Echocardiography

Educational Purpose:  The educational purpose of this rotation is to gain understanding of the indications for appropriate use of a variety of Echocardiographic testing along with proficiency in performing and interpreting these tests, which include M-mode, 2D, and 3D echocardiography (both transthoracic and transesophageal), Doppler echocardiography, stress echocardiography, and metabolic testing.  The rotations are structured progressively throughout the fellowship training so that by the end of 3 years, the fellow will be able to obtain at least Level II competency in echocardiography and be able to independently perform and interpret all modalities involving echocardiography.  Fellows should also be familiar with the physical principles underlying echocardiography and have the opportunity to perform a sufficient number of studies to qualify for the comprehensive certification exam in adult echocardiography.  Fellows will become familiar with the indications and contraindications for performing stress and transesophageal echo based on a wide variety of patients with a broad spectrum of cardiovascular disease referred from all services within the hospital. 
 
Fellows will acquire skills in communicating with the referring physicians in order to both discuss and determine the indications or contraindications for studies and communicate findings and their significance in context.  Skill in performing stress and transesophageal echo will be gained by direct attending physician supervision, with all transesophageal echoes entirely supervised.  The fellows will gain experience in the technical performance of transthoracic echo with guidance by both the echocardiography technologists and attending physicians.  They will independently interpret a large number of echocardiograms, which will be fully reviewed by the attending physician with the interpretations discussed with the fellow. 
 
The fellow’s performance will be evaluated by direct observation by the attending in the Echocardiography Laboratory, as well as by peers and supporting staff in the hospital environment. 
 
Overall Goals:
·         To become competent in understanding the indications and contraindications for performing all modalities of echocardiography listed above.  (COMPETENCIES:  patient care, medical knowledge, professionalism, system-based practice,  practice-based learning, interpersonal and communication skills)
·         To learn how to apply evidence-based, cost conscious strategies for using echocardiography to diagnose and manage hospitalized patients, outpatients, and emergency room patients.   (COMPETENCIES: patient care, medical knowledge, practice-based learning)
·         To learn to function as a part of a multi-disciplinary team within the Cardiovascular Service.  (COMPETENCIES: patient care, professionalism, interpersonal and communication skills)
·         To be able to participate in education of physicians on non-cardiovascular services, in regards to the uses, limitations and indications for all modalities of echocardiography. (COMPETENCIES: interpersonal and communication skills, professionalism)
·         To effectively participate in discussions of patient care and management in relation to echocardiography uses and findings with other medical disciplines and specialties. (COMPETENCIES: Patient care, interpersonal and communication skills, professionalism)
·        Demonstrate competency in performing stress echocardiography, recognizing indications and contraindications and have skill in performing the stress portion of the test.  (COMPETENCIES: patient care, interpersonal and communication skills, medical knowledge)
·      Formulate a comprehensive interpretation of echocardiographic studies.   (COMPETENCIES: patient care, medical knowledge).
·      Demonstrate organizational skills necessary to integrate the findings into digital storage and reporting systems so that results are accessible to other physicians.   (COMPETENCIES: practice-based learning, system-based practice, patient care)
·      Demonstrate the ability to distinguish artifacts from clinically important findings and to begin getting experience in technical aspects of performing studies to better recognize potential difficulties associated with acquisition which may influence the interpretation of studies.   (COMPETENCIES: system-based practice, practice-based learning)
·      Efficiently and effectively document in writing the interpretations, observations, measurements, conclusions and suggestions that will be entered into the medical record (COMPETENCIES: medical knowledge, system-based practice, practice-based learning, interpersonal and communication skills)
·        Demonstrate effective communication with patients’ families, consulting providers, other consultants and staff.  (COMPETENCIES: communication and interpersonal skills, professionalism)
 
Competency-Based Learning Objectives:
In addition to continuing development of the competencies based on the learning objectives above, as more experience is gained, the fellow will be able to:
·         Demonstrate the ability to independently perform transthoracic echocardiograms of a diagnostic quality.  (COMPETENCIES:  medical knowledge, system-based practice, practice-based learning)
·         Demonstrate competency to independently perform conscious sedation for transesophageal studies, and competence in insertion of transesophageal probe, and performance of a complete transesophageal exam.  This includes knowledge of the indications and contraindications of both conscious sedation and transesophageal echo.
 
Goals & Objectives by PGY level:
PGY 4:
1.      Formulate a comprehensive interpretation of echocardiographic studies.  
2.      Learn how to apply evidence-based, cost conscious strategies for using echocardiography to diagnose and manage hospitalized patients, outpatients, and emergency room patients.  
3.      Demonstrate the ability to distinguish artifacts from clinically important findings and to begin getting experience in technical aspects of performing studies to better recognize potential difficulties associated with acquisition which may influence the interpretation of studies.   
4.      Efficiently and effectively document in writing the interpretations, observations, measurements, conclusions and suggestions that will be entered into the medical record
5.      Effectively participate in discussions of patient care and management in relation to echocardiography uses and findings with other medical disciplines and specialties and
6.      Introduction to acquisition of transthoracic echocardiograms of a diagnostic quality
7.      To learn how to apply evidence-based, cost conscious strategies for using echocardiography to diagnose and manage hospitalized patients, outpatients, and emergency room patients.  
 
PGY 5:
1.      Further develop the skills obtained in PGY 4.
2.      Demonstrate competency in performing stress echocardiography, recognizing indications and contraindications and have skill in performing the stress portion of the test. 
3.      Demonstrate the ability to independently perform transthoracic echocardiograms of a diagnostic quality.
4.      Demonstrate competency to independently perform conscious sedation for transesophageal studies, and competence in insertion of transesophageal probe, and performance of a complete transesophageal exam.  This includes knowledge of the indications and contraindications of both conscious sedation and transesophageal echo.
5.      To be able to participate in education of physicians on non-cardiovascular services, in regards to the uses, limitations and indications for all modalities of echocardiography.
PGY 6:
1.      Further develop the skills obtained in PGY 4 and PGY 5
2.      To become competent in understanding the indications and contraindications for performing all modalities of echocardiography
3.      Be able to obtain Level III competency in echocardiography according to the COCATS guidelines if desired 
 
 
Mix of Diseases: Fellows will be exposed to patients requiring echo procedures with a wide range of cardiovascular disorders and complications of other diseases or procedures at varying degrees of progression (from initial presentation and diagnosis to end-stage disease).  Patients seen by the Cardiology fellow will include a full range of adults and selected adolescent patients, from a comprehensive mix of ethnic and racial origins.  At JMH and UMH, the gender mix will be balanced; at the VAMC, the majority of patients will be male.  Cardiac diseases encountered and managed typically include but are not limited to the following: Coronary artery disease, ischemic and non-ischemic cardiomyopathies and congestive heart failure, valvular disorders, pericardial disease, as well as congenital heart disease in the adult.  Furthermore, pregnant patients with cardiovascular disease may be encountered, as well as patients needing clearance for high risk surgical procedures such as organ transplantation.         
                                                                                               
Teaching Methods:

·         Patient-Centered Teaching/Learning: Teaching will take place in the Echocardiography Laboratory, and/or in locations where portable procedures are done with direct interaction with the attending who will review all studies the fellows have performed and interpreted and directly supervise the transesophageal procedures.   Fellows are expected to identify knowledge gaps and search for answers to their questions on a routine basis.  
·         Conferences/Didactic Learning: Fellows are expected to attend the Division of Cardiology Fellows’ Core Curriculum Lectures given throughout the academic year in addition to the departmental Grand Rounds.  The Thursday Imaging Lecture Series will cover a variety of topics in echocardiography.
 

Procedures:  Fellows will perform a focused history and physical exam and chart review prior to performing any study.  They will be trained in stress echocardiography, transthoracic echo and Doppler, and transesophageal echo under the direct supervision of the cardiology attendings in the Echocardiography Laboratory.  Through their integration of the cardiac information obtained, they should develop a correlation between patients’ physical findings and history and the findings obtained by echocardiography examination.

 
Pathologic Material/Educational References:
·         The fellows will review EKGs, chest X-rays, cardiac catheterizations, CT scans, stress tests and echocardiograms as indicated by the patient’s cardiac condition. 
·         AHA: http://learn.heart.org/ihtml/application/student/interface.heart2/index.html
·         ASE: http://www.asecho.org/i4a/pages/index.cfm?pageid=3306
·         Up to Date: http://www.uptodate.com/home/index.html
·         PubMed: www.ncbi.nlm.nih.gov/pubmed/
·         Text books:  Cardiology textbooks are available in the Echocardiography Lab, Hospital Library and the Calder Medical Library.
·         Institutional access for http://www.cardiosource.org  and CardiosourcePlus with ACCSAP7.
 
Evaluations: Fellows will be evaluated by their supervising attending physician(s) using a competency-based system on New Innovation.  Feedback will be provided during and at the end of the rotation.
 
Supervision Policy: Direct/Indirect with direct supervision immediately available.
 
Team Structure: 
·         Supervising Attending (one is in the laboratory or immediately available during all regular hours);
·         1-3 fellows per site
 
Attending Responsibilities:
·        Supervises and assumes responsibility for the performance and interpretation of all echocardiographic modalities
·        Directly supervises all transesophageal echo examinations.
·        Daily reading sessions with the fellows on the Echocardiography rotation with concurrent teaching and feedback on fellows’ readings.
·         Responsible for providing verbal and written feedback to the fellow
 
Fellow Responsibilities:
·         Initial screening
o   The fellow will screen all transthoracic echocardiograms for which the technologist has a question as to the appropriateness or meeting standard indications.
o   All requests for transesophageal echocardiograms will be screened by the fellow.  The patient must be evaluated prior to the procedure and written informed consent must be obtained.
o   Outpatients undergoing stress echocardiography will be screened by the fellow and consent obtained prior to beginning the examination.
·         Perform a sufficient number of transthoracic echocardiograms during their rotations with assistance from the technologist or attending, as necessary, to gain competence.
·        Responsible for keeping a log of all procedures in New Innovations
·         Communicate with the referring physicians as necessary for determination of appropriateness of the study and for relaying any urgent findings.
·         Fellow will record initial readings for subsequent review with the attending. 
·         Write procedure note for all transesophageal studies and any other studies where it is appropriate.
·         Attends all divisional conferences.
·         Attends assigned Cardiology Clinic.
·         Completes a written evaluation of the attending.
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