Supervisory Lines of Responsibility

General Policies

The Cardiovascular Medicine training program is conducted at two hospitals: Stanford Hospital and Clinics and the VA Palo Alto Health Care System. Both hospitals have a full complement of Stanford Medicine housestaff.

New fellows receive an orientation notebook which contains the policies of the fellowship and the requirements of ABIM and ACGME. In addition, the Division of Cardiovascular Medicine maintains a web site with all this information so that fellows and faculty are able to gain access easily and rapidly to clarify issues regarding these policies.

During orientation the fellows receive the curriculum for each rotation. In addition, the curriculum and the goals of each rotation is reviewed by an attending at the start of each rotation.

Medicine housestaff have primary responsibility for the care of inpatients. Cardiovascular Medicine serves as a consultant to these services. The Medicine residents write all orders.

Cardiovascular Medicine fellows write orders on outpatients who are seen in the various clinical laboratories. Certain specialized patients (for example, patients undergoing a coronary intervention) may be admitted directly to the Cardiovascular Medicine service, in which case the fellow may write orders.

Specific Policies

Continuity Clinic

Cardiology fellows examine the patient and formulate a treatment plan. The patient is then discussed with the attending. A discussion regarding management of the patient and also issues regarding the general approach to such patients is then conducted. This is an important component of both patient management and also fellow teaching and training.

Fellows will write orders for tests and therapy on their clinic patients following discussion with the attending. The clinic note is signed by the fellow, and then countersigned by the continuity clinic attending.

Inpatient Consultation Services

Fellows rotate through these services at Stanford Hospital and the VAPAHCS. Frequently students and housestaff also rotate through the service. In these cases, the fellow functions as a junior attending, and assists in the organization of the service. After the patient has been interviewed and examined and pertinent clinical data collected, this information is presented to the attending. Discussion (specific and related to teaching) ensues. Recommendations to the referring physicians are given after discussion and concurrence of the faculty physician.

Cardiac Catheterization Laboratory

The Cardiovascular Medicine fellows perform a pre-cath workup on patients presenting for diagnostic or therapeutic procedures. They will then scrub on patients and perform procedures under the direction of an attending physician. Following the procedure, the fellow will write a short post-procedure note, and will then complete the final report. These documents are done following review of the patient’s findings with the faculty physician. The pre- and post-cath note are countersigned by the attending, as is the final report.

Echocardiography Laboratory

Fellows learn to perform noninvasive imaging studies under the direction of the attending physicians and the sonographers. All reports are reviewed by the attending. The fellows sometimes pre-read studies and then review them with the attending. At other times, the fellows jointly review studies with the attending. This is done in a teaching environment.

All studies requiring conscious sedation (transesophageal echo) are performed under the direction of an attending cardiologist.

Electrophysiology/Arrhythmia

Under faculty supervision, fellows learn a variety of skills, including:

• Performance and interpretation of exercise tests
• Pacemaker/ICDs and other devices interrogation
• Performance and interpretation of ambulatory ECGs
• Interpretation of ECGs
• Performance and interpretation of tilt table examinations
• Arrhythmia consultations
• All reports/interpretations are reviewed with and countersigned by the faculty attending physician.

Fellows also are exposed to cardiac electrophysiology studies while rotating on this service.

Nuclear Medicine

Fellows learn how to perform and interpret nuclear cardiology studies. Studies are reviewed and discussed with the attending physician. The reports are all countersigned by the attending faculty physician.

Policies Regarding Performance of Various Procedures

Throughout the year, fellows on call may be called upon to provide vascular access, to place pulmonary artery catheters, to place temporary pacemakers, and to perform transthoracic echocardiograms. A system is in place to track the competency of each fellow as they learn those skills. Once the fellow has received the requisite training, and is listed as being competent in performing those studies, he/she may perform these procedures without an attending directly present. However, the results of these studies are discussed with an attending physician, and are formally reviewed with the attending.

Advanced procedures such as diagnostic cardiac catheterization, coronary angiography, transesophageal echocardiography, right ventricular biopsy and elective cardioversion are only performed under the supervision of the attending physician.

Research Fellows

Introduction to the research fellowship years range from one to three years in duration. All research fellows are oriented to laboratory procedures, the ethics of handling animals (if animals are used), and the ethics and regulations of carrying out research in human subjects (if they are engaged in clinical research). All fellows must complete relevant training required by the University and the VA Hospital. The fellows are closely supervised by a faculty member who is the Principal Investigator of the research project in which the fellows are engaged.

All fellows are encouraged to give research seminars, present their experimental results to outside meetings and write at least one paper for ublication ina peer-reviewed journal. These activities are supervised by a faculty member.

All research fellows who are in the Core Cardiovascular Medicine fellowship are required to attend the core conferences as outlined, and their attendance is tracked.

Written Curriculum

A written curriculum for each clinical rotation is posted on the CV Medicine website under "Educational Objectives." For specific rotations in which a more detailed orientation manual exists, those manuals are also available online for download. At the beginning of each rotation, fellows are expected to review the relevant sections of the educational curriculum with the attending physician.

Evaluations

Evaluations of Faculty
At the completion of each rotation, fellows complete an evaluation of the teaching faculty. These evaluations are very important for faculty promotion as well as faculty assignments to teaching services. The Division leadership and Program Director strongly consider the opinion of the fellows in selecting teaching attendings.

Evaluation of Fellows
Fellows are evaluated by the teaching faculty at the conclusion of each rotation and by the entire division faculty throughout the year. Faculty are asked to review the fellow's performance with him or her at the conclusion of the rotation. This face-to-face feedback session is a very important part of the educational process, and fellows should remind the faculty if this session does not occur. Fellows are able to review their evaluations online. The Program Director also meets each fellow on a formal basis twice a year to review his/her performance. A letter summarizing the fellow's performance over the past 6 months is then generated and placed in the fellow's file. Fellows wishing to appeal a negative evaluation should contact the Program Director. Fellows are given an opportunity to discuss the rotation as well as fellow performance and any mitigating circumstances with the Program Director directly. The program director will then contact the rotation faculty and attempt to resolve the discrepancy between the fellow's perceived level of performance and his/her performance evaluation by the faculty. If a disagreement persists between the fellow and rotation faculty, a final meeting with the fellow, program director, and rotation faculty will be scheduled. Based upon the input of all parties, the Program Director will decide on the final evaluation.

Evaluation of Program
Fellows meet with the Program Director as a group on multiple occasions. At least once per year, fellows evaluate the Fellowship Program as a whole. The strengths and weaknesses of individual rotations are discussed. The comments from this session are then communicated, in aggregate form, to the Division leadership and to the individual rotation faculty.

Moonlighting

We recognize that moonlighting sometimes occurs in response to high housing costs in the Bay Area. We believe that moonlighting does hinder the quality of clinical and research efforts by inevitably distracting time and attention from the training program. At no time may moonlighting activities impinge on daytime clinical and research activities or on attendance at educational conferences and courses. Moreover, Cath/Angio rotations often require early morning or late evening attendance. Weekday moonlighting is therefore prohibited for fellows on those rotations because of high potential for time conflicts.

The hours of work in the hospital or clinical setting (both clinical activities relating to the fellowship as well as moonlighting activities) cannot exceed 30 continuous hours or 80 hours/week on average over each month.

Each fellow is required to declare the estimated total number of moonlighting hours worked per month. This should be done on a yearly basis by completing the Moonlighting Acknowledgment Form (PDF) , which is available for download in pdf format. The form should be updated throughout the year as major changes occur in the fellow's moonlighting activities.

Work Hours

In accordance with recent ACGME requirements, it is the policy of the training program that the hours of work in the hospital or clinical setting (both clinical activities relating to the fellowship as well as moonlighting activities) by a fellow cannot exceed 30 continuous hours or 80 hours/week on average over each month. If, at any time during the fellowship, an individual approaches the work hour limits, he or she should contact the attending physician on that rotation to request coverage by the attending physician for part of or the remainder of the work day. If the attending physician cannot provide coverage, the fellow should contact one of the chief fellows. The chief fellows will then arrange for coverage according to the following protocol:

• At Stanford University Medical Center, the backup will be the Consult fellow.
• At the VA Hospital, the backup will be the Nuclear Medicine fellow.
• If one of these fellows is not available, then the alternate person will be called.
• If both fellows are not available, then the chief fellows will ask a research fellow to provide coverage.
  

Call Rooms and Lounge

A private call room is available for fellows. The location is HG402. This is a double room on the East side of the hospital, on the forth floor, over the ED area. Please contact Staci Leitner or the chief fellows to obtain your combination. Fellows also have access to the Housestaff lounge, which is located on the fourth floor of the hospital. Access to this area is via your hospital card ID.

Fellow Offices

Fellows have access to a shared office in Room S107. This is in the Grant Building, right across from the Department of Medicine Housestaff Office. Please pick up your key from Staci. The communal office provides a secute place to store books, medical equipment, and other possessions. It also contains miscellaneous books, office supplies, several phones, 4 windows-based PC's, and one good quality laser printer. The computers and printer are connected to the CV Med network.

Procedure Documentation

Each fellow is required to document the number of procedures performed during the 3 years of accredited training. These procedures include:

• Elective cardioversions*
• Tilt table tests*
• Ambulatory ECG recordings (ACGME minimum = 75)
• ECG interpretation (ACGME minimum = 3,500)
• Programming and follow-up surveillance of PPM and AICD
• Left heart catherization, including coronary arteriography* (ACGME minimum = 100)
• Pericardiocentesis*
• IABP placement*
• PTCA and interventional procedures*
• Intracardiac EP studies*
• PPM and AICD implantation*
• Transvenous pacemaker insertion*
• Transthoracic echocardiogram (performance and interpretation)
• Transesophageal echocardiogram (performance and interpretation)* (ACGME minimum for TTE and TEE = 150)
• Radionuclide study interpretation
• Exercise stress testing (ACGME minimum = 50)

For the procedures followed by an *, the fellow is also expected to provide documentation of the patient's name, medical record number, date performed, and supervising physician. A Procedure Tracking Form (PDF) , available for download in pdf format, should be completed and returned to the fellowship coordinators on a bi-annual basis (June and December).