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Fellowship Handbook 20082009 Division of Cardiology.rtf

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Fellowship Handbook 20082009  Division of Cardiology.rtf Powered By Docstoc
					                         The George Washington University Hospital

        CARDIOLOGY FELLOWSHIP TRAINING PROGRAM
                       Fellowship Handbook and Program Summary

                                                   2008-2009
Section 1         Organization                                                                                2
Section 2         Program Goals/Content                                                                       3
Section 3         Rotations                                                                                   5
Section 4         Conferences                                                                                31
Section 5         Research                                                                                   34
Section 6         Ambulatory Care                                                                            38
Section 7         Evaluation/Feedback                                                                        39
                  Competencies in Cardiology                                                                 41
Section 8         Appointment/Reappointment                                                                  45
Section 9         Policies and Regulations                                                                   49
Section 10        Salary/Benefits                                                                            75
Section 11        Educational Resources                                                                      78
Section 12        Fourth Year Training Opportunities                                                         79
----------------------------------------------------------------------------------------------------------------
Appendix I        Rotation Schedule for 2008-2009

Appendix II       Conference Schedules

Appendix III Research Schedule

Appendix IV Evaluation Forms

Appendix V        Attending Schedule

Appendix VI Fellow Leave Form




                                                                                                                   1
                                           Section 1
                                          Organization
       Administration

       1.      Division Chief:       Richard Katz, M.D. (202-741-2323)

       2.      Associate Director of Cardiology:     Cynthia Tracy, M.D. (202-741-2668)

       3.      Cardiology Fellowship Program Director: Allen Solomon, MD. (202-741-2668)

       4.      Fellowship Coordinator: Turnice Brown
               Phone: (202-741-2323) Fax: (202-741-2324)
               E-mail: tbrown@mfa.gwu.edu

       5.      Name                    Phone                Page                   Home

               Tsung Cheng         202-741-2426             741-1971
               Brian Choi, MD      202-741-2323             741-0094
               Richard Katz, MD    202-741-2323             741-2167               301-229-3811
               Jannet Lewis, MD    202-741-2323             741-0816               301-879-3313
               Lisa Martin, MD     202-741-2323             741-0409               301-469-0753
               Ramesh Mazhari, MD 202-741-2323              741-2858               202-215-7104
               Marco Mercader, MD 202-741-2323              741-1293               703-892-0725
               Jonathan Reiner, MD 202-741-2323             888-432-6812           301-983-4796
               Allen Solomon, MD 202-741-2668               741-0021               301-589-0182
               Cynthia Tracy, MD 202-741-2668               741-0020               301-942-1862
               Jacob Varghese, MD 202-741-2323              741-1972
               W. Weglicki, MD     202-741-2323             741-2104


1.      George Washington University Hospital: The George Washington University Hospital
is the sponsoring institution. All fellows will therefore have appointments through the House
Staff Office of The George Washington University Hospital, and both the Program Director and
Fellowship Coordinator will be based at The George Washington University Hospital. The
fellows will therefore be accorded all rights and privileges of, and be expected to adhere to all
rules pertaining to, house staff of The George Washington University Hospital and Department
of Medicine.

2.      Inova Fairfax Hospital: Inova Fairfax Hospital, located at 3300 Gallows Road in Falls
Church, Virginia, has recently completed a new Cardiovascular Hospital. As a result, fellows
will spend 1 month per year at this institution performing rotations in the Coronary Care Unit,
Cardiac Transplantation, Cardiac Rehabilitation, Cardiac Surgery, Pediatric Cardiology and
Adult Congenital Heart Disease. This is an Affiliated Institution participating in the fellowship
experience.

3.      Washington Veterans Affairs Medical Center: The Washington VA will sponsor an
elective rotation in Non-invasive cardiology under the direction of Michael Greenberg, MD.
During this rotation, fellows will learn cardiac MR, nuclear cardiology and echocardiography.
This is an Affiliated Institution participating in the fellowship experience.
                                                                                                    2
                                     Section 2
                               Program Goals/Content
The goal of the The George Washington University Hospital Adult Cardiology Training Program
is to provide opportunities for Fellows to develop clinical competence and scientific excellence
in the field of Adult Cardiology. In addition to obtaining the clinical and technical skills
required to be a competent cardiovascular specialist, the program will afford Fellows the
opportunity to obtain the skills required for academic careers.

Specific program content will include:

A.     Opportunities to acquire skill in interpretation of the following:

       1.     Electrocardiography (minimum of 3500)
       2.     Ambulatory ECG monitoring (minimum of 150)
       3.     Exercise and pharmacologic stress testing
       4.     Echocardiography
       5.     Cardiac Hemodynamics
       6.     Cardiac and coronary angiography
       7.     Chest radiography
       8.     Radionuclide studies
       9.     Electrophysiological recordings
       10.    Cardiac MR and computed tomography
       11.    Non-invasive vascular studies
       12.    Endomyocardial biopsies
       13.    Pacemaker and ICD follow up

B.     Opportunities to acquire skill in performance of the following:

       1.     History and physical examination
       2.     Cardiopulmonary resuscitation and advanced cardiac life support
       3.     Cardioversion
       4.     Bedside right heart catheterization
       5.     Insertion and management of temporary pacemakers
       6.     Arterial cannulation
       7.     Pericardiocentesis
       8.     Permanent pacemaker and ICD surveillance
       9.     Critical analysis of published cardiovascular data in laboratory and clinical
              research
       10.    Management of critically ill patients
       11.    Electrocardiography
       12.    Ambulatory ECG
       13.    Stress testing (exercise and pharmacologic)
       14.    Echocardiography
       15.    Right and left heart catheterization
       16.    Intracardiac electrophysiological studies and their interpretation
       17.    Radionuclide evaluation of cardiovascular function and myocardial perfusion
       18.    Pacemaker programming and follow-up
       19.    Cardiovascular research and evaluation

                                                                                              3
     20.    Insertion and management of intraaortic balloon counterpulsation
     21.    Cardiac consultation
     22.    Cardiac MR
     23.    Non-invasive vascular studies
     24.    Endomyocardial biopsies
     25.    Cardiac rehabilitation

C.   Opportunities to acquire knowledge through formal instruction in:

     1.     Cardiovascular anatomy, physiology, and metabolism
     2.     Cardiovascular pharmacology, including drug metabolism
     3.     Hypertension
     4.     Lipid abnormalities
     5.     Congenital heart disease
     6.     Prevention of cardiovascular disease (risk factors)
     7.     Heart disease and pregnancy
     8.     Principles of cardiovascular rehabilitation
     9.     Cardiovascular pathology
     10.    Peripheral and cerebral vascular disease
     11.    Biostatistics
     12.    Cardiovascular epidemiology
     13.    Pulmonary vascular disease
     14.    Myocardial biopsy
     15.    Permanent pacemaker implantation
     16.    Magnetic resonance imaging and fast CT
     17.    Molecular biology of the cardiovascular system
     18.    CAD/Acute MI/Stable and unstable angina
     19.    Arrhythmias
     20.    Cardiomyopathy/CHF
     21.    Valvular heart disease
     22.    Pericardial disease
     23.    Pulmonary heart disease
     24.    Preoperative evaluation and postoperative management of the cardiac patient
     25.    Cardiac Transplant
     26.    PET
     27.    Quality assessment and improvement
     28.    Genetic causes of cardiovascular disease
     29.    Geriatric patients with cardiovascular disease




                                                                                          4
                                              Section 3
                                              Rotations
General comments:

1.      Rotation schedule: Fellows will rotate through various rotations in one month blocks.
In the spring of each year, requests for preferred rotation schedule will be forwarded to the
Fellows to complete and return to the Fellowship Director. The Fellows will develop the yearly
schedule in consultation with the Fellowship program director and faculty. A preliminary
schedule will then be distributed to the Fellows for their review. Fellows will have an
opportunity to discuss their schedules in an open meeting, where appropriate, revisions will be
made and their schedules finalized shortly thereafter. Once finalized, the schedule can be
changed only with approval of the Fellowship Director. (Appendix I: Rotation Schedule for
2008-2009)

2.      Rotation Responsibilities: Responsibility of the Fellow will vary among the individual
rotations. A more complete outline of training goals and Fellow responsibilities is outlined
below. Fellows are advised to review these guidelines and discuss them with the rotation
supervisor at the outset of each rotation.

3.     Concept of Graded responsibility: The fellowship is designed to provide graded
responsibility in which fellows assume increasing autonomy commensurate with clinical and
technical experience and proficiency. This occurs on several levels. First the overall fellowship
is designed to provide first year fellows with a core experience in most areas including CCU,
consults, non-invasive testing, arrhythmia management and catheterization. First year fellows
will meet with the fellowship director in the winter of the first year to discuss their long-range
plans. The second and third year programs will be tailored to provide a more concentrated
experience in a given area such as non-invasive cardiac imaging, cardiac catheterization, or
arrhythmias. Fellows will also experience graded responsibility during individual rotations.
This will, of course, depend on the rotation and the fellow’s experience and technical
proficiency. For instance, it is expected that a first year fellow or a more senior fellow will be
assigned to the cardiac catheterization lab at any time. The senior fellow will be expected to
perform more challenging cases and with increased autonomy compared to a junior fellow.

4.    Rotation Evaluation: Internet based evaluations, using E value, will be completed by the
      supervising faculty at the end of each Fellow’s rotation. This will immediately be
      available to each individual fellow for review. In addition, Fellows will have the
      opportunity to evaluate the faculty and rotations (See Section 7).




                                                                                                  5
                                 Arrhythmia Service
1.   Organization

     a.    Rotation Supervisor: Cynthia Tracy, M.D.,
     b.    Faculty: Allen J. Solomon, M.D., Marco Mercader, M.D.

2.   Rotation Goals
     a.   Recognize common and complex dysrhythmias, including atrial fibrillation, atrial
          flutter, AVNRT, AVRT, PAT (with or without block), junctional rhythms,
          ventricular tachycardia, and fibrillation.

     b.    Understand the appropriate physical findings associated with each rhythm
           disturbance.

     c.    Understand the appropriate noninvasive evaluation of arrhythmias, including
           appropriate use of echocardiography, exercise stress testing, ambulatory ECG
           monitoring, event recorders, signal-averaged ECG and heart rate variability.

     d.    Understand the pharmacology of antiarrhythmic drugs.

     e.    Understand appropriate use of antiarrhythmic drugs, including combination therapy.

     f.    Recognize toxicity of antiarrhythmic drugs.

     g.    Understand the indications and contraindications for invasive electrophysiological
           testing.

     h.    Understand the indications and contraindications for permanent pacemaker
           implantation.

     i.    Understand the indications and contraindications for ICD implantation, including
          CRT.

     j.    Attain competence in elective and emergency cardioversion.

     k.    Demonstrate proficiency in pacemaker and ICD follow-up.

     l.    Understand the use and interpretation of tilt testing.

     m.    Understand the indications and contraindications for ablative therapy.




                                                                                                6
3.       Overview of Responsibilities

Year 1
         a.   The Arrhythmia Fellow will serve as a member of the Arrhythmia consult service
              under the supervision of the fourth-year EP Fellow and Arrhythmia faculty.
              Fellows will assist in evaluation of new consultations and follow-up of inpatients on
              the Arrhythmia Service.

         b.   Fellows will participate in reading noninvasive studies as appropriate, including
              ambulatory ECG, signal-averaged ECGs, and T wave alternans.

         c.   Fellows will participate in performance and interpretation of tilt testing.

         d.   Fellows will participate in the Tuesday, Wednesday, Thursday and Friday afternoon
              arrhythmia clinics and assist in evaluating new patients and follow-ups. Fellows
              will also see patients in pacemaker and ICD clinic.

         e.   Fellows are expected to actively participate in the Friday morning Arrhythmia
              Conference, and will be asked to present and discuss interesting cases during one of
              the case management discussions.

         f.   Fellows will also be responsible for instructing Internal Medicine residents and
              students during inpatient consultations.

         g.   Fellows will see 3-5 inpatients per day and 3-5 outpatients per clinic session.

Year 2 – 3

         h.   Fellows will participate in performance and interpretation of electrophysiological
              testing .

         i.   Fellows are encouraged to participate in ablative procedures: however,
              manipulation of ablative catheters will be reserved for the EP Fellows and staff.
              Fellows will also be encouraged to participate in pacemaker and defibrillator
              implants.

         j.   All Year 1 responsibilities

4.       Suggested Reading:
         Atrial Fibrillation: Mechanisms and Management, Falk RH, Podrid PJ, Eds. Raven Press,
         1999.

         Cardiac Electro physiology: From Cell to Bedside, Zipes D, Ed WB Saunders, 2000.

         Clinical Cardiac Pacing and Defibrillation, Ellenbogen, Kay, Wilkoff, Eds. WB
         Saunders, 2000.




                                                                                                   7
                              Non-Invasive Cardiology
                       (Nuclear Cardiology and Stress Testing)
1. Organization

      a.   Rotation Supervisor:     Jannet Lewis, M.D.

      b.   Faculty: Richard Katz, M.D., Lisa Martin, MD, and Brian Choi, MD



2.    Rotation Goals

      a.   Understand the clinical indications and contraindications to treadmill and nuclear
           exercise and pharmacologic stress testing, as well as the potential adverse effects of
           testing.

      b.   Understand and apply Bayes’s Theorem of pre- and post-test probability to the
           selection of patients for exercise testing, nuclear imaging or coronary arteriography.

      c.   Understand factors leading to false positive and/or indeterminate
           electrocardiographic and nuclear stress tests.

      d.   Understand normal and abnormal physiologic, and electrocardiographic responses
           to exercise.

      e.   Understand the definition and calculation of metabolic equivalents (METs)

      f.   Understand use of the BORG scale.

      g.   Understand and demonstrate proficiency in accurate interpretation of
           electrocardiographic stress testing.

      h.   Understand the indications for, and demonstrate proficiency for patient selection,
           performance and interpretation of, oxygen consumption stress tests.

      i.   Understand the indications and contraindications for rest and exercise RVG studies.

      j.   Understand the indications and contraindications for myocardial perfusion imaging
           and thallium and technetium-99m tracers.

      k.   Understand camera acquisition, computer processing and display required for
           perfusion blood pool imaging.

      l.   Understand the pharmacokinetics and physical properties of nuclear tracers,
           including thallium-201, technetium-99 sestamibi and Tc-99m tetrofomin.

      m.   Understand the procedure for RBC labeling for gated blood pool scans.


                                                                                                8
       n.   Understand visual and quantitative methods of analysis for nuclear cardiology
            images.

       o.   Understand the dosimetry methods and radiation safety precautions including room
            survey, wipe test, and storage and disposal of radioactive material.

       p.   Demonstrate proficiency for interpretation of TI-201 and technetium perfusion
            agents, gated SPECT and rest and exercise blood pool scans.

       q.   Recognize causes for false positive and false negative myocardial perfusion images.

       r.   Understand methods to determine myocardial viability.

       s.   Understand the indications for, and demonstrate proficiency in performing and
            interpreting, pharmacologic stress tests, including dipyridamole, adenosine and
            dobutamine.

       t.   Individually meet with Dr. Katz or Dr. Hsia (for approximately one hour) at least
            twice per week to review workbook exercises, go over interesting cases and/or to
            prepare conferences



2. Overview of Responsibilities

Year 1-3

       a.   Fellows will participate in daily reading sessions. ―Pre-reading‖ of studies is
            strongly recommended.

       c.   Suggested reading texts, articles, and on-line educational tools will be distributed
            prior to the initiation of the rotation.

       d.   Fellows will be expected to take an active role in the weekly conferences during
            their rotations. This may include presentation of instructive studies and/or
            presentation at Cardiac Catheterization Conference.

       e. Fellows will learn to perform and interpret both electrocardiographic-based and
           nuclear-based exercise and pharmacologic stress testing. Fellows will be available
           to supervise all persantine, adenosine and dobutamine stress and exercise RVGs in
           the Nuclear Cardiology and Adult Exercise Stress Laboratories.




                                                                                                   9
4.     Suggested Reading


Mayo Clinic/ACC teaching tapes

Nuclear Cardiology. Manuel D. Cerqueira (Ed.), Blackwell Scientific, 1994.

Cardiac Imaging. (A companion to Braunwald’s Heart Disease); Marcus, Schelbert, Skorton,
and Wolf; W.B. Saunders, 1991.

Nuclear Cardiac Imaging: Principles and Applications. 2nd Edition. Iskandrian and Verani. F.A.
Davis (publisher), 1996.

Clinical Nuclear Cardiology. Beiler. W.B. Saunders Co. (publisher), 1996.

Cardiac SPECT Imaging. DePuey. Raven (publisher), 1995.




                                                                                           10
                                    Non-Invasive Cardiology
                                      (Echocardiography)
   1. Organization

       a.    Rotation Supervisor:     Jannet Lewis, M.D.

       b.    Faculty:   Richard Katz, M.D., Lisa Martin, MD

   2. Objectives

            a. Every fellow should understand the basic aspects of cardiac ultrasound, including
               physical principles, instrumentation, cardiovascular anatomy, cardiovascular
               physiology, and cardiovascular pathophysiology
            b. Each fellow should master the skills of performing a transthoracic
               echocardiogram and Doppler examination and be able to integrate their
               understanding of 3-dimensional cardiac anatomy
            c. The fellow should understand how to perform a stress echocardiogram, including
               exercise stress, as well as pharmacologic stress testing
            d. The fellow should learn how to perform a transesophageal echocardiogram
            e. The fellow is encouraged to learn how to correlate the findings from the
               echocardiographic and Doppler exam with the results of other imaging modalities
               and physical examination
            f. The fellow should master the relationship between the results of the
               echocardiographic examination and findings of other cardiovascular tests, such as
               the cardiac catheterization and electrophysiology
            g. Every cardiovascular fellow will be exposed to and become familiar with the
               technical performance, interpretation, strengths, and limitations of 2-dimensional
               echocardiography and Doppler


3. Work schedule/ Logistics:

Each month, Dr. Lewis will review this introduction and give feedback at the end of the rotation.
The Echocardiography laboratory is open Monday – Friday 7:30 am to 4:30 p.m. The
noninvasive fellow(s) are expected to be available in the echo lab or in the vicinity of the echo
lab by 8:00am (except during conferences and clinic) to 5:30pm. Upon special request (to
supervise stress echo or prepare for TEE) you may be asked to be present at 7:30 am. If for
some reason, personal or professional, you cannot attend the echo lab as scheduled be sure to
discuss coverage with the Noninvasive Attending.
The echo fellow is expected to become part of the lab, learning from the sonographers and
attendings as well as helping to evaluate patients for procedures.




                                                                                               11
4. Non-invasive training in the Echo lab:

Practical hands-on training

To become a skilled echocardiographer, it is critical to also learn how to acquire the images.
Image acquisition is important to better understand the scan planes and their relationship, as a
well as the importance of artifacts, gain settings, depth settings, etc. Fellows are expected to
learn these skills primarily from the sonographers who are professionally educated and trained to
perform ultrasound procedures, specifically cardiac ultrasound. The sonographers will also teach
the fellows the basic knowledge needed to operate the ultrasound scanners and Heart Labs work
station. Fellows should get daily hands-on transducer time and instructions.

Based on the guidelines (see below) for the recommended minimum number of studies (150) to
be performed over the minimum of 3 months of echocardiography, the fellow should perform 1-
2 transthoracic studies per day, particularly in the first month.

Reading with attending.

The fellow should spend part of each day with the attending to learn the skills of interpreting the
ultrasound studies and how these studies are evaluated in context to cardiac disease. The
majority of studies are read between 1:00pm and 5:30pm, but reading times vary based on
urgency of individual studies, procedures, conferences and other commitments.

After your very initial time in the echo lab, it would be reasonable for you to try to ―pre-read‖ the
echocardiograms to fine-tune your skills as an interpreter. The Attendings will commit a
dedicated time each day to review your ―pre-read‖ studies. It is up to each attending to arrange
with the fellow when such reading time will take place.

Self-Education.

There is ample opportunity to find issues and subjects to study while in the echo lab, including
very technical aspects of echocardiography and Doppler as well as limitations of the tests and
their sensitivity, specificity, accuracy, indications, contraindications. In addition, the noninvasive
rotation provides an excellent opportunity to learn about cardiology in general. Nearly every
clinical cardiac condition is evaluated by echocardiography. The Internet is available in the echo
lab for ready access to Pubmed searches and other sources. Reading material is listed in
Appendix A.

Echo Conference

Conference is held every Wednesday at 8:00am. This conference is dedicated to
echocardiography and other cardiovascular imaging. The goal is to present interesting cases to
fellows, faculty, and staff and to provide an opportunity for more in-depth learning for the
fellow. It is expected that the fellow will compile a number of studies (4-6 on average), that
preferably address a particular clinical disorder. Attendings are available for consultation and
image review in selecting and preparing cases. The primary focus should be on presenting
images, with supporting didactic and clinical information. At the beginning of the academic year,
several didactic presentations will be given by the noninvasive attendings. Also, approximately
                                                                                                 12
one conference monthly will be dedicated to Nuclear Cardiology, MRI or PET scanning.

5. Echocardiography testing:

Transthoracic echo:

Transthoracic echocardiography (and Doppler) is the backbone of echocardiography. It is
important to learn all the basic scan planes and learn to evaluate (at a minimum), cardiac
chambers, including volume, function and mass, cardiac valves, pericardium and myocardium.
Doppler assessment affords the capability to examine cardiac physiology, including valvular
stenosis and regurgitation, cardiac shunts as well as diastolic ventricular function.

Transesophageal echo:

Fellows will be introduced to transesophageal echo on their first day of the echo rotation. Work
is one-on-one with the echo attending throughout the procedure. Fellows are carefully instructed
regarding indications, contraindications and preparation of the patient prior to the procedure.
Most TEE studies are performed in the Endoscopy suite or Intensive care units. It is the Fellow’s
responsibility to carefully assess the patient prior to the procedure and schedule the study with
the nursing unit or Endoscopy suite, Echocardiography Lab, and Echocardiography Attending. A
sonographer will assist with the preparation, but must be given ample notice. Please understand
that the echo faculty and staff have no control over the number of TEE requests, and the load
varies from 1-4 TEEs per day. During the first several TE echo procedures, it is important that
the attending is with you from the very beginning to make sure that you learn proper preparation
techniques. The attending will always be with you as you are ready to intubate the patient and
throughout the procedure.


Following the procedure, the probe should be taken to the specified cleaning room. The probe
requires a specific protocol for cleaning. The sonographer assisting with the procedure generally
performs this. In the absence of a sonographer (during studies performed outside lab hours,
emergent TEEs or when a sonographer is unavailable to assist with the procedure), the fellow
should follow the attached protocol. Under no circumstances should the probe be left at the
bedside or on the machine. Failure to promptly clean the probe may cause permanent equipment
damage.


Conscious sedation:


The patient must be evaluated prior to procedure for indications, contraindications and safety
issues. Patients are monitored with pulse oximetry and vital signs (BP, HR and RR) at the
beginning and continuously thereafter. Versed and fentanyl are given. Doses of ½ mg to 4 mg
Versed, 25-150 mg Fentanyl. Drugs are given gradually in ½ to 1-mg increments and 25-50 mg
increments respectively. The Attending should be present at the outset of the study for the first
several procedures to learn how to consent the patient appropriately prior to the procedure and
understand how to judge the patient’s level of sedation and evaluate potential problems. Oxygen
is available in the room and should be given any time SAT is less than 95% (general guideline).

                                                                                               13
Main indications are source of embolization, endocarditis, prosthetic valve assessment, aortic
dissection, congenital heart disease, unstable post cardiac surgery patients, exclusion of clot prior
to cardioversion and transseptal guidance.
A general protocol for performing a TEE does exist, but in consciously sedated patients, the
procedure should be tailored to the specific clinical question. See Appendix B for performing a
comprehensive study.

Stress echo:

Stress echo is a very important part of our lab activities. A fellow, sonographer and ECG tech
perform the stress echo examination. It is important that the fellow learn the indications,
contraindications and test protocol to understand the benefit and limitations of testing. The
fellow is not expected to scan a patient during stress testing, but routinely supervises treadmill
testing or dobutamine drug infusion.


Total training time during clinical fellowship.

Minimum training in Echocardiography is 3 months to qualify for Cardiovascular Board eligible.
Most fellows complete a minimum of 4 months of echo training and many complete an
additional 1-2 months, depending on their level of interest. We utilize established guidelines for
time and procedures needed for different competency levels. See below.


6. Levels of training (COCATS Core Cardiology training Symposium Document)

There are three levels of training.

Level 1: 3 months training, considered ―introductory training‖.
Minimal number of Transthoracic performance and interpretation of examinations: 150.
No TEE or Stress required.
This training allows a physician to understand the functional anatomy and physiology in relation
to the echocardiographic examination.

Level 2: 6 months training
Minimal number of Transthoracic performance and interpretation of examinations: 300.
No TEE or Stress required.
This training emphasizes the intensity, quality and completeness of diagnostic studies.
Competence at the second level denotes that the trainee is sufficiently experienced to interpret
the echocardiographic examination accurately and independently.

Level 3: 12 months training
Minimal number of Transthoracic performance and interpretation of examinations: 750.
Procedural echo, including TEE and stress, intraoperative, contrast, interventional and complex
congenital heart disease.
This training is needed for someone who aspires to be the director of a laboratory. Exposure and
proficiency of all echocardiographic procedures is expected at the end of level 3 training.

                                                                                                     14
Documenting procedures:

As part of your training requirements, you will need to provide documentation that you have
performed the recommended number of procedures as detailed above. You should maintain a log
or collect the reports for all echo studies in which you participated in over the course of the
month, indicating performance, interpretation, or both. This will be reviewed at the end of the
month.


Evaluations:

At the end of each month of rotation you will be reviewing your experience with one of the echo
lab Attendings and get feedback on your progress. Likewise this would be an opportunity to
express any constructive criticism of attending teaching, availability, learning experience, etc.


7. General guidelines for proficiency in echocardiography during training:


After your 1st echo month:


The fellow should make sure to get enough ―hands-on‖ experience to perform a standard 2D
echocardiogram with routine Doppler for assessment of presence or absence of aortic and mitral
stenosis, valvular regurgitation, presence of wall motion abnormalities, LV function, RV
function and pericardial effusion.
The fellow should also feel comfortable assessing patients prior to TEE procedure and have a
basic understanding of the examination. The fellow should also become familiar with the basic
performance and evaluation of stress echocardiograms. Start ―pre-reading‖ echocardiograms as
soon as you are comfortable with the computers and have the very basic understanding of
echocardiography.


After your 2nd echo month:
The fellow should learn more about valvular heart disease, complications of CAD/MI,
hypertrophic cardiomyopathy, diastolic function, etc.
The fellow should feel comfortable to assess patients prior to stress testing and be able to
perform exercise and Dobutamine stress studies independently. The fellow can start to generate a
preliminary report by ―pre-reading‖ studies that have been entered by the sonographers before
the attending interprets them.


After your 3rd -4th echo months:
The fellow should feel comfortable with the basic echocardiography and Doppler examination of
most common cardiac diseases. The fellow should be able to recognize all common pathologic
entities. Some exposure to congenital heart disease is expected. The fellow should now be able to
generate a fairly accurate preliminary report by ―pre-reading‖ studies before the attending
                                                                                              15
interprets them.


After your 5th –6th month:
The fellow should have a comprehensive understanding of what constitutes a high quality and
complete study. The fellow should understand the correlation with clinical results in a broad
range of problems. A fellow that has completed 6 months of echocardiography training should be
able to independently perform and interpret an echocardiographic study and Doppler that is
diagnostic, complete and accurate.


8. Generic TEE protocol
The initial imaging should focus on the most important clinical question. The goal of this
protocol is to make it easier for the fellow to focus on the images as they are acquired, rather
than focusing specific steps to the examination.

Aortic valve: 25-45 degrees to visualize aortic cusps, color Doppler. Change to 110 degrees,
color Doppler.
Also image ascending aorta here (partially withdraw probe)

Mitral valve: 0 degree, color Doppler. Slowly examine the mitral valve at approximately 60, 90
and 120 degrees, color Doppler.

Tricuspid valve: 0 degrees (may need to unflex probe), color Doppler, ~50-60 or 90 degrees,
color Doppler.

Pulmonic valve: 50-90 (usually 70) degrees, color Doppler.
At this point you can also follow pulmonary artery out to the bifurcation at 90 degrees

Atria:
0 degrees:
LA: pan (in/out along lateral wall, in/out along septum),
RA: pan (in/out), color Doppler of septum.
Change to 90 degrees:
LA: pan (rotate).
RA: pan (rotate), visualize SVC (probe out), and IVC (probe in). Focus on IAS, color Doppler,
[measure septal separation], [saline contrast study].

90 degrees:
LA Appendage: behind MV, zoom, [color Doppler and PW Doppler].
0 degrees:
LA Appendage, examine [color Doppler, PW Doppler].
Pumonary veins: visualize and pulsed Doppler of 2-4 pulmonary veins.

Ventricles: Left and right ventricle: 0 degrees, unflex probe for apical 4C view (with apex), 90
degrees for apical 2C, 120-130 degree for apical long axis view.

Transgastric - 0 degree to view LV/RV (in/out), 90 degrees for long-axis LV/RV (rotate).

                                                                                                   16
Descending Aorta and arch: 0 degrees, probe not too deep, rotate toward left heart. Withdraw
probe slowly while keeping Ao centered. [measure as needed]. At arch follow and then change to
90 degrees.

Please note: There may also be specific instructions for the performance and reporting of
particular research-related studies (see appendix for Source of Embolism protocol).


9. Source of Embolism TEE protocol

Equipment: All Transesophageal echocardiograms will be performed according to our standard
clinical guidelines in regards to conscious sedation.

Structures to be imaged:
Left ventricle:
       Purpose: rule out apical thrombus
       Views: Apical 4-chamber, apical 2-chamber and apical long axis (135 degree) views.

Left atrium:
       Purpose: rule out clot, myxoma, spontaneous echo contrast (SEC or ―smoke‖)
       Views: 0 degrees and 90 degrees.

               Special procedure: SEC is evaluated as absent (0), mild (1+), mild-to-moderate
               (2+), moderate (3+) or severe (4+).
               1+ = minimal echogenicity, may be detectable only transiently, imperceptible at
                     operating gain settings for 2D.
               2+ = more dense than 1+, detectable without changing gain settings
               3+ = dense swirling, detectable constantly during the cycle. LAA>LA
               4+ = severe. LAA=LA

Left atrial appendage:
       Purpose: rules out clot, spontaneous echo contrast, assess function
       Views: 0-30 degrees and 90 degrees.
               All views will be done with ZOOM or at least no more depth scale than
               necessary.

       Special procedure: Color Doppler and PW Doppler (obtained at the orifice of the
       appendage) should be applied in at least one of the views. Note the maximum
       filling/emptying velocities (average 3 beats in sinus and 5 beats in atrial fibrillation)
                SEC has to be evaluated as none (0), mild (1+) mild-to-moderate (2+), moderate
                (3+) or severe (4+).
   1+ = minimal echogenicity, may be detectable only transiently, imperceptible at operating
   gain settings for 2D.
               2+ = more dense than 1+, detectable without changing gain settings
               3+ = dense swirling, detectable constantly during the cycle. LAA>LA.
               4+ = severe. LAA=LA.
Mitral valve:
       Purpose: rule out myxomatous valve with MVP, endocarditis, papilloma and MAC and
       MVR.
                                                                                                 17
       Views: 0 degree and 90 degree (minimum)
              Both views should include ZOOM or at least no more depth scale than necessary.
Aortic valve:
       Purpose: rule out endocarditis and papilloma and AVR.
       Views: Approximately 45 degrees and 110 degrees.
              Both views should include ZOOM or at least no more depth scale than necessary.

Intra-atrial septum:
       Purpose: rule out PFO and ASD
       Views: 90 degree view (range: 70-110 degrees).

         Special procedure:
         1) Presence/absence of aneurysm. Measure the mobility of the septum primum: Total
            deviation from the mid-line (total excursion into the right and the left atrium).
         2) Measure the separation between the septum primum and septum secundum during
            REST and during VALSALVA. (Assess the largest opening by going frame-by-frame
            (off line). Please label image as ―Rest‖ and ―Valsalva‖
         3) Contrast –injection at REST and with VALSALVA. Please label image as ―Rest‖ and
            ―Valsalva‖. The right atrium should be completely opacified. The number of targets
            crossing should be assessed as: 1+ = (< 1-5), 2+ = (6 - 25), 3+ = (> 25).

Aorta:
         Purpose: Rule out atheroma/clots in the aorta from the Aortic valve to the left subclavian.
         Views: Ascending aorta: long axis (approximately 110 degrees) of the valve and the root.
                Short axis (0 degrees), pulling back from the valve plan as far proximal as
                possible.
                Aortic arch: long axis (0 degrees) and short axis (90 degrees).
                Descending aorta: (0 degree)

            Special procedure: All plaques larger than 2 mm should be specifically noted. If less
               than 2 mm: mild disease. If equal to or thicker than 2mm, please note absolute
               thickness. The thickest plaque for each segment of the Aorta should be registered
               if there are more than one plaque. The measurement should be obtained
               perpendicular to the wall segment in question. Also note: Mobility of the plaque
               mobile/non-mobile, presence of ulceration and/or calcification.


Summary of SOE reports for TE Echo:
Please mention the following items:
1) LV thrombus.
2) LA thrombus. LAA thrombus.
3) SEC in LA or LAA; none to 4+
4) LAA emptying/filling velocities, with measurement of velocities. (>0.5 m/s is nl)
5) Inter-atrial septum; normal or inter-atrial septal aneurysm.
6) Contrast injection; no shunt or +shunt (describe shunt (septal mobility, targets, separation)
7) Mitral valve.
8) Aortic valve.
Ascending aorta, arch (and descending aorta). Describe plaques thicker than 2mm. Ulcerated a/o
mobile.


                                                                                                  18
10. Reading material

Textbook of Clinical Echocardiography (Otto)

Echocardiography (Feigenbaum)

The Echo Manual (Oh, Seward, Tajik)

Principles and Practice of Echocardiography (Weyman)

Anatomic atlases:
              Cardiac Anatomy (Anderson, Becker)
              Heart and Coronary Arteries (McAlpine)




                                                       19
                              Non-Invasive Cardiology II
                           Vascular Studies and Cardiac MR


1. Organization
   a. Rotation Supervisor: Richard Katz, MD
   b. Faculty: Michael Greenberg, MD, Lisa Martin, MD, Brian Choi, MD

2. Rotation Goals
   a. To interpret and understand the indications for:
               i.      tomographic still-frame CMR for morphology with and without contrast
               ii.     cine CMR to assess LV function
               iii.    MRA and cine CMR of the great vessels, anomalous coronary arteries and
                       CABG grafts
               iv.     Delayed contrast-enhanced CMR imaging for infarction, ischemia, and
                       viability
               v.      First-pass CMR imaging for myocardial perfusion and ischemia detection
               vi.     Phase-contrast velocity mapping for evaluation of stenosis, regurgitation
                       and shunts
   b. Actively participate in daily cardiac MR study interpretation under the direction of
       Dr. Michael Greenberg and other members of the cardiac MR program.
   c. Correlate information from cardiac MR study with angiographic, echocardiographic,
   radionuclide, CT, or hemodynamic data, when available
   d. Demonstrate a basic understanding of magnetic resonance physics
   e. Understand the physics of magnetic resonance as it relates to image intensity and
       contrast, including flow, T1 (spin-lattice relaxation time), T2 (spin-spin relaxation
       time) and contrast agents
   f. Understand the source of artifacts, including motion, arrhythmias, and metal
       objects, as well as contrast agent side effects
   g. Know the safety of devices in the cardiac MR environment
   h. Understand general post-processing tools and analyses
   i. Understand the clinical indications and contraindications to cardiac MR, as well as
       the potential adverse effects of testing.
   j. Understand the clinical indications and contraindications to vascular studies, as well as
   the potential adverse effects of testing. This includes arterial and venous studies
   k. Understand and demonstrate proficiency in accurate interpretation of peripheral arterial
   Doppler studies, venous Doppler studies, carotid ultrasound and aortic ultrasound
   l. Recognize the causes of false positive and false negative vascular studies


 3. Overview of Resposibilities

Year 1-3

Monday – Tuesday: Vascular Laboratory

Wednesday – Friday: Cardiac MRA

       a.    Fellows will perform a focused chart review of all patients scheduled for cardiac
             MR. Based on this review, the appropriate information will be entered into the
                                                                                                 20
             clinical database and the fellow will select the appropriate protocol for each patient.

       b.    Fellows will screen each patient at the time of their arrival to see if there are any
             contraindications to the procedure. Fellows will then assist in prepping the patient
             for the cardiac MR, MRA, or stress study depending upon the protocol selected.

       c.    The fellows will observe and assist the MRI technician with the performance of the
             study.

       d.    Fellows will carry out post processing image preparation, analysis and
             measurements for all studies performed Following this, they will pre-read the study
             and provide their own interpretation.

       e. Fellows will be expected to take an active role in weekly conferences and to prepare
           for presentation and discussion at Cardiac Catheterization conference.

       f.   The fellow will prepare and present two 45 minute conferences during the rotation.
             (1) The use of Cardiac MR for evaluation of Cardiac Structure and Function
             (2) The use of Cardiac MR for evaluation of myocardial viability

       g. The fellow will independently review and interpret a total of 50 studies from the
           teaching database. They will make all appropriate measurements, evaluate the
           studies for assessment of ventricular function, cardiac structure, evidence of
           ischemia or artifact, aortic pathology and any abnormalities of non cardiac
           structures. These interpretations will be submitted at the completion of the rotation.




4.     Suggested Reading

Imaging in Cardiovascular Disease. Gerald Pohost (Editor), 2000.

MRI Made Easy. H.H. Schild. Berlex Laboratories, 1999



A Non Mathematical Approach To Basic MRI. H.J. Smith, F. N Ranallo. Medical Physics
Publishing, 1989



All You Really Need To Know About MRI Physics.M.N. Avier 1997



Imaging in Cardiovascular Disease. Gerald Pohost (Editor), 2000.




                                                                                                  21
                                Coronary Care Unit
1.   Organization

          a.        Rotation Supervisor: Allen J. Solomon, MD

          b.      Faculty: Cynthia M. Tracy, M.D.; Richard Katz, M.D.; Jannet Lewis,
          M.D.; Marco Mercader, M.D., William Weglicki, MD, Lisa Martin, MD and Brian
          Choi, MD

2.   Rotation Goals

     a.   Management of unstable angina, including appropriate use of aspirin, clopidogrel,
          unfractionated and low molecular weight heparins, bivalarudin, nitroglycerine,
          glycoprotein IIb/IIIa receptor blockers, beta-blockers, and interventional
          cardiology.

     b.   Demonstrate proficiency in treating patients with acute myocardial infarction (both
          ST elevation and non-ST elevation), including appropriate use of thrombolytics,
          aspirin, heparin, nitroglycerine, glycoprotein IIb/IIIa receptor blockers, bivalarudin,
          beta blockers, clopidogrel, statins, ACE inhibitors, and primary PTCA.

     c.   Understand indications for, and demonstrate proficiency in, placement of temporary
          pacemakers.

     d.   Recognize, diagnose and treat brady- and tachy- arrhythmias.

     e.   Understand the indications for, and demonstrate proficiency in, insertion and
          management of Swan-Ganz catheters.

     f.   Understand and interpret invasive hemodynamic measurements.

     g.   Understand pharmacology and demonstrate proficiency in use of intravenous
          inotropes and vasodilators, including epinephrine, noesynephrine, isoproterenol,
          dopamine, dobutamine, amrinone, milrinone, niseritide, and nitroprusside.

     h.   Understand and demonstrate proficiency in management of acute pulmonary edema
          and circulatory failure.

     i.   Recognize and demonstrate proficiency in treating hemodynamically significant
          valvular heart disease.

     j.   Understand the indications, contraindications and complications of intraaortic
          balloon pump.

     k.   Demonstrate proficiency in managing the mechanically ventilated patient.




                                                                                               22
3.     Daily Schedule
       8:00 AM – 12:00 AM           Rounds with attending and residents
       12:00 AM - 5:00 PM           Charting on all patients
                                    Evaluate new/old patients (charting, review,
                                    noninvasive and invasive studies)
       5:00 PM - 6:00 PM            Check out rounds with CCU team

Overview of Responsibilities

Year 1-3

       a.     Serve as a member of the CCU team by participating actively in morning rounds
              and developing daily care plan for each patient on the University service.

       b.     Evaluate all new admissions to the University service.

       c.     Perform daily evaluation and progress notes on all University service patients.
              You may be asked to follow arrhythmia service patients during their admission in
              the CCU. Fellows will review these patients with the arrhythmia service
              attendings.

       d.     You will be responsible for evaluating and managing private patients in the CCU,
              if requested.

       e.     Take an active role in supervising house staff and medical students. Fellows
              should take an active role in formulating care plans, but do not perform ―resident
              duties‖, such as writing orders, discharge summaries, etc.

       f.     Assist in bedside procedures (Swan) etc. on both University and private service
              patients with attending supervision.

       g.     Communicate with referring physicians re: patient status care plan, etc.

       h.     Conduct check out rounds; informal rounds with the residents designed to review
              status of existing patients and assess new admissions.

       i.     Fellows will be responsible for all cardiac patients in the ICU and Cardiac Step
              Down Units.


5.     Suggested Reading

       Heart Disease: A Textbook of Cardiovascular Medicine. Eugene Braunwald (Editor), 6th
       Edition 2001.

       Chapter 35, Acute Myocardial infarction;
       Chapter 37, Chronic Ischemic Heart Disease;
       Chapter 39, Rehabilitation of Patients with Coronary Artery Disease;
       Chapter 40, Diseases of the Aorta;
       Chapters 18 and 21, Management of Heart Failure;
                                                                                                 23
           Cardiac Catheterization Laboratory
1.   Organization

     a.    Supervisor: Jonathan Reiner, M.D.
           Director, Cardiac Catherization and Interventional Laboratory

     b.    Faculty: Roy Leiboff, MD, Joel Rosenberg, MD

2.   Rotation Goals

     a.    Understand the indications and contraindications to diagnostic coronary
           arteriography.

     b.    Understand the indications and diagnostic value of right and left heart
           catheterization.

     c.    Understand proper measurement and interpretation of cardiovascular
           hemodynamics, including measurement of cardiac output (thermodilution, FICK,
           and other methods), shunt calculation, determination of valve stenosis and
           regurgitation.

     d.    Understand normal coronary anatomy as well as common variations and
           anomalies and demonstrate proficiency in interpretation of coronary angiograms.

     e.    Understand and demonstrate proficiency in obtaining vascular access and
           hemostasis.

     f.    Understand differences and demonstrate proficiency in selection of appropriate
           guidewires and diagnostic catheters.

     g.    Understand differences and method of selection of various contrast agents.

     h.    Understand and demonstrate proficiency in responding to complications and
           emergencies, including contrast reactions, arrhythmias, hemodynamic instability,
           dissection, and embolization.

     i.    Understand principles of radiation physics, including factors, which affect patient
           and physician exposure, and proper use of shielding.

     j.    Understand indications for intracoronary administration of nitroglycerine, calcium
           channel blockers, acetylcholine, ergonovine, and thrombolytics.

     k.    Understand indications and contraindications to balloon angioplasty, directional
           atherectomy, intracoronary stenting, rotational atherectomy, and laser angioplasty.

     l.    Understand indications and contraindications to coronary bypass surgery.

     m.    Understand and demonstrate proficiency in evaluation of left ventricular function
           and wall motion.
                                                                                            24
       3.      Overview of responsibilities: Fellows will perform diagnostic cardiac
               catheterization, including right and left heart catheterization and coronary
               angiography, under the supervision of the full-time faculty or private attendings.
               Fellows will participate on all diagnostic studies. Interventional fellows will be
               responsible for all interventional procedures. Performance of diagnostic studies
               requires all of the following:

       Year 1-3

       a.      Performance of a focused preprocedure history and physical.

       b.      Reviewing non-invasive and laboratory studies, including pre-procedure lab
               work.

       c.      Obtaining informed consent.

       d.      Review selection of guidewires, catheters, and contrast material with
               responsible attending.

       e.      Assist in performance of procedure, under the direct supervision of the
               responsible attending.

       f.      Obtain hemostasis following procedure.

       g.      Review hemodynamic data and angiograms with responsible attending.

       h.      Accurately complete cardiac catheterization report and same-day admission
               forms, where appropriate.

       i.      Perform a brief pre-discharge evaluation, including evaluation of catheter site and
               distal pulses.

       j.      Fellows will usually perform 3-6 procedures per day. Fellows will follow each of
               their patients until hospital discharge or transfer to another service.

The laboratory schedule will be posted by 4:00 pm each day. The senior fellow will assume
responsibility for dividing cases and will be expected to participate in the more challenging
cases.

Cardiac catherization is a complex task, which requires synthesis of a number of technical and
cognitive skills. Fellows will initially be given limited responsibility during each case and will
progress commensurate with their demonstrated proficiency at the discretion of the responsible
attending.




                                                                                                 25
Organization in the Cardiac Catheterization Laboratory

     1. Cardiology fellows are trainees. As such, it is the responsibility of the faculty and
        institution to foster an environment conducive to learning. Fellows will not be treated as
        technologists.
     2. Fellows (general and interventional) will scrub with members of the teaching faculty
        (full-time and voluntary). Not all attendings will be part of the teaching service. Non-
        teaching attendings will scrub with highly trained technologists or nurses.
     3. The interventional cardiology fellow will act as chief fellow in the cath lab. This role
        requires the interventional fellow to play an essential role in the training of the general
        fellows on rotation in the catheterization lab.
     4. Each morning the fellows will pick a catheterization lab in which they will scrub. When
        there are 2 general fellows on rotation in the catheterization lab, one fellow will scrub in
        catheterization lab 1 and the second fellow will scrub in catheterization lab 2. On days
        when there is an unequal distribution of cases between the rooms or the particular cases
        are inappropriate for the junior fellows (interventional procedures) the fellows may
        distribute the remaining cases equitably.
     5. The interventional fellow will float amongst the various rooms.
     6. Fellows are expected to perform an evaluation and write a pre-catheterization note on all
        patients they catheterization.
     7. It is the responsibility of the attending to generate the preliminary and final
        catheterization procedure reports. Fellows are not expected to generate these reports.
     8. Sheaths that cannot be removed in-lab will be removed by nurses or technologists.
     9. Prior to the conclusion of the day, fellows are expected to evaluate all patients they have
        performed a catheterization and write a brief post-procedure note.

4.      Suggested Reading

Textbook of Interventional Cardiology, Eric Topol, 3rd edition, W.B. Saunders Company, 1999.




                                                                                                  26
                                        Consult Service
1.      Organization

        a.     Supervisor: Richard Katz, M.D.

        b.     Faculty: Lisa Martin, MD, Allen J. Solomon, M.D., Cynthia Tracy, M.D., Jannet
               Lewis, M.D., Marco Mercader, M.D.

2.      Rotation Goals

               a.        Understand methods to risk-stratify patients referred for noncardiac
                         surgery.

                    b.    Demonstrate proficiency in performing consultative cardiology on in-
                          house patients with common cardiovascular problems, including
                          arrhythmias, coronary artery, peripheral vascular, and cerebrovascular
                          disease; and congestive heart failure.

                    c.    Identify critically ill patients who require transfer to CCU.

                    d.    Demonstrate proficiency in postoperative management of patients with
                          noncardiac surgery.

     3. Overview of Responsibilities

Year 1-3

        a.     Evaluate all new cardiology consults

        b.     Perform preoperative risk analysis and management of patients referred for
               noncardiac surgery.

        c.     Assist in the performance and interpretation of noninvasive procedures on consult
               service patients.

        d.     Perform daily follow-up of all consult service patients.

        e.     Round on a daily basis with the faculty attending.

        f.     Supervise and educate residents and medical students assigned to the consult
               service.

        g.     Be able to assist in the management of any private cardiology patient admitted to
               the ICU, following a request by the attending physician.




                                                                                                   27
                                    Inova Fairfax Hospital

                       Cardiac Transplant - Coronary Care Unit

1.   Organization

                 a.       Rotation Supervisor: Shashank Desai, MD

                 b.       Faculty: Joseph Kiernan, MD

2.   Rotation Goals

     1) To learn the evaluation process of potential heart transplant candidates
     2) Evaluation of potential heart transplant candidates
                    types of cardiac diseases for which transplantation is an option
                    indications for transplantation
                    contraindications to transplantation
     3) Evaluation of the potential heart donor.
     4) Understand the indications for an exercise VO2 test. Observe and be able to interpret the
         results of an exercise VO2 test.
     5) Observation of heart transplant and LVAD surgery
     6) Catheterization of and understanding the hemodynamics potential heart transplant
         recipients
     7) In-house management of heart transplant recipients in the peri-operative period
                    Hemodynamic management of heart recipients
                    Infectious disease prophylaxis
                    Diagnosis and management of acute allograft rejection
                    Immunosuppression
     8) Indications for LVAD placement
     9) Inpatient and outpatient management of LVAD patients
     10) Management of heart failure patients
     11) Outpatient management of heart transplant recipients
                    Outpatient monitoring of the cardiac allograft
                    Endomyocardial biopsy interpretation of heart recipients
                    Outpatient immunosuppression management
                    Recognition and management of long-term complications
                    Management of patients with pulmonary hypertension
          Assessment and work-up of patients with pulmonary hypertension
          Indications for the various available therapies
          Short-term vasodilator studies
          Initiation and ongoing management of heart failure / pulmonary hypertension patients
             with;
              continuous intravenous epoprostenol
              IV or subcutaneous treprostinil
              inhaled iloprost therapy
              bosentan
              sildenafil
              IV milrinone / dobutamine
                                                                                                    28
 Fellow activities and expectations

 Schedule:


             8-9 am       9-10 am      10-11 am     11-12pm      12-1 pm    1-2 pm      2-3 pm       4-5pm

Monday       7:00 am      Outpatient   Outpatient   Outpatient lunch        Consults/   Consults/    Review
             EMBx                      clinic       clinic                  PH pts      review Hx    labs/inpts
             Inpatients   Inpatient    Inpatient    Inpatient                           labs
                          Rounds       Rounds       Rounds
Tuesday      HF/Tx        Inpatients   Outpatient   Outpatient       GR     GR          Consults/    Review
             meeting                   clinic       clinic                              review Hx    labs/inpts
             Starts at 7 Inpatient     Inpatient    Inpatient                           labs
             am to 8 am Rounds         Rounds       Rounds
Wednesday    Inpatients Outpatient     Outpatient   Outpatient Lunch**      Consults/   Consults/    Review
                         Inpatient     clinic       clinic                  PH pts      review Hx    labs/inpts
                         Rounds        Inpatient    Inpatient                           labs
                                       Rounds       Rounds

Thursday     7:00 am      Outpatient   PPH clinic   PPH clinic   Lunch***   Consults/   Consults/    Heart/lungTra
             EMBx         Inpatient    Inpatient    Inpatient               PH pts      review Hx    nsplantmeetin
             Inpatients   Rounds       Rounds       Rounds                              labs         g*
Friday       Inpatients   Inpatient    Inpatient    Inpatient    lunch      catchup     Review
                          Rounds       Rounds       Rounds                              labs/inpts




 * _ Adult congenital heart program meeting/clinic – 1st and 3rd Thursday of the Month 4-6:30
 ** - Transplant grand rounds every 4th Wednesday
 *** - Heart/lung journal club 4th Thursday of every month
 GR- medical grand rounds
 Lab review: 4:00 pm daily

 All Fellows are expected to have a Virginia medical license or temporary license at the
 start of the rotation. They should bring a copy of this with them on the first day of the
 rotation.
 Inpatients will include: Heart transplant recipients, heart failure patients, LVAD patients and
 PAH patients.
 Fellows will be expected to participate in all the activities outlined in the schedule above.
 Fellows will be expected to take call two of the weeks and two out of the four weekends.
 Procedures which will be performed on occasion and in which the Fellow will participate include:
 endomyocardial biopsies (Monday and Thursday am starting at 7am). The Fellow should check
 with the Coordinators the day before to see if there are any EMBx’s on the schedule.
 left and right cardiac catheterizations. These could happen anytime on any given day. The
 Fellow should check at the start of the week to see if there are any caths schdeuled.
 Fellows will be expected to present 1-2 articles at the monthly journal club.




                                                                                                     29
 Heart transplant Coordinator time table:
Time      Monday              Tuesday              Wednesday            Thursday             Friday
08:00     Clinic              Heart transplant     Clinic               Clinic               administrative
                              meeting STARTS
                              AT 7 am to 8 am.
09:00     Clinic              administrative       Clinic               Clinic               administrative
10:00     Clinic              administrative       Clinic               Clinic
11:00     In Patients         In Patients          In Patients          In Patients          In Patients
12:00     lunch               lunch                lunch                lunch                lunch
13:00     administrative      administrative       administrative       administrative       administrative
14:00     administrative      administrative       administrative       administrative       administrative
15:00     Review labs         Review labs          Review labs          Review labs          Review labs
16:00-    Call backs          Call backs           Call backs           Collaborative        Call backs
16:30                                                                   practice meeting
                                                                        until 17:00

 Clinic: (4- 10 patients)
 Routine follow- up visits including, initial weekly to every 3 month as per protocol and yearly visits
 Endomyocardial biopsies along with routine clinic visits ( If groin stick are seen in ICAR)
 Full cath and biopsy patients (or rarely cath only) are seen in ICAR
 Lab only visits/ outside labs: labs reviewed and patients are called back with in 1 business day.
 Sick visits ( may be any week day between 08:00 and 15:00)

 Includes:
 H+P: (including evaluation of comorbidities and complications)
 Medication review
 Health maintenance review
 Periodic psychosocial review
 Lab results reviewed after received
 Results and Plan called to patient with in 1 business day

 Endomyocardial biopsies on Mondays and Thursdays: (1-5 procedures)
 Usually done via RIJ in transplant clinic biopsy suite
 They are scheduled according to protocol and PRN
 All biopsies are followed by clinic visits

 Cardiac caths: (0-3 procedures) May not be on clinic days
 Usually done via groin in Cath lab
 Labs done 7-10 days prior to procedure
 Patients seen at time of lab draw (if labs allowed at IFH) or in ICAR after procedure.
 Results and plan called to patient within 1 business day




                                                                                                              30
                                         Section 4
                                        Conferences
(See Appendix II for 2008-2009 schedules)

A.     Goals of didactic conference series: A well-organized comprehensive conference series
       is essential to training in Cardiovascular Disease. This conference series should provide
       organized instruction in both core (areas of fundamental knowledge essentials for all
       trainees) and non-core (topics which stress the depth and breadth of knowledge) and
       topics in both basic and clinical science areas. In addition, the conference series is an
       excellent opportunity to reinforce knowledge gained at the bedside and an opportunity to
       review and discuss interesting cases.

B.     Protected conference time: The conference times will be, to the greatest extent possible,
       protected from clinical responsibilities, so that all fellows can attend as many conferences
       as possible. It is recognized that some exceptions are necessary given the nature of
       Cardiology. In general, however, Fellows will not be requested to perform routine
       clinical responsibilities, including elective consultations and non-invasive examinations,
       during conference times.

C.     Weekly conferences

       1.     Core Curriculum Conference
              a.    Time: Monday, 8:00 - 9:00 am
              b.    Location:       4th Floor Conference Room
                                    MFA
              c.    Coordinator: Allen J. Solomon, M.D.
              d.    Goals/Structure: The core curriculum conference will consist of organized
                    lectures covering topics of essential knowledge. Both George Washington
                    faculty and selected outside faculty will provide approximately one half of
                    the lectures. Fellows will be expected to present the other one half. The
                    series will repeat at approximately yearly intervals, so that each Fellow
                    will have an opportunity to hear several lectures on each core topic
                    throughout his or her Fellowship. Core topics in the arrhythmia and
                    imaging conferences will be discussed at the appropriate conference.

2.            Cardiac Catheterization Conference
              a.      Time: Tuesday, 8:00-9:00 am
              b.      Location:      6th Floor Conference Room
                                     Main Hospital
              c. Coordinator: Jonathan Reiner, M.D.
              d. Goals/structure: Interesting and challenging cases will be presented to faculty
              (medical and surgical), Fellows, and students by the Fellows rotating on the
              cardiac catheterization service. The cases will then be discussed, and various
              issues pertaining to patient management will be discussed. It is expected that
              through attendance at this conference, Fellows will gain insights into the decision-
              making process involving coronary artery disease management including
              performance of coronary interventions and coronary bypass surgery.

                                                                                                31
3.   Non-Invasive Cardiology Conference
     a.    Time: Wednesday, 8:00- 9:00 am
     b.    Location: Location: 6th Floor Conference Room
                                  Main Hospital
     c.    Coordinator: Jannet Lewis, M.D.
     d.    Goals/structure: This conference provides a core curriculum of didactic
           lectures on the principles and practice of cardiac ultrasound, nuclear
           imaging and cardiac MR; interpretation of interesting echo cases; guest
           lectures and ―debates‖ on controversial topics in cardiology.

4.   Cardiology Grand Rounds
     a.    Time: Wednesday, 5:00-6:00 pm
     b.    Location: 6th Floor Conference Room
                       Main Hospital
     c.    Coordinator: Allen Solomon, MD
     d.    Goals / Structure: During this conference, invited speakers will give
           exciting talks on new areas of study in Cardiovascular Medicine.

5.   ECG/Arrhythmia Conference
     a.   Time: Friday, 8:00-9:00 am
     b.   Location:       6th Floor Conference Room
                          Main Hospital
     c.   Coordinator: Cynthia Tracy, M.D.
     e.   Goals/structure: ECG/Arrhythmia conference will be divided such that
          approximately one-third of conferences involve reading of unknown
          ECGs, one-third consist of didactic lectures on core arrhythmia topics, and
          the final third will be a discussion of interesting arrhythmia cases. The
          core lecture series will rotate on approximately yearly basis.

6.   Journal Club
     a.    Time: Tuesday, 12:00 noon -1:00 pm
     b.    Location:        4th Floor Conference Room
                            MFA
     c.    Coordinator: Allen J. Solomon, M.D.
     d.    Goals/structure: Two to three interesting articles from the current
           cardiology literature will be critically reviewed during each conference. It
           is the goal of this conference to teach fellows the skills necessary for
           critical scholarly reviews of the literature, and to keep the fellows and
           faculty abreast of current literature.

7.   Cardiology Board Review
     a.    Time: Thursday, 8:00 -9:00 am
     e.    Location:        6th Floor Conference Room
                            Main Hospital
     f.    Coordinator: Allen J. Solomon, M.D.
     g.    Goals/structure: Approximately 50% of the conferences will involve a
           discussion of sample Cardiology Board Review questions. The other 50%
           will be didactic presentations of key topics in cardiovascular medicine. It
           is the goal of this conference to teach fellows the skills necessary for
                                                                                     32
                     performing at a high level on the Cardiology Boards.

8.           Medicine Grand Rounds
             a.    Time: Thursday, 12:00-1:00 pm
             b.    Location: Ground floor Auditorium
                               Main Hospital
             e.    Coordinator: Alan Wasserman, MD
             f.    Goals / Structure: During this conference, invited speakers will give
                   exciting talks on new areas of study in Internal Medicine.

D.           Monthly Conferences:

      1.      Cardiology Morbidity and Mortality
              a.     Time: First Wednesday of the month, 5:00-6:00 pm
              b.     Location:     6th Floor Conference Room
                                   Main Hospital
              c.     Coordinator: Jonathan Reiner, M.D.
              d.     Goals/Structure: Morbidity and mortality related to the CCU Service will
      be reviewed along with the associated cardiac pathology.

      2.      Cardiovascular Research Conference
              a.      Time: Third Wednesday of the month, 5:00-6:00 pm
              b.      Location:      6th Floor Conference Room
                                     Main Hospital
              c.      Coordinator: Allen Solomon, M.D.
              d.      Goals/Structure: A member of the George Washington University faculty
      will present an overview of their research. This will consist of a research presentation and
      a careful critique by the audience.



D.    Other Conference Opportunities

      Cardiovascular Surgery Morbidity and Mortality Conference. This conference is
conducted the second Wednesday of each month at 7:00 am in the Surgery Conference Room.




                                                                                               33
                                           Section 5
                                           Research

       The Program is embarking in an ambitious effort to promote clinical research by
            providing Fellows with continuous blocks of time during the second and third year of
            training. Direct involvement of the fellow in a research program is designed to
            enhance their scholarly development, provide a foundation for logical and critical
            thinking and encourage life-long habits of continuing scholarship. Through their
            research experience, each fellow will learn:
       • the design and interpretation of research studies
       • the evaluation of investigative methods and the interpretation of data
       • to develop competence in critical assessment of the medical literature

       Second and third year fellows are given six to twelve months of research time.
       Depending upon the progress of their investigations, more months may be allocated for
       research. This time is dedicated to research.

       The fellow has the opportunity to participate in at least one major research project under
       the guidance of a Faculty member. The conduct of other, smaller projects is also
       encouraged. This takes the form of case reports, chart reviews, and small clinical
       projects.

       During the first year the fellows are introduced to the research interest of the faculty. It is
       expected that during fall of that year, each fellow will discuss projects with various
       faculty members and then decide on a research theme. One faculty member will act as a
       preceptor for the project and will meet frequently with the fellow to review his or her
       work. It is fully expected that a fellow will initiate and complete one or two projects
       during the fellowship training. Funding will be made available from Divisional resources
       to permit each fellow to present and accepted paper or abstract at regional and
       national meetings and to pursue a wide range of individual studies.

       During the third year of training the fellow is expected to give a Research Seminar,
       present the findings of the study at a national meeting (AHA, ACC, ASE, or HRA) and,
       under faculty supervision, write a manuscript for submission to a scientific or clinical
       journal

A.       Research Goals: The George Washington University Cardiology program is committed
to the training of academic cardiologists. This training includes opportunity to learn research
methodology and perform scholarly research projects. The ultimate goal of the research rotation
is to develop skills necessary to become and independent researcher. At the conclusion of the
research rotation, each Fellow will demonstrate understanding and proficiency in the following
areas:

1.    Design of a research project
2.    Completion of appropriate regulatory forms (IRB, Animal Care and Use Committee, etc.)
3.    Implementation of research protocol
4.    Data collection and database management
5.    Statistical analysis, including analysis of power

                                                                                                    34
6.     Data analysis presentation.

Fellows are encouraged to submit abstracts of completed work to the American College of
Cardiology and the American Heart Association for national presentation.

B.    Dedicated research time: It is expected that each Fellow will have approximately twelve
months of dedicated research time, during which clinical responsibilities will be minimal.

C.     Research Schedule: A schedule has been developed to aid fellows in creating a research
program and grant proposal (See Appendix III)

D.      Mentor Program: Fellows may choose a research mentor depending on their interests.
Dr. Allen Solomon will help in the selection process. Fellows will be expected to meet with
their research mentor on a regular basis (at least twice yearly to discuss their research goals and
progress). Fellows may ultimately choose --but are not required-- to work with their research
mentor during their dedicated research time. It is hoped that the fellow can assist the research
mentor in ongoing longitudinal projects while they are on clinical rotations.

E.      Research opportunities: A number of research opportunities exist within the Division of
Cardiology at George Washington. Finally, a number of excellent research opportunities exist
within the basic sciences at George Washington, including the Departments of Pharmacology
and Physiology. A brief summary of potential research opportunities is listed below.

       1.      George Washington

               a. Lipid Disorders Center: A number of clinical projects and drug studies are
                  currently underway, under the direction of Dr. Lisa Martin. These include the
                  effects of simvastatin and atorvastatin on lipid profiles, titers of anti-
                  antibodies to oxidized LDL and blood levels of vitamin E in men and women
                  over age 65 years with and without coronary and/or cerebrovascular disease.

               b. Congestive Heart Failure Clinic. This clinic, under the supervision of Dr.
                  Shashank Desai is currently conducting a number of studies in congestive
                  heart failure.

               c. Cardiac Catheterization Laboratory. There is a wide range of research
               opportunities available at George Washington University under the direction of
               Dr. Jonathan Reiner.

               d. Arrhythmia Service. The Arrhythmia Service, under the direction of Dr.
               Cynthia Tracy, has a number of ongoing studies, including:

               i.      Atrial Fibrillation Ablation

               ii.     Electroanatomical mapping systems

               iii.    Multicenter coordinating site for catherer ablation studies

               iv.     Non-thoracotomy defibrillators


                                                                                                  35
              v.      New indications for cardiac pacing

              vi.     Post operative arrhythmias following cardiac surgery

              vii.    Biventricular Pacing, with special emphasis on cardiac resynchronization

              ix.     Clinical Trials

              x.      Autonomic nervous system in arrhythmogenesis

              xi.     Sudden cardiac death in ESRD

              xii.    Atrial fibrillation

              xiii.   Laboratory evaluation of new genetic markers

               e.      General Echocardiography Research: The Echocardiography laboratory
       is involved in a number of research protocols, including the use of 2D and 3D ECHO.

       2.     National Institute of Health: A number of research opportunities are available at
       the NIH, including cardiac MRI, Interventional Cardiology, molecular genetics, and basic
       science projects.


E.     Research Conferences

A number of conference opportunities exist within the Division of Cardiology and Department of
Medicine. These include:

       1.     Department of Medicine core curriculum in research methodology.

       2.     Department of Medicine annual research conference: The Department of
              Medicine holds an annual research conference. This all-day conference included
              both oral and poster presentations of research within the Department of Medicine.

       3.      Department of Medicine monthly research conference: The Department of
       Medicine sponsors a monthly research conference highlighting research achievements
       with the Department. The Division of Cardiology conducts this conference on a rotating
       basis, presenting conferences approximately twice annually.

F.      Research Funding and Support: Although not required, Fellows are encouraged to
apply for research awards and fellowships. These awards are invaluable in supporting research
efforts and fostering academic careers. A number of support opportunities for Fellows are
available, including:


       1.     Lynn B. and Richard V. Cheney Cardiovascular Institute: GW fellows will
              be eligible to apply for research grants through this institute. Application
              deadlines are on June 1 and December 1 in each academic year. Applicants may
              request up to $25,000 for 1 year (allowable expenses include salary support,
                                                                                             36
       equipment, supplies, publication / presentation costs and travel).

2.      American Heart Association Nation’s Capitol Affiliate Fellowship awards: Due
date early December, annually. Three awards are available each year for post-doctoral
fellows performing research within the District of Columbia.

3.     Merck/American College of Cardiology Research Awards: Approximately five
awards are available each year for scholoary research activities. This is a highly
competitive award available only to ACC affilliates-in training.

4.     Pfizer Research Awards: These are competitive awards available to call
Cardiology Fellows.

5.     Hewlett-Packard Fellow Research Awards: Competitive awards awarded
annually for proposals involving diagnostic cardiology imaging.




                                                                                  37
                                       Section 6
                                    Ambulatory Care
A.      Goals: Experience in longitudinal care is essential to modern cardiovascular training.
This is especially true as a greater percentage of American health care is conducted on an
outpatient basis. Fellows will be expected to demonstrate proficiency in managing chronic
cardiovascular problems, including hypertension, hyperlipidemia, chronic stable angina,
congestive heart failure, arrhythmias, peripheral vascular disease, and other disorders. In
addition, routine preventive health care, including cardiovascular risk factor modification such as
cholesterol reduction and smoking cessation, will be learned.

   B.     Structure of the ambulatory experience: Each Fellow will be assigned to a
          cardiology clinic, along with a member of the Attending staff. This continuity clinic
          experience will meet for one half day each week for the entire three years of
          fellowship training. The Fellows will be encouraged to take a primary care
          responsibility for patients in their clinic. Fellows will be under the direct supervision
          of an attending and each patient will be reviewed. This experience provides an
          opportunity to develop an understanding of the natural history of cardiovascular
          disease over an extended period of time. During these ambulatory sessions, the fellow
          assumes an active role in the initial evaluation and follow-up care of patients assigned
          to him/her. The fellow is responsible for careful review of all laboratory tests and
          abnormal results will be discussed with attending faculty. Fellows are responsible for
          telephone communication with their patients, including the discussion of results, side
          effects of prescribed medications, prescription orders, and referrals to outside
          agencies. The goal of this experience will be for the fellows to gain expertise in the
          outpatient evaluation and efficient and cost-effective management of pulmonary
          diseases. The fellow will also learn to interact with other members of the health care
          team, especially nurses, physical and occupational therapists, residents and attending
          physicians in other specialties.
   C.
        All patients are seen under the direct supervision of the assigned attending physician. No
        patient is to be seen by a fellow without also being physically interviewed and examined
        by the attending physician. Patients to be discharged from the outpatient area should be
        reviewed and discussed with the attending prior to the discharge. ALL NOTES MUST
        BE ENTERED INTO THE TOUCHWORKS SYSTEM. The attending must review the
        resident’s dictation. Faculty supervision of the Fellow must assure that quality patient
        care is provided. This includes examining, evaluating and writing an attending note of the
        patients for each visit. The Fellow will be given progressive clinical responsibilities to
        assure achievement of skills necessary for independent practice as completion of the
        Fellowship Program. The attending physician retains final responsibility for patient care
        and billing.




                                                                                                 38
                                       Section 7
                                  Evaluation/Feedback
Regular thorough evaluation of performance and appropriate feedback is essential for the
professional growth and development of fellows. Likewise, a Fellow shall have the opportunity
to periodically evaluate the program in order to strengthen and continually improve the
Fellowship training experience. Examples of evaluation form are contained in appendix IV.

A.      Rotation Evaluations: All Fellows will be evaluated at the end of each rotation by the
principal supervisor(s) of their respective rotations, using the Internet based E value system. The
ABIM approved evaluation form for cardiovascular trainees, which uses a performance scale of
0-9, will be utilized for this purpose. All evaluations will be confidential and maintained within
the Fellow’s file, and available for periodic review.

       The evaluation of fellows is done on a monthly, semiannual and annual basis as described
       below.

       • At the end of each monthly rotation written evaluations are obtained by fellows from
       the faculty supervising the fellow after the end of these monthly rotations. Teaching
       faculty is responsible for discussing these evaluations with the fellows.

       • These evaluations attempt to evaluate Clinical Competencies, including patient care,
       medical knowledge, procedural skills, practice based learning, attitudes and interpersonal
       relationships, as well as professionalism. The evaluations are documented on the forms
       suggested by the American Board of Internal Medicine. The attending reviews the
       evaluation with the fellow at the end of the rotation.

       • These evaluations are reviewed by the Program Director.

       • CREDIT FOR THE MONTHLY ROTATION 'WILL BE GIVEN ONLY AFTER THE
       EVALUATIONS ARE SUBMITTED TO THE PROGRAM DIRECTOR.

       • Each procedure performed by the Cardiovascular fellows is to be documented in a
       procedure log sheet by the fellow including the indications and complications. This is to
       be countersigned by the supervising attending who attests to the performance of the
       fellows whether it was satisfactory or unsatisfactory.

       • Maintenance of procedure logs for all invasive and non-invasive procedures is
       mandatory for all fellows. These will be monitored on a yearly basis for completeness
       and accuracy.

       • Fellows are responsible for having their log books counter signed and submitted to the
       Program Director by the end of the rotation.

       • Fellows are encouraged to review their personal folder and review their evaluations on a
       regular basis. All evaluations received are reviewed by the program director who
       forwards them for the comments by fellows only if laudatory comments are made or
       reservations are expressed about the performance.


                                                                                                39
       • The Program Director meets with the fellows every six months. The Program Director
       reviews the evaluations for the previous six months with them, gives an assessment of
       their progress, prepares a cumulative evaluation and updates the level of privileging for
       procedures.

B.     Annual Performance Evaluation: At the end of each academic year, the Fellowship
Director will review all rotation evaluations for that year with the Fellow. First year Fellows will
also have a mid year evaluation. There are several goals to the annual performance evaluation,
including provision of the opportunity for mutual feedback, identification of strengths and
weaknesses, and discussion of research interests and career goals.

C.      Fellow Evaluations of Faculty: Each Fellow is asked to evaluate the quality of faculty
instruction using a five-point likert scale in nine categories. Results are compiled by the
Fellowship Coordinator, and confidentiality is maintained. Except for those instances in which
written permission is provided by the Fellow, information is shared only in aggregate form as
part of academic quality review efforts within the Division.

D.      Annual Fellow Evaluation of Program: The Director of Fellowship Training will
distribute a comprehensive evaluation form to be completed by each Fellow at least once in each
academic year. This will provide an opportunity for Fellows to anonymously review fellowship
rotations and conferences, as well as individual faculty members. These will be reviewed in
aggregate form by the Fellowship Director and faculty members, along with Faculty Evaluation
data for each rotation, and changes in the program will be made where appropriate.

E.      Procedure Log: Fellows are required to maintain a log of all invasive procedures,
including a description of procedure, patient name, and supervisor. Logs must be kept up to date
and forwarded to the Fellowship Director at the end of each year. They will then be placed in the
Fellow’s file and during the annual performance evaluation. Please note that the Fellowship
Director will be unable to verify eligibility for the Boards or credentials for hospital procedure
unless this log is complete.

F.     Fellows Meetings: A meeting of the Fellows and the Fellowship Director will be held on
a bimonthly basis. Using an informal format, the Fellows will be updated as to news within the
University, Department of Medicine, and Division of Cardiology. This will also serve as a
forum for the Fellows to alert the Faculty as to ongoing problems. Additional Fellow meetings
may by requested by the Fellows at any time, as needed.

G.     Mechanisms for Remediation: Any serious weaknesses identified during the annual
performance evaluation or at any time during the fellowship will require remediation. Specific
remediation will be determined by the Fellowship Director and faculty.

H.     Open Door Policy: Fellows are welcome to discuss personal problems, grievances, or
request career counseling at any time.




                                                                                                 40
            General Competencies in Cardiovascular Medicine

The Fellowship Program in Cardiovascular Medicine provides residents adequate opportunity to
become leaders in the organization and management of patient care. The Cardiology Fellowship
program emphasizes scholarship, self-instruction, development of critical analysis of clinical
problems, and the ability to make appropriate decisions. Appropriate faculty supervision of the
residents must be provided during all of their educational experiences. Cardiology fellows
participate in six main areas: (1) Coronary Care Unit; (2) Cardiac Catheterization Laboratory; (3)
Echocardiography; (4) Nuclear Cardiology; (5) Arrhythmia; and (6) Cardiac Consultation. The
level of participation in clinical procedures and care is progressively increased relative to the
acquisition of skill sets by the Resident. The rate of progression varies with each Resident and is
regulated by the Faculty. No procedures are performed without direct Faculty participation.


Learning Venues                                                     Evaluation Methods

1. Performance and interpretation of ECHO studies                   A. Attending Evaluation
2. Performance and interpretation of Nuclear studies                B. Direct Observation
3. Performance of cardiac consultation                              C. Fellow Evaluation
4. Clinical inpatient and outpatient care of cardiac patients       D. Written Examination
5. Weekly conferences                                               E. Procedure logs
6. Attendance at national meetings relating to Cardiology           F. Developing 360 degrees
7. Management of CCU patients
8. Performance of Cardiac Catheterization
9. Management of Arrhythmia patients
10. Self study



 Competency: Patient Care:         Learning Venues                 Evaluation Methods
 ECHO
 Demonstrate the ability to        1,3,4,5,6,7,10                  A,B,C,E
 perform and interpret an
 ECHO study
 Demonstrate ability to            1,3,4,5,6,7,10                  A,B,C,D
 generate differential
 diagnosis, diagnostic strategy,
 and to define appropriate
 therapeutic plan and
 modifications to ongoing
 therapy in patient undergoing
 ECHO as detailed in the
 specific program content
 Demonstrate the ability to        1,3,4,5,6,7,10                  A,B,C,D
 choose appropriate patient
 selection for ECHO as
 detailed in the specific
 program content

                                                                                                41
Competency: Patient care:
Cardiac catheterization
Demonstrate the ability to        3,4,5,7,8        A,B,C,E
perform and interpret results
of cardiac catheterization as
detailed in the specific
program content
Demonstrate the ability to        3,4,5,7,8        A,B,C
recognize and manage
complications related to
performance of cardiac
catheterization as detailed in
the specific program content
Demonstrate the ability to        3,4,5,7,8        A,B,C,D
choose appropriate patient
selection for catheterization
recognizing indications and
contraindications
Competency: Patient Care:
Nuclear Cardiology
Demonstrate the ability to        2,3,4,5,6,7,10   A,B,C,E
perform and interpret nuclear
cardiology studies
Demonstrate the ability to        2,3,4,5,6,7,10   A,B,C
recognize and treat
complications related to
nuclear studies
Demonstrate the ability to        2,3,4,5,6,7,10   A,B,C,D
choose appropriate patient
selection for nuclear studies,
including indications and
contraindications as well as
awareness of current relevant
clinical trials
Demonstrate the ability to        2,10             A,B,C,D
understand specific issues
related to the use of
radioisotopes
Competency: Clinical
inpatient and outpatient
care of cardiac patients
Demonstrate the ability to use    4                A,B,C
history, physical exam,
laboratory and ancillary tests
to assess cardiology patients
Demonstrate the ability to        4                A,B,C
generate differential
diagnosis, diagnostic strategy,
and to define appropriate
therapeutic plan and
                                                             42
modifications to ongoing
therapy in cardiology patients
Competency: Medical
Knowledge
Articulate the                   1,2,3,4,5,7,8          A,C,D
pathophysiology, evaluation,
and management of
cardiology patients
Articulate the pathology, the    4,5,6,8                A,D
epidemiology and clinical
trials of cardiac patients and
their impact on clinical
practice as detailed in the
specific program content.
Competency: Interpersonal
and Communication Skills
Interact in an effective way     1-4, 7-9               A,B,C,F
with physicians and nurses
participating in the care of
patients requiring cardiac
consultation or care
(including physicians
requesting consultation,
fellows, attendings, medical
students, and nursing unit
personnel)
Show understanding of            1-4, 7-9               A,B,C,F
differing patient preferences
in diagnostic evaluation and
management of cardiac
diagnoses
Competency:
Professionalism
Treat team members, primary      1,2,3,4,5,6,7,8,9,10   A,B,C,F
care-givers, and patients with
respect
Actively participate in          1-10                   A,B,C,F
consultations and rounds
Attend and participate in all    5,6                    attendance, A,F
scheduled conferences
Competency: Practice-
Based Learning
Identify limitations of          1,2,4,5,6,7,8          A
medical knowledge in
evaluation and management
of cardiac patients and use
medical literature (primary
and reference) to address
these gaps in medical

                                                                          43
knowledge
Competency: Systems-
Based Practice
Understand barriers to          1,2,3,4,7,8   A
optimal care of patients with
cardiac diagnoses
Understand need for effective   1,2,3,4,7,8   A
communication between
multiple caregivers and sites
(e.g., electrophysiologists,
primary care physicians,
cardiologists, surgeons,
nurses, dieticians, social
workers, and hospitals, in
delivering optimal care to
arrhythmia patients




                                                  44
                                 Section 8
                     Terms and Conditions of Employment

A.      Appointment: The Division of Cardiology participates in the Medical Specialties
Subspecialty Match (MSMP) of the National Resident Matching Program (NRMP).
Applications for the program will be available on-line in the summer of each academic year.
Deadline for receipt of completed applications will be December 31. Interviews will be
conducted in March and April, and successful candidates will be notified through the Match in
June. Only candidates expected to complete an ACGME-approved three-year training program
in Internal Medicine will be considered. Foreign medical graduates will be considered if they
have successfully met the requirements for ECFMG certification and completed an ACGME-
approved residency training program in Internal Medicine. Each Fellow will be required to
complete a George Washington University Hospital appointment form once notified of the
results of the the March.

B.     Reappointment: Fellows are appointed for one-year terms. They will be required to
complete a new appointment form at the end of each academic year. It is anticipated that all
fellows entering the program will complete three consecutive years of fellowship training, after
which they will be board-eligible in Cardiovascular Disease.




                                                                                               45
 APPOINTMENT
Medical Center offers and the Resident Physician accepts an Appointment at the Medical Center in
(program) for a period of one (1) year, unless terminated sooner in accordance with the provisions
of this Agreement or the Resident Manual, as amended from time to time (the "Term"). No
appointment beyond the Term is promised, assured, or to be implied by an agreement.
Reappointment shall be determined in accordance with the specific policies set forth in the Resident
Manual.
 FINANCIAL SUPPORT
Medical Center shall pay Resident Physician annual financial support according to the PGY level
and the salary scale approved by the Medical Center in equal bi-weekly installments during the
Term, unless the Agreement is terminated, in which case, Resident Physician shall not be entitled to
any Medical Center financial support or benefits under an agreement as of the effective date of the
termination.
 RESIDENT MANUAL
The Resident Manual provides detailed information about the benefits and obligations of Resident
Physicians who participate in the Program. The policies, terms, and conditions of the Resident
Manual are incorporated by reference into a Residency Agreement, and Resident Physician will
acknowledge receipt of the Resident Manual and agrees to abide by its policies, terms, and
conditions, as they may be amended from time to time. The following provisions identify some, but
not all, of the requirements set forth in the Resident Manual.
 RESIDENT BENEFITS
Among other things, the Resident Manual describes the benefits Medical Center affords Resident
Physician during the Term. In particular, the Resident Manual addresses vacation, professional
liability insurance, disability insurance, health insurance, professional, parental, and sick leave,
living quarters, meals and laundry or equivalents, medical and psychological counseling and other
support services, payment of DEA registration fees, reimbursement for certain medical licenses,
and other potential benefits. Moonlighting and Grievance Procedures are also set forth in the
Resident Manual which will be provided to you with your Residency Agreement if accepted into
the program.
 MEDICAL CENTER OBLIGATIONS
Educational Experience/ACGME Standards.Medical     Center agrees to provide a suitable academic
environment for the educational experience of the Resident Physician and graduate medical
education or graduate clinical training which substantially meets the standards and essentials of the
Accreditation Council for Graduate Medical Education ("ACGME") and its Residency Review
Committee. Medical Center will conduct regular evaluations of the learning and competence of the
Resident Physician, including a combination of supervised, more complex and independent patient
evaluation and management functions and formal educational activities, and will maintain a
confidential record of such evaluations.
Harassment. Medical Center agrees to comply with its policies and procedures governing harassment
complaints. A copy of the policy is set forth in the Resident Manual.
Resident Manual. Medical Center will make reasonable efforts to notify Resident Physician of any
material changes in the Resident Manual. Medical Center 's current notice practice is to mail
changes to the Resident Manual to the last current address of Resident Physician maintained by the
Office of Graduate Medical Education. It is the Resident Physician's responsibility to provide the
Office of Graduate Medical Education with his or her current address and any changes thereto.
RESIDENT PHYSICIAN’S OBLIGATIONS
By entering into an agreement, Resident Physician agrees to undertake many academic and clinical
obligations in exchange for the educational and academic opportunity to participate in the Program
at PGY Level identified in the Residency Agreement. Many of these Resident Physician's
obligations have been are set forth in the Program's documents, the Resident Physician's job

                                                                                                46
description, and the Resident Manual, among other documents, each of which Resident Physician
acknowledges have been provided or made available to Resident Physician, he or she has read and
agrees to furnish, and which are incorporated into an agreement by reference.
Clinical and Educational Requirements. Resident Physician shall use his/her best efforts, judgment and
diligence in fulfilling the duties, tasks, responsibilities and any other clinical and educational
requirements, of whatever nature, in a professional and appropriate manner, as assigned to the
Resident Physician during the duration of the Program. Resident Physician acknowledges that a
failure to fulfill such requirements may result in disciplinary action, including but not limited to
termination, as outlined in the Resident Manual. Resident Physician shall at all times meet the
qualifications for resident eligibility outlined in the Essentials of Accredited Residencies in
Graduate Medical Education in the ACGME Directory.
Licensure. Resident Physician shall timely obtain and shall maintain in good standing appropriate
licensure, or exemption from licensure, in accordance with state and local law, as described in the
Resident Manual or otherwise communicated to Resident Physician.
Medical Records. Resident Physician shall complete all discharge summaries and all other medical
records related to the activities assigned to the Resident Physician in accordance with the policy
outlined in the Resident Manual.
OSHA Training. Resident Physician shall complete OSHA training, as set forth in the Resident
Manual, not later than July 31st of the Term.
Medical Clearance. Resident Physician shall obtain medical clearance prior to participating in any
clinical activities in accordance with Medical Center policy. Such clearance shall be completed not
more than three (3) months prior to, nor more than fifteen (15) days after the commencement of the
Term.
Cooperation/Assistance in Litigation. Resident Physician will assist and cooperate fully with Medical
Center in the defense of any and all claims and litigation brought against Medical Center, its
insurance company/ representatives and attorneys, teaching faculty and employees or teaching
centers or health care facilities in which Resident Physician rotates and their employees, including
but not limited to, the physician faculty, residents, interns, students, and agents in any way relating
to or arising out of Resident Physician's activities in the Program. Resident Physician agrees to
make himself/herself available in the District of Columbia for litigation preparation, meetings,
depositions and trial testimony. This obligation shall survive the termination or expiration of an
agreement and his/her appointment in the Program.
Inventions. All inventions, discoveries and improvements invented, developed or discovered by the
Resident Physician while performing his/her duties and responsibilities under the residency
program of Medical Center shall be and remain the sole and exclusive property of Medical Center .
The Resident Physician shall promptly disclose in writing to his/her Program Director and
Department Chair all such inventions, discoveries and improvements and shall execute from time to
time, during or after the termination of the appointment, any documents, including without
limitation, applications for letters of patents and assignment thereof, as may be deemed necessary
or desirable by Medical Center, to effectuate the provisions of this Agreement. All inventions,
discoveries and improvements invented, developed or discovered by the Resident Physician outside
the scope of his/her responsibilities under the residency program are not the property of Medical
Center and issuer not controlled by this section. This provision shall survive the termination of an
agreement.
Resident Manual. Resident Physician shall be familiar with and abide by the policies, terms, and
conditions of the Resident Manual. Resident Physician shall keep current with any and all changes
made thereto.
Visas. Resident Physician shall obtain, as applicable, appropriate visas for training.
Compliance with Law. Resident Physician shall comply with all applicable state and federal laws and
regulations.
                                                                                                 47
 DISCIPLINE
Medical Center shall conduct disciplinary actions involving Resident Physician pursuant to the
procedures set forth in the Resident Manual.
 TERMINATION
Termination By Medical Center. Medical    Center may terminate an agreement, and thereby the Resident
Physician's Appointment, upon the failure of the Resident Physician to comply with any of an
agreement's terms and conditions, if Resident Physician has made any false or misleading
information statements or Medical Center may terminate an agreement, and thereby the Resident
Physician's appointment. Upon the failure of the Resident Physician to comply with any of an
agreement's terms and conditions, if Resident Physician has made any false or misleading
statements or has failed to provide complete and accurate information on his/her or application, or
as a result of disciplinary actions conducted pursuant to the Resident Manual. Resident Physician
shall have no right to cure any violations of this Agreement.
Termination by Resident Physician. Resident Physician may terminate this Agreement upon the failure
of Medical Center to perform any of its obligations under this Agreement or upon the Resident
Physician's inability to fulfill this Agreement due to total incapacity or extreme hardship. Resident
Physician must provide Medical Center with thirty (30) days written notice of such termination.
Termination by Mutual Agreement. An agreement may also be terminated at any time upon the mutual
agreement of Resident Physician and Medical Center . Such termination must be in writing and
signed by both Resident Physician and Medical Center .
Financial Support and Benefits. As of the effective date of the termination of an agreement for any
reason, Resident Physician shall have no right to further compensation or benefits from Medical
Center .




The George Washington University is an Equal Opportunity/Affirmative Action Employer
Disabled individuals who need special information should call the Office of Disability Support
Services. (202) 994-8250 (TTD/voice).
© 2003 - 2006 The George Washington School of Medicine and Health Sciences
Last updated: November 21, 2005




                                                                                                 48
                                 Section 9
                         Policies and Regulations

PROCEDURES FOR HEARING AND REVIEW OF DISCIPLINARY ACTIONS
INVOLVING FELLOWS

STANDARDS OF CONDUCT

All fellows participating in the training programs of the George Washington University
Medical Center shall achieve standards of conduct in accordance with highest ethical
standards and the code of professionalism delineated throughout this Manual as well as
those set forth by the profession, including those of the clinical department and affiliated
hospitals and institutions to which fellow is assigned. Fellows shall refrain from any
conduct prejudicial to good order, efficiency, or the provision of high quality care to
patients at GWU or its affiliated institutions as appropriate.

DISCIPLINARY ACTIONS

Disciplinary action may be undertaken in response to several concerns regarding fellows,
including failure to meet fellow responsibilities or standards of conduct, concerns
regarding professional competence, failure to progress in knowledge base or meet levels
noted for improvement. The Program Director is the ultimate authority in undertaking the
following disciplinary actions as he/she deems appropriate: formal warning, probation,
suspension preparatory to termination, non-reappointment to the training program for the
following year. Program Directors are to maintain and be able to produce written
documentation of the problem(s) that have led to disciplinary action.

CALCULATING DEADLINES

In calculating the deadline for submitting requests under this article and in scheduling
meeting times, if the deadline falls on a Saturday, Sunday, or University holiday or
closure due to inclement weather, the deadline shall be the next business day.

FELLOW NOTIFICATION

For each of the disciplinary actions described above, notification of the fellow of the
disciplinary actions taken and the reasons for same shall be provided both verbally and in
writing by the Program Director or his/her designee. If the disciplinary action involves
suspension or non-reappointment for reasons related to professional incompetence, the
fellow shall also be provided a copy of these Procedures for Appeal and Review of
Disciplinary Actions Involving Fellows with the written notification. The written
notification shall be sent by regular and certified mail to the address on file for the fellow
at the GME office, which is the fellow’s address of record.

APPLICABILITY OF HEARING PROCESS

The hearing mechanisms set forth below shall not apply to disciplinary actions involving
formal warning or probation. Such hearing mechanisms shall, however, apply to
disciplinary actions involving suspension preparatory to termination or non-
                                                                                            49
reappointment to the training program for the following year for reasons related to
professional incompetence. Nonreappointment for reasons unrelated to professional
incompetence, such as failure to obtain proper licensure, is specifically excluded from the
hearing mechanisms.

INITIATION OF HEARING

Within 14 days following receipt of written notice of suspension preparatory to
termination or non-reappointment for reasons related to professional incompetence, the
fellow may request a hearing by delivering a request for hearing to the GME Office in
writing. If the fellow fails to deliver to the GME Office a written notice requesting a
hearing within the specified time period, he/she is considered as having given up the right
to (waived) the hearing and is considered as accepting the disciplinary action. The written
notice shall be considered as received three days following the date of the notice.

HEARING COMMITTEE AND COMPOSITION

Upon receipt of a written request for hearing from the involved fellow, the Program
Director shall appoint a Hearing Committee. This Hearing Committee may either be an
ad hoc committee established for this purpose, or a standing hearing committee having
major responsibilities in relation to residency training programs. The Hearing Committee
shall consist of no more than 10 nor fewer than 3 members, at least one of whom shall be
a fellow. Preference in selecting the fellow member(s) shall be for fellows in the same or
greater year of postgraduate education and for those who are in the same program or
similar areas of training. In no case shall peer (fellow) membership on the Hearing
Committee exceed one-third of the total membership of the Hearing Committee. No
individual who has actively been involved in the issue(s) under consideration shall serve
as a member of the Hearing Committee. Voluntary faculty with appointments in the
fellow’s department may serve on the Hearing Committee. The Hearing Committee, if
not a standing committee, shall determine its own chair.

NOTICE AND SCHEDULE OF HEARING PROCESS

Within 7 business days of receipt of written request for hearing from the involved fellow,
the Program Director or designee shall coordinate the composition of the Hearing
Committee. The GME Office shall notify the fellow in writing of the time, place and date
of the hearing as soon as practicable thereafter, but not less than 72 hours in advance of
the hearing. The meeting date shall be not less than 14 days from the date of receipt of
the written request for hearing and shall be scheduled as soon as practicable thereafter.

There shall be at least a majority of members of the Hearing Committee present when the
hearing takes place, and no member may vote by proxy. A vote of the majority of the
Hearing Committee who attended the hearing shall be the recommendation of the
Hearing Committee. The personal appearance of the fellow involved is required. A fellow
who fails without good reason to appear and proceed at the hearing gives up his/her rights
to have a hearing and further review of the disciplinary action and to have accepted the
disciplinary action taken.

Postponement of the hearing shall be only with the approval of the Hearing Committee,
at its sole discretion, for good cause.
                                                                                        50
At the hearing, the involved fellow may bring one person to accompany him/her. This
person may, but need not, be an attorney. The assistant may only assist the fellow in
presenting his/her case to the Hearing Committee and may not directly or indirectly
address the Hearing Committee or witnesses, whether through statements, questions or
otherwise. The fellow may ask a Program Director of another program to be the assistant
or to answer questions the fellow may have regarding this process.

The fellow will be provided with a copy of the materials given to the Hearing Committee
for its review of the matter. It shall include materials determined by the Program Director
to be relevant to the disciplinary matter as well as any materials that weigh against the
disciplinary action.

The fellow shall provide the GME Office with copies of any documentary evidence
he/she presents to the Hearing Committee. The Hearing Committee will not be provided
with any further information from the fellow’s file. The Program Director, through the
GME Office, shall identify his/her witnesses to the fellow; the fellow is responsible for
asking other people to attend whom he/she deems relevant.

The chair of the Hearing Committee shall determine the order of procedure during the
hearing, to assure that all participants in the review have a reasonable opportunity to
present relevant oral and documentary evidence, and to maintain decorum. The hearing
will not be conducted according to rules of evidence.

The involved fellow may call and examine witnesses, introduce written evidence, cross-
examine any witness on any matter relevant to the issue of the review of appeal,
challenge any witness, rebut evidence, and submit a written statement to the record. If the
fellow does not address the committee on his/her behalf, he/she may be called and
examined as if under cross-examination.

The Hearing Committee may, without special notice, recess the hearing and reconvene
the same for the convenience of the Hearing Committee or for the purpose of obtaining
new or additional evidence or consultation. Upon conclusion of the presentation of oral
and written evidence, the hearing shall be concluded. The Hearing Committee shall
thereupon, at a time convenient to itself, conduct its deliberations outside the presence of
the involved fellow and the Program Director.

Within 7 business days after it concludes its deliberations, the Hearing Committee shall
formulate a written report and recommendation(s) and shall forward the same, together
with the record, to the Program Director. The report may recommend confirmation,
modification, or rejection of the original disciplinary action(s).

NOTIFICATION OF FELLOW OF HEARING COMMITTEE
RECOMMENDATIONS

Within 7 business days following receipt of the Hearing Committee report and
recommendations, the Program Director shall notify the involved fellow of same and
his/her intended course of action in writing, by regular and certified mail. The
notification shall include a copy of the report and recommendation of the Hearing
Committee.


                                                                                          51
REQUEST FOR REVIEW BY THE COMMITTEE ON GRADUATE MEDICAL
EDUCATION

If the Hearing Committee has upheld the proposed disciplinary action or has proposed a
modified disciplinary action agreed to by the Department Chair, or if the Department
Chair has pursued an independent course of action adverse to the fellow, the involved
fellow shall be entitled to seek review of the Committee on Graduate Medical Education.
Such request must be submitted in writing to the Associate Dean for Graduate Medical
Education within 14 days following receipt of written notification from the Program
Director. The notification shall be deemed received three days following the date of the
notice. If the fellow fails to file such written request within the time specified, he/she
shall automatically waive his/her right to further review and is considered as having
accepted the Program Director’s course of action.

The request for review shall state the reason review is requested. Unless the fellow
identifies new, relevant material not available at the time of the hearing or identifies plain
error in the Hearing Committee report, the review of the Committee on Graduate Medical
Education will be confined to verifying that the hearing procedures in this Manual were
made available to the fellow.

COMMITTEE ON GRADUATE MEDICAL EDUCATION REVIEW

Upon receipt of a request for review from the involved fellow, the Associate Dean for
Graduate Medical Education shall arrange a meeting of the Committee on Graduate
Medical Education. The meeting must take place within 21 business days of receipt of the
fellow's written request. A majority of Committee members must be present in order to
review the appeal. No member who was involved as a witness, Hearing Committee
member or otherwise has first hand knowledge of the matter shall be present during or
participate in the review.

The Committee on Graduate Medical Education's review shall be made on the record of
the Hearing Committee and shall be limited to determining whether the fellow was
afforded the hearing procedures set forth in this Manual. If, however, the fellow has
identified new, relevant material unavailable at the time of the Hearing Committee
review or a plain error on the part of the Hearing Committee, the Committee may review
the substance of the record. The fellow shall submit the material in writing to the
Committee; the Program Director shall be given a copy and be permitted to submit
material related to the new submission. Thereafter, the Committee shall determine
whether the record, as supplemented, supports the recommendation or course of action of
the Program Director, even if the Committee may disagree with that recommendation or
course of action. The Committee on Graduate Medical Education shall, within 7 business
days of completing this review, formulate its recommendation(s) and forward same to the
Program Director.

FINAL NOTIFICATION OF FELLOW

Within 7 days following receipt of the Committee on Graduate Medical Education's
recommendations, the Program Director shall advise the Associate Dean for Graduate
Medical Education in writing of his/her proposed determination. The Associate Dean for
Graduate Medical Education shall review the Program Director’s determination to assure
                                                                                           52
that institutional interests are not compromised. If the Associate Dean for Graduate
Medical Education is so assured, he/she shall notify the Program Director in writing, who
shall in turn provide written notification to the involved fellow as to the final
determination. In the instance of non-concurrence between the Program Director and the
Associate Dean for Graduate Medical Education as to considerations involving
institutional interests, the matter shall be referred to the Vice President for Health Affairs,
who shall make a final determination and so notify the fellow as to the final
determination. Such administrative review and notification as herein described shall be
completed no later than 21 days following the Program’s receipt of the Committee on
Graduate Medical Education recommendations.




                      POLICY ON NON-TEACHING PATIENTS

Purpose:
To establish guidelines concerning the interaction of Fellows with patients in the Consult
or ICU services who are designated as ―non-teaching‖.

Scope:
This policy will apply to all fellows who participate in a graduate medical education
program within GWU.

Responsibilities/Requirements:
1. All patients in the Consult or ICU services at any participating hospital are considered
to be teaching patients.
2. The Fellow is not responsible for the routine care of ―non-teaching‖ patients, including
admission, orders, phone calls or discharge. Should a consult be requested on a patient
designated as ―non-teaching‖, the Fellow should immediately contact the Consult Service
Attending Physician who at his or her discretion may elect to evaluate or treat the patient.
3. Fellows are expected to respond immediately to any call for emergency assistance on
any patient, including non-teaching service patients. All care for the patient should revert
to the attending physician immediately after the emergent situation, unless the patient is
then transferred to the teaching service.
Effective: July 1, 2004
Reviewed and Approved by the GMEC:
Revised, reviewed, and approved by the GMEC:




                                                                                            53
                           POLICY ON ORDER WRITING

Purpose:
To establish guidelines for writing medical orders concerning patients in the Consult or
ICU services.

Scope:
This policy will apply to all fellows who participate in a graduate medical education
program within GWU.

Definitions:
Teaching Hospital refers to The George Washington University Hospital. Participating
Hospitals include the Washington VA Medical Center, and Inova Fairfax
Hospital.
Responsibilities/Requirements:
1. Fellows in the Pulmonary Consult services at the Teaching Hospital or any
Participating Hospital may not write orders in the chart of patients, unless the orders are
related to a procedure performed by the Fellow under Attending Physician supervision.
2. Fellows may write orders for patients directly under their care while rounding in an
ICU service of the Teaching Hospital or any of the Participating Hospitals.
3. Fellows may write orders in patients of the Teaching Hospital or any Participating
Hospital when
involved in direct patient care as the result of an emergency situation.
Effective: July 1, 2004
Reviewed and Approved by the GMEC:
Revised, reviewed, and approved by the GMEC:




                    POLICY ON SUPERVISION OF RESIDENTS

1. Fellows in Cardiology are credentialed at beginning of their training and semi-annually
there after for the procedures and the level of supervision that they need for each of the
procedures used in Cardiovascular Medicine.
2. At the participating institutions and during all scheduled rotations, in both in-patient
and out-patient working areas, the fellows work with an assigned supervising attending
during the daytime on weekdays. This supervising attending is either present with the
fellow or is readily available by phone or paging system. After hours on weekdays and
during the weekends and holidays an attending is on-call and is available to the fellows
by phone or paging system.
Approved by GMEC: 12/14/99




                                                                                           54
                      POLICY ON FELLOW MOONLIGHTING

Purpose:
To establish guidelines for employment outside of the residency program at the George
Washington University School of Medicine.

Scope:
This policy will apply to all fellows who participate in a graduate medical education
program within GWU.

Definitions:
A. Fellow – refers to all interns, fellows and fellows participating in an ACGME-
accredited post-graduate training program.
B. Post-Graduate Training Program – refers to an internship, residency or fellowship
educational program
C. Moonlighting – refers to any and all clinical activities outside of the scope of the post-
graduate training program.

Responsibilities/Requirements:
A. Fellows must not be required to moonlight.
B. Moonlighting is permissible as long as, in the judgment of the program director, such
activity does not interfere with the fellow’s ability to meet his/her educational obligations
in a satisfactory manner.
C. Prior to engaging in moonlighting, the fellow must notify the program director
D. While engaging in moonlighting activities, the fellow is not acting as an employee or
agent of GWU
E. Professional liability coverage is not provided by GWU for moonlighting activities
F. The program director must acknowledge, in writing, all moonlighting of the fellows
within the scope of their supervision. This written acknowledgment must be kept in the
fellow’s permanent file in the GME Office. A program director’s acknowledgment of
moonlighting does not extend coverage for professional liability insurance.
G. Any fellow holding an H-1B or J-1 visa, by virtue of INS regulations and ECFMG
sponsorship, is not permitted to accept work or receive income in any capacity other than
that of a fellow as specified on the IAP-66 issued by the ECFMG or the Labor Condition
Application approved by the INS.
Effective: November 19, 2001
Reviewed and Approved by the GMEC: December 17, 2001
Revised, reviewed, and approved by the GMEC: July 15, 2002




                                                                                           55
                           POLICIES GOVERNING LEAVE



VACATION
The general vacation policy provides for two weeks of paid vacation each year, including
weekends and holidays. Departments may extend this by one or two weeks. Unused leave
may not be carried from one year to another and will not be redeemed for equivalent
salary. Vacation is generally not approved for the last two weeks of the training year.

HOLIDAY LEAVE
Please consult with your department regarding holiday leave and coverage.

SICK LEAVE
Sick leave benefits are determined by each department on an individual basis. In general,
fellows who become ill for a period of time sufficient to interfere with their participation
in the training program, are covered under policies governing Temporary Disability
Leave. Please see Section VI for detailed information.

FAMILY AND MEDICAL LEAVE
Periods of leave due to the serious illness of an employee, the birth or adoption of a child,
or the serious illness of a family member may be covered under the D.C. or Federal
Family and Medical Leave Acts (FMLA). The D.C. Act provides for 16 weeks of leave in
a 24 month period after an employee has completed one year of employment and has
worked at least 1,000 hours during the 12-month period immediately preceding the
request for family or medical leave. In most cases, benefits under the D.C. Act are more
generous than under the Federal Act, but employees are entitled to whichever provides
the most favorable benefits. GW policies governing Temporary Disability Leave,
Vacation Leave, Sick Leave, and unpaid leave will determine the appropriate pay status.
The Medical Center will continue to contribute to all University paid benefits during
Family & Medical Leave, but the employee is responsible for their portion of benefit
premiums. Please note: FMLA does NOT mandate paid leave. Payments to fellows while
on FMLA leave may be available through the above mentioned GW policies.

TEMPORARY DISABILITY LEAVE
Temporary Disability Leave is provided for physical or mental conditions which are
sufficiently incapacitating to require that a Fellow temporarily terminate participation in
the residency training program. Temporary disability is paid for up to 60 consecutive
days annually, including weekends and holidays. Family & Medical Leave Act
provisions may apply in cases of leave use. Please see Section VII for detailed
information on periods of Temporary Disability Leave.

MATERNITY LEAVE
Maternity Leave is provided for medical disability resulting from pregnancy, childbirth or
related medical conditions on the same basis on which leave is provided for other medical
disabilities. Family & Medical Leave Acts and policies governing the use of Sick,
Vacation, and Temporary Disability for medical disability purposes may therefore apply.
Non-medical absences for the birth or adoption of a child are covered under the Family &
Medical Leave Acts. Please refer to Temporary Disability Leave, Section VI.


                                                                                          56
LEAVE OF ABSENCE
At the discretion of the department chair, a Leave of Absence may be approved for
unusual personal situations provided the operational needs of the department are not
adversely affected. Leave of absence is always unpaid leave, and must be requested in
writing. All accrued Vacation Leave must be exhausted prior to a request for a Leave of
Absence, unless the absence falls within the provisions of the Family & Medical Leave
Acts. Eligibility for leave under the FMLA governs requests for periods of Leave of
Absence for the birth or adoption of a child or the serious illness of a family member.

BEREAVEMENT LEAVE
Paid Bereavement Leave is provided to employees upon the death of a spouse, child,
parent, grandparent, sister, brother, mother-in-law, father-in-law, son-in-law, or daughter-
in-law. Bereavement Leave must be requested in writing to supervisory staff for a period
not to exceed 3 days. Bereavement Leave does not accrue or pay out upon termination.

LEAVE FOR JURY DUTY
Jury Duty Leave is provided to Fellows who are summoned to jury duty. Fellows will be
granted paid leave for scheduled work hours/days missed to comply with the summons
for jury duty. Leave must be requested in writing to supervisory staff as far in advance as
possible and must include supporting court documents. Fellows are required to remit to
the University any remuneration received from the court, except for food or
transportation allowance. Fellows are required to report to work on those days or partial
days when attendance in court is not required.

LEAVE FOR COURT APPEARANCES
Court Appearance Leave is provided to fellows who are summoned by court process to
appear as a witness in judicial proceedings. Fellows will be granted 1 day of paid leave
for scheduled work hours/days missed to comply with the summons for Court
Appearance. Fellows who are summoned for Court appearance in excess of 1 day may
request use of Vacation Leave or Leave of Absence.

MILITARY DUTY LEAVE
Military Duty is unpaid leave and may be requested by Fellows for the period necessary
to perform military duty. The request should be submitted in writing to the supervisor
with as much advance notice as possible and include official written military orders, as
soon as they are available, and an expected date of return to work. Employees may
request the use of Vacation Leave for part or all of the period of military duty. Employees
who leave their positions to perform duty for training in the Reserves, including National
Guard (other than for an initial period of training for 12 weeks or more), must request a
Leave of Absence for the period in question to be entitled to reinstatement. Under federal
law, employees who leave regular positions voluntarily or involuntarily for the purpose
of performing military duty, including Reserve duty, have a right to reinstatement without
loss of seniority if certain conditions are met. In situations involving a request for
reinstatement, the Department of Human Resource Services should be consulted for
information concerning eligibility for reinstatement, applicable salary issues, and
benefits. For more information regarding Military Leave, please refer to:
http://www.gwu.edu/~hrs/benefits/leave/militaryleave.html




                                                                                           57
     GUIDELINES FOR DISABILITY LEAVE AND LEAVE WITHOUT PAY



TEMPORARY DISABILITY LEAVE

A. Definition
Disability is defined as any physical or mental condition which is sufficiently
incapacitating to require that the fellow temporarily terminate participation in the
residency training program. Temporary disability is paid for up to 60 consecutive days
annually, including weekends and holidays.

B. Provisions and Restrictions
1. For fellows who are temporarily disabled in accordance with the definition in Section
A, up to 60 days of leave with full salary are to be provided annually, subject to the
restrictions defined in Sections B.2, B.7, B.8, and B.9 below. Supplemental salary
provided by Departments is to be excluded from such determinations.

2. A fellow who is participating in a part-time residency or who otherwise participates in
a residency for only a portion of the training year is entitled to temporary disability leave
on a pro-rated basis as a function of the percentage of the full-time effort and salary
described in the fellow contract.

3. Temporary disability leave with pay does not accrue and may not be carried over from
year to year.

4. A fellow who has utilized full temporary disability leave entitlement and all earned
annual leave during a training year is classified as being on leave without pay (see next
section) unless the fellow desires to terminate his/her relationship with the University.

5. Fellows may not be required to utilize annual leave before being placed on temporary
disability leave.

6. Fellows are entitled to all normally provided fringe benefits while on temporary
disability leave.

7. A fellow who, during the training year, is placed on any combination of temporary
disability leave and leave without pay which involves 60 or more days and which occurs
during any portion of the last six months of the training year, and who is reappointed for
the following training year, is not eligible for temporary disability leave during the
referenced re-appointment year until he/she has resumed training of at least 50% effort,
as described in the fellow contract, for a minimum of six months which may include
earned annual leave or may be extended by other types of leave authorized by
University personnel policies. Similarly, a fellow who, during the training year, is
placed on temporary disability leave which involves more than 30 but less than 60 days
and which occurs during any portion of the last three months of the training year, and
who is re-appointed for the following training year, is not eligible for temporary
disability leave during the referenced re-appointment year until he/she has resumed
training of at least 50% effort, as described in the fellow contract, for a minimum of
three months which may include earned annual leave or may be extended by other types
                                                                                            58
of leave authorized by University personnel policies.

8. A fellow who concludes the training year on temporary disability leave and is re-
appointed
for the following training year is entitled to the balance of temporary disability leave not
utilized by him/her during the previous training year. Such temporary disability leave in
the referenced re-appointment year must be taken consecutively with the temporary
disability leave from the previous year, and the total length of this consecutive disability
leave may not exceed 60 days. Thereafter, the fellow is not eligible for temporary
disability leave until he/she has resumed training of at least 50% effort, as described in
the fellow contract, for a minimum of six months which may include earned annual
leave or may be extended by other types of leave authorized by University personnel
policies. If the fellow requires temporary disability leave taken consecutively with the
training year, it is to be subtracted from this entitlement.

9. A fellow who has been disabled for more than 60 days, has been placed on leave
without pay through the termination of the training year, and is re-appointed for the
following or subsequent training years, is not eligible for temporary disability leave
during the referenced re-appointment year until he/she has resumed training of at least
50% effort, as described in he fellow contract, for a minimum of six consecutive months
which may include earned annual leave or may be extended by other types of leave
authorized by University Personnel policies. Similarly, a fellow who has been disabled
for more than 60 days and now has been placed on leave without pay which carries over
from one training year to the next, is not eligible for temporary disability leave during the
next following or subsequent training years until he/she has resumed training of at least
50% effort, as described in the fellow contract, for a minimum of six consecutive
months, which may include earned annual leave or may be extended by other types of
leave authorized by University Personnel policies.

C. Funding

1. For fellows who are paid directly by the University, temporary disability leave pay will
be funded from the University. Such funds may have been budgeted specifically in the
University or be recoverable on the basis of reimbursement agreements with affiliated
institutions.

2. For fellows who are paid partially or totally from extramural sources and/or from
Departmental funds, temporary disability leave pay will be funded from these sources
proportionally to the maximum extent possible. If such pay is less than that due to the
fellow, the University shall fund the balance of pay to the fellow. Departmental funds
may have been budgeted specifically for the Department to be recoverable on the basis
of reimbursement agreements with affiliated institutions.

3. For fellows who are paid directly by an affiliated institution (usually an institution
governed by federal or state policies), the fellow will receive temporary disability leave
pay (usually under the institution's sick leave provisions) from the affiliated institution up
to the maximum amount permitted by that institution's policies. If such pay is less than
that due to the fellow in accordance with this policy, the University shall provide the
balance of the pay due to the fellow.


                                                                                           59
D. Notification and Documentation Requirements

1. Determinations as to the appropriateness of placing a fellow on temporary disability
leave are the responsibility of the Program Director.

2. The Program Director is responsible for maintaining accurate records of temporary
disability leave for each fellow in the Department. At the end of each fiscal year, each
Program Director is to provide to the Office of Graduate Medical Education a summary
listing of those fellows placed on temporary disability leave during the year and the
amount of such leave for each.

3. For each fellow who is placed on temporary disability leave for a consecutive period of
14 days or longer, documentation supporting the appropriateness of such leave is to be
provided by the Program Director to the Office of Graduate Medical Education for
inclusion in the fellow's University Hospital personnel file. Such documentation should
be provided in a timely fashion but, in any event, no later than 30 days after the
conclusion of the 14-day period.

E. Training Program Adjustments

1. If the Program Director determines that the absence of a disabled fellow will have or is
having a significant adverse effect on the training program, he/she may make suitable
arrangements for coverage during the period in question. Funding for coverage
arrangements may draw upon uncommitted University or Departmental funds budgeted
for fellow salaries for the fiscal year in which the temporary disability problem arises,
plus the equivalent of the salary dollars paid to the temporarily disabled fellow during
the period of disability. Departmental requests to utilize uncommitted residency funds
or to augment budgets, as necessary, are to be submitted in accordance with established
administrative procedures and will be approved provided the reporting requirements
described in Section D have been met. Funds necessary to provide coverage
arrangements which are in excess of authorized resources must derive from other
departmental accounts.

2. Where temporary disability leave places the fellow out of cycle in completing the
requirements of the training program, funding for such fellows must be requested from
the GME Office no later than February 1 of the year preceding the academic year in
which the time will be made up.

3. The effect of extended leave on the completion of the training program and the timing
thereof must be determined by departmental policy.

LEAVE WITHOUT PAY

A. Definition
Leave without pay is defined as leave necessitated by temporary disability which
extends beyond the house officer's entitlement in a training year or leave for other
reasons agreed upon by the fellow and the appropriate Program Director. Fellows who
have been in training in a University-sponsored residency program for two years or
                                                                                          60
more and meet the criteria for extended disability may be eligible for coverage by the

University's disability insurance program. Family & Medical Leave Act provisions may
also apply.

B. Provisions and Restrictions
1. Leave without pay is by definition non-salaried leave.

2. A fellow who has utilized his/her full temporary disability leave entitlement and all
earned annual leave during the training year is entitled to be placed on leave without
pay for the remainder of the training year in which the temporary disability occurs.

3. Fellows must utilize all temporary disability leave and all annual leave before being
placed on leave without pay.

4. Leave without pay shall in no instance extend beyond one calendar year. Leave
without pay of 90 days or less may be approved by the appropriate Program Director.
Leave without pay of more than 90 days requires the endorsement of the Associate
Dean for Graduate Medical Education. Fellows with extended temporary disability are
eligible for, but not entitled to, extensions of leave without pay for up to one calendar
year.

5. Fellows on leave without pay are not entitled to normally provided fringe benefits.
However, such fellows may continue their health insurance and life insurance coverage
under the University programs provided that they assume personal responsibility for the
appropriate premium payments. For fellows who participate in the TIAA/CREF
retirement program, all contributions will be discontinued while the fellow is on leave
without pay, but benefits will be resumed if and when the fellow returns to full-time
training status.

6. For fellows who are placed on leave without pay, reinstatement to full-time or parttime
training status is at the discretion of the appropriate Program Director.

C. Notification and Documentation Requirements
1. Except for the leave without pay entitlement described in Section B.2, determinations
as to the appropriateness of placing a fellow on such leave are the responsibility of the
Program Director.

2. The Program Director is responsible for maintaining accurate records of leave without
pay for each fellow in the Department.

3. For each fellow who is placed on leave without pay, the Program Director is
responsible for prompt notification to the Office of Graduate Medical Education so as to
assure timely termination of salary and appropriate arrangements concerning fringe
benefits. Such notification is to include the intended length of leave without pay. As
stated in Section B.4, leave without pay for more than 90 days requires the endorsement
of the Associate Dean for Graduate Medical Education.

D. Training Program Adjustments
1. If the Program Director determines that the absence of a fellow on leave without pay
                                                                                            61
will have or is having an adverse effect on the training program, he/she may make
suitable arrangements for coverage during the period in question. Funding for coverage
arrangements may draw upon uncommitted University or Departmental funds budgeted
for fellow salaries for the fiscal year in which the fellow is placed on leave without pay.
Departmental requests to utilize uncommitted funds are to be submitted in accordance
with established administrative procedures and will be approved provided that the
reporting requirements described in Section C have been met. Funds necessary to
provide coverage arrangements which are in excess of authorized resources must derive
from other departmental accounts.

2. Where leave without pay places the fellow out of the cycle in completing the
requirements of the training program, funding for such fellows must be requested from
the GME Office no later than February 1 of the year preceding the academic year in
which the time will be made up.

3. The effect of extended leave on the completion of the training program and the timing
thereof must be determined by departmental policy.




    LEAVE OF ABSENCE POLICY FOR FELLOWS AND THE EFFECT ON
                    PROGRAM COMPLETION

PURPOSE:
This policy is designed to outline the effect a leave of absence may have on the
completion of residency training.

POLICY:
At the discretion of the department chair or residency program director, a leave of
absence may be approved for unusual personal situations provided the operational needs
of the department are not adversely affected. Leave of absence is always unpaid leave,
and must be requested in writing. All accrued vacation leave must be exhausted prior to a
request for a leave of absence, unless the absence falls within the provisions of the
Family & Medical Leave Acts. Eligibility for leave under the FMLA governs requests for
periods of leave of absences for the birth or adoption of a child or the serious illness of a
family member.

Where the leave of absence places the fellow out of cycle in completing the requirements
of the training program, funding for such fellows must be requested from the GME
Office no later than February 1 of the year preceding the academic year in which the time
will be made up.

The effect of extended leave on the completion of the training program and the timing
thereof is determined by the program director. It is required that the fellow be provided
with a written agreement of the make up time.

APPROVED BY THE GMEC: October 18, 1999
                                                                                            62
                      POLICY ON SCHEDULING VACATION


1. VACATION AND HOLIDAY TIME: Each fellow is entitled to 15 working days of
vacation during each academic year. No vacation time may be carried over to the
following year. Requests for leave to attend job interviews will also be counted towards
vacation.

2. SCHEDULING OF VACATIONS: In view of our large fellowship program and its
scope with regards to various institutions, it becomes imperative to organize scheduling
of vacations for fellows. The following are the guidelines that will be in effect for the
academic year 2005-2006 and should be followed without exception.

All vacation requests must be approved in advance in writing by the Program Director
after the request has been cleared by the attending with whom you are scheduled to be
working during that period of vacation.

Preference will be given to the fellows according to the principle "First Come First
Served". Efforts will be made to accommodate individual fellow’s requests.

The Division’s Administrative Assistant (202-741-2323) will coordinate all requests for
vacation and leave. Each individual should submit requests to her as soon as possible
during the academic year.




                MEDICAL CLEARANCE POLICY FOR FELLOWS

PURPOSE:
To ensure compliance with District of Columbia Law and the Rules and Regulations of
The George Washington University Hospital regarding health clearance policies for
employees involved in direct patient care.

STATEMENT:
District of Columbia law states that each individual who is involved in direct patient care
must have a medical clearance no more than three months prior and no more than 15 days
after the starting date of clinical care, and then annually thereafter. The medical clearance
should include a history, physical examination, and clearance of infectious risk.
Clearance forms can be filled out by any licensed physician. Fellows should obtain
medical clearance prior to coming to GWU as a fellow. We must be strict about
compliance with this regulation in order to comply with D.C. law. It is each
fellow's responsibility to ensure that this medical clearance is accomplished in the
appropriate time frame. Fellows who do not have their health clearance within the
allotted time, will be suspended without pay from further participation in their training
program until medical clearance is obtained and recorded to the satisfaction of The
                                                                                          63
University.

REQUIREMENTS:

PPD/Chest Xray Requirement
Tuberculosis is of particular concern here in the District of Columbia. Our goal is to be
sure that our providers and patients are protected from and appropriately treated for this
highly communicable disease. A CXR report will be accepted only with a previous
history of a positive PPD. OSHA requires that the skin test performed on new fellows
must include a two-step test unless the fellow has a documented negative test within the
last 12 months. If the fellow does have written documentation of a negative PPD within
the past twelve months, s/he will need to undergo an additional PPD test during
orientation. If the fellow is unable to show written documentation of a negative PPD test
from the past 12 months, s/he will have two PPD tests performed between 1-3 weeks
apart. This prevents us from interpreting an old prior infection as a recent conversion
when you are tested annually.

Immunizations
In 1988, GWU developed regulations to further reduce the possible spread of
communicable diseases such as measles (rubeola), mumps, and German measles (rubella)
within its community. Immunization records or proof of immunity by a blood test are
required of each fellow.

Mumps: A physician-documented history of having had mumps, or proof of immunity to
the mumps (the last immunization given in 1980 or later) or proof of immunity by blood
test is required.

Measles (Rubeola): Proof of immunization or proof of immunity by a blood test is
required. Measles vaccine should have been given on or after the first birthday and a
second one given in 1980 or later. Measles vaccine should be repeated if this is not the
case.

German Measles (Rubella): Proof of immunization or proof of immunity by a blood test
is required.
Two immunizations should have been given since birth. The last immunization should
have been given
in 1980 or later. Rubella vaccine should be repeated if this is not the case.

Chicken Pox (Varicella Zoster): A titer for varicella is required if the fellow does not
have physician documentation of having had this disease. If the titer is negative, it is
mandatory that the fellow receive the vaccine (a series of two injections) unless contra
indicated. If a fellow is exposed to the virus and has not received the vaccine, he/she will
be excluded from duty from the 10th day of exposure to the 21st day and this time off
will be charged against sick/annual leave. Fellows must provide proof of immunity or be
immunized. Immunization requirements will be waived on receipt of written certification
from a physician or public health authority that they are medically
contraindicated. A requirement of blood tests will be substituted.

MEDICAL CLEARANCE FOR SUBSEQUENT YEARS:
D.C. Law requires each fellow to complete an annual medical clearance. If the Medical
                                                                                           64
Clearance is not accomplished in time, the fellow will be suspended from work without
pay until the Medical Clearance is appropriately completed.
APPROVED BY GMEC: August 28, 1995
REVIEWED AND REVISED BY GMEC: April 16, 2001
REVISED AND APPROVED BY GMEC: March 17, 2003




      POLICY ON FELLOW DUTY HOURS AND WORK ENVIRONMENT

PURPOSE:
This policy is designed to establish an institutional policy to ensure an appropriate work
environment for all fellows of The George Washington University Medical Center and to
assist program directors in the development of their individual program policy governing
working environment and duty hours.

DEFINITIONS:
1. Duty Hours: all clinical and academic activities related to the residency program; i.e.,
patient care (both inpatient and outpatient), administrative duties related to patient care,
the provision for transfer of patient care, time spent in-house during call activities, and
scheduled academic activities such as conferences. Duty hours do not include reading and
preparation time spent away from the duty site.
2. In-house call: those duty hours beyond the normal workday when fellows are required
to be immediately available in the assigned institution.
3. One day: one continuous twenty-four (24) hour period.
4. New patient: any patient for whom the fellow has not previously provided care.
5. At home call (pager call): call taken from outside the assigned institution.

POLICY:
1. Each residency program must have written policies governing fellow duty hours and
working environment that are optimal for both fellow education and the care of patients.
2. Program policies must be approved by the GME Committee and distributed to fellows
and faculty.
3. The educational goals of the program and learning objectives of fellows must not be
compromised by excessive reliance on fellows to fulfill service obligations. Monitoring
of duty hours is required with frequency sufficient to ensure an appropriate balance
between education and service. Didactic and clinical education must have priority in the
allotment of fellows’ time and energies.
4. The program must provide services and develop systems to minimize the work of
fellows that is extraneous to their educational programs.
5. Program policies must apply to all participating institutions used by the fellows.

REQUIREMENTS:
1. Duty hours must be limited to eighty (80) hours per week, averaged over a four-week
period, inclusive of all in-house call activities. When fellows are called into the hospital
from home, the hours fellows spend in-house are counted toward the eighty (80) hour
limit.
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2. Fellows must be provided with one (1) day in seven (7) free from all educational and
clinical responsibilities, averaged over a four-week period, inclusive of in-house and at-
home call.
3. A ten (10) hour time period for rest and personal activities must be provided between
all daily duty periods, and after in-house call.
4. In-house call must occur no more frequently than every third night, averaged over a
four-week period.
5. Continuous on-site duty, including in-house call, must not exceed twenty-four (24)
consecutive hours. Fellows may remain on duty for up to six (6) additional hours to
participate in didactic activities, maintain continuity of medical and surgical care, or
conduct outpatient continuity clinics.
6. No new patients may be accepted after twenty-four (24) hours of continuous duty
except in outpatient continuity clinics.
7. In certain programs, such as emergency medicine and anesthesiology, where program
requirements are more rigorous than institutional requirements, the more restrictive limits
will apply.

OVERSIGHT:
The responsibility for ensuring that the working environment and duty hours are
appropriate and in compliance with institutional and program requirements are
determined by the GMEC through:
1. Review of programs' policies on duty hours and fellow working environment
2. Monitoring of duty hours and call schedules for all programs
3. The GMEC internal review process

REQUESTS FOR INCREASES/CHANGES IN FELLOW DUTY HOURS:
Requests for endorsement of exceptions to the weekly limit on duty hours must be made
to the GME Committee before said request is submitted to the Residency Review
Committee (RRC). The sole intent for such increase must be to improve fellows’
educational experience.
1. The program director must submit his request in writing to the GME Committee.
2. The program must be in compliance with institutional and program requirements at all
sites to apply for an exception to the weekly limit on duty hours.
3. The program director must be specific in requesting the exception regarding level of
fellows, rotation, or experience.
4. The program director must demonstrate how the change in duty hours will contribute
to the fellows’ education.
5. The GME Committee may appoint a member of the committee to interview teaching
faculty and fellows to determine if the request for an exception is warranted.
6. The decision of the GME Committee shall be made after discussion and vote by the
membership.
7. The decision of the GME Committee shall be recorded in the minutes of the meeting.
APPROVED BY GMEC: November 20, 1995
REVIEWED BY GMEC: March 18, 2002
REVIEWED AND APPROVED BY GMEC: Feb. 24, 2003




                                                                                        66
           POLICY ON FELLOWSHIP DUTY HOURS VERIFICATION

Goals:
1. Fellows will work no more than 80 hours per week.
2. Fellows should have at least 1 day off in 7 when averaged over 4 weeks.
3. The Program director should be aware of infractions in this policy and conditions that
promote excessive work hours.

Strategy:
1. Fellows in Cardiology work from 8:00 A.M. to 6:00 P.M. every weekday irrespective
of the institution they are rotating.
2. George Washington University Medical Center - Fellows do not sleep in-house, either
during the weekdays or weekends. They are however available for consultation after
work hours during weekdays by phone or paging system. During the weekends fellows
are on call either on Saturday or Sunday. When on call over the weekend (either or
Saturday or Sunday) the fellow makes rounds on patients on the Cardiology Service
(Gold Team) and on the Cardiology Consultation Service and is available for consultation
by phone or paging system till the next morning. All fellows get one day per weekend
completely free of any clinical responsibilities.




                  POLICY ON OSHA TRAINING FOR FELLOWS

PURPOSE:
To ensure compliance with the Occupational Safety and Health Administration standards
under the Occupational Safety and Health Act. The purpose of the standard is to prevent
or to reduce the possibility of exposure to bloodborne pathogens in the workplace.

REQUIREMENTS: Fellows must receive annual training in occupational risks and
methods to reduce risks in compliance with OSHA standards on occupational exposure to
bloodborne pathogens. Fellows are required to take and pass the OSHA test provided at
each training session. Documentation of attendance at annual training will be retained in
the GME Office and provided to affiliate institutions upon request.

EFFECTIVE DATE: July 1, 1993
APPROVED BY GMEC: February 24, 1993
REVISED AND APPROVED BY GMEC: April 16, 2001




                                                                                        67
                  POLICY ON HIPAA TRAINING FOR FELLOWS

PURPOSE:
To ensure compliance with the Health Insurance Portability and Accountability Act of
1996 (HIPAA) and related regulations. The purpose of the standard is to protect the
privacy and confidentiality of protected health information in accordance with federal
and state/local laws.

REQUIREMENTS:
Fellows must receive annual training in compliance with HIPAA requirements.
Documentation of completion of annual HIPAA training will be retained in the GME
Office.

Effective date: Feb. 24, 2003
Approved by GMEC: Feb. 24, 2003




                      POLICY FELLOW LICENSURE POLICY

PURPOSE:
To comply with District of Columbia law for licensure of physician fellows.

REQUIREMENTS:
Fellows have the responsibility for familiarizing themselves with the physician licensure
requirements of D.C. law and regulations, and for obtaining requisite licenses. Generally,
the D.C. Board of Medicine requires fellows in ACGME-accredited programs to obtain
licensure as follows:

• Fellows who are graduates of US medical schools are required to obtain a D.C. license
four (4) years after graduation.

• Fellows who are international medical graduates (IMG) are required to obtain a D.C.
license after four (4) years of graduate medical education in the United States, prior to
beginning the fifth year of training.

Exceptions to the above rules:
• If a physician has at any time been licensed in D.C. or any other jurisdiction in the US,
that physician must have a D.C. medical license in order to participate in a residency
program unless the physician is an international medical graduate who became licensed
in a jurisdiction that required less than three (3) years of U.S. postgraduate training or has
not yet completed the three (3) years of U.S. postgraduate training required for an IMG to
become licensed in D.C.

Timely proof of licensure must be submitted to the Office of Graduate Medical
                                                                                            68
Education. Fellows who do not obtain licensure in accordance with D.C. law may not
provide patient care.
REIMBURSEMENT:
The Office of Graduate Medical Education will typically reimburse fellows who are
required by law to be licensed for payment of their license fees and the annual non-
regulatory professional license fee. If, however, a fellow must obtain D.C. licensure
because he/she already has an unrestricted license to practice medicine in another state or
because he/she obtains such a license during the first four years of participation in
postgraduate training, the fellow shall bear the cost of such licensure.

The Office of Graduate Medical Education will not pay for expenses incurred for
substantiating documentation to accompany the licensure application; i.e., Board scores
and transcripts, nor will it pay for fines assessed by the regulatory boards for failure to
timely apply for and obtain licensure.

Fellows who are not required by law to maintain licensure are permitted to apply for
licensure in the District of Columbia or elsewhere; however, they will not receive
reimbursement from the Office of Graduate Medical Education. Exceptions may be
requested by Program Directors for individuals who may need licensure in order to
comply with hospital or departmental requirements. Such requests will be evaluated by
the Director of Graduate Medical Education and, if deemed appropriate, granted based
on availability of funds.

Virginia and Maryland laws require fellows rotating to affiliated institutions in these
states to have temporary medical licenses. Applications for Virginia and Maryland
temporary licenses must be completed by the fellow and submitted to the appropriate
state medical board by the Office of Graduate Medical Education. These licenses must be
renewed every year. The cost of these licenses and renewals will be paid directly by the
Office of Graduate Medical Education if applications are submitted at least two months
prior to the rotation. Fellows who submit applications for temporary licenses less than
two months prior to the start of a rotation in Maryland or Virginia are required to include
a personal check with the application ($100 for Maryland; $55 for Virginia). The GME
Office will file a claim for reimbursement with University Accounting on behalf of the
fellow.

EFFECTIVE DATE: September 21, 1992
REVISED: April 17, 2000
REVISED AND APPROVED BY GMEC: Feb. 24, 2003




                                                                                          69
                POLICY ON USE OF RESTRICTIVE COVENANTS

PURPOSE:
To outline the institution’s position on the use of restrictive covenants in fellow
employment contracts.

POLICY:
In accordance with ACGME requirements, the institution prohibits the use of restrictive
covenants in any fellow employment contract. This includes the official contract offered
by the GME Office as well as any communications from the residency program.

Effective: July 1, 1999
Review and Approved by GMEC: December 14, 1999




                  POLICY ON FELLOW GRIEVANCE PROCESS

PURPOSE:
This policy is designed to outline the process used by fellows who have a grievance with
the residency program or the Medical Center. Fellow physicians should refer to the
Fellow Manual for policies that apply to concerns related to sexual harassment and equal
employment.

POLICY:
Should one or more fellow physicians have a grievance with the residency program or the
Medical Center, they should submit such grievance to their Program Director. If not
resolved to their satisfaction, the fellow physician may bring the matter before his/her
Department Chair. If the matter is still not resolved to their satisfaction, he/she may refer
the matter to the Chair of the Graduate Medical Education Committee (GMEC). The
decision of the GMEC is final. Grievances addressed under these procedures include but
are not limited to, working conditions, benefits and failure of GWU to fill its obligations
to the fellow under the terms of his/her residency contract.

Any fellow who has reasonable concern about approaching the Program Director or
Department Chair has the option of bringing the concern(s) directly to the Chair of the
GMEC.

Effective: July 1, 1999
Revised, reviewed and approved: GMEC, November 15, 1999




                                                                                          70
     POLICY ON FELLOW PROGRAM SIZE REDUCTION OR CLOSURE

PURPOSE:
This policy is designed to outline the process which will be followed by the Medical
Center and residency programs in the case of program closure or reduction.

POLICY:
1. In the event of a program closure or reduction in size, the Medical Center will make
every effort to allow fellows already in the program to complete their education.

2. The fellows will be notified as early as possible regarding program closure or
reduction in size.

3. If the Medical Center is unable to allow the fellows to complete the program, every
effort will be made in assisting the fellows in enrolling in an ACGME accredited program
in which they can continue their education.

Effective: July 1, 1999
Revised, reviewed and approved: GMEC November 15, 1999
Revised, reviewed and approved by the GMEC: July 15, 2002




                         FELLOW IMPAIRMENT POLICY

PURPOSE:

This policy is intended to provide a process for programs to follow when it is necessary
to investigate and determine if a fellow suffers from an impairment as well as a course
of action if it is determined that a fellow may have an impairment.

POLICY:
Initial Report:
If any individual reasonably suspects that a fellow is impaired, the following steps should
be taken in a timely manner:

1. The individual should report their suspicion to the appropriate Residency Program
Director.

2. The Program Director shall attempt to discuss these suspicions with the individual
making the initial report and advise the Associate Dean of Graduate Medical Education
(―GME‖) of the initial report, his discussion with the person filing the report and
recommend whether to initiate an investigation.

3. The Program Director shall also discuss with the Associate Dean for GME whether,
                                                                                          71
based upon the existing information, the fellow presents a risk to him/herself or others
and should be temporarily removed from patient care pending an investigation.
Investigation of Initial Report:
1. The Associate Dean of GME, in conjunction with the Program Director, shall then
determine whether an investigation is warranted. If so, they shall:
a. investigate the allegations;
b. determine whether the District of Columbia Medical Society’s (DCMS) Impaired
Physician Program, or similar organization, should be contacted and involved in the
investigation;
c. take reasonable steps to maintain the confidentiality of the investigation;
d. provide a written report to the Associate Dean of GME indicating, in part, whether an
impairment may exist, if patient care may be affected, and his/her recommendations
including but not limited to whether the fellow should be required as a condition of
remaining in his/her residency program to participate in the DCMS Impaired Physician
Program or a similar treatment program.

2. The Associate Dean of GME may adopt, amend, or reject, in whole or in part, the
findings and recommendations of the investigation report and may take any steps that
he/she deems reasonably necessary. His/her decision will be in writing and is the final
decision. The decision of the Associate Dean of GME may include, in part, that the
fellow be required to participate in a treatment program as a condition of his/her
remaining in or returning to a residency program or, even if no impairment is
found, further monitoring.

3. If the written decision of the Associate Dean of GME indicates that a possible
physician impairment(s) exists, the Associate Dean of GME, the Program Director,
and/or other designees, and at his/her discretion a person with experience in physician
impairment issues shall meet with the fellow. At such meeting, the fellow will be
informed of the findings of the investigation and given the opportunity to acknowledge
whether he/she is impaired. The name of the individual filing the initial report should not
be revealed and, at the discretion of the Associate Dean for GME, the incidents that
gave rise to the initial report do not have to be revealed. Evaluation and testing may be
requested.

4. The fellow may request a second medical exam or re-testing. The Associate Dean of
GME and the Program Director also have the right to require an additional medical
examination or testing from another physician/consultant of his/her choice. The expense
of the additional medical examination or testing will be the responsibility of the person
requesting the additional exam or test. The Associate Dean of GME has the right to alter,
amend or not change his decision based upon the second medical examination or re-
testing.

5. The results of such medical examination and testing will be maintained in a separate
confidential record of the fellow in Office of Graduate Medical Education.

6. The decision of the Associate Dean of GME and the written report will also be
maintained in a separate confidential file by the Office of Graduate Medical Education.

7. The Associate Dean of GME and the Program Director shall seek the advice of the
University’s legal counsel to determine whether any conduct must be reported to law
                                                                                          72
enforcement or other governmental agencies, and what further steps should be taken.

8. The Associate Dean of GME of the Program Director may verbally inform the
individual who made
the initial report only that appropriate action was taken.

TREATMENT AND MONITORING:

1. When treatment and monitoring is required by the decision of the Associate Dean of
GME, the Associate Dean of GME and the Program Director shall assist the fellow in
locating an appropriate treatment program.

2. The Office of GME and the residency program permit the fellow to resume training
only when they have received documentation to their satisfaction as set forth in III.3.
below.

3. In order to resume residency training, the fellow must at least:
a. Authorize the release of information by all treatment and monitoring programs in
which he or she participates or participated. The fellow must also supply his/her Program
Director with a letter from the physician/director of his/her treatment/monitoring program
regarding the following concerns:
(1) whether the fellow is participating in the treatment and monitoring program;
(2) whether the fellow is in compliance with the terms of the treatment and monitoring
program;
(3) whether and to what extent the fellow’s conduct is monitored and the results of such
monitoring;
(4) whether the fellow is capable of resuming medical training and safely providing an
appropriate level of care to patients; and,
(5) any limitations, supervision or other appropriate actions the residency training
program should take in order for the fellow to return to his residency program and to
provide safe and effective patient care.

b. The fellow shall provide the Program Director with the name and address of his/her
primary care physician, and shall authorize that physician to release information
regarding his or her condition and treatment. The Office of GME and the Program
Director must be able to obtain information to their satisfaction regarding the precise
nature of the fellow’s condition and course of treatment. In order to maximize
confidentiality, a fellow may request a referral to a non-GWU primary care physician.
The Office of GME shall facilitate the fellow in identifying such a physician.

c. If the Office of GME and the Program Director are satisfied that the information
received indicates that the fellow is capable of returning to the residency program, the
Program Director shall develop a written monitoring plan, which at a minimum, includes
some or all of the following:
(1) periodic written feedback from the treatment program director or primary physician
(2) review of pertinent laboratory data and/or tests
(3) direct observation by the Program Director or other faculty members. The Office of
GME must approve the monitoring plan that may be amended from time to time as
needed.


                                                                                          73
d. If restrictions have been imposed, the residency Program Director should document
monitoring of the fellow.
e. If the impairment is a drug or alcohol addiction, the fellow must submit to random
alcohol or drug screening test(s) upon request of the Office of GME and the Program
Director. Reviewed, amended and approved by GME Committee: December 14, 1999

FELLOW PROMOTION

PURPOSE:
This policy is designed to provide a guideline for fellow promotion to the next level of
post-graduate training.

POLICY:

1. The decision to promote a fellow to the next level of post-graduate training will be the
decision of the residency program director after review of appropriate criteria outlined in
the residency program’s policy on fellow promotion.

2. If a program director determines that a fellow will not be reappointed, the fellow
should be notified no later than 4 months prior to the end of the fellow’s current contract.
However if the primary reason(s) for the nonrenewal occurs within the four months prior
to the end of the contract, the fellow must be provided with as much written notice of the
intent not to renew as the circumstances will reasonably allow, prior to the end of the
contract

3. Each program director will establish an appropriate time frame for promotion
decisions.

4. In the event a fellow’s performance is not satisfactory, the program director will follow
the procedures outlined in the Fellow Grievance Policy and in the Fellow Manual under
―Procedures for Hearing and Review of Disciplinary Actions Involving Fellows.‖

Approved by GME Committee: January 24, 2000
Revised, reviewed, and approved by the GMEC: July 15, 2002




                                                                                           74
                                     Section 10
                                   Salary/Benefits

    Salaries for the 2007-2008 academic year are as follows:

    PGY 4 $52,367.04
    PGY 5 $54,747.36
    PGY 6 $56,877.12

    The following benefits are available to all George Washington University Medical Center
    fellows. All benefits are subject to change without advance notice.

   Long-Term Disability Insurance
    For the first year of training, an individual policy is paid by the Medical Center, which
    provides $2,000/month after 180 days of total disability, with provisions for partial claims.
    This coverage can be continued by the resident on an individual basis at a discounted rate
    after the first year. After the first year of training, residents are enrolled in the University
    Long-Term Disability Insurance plan.
   Drug Enforcement Administration (DEA) registration fees for eligible residents
    Paid for residents who are required to obtain a DC medical license according to DC law.
    The Federal DEA registration fee is reimbursed at the rate of 1/3 of the total cost for each
    year the resident remains at GW.
   Employee Assistance Program
    Confidential problem assessment, counseling, and referral services are provided.
   Health and Wellness Center
    The Lerner Health and Wellness Center is located at 2301 G Street. The annual
    membership fee is $295.00 and can be paid through payroll deduction.
   Lab Coats
    One personalized white lab coat is provided to each resident on an annual basis.
   Liability Insurance
    Professional Liability insurance is provided for those activities and services within the
    scope of duties as defined by the Resident Program Director or Medical Center. Liability
    insurance is not provided for activities outside the course and scope of duties, such as
    moonlighting.
   Medical Licensure fees for eligible residents
    Residents required by law to be licensed in the District of Columbia because they
    graduated from a U.S. medical school at least 5 years ago, have completed a postgraduate
    clinical training program, or are international medical graduates beginning their 6th post-
    graduate training year will be reimbursed by the GME Office for the cost of the license
    only. The DC Board of Medicine requires any resident who has or obtains a non-restricted
    license in another state to apply for licensure in DC. Residents must comply with this
    requirement and submit proof of licensure to the GME Office; however, this cost is not
    reimbursed unless the resident meets the above criteria pertaining to completion of a
    postgraduate training program or the number of years it has been since they graduated
    from medical school. Costs for temporary licenses required for training in the District of
    Columbia, Maryland and Virginia are paid by the GME Office.
                                                                                               75
     Parking is provided free in assigned University garages and parking lots.
     Student loan deferment processing is provided by the GME Office.
In addition to the benefits listed above, the following benefits are available to residents paid by
GWU:
     Health Insurance
        Residents are eligible to participate in several plans, including Care First BC/BS Select
        PPO, CIGNA HMO and CIGNA POS. The cost to the resident depends on the options
        selected.
     Prescription Drug Plan
        Prescription drug benefits are provided through CaremarkPCS. After an annual deductible,
        there is a flat dollar co-pay.
     Group Dental Plan
        Residents are eligible to participate in the Group Dental Plan offered through Guardian
        Life Insurance. There are two options—a low option plan for basic and preventive services
        and a high option plan to provide a greater level of coverage.
     Supplemental Long-Term Disability
        Individual supplemental long-term disability that provides an additional 15% monthly
        benefit is available for purchase.
     Flexible Spending Account Program - FlexFund
        This program allows residents to set aside tax-free dollars in special accounts to pay out of
        pocket medical and/or dependent care expenses.
     Life Insurance
        Basic Life and Accidental Death and dismemberment coverage equal to the base
        annualized salary is provided at no cost. Optional term and universal insurance is available
        at an additional charge.
     Retirement Benefits
        Residents must be at least 21 years of age and have completed two years of service to
        participate. GW contributes 4% of the annualized regular salary to the plan. Residents who
        contribute a portion of their salary to the plan are eligible to receive matching
        contributions equal to 1.5 times the employee contribution, up to a maximum of 6%.
     Short Term Disability Income Plan
        Residents are eligible to purchase this coverage through the Benefit Office. Provident Life
        Insurance is the provider.
     Voluntary Legal Services
        Residents are eligible to purchase a membership with Legal Resources. Membership
        provides a variety of legal services through participating attorneys for a monthly fee.
     Tuition Benefits
        Tuition benefits cover a maximum of six credit hours in the fall and spring semesters and
        nine credit hours in the summer sessions for courses taken in degree programs. Some
        exclusions apply. Benefits for spouses and dependent children vary depending on years of
        service to the University.
     Tuition Exchange Program
        The University is a member of the Tuition Exchange, Inc., which provides a limited
        number of tuition remission scholarships for employees of member colleges and
        universities. The Benefits Office determines eligibility.
     Family Care Consultation and Resource and Referral Service
        Family Care Resources assists employees who need help in finding reliable, quality care
        for their children, or in resolving issues relating to disabled or elderly parents or relatives.
     GW Home Program
                                                                                                   76
       This program is an employer-assisted housing program, which provides resources and
       information related to home ownership, including home buyer educational workshops and
       financial assistance programs.
Residents are eligible for the following leave according to University Policy and as stated in the
Resident Manual:
    Vacation, holiday leave, and sick leave
       These leave benefits are determined by each program/department.
    Family and medical leave
    Temporary disability leave
    Maternity leave
    Leave of absence
    Bereavement leave
    Leave for jury duty
    Military duty leave




The George Washington University is an Equal Opportunity/Affirmative Action Employer
Disabled individuals who need special information should call the Office of Disability
Support Services. (202) 994-8250 (TTD/voice).
© 2003 - 2006 The George Washington School of Medicine and Health Sciences
Last updated: June 5, 2006




                                                                                              77
                                     Section 11
                                Educational Resources
A number of invaluable educational resources exist to supplement the cardiovascular training at
George Washington: These include:

Medical Library

National Library of Medicine

Mini-Medline: This can be accessed through the computer located in the Fellow’ Room as well
as through the Dahlgren Library.

American College of Cardiology Heart House: The Heart House, located in Washington DC, is
the national headquarters of the ACC. A number of educational resources, including the ACC’s
CardioSource Plus, are available. The Heart House sponsors a number of excellent continuing
medical education courses at its state-of-the-art conference center. The Heart House will allow
up to two fellows each year to attend one conference at the Heart House free of charge. In
addition, a number of conferences are available at reduced cost to fellows, and occasionally a
number of free slots become available at the last minute.

ACC Self-Assessment Program: This self-study guide, similar to the MKSAP, was recently
published by the ACC. A copy was purchased for the fellows and can be borrowed from the
Fellowship Director.




                                                                                              78
                                   Section 12
                       Fourth Year Training Opportunities
Several fourth-year training opportunities are available. These opportunities will be available, a
competitive basis. These include:

A.     Interventional Cardiology: Two slots will be available each year for training in
       Interventional Cardiology under the direction of Dr. Jonathan Reiner.

B.     Arrhythmia and Electrophysiology: Two to three slots will be available for specialized
       training in Cardiac Electrophysiology under the direction of Dr. Cynthia Tracy.




                                                                                                79
                                         Appendix I
                                 Fellows Rotation Schedule


Month    Cath1     Cath2      Non-Inv1      Non-Inv2     EP     Consult    Fairfax    Res.

July    Reza        Mike     Const./Raman              Amit/Mark           Alex      Payam

Aug     Payam       Raman    Amit/Mark/ Const          Amit/Mark
                               Reza
Sept    Mark        Amit     Payam/Mike                                    Raman     Const

Oct     Reza                  Amit          Mark         Mike               Payam     Const

Nov     Mark        Mike      Raman         Payam                           Reza     Const

Dec     Raman                  Reza         Amit                   Mike    Const     Payam

Jan     Amit        Reza       Const                               Raman   Mark      Payam

Feb     Payam       Mark       Mike         Const       Raman      Amit

March Mike                     Reza                                Mark              Payam
                                                                                     Const
                                                                                     Amit
April   Raman       Const      Mark                      Reza               Amit     Payam

May     Amit                   Raman                     Mark               Mike     Payam
                                                                                     Const
June    Mark                    Mike                     Amit       Reza             Payam
                                                                                     Const


CCU / Gold

July           Mark / Amit
Aug            Mike
Sept           Reza
Oct            Raman
Nov            Amit
Dec            Mark
Jan            Mike
Feb            Reza
March          Raman
April          Mike
May            Reza
June           Raman




                                                                                         80
                                Appendix II
                            Conference Schedules


                    Weekly Cardiology Conference Schedule


Monday      8:00      Fellows Conference

Tuesday     8:00      Cardiac Catheterization Conference

Tuesday     12:00     Journal Club

Wednesday   8:00      Non-Invasive Conference

Wednesday   5:00      Cardiology Grand Rounds

Thursday    8:00      Board Review

Thursday    12:00     Medical Grand Rounds

Friday      8:00      EP Conference




                                                            81
                     Orientation Lecture Series
                    2008 Cardiovascular Fellows
                      6th Floor Hospital - 0800


July 1    Fellow Orientation                      -----

July 2    Preoperative Evaluations                Solomon

July 3    Arrhythmia Management                   Solomon

July 4    Holiday                                 -----



July 7    Introduction to Heart Failure           Desai

July 8    Cardiac Catheterization Conference      Reiner

July 9    Introduction to Echo – Part I           Lewis

July 10   Acute Coronary Syndromes                Reiner

July 11   Pacemakers and ICD’s                    Osborn /Tracy



July 14   Pre- and Post Cath Issues               Mazhari

July 15   Cardiac Catheterization Conference      Reiner

July 16   Introduction to Echo – Part II          Lewis

July 17   Stress Testing                          Katz

July 18   Introduction to ECG’s                   Mercader



July 24   Introduction to IABP                    Sherri Welch




                                                                  82
                   Cardiology Grand Rounds
                          2008 –2009

Date       Topic                            Speaker

Sept. 3    M&M                              Michael Goldstein, MD

Sept. 10   Exercise Physiology and          G. Gutierrez, MD
           Cardiopulmonary Stress Testing

Sept. 17   Aspirin Resistance               Payam Fallahi, MD

Sept. 24   TBA

Oct. 1     M&M                              Reza Sanai, MD

Oct. 8     Yom Kippur                       ------

Oct. 15    Adriamycin Cardiotoxicity        Constantine Tziros, MD

Oct. 22    Adult Congenital Heart Disease   Karen Kuehl, MD

Oct. 29    EP Visiting Professor            Michael Gold, MD, PhD

Nov. 5     M&M                              Raman Dusaj, MD

Nov. 12    What I learned at AHA            CV Fellows

Nov. 19    Sleep Apnea and the Heart        Vivek Jain, MD

Nov. 26    Thanksgivng                      ------

Dec. 3     M&M                              Amit Shah, MD

Dec. 10    EP Visiting Professor            Doug Packer, MD

Dec. 17    TBA                              Brian Choi, MD

Dec. 24    Winter Holiday                   ------

Dec. 31    New Years Eve                    ------

Dec. 31    New Years Eve                    ------




                                                                     83
                                       Appendix III

              RESEARCH FOR CARDIOVASCULAR FELLOWS
           GEORGE WASHINGTON UNIVERSITY MEDICAL CENTER

Year 1

July 1     Arrival of new fellows

Aug        General discussion of: research tracks at George Washington
                                         basic science
                                         clinical research
                                         clinical
           Ongoing and future research projects
           Mentorship

Oct        Each fellow will meet individually with the fellowship director to discuss research
           interests and identify a mentor

Nov        First meeting between fellow and research mentor

Dec        Discuss topic of interest and research proposal with mentors

Jan        Each fellow will submit title of research proposal to fellowship director and
           mentor

Feb        Specific aims of projects to fellowship director and mentor

March      Summary statements to fellowship director and mentor

April      Background information to fellowship director and mentor

May        Rational / methods to fellowship director and mentor


Year 2

July-Aug   Grant proposal writing

Sept       Oral presentation of the proposal to the faculty for constructive criticism

Oct        Fine tuning of grant proposal

Nov        Grants read by other referees before submission

Dec        Submission of the proposal

Jan-June   Initiate research project

May        Submit AHA Abstract
                                                                                           84
Year 3

Sept       Submit ACC Abstract

Jan-June   Presentation of data at George Washington research conference




                                                                           85
                                            Appendix IV

                                  Division of Cardiology
                         2008-2009 Fellowship Program Evaluation

In conjunction with the efforts of the Division of Cardiology to continually improve the
fellowship training experience, and the requirements of the Accreditation Council for Graduate
Medical Education (ACGME) that written program evaluations be obtained during the year, each
assessment form to the Office of GME. They will prepare a composite evaluation for subsequent
group review by the Fellows and Faculty of the Division. NOTE: Your individual comments
will be held in strict confidence.

Evaluation Period:    July 1, 2005 to June 30, 2006

Please assign number scores for each of the following areas and include comments where
indicated:
               UNACCEPTABLE = 1
               NEEDS IMPROVEMENT = 2
               ADEQUATE = 3
               VERY GOOD = 4
               EXCELLENT = 5



PART I.       ROTATIONS

ARRHYTHMIA SERVICE
1.  Structure of Rotation hours, rounds etc:              ______
2.  Degree of Responsibility                              ______
3.  Opportunity to learn and read independently           ______
7.  Supervision of Attendings                             ______
8.  Instruction by Attendings                             ______
9.  Educational value of patients                         ______
10. Overall educational value of the rotation             ______

Summarize the strengths of this rotation:




Summarize areas in improvement in this rotation:




______________________________________________________________________________

                                                                                           86
CORONARY CARE UNIT (CCU)
1.  Structure of Rotation hours, rounds etc:        ______
2.  Degree of Responsibility                        ______
3.  Opportunity to learn and read independently     ______
4.  Supervision by Attendings                       ______
5.  Instruction by Attendings                       ______
6.  Educational value or patients                   ______
7.  Overall educational value of the rotation       ______

Summarize the strengths of this rotation:


Summarize areas in improvement in this rotation:



NON-INVASIVE (GW)
1.   Structure or Rotation hours, rounds, etc:      ______
2.   Degree of Responsibility                       ______
3.   Opportunity to learn and read independently    ______
4.   Supervision by Attendings                      ______
5.   Instruction by Attendings                      ______
6.   Educational value of patients                  ______
7.   Overall educational value of the rotation      ______

Summarize the strengths of this rotation:




Summarize areas for improvement in this rotation:

_____________________________________________________________________________

NON-INVASIVE II (VA)
1.   Structure or Rotation hours, rounds, etc:      ______
2.   Degree of Responsibility                       ______
3.   Opportunity to learn and read independently    ______
4.   Supervision by Attendings                      ______
5.   Instruction by Attendings                      ______
6.   Educational value of patients                  ______
7.   Overall educational value of the rotation      ______

Summarize the strengths of this rotation:




Summarize areas for improvement in this rotation:
                                                                            87
_____________________________________________________________________________
CATH LAB
1.    Structure or Rotation hours, rounds, etc:   ______
2.    Degree of Responsibility                    ______
3.    Opportunity to learn and read independently ______
4.    Supervision by Attendings                   ______
5.    Instruction by Attendings                   ______
6.    Educational value of patients               ______
7.    Overall educational value of the rotation   ______

Summarize the strengths of this rotation:



Summarize areas for improvement in this rotation:

CONSULT SERVICE
1.  Structure or Rotation hours, rounds, etc:       ______
2.  Degree of Responsibility                        ______
3.  Opportunity to learn and read independently     ______
4.  Supervision by Attendings                       ______
5.  Instruction by Attendings                       ______
6.  Educational value of patients                   ______
7.  Overall educational value of the rotation       ______


Summarize the strengths of this rotation:


Summarize areas for improvement in this rotation:


INOVA FAIRFAX HOSPITAL
1.   Structure or Rotation hours, rounds, etc:      ______
2.   Degree of Responsibility                       ______
3.   Opportunity to learn and read independently    ______
4.   Supervision by Attendings                      ______
5.   Instruction by Attendings                      ______
6.   Educational value of patients                  ______
7.   Overall educational value of the rotation      ______


Summarize the strengths of this rotation:


Summarize areas for improvement in this rotation:




                                                                            88
PART II.      CONFERENCES

CORE CURRICULUM
1.  Conference organization               ______
2.  Quality of presentations              ______
3.  Quality of topics                     ______
4.  Overall Conference value              ______

Strengths:



Weaknesses:


______________________________________________________________________________

JOURNAL CLUB
1.  Conference organization               ______
2.  Quality of presentations              ______
3.  Quality of topics                     ______
4.  Overall Conference value              ______

Strengths:



Weaknesses:


______________________________________________________________________________

ARRHYTHMIA (ECG) CONFERENCE
1.  Conference organization               ______
2.  Quality of presentations              ______
3.  Quality of topics                     ______
4.  Overall Conference value              ______

Strengths:



Weaknesses:



______________________________________________________________________________




                                                                            89
CATH CONFERENCE
1.  Conference organization               ______
2.  Quality of presentations              ______
3.  Quality of topics                     ______
4.  Overall Conference value              ______

Strengths:



Weaknesses:


______________________________________________________________________________

NONINVASIVE CONFERENCE
1.   Conference organization              ______
2.   Quality of presentations             ______
3.   Quality of topics                    ______
4.   Overall Conference value             ______

Strengths:



Weaknesses:




MORBIDITY AND MORTALITY CONFERENCE (Monthly, Wednesday PM)
1.  Conference organization     ______
2.  Quality of presentations    ______
3.  Quality of topics           ______
4.  Overall Conference value    ______

Strengths:



Weaknesses:




                                                                            90
RESEARCH CONFERENCE (One Wednesday per Month, 5:00 P.M.)
1.   Conference organization         ______
2.   Quality of presentations        ______
3.   Quality of topics               ______
4.   Overall Conference value        ______

Strengths:



Weaknesses:


______________________________________________________________________________

Are there any conferences that you would like to add?




Are there any conferences that you would like to delete?



Do you have any suggestions that might improve conference attendance?




                                                                            91
PART III     RESEARCH

1.    What is your opinion of research opportunities at George Washington?




Other comments:




                                                                             92
                    INDIVIDUAL ATTENDING EVALUATION
Please use the following scale:   5 = Superior
                                  4 = Very Good
                                  3 = Good
                                  2 = Below average
                                  1 = Unacceptable
                                  N/A Not applicable or insufficient contact

Georgetown University Hospital Faculty

A.     ALLEN J. SOLOMON, M.D.
       1.  Medical knowledge in Cardiology                             ______
       2.  Medical knowledge in Cardiac Subspecialty                   ______
       3.  General medical knowledge                                   ______
       4.  Helps Fellow with difficult problems                        ______
       5.  Teaching capacity for Fellows and Residents                 ______
       6.  Patient rapport                                             ______
       7.  Punctuality                                                 ______
       8.  Availability                                                ______
       9.  Comments:                                                   ______

       Strengths:



       Areas to improve upon:


B.     RICHARD KATZ, MD
       1.   Medical knowledge in Cardiology                            ______
       2.   Medical knowledge in Cardiac Subspecialty                  ______
       3.   General medical knowledge                                  ______
       4.   Helps Fellow with difficult problems                       ______
       5.   Teaching capacity for Fellows and Residents                ______
       6.   Patient rapport                                            ______
       7.   Punctuality                                                ______
       8.   Availability                                               ______
       9.   Comments:                                                  ______

       Strengths:



       Areas to improve upon:




                                                                                93
C.   LISA MARTIN, M.D.
     1.   Medical knowledge in Cardiology               ______
     2.   Medical knowledge in Cardiac Subspecialty     ______
     3.   General medical knowledge                     ______
     4.   Helps Fellow with difficult problems          ______
     5.   Teaching capacity for Fellows and Residents   ______
     6.   Patient rapport                               ______
     7.   Punctuality                                   ______
     8.   Availability                                  ______
     9.   Comments:                                     ______

     Strengths:


     Areas to improve upon:


E.   JANNET LEWIS, M.D.
     1.   Medical knowledge in Cardiology               ______
     2.   Medical knowledge in Cardiac Subspecialty     ______
     3.   General medical knowledge                     ______
     4.   Helps Fellow with difficult problems          ______
     5.   Teaching capacity for Fellows and Residents   ______
     6.   Patient rapport                               ______
     7.   Punctuality                                   ______
     8.   Availability                                  ______
     9.   Comments:                                     ______

     Strengths:


     Areas to improve upon:


F.   JONATHAN REINER, M.D.
     1.  Medical knowledge in Cardiology                ______
     2.  Medical knowledge in Cardiac Subspecialty      ______
     3.  General medical knowledge                      ______
     4.  Helps Fellow with difficult problems           ______
     5.  Teaching capacity for Fellows and Residents    ______
     6.  Patient rapport                                ______
     7.  Punctuality                                    ______
     8.  Availability                                   ______
     9.  Comments:                                      ______

     Strengths:


     Areas to improve upon:


                                                                 94
G.   JACOB VARGHESE, M.D.
     1.  Medical knowledge in Cardiology               ______
     2.  Medical knowledge in Cardiac Subspecialty     ______
     3.  General medical knowledge                     ______
     4.  Helps Fellow with difficult problems          ______
     5.  Teaching capacity for Fellows and Residents   ______
     6.  Patient rapport                               ______
     7.  Punctuality                                   ______
     8.  Availability                                  ______
     9.  Comments:                                     ______

     Strengths:


     Areas to improve upon:


G.   MARCO MERCADER, M.D.
     1.  Medical knowledge in Cardiology               ______
     2.  Medical knowledge in Cardiac Subspecialty     ______
     3.  General medical knowledge                     ______
     4.  Helps Fellow with difficult problems          ______
     5.  Teaching capacity for Fellows and Residents   ______
     6.  Patient rapport                               ______
     7.  Punctuality                                   ______
     8.  Availability                                  ______
     9.  Comments:                                     ______

     Strengths:


     Areas to improve upon:


I.   CYNTHIA TRACY, M.D.
     1.  Medical knowledge in Cardiology               ______
     2.  Medical knowledge in Cardiac Subspecialty     ______
     3.  General medical knowledge                     ______
     4.  Helps Fellow with difficult problems          ______
     5.  Teaching capacity for Fellows and Residents   ______
     6.  Patient rapport                               ______
     7.  Punctuality                                   ______
     8.  Availability                                  ______
     9.  Comments:                                     ______

     Strengths:


     Areas to improve upon:
                                                                95
                                      Appendix V

                                  Attending Schedule


     CARDIOLOGY FACULTY SCHEDULE
Service    July      August      September     October       November   December

Holter     Tracy    Mercader      Solomon          Solomon    Tracy      Mercader
           Mercader Tracy

CCU        Mercader Katz           Lewis        Mercader     Solomon    Choi
           Tracy    Solomon        Choi         Tracy        Lewis      Katz

Non-Inv.   Lewis      Lewis        Lewis        Lewis         Lewis     Lewis
           Katz       Katz         Katz         Katz          Katz      Katz
           Martin     Martin       Martin       Martin        Martin    Martin
           Choi       Choi         Choi          Choi          Choi     Choi

Consults   Martin     Mercader      Tracy          Lewis      Choi      Solomon

EP         Tracy    Tracy           Tracy       Tracy         Tracy      Tracy
           Solomon Solomon         Solomon     Solomon       Solomon    Solomon
           Mercader Mercader       Mercader    Mercader      Mercader   Mercader

Cath       Reiner      Reiner       Reiner         Reiner     Reiner     Reiner
           Mazhari     Mazhari      Mazhari        Mazhari    Mazhari    Mazhari

EKG        Varghese    Mercader      Tracy         Solomon     Katz       Martin




                                                                                   96
                                          Appendix VI
              George Washington University
                  Division of Cardiology
Fellow Leave Form

                                                        Today's Date:


Fellow Name:
                                      Print Name

I am requesting leave for the following dates:

                      Day of Week                  Month/Day              Year
From

Through

Returning on

Type of Leave
                       Type of Leave - Annual, Conference, CME, Leave without Pay
                        (If combining leave types indicate number of days of each)

While away, I will have the following coverage (include signature):

                                    responsible for

                                    responsible for


In case of an emergency I can be reached at:



                      Signature



Attending Signature           Program Director Signature




                                                                                     97

				
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