CHILDRENS HOSPITAL LOS ANGELES (DOC)

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					                        CHILDRENS HOSPITAL LOS ANGELES
                       RESIDENCY IN PEDIATRIC CARDIOLOGY

I.    Duration and Scope of Training
      The program in pediatric cardiology at Childrens Hospital Los Angeles is 3 years in
      duration. The purpose of the training program is to provide residents with a firm
      foundation for understanding normal and abnormal cardiovascular conditions, including a
      strong emphasis on the pathophysiologic basis of cardiovascular disease. The goal is to
      prepare residents for careers as academic pediatric cardiology consultants to provide
      optimal care for pediatric patients (from the fetus to the young adult) with cardiovascular
      disease.

      The program provides a balanced and structured experience in the care of patients on
      inpatient units, the Cardiothoracic Intensive Care Unit, in ambulatory cardiology clinic as
      well as the cardiac catheterization laboratory, noninvasive cardiology, i.e.
      echocardiography, electrocardiography and magnetic resonance imaging, and
      electrophysiology. Residents are afforded progressive responsibility commensurate with
      their level of training and experience.

      See Appendix A. Program Goals and Objectives

II.   Faculty
      A.     Pediatric Cardiologists
             There are 11 full- time faculty, and 2 part-time, board certified pediatric
             cardiologists in the division.
             (Name, faculty position, clinical &/or research interests)
             Michael J. Silka, M.D., Division Head, Professor of Pediatrics
                     Electrophysiology and arrhythmias
             Alan B. Lewis, M.D., Director, Fellowship Program, Professor of Pediatrics
                     Cardiomyopathy, cardiac failure, hyperlipidemia
             Sarah Badran, M.D., Assistant Professor of Clinical Pediatrics
                     Cardiac catheterization and interventional cardiology
             Yaniv Bar-Cohen, M.D., Assistant Professor of Clinical Pediatrics
                     Electrophysiology and arrhythmias
             Arno R. Hohn, M.D., Professor of Pediatrics Emeritus. Part-time
                     Hypertension
             Grace Kung, M.D., Assistant Professor of Clinical Pediatrics
                     Echocardiography
             Jon David Menteer, M.D., Assistant Professor of Clinical Pediatrics
                     Cardiac transplantation, cardiac failure and pulmonary hypertension
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             Jay Preutz, M.D., Assistant Professor of Clinical Pediatrics
                     Non-invasive imaging
             Mark Sklansky, M.D., Associate Professor of Clinical Pediatrics
                     Fetal and general echocardiography
             Jacqueline Szmuszkovicz, M.D., Assistant Professor o f Clinical Pediatrics
                     Cardiac transplantation and pulmonary hypertension
             Masato Takahashi, M.D., Professor of Pediatrics Emeritus. Part-time
                     Adult Congenital Heart Disease, Kawasaki disease
             Cheryl Takao, M.D., Assistant Professor of Clinical Pediatrics
                     Cardiac catheterization and interventional cardiology
             Pierre C. Wong, M.D., Associate Professor of Clinical Pediatrics
                     Director, Echocardiography
             John Wood, M.D., Assistant Professor of Pediatrics
                     MRI


      B.     Other Physician Teaching and Consultant Faculty
             Cardiothoracic Intensive Care Unit
             Randall Wetzel, M.D. Head, Department of Anesthesia and Critical Care,
             Professor of Pediatrics and Anesthesia
             David Morimasato, M.D., Assistant Professor of Clinical Pediatrics. Medical
             Director of CTICU
             David Epstein, M.D., Assistant Professor of Clinical Pediatrics
             Laurie Hastings, M.D. Assistant Professor of Clinical Pediatrics and Anesthesia.
             Sylvia DelCastillo, M.D. Assistant Professor of Clinical Pediatrics
             Niurka Rivero, M.D. Assistant Professor of Clinical Pediatrics

             Cardiothoracic Surgery
             Vaughn A. Starnes, M.D. Head, Division of Cardiothoracic Surgery,
             Professor and Chair of Cardiothoracic Surgery
             Winfield Wells, M.D., Associate Professor of Cardiothoracic Surgery
             Cynthia Herrington, M.D. Assistant Professor of Cardiothoracic Surgery

             Radiology
             Marvin Nelson, M.D. Head Department of Radiology, Professor of Radiology
             Philip Stanley, M.D. Professor of Radiology

             Faculty in other pediatric disciplines, particularly pulmonology, neonatology,
             critical care, genetics, nephrology, infectious diseases, clinical immunology,
             general pediatrics, hematology-oncology, anesthesiology, pathology and pediatric
             surgery, are readily available at CHLA. Adult cardiology is available for
             consultation at USC School of Medicine


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              The residents also work closely with cardiac catheterization technicians and
              nurses, sonographers, ambulatory care nursing staff, social workers and
              secretaries.

III.   Facilities and Resources
       A.      Inpatient and Outpatient Services
               The Cardiothoracic Intensive Care Unit is a 15 bed dedicated unit. In addition,
               there are separate Neonatal and Pediatric Intensive Care Units into which
               appropriate patients with cardiac disease may be admitted. Cardiac patients who
               do not require ICU care, are admitted to the 6W unit. The nursing personnel are
               experienced in caring for infants and children with cardiopulmonary disease. The
               unit also has a telemetry capability for continuous monitoring of cardiac rhythm.

              A new inpatient tower is scheduled to open early in 2010. The entire 2nd floor of
              the new tower will be dedicated to Cardiac services including a 25 bed
              Cardiothoracic Intensive Care Unit, a 30 bed step-down, inpatient unit,
              Cardiology outpatient services, echocardiography, cardiac catheterization labs (2)
              and office suites for Cardiology and Cardiac Surgery.


       B.     Cardiac Data Base
              The Division of Cardiology is in the process of acquiring a comprehensive,
              clinical database that incorporate all patients clinical, catheterization,
              echocardiographic and surgical encounters and outcomes and will integrate into
              the hospitals electronic medical record (KIDS). The Division of Cardiothoracic
              Surgery currently maintains its own, independent surgical database that is
              available for inquiry by the cardiology division. CHLA has adopted an electronic
              medical record (KIDS) using the Cerner Corporation systemic. The KIDS system
              went on- line in June 2004 and includes all inpatient activity, clinical laboratory
              testing, demographic information, patient scheduling.

       C.     Support Facilities
              All of the following facilities are available:
              1. Diagnostic imaging including conventional radiography, CT, MRI, nuclear
                  radiology
              2. Diagnostic and interventional cardiac catheterization laboratories. Between
                  450-500 cardiac catheterization procedures are performed annually. In 2002,
                  construction of a second, fully equipped biplane cardiac catheterization
                  laboratory was completed. Diagnostic and interventional cardiac
                  electrophysiology procedures are performed in one of the biplane laboratories
                  fully equipped for electrophysiology. Over 100 pediatric radiofrequency
                  ablation procedures are performed annually. (Appendix C)


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             3. Comprehensive clinical laboratory facility that performs all routine and
                special analyses of blood and urine including blood gas analysis, blood
                chemistry, coagulation studies and blood cross matching.
             4. Completely new operating rooms were opened in the new Anderson Building
                were opened in 2001. These included 2 dedicated cardiac surgical operating
                rooms for cardiopulmonary bypass equipped with approp riate monitors,
                defibrillators and cardiac pacing devices.
             5. A comprehensive blood bank that is equipped to meet the demands of our
                large cardiac surgery program. Nearly all of the blood used for transfusion at
                CHLA is obtained from our own institutional donor program.


IV.   Educational Program
      A.    Clinical Experience
            1. Patient Population
            The population of patients served by the Division of Cardiology, Childrens
            Hospital Los Angeles encompasses ages from the fetus and newborn through
            young adults. Older adults with congenital heart disease may be seen by the
            Division of (adult) Cardiology at the Los Angeles County-USC Medical Center
            and/or the Adult CHD program at USC University Hospital. Residents are
            afforded the opportunity to arrange 4 week elective in Adult Congenital Heart
            Disease at major adult CHD centers such as UCLA or other nationally recognized
            programs. The resident is exposed to the full spectrum of pathology from
            minimal to that requiring the highest intensity of care. The experience
            encompasses pre and postoperative care as well as a broad spectrum of acute and
            chronic congenital and acquired cardiovascular conditions.

             Patients admitted to the inpatient cardiology service are under the direct
             supervision of the attending cardiologist while consultative services are provided
             to inpatients on other services. All such patients are available to the cardiology
             residents.

             Training in history taking and physical examination is a key element of the
             program and is particularly emphasized in the ambulatory setting but certainly
             incorporated into the care and management of inpatients. Family history is a vital
             aspect of the evaluation of children with suspected cardiovascular disease.

                    a. Noninvasive Techniques (See Appendix A)
                    The program at Childrens Hospital Los Angeles provides a comprehensive
                    education in clinical diagnosis with emphasis on the full gamut of
                    noninvasive imaging and diagnostic modalities. These include standard
                    radiology, electrocardiography, echocardiography (both transthoracic and
                    transesophageal), rapid CT and cardiac MRI. Though some fetal echo
                    studies are performed at CHLA, the majority of such examinations are
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                      conducted at the Perinatal Medicine Programs at LAC/USC Medical
                      Center and Queen of Angels/Hollywood Presbyterian Medical Center.
                      The echocardiography laboratory performs >7,000 studies annually. It is
                      expected that each resident will perform &/or interpret at least 1,000
                      pediatric echocardiography studies over the 3 year training period.
                      The large clinical volume also provides sufficient experience for residents
                      to acquire skill in the interpretation of electrocardiograms (3,500/year),
                      Holters (100/year) and treadmill stress testing with ECG monitoring
                      (100/year). The program complies with the Society of Pediatric
                      Cardiology Training Program Directors Draft "Guidelines for Training in
                      Noninvasive Cardiac Imaging" 2002. (Appendix E)

                      b. Invasive Techniques (See Appendix A)
                      The resident is afforded experience and training in the indications,
                      limitations and techniques of diagnostic cardiac catheterization and
                      cardiac angiography; electrophysiologic testing, radiofrequency ablation
                      and pacemaker implantation and monitoring; interventional catheterization
                      (particularly balloon atrial septostomy for the newborn with complete
                      transposition of the great arteries, pulmonary and aortic balloon
                      valvuloplasty). Additional interventional techniques are included
                      depending upon resident interest and career goals.
                      At Childrens Hospital Los Angeles 450-500 cardiac catheterization
                      procedures are performed annually. There are approximately 100 EP
                      procedures (generally including RF ablation). Residents are expected to
                      participate in performing a minimum of 100-150 cardiac catheterization
                      procedures and 5-10 intracardiac EP studies. (Appendix C).

                      c. Resuscitation Techniques
                      Residents receive instruction and experience in techniques and indications
                      for pericardiocentesis, thoracentesis, cardiopulmonary resuscitation,
                      endotracheal intubation, mechanically assisted ventilation, pharmacologic
                      and electrical cardioversion and temporary transthoracic or transvenous
                      cardiac pacing.

                      d. Technical and other skills
                      The residents receive instruction in the basic use of relevant electronic
                      equipment necessary to perform cardiac catheterization,
                      echocardiography, ambulatory electrocardiography and EP studies. The
                      radiation safety officer for CHLA delivers a lecture on the fundamentals
                      of radiation safety.

             2. Preoperative and Postoperative Care
             Residents participate in the care of pre and postoperative patients undergoing both
             closed and open-heart procedures. Approximately 850-900 cardiac surgical
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              procedures are performed annually at CHLA. Residents are assigned to the
              Cardiothoracic Intensive Care Unit for 2 months during each of the first 2 years of
              residency. During that period they work under the direct supervision of the
              attending CTICU attending in close collaboration with the cardiac surgical
              attending and alongside pediatric critical care residents, cardiac surgical residents
              and congenital heart surgical fellow. Cardiology residents gain a broad
              experience in current surgical techniques, particularly neonatal cardiac surgery,
              mechanical ventilation, cardiopulmonary bypass and hypothermia. They receive
              instruction on the indications and the acute and chronic use of pharmacologic
              agents to support cardiovascular function including intravenous inotropes,
              vasodilators, diuretics, sedatives and analgesics.
              They are provided the opportunity for long-term follow- up of cardiac surgical
              patients in the Pediatric Cardiology clinic.
              Residents are responsible for the preparation and presentation of patients at the
              weekly Cardiac Surgery/Cardiology Case Conference. All patients scheduled to
              under surgery during the following week are presented, including clinical,
              echocardiographic and cardiac catheterization data. The attending surgeons and
              cardiologists discuss the cases. In addition, difficult management problems are
              presented at the conference for interdisciplinary discussion and management
              planning.

              3. Pediatric Cardiology Clinic (Appendix A)
                 First year residents attend the pediatric cardiology clinic at LAC/USC under
                 the direct supervision of the CHLA Division of Cardiology faculty. They are
                 afforded the opportunity to evaluate and examine large numbers of patients
                 referred for evaluation of heart murmurs. They can also gain follow- up of
                 LAC/USC patients who had undergone surgery at CHLA. During the second
                 year, the resident is assigned to attend clinic 1/2 day per week with a faculty
                 cardiologist. This provides the resident with an ambulatory cardiology
                 continuity experience for the 2nd and 3rd years of training. Furthermore, this
                 1:1 faculty: resident relationship affords the resident a more personal and
                 intimate educational experience with a senior cardiologist.

             4. Other Clinical Experiences
             Childrens Hospital Los Angeles is the largest, most diverse children's hospital in
             the western United States. As such it provides the resident with opportunities for
             clinical experience in a wide variety of other clinical experiences. For example,
             the institution has the largest experience with Kawasaki Disease in the West and
             one of the largest in the entire country. Dr. Takahashi, in the Division of
             Cardiology, is a nationally and internationally recognized leader in the fie ld.
             Rheumatic heart disease has become rare in the US in general. However, because
             of the large immigrant population in Los Angeles, particularly from Mexico,
             Central America and the South Pacific, our residents are afforded opportunities to
             evaluation and manage children with acute and chronic rheumatic heart disease.
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              Other conditions such as collagen vascular diseases infective endocarditis and
              other metabolic and infectious diseases are seen in abundance. The
              hematology/oncology program at CHLA is one of the largest in the US.
              Cardiovascular abnormalities associated with hematological disorders, e.g. sickle
              cell disease or thalassemia, as well as childhood cancer and the consequences of
              chemotherapy or bone marrow transplantation are seen frequently in consultation.

              Residents receive instruction in prevention and management of cardiovascular
              disease such as hypertension, atherosclerotic coronary heart disease and
              hyperlipidemia. They may elect to participate in the bimonthly Lipid Clinic.

              The Cardiothoracic Transplant Program is a full-service unit encompassing heart
              and lung transplant as well as management of primary pulmonary hypertension.
              The transplant clinic meets twice weekly. Residents may elect to participate in
              the transplant clinic under the supervision of Drs. Jackie Szmuszkovicz and JD
              Menteer.

              5. Other educational experience:
              Residents have been given access to the web-based medical ethics journal from
              the AMA, "Virtual Mentor". They are encouraged to read and discuss on a
              monthly basis. http://www.virtualmentor.org


       B.     Curriculum ( See Appendix B)
              The training program at CHLA offers seminars, lectures and conferences that
              provide a satisfactory background in basic cardiovascular anatomy and
              physiology. Lectures by the faculty include anatomy and physiology,
              embryology, pathology, pharmacology, immunology, genetics and
              nutrition/metabolism. (See Appendix D for listing of faculty lecture series).
              The pediatric cardiology residents prepare and present the weekly Cardiac
              Surgery-Cardiology Conference, Cardiac Catheterization conference. They
              prepare and present the monthly Cardiac Pathology conference and are
              responsible for a review of the pathologic anatomy as well as presentation of
              specimens. Residents also present a current article of interest at a monthly journal
              review conference attended by faculty and residents.
              Residents are also expected to complete a course in biostatistics provided by the
              Research Institute of CHLA.

       C.    Teaching Experience
             Pediatric Cardiology residents are given the opportunity to teach and assume
             administrative responsibilities. Cardiology residents on the inpatient cardiology
             service are responsible for teaching and directing pediatric residents and medical
             students on the Cardiology elective. They are also the prime "teachers" for the
             monthly Cardiac Pathology conference.
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               Administrative responsibility for the yearly service schedule as well as the "on-
               call" schedule is the responsibility of the 2 nd and 3rd year cardiology residents with
               the approval of the program director.

        D.      Subspecialty Resident Policies
                The Policies and Procedures for cardiology residents are fully compliant with the
                general Policies of the "parent" Pediatric Resident Policies at CHLA. They are
                each "on call" in the hospital (CTICU) 1 weekday night and 2 weekend days per
                month. During the remaining weeks, they are on "beeper call" 1 weekday night
                per week. The average number of "on call" nights/weekend days is 5-6 per
                month. The program complies with the ACGME guidelines on resident duty
                hours (June 11, 2002). Residents are not scheduled for more than 80 duty hours
                per week, averaged over a four-week period. At least one day in seven is free of
                patient care responsibilities, averaged over a 4-week period. Residents are not
                "on-call" more frequently than every third night, averaged over a 4-week period.
                There is a 24-hour limit on on-call duty, with up to 6 additional hours for
                continuity/transfer of care and educational activities. Residents are assigned no
                new patients after 24 hours and do not participate in new cardiac procedures, e.g.
                do not participate in new cardiac catheterization procedures after being on-duty in
                the hospital for 24 hours. When residents take call from home, only the time
                spent in the hospital is counted toward the daily 24-hour and weekly 80-hour duty
                hour limit.
                Vacation:
   1.   Fellows are entitled to 3 weeks vacation (15 work days) plus appropriate time to attend
        one national cardiology meeting (AHA, ACC, AAP, APS-SPR) per year
   2.   Requests for vacation days must be submitted sufficiently far in advance to assure
        appropriate coverage of divisional activities. In general, vacation requests should be
        submitted to the program director at least 2 months in advance. Vacation times must be
        posted into the master fellow rotation schedule.
   3.   Vacations should be scheduled during Echo, Cath, Research or elective months and
        should not be scheduled during inpatient General Cardiology or CTICU rotations. If
        scheduling of vacation during inpatient rotations is unavoidable, the fellow is responsible
        for arranging for appropriate daytime, night and weekend coverage. Approval of the
        request is contingent upon coverage. The fellow will be required to “make up” the days
        off at another time.
   4.   Vacation days requested less than 2 months in advance will be approved only on a case-
        by-case basis and depend upon coverage arrangements.
   5.   Only one fellow will be allowed to take vacation at a time

        E.     Research and Scholarly Activity
               Scholarly activities are a fundamental part of the training program in pediatric
               cardiology.

             1. Research Program for Pediatric Cardiology Residents
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             Fellows are “expected to engage in specific areas of scholarly activity to allow
             acquisition of skills in the critical analysis of the work of others; to assimilate new
             knowledge, concepts and techniques related to pediatric cardiology; to formulate
             clear and testable questions from a body of information/data to be prepared to
             become effective subspecialists and to advance research in pediatrics; to translate
             ideas into written and oral forms as teachers; to serve as consultants for
             colleagues in other medical or scientific specialties; and to develop as leaders in
             their field.” (The American Board of Pediatrics, Training Require ments for
             Subspecialty Certification. January 2004)

             “All fellows will be expected to engage in projects in which they develop
             hypotheses or in projects of substantive scholarly exploration and analysis that
             require critical thinking. Areas in which scholarly activity may be pursued
             include, but are not limited to: basic, clinical or translational biomedicine; health
             services; quality improvement; bioethics; education; and public policy. Fellows
             must gather and analyze data, derive and defend conclusions, place conclusions in
             the context of what is known or unknown about a specific area of inquiry and
             present their work in oral and written form to the Scholarship Oversight
             Committee (see below) and elsewhere,” e.g. regional and national professional
             society meetings.

             Fellows are required to begin thinking about research activities during year 1 and
             are expected to begin the background work for their research projects during year
             2. These activities include discussions and instruction by faculty mentors,
             background literature search, design of the research protocol and submission of
             the protocol and consent documents to the IRB (Committee on Clinical
             Investigations). Each resident is required to obtain certification from the CCI
             documenting their education and knowledge in the bioethics of human subjects'
             research and the regulations governing such research. The resident is expected to
             begin their research activities during year 2 and complete the data acquisition and
             statistical analysis during year 3. Preparation of an abstract for presentation at a
             national meeting and manuscript for submission to a peer review journal is
             required. Presentation of their research to the faculty and staff as interim works in
             progress and following completion of the project is integrated into the conference
             schedule.

             To meet the ABP Subspecialty Board requirements for Cardiology Certification
             for fellows beginning July 1, 2004 the specific written, “work product(s)” may
             include:
                      A. A peer-reviewed publication in which a fellow played a substantial role
                      B. An in-depth manuscript describing a completed project
                      C. A thesis or dissertation written in connection with the pursuit of an
                      advanced degree

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                      D. An extramural grant application that has either been accepted or
                      favorably reviewed
                      E. A progress report for projects of exceptional complexity, such as a
                      multi- year clinical trial

               The fellow is required to attend the CHLA sponsored course: Fellows’ Course in
               Scholarship Skills that was initiated in 2004. (Appendix) The course will consist
               of formal training in research study design, biostatistics, principles of evidence-
               based medicine, etc. It will combine didactic teaching with interactive learning.
               The focus will be how to develop, implement, and analyze a research protocol. In
               addition, the format will foster interaction of fellows from different Divisions, and
               may even encourage research collaboration across Division lines. Fellows can
               use their own research studies as "homework" in the course, which will provide
               them with practice of the skills learned in a format they should be motivated to
               pursue.

Fellows also have had the opportunity to attend a separate course in Biomedical Statistics
sponsored by the Research Institute.

               2. Scholarship Oversight Committee (SOC):
                  In compliance with the subspecialty training requirements for fellows
                  beginning training July 1, 2004, the SOC has been established in the division
                  of cardiology. It includes 2 members of the faculty from the division of
                  cardiology and 1 from the division of cardiac intensive care. In addition, the
                  training program director is a non-standing member. The members of the
                  SOC include: John Wood, M.D.,PhD, Masato Takahashi, M.D., David
                  Moromasato, M.D.
                  The SOC will:
                      a. Determine whether a specific research project is appropriate to meet
                          the ABP guidelines for scholarly activity.
                      b. Determine a course of preparation beyond the core fellowship
                          curriculum to ensure successful completion of the project.
                      c. Evaluate the fellow’s progress
                      d. Meet with each fellow early during Year 1 and regularly thereafter.
                      e. The fellow will present the progress on the project.
                      f. Advise the program director on the fellow’s progress and assess
                          whether the fellow has satisfactorily met the guidelines associated with
                          the requirement for active participation in scholarly activities.

               3. Faculty Research/Scholarly Activity
                  Evidence of the ongoing commitment to research in pediatric cardiology is
                  provided in Appendix H

               4. Conference Schedule
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                    a. Echocardiography. Monday AM, weekly. Faculty leader: Pierre Wong,
                       M.D.
                    b. Cardiac physiology. Tuesday AM, weekly. Faculty Leader: Alan B.
                       Lewis, M.D.
                    c. Journal club. Wednesday AM. monthly Faculty Leader: Alan B. Lewis,
                       M.D.
                    d. Pediatric resident presentations. Wednesday, AM. Monthly. Faculty
                       leader: Jay Preutz, M.D.
                    e. Cardiac Pathology. Wednesday, AM. Monthly.
                    f. Morbidity and Mortality Conference. Wednesday, AM. Quarterly. Faculty
                       Leader: David Moromasato, M.D. and Michael Silka, M.D.
                    g. Faculty lecture series. Wednesday. Noon. (See Appendix D)
                    h. Electrocardiography. Weekly. Faculty leader: Yaniv Bar Cohen, M.D.
                    i. Cardiac Surgery. Thursday, AM. Weekly. Faculty leader: Vaughn Starnes,
                       M.D., Michael Silka, M.D.
                    j. Cardiac catheterization. Friday, PM. Weekly. Faculty leader: Sarah
                       Badran, M.D. Cheryl Takao, M.D.
                    k. Adult Congenital Heart Disease. 2nd Thursday of month at LAC/USC.
                       Faculty leader: Masato Takahashi, M.D., Enrique Ostrzega, M.D.

V.       Evaluation
         A. Evaluation of Pediatric Cardiology Residents (Appendix I)
             a. Each resident meets with the program director quarterly. The resident is provided a
             verbal and written assessment of performance and suggestions for improvement. The
             assessment tool is based upon personal knowledge of the program director and input
             from the Cardiology and Cardiothoracic ICU faculty. The resident is given the
             opportunity to respond both verbally and in writing. The resident is asked for
             suggestions on improving the education and training experience. A written
             evaluation is provided to the resident for review, comment and signature. The
             summary is maintained in the resident's file.
         B. Evaluation of Pediatric Cardiology Resident Core Competencies (Appendix J)
     Core Competency evaluation is incorporated into the quarterly resident evaluation process
     using the evaluation tool (Appendix J).
     The Program has adopted the recommendations advocated by the ACGME:

       Institutions must ensure that each program has defined, in accordance with the Program
       Requirements, the specific knowledge, skills, and attitudes required and provide
       educational experiences as needed in order for their residents to demonstrate the
       following:
   a. Patient care that is compassionate, appropriate, and effective for the treatment of health
       problems and the promotion of health
   b. Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g.
       epidemiological and social-behavioral) sciences and the application of this knowledge to
       patient care
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   c. Practice-based learning and improvement that involves investigation and evaluation of
      their own patient care, appraisal and assimilation of scientific evidence, and
      improvements in patient care
   d. Interpersonal and communication skills that result in effective information exchange and
      teaming with patients, their families, and other health professionals
   e. Professionalism, as manifested through a commitment to carrying out professional
      responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
      population and
   f. Systems-based practice, as manifested by actions that demonstrate an awareness of and
      responsiveness to the larger context and system for health care and the ability to
      effectively call on system resources to provide care that is of optimal value.

                     Evaluation Tools Used or In Development by Division of Cardiology
General
Competencies
Patient Care          Faculty         Input from          Presentation at
                      Assessment      patients/families   Patient Care
                                                          Conferences
Medical Knowledge     Faculty         Presentation at     Assessment of        Performance on
                      Assessment      Journal Review      Clinical             Cardiology In-
                                      Conferences         Research             service exam
Practice-based        Procedure       Faculty             Faculty              Faculty
Learning              logs            assessment of       assessment of        assessment of
                                      echo skills         catheter skills      ICU skills
Interpersonal and     Faculty/staff   Patient and         Developing           Teaching skills
Communication         Assessment      family              Health               (presentations at
Skills                                interaction         Professional and     journal club,
                                                          staff surveys        path/cath/echo
                                                                               conf)
Professionalism       Faculty         Conscientious       Cultural             Certification/rece
                      Assessment      (timely             sensitivity          rtification
                                      completion of       Ethical principles   PALS/BLS
                                      medical records)    Uses web-based
                                                          medical ethics
                                                          journal:
                                                          http://www.virtu
                                                          almentor.org

Systems-based         Faculty/staff   Use of system       participation on
Practice              Assessment      resources, e,g,     hospital
                                        social work,      committees
                                      home nursing,
                                      regional center,

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                                      etc.


      B. Evaluation of Faculty
         a. Teaching faculty undergo an annual evaluation emphasizing clinical performance
         and knowledge, teaching ability and contribution to resident education and
         participation in scholarly activities. These evaluations are performed by the Division
         Head and are forwarded to the Department head. Faculty receive formal feedback
         from these evaluations.
         b. Residents are requested to provide an annual, confidential written evaluation of
         faculty performance with regard to education, availability, interest in training
         program and clinical knowledge. In addition, graduating residents are asked to
         provide a written summary evaluation of the program, its strengths and weakness and
         recommendations for improvement. These assessments are shared with the division
         head and with the faculty, both individually and collectively as appropriate.
      C. Evaluation of the Program
         The faculty meet at least annually to review program goals and objectives and the
         effectiveness of the program. The written evaluations by the residents are
         incorporated into the discussion and deliberations.
         The program also undergoes internal institutional review by an independent review
         committee. The analysis and recommendations of the committee have been shared
         with the program director and division head. The program director has used these
         valuable interactions to institute improvements in the training program. The most
         recent review was completed in April 2002.

VI.   Duty Hours
      The program has adopted the guidelines stipulated by the ACGME in the statement of
      September 2002. (Appendix K). The program adheres to the 80-hour/week limit with
      the maximum of 24 hours of consecutive in- house duty. Up to 6 additional hours may be
      incorporated for didactic conferences or continuity clinic.




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Appendix A
                      FELLOWSHIP IN PEDIATRIC CARDIOLOGY
                        CHILDRENS HOSPITAL LOS ANGELES
                           DEPARTMENT OF PEDIATRICS
                       UNIVERSITY OF SOUTHERN CALIFORNIA
                              SCHOOL OF MEDICINE


PROGRAM GOALS AND OBJECTIVES
         The goal of the training program is to prepare each resident for a career as a Board
certified consultant in pediatric cardiology. To that end the following goals and objectives are
established:
a. Each resident understands the embryology, fetal and perinatal physiology, and postnatal
physiology and anatomy of normal cardiac development and the entire spectrum of congenital
heart lesions and acquired cardiac disorders.
b. Understands the clinical pharmacology and role of medical therapy in the treatment of
cardiovascular disorders including cardiac failure, left to right shunts, cyanosis, arrhythmias,
pulmonary and systemic hypertension, hyperlipidemia and preventive cardiology.
c. Understands the role and appropriate timing of cardiac surgery for congenital and acquired
cardiac malformations.
d. Is technically proficient in performing and interpreting cardiac procedures including
echocardiography (transthoracic, transesophageal and fetal), electrocardiography and cardiac
catheterization. Minimum numbers of procedures to be performed or participate in are
summarized on the Curriculum. Is technically proficient in performing selective interventional
procedures including balloon atrial septostomy, balloon pulmonary valvotomy, balloon
angioplasty for coarctation of aorta (restenosis) and right ventricular endomyocardial biopsy. Is
exposed to invasive electrophysiology and selective, complex, higher risk interventional
catheterization procedures, e.g. balloon aortic valvuloplasty, stents, PDA and ASD closure, and
understands their role in the management of patients.
e. Is proficient in the management of pre and postoperative patients including those with
complex congenital heart malformations.
f. Understands the family and social context of the child with cardiac disease and incorporates
that understanding into the total treatment plan. Utilizes other professionals e.g. nurses and
social workers as a multidimensional team in the management of each patient.
g. Develops the analytic skills to critically assess new developments and incorporate appropriate
advances into clinical practice.
h. Is cognizant of the role of managed care. Utilizes testing and consultations appropriately and
efficiently. Understands the need for coordinating care through the primary physician and
obtaining authorization from private and government payers.

        The fellowship consists of 3 years of training. The attached curriculum summarizes the
areas of concentration. Year 1 & 2 are dedicated to clinical training with increasing time
available for initiating research during the 2nd year. The 3rd year is principally devoted to
research activities, either clinical or basic depending on individual preferences.
                                                   14
Version Nov 2008
INPATIENT CARDIOLOGY:
        Activity on the inpatient Cardiology service includes daily morning rounds with the
faculty attending cardiologist, pediatric residents and medical students. Patients in the Cardiac
Intensive Care Unit (2W) as well as in the general inpatient unit (6W) are reviewed. The
resident is encouraged to assume increasing responsibility for patient care commensurate with
his/her level of training. During Year 1 the resident reviews all cases with the attending prior to
any recommendations. The resident guides the pediatric residents and medical students. During
Year 2 the resident takes increased responsibility for patient management. The attending sees all
patients daily but the resident is encouraged to independently plan the patients' management.
The resident is responsible for leading rounds with the team. During Year 3 the resident serves
as a junior attending. The resident is responsible for leading rounds and for independently
planning the patient's management. The attending's role is to approve and modify where
appropriate the management plan developed by the resident. The third year resident is
responsible for both bedside teaching as well as lectures to the pediatric residents and medical
students.
        The rounding team performs consultations on patients throughout the hospital.

CARDIOTHORACIC INTENSIVE CARE UNIT:
        In addition to the General Cardiology Service, residents will be assigned specifically to
the Cardiac Intensive Care Unit for a period of 2 months during each of Years 1 & 2. The
resident will work under the supervision of the attending cardiac intensivist and cardiac surgeon
along with pediatric intensive care residents and cardiac surgical residents/residents. The goal of
this very intense experience is to allow the resident to become proficient in the pre and
postoperative management of infants and children with congenital and acquired heart disease. In
addition to the congenital malformations, the resident will be trained in the medical and
pharmacologic management of cardiac arrhythmias, acute and chronic congestive heart failure,
respiratory failure. Specific procedural skills to be acquired include central venous and
peripheral arterial catheterization, endotracheal intubation, ventilator management, temporary
transvenous pacemaker insertion, principals or pacemaker use, thoracentesis, pericardiocentesis.
Responsibility and independence of action are gradually increased as these skills are acquired. It
is expected that the Year 2 resident will perform on a semi- independent level under the
supervision of the CT ICU attending.
        Approximately, 850 cardiac surgical procedures are performed annually.

ON-CALL:
 Night and weekend coverage generally consists of 6 week night (beeper on-call) and weekend
days per month. The resident is expected to be "in house" approximately one night/week and one
weekend day twice during the month.

OUTPATIEN T CARDIOLOGY:
       Each 1st year cardiology resident will attend a weekly half-day cardiology clinic at the
LAC/USC Medical Center Women's and Children's Hospital under the direct supervision of
CHLA faculty member. The resident is encouraged to evaluate and p lan the continuing care of
                                                 15
Version Nov 2008
cardiac outpatients under the direction of a faculty cardiologist. This includes working with CCS
and Medi-Cal to assure coverage for services. Residents are encouraged to follow-up patients at
LAC/USC who require cardiology or cardiac surgery procedures at CHLA so as to provide
continuity for both the patient and the physician.
        Year 2 residents begin a continuity clinic at CHLA working in close collaboration with a
single attending cardiologist. Residents experience first ha nd the need to work with managed
care plans to receive appropriate authorizations. They also learn how to perform proper ICD-9
diagnostic and CPT-4 procedure coding as well as providing the necessary level of
documentation to support the procedure code selection.
        There are approximately 5,500 outpatient cardiology visits annually at Childrens Hospital
Los Angeles




                                               16
Version Nov 2008
ELECTROCARDIOGRAPHY: Residents will have the opportunity to review and interpret 500-
1,000 studies over the 3 years of residency. Opportunities for interpretation are during the Non-
Invasive Cardiology rotations, the inpatient service rotation and during outpatient clinic. The
laboratory performs 3,500 examinations annually.

CARDIAC CATHETERIZATION :
         Three months of training in the cardiac catheterization laboratory are allocated during the
first year. In addition, the resident will be able to participate in catheterizations one day/week
during those months not committed to the inpatient service. Nearly 90% of cardiac
catheterizations are performed on an outpatient basis. The resident will review the patient's
history, examine the patient and discuss the procedure with the parents prior to catheterization.
The resident will become familiar with all the physiologic, monitoring and radiologic equipment
in the laboratory. The resident will perform as much of the procedure as his/her level of training
and experience warrants. All procedures are done under the immediate, direct supervision of an
attending cardiologist. As skill levels progress, the resident will be afforded the opportunity to
catheterize newborn and young infants toward the end of the first year and during the second
year of training. Participation in interventional procedures will begin in the second year. The
resident will be responsible for calculation of hemodynamic data and timely preparation of the
catheterization report. The number of procedures to be performed is listed in the Curriculum
outline. During Year 2, the resident is afforded increased opportunity to perform as much of the
procedure as his/her skill allows. As always, the attending, supervising cardiologist is
immediately at hand in the cath lab to assist/perform the procedure as needed. The resident is
expected to be able to performed balloon atrial septostomy, begin performed endomyocardial
biopsies, and participate in balloon angioplasty/valvuloplasty procedures.
         There are 450-500 cardiac catheterization procedures performed annually.

ECHOCARDIOGRAPHY:
         Echocardiography training begins early in the training program. It is anticipated that the
resident will be adept at performing and interpreting all but the most complex malformations by
the second half of Year 1. Numerical goals for the number of procedures in which the resident
participates/performs are listed in the Curriculum. With additional experience, the resident
should achieve a high level of sophistication in all echo procedures. It is expected that the
resident's skills are sufficiently developed by their second Echo month that they may perfo rm
echocardiograms independently in the CT ICU when they are on night and weekend call. There
is, however, a qualified sonographer always on-call to back up the resident when needed along
with attending cardiologist, particularly for complex cardiac malformations.
         Opportunity to assist and perform transesophageal echocardiograms will be provided
during the second year. Residents interested in concentrating on noninvasive imaging as a career
goal are afforded the increased opportunity to become a proficie nt, skilled transesophageal
echocardiographer. Fetal echocardiography is another area where residents are provided
exposure during the second year. As with TEE, residents interested in pursuing
echocardiography as an area of specialization can concentrate more fully on echocardiography
during their third year as part of their research experience. However, purely clinical training
during the third year is discouraged, as this is the year in which research productivity is stressed.
It is expected that residents will have performed &/or interpreted 500 echocardiograms during
                                            November 2008
their fellowship. The echocardiography laboratory performs 6,500 studies per year; half in
outpatients and half for inpatients.
         As part of the overall echo lab training program, the resident will provide first call echo
service during his/her nights and weekends on-call.
         Residents attend and participate in a weekly Echo conference under the leadership of Dr.
Pierre Wong. The conference focuses on "interesting" cases, optimizing imaging techniques,
echocardiographic assessment of cardiac anatomy and physiology, particularly of complex
congenital heart malformations.


ELECTROPHYSIOLOGY:
        Residents will have the opportunity to spend a dedicated month on the EP service during
their second year. This may include EP/arrhythmia rounds, EP/arrhythmia consultations,
pacemaker clinic, observing invasive EP studies and interpretation (also available during Cath
Lab assigned months). In addition, residents are expected to interpret electrocardiogra ms, Holter
examinations and treadmill stress tests during their Echo/noninvasive Cardiology rotations.
Residents may elect to devote their Basic Science month during Year 1 to basic
electrophysiology. Over 85 invasive EP studies, almost all with RF ablation, are performed
annually. The program is structured to comply with the Level 1 (General Pediatric Cardiology
Training) guidelines outlined in the Society of Pediatric Cardiology Training Program Directors
Draft "Guidelines for Training in Pediatric Clinical Cardiac Electrophysiology" 2002.
(Appendix F)

RESEARCH:
         In keeping with the academic orientation of the training program and the requirements of
the Sub Board of Pediatric Cardiology, ample opportunity is afforded the resident for research
activities. The Scholarship Oversight Committee of the Division of Cardiology monitors the
research progress of each Cardiology Resident. The resident is encouraged to participate in a
clinical research project starting in Year 1. The latter may serve as the basis for a more
extensive, prospective clinical research project to be developed during the second year and
completed during Year 3. Residents who wish to pursue basic science research will be
encouraged to identify a mentor early during Year 2. Each resident is expected to perform an
extensive background literature search and write a formal grant proposal for the research work to
be performed. The grant should be prepared in time for submission to the CHLA Research
Institute Grant Committee, the American Heart Association, Greater Los Angeles Affiliate &/or
any other appropriate governmental or private funding agency. The program endeavors to
comply with the 2002draft guidelines of the Society of Pediatric Cardiology Training Program
Directors "Guidelines for Research Training in Pediatric Cardiology" (Appendix G)

ADULT CONGENITAL HEART DISEASE:
        The success of corrective surgery for infants and children with congenital heart disease
has resulted in a significant increase in the number of adults with CHD in the past 20 years. An
Adult Congenital Heart Conference was initiated in 2004 as a joint enterprise between the
Division of Cardiology, Childrens Hospital Los Angeles and the Division of Cardiology,

                                           November 2008
Department of Medicine, USC School of Medicine. The conference is held monthly on the
campus of the LAC/USC Medical Center.
The trainee will have the opportunity to spend 1 month (usually during year 2 or 3) devoted to
ACHD care. In addition, they may gain additional experience during their regular outpatient
cardiology clinic time. Areas to be emphasized include: adolescent issues, postoperative residua,
adult cardiovascular diseases overlying congenital heart problems, contraception, pregnancy,
gynecology, employment, sports, activity counseling, insurability, psychosocial issues. Since we
are a children’s hospital, there is a limited opportunity to follow adults with congenital heart
disease beyond 21-25 years of age. Therefore, fellows are given the opportunity to do an
elective in Adult CHD at USC/LAC Medical Center other recognized programs, e.g. UCLA.




                                          November 2008
                           YEAR 4 CARDIOLOGY FELLOWSHIP


1. Purpose: To provide selected fellows the opportunity for clinical and research
   concentration in one of several specialty areas of pediatric cardiology beyond the categorical
   3 years of specialty training. Following completion of their training, it is anticipated that the
   fellow would pursue a career in academic cardiology in the area of subspecialization.
2. Areas of Specialization:
   a. Electrophysiology
   b. Echocardiography
       i.       Transesophageal echocardiography
       ii.      Fetal echocardiography
   c. Transplant Cardiology
       i.       Heart Transplant
       ii.      Pulmonary hypertension
       iii.     Heart Failure/Cardiomyopathy
   d. Interventional Cardiology
   e. Cardiac MRI
3. Clinical/Research Profile: The position would provide approximately 50% clinical time and
   50% research time.
4. Funding:
   a. Fellows are encouraged have their own independent funding (grants, contracts,
       sponsoring institution or agency)
   b. Fellows who do not have their own sponsorship may apply for funding through
       hospital/divisional/Heart Insititute sources. Up to 50% of funding may be provided by the
       Division of Cardiology (approximately $20,000) from divisional reserves. 50% provided
       by the Heart Institute. Fellow candidates would be encouraged to apply for CHLA
       Research Institute and regional AHA research funding to partly offset divisional/Heart
       Institute Funding. The fellow is expected to do one 4-week rotation in the CTICU and
       would participate in the night/weekend on-call rotation in the CTICU if they do not have
       their own independent funding.




                                           November 2008
       Appendix B
                     CURRICULUM FOR CLINICAL AND RESEARCH TRAINING
                               IN PEDIATRIC CARDIOLOGY


                                                      Year 1
The schedule is divided into 4-week units for a total of 13 units/year


Service/Activity                         Duration                        Approximate       Number     of
                                                                         Patients or Procedures

1. Inpatient                             4 months
                                          2 months                       Cardiology Rounding
                                          2 month                        Cardiothoracic ICU

2. Outpatient                            1-half day/wk                   100-150 patient visits
                                         7 months

3. Echocardiography/                     3 months                        300 studies
  Non-invasive                                                           500 ECG over 3 yrs (inpatient,
                                                                         outpatient, non- invasive)

4. Cath Lab                              3 months                        50 procedures


5.Research/Basic                         1 month                         Cardiac Pathology
 Science                                                                 Begin planning research project

6. Night/Weekend                         One weeknight/wk,
  Call                                   1 weekend/month


7. Vacation                              3 weeks Plus one national
                                         meeting




                                                    November 2008
                                              Year 2

                                                                      Approximate      Number      of
Service/Activity                Duration                              Patients/Procedures


1. Inpatient                    4 months
                                 2 month                              Cardiothoracic ICU
                                 2 months                             Cardiology Rounding

2. Outpatient                   1-half day/week                       100-150 patient visits. Includes
                                for 7 months                          Transplant Cardiology for 1
                                                                      month during Yr2 or 3.
3. Echocardiography/            1 month                               100 studies.
  Non-Invasive                                                        500 ECG over 3 yrs (inpatient,
                                                                      outpatient, non- invasive)

4. Cath Lab                     2 months                              50 procedures: infants
                                                                      some interventional

5. Research                     2 months                              Initiate basic &/or clinical
                                                                      research project. Write grant
                                                                      application for 3rd Yr.



6. Electrophysiology            1 month                               Assist in EP cases. 10 EPS
                                                                      cases of which 5 are RFA.
7. Heart Transplant/Pulmonary   1 month. Could be selected for
Hypertension.                   yr 3.

8. Night/Weekend
  Call                          One week- night/wk,
                                1 weekend/mo.


9. Vacation                     3 weeks plus           attend   one
                                national meeting




                                           November 2008
Service/Activity                    Duration                           Approximate      Number       of
                                                                       Patients/Procedures

1. Inpatient                        1 month                            Supervise               students/
                                                                       residents/junior fellows


2. Outpatient                       1/2 day/week X 10 months           120 ambulatory patients


3. Echocardiography/                1 month TEE and Fetal echo*        100 TTE studies.        25 TEE
  Non-Invasive                                                         studies
                                                                       500 ECG over 3 yrs. (inpatient,
                                                                       outpatient, non- invasive)
4. Cardiac Cath lab                 1 day/week*
                                    X 6 months                         Infants and interventional cases
                                                                       (min 20 interventions) May
                                                                       include EP cases to fulfill
                                                                       requirements
5. Research                         9 months
                                                                       Completion of research project.
                                                                       Prepare      manuscript      for
6. Adult       Congenital   Heart   1 month                            presentation/publication.
Disease                                                                Complete course in Biostatistics

                                    1 night/week
6. Night/Weekend Call               1 weekend/month


                                    3 weeks plus one national
7. Vacation                         meeting/year


                                    *Flexible     depending       on
                                    interests




                                         November 2008