpersonal and communication skills Definition: residents must be able to demonstrate interpersonal and communication skill that result in effective information exchange and teaming with patients, their families, and professional associates. Residents are expected to 1. create and sustain a therapeutic and ethically sound relationship with patients 2. use effective listening skills and elicit and provide information using effective non-verbal, explanatory, questioning, and writing skills 3. Work effectively with others as a member or a leader of a health care team or other professional group Similar to professionalism, this competency is hard to teach, but again will be demonstrated by faculty via example. This competency will be assessed monthly as well as via the biannual 360 evaluations with emphasis on the colleague and nurse evaluations. Page 10 of 10