Cardiovascular Imaging and Hemodynamic Laboratory Rotation
at Tufts Medical Center Cardiology Fellowship
Introduction
During the two clinical years of the fellowship program, the cardiology fellow will spend a minimum of three months on the echocardiography rotation. During the dedicated echocardiography rotation, no other clinical/service responsibilities (other than required outpatient clinic and night call duties) are required of the fellow. Additional clinical training as well as research opportunities are available during the fellow's third year. During the clinical months, the trainee spends an average of 55 hours per week in the hospital on this rotation with an average of seven full days off during the month.
An average working day starts at 8:00 a.m. and finishes at approximately 6:00 p.m. The trainee is expected to attend conferences in the morning and then perform echocardiograms afterward. There is a formal reading session in the afternoon lasting an average of two hours that is headed by one of the echocardiography attendings. This session is designed to teach fellows echocardiography and cardiovascular physiology.
In addition to the daily case studies, fellows also are required to review many additional educational case studies available in a variety of teaching tapes. Weekly echo conferences allow staff and fellows to present and discuss educational case studies and provide didactic sessions to review evolving echocardiographic technologies and applications of echocardiography. Furthermore, fellows participate in selected clinical research projects under the supervision of the faculty. Fellows are expected to perform at least two transthoracic echocardiographic studies per day and assist in transesophageal studies as well as exercise and pharmacologic stress testing. The fellow is also responsible for all studies performed between 4 - 5 p.m. The on-call fellow takes over after 5 p.m.
Specific Goals of Echocardiography Rotations
- Understand the indications for transthoracic and transesophageal echocardiography procedures and how to incorporate the echocardiographic data in patient management.
- Understand the physics and principles of cardiovascular ultrasound imaging and Doppler recordings, learn the hemodynamic basis of flow velocity profiles and Doppler calculations.
- Acquire sufficient skill to perform and interpret two-dimensional and Doppler echocardiographic studies in various clinical settings (outpatient, inpatient, and intensive care setting).
- Learn how to perform and interpret transesophageal and intraoperative echocardiography and exercise / pharmacologic stress echocardiography (level 3 training).
Training Plan
The echocardiography educational and training plan includes various levels along the guidelines of the American Society of Echocardiography and the American College of Cardiology. Training in interpretation and performance of echocardiographic studies is conducted under the supervision of the laboratory director, designated faculty, and cardiac sonographers.
Level 1 Training requires three months (or equivalent) of training dedicated exclusively to echocardiography, wherein the fellow (under supervision) performs and interprets a minimum of 75 transthoracic echocardiograms, and participates in the interpretation of at least 150 echocardiograms (M-mode, two-dimensional echocardiography, color Doppler, and spectral Doppler studies).
In addition, the fellow assists in transesophageal and stress echo studies. The Level 1 trainee should be able to recognize the common cardiovascular pathologic entities, but the trainee will not be able to perform echocardiography or interpret echocardiograms independently. At the completion of three clinical months, all fellows surpass Level 1 training, but do not fulfill Level 2 training.
Level 2 Training requires an additional three months of training. During Level 2 training, the trainee performs an additional 75 transthoracic studies (150 total), and learns to provide interpretation in an additional 150 studies (300 total). Training in the performance and interpretation of contrast echo for cavity opacification is also provided.
Level 2 training is designed to provide the knowledge and experience necessary for independent performance and interpretation of complete echocardiographic and Doppler studies.
Level 3 Training is offered to interested fellows who will gain further training in transthoracic echocardiography, learn and perform transesophageal studies (50 or more) as well as stress echocardiograms (100 studies). Fellows are taught all aspects of transesophageal echocardiography: full knowledge of protocols, setting up the laboratory, sedation, appropriate patient preparation, procedure performance, study interpretation and reporting, and patient monitoring and follow-up.
Level 3 training requires, in our laboratory, a minimum of six months training. It is geared so that the individual, upon successful completion of the training, will be able to direct an echocardiography laboratory, as well as perform various special ultrasound procedures.
Individual Aspects of Echocardiography Training
- Transthoracic echocardiography
- 2-D Echocardiographic Imaging
- Pulsed and Continuous Wave Doppler Recordings
- Color Doppler Echocardiography
- Quantitative 2-D Echocardiography
- Hemodynamic Calculations
- Stress Echocardiography
- Exercise Testing
- Exercise Echo Imaging
- Dobutamine Stress Echocardiography
Transesophageal Echocardiography
Intraoperative Echocardiography
- Contrast Echocardiography
- Ventricular Cavity Opacification
- Myocardial Perfusion Imaging
Evaluation
Beginning in their first rotation, fellows maintain a log book recording all the echocardiographic studies they performed and participated in interpreting. This includes indications for the procedure, findings, and in the case of transesophageal and stress studies, complications, if any. On a weekly basis and monthly basis, their ongoing educational process, competence, and knowledge acquired are evaluated by the attendings through discussions with the fellows and through the opportunity to present cases in conferences. Most importantly, interactive interpretation sessions and review of studies performed by the fellow provide the optimum opportunity to assess fellows' performance, knowledge and competence.
Fellows are encouraged to request a review of their progress at any time. A written evaluation is performed at the close of the rotation. Following every month of echo rotation, fellows provide evaluation of the faculty, their teaching ability, knowledge, time they spent with fellows and the level of supervision offered.