Educational Objectives

COCATS 2006 Updates (pdf)

Recommendations from the Accreditation Council for Graduate Medical Education (ACGME) (website)

Stanford Cardiovascular Medicine Training Program Goals and Objectives

The primary goal of the Stanford Cardiovascular Diseases Postdoctoral Fellowship Program is to train cardiovascular medicine specialists for careers in academic cardiology. Thus, the program has a strong emphasis on balancing clinical training with investigative training. It is a three-year program; two years of clinical training and one year of investigative training. Most of our trainees remain at Stanford for a fourth year to complete advanced research training or subspecialty training in Electrophysiology, Interventional Cardiology, Heart Failure and Cardiac Transplantation, and Cardiac Imaging.

Specifically, we aim to:

• Teach the knowledge, skills, clinical judgement, attitudes, and values that are essential to cardiovascular medicine.
• Foster humanistic and ethical attributes in our trainees.
• Encourage an appropriate balance between academic endeavors and clinical service. During their training, faculty encourage trainees to cultivate an attitude of scholarship and dedication to continuing education that will remain with them throughout their professional careers. The development of a scholarly attitude includes active participation in and completion of one or more research projects supervised by faculty and ideally followed by publication in critically reviewed journals.
• Develop teaching skills by actively engaging our trainees in teaching activities with the Stanford medical students, residents, and allied health professionals.

Stanford Cardiovascular Medicine Training Program Rotation Goals and Objectives:

• Cardiac Catheterization
• Echocardiography
• Nuclear Medicine
• Consultative Cardiology
• Coronary Care Unit
• A Inpatient Rotation
• Arrhythmia and Cardiac Electrophysiology

Cardiac Catheterization

Goals:
The goals of the rotation are to gain an understanding of coronary anatomy and hemodynamics and to acquire the technical skills required to gain venous and arterial access and to perform coronary angiography.

Objectives:
Knowledge
Vascular Access:

• Basic understanding of access site anatomy, including femoral artery and vein, internal jugular vein, and brachial artery
• Basic Understanding of disease conditions (and surgical correction) involving these anatomic structures
• Appreciate atherosclerotic disease of the ileo-femoral system and knowledge of surgical revascularization anatomy, including Aorto-bifemoral graft, Fem-fem bypass, and Fem-pop bypass

Right Heart Catheterrization (Hemodynamics):
Basic understanding of normal and abnormal right heart hemodynamics with specific attention to the following disease states.

• Congenital ASD
• Congenital VSD
• 1° Pulomonary Hypertension
• Congestive Heart Failure
• Constrictive physiology
• Cardiac Tamponade

Left Heart Catheterization (Hemodynamic):
Basic understanding of normal and abnormal left heart hemodynamics with specific attention to the following disease states.

• Aortic Insufficiency
• Aortic Stenosis
• Gorlin Equation
• Hypertrophic Cardiomyopathy
• Mitral Insufficiency
• Mitral Stenosis
• Gorlin Equation
• Cardiomyopathy
• Constrictive physiology
• Cardiac Tamponade
• Measurements of Cardiac Output: Fick, Thermodilution

Left Ventriculography:
Basic understanding of normal and abnormal left ventricular function with specific attention to the following disease states:

• Coronary Artery Disease
• Mitral Insufficiency
• Hypertrophic Cardiomyopathy
• Estimation of Ejection Fraction

Coronary Angiography:
Basic understanding of normal anatomy, pathologic impact on anatomy and surgical impact. with specific attention on the following:

• Normal Coronary Anatomy
• Common Congenital Abnormalities
• Anomalous Origins of the major Coronary Arteries
• Coronary Artery Disease
• Saphenous Vein Grafts
• Internal Mammary Arteries

Aortography & Ileo-femoral angiography:
Basic understanding of normal anatomy, pathologic impact on anatomy and surgical impact. with specific attention on the following:

• Aortic Insufficiency
• Aneurysm
• Ascending Aorta
• Descending Aorta
• Abdominal Aorta
• Aortic Dissection
• Surgical Repair of Aortic Dissection

Right Ventricular Biopsy:
Basic understanding of cardiomyopathic conditions in which right ventricular biopsy plays a role in diagnosis and/or management:

• Allograft Rejection
• Infiltrative Cardiomyopathy
• Anthracycline Cardiomyopathy

Intra-aortic Balloon Pump:
Basic understanding of the indications, contraindications, insertion techniques, and troubleshooting.

Cardiac Catheterization Laboratory Equipment:
Basic understanding of the equipment and devices used in the Catheterization Laboratory

• x-ray/fluoroscopic equipment
• Pressure Manometers
• Digital Storage System

Skills
Vascular Access:
Obtain access via the Modified Seldinger Technique without assistance from others:

• Femoral Artery & Vein
• Internal Jugular Vein
• Brachial Artery (2nd year Only)

Remove sheaths and obtain hemostasis by manual compression and use of femoral closure device (femoral artery only)

Right Heart Catheterization (Hemodynamic):
perform right heart catheterization without assistance.

Left Heart Catheterizatization (Hemodynamic):
perform left heart catheterization with assistance.

Left Ventriculography:
perform left heart catheterization with assistance

Coronary Angiography

• Perform coronary angiography with assistance (1st year)
• Perform coronary angiography without assistance (2nd year)

Aortography & Ileo-femoral angiography

• Perform Aortography & Ileo-femoral angiography with assistance (1st year)
• Perform Aortography & Ileo-femoral angiography without assistance (2nd year)

Right Ventricular Biopsy:
perform right ventricular biopsy in patients s/p heart transplantation with assistance

Intra-aortic Balloon Pump

• Place an Intra-aortic Balloon Pump in an elective manner (1st year)
• Place an Intra-aortic Balloon Pump in an emergent manner (2nd year)

Cardiac Catheterization Laboratory Equipment:
Trouble shoot common problems with equipment

Teaching Methods

• Pre-cath evaluation: Fellows are responsible for the pre-procedure evaluation of each patient scheduled for cardiac catherization. They present their findings to the attending physician. During the case presentation, the workup is critiqued by the attending. When warranted, discussion of recent literature pertaining to patient management occurs at this time.
• Cath Procedure: Direct observation.All cases are closely supervised by the attending.Early in the year, the attending performs the majority of the procedure and explains the techniques ‘in real time’.By the second week of their first cath rotation, fellows are the primary operators during each diagnostic procedure but continue to receive close supervisition from the attendings.
• Post Procedure Care: Fellows are responsible for the post-procedure care and evaluation of patients undergoing diagnostic cardiac catherizations.All complications should be reviewed with the attendings.

Methods of Evaluation

• Direct observation by the faculty
• Chart review by faculty

Vascular Access

• Baim DS and Grossman W.Percutaneous approach and transseptal catheterization. Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 59-75.

Right Heart Catheterization (Hemodynamic)

• Ganz P, Swan HJC & Grossman W.Balloon-Tipped Flow-Directed Catheters. Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 88-100. Grossman W.Blood Flow Measurements:The Cardiac Output. Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 101-117. Grossman W.Clinical Measurement of Vascular Resistance and Assessment of Vasodilator Drugs.Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 135-142.
• Grossman W.Shunt Detection and Measurement. Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 155-172.

Left Heart Catheterization (Hemodynamic)

• Carabello BA and Grossman W.Calculation of Stenotic Valve Area.Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 143-154.

Left Ventriculography

• Hillis LD, Grossman W. Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 200-212.

Coronary Angiography

• Silverman JF. Coronary Angiography.An introduction to interpretation and technique.1984.
• ACC/AHA Practice Guidelines for Coronary Angiography.J Am Coll Cardiol 1999;33:1756-1824.

Aortography &Ileo-femoral angiography

• Paulin S. Aortography. Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 227-251.

Right Ventricular Biopsy

• Fowels RE, Baim DS. Endomyocardial Biopsy. Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 506-516.

Intra-aortic Balloon Pump

• Aroesty JM.Percutaneous Intraaortic Balloon Insertion. Cardiac Catheterization and Angiography(Grossman W Editor).Lea & Febiger, Philadelphia 1985.pp. 493-505.

Percutaneous Coronary Interventions

• ACC/AHA Practice Guidelines for Percutaneous Coronary Interventions.J Am Coll Cardiol2001;37:2239.

Coronary Bypass Surgery

• ACC/AHA Practice Guidelines for Coronary Artery Bypass Graft Surgery.J Am Coll Cardiol1999;47:1262-347.

Aortic Valve Disease

• ACC/AHA Practice Guidelines for the Management of Patients with Valvular Heart Disease.J Am Coll Cardiol1998;32:1486-588.

Mitral Valve Replacement/Repair

ACC/AHA Practice Guidelines for the Management of Patients with Valvular Heart Disease.J Am Coll Cardiol1998;32:1486-588.

Echocardiography

Goals
The goals of the rotation are to gain a basic understanding of cardiac ultrasound principles and of cardiac anatomy as they are visualized through ultrasonography. Trainees should also gain the skills required to independently perform and interpret echocardiograms.

Objectives
Knowledge

• Every trainee should understand the basic aspects of cardiac ultrasound, including physical principles, instrumentation, cardiovascular anatomy, cardiovascular physiology, and cardiovascular pathophysiology.
• The trainee will be exposed to and become familiar with the technical performance, interpretation, strengths, and limitations of 2-dimensional echocardiography and Doppler.
• The trainee is encouraged to learn how to correlate the findings from the echocardiographic and Doppler exam with the results of other imaging modalities and physical examination.

Skills

• Each trainee should master the skills of performing a transthoracic echocardiogram and Doppler examination and be able to integrate their understanding of 3-dimentional cardiac anatomy.
• The trainee should understand how to perform a stress echocardiogram, including exercise stress as well as pharmacologic stress testing.
• The trainee should learn how to perform a transesophageal echocardiogram.

Teaching Methods

• Interactive learning during performance of transthoracic and transesophageal exams
• Interactive learning during reading sessions with the attendings
• Interactive and didactic learning during the weekly echocardiography conferences
• Selected self-directed reading of the current literature

Methods of Evaluation

• Direct observation of performance during echocardiography examinations
• Direct observation of echocardiography knowledge and interpretation during reading sessions

Nuclear Cardiology

Goals
The goals of the rotation are to understand the basic principles of radio-isotopes and myocardial perfusion imaging. The trainee should also gain the skills required to independently interpret nuclear perfusion studies.

Objectives
Knowledge

• Understand the principles of myocardial perfusion and blood flow, factors determining flow, coronary flow regulation, vasoreactivity, coronary flow reserve, regional flow differences, and flow variability.
• Understand the principles of radioactivity, radioactive decay, radionuclide production, radionuclide generators, photon interactions with matter, and spectrum radiating detectors
• Have a basic understanding of the instrumentation, techniques, and principles involved in nuclear imaging, including collimation, resolution, contrast, localization, noise, ECT, SPECT, PET, image reconstitution methods, and attenuation and scatter correction
• Know the various methods of stress testing (treadmill, upright and reclining bicycle, pharmacologic), including indications, exclusions, safety, and technique
• Understand the difference between a direct and indirect test of coronary flow reserve
• Understand the advantages, disadvantages, and differences between various protocols for image acquisition.
• Know the differences between the various radioisotopes used in nuclear cardiology, including their energy, half lives, and organs of elimination.
• Know the value of perfusion imaging in the diagnosis, prognosis, and management of patients with coronary artery disease.

Skills

• The trainee should be able to independently interpret the results of a stress or viability myocardial perfusion study.
• The trainee should be able to interpret the results of a blood pool imaging study.
• The trainee should be able to recognize potential attenuation artifacts.

Teaching Methods

• Interactive reading sessions with the attending physician.
• Participation in monthly Nuclear Cardiology Tutorial.
• Independent reading of Nuclear Cardiology Review books provided by Dr. Segal at the beginning of the rotation.

Methods of Evaluation

• Direct interaction with the attending physician during the supervision and interpretation of nuclear myocardial imaging studies
• Review of individual fellow projects by the attending physician at the end of the rotation.

Consultative Cardiology

Goals
To develop expertise in the consultative evaluation of cardiovascular problems and presentations, to acquire the skills necessary to rapidly and efficiently triage medical problems, to communicate assessments and recommendations to colleagues and, where necessary, to implement diagnostic and therapeutic strategies

Objectives
Knowledge

• The elements of an effective consultation
• Techniques for enhancing compliance and adherence to consultative recommendations
• Pre-operative evaluation of cardiovascular operative risk
• Assessment of abnormalities in serological determinants of cardiac injury, particularly in the peri-operative patient
• Evaluation of chest pain, especially in post-operative patients
• Assessment of newly-detected or changing heart murmurs
• Assessment of cardiac physical findings, electrocardiographic changes and arrhythmias in pregnancy, labor and delivery
• Assessment and management of tachyarrhythmias, particularly in the peri-operative patient
• Evaluation of possible infectious endocarditis in hospitalized patients with new cardiac findings
• Management of unstable ischemia and infarction outside of the CCU setting
• Management of uncontrolled hypertension in the hospitalized patient
• Asssessment and management of ischemic risk factors, particular the dysmetabolic syndromes
• Medical management of peripheral arterial, venous and lymphatic disease

Teaching Methods

• In-patient consultation: Fellows triage, supervise, or directly perform the initial consultative evaluation of patients at Stanford Hospital (SHC) or the VA Palo Alto Health Care System (VAPAHCS), as requested by the services of Medicine, Surgery and Obstetrics-Gynecology. Consultative evaluation is comprised of a thorough cardiovascular evaluation which is recorded in a detailed note. Subsequent presentation to the attending senior cardiologist provides the opportunity for in-depth discussion of pathophysiology, differential diagnosis, physical examination, and review of pertinent objective data, including electrocardiographic recordings.
• Guided Reading: The fellows are provided with opportunities to amplify their direct observations in consultative cases with appropriate materials drawn from textual sources and current cardiovascular literature.
• Teaching rounds: Daily didactic sessions are conducted with medical students, medical residents and cardiovascular fellows. These sessions include in-depth discussions of the cardiac physical examination, natural history of cardiac diseases, cardiovascular physiology and pharmacology, and electrocardiographic interpretation.

Methods of Evaluation

• Direct observation by the attending faculty.
• Chart review by faculty.
• At the end of each rotation, the fellow's progress is reviewed by the Division Faculty.

References

1. ACC/AHA task force report. Special report: guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Cardiothorac Vasc Anesth. 1996;10:540-52.
2. Bach DS. Management of specific medical conditions in the perioperative period. Prog Cardiovasc Dis. 1998;40:469-76.
3. Bartels C, Bechtel JF, Hossmann V, Horsch S. Cardiac risk stratification for high-risk vascular surgery. Circulation. 1997;95:2473-5.
4. Bigatel DA, Franklin DP, Elmore JR, Nassef LA, Youkey JR. Dobutamine stress echocardiography prior to aortic surgery: long-term cardiac outcome. Ann Vasc Surg. 1999;13:17-22.
5. Chaitman BR, Miller DD. Perioperative cardiac evaluation for noncardiac surgery noninvasive cardiac testing. Prog Cardiovasc Dis. 1998;40:405-18.
6. Cohen MC. The role of the cardiology consultant: putting it all together. Prog Cardiovasc Dis. 1998;40:419-40.
7. Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, Leppo JA, Ryan T, Schlant RC, Spencer WHd, Spittell JA, Jr., Twiss RD, Ritchie JL, Cheitlin MD, Gardner TJ, Garson A, Jr., Lewis RP, Gibbons RJ, O'Rourke RA, Ryan TJ. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 1996;27:910-48
8. Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, Leppo JA, Ryan T, Schlant RC, Spencer WH, 3rd, Spittell JA, Jr., Twiss RD, Ritchie JL, Cheitlin MD, Gardner TJ, Garson A, Jr., Lewis RP, Gibbons RJ, O'Rourke RA, Ryan TJ. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery [see comments]. Circulation. 1996;93:1278-317.
9. Froehlich JB. Clinical determinants in perioperative cardiac evaluation. Prog Cardiovasc Dis. 1998;40:373-81.
10. Hollenberg SM. Preoperative cardiac risk assessment. Chest. 1999;115:51S-57S.
11. Itani KM, Miller CC, Guinn G, Jones JW. Preoperative cardiac evaluation is unnecessary in most patients undergoing vascular operations. Am J Surg. 1998;176:671-5.
12. Klonaris CN, Bastounis EA, Xiromeritis NC, Balas PE. The predictive value of dipyridamole-thallium scintigraphy for cardiac risk assessment before major vascular surgery. Int Angiol. 1998;17:171-8.
13. Roghi A, Palmieri B, Crivellaro W, Sara R, Puttini M, Faletra F. Preoperative assessment of cardiac risk in noncardiac major vascular surgery. Am J Cardiol. 1999;83:169-74.
14. Wirthlin DJ, Cambria RP. Surgery-specific considerations in the cardiac patient undergoing noncardiac surgery. Prog Cardiovasc Dis. 1998;40:453-68.
15. Wong T, Detsky AS. Preoperative cardiac risk assessment for patients having peripheral vascular surgery. Ann Intern Med. 1992;116:743-53.

Coronary Care Unit

Goals
Trainees should become comfortable with the care of critically ill, hospitalized patients with a broad range of cardiovascular diseases, including acute myocardial infarction, congestive heart failure, congenital heart disease, serious arrhythmias, and advanced valvular heart disease.

Objectives

Knowledge

• Understand the indications for, interpretation of, and risks of the common cardiovascular testing modalities: ECG, CXR, CT scan, myocardial serum marker interpretation for ACS, echocardiography, cardiac catheterrization, and electrophysiologic testing
• Understand the risk factors for CAD and their impact on clinical presentation, prognosis, and treatment options.
• Understand the spectrum of disease from silent ischemia to acute coronary syndrome in the coronary vasculature, and from claudication to limb loss in the peripheral vasculature
• Understand the diagnostic and prognostic evaluation of valvular insufficiency and stenosis (AS, AR, MS, MR, TR) as well as the role of medical treatment and considerations for angiographic evaluation, treatment, and surgical intervention.
• Understand the etiology, work-up, medical treatment, and prognostic evaluation of patients with congestive heart failure.
• Become familiar with the treatment of endstage heart failure and cardiogenic shock (including medical, surgical, and mechanical interventions).
• Understand the indications for and long-term care of patients undergoing orthotopic heart transplantation.
• Be familiar with the evaluation of pulmonary hypertension and understand the medical, surgical, and intravascular treatment options for primary pulmonary hypertension.
• Appreciate the spectrum of congenital heart disease, know the clinical presentation of the uncorrected adult patient, and understand the most common complications of corrected congenital lesions.
• Review the most common collagen vascular diseases (Marfan's, Scleroderma, Sjogren's) and rheumatologic disorders (SLE, RA) affecting the cardiovascular system.
• Be familiar with the post-operative care of patients undergoing coronary artery bypass grafting, valvular repair or replacement, and aortic aneurysm repair.

Skills

• Recognize physical exam findings associated with common structural and valvular abnormalities, including AS, AI, MS, MR, VSD, IHSS, and TR.
• Recognize physical exam findings associated with congestive heart failure, cardiogenic shock, pulmonary hypertension, and pericardial tamponade.
• Be able to independently perform and interpret the results of bedside right heart catherization.
• Be comfortable with the management and troubleshooting of intra-aortic balloon pumps.

Teaching Methods

• Active participation in CCU (Stanford), heart failure (Stanford), and surgical rounds (VA)
• Cardiovascular Medicine Didactic Core Conferences
• Participation at Stanford Cath conference and Heart Failure conference
• Review of ACC/AHA Guidelines
• Literature review of specific topics as they relate to the care of individual patients on service

Methods of Evaluation

• Direct observation by the attending physician of the fellow's diagnostic evaluation of patients and formulation of a therapeutic plan
• Chart review of the fellow's notes by the attending physician.

VA Inpatient Rotation

Goals
Trainees should be comfortable and proficient in the care of hospitalized patients who have recently undergone cardiovascular surgical procedures. In addition, trainees should become familiar with the care of post-cardiac transplant patients. Finally, trainees should gain hands-on experience in outpatient cardiac rehabilitation.

Objectives
Knowledge

• The trainee should have an understanding of the pre-operative, anesthetic, surgical, and early post-operative care of the cardiac surgery patient, including understanding of medications, ventillation, hemodynamic patterns, pacemaker function, arrhythmias, bleeding, tamponade, low output states, and ventricular dysfunction.
• The trainee should undersand the role of risk factor modification (hypertension, dyslipidemia, diabetes, exercise, smoking cessation) in the secondary prevention of cardiovascular diseases.
• The trainee should understand the role of immunosuppression in the management of the post-cardiac transplant patient. He or she should have an understanding of the indications, side effect profile, and dosing of the most commonly used immunosuppressives including corticosteroids, cyclosporine, tacrolimus, azathioprine, mycopholate mofetil, and sirolimus.
• The trainee should know the basic principles of allograft rejection surveillance and treatment of cellular and humoral rejection.
• The trainee should have an understanding of the risk factors, prevention of, detection, and treatment of coronary allograft vasculopathy.

Skills

• The trainee should be able to provide traditional cardiac rehabilitation (i.e., counseling on diet, exercise, nutrition, stress reduction, and pharmacologic treatment of hypertension and dyslipidemia) services in the secondary prevention of cardiovascular disease.
• The trainee should be able to manage chronic complications resulting from the immunosuppression of post-transplant patients, including hypertension, dyslipidemia, diabetes, renal insufficiency, and osteopenia.
• The trainee should be able to serve as a consultant to the Cardiac Surgery service and provide recommendations regarding management of heart failure and arrhythmias during the immediate post-operative period.

Teaching Methods

• Discussion of inpatient work-up (for patients being evaluated for invasive cardiac procedures) with the Cardiac Catheterization Laboratory and EP Attendings.
• Discussion of patients during Cardiac Surgery Rounds.
• Observation and direct patient care in the Cardiac Rehabilitation Clinic.
• Participation in Consult Rounds as they pertain to patients co-followed by the Heart Failure and Cardiac Transplant service.
• Participation in the Cardiomyopathy and Cardiac Transplant clinic management rounds.
• Self-paced reading of the Active Partnership for the Health of Your Heart booklet provided at the start of the rotation.

Methods of Evaluation:

• Direct interaction with the Cardiac Surgery attending during surgical rounds.
• Direct observation of performance by the VA Cardiology faculty.

References

• An Active Partnership for the Health of Your Heart.American Heart Association, Dallas, TX 2002.
• AHCPR Clinical Practice Guideline for Cardiac Rehabilitation.Department of Health and Human Services, Bethesda, MD 1996.

Arrhythmia and Cardiac Electrophysiology

Goals
Trainees should gain an understanding of the indications, implantation, and troubleshooting of EP devices, including pacemakers and defibrillators. They should be able to manage patients with common arrhythmias. In addition, they should gain proficiency in the interpretation of electrocardiograms and ambulatory ECG tracings (Holters).

Objectives
Knowledge

• Understand the indications, function, and troubleshooting of pacemakers and ICDs.
• Diagnose and treat common arrhythmias such as atrial fibrillation, atrial flutter, SVT, A-V block, and VT acutely and chronically.
• Describe the management of syncope.
• Interpret abnormalities of ECGs, Ambulatory ECGs, and ECG stress tests.
• Describe to a physician or patient the basic elements, success rate, and risks of common arrhythmia procedures.

Skills

• The trainee should be able to interrogate and assess the function of pacemakers and ICD's.
• The trainee should be able to independently supervise and perform ECG stress tests.
• The trainee should be able to perform and interpret a tilt table testing, including pharmacologic provocation.
• The trainee should be able to perform direct current and chemical cardioversion.
• The trainee should, with assistance, be able to implant pacemakers and ICDs.

Teaching Methods

• Active participation during daily morning EP rounds.
• Didactic teaching during the daily morning EP rounds and Tuesday morning EP presentations.
• Interactive teaching by the procedural and consult EP attendings throughout the month.
• Active participation in the pacemaker and ICD follow-up clinic.

Methods of Evaluation

• Review of the fellow's evaluation of patients on the arrhythmia consult service with the attending physician.
• Review of the fellow's ECG and Holter monitor interpretation with the attending physician.
• Chart review of the fellow's notes, procedure reports, and dictations.