Clinical Rotations

Upstate Medical University Hospital Clinical Service

The fellow on the Upstate Medical University Hospital clinical service is responsible as the primary contact person for all in-house Cardiology consults. The fellow receives the initial call from the various non-Cardiology services and is responsible for overseeing the initial evaluation of the patient. The consult team usually is composed not only of the fellow but also an Internal Medicine resident, as well as senior medical students. It is the fellow's responsibility to delegate various work appropriately. The consult fellow is then responsible for overseeing the collection and interpretation of data and making recommendations ultimately for the presentation to the consult attending. In addition, while on the clinical service the consult fellow is also required to participate in the morning coronary care unit rounds if there is no fellow assigned to the CCU rotation. These rounds are attended by the inpatient Cardiology team, the inpatient attending as well as the Cardiology consult team. During this time, the patients in the Coronary Care Unit are reviewed. Acute critical care problems are dealt with at that time. In addition, presentations on various topics that may or may not directly relate to the patients that are in the Coronary Care Unit are also given at this time. The Cardiology fellow is responsible for giving some of these presentations and also for participating in the discussion of presentations given by others. The clinical fellow will be contacted if any of the patients in the Coronary Care Unit need various procedures done, in absence of a CCU fellow. The clinical fellow, finally, may also be the first contact if the inpatient service has general questions about management of certain cardiac problems.

Upstate Medical University Hospital Catheterization Laboratory

The Upstate Medical University Hospital catheterization fellow is responsible for assisting with all procedures done in the cardiac catheterization laboratory which include but are not limited to routine catheterizations as well as angioplasty/stent. It is the responsibility of the fellow to see each patient prior to the procedure to review the indications and insure that all the appropriate data has been collected and consent has been signed. Because of the different arrival times of the outpatients, at least a brief review of the patient and their problems prior to the procedure is expected. The catheterization fellow is to see all inpatients scheduled for procedure the night before prior to the end of their day and first thing the following morning. During the cardiac catheterization rotation, the fellow will be exposed to several different attendings that at some point will participate in the evaluation of that fellow. All cases are performed with an attending present. At the completion of the studies, the cases are reviewed so that reports can be generated. The catheterization fellow is also responsible for initial response to any urgent problems with cath patients both pre and post procedure. The catheterization fellow is responsible for dictating the history and physical on each patient that has a procedure in the cath lab and reviewing these dictations for the final report. While on this rotation the fellow will assist in approximately 70 catheterizations and 13 angioplasty/stent procedures. Finally, the catheterization fellow is responsible for assisting in the presentation of any patients that are reviewed during the Monday Morning Invasive Laboratory Conference.

The Syracuse VA Medical Center Clinical Fellow

The responsibilities of the fellow on the VA Medical Center Clinical service are similar to those on the Upstate Medical University Hospital clinical service. The exception is that there are no formal Coronary Care Unit rounds at the VA Medical Center. In addition, there is no specific inpatient Cardiology team. All patients are admitted to General Ward Services so therefore the consult team will see all patients with cardiac problems. The team again is made up of similar members as outlined in the Upstate Medical University Hospital team, which may consist of one or more Internal Medicine Residents and one or more senior medical students.

The VA Medical Center clinical fellow is responsible for reporting to the attending Cardiologist at the VA Medical Center.

The clinical fellow at the VA is supposed to round on all patients on the consult service Mon through Saturday , discuss/see each patient with the attending and write a note documenting that the pt was seen/ discussed with the attending (the attending has to be named) All new consult notes have to be sent to the respective attending for a co-signature.

The on-call fellow will round on the VA consult service patients on Sunday and discuss them with the VA attending and document as stated above.

It is the responsibility of the VA clinical fellow to participate in all TEE's inpatient and outpatient. Each TEE patient has to be seen and evaluated to rule out contraindications, they have to be appropriately consented and the pre-sedation assessment form has to be completed PRIOR to the TEE being done.

It is the responsibility of the fellow on the consult rotation/ cath rotation to follow up on all patients returning to the VA from UH after cath/PCI. There should be a short procedure note (template created ) and appropriate orders (i.e ECASA, PLAVIX, d/c heparin etc) should be written and the appropriate non formulary forms filled out.

VA Cardiac Catheterization Fellow

Like the Upstate Medical University Hospital catheterization fellow, the VA Medical Center catheterization fellow is responsible for participating in all the catheterization laboratory procedures for the month that they are assigned to that rotation. Again, the catheterization fellow works in conjunction with the catheterization attending at the VA Medical Center in the performance of the various procedures. In addition to catheterizations, the VA Medical Center catheterization laboratory is the site of placement of permanent pacemakers, and the VA Medical Center has the opportunity to also participate in those procedures while on the rotation. Finally, because of the lower volume at the VA Medical Center catheterization laboratory, the catheterization fellow will also be responsible as much as possible to assist in the performance of the various stress tests performed at The VA Medical Center. These include exercise treadmills, stress echos (both exercise and pharmacologic) as well as nuclear stress tests (both exercise and pharmacologic). The fellow on the VA Medical Center catheterization rotation again, may be responsible for a component of the presentation if any of the patients underwent a cardiac catheterization during his month of rotation at the weekly Monday Morning Invasive Laboratory Cardiology Conference at Upstate Medical University Hospital.

Echocardiogram/Non-invasive Laboratory

Each fellow will spend a minimum of three months on the echocardiography rotation during their clinical training. The primary purpose of this rotation is to learn the underlying principals of ultrasound and the application of technique as utilized in Cardiology. The fellow will have the opportunity to evaluate echocardiograms in consult with faculty member as well as the opportunity to work with the sonographers themselves to learn the actual techniques involved in recording echocardiograms.

The fellow will have an opportunity, in addition, to review the core teaching tapes in the echocardiogram lab to allow review and independent study of the primary basic concepts of echocardiography.

While in the echocardiography lab at Upstate Medical University Hospital, the fellow will also participate in the performance of image enhanced stress tests, specifically stress echocardiography and pharmacologic stress echocardiography.

In addition to transthoracic echocardiography, the fellow will also learn the technique and become proficient in the performance of the transesophageal echocardiography. Again, there are written materials as well as audiovisual learning materials that the fellow has available during this rotation to enhance their understanding of the basic principals of the echocardiographic technique.

In an average month the fellow will have the opportunity to participate in the performance of approximately: 50 exercise stress tests, 50 pharmacological stress tests, 20 transesophageal echocardiograms and 300 transthoracic echocardiograms.

The fellow on the non-invasive laboratory rotation will have minimally, approximately two months of exposure to Nuclear Medicine. They will have the opportunity to review the studies that are performed at Upstate Medical University Hospital with the attending Nuclear Medicine faculty to understand the interpretation of nuclear studies. There are specific assigned readings, computer tapes based educational information and specific didactic lectures that are included as part of the non-invasive echocardiography/nuclear conference. These allow the fellows to develop a basic understanding of the physics of isotopes, their use, biologic mechanisms and the basic principals in deriving from images. The Nuclear Cardiology Conference, which is held once a month, and part of the echocardiography conference schedule, allows fellows to be exposed throughout the three years of their training to the interpretation of nuclear studies. These conferences are both case based with a review of individual cases including the interpretation of the studies as well as a didactic format in which basic principals of nuclear studies are discussed by the Nuclear Medicine Department at Upstate Medical University Hospital.

CCU/electrocardiography

While assigned to the CCU/ECG rotation, the fellow is expected to participate in daily CCU rounds at University Hospital. Traditionally these rounds begin at 7:30 AM, but this time is at the discretion of the attending on service. During these rounds, all patients in the CCU are reviewed including physical exam, laboratories and clinical course over the preceding 24 hours. Both patient specific and general pathophysiologic concepts are discussed during this time. The fellow will be responsible for assisting with all bedside procedures done on the patients in CCU. They will be expected to initially evaluate patients being admitted to the CCU during regular working hours. In addition, the fellow may be asked to prepare and present brief subject reviews as part of the teaching component of morning rounds. It is also expected that the fellow assigned to the CCU will "sign-out" the CCU patients to the on-call fellow for evenings and weekends. When there is no fellow assigned to the CCU rotation, then the responsibility of CCU falls to the University Hospital consult fellow.

In addition, while on the CCU rotation, the fellow is expected to use their extra time to participate in reading electrocardiograms. During their time spent on the EKG rotation, fellows have an opportunity to review multiple EKG waveforms generated at Upstate Medical University Hospital. The evaluation of these waveforms is under the direct supervision of an attending cardiologist. In addition, to the standard 12-lead format, fellows are also exposed to the evaluation and interpretation of Holter monitors, event monitors and transtelephonic pacemaker surveillance.

In addition to the formal evaluation of tracings, fellows are provided with ample reading material to review on the interpretation of electrocardiograms. Besides the evaluation, there is also informal teaching that is conducted during the rotation. On an average month, the fellow will assist with the interpretation of close to 2000 EKG's as well as approximately 12–15 Holter monitors.

Finally, a weekly Electrocardiography Conference is held in which challenging and interesting tracings are displayed and interpreted in a conference type format, which allows the participation as well as ongoing education during these conferences. As a component of these conferences, competency in EKG interpretation is also been evaluated by the administration for review, selected questions from the ACC EKG proficiency test.

VA Echocardiography/UH cardiac rehab rotation

The VA echocardiography rotation, allows a fellow to gain additional exposure to echocardiography and stress testing by assisting with procedures done at the VA Medical Center. As with the echocardiography rotation at University Hospital, the fellow will have the opportunity to review transthoracic studies in conjunction with the attending at the VA. The fellow will also participate in the performance and interpretation of exercise treadmill stress tests, pharmacologic and stress echocardiograms. Finally, the fellow will assist in the performance and interpretation of transesophageal echocardiograms.

While on this rotation, the fellow will also participate in the cardiac rehabilitation program at University Hospital. They will attend the exercise sessions that occur three days a week. The fellow will also have the opportunity to attend the educational classes that are held weekly for the cardiac rehabilitation patients as well as assisting in the counseling of individual patients. As part of this rotation, the fellow will review and assist in the writing of exercise prescriptions for individual patients.

Electrophysiology

A fellow assigned to the electrophysiology rotation has the opportunity to participate directly in the performance of various electrophysiologic procedures. These include, but are not limited to the evaluation of supraventricular and ventricular arrhythmias, the ablation of supraventricular and ventricular arrhythmias, the placement and surveillance of ICDs, and placement and surveillance of permanent pacemakers. The fellow on the electrophysiology rotation will participate in the primary procedures in the electrophysiology laboratory at Upstate Medical University Hospital, and, when appropriate, at the electrophysiology laboratory at Crouse Hospital. In addition, while on this rotation, the fellow attends the primary Electrophysiology clinic and gains experience with the evaluation of implanted permanent devices (both pacemakers and ICDs). The fellow assigned to the electrophysiology rotation may be asked to perform consults on inpatients with a specific electrophysiology question. This could include the appropriateness of placement of a pacing or ICD device, a primary arrhythmia that may require study or the acute evaluation of an implanted permanent device. Fellows that are assigned to the electrophysiology rotation as well as fellows that may be on the EKG rotation will also participate in the performance of tilt table testing for the evaluation of syncope.

Research

The Cardiology fellows are actively encouraged to participate in both basic and clinical research projects. There is a formal research block that is between six and twelve months depending on the project that is proposed. All fellows on the research block must first identify the appropriate mentor as well as have a basic concept of the project prior to beginning a research block. During this time the fellow is free of routine clinical duties. Because of the importance of continuity of care the fellows will still main their half day continuity clinic. Fellows on the research block will also be expected to participate in the on call schedule. Other than those responsibilities, the fellow is essentially free of other clinically duties at the time dedicated to their specific research projects. As part of the on going fellows conference, excerpts from the fellows research project will be presented at some time during the year, allowing the fellow the opportunity to present his work to his peers. It is anticipated that fellows participating in specific projects will present their work in a formal fashion to the Division of Cardiology. In addition, adequate support will be given to the fellow to further present his or her work, whether it is a written article or a presentation at a regional or national meeting.

Elective

Normally during the third year of the fellowship, the fellows have an opportunity to take elective rotations. It is the purpose of these elective rotations to enhance the fundamental training that fellows receive during the three year program. With certain electives, it may involve increasing the exposure, through volume of procedures, such as in invasive or nuclear cardiology. In other cases, it may involve a formal clinical exposure to different aspects of Cardiology training such as transplant cardiology, which are not available at our institution. Elective rotations are strongly encouraged. The requirement, includes the identification of a specific elective sponsor, an identified course of study, with the appropriate mechanism for a formal evaluation at the end of the elective. All electives require the pre-approval of the Program Director and must have an affiliation agreement in place prior to the start of the rotation.

Ambulatory Experience

The Fellows will participate one half day a week in a continuity of care Ambulatory Clinic. Their time is divided between Upstate Medical University Hospital and the Syracuse VA Medical Center on an alternating week basis. Fellows will have a specific pool of patients that they follow longitudinally. Both clinic settings under the direct supervision of a attending cardiologist. The fellow is identified as the primary provider for these patients. All evaluations, decisions for testing, interpretation of studies and specific therapeutic decisions are made in conjunction with an attending cardiologist. The fellows will follow these patients during their three-year training. All efforts will be made for the patients to remain with a single fellow throughout the time period of their training. Exceptions will be made in the case of emergencies where other fellows or attendings will be asked to participate in emergent type evaluations of these patients. Various measures including monitoring of the schedules and the patients assigned have been established to insure that the volume of patients that the Fellow sees will allow adequate review and discussion of principles of care during the clinic sessions.

During their three years of training, fellows participate in a weekly continuity clinic. Patients seen in this clinic cover a wide range of cardiovascular pathology. Fellows will follow a relatively stable co-hort of patients during their three years. Seeing new consults and patients discharged from the hospital. Patients are evaluated initially by the fellow and then presented to a supervising attending who then discusses specific aspects of the patient care. The fellow is considered the primary care giver in the settings, filling out forms, making referrals, history and physicals, developing long term care plans, all under the supervision of an attending physician.