Clinical Cardiac Electrophysiology Fellowship Program Details
Evaluations & Completion of Training
The clinical cardiac electrophysiology resident will be given the opportunity of acquire the full range of basic and clinical knowledge and clinical skills beyond the introductory level necessary to independently assume the responsibilities of an academic or practicing electrophysiologist. Particular emphasis will be placed on developing the residents for academic positions. The specific objectives are as follows:
- To learn the normal electrophysiology of the human heart. Specifically this includes obtaining an understanding of the electrophysiology of the atrial and ventricular myocardium, sinus node, AV node and His-Purkinje system under normal and diseased conditions, and learning how to apply this knowledge to clinical situations and research.
- To understand the basic pharmacological properties and actions of antiarrhythmic drugs and how to perform clinical trials of pharmacological efficacy.
- To understand how the autonomic nervous system, ischemia, electrolyte disturbances, cardiac disease and other conditions affect cardiac electrophysiology and the alter pharmacological properties of antiarrhythmic drugs; and how to study the autonomic nervous system in the electrophysiology laboratory.
- To learn the pathogenesis of the full gamut of arrhythmias, related symptom complexes and syndromes, and neurocardiac diseases and to understand the technique, application, indications, limitation, sensitivity and specificity of the various non-invasive and invasive diagnostic tests. These arrhythmias and clinical syndromes include sinus node dysfunction, heart block due to AV node and His-Purkinje dysfunction; supraventricular tachycardias; ventricular tachycardias; resuscitated sudden cardiac death; patient population at risk of sudden cardiac death; syncope; palpitations; long QT and other hereditary arrhythmia syndromes; proarrhythmic complications; and neurocardiogenic syncope syndromes.
- To learn the indication, limitations and risks of available and experimental pharmacological and non-pharmacological treatments for the above disorders. Specific non-pharmacological approaches include catheter ablation, pacemakers, implantable defibrillators, surgical ablation, and implantable pharmacological devices.
- Specific emphasis will be placed on developing the resident’s skill in ablation of complex arrhythmias, such as atrial fibrillation, focal and macroreentrant atrial tachycardias, and ventricular tachycardia.
- To further develop the resident’s understanding of the indications, limitation and risks of electrophysiological studies and to become facile in their performance and interpretation, particular of complex or rare conditions. This also involves development of a thorough understanding of the appropriate use and risks of fluoroscopic imaging equipment and the management of acute complications such as cardiac tamponade related to the performance of electrophysiologic studies.
- To develop a thorough understanding of the indications, limitation and risks of pacemaker and defibrillator implantation, to improve their techniques of device implantation, troubleshooting implantable device related problems, and to managing pacemaker and defibrillator patients. Particular emphasis will be placed on indications and implantation techniques for biventricular pacemakers for management of congestive heart failure and prophylaxis for sudden cardiac death. To gain an advanced understanding of electrocardiography as well as other non-invasive risk stratifying studies such as signal-averaged electrocardiography, T wave alternans testing, heart rate variability analysis, and autonomic testing.
- To further the resident’s management, patient management and consultation skills for patients with all types of arrhythmias or arrhythmia-related problems in a variety of settings including outpatient clinics, inpatient wards, CCU, ACU, MICU, SICU’s, and ER.
The educational objectives will be obtained by involvement in the various components of the Clinical Cardiac Electrophysiology Service during the care of patients referred for evaluation and management of arrhythmia-related problems. The various components include outpatient and inpatient consultations, pacemaker clinic, ICD clinic, care of patients before, during and after, electrophysiologic studies, catheter ablation, pacemaker implantation, defibrillator implantation, and arrhythmia surgery, teaching rounds, and educational conferences. The advanced level clinical cardiac electrophysiology resident will be expected to already be familiar with most aspects of clinical cardiac electrophysiology. The goal of training for the advanced-level clinical cardiac electrophysiology resident will be to further develop their skills to allow them to be fully independent to perform and analyze the full range of diagnostic and therapeutic electrophysiologic procedures.
To insure procedural competency, each clinical cardiac electrophysiology resident will have performed each category of electrophysiologic procedure in excess of minimum stated requirements. For the advanced level resident, emphasis will be placed on developing their skills with complex or unusual cases, as would be referred to tertiary care centers. All procedures will be performed directly with one of the Clinical Cardiac Electrophysiology faculty to maximize training and safety. The advanced level clinical cardiac electrophysiology resident will be expected to develop and complete at least two clinical research projects and to actively participate in other on-going research endeavors in conjunction with one or more of the faculty. The goal is to develop the resident’s capability to assume independent research upon completion of their training.
The advanced level clinical cardiac electrophysiology residents will spend a minimum of twelve months on the Electrophysiology Service of the Medical University of South Carolina. This time will be distributed among well-defined experiences in a number of specific settings listed below, which are designed to assure that all the educational objectives are met:
- Electrophysiology Laboratory
The electrophysiology laboratory experience will result in extensive exposure to the accepted indications for invasive EP procedures, techniques, and pre- and post-operative management of diagnostic and therapeutic procedures for patients with the full range of cardiac arrhythmias. The advanced resident is expected to master the techniques of venous and arterial catheterization, interpretation of intracardiac electrograms, characterization and diagnosis of various arrhythmias, transeptal catheterization, conventional mapping, contact and non-contact three-dimensional mapping, stereotactic catheter manipulation and ablation, and ablation with radiofrequency current as well as newer energy sources.
- Inpatient and Outpatient Consultants
The advanced clinical cardiac electrophysiology resident will attain facility with arrhythmia consultation on patients with the entire spectrum of arrhythmia disorders. The settings in which consultations will be performed include the cardiac, medical and surgical intensive care units, inpatient wards, outpatient clinics, and emergency room.
- Intensive Care Units
The advanced clinical cardiac electrophysiology resident will acquire additional skills of arrhythmia management in the ICU setting by assisting in the care of critically ill patients having recurrent arrhythmias. This will include the proper use of antiarrhythmic agents, pacing, defibrillation, cardiopulmonary resuscitation, evaluation for ischemia, and arrhythmia ablation.
- ICD and Pacemaker Implantation
The advanced clinical cardiac electrophysiology resident will obtain complete competency in the evaluation of patients for pacemaker and ICD implantation, implantation of single and dual chamber and bi-ventricular systems, implantable diagnostic recording devices, atrial defibrillators, intra-operative device testing, defibrillation threshold testing, anti-tachycardia pacing testing, and low energy cardioversion testing. The resident will learn the indications for device placement and will become familiar with device interpretation, programming, and post-operative management. A particular emphasis will be placed on gaining skills for implantation of biventricular ICD’s and pacemakers.
- ICD and Pacemaker Clinic
The advanced clinical cardiac electrophysiology resident will further develop their skills for outpatient management of patients with implanted arrhythmia devices including device interrogation, evaluation, and reprogramming, interpretation of delivered therapies, interpretation of stored intracardiac electrograms, and determination of the indications for device replacement.
- Clinical Research
The advanced clinical cardiac electrophysiology resident will be expected to develop skills in clinical and, if desired, basic electrophysiology research. The resident will be expected to design and implement at least two clinical research studies, to present their research at national or international meetings, and to publish their results in peer-reviewed journals. Protected time will be provided to insure completion of their research responsibilities. Appropriate mentoring will be provided by one or more of the clinical electrophysiology faculty.
The percentage of time spent by the advanced clinical cardiac electrophysiology resident in each of the different areas is not strictly defined by specific rotations. Each week will be composed of some time spent in each of the categories. This flexibility allows alteration in the resident’s time commitments to allow concentration on areas of interest or specific educational needs. However, it is anticipated that approximately 60% of the resident’s time will be spent in the electrophysiology laboratory, 20% in the various in-patient and outpatient settings, and 20% in research.
The maximum workweek will not exceed 60 hours and each resident in guaranteed at least one day completely off and without call per week on average.
Call for emergency electrophysiology consultation will be alternated with the General Cardiology fellow on the Electrophysiology Service. After hours emergency consultations occur infrequently and can often be managed by telephone only. There is no in-hospital call required.
The advanced clinical cardiac electrophysiology resident will be supervised every day directly by a faculty member in each of the above settings. It is the faculty member’s responsibility to insure that the procedure or patient evaluation is being performed appropriately and to educate the resident in proper techniques and procedures. This includes assessing the resident’s knowledge of the etiology, pathogenesis, clinical presentation and natural history of the diseases involved and the decision-making process in designing a course of treatment. Feedback will be given to the resident continuously in all areas of clinical care during these supervised activities. These daily interactions between faculty and advanced clinical cardiac electrophysiology resident during patient care provide continuous practice-based learning opportunities for the resident.
The advanced clinical cardiac electrophysiology resident will attend conferences to compliment their patient care educational activities. These include the electrophysiology teaching conference, the electrophysiology research conferences, electrophysiology journal club, clinical case conferences, EGG conferences, and cardiology grand rounds. A Patient Care Teaching Conference specific for clinical electrophysiology will be held every Monday morning from 7:30 to 8:30 AM. During this conference, specific problems related to patient care will be discussed, as will problems related to running the EP Service and Laboratories, quality assurance, morbidity and mortality report, and related patient care issues. Teaching Conferences will be held on Tuesday and Wednesday mornings from 7:00-8:00 AM at Port City Java on Calhoun Street, across from Rutledge Tower. Teaching Conferences will be composed of didactic talks, literature reviews, and reviews of complex and/or interesting cases. The schedule of lectures is listed on the curriculum handout.
Electrophysiology research conferences will be held on one Tuesday morning each month from 7:30 to 8:30 AM in place of Teaching Conferences. Research conferences will be aimed at discussing on-going research or devising new research projects and will entail reviews of the relevant literature. You will be expected to present the results of your research near the end of your year of training in EP in one of these research conferences. In addition to the EP specific conferences, you are encouraged to participate in general cardiology conferences, especially cardiology grand rounds and ECG conference, and cardiac catheterization conference.
One of the major goals for your training is to develop the skills necessary to establish yourself as a clinical investigator. The clinical cardiac electrophysiology resident will be expected to participate in clinical and/or basic electrophysiology research. Each resident is expected to design, implement and analyze at least two research protocols during their training in conjunction with one or more of the faculty members. Data from this research experience will be formally presented during the electrophysiology research meetings and also during national meetings. The resident will be strongly encouraged to write manuscripts describing their results for publication in peer-reviewed journals. In addition, during the year there will be opportunities to write reviews about electrophysiologic topics in conjunction with one of the faculty members for further development of writing skills.
Since clinical research always takes more time than one anticipates, you should start designing your projects at the onset of your EP fellowship (or preferably a couple of months before). As mentioned above, your schedule has been arranged so that you have one fifth of your time protected for performing EP research. This time should be used wisely to ensure that you can completely finish and write-up your research projects before you complete your EP training.
The EP fellows are encouraged to present their research at scientific meetings. Travel to the meetings of the American Heart Association, the American College of Cardiology, and the North American Society of Pacing and Electrophysiology to present research performed at MUSC are not considered part of your vacation time. Travel to these meetings solely as a member of the audience is counted as vacation time. The Cardiology Division will pay the expenses for only one scientific meeting per year. Subsequent meetings must be paid for by the fellow’s mentor provided the mentor is in agreement and has the appropriate funds. Corporate sponsorship should be sought in all cases of research funded by industry, even if the Division has not paid your expenses for a meeting prior to that time. Corporate funding can occasionally be obtained for attendance to meetings independent of presenting corporately sponsored research. Questions regarding this should be addressed to Dr. Wharton.
The Division will pay for travel (coach class only or mileage), ground transportation (taxi fare only – no rental cars), and lodging. Fellows must share accommodations. Please keep all of your receipts, which are then to be turned into Dr. Gold’s office for reimbursement. Undocumented expenses will not be reimbursed.
Clinical Cardiac Electrophysiology Residency is a full time educational experience. Extramural paid activities (moonlighting) must not interfere with the resident’s educational performance nor interfere with the resident’s opportunities for rest, relaxation, and independent study. For a resident to moonlight, s(he) must have a permanent South Carolina medical license; moonlighting is prohibited on a training license by the State Medical Board of Examiners. The resident must also obtain and provide professional liability insurance. MUSC bears no legal or professional responsibility for the residents while moonlighting. Issues regarding professional liability coverage must be directed to University Risk Management (792-3883).
New concerns from the International Office and the ECFMG make it mandatory that no fellow on a J-1 visa moonlight in ANY area without explicit approval from the ECFMG. This is a serious issue and can result in loss of your visa if not followed exactly.
Evaluations & Completion of Training
To assist you in your training, your patient care, clinical and technical skills, interpersonal skill and medical knowledge will be evaluated every three months by the faculty and will be reviewed with you. The purpose of this is to identify areas of performance that need to be strengthened and thus to optimize your learning experience. If there are areas which you feel you need more exposure to, either didactically or practically, please let one of the faculty know so that we can try to accommodate your needs. Similarly, you will be given an opportunity to critique the faculty and EP Program so that we can continue to improve it. At any time we will be glad to entertain any ideas you have regarding how to make the program run more effectively and efficiently.
For satisfactory completion of the Clinical EP fellowship, all EP procedure and clinic notes that were your responsibility to provide must be completed. Your fellowship in EP will not be considered complete until all paperwork is finished satisfactorily. Satisfactory completion of the Clinical EP fellowship also requires that you perform the minimum number of ICD, pacemaker and ablation procedures outlined by the ABIM for board eligibility. This will be monitored throughout your fellowship and, given the large volume of cases at MUSC, these limits will be greatly surpassed unless you miss a large portion of you fellowship because of health or personal reasons.
You can obtain an update of the number of each type of procedure that you have performed by asking Shirley Thompson in Dr. Wharton’s office to pull this off the EP database. If you have any questions regarding distribution of cases that you have performed or other questions regarding completion of your EP fellowship, please feel free to discuss your concerns with Dr. Wharton. There is much flexibility within the Clinical Cardiac Electrophysiology Residency to help maximize your learning experience.
The EP faculty will be glad to assist you in any way in seeking out and evaluating job opportunities. There is a constantly updated file of job opportunities, including both academic and private practice jobs, in Dr. Wharton’s office. Please ask Shirley Thompson for the file to review. You are encouraged to talk to the EP faculty about your career plans so that they can assist you in finding the best opportunities.