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Introduction
Credentialing Requirements and Application Process
Program Content and Description
Evaluation of Fellows
Accreditation
Introduction
The Adult Cardiac Anesthesia Fellowship Program at Tufts Medical Center is a well-established training program attracting national and international applicants. Each year 1-2 candidates are accepted into the Cardiac Anesthesiology Fellowship Program at Tufts Medical Center.
The period spent in the Fellowship can be no less than 12 months, with no more than one interrupted period due to reasonable circumstances. A second 12-month period for the continuation or pursuit of research or clinical interests can be optional.
Salary is monthly based on an annual stipend. Vacation time of 15 working days, three personal days, five CME days and up to 12 days of paid sick leave per year are included.
Fellows should start preferable in January or July of a given year.
Credentialing Requirements and Application Process
All candidates for the Fellowship must have satisfactorily completed an accredited residency program in Anesthesiology and be eligible for and obtain a Massachusetts medical license.
Application for a fellowship position should contain a
Please send your applications to:
Bhawana Dave, MD
Director, Cardiac Anesthesia Fellowship Program
800 Washington Street
Tufts Medical Center #298
Boston, MA 02111
bdave@tuftsmedicalcenter.org
After the review of the applications by the cardiac anesthesia group, selected candidates will be interviewed. The finalists will be selected after a unanimous decision of the cardiac anesthesia group.
Program Content and Description
The program is described as a Clinical Adult Cardiac Fellowship program: This involves 100 percent clinical rotation with five days a week clinical service. In addition, the fellows are expected to take 10 calls per month. The call is from home and if a team works at night, the team will get the next day off. Call does not include any ICU involvement. Fellows will also be exposed to pacemaker and defibrillator insertions, heart catheterization procedures and percutaneous closure of atrial septal defects.
Staff anesthesiologists will supervise fellows with reducing supervision as their clinical year progresses. The fellows at all times will be responsible for their own cases.
Depending on the caseload on any particular day, fellows may be doing their own cases or supervising residents. Fellows rotate for up to three months in the echocardiography lab supervised by the cardiology/echocardiography attendings. They are expected to participate in all the activities of the echocardiography lab, including the afternoon ECHO reading sessions.
Clinical Responsibilities
During the year, the fellow gains further proficiency in and exposure to the perioperative evaluation and intraoperative management of elective and emergency cardiac patients undergoing primary and repeat revascularizations, valvular replacements and repairs, insertion of mechanical assist devices, heart transplantation, minimally invasive heart surgery, off-pump heart surgery and combination procedures.
During the first week of clinical work it may be required for the fellow to work with a senior resident/CRNA. This will allow time for the fellow to become familiar with local practice and customs. During the first three months of the fellowship year, set as probationary period, the fellow will be closely supervised in a one-to-one capacity by staff anesthesiologists during cardiac operations and be assessed for suitability of clinical skills. Following successful completion of the probationary period, fellows are expected to be able to function with minimum supervision, although staff coverage will always be readily available.
Transesophageal Echocardiography
TEE is used routinely for all cardiac operations. Therefore with everyday use and the ECHO rotation, fellows can get enough exposure and knowledge to be able to sit for the examination after the end of their fellowship.
The goals of the ECHO training include:
- Basic understanding of the indications, contraindications and risks of peri-operative TEE.
- Understanding of the principles of 2D and Doppler echocardiography and an understanding of the physical principles of the Echo machine.
- Understanding and recognition of normal cardiac structures and common pathological echocardiographic findings, such as LV function, regional wall motion abnormalities, degree of Mitral Regurgitation, Aortic Stenosis, etc. This includes the measurements of regurgitant flow, gradients and valve area calculations.
- The fellow should be able to perform a routine monitoring TEE, including insertion of the TEE probe and gaining standard echo views (Mid-esophageal 3-chamber, mid-esophageal 4-chamber, trans gastric short axis, etc.)
- Gain basic knowledge to provide a basis for further training in TEE and perioperative cardiac anesthesia management.
- Basic care for and maintenance of the TEE probe and machine (cleaning and storage).
Although there will be guidance and teaching, the fellows are ultimately responsible for their background learning of TEE. Reading materials and video's are available either through handouts or in the Department’s library. The formal echo rotation, in the ECHO lab, will be up to three months in duration and will provide most of the hands on education for the fellow. The attending cardiology echo staff will supervise this activity. During the rotation, the fellow is expected to attend all operating room cases where TEE is involved and cardiology is consulted, except when other clinical duties interfere. In addition, all ECHO findings will be discussed in every case with the attending Anesthesiologist and the form describing the findings should be filled out and attached to the patient chart. There will also be regular seminars and echo case discussions throughout the year that will be mandatory to attend. Fellows are expected to familiarize themselves with the location of equipment and familiarize themselves with the proper maintenance and cleaning of the equipment.
Clinical Goals
At the end of the fellowship year the individual is expected to have accomplished the following goals:
- Staff-level preoperative assessment of the patient with cardiopulmonary disease.
- Evaluation of anesthetic risks and knowledge of the necessary interventions to minimize risk.
- Determination of cardiovascular and pulmonary monitoring requirements and expertise in the use and interpretation of values of invasive monitoring techniques including TEE.
- Formulation of anesthetic plan and administration of anesthetic medications for providing optimal surgical conditions, with consideration of patient disease processes.
- Effective perioperative management of the cardiac surgical patient with complex cardiovascular pathophysiology based upon knowledge and consideration of cardiac, respiratory, neurologic, renal, hepatic, neuromuscular, hematologic and coagulation systems.
- Preoperative, intraoperative and postoperative management of patients with coronary artery disease, valvular disease, congenital heart disease, cardiomyopathies, transplants, dysrhythmias, thoracic and aortic disease.
- Management of the patients difficult to wean from cardiopulmonary bypass.
- Anticoagulation and coagulation management during and after cardiopulmonary bypass.
- Management of the patient in the Cardiac Catheterization Lab, from the routine invasive procedure to the emergent complication.
- Understanding of the principles of extracorporeal circulation, cardiopulmonary bypass and circulatory assist devices.
- Understanding of the principles of myocardial preservation.
- Acute management of routine and ill patients in the postoperative cardiac intensive care setting.
- Critical review of the cardiovascular literature.
- Participation in didactic sessions (for example, Anesthesiology Grand Rounds), clinical teaching and organization of and presentation at Cardiovascular Journal Club.
It is expected that each fellow will be responsible for two major seminars during the year. This will involve the preparation of two presentations to be given in one of the Department’s didactic sessions on topics related to broader cardiac anesthesia spectrum as indicated in the following list:
- Cardiovascular Physiology and Pharmacology
- Fast Track Cardiac Anesthesia
- Weaning From Cardiopulmonary Bypass
- Cardiopulmonary Bypass Equipment
- Pathophysiology of Cardiopulmonary Bypass
- Caogulation/ anticoagulation/ antifibrinolytics
- Intraaortic Balloon Pump
- Management of Perioperative Dysrhythmias
- Myocardial Protection
- Adult Congenital Heart Disease
- Thoracic Aneurysms
- Cardiac Assist Devices
- Alternative Cardiac Surgery Techniques (e.g., MIDCABS)
- Blood Conservation
- Heart Transplantation
- Cerebral Protection and Outcomes
- "Common Problems" In Cardiovascular ICU
Evaluation of Fellows
- Written evaluation of each fellow quarterly. These evaluations include attitude, interpersonal relationships, professionalism, fund of knowledge, manual skills, patient management, decision-making skills and situational analysis. The Fellowship Director will meet each fellow individually to discuss their evaluations and allow the fellow to voice concerns or questions.
- Direct daily feedback throughout the subspecialty training from faculty.
- Assessment of presentations of a cardiac topic as above.
- Assessment of Research Project.
Accreditation
- Cardiac Fellowship programs, at the moment, are not officially recognized by any governing body. However, their guidelines are set forth by the Program Requirements for Residency Education in Anesthesiology (ACGME).
- This training is not recognized toward residency training in Massachussets. However, the Fellowship may lead to Perioperative Transesophageal Echocardiography Certification.
- Although not subject to Board Certification, Cardiac Anesthesia subspecialty is recognized by the American Society of Anesthesiologists and the Canadian Society of Cardiovascular Anesthesiologists.
- Certificates are given to the fellows who successfully complete the program
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