Training/Education

• Inpatient Care
• Outpatient Care
• Echocardiography
• Cardiac Catheterization Laboratory
• Electrophysiology
• Other Clinical Rotations

The requirements for Sub-Board accreditation are extensive, given the highly technical and multidimensional nature of the specialty. Clinical evaluation and management of the infant and child with congenital or acquired heart disease is only a small portion of the expertise required to complete clinical training. In addition to inpatient and outpatient training in general cardiology, some degree of experience is required in many areas, including: non-invasive and invasive electrophysiology; M-Mode, 2-dimensional, Doppler and color Doppler echocardiography via standard, fetal and transesophageal approaches; other non-invasive techniques, including magnetic resonance imaging and nuclear cardiology; diagnostic and interventional cardiac catheterization; and post-operative ICU management.

This enormous clinical training load must be met within a maximum of 24 months, given the 12-month requirement for research training within the three compulsory years of fellowship. From the table below, it is clear that many of the areas have barely acceptable periods of assigned time. In this regard, this table presents only a "minimum" requirement for clinical training in these areas, and is to be used by the fellow and advisor as a rough guideline only. Additional training in any areas of deficiency might extend the clinical training, but it is not possible to achieve adequate expertise in each area in less than the time allocated below. It should also be noted that, although the table below presents training in month equivalents, these months are not necessarily distinct blocks of time - for example, adequate training in cardiac catheterization requires approximately 1 day per week in the catheterization laboratory throughout most of the fellow's training.

Training in specific clinical areas of pediatric cardiology will be offered to each fellow according to his/her interests and the requirements of the fellowship program and of the Sub-Board of Pediatric Cardiology. The vast majority of this training will be performed at the Moffitt/Long Hospital of the University of California, San Francisco, Parnassus campus. Training includes didactic sessions and informal training during active involvement in patient care. The clinical responsibilities of the fellow in each of the individual areas are presented below.

Inpatient Care

Each fellow is responsible for the care of all patients followed by the cardiology service during several blocks of time throughout the fellowship. Primary care is performed on the cardiac medical and surgical patients on the pediatric wards and consultative care is performed on cardiac patients in the pediatric and neonatal intensive care units and on non-cardiac patients in all units for whom consultations are requested. The only patients excluded are those who are admitted for elective cardiac catheterization or electrophysiologic study. There is often a pediatric resident and a medical student on the service as well. Rounds are performed with the attending faculty on a daily basis, and include discussions on a broad base of didactic topics as well as on direct patient care management. There are other teaching and didactic rounds throughout the week attended by all fellows but which center around patient care and which are often organized by the fellow on service. The duration of these blocks of service may be determined by the fellows involved, but the overall goal of continuity of care must be appreciated. In general, such blocks are 4 weeks long, but not less than 2 weeks. A handout has been prepared describing in detail the inpatient duties, and is given to each fellow at the beginning of the first rotation.

Outpatient Care

The primary goal of the outpatient training is to develop skills in physical examination and decision making. The fellow attends outreach clinics throughout Northern California with an attending cardiologist and can follow his/her own patients in the UCSF clinic with one of the faculty. The senior fellows run a pediatric cardiology clinic at the San Francisco General Hospital, where they will be able to make diagnostic and therapeutic decisions. Supervision for this clinic is performed by means of a subsequent review of the charts with one of the attending cardiologists.

Echocardiography

The goal of the echocardiography rotation is to provide a broad-based knowledge of and expertise in all phases of echocardiography. This encompasses precordial, transesophageal and fetal techniques in 2-dimensional, Doppler, and color Doppler studies. At the completion of the fellowship, it is expected that all fellows will have acquired the skills required for competence in pediatric echocardiography and have at least a working knowledge of the research in the field. Understandably, the expectations for each fellow's involvement in the echocardiography laboratory and the development of skills will vary, but below is a general outline of the yearly progress expected.

During the first year, the emphasis is on learning the techniques required to obtain a complete diagnostic echocardiographic study on any pediatric patient. This includes a thorough knowledge of the various echocardiographic views as well as the advantages and disadvantages of each. In addition, it involves a basic knowledge of the physical laws upon which echocardiography is based, and which help to provide optimal echo images. Fellows in the first year should also start to become familiar with the specific questions which are most crucial to answer with echo. These questions will vary with the type of lesion, thus it requires knowledge of the physiology of various lesions and associations.

By the second year, the rotation focuses on more advanced interpretation of echo studies. Fellows are encouraged to provide a complete interpretation of the study, and to comment on aspects which could be improved, or specific points which need to be focused upon. This year is also an ideal time for the fellow to spend time in the operating rooms becoming familiar with transesophageal echo; including the skills required to pass the probe, learning the TEE views as they differ from precordial views, and understanding the most important aspects of a post bypass TEE study.

By the third year, the fellow is capable of functioning independently in the laboratory. He/she should be able to interpret all studies done in a timely fashion with little guidance. Fellows will be allowed, as much as possible, to run the laboratory during their time here. Specific focus should be on any area in which the fellow feels deficient, or in which he has a particular interest.

Research, while not mandatory, is strongly encouraged. This would at a minimum consist of small-scale projects focused upon a specific lesion. Fellows particularly interested in echocardiography are encouraged to develop more large scale research projects, which may be clinically based or based in our in vitro flow mechanics or large animal physiology laboratories.

Most teaching in the echo lab will be informal during the rotations; either at the bedside performing studies, or reviewing the features of a particular echo. However, didactic lectures for all fellows are held weekly. The schedule of these sessions varies. In addition, the fellow is encouraged to attend the adult congenital conference when these are held. This schedule is available in the laboratory.

Cardiac Catheterization Laboratory

All fellows spend time throughout every year of their fellowship in the cardiac catheterization laboratory. It is expected that each will perform at least 180 catheterizations, 35 to 40 percent of which will be interventional. Rather than separate rotations in the cardiac catheterization laboratory we feel that the best way to develop and maintain skills in this area is to perform catheterizations on a more or less continual basis. Generally, each fellow has 1 day in the catheterization laboratory most weeks of the year for elective cases except when he/she is on clinical service or has intensive research requirements. When on clinical service the fellow is expected to perform all emergency catheterizations.

The goal of this rotation is to achieve expertise in percutaneous vascular access, routine catheter manipulation in diagnostic cases, and an extensive understanding of cardiovascular pathophysiology so that the fellow can fully understand the hemodynamic status of each patient undergoing catheterization. All fellows are involved in the interventional catheterizations but it is understood that only those with a specific interest need to develop expertise in this area. From the beginning of the first year the fellow is the primary person responsible for performing the catheterization and writes a first draft of the report. Thus, prior to any service commitment, the fellow will have enough expertise to be able to perform emergency catheterization under the direction of the interventional faculty member when on call.

As described above, the summer of the first year includes didactic sessions and intense training in cardiac catheterization. On a weekly basis throughout the training program there are post-catheterization rounds on Friday afternoon in which each fellow presents the catheterization data and leads the discussion on subsequent management. Research activity in the catheterization laboratory is encouraged in both estimation of cardiac mechanics using sophisticated techniques such as pressure-volume analysis and in performance and evaluation of interventional techniques.

Electrophysiology

Each fellow should have interpreted, with the help of the attending, 15 electrophysiologic studies by the end of two years of cardiology fellowship. This should include at least 4 full four-wire studies of Wolff-Parkinson-White syndrome. The presence of the fellow for electrophysiologic studies is important for patient safety and for learning about manipulation of pacing catheters, but the fellow need not read out every study. We expect that 2-3 one-month rotations in electrophysiology will be necessary to fulfill these goals and those listed in the subsequent paragraphs.

There is no need for a fellow to gain experience in implantation of permanent transvenous pacemakers, unless there is a particular interest in electrophysiology as a career. Therefore, fellows will not scrub on pediatric pacemakers routinely. However, an understanding of normal and abnormal pacemaker function is very important. Each fellow will manage the temporary postoperative pacemakers when on clinical duty and will attend the pediatric pacemaker clinic 4 times a year for two years.

24 hour ambulatory monitoring has become a routine part of pediatric cardiology practice. One fellow is appointed the Holter reader each week. All pediatric Holters are first read by the fellow, and then reviewed with the electrophysiology attending.

Approximately once every two months, the Wednesday morning patient management conference should be devoted to a primary electrophysiologic problem. Other didactic sessions in electrophysiology will be devoted to basic electrophysiology principles and the diagnosis and management of arrhythmias.

Other Clinical Rotations

There are several other clinical rotations which can be undertaken by the fellow but which are not mandatory. These include rotations in noninvasive imaging, including nuclear cardiology, exercise cardiology, and magnetic resonance imaging. Within the Department of Radiology there are specific faculty who primarily perform these studies on pediatric cardiology patients and who are available to work with according to the desires of the fellow. In addition, there is a surgical rotation in which the fellow does not function as a surgical resident but rather is involved with the support team in the operating room. This includes involvement in transesophageal echocardiograms, which are performed by the anesthesiologist under the direction of the pediatric echocardiography attending, and in the workings of the bypass system and various other support systems for cardiovascular problems under the direction of the pump technician and the anesthesiologists.