Aims of the Fellowship Program in Cardiovascular Disease
At Boston University Chobanian & Avedisian School of Medicine, the goal of our Fellowship Program in Cardiovascular Diseases is to train outstanding cardiologists in both the clinical and research areas. To achieve this level of excellence, we believe that a well-trained cardiologist should have not only excellent clinical skills, but also should possess a firm knowledge of the cardiovascular literature. It is crucial to be able to evaluate new developments in the literature in a critical manner for the benefit of his or her patients. Accordingly, our fellowship program combines both clinical training and an intensive research experience. This dual commitment to excellent clinical training and an intensive research experience is designed to position our trainees for productive careers in academic and/or clinical cardiology.
The clinical training portion of our Fellowship in Cardiovascular Diseases takes place over 24 months. During this period, fellows are involved in patient care at our two main institutions, Boston Medical Center and the VA Boston Healthcare System. The former institution is a product of the merger between Boston City Hospital and the University Hospital. This merger combines the Outreach Programs of an urban hospital serving a diverse and multi-cultural population with that of a private hospital, which serves as a tertiary referral center for many suburban physicians and patients. In contrast, the VA Boston Healthcare systems care solely for the veteran population in both inpatient and outpatient settings.
The Fellowship Program in Cardiovascular Diseases at Boston University Chobanian & Avedisian School of Medicine also includes a very strong and intensive research experience. Each fellow is provided with 10 months of research elective time in the third year to pursue original research in cardiovascular diseases under the direction of a faculty member. During this period, trainees are exposed to cutting edge research at either the clinical or basic science level. It is expected that fellows will pursue an independent research project that will provide him or her with the ability to rapidly synthesize and critically evaluate emerging developments in the field of cardiovascular diseases. Fellows also must complete at quality improvement (QI) project in their third year. Working in teams of faculty, nursing staff, and other professional staff, the QI experience has proven to be a rewarding and important aspect of training at BMC. Trainees who develop a continuing interest in cardiovascular research will find opportunities for more extensive training among the many investigators in the Whitaker Cardiovascular Institute, the main research arm of the Cardiology Section at Boston University Chobanian & Avedisian School of Medicine.
Clinical Training in Cardiovascular Diseases
The hallmark of an excellent cardiologist is the ability to care for critically ill patients in the coronary care unit and the ability to offer effective advice in the consultative management of hospitalized patients with cardiovascular diseases. Our fellows acquire these abilities through one-on-one interaction with a staff cardiologist on both the consult service and coronary care unit service inpatient rotations.
We offer intensive training in the management of patients with acute cardiovascular disease over approximately eight months at the Boston Medical Center and the VA Boston Healthcare System. Each fellow works closely with a single member of the cardiology attending staff in providing patient care in the inpatient general cardiology service, the inpatient cardiomyopathy service, and the cardiac ICU (CCU) service. The fellow also directly supervises a housestaff team in the day-to-day management of patients. Ample opportunity is also provided for fellows to perform and supervise invasive procedures.
Providing clear and concise consultative advice to other clinicians about the care of patients with cardiovascular diseases is a mainstay of clinical cardiology practice. Accordingly, our Fellowship Program in Cardiovascular Diseases includes a diverse training experience in clinical consultative cardiology that is evenly split between the Boston Medical Center and the VA Boston Healthcare System. Fellows are paired with a single member of the Cardiology Staff in order to provide diagnostic evaluation and management of patients on the inpatient wards who require consultative cardiovascular care. This experience provides the fellow with expertise in the preoperative assessment of cardiovascular risk and the acute management of cardiovascular problems in patients who have undergone both cardiac and non-cardiac surgery. We also have very active inpatient medical services at both the Boston Medical Center and the VA Boston Healthcare System that are served by our cardiology consult service.
Non-Invasive Cardiology Training
The clinical practice of cardiology today requires clinicians to be proficient in the performance and interpretation of non-invasive studies for the diagnosis and management of cardiovascular diseases. The Boston University Chobanian & Avedisian School of Medicine Fellowship in Cardiovascular Diseases emphasizes non-invasive cardiology training in four main areas: echocardiography, exercise testing, nuclear medicine, and advanced cardiac imaging involving cardiac MRI, CT, and PET. This training in non-invasive cardiology occupies six months of the clinical training period during the first two years of fellowship. For those individuals with a particular interest in the non-invasive services, we provide an option for advanced training that is available in the third fellowship year.
The Boston Medical Center and the VA Boston Healthcare System both have very active echocardiography programs. We offer an intensive training experience that provides individuals with absolute proficiency in the performance and interpretation of echocardiograms utilizing 2D, pulsed-, and color-Doppler analysis. Under the supervision of both technical and attending staff, fellows directly participate in acquiring technically suitable studies required to answer important diagnostic questions. Fellows then work individually with a member of the Echocardiography Laboratory Attending Staff in the interpretation of studies performed throughout the day. This experience also involves training in the interpretation of transesophageal echocardiograms that are performed at both institutions. For interested fellows, we offer clinical training in the performance of transesophageal echocardiography during the third year of fellowship.
The mainstay of risk stratification in patients with known or suspected coronary artery disease is exercise testing. Accordingly, our Fellowship Program in Cardiovascular Diseases offers comprehensive training in all modalities of exercise testing. This experience provides proficiency in both the performance and interpretation of exercise tests that are performed in the exercise test laboratories of the Boston Medical Center and the VA Boston Healthcare System. Particular emphasis is focused on alternative methods of detecting ischemia such as stress echocardiography, Dobutamine stress testing, and nuclear perfusion (see below). We have specifically structured this rotation so the fellow may work one-on-one with a member of the cardiology attending staff.
During the exercise testing rotation, the fellow becomes involved in the performance and interpretation of nuclear perfusion studies at the Boston Medical Center and the VA Boston Healthcare System. The fellow works closely with a staff nuclear cardiologist and/or radiologist in reading both planar and SPECT and PET nuclear perfusion studies. As part of this rotation, the fellow also organizes and participates in a weekly non-invasive conference that highlights interesting findings from the echocardiography, stress testing, and nuclear medicine laboratories. Third year fellows gain valuable experience with FDG and Rb-82 cardiac PET in year three. For the purpose of nuclear credentialing, we make available a three-month rotation during the third year that offers a more intensive experience in nuclear cardiology for those fellows who wish to pursue this training.
Cardiovascular MR and Cardiac CT
Exposure to cardiovascular MR (CMR) and cardiac CT is a requirement for board certification. All fellows rotate onto the Advanced Cardiac Imaging (AI) rotation for 2 months during their third year to gain this exposure. Additional training for higher level certification is also possible in the third year and beyond. In their first 2 years, fellows will be exposed to CMR and CT through lectures, clinical cases presentations, and individual cases during their clinical rotations. Boston Medical Center has established a program in CMR and cardiac CT that represents a collaborative effort between the Section of Cardiology and Department of Radiology. Equipment includes 1.5 T Philips and 3.0 T Philips MR systems, as well as 64-slice GE CT systems. Fellows will participate in quantitative analysis and interpretation, reporting, and have the opportunity to directly supervise image acquisition.
One hallmark of excellence in clinical cardiology is the sophisticated interpretation of electrocardiographic tracings. During the non-invasive rotation, trainees have the opportunity to interpret electrocardiograms and Holter monitor examinations that are performed at the Boston Medical Center and the Boston VA Medical Center. These interpretations are then reviewed with the fellow by a rotating staff cardiologist. Interesting tracings or examinations are often included in the weekly non-invasive conference.
The Boston Medical Center has a state-of-the-art preventive cardiology program that involves comprehensive coronary risk factor reduction including the management of lipid disorders, exercise training, nutrition, and smoking cessation. During the exercise laboratory experience at the Boston Medical Center, fellows spend one day per week in the preventive cardiology clinic working one-on-one with a staff cardiologist. Fellows are involved in the diagnosis and management of patients with a variety of lipid disorders as well as in the design of programs for exercise and rehabilitative training in the cardiovascular risk reduction and rehabilitation center.
Invasive Cardiology Training
The Boston Medical Center Arrhythmia Service, provides comprehensive care for patients with all forms of cardiac arrhythmia disturbances. The service has three component parts:
- A recently built electrophysiology laboratory with state-of-the-art imaging and mapping system. This laboratory is used for all electrophysiology related procedures, including diagnostic EP testing, radiofrequency ablation of supraventricular and ventricular tachycardias, as well as pacemaker and ICD implantation, performed by electrophysiologists, in conjunction with the rotating EP fellow.
- The arrhythmia consult service provides full consultative service for in-house and referred arrhythmia patients. The service is staffed by an attending electrophysiologist as well as a physician’s assistant and the rotating cardiology fellow. Consultation is provided for all tachy and brady arrhythmias throughout the Harrison Avenue campus; including patients in intermediate care units, surgical intensive care, and post-operative units. The cardiology fellow will have primary responsibility in running the service.
- A Pacemaker/ICD Center. This center provides ongoing outpatient evaluation of all patients with pacemakers and implanted devices. The clinic currently runs three afternoons per week. Through this clinic, the fellow will gain exposure to basic and advanced pacemaker technology, cardiac resynchronization, and learn techniques for troubleshooting and on-going management of patients with implanted devices.
Cardiac Catheterization and Invasive Cardiology
An essential feature of a well-trained cardiologist is the sophisticated interpretation of coronary angiograms and a solid working knowledge of coronary anatomy. As part of our fellowship in cardiovascular diseases, we provide an intensive and comprehensive four-month experience in cardiac catheterization. This experience involves two months in each of two years of fellowship at the Boston Medical Center and at the Boston VA Medical Center. This training is not limited to the technical aspects of cardiac catheterization. In contrast, our fellows become involved in the diagnostic evaluation of patients referred for cardiac catheterization including the synthesis of clinical data and the establishment of an indication for cardiac catheterization on patients that they have evaluated. After performing a procedure, fellows work one-on-one with a member of the cardiac catheterization laboratory attending staff in synthesizing the catheterization findings and providing recommendations for further evaluation and management of patients. During the third year, we find that our fellows have gained sufficient experience to perform procedures semi-independently at the VA Boston Healthcare System.
Cardiomyopathy and Congestive Heart Failure Management
The Boston Medical Center has a very active and nationally recognized program in cardiomyopathy and congestive heart failure management. The core of this program is the cardiomyopathy service, which provides diagnostic evaluation, and management services on a consultative basis to both the Boston Medical Center, and a busy inpatient cardiomyopathy service. The cardiomyopathy service uses a variety of tools in the evaluation and management of patients with congestive heart failure and cardiomyopathy. These include sophisticated right heart catheterization with a combination of resting, exercise, or inotropic hemodynamic analysis; cardiopulmonary exercise testing; endomyocardial biopsy; and cardiac transplantation evaluation. In addition to patient management, the cardiomyopathy service is involved in a variety of basic and clinical protocols used in understanding the pathophysiology of cardiac myopathy as well as the investigation of new drugs. Fellows on this service also participate in a cardiomyopathy conference, which is held one morning per week.
Didactic Sessions and Teaching Rounds
We have organized a series of teaching rounds and didactic sessions that are designed to ensure that each trainee develops the core knowledge necessary for proficiency in the clinical and/or academic practice of cardiology.
Daily Teaching Rounds: The cornerstone of teaching in our Fellowship Program in Cardiovascular Disease is daily teaching rounds on both the consultation service and the coronary care unit rotation. During these rounds the attending staff discuss in great detail specific cases and relevant literature concerning problems confronting the patient care team on any given day. For fellows on the cardiac catheterization rotation, there is a conference that takes place everyday at 7:15 AM in which proposed patients for cardiac catheterization are presented and fully discussed in the context of appropriate indications for catheterization, appropriate indications for catheterization, appropriate management issues, and appropriate methods of cardiac catheterization.
Summer School: We hold a series of summer cardiovascular lectures three times a week from July through September. These lectures are designed to be practical presentations that introduce fellows to a variety of cardiac diagnostic techniques and procedures in preparation for assuming their role as a cardiology fellow. Practical issues of performing right heart catheterization, echocardiography, and interpretation of coronary angiograms are addressed in order to provide the fellow with some basic information that will be used throughout the remainder of the year.
Cardiology Grand Rounds: We hold a weekly luncheon lecture series from September through June for both fellows and cardiology attending staff. At Grand Rounds, we invite nationally and internationally recognized investigators to speak about their current research findings and the latest updates on state-of-the-art methods in the practice of cardiology. This conference presents fellows with a rare opportunity to meet and listen to prominent cardiologists from around the world who are involved in shaping cardiology for the future.
Revascularization Conference: Every week we hold revascularization conference in which the cardiology attending staff and the cardiothoracic surgery attending staff participate in case discussions. Fellows from the cardiac catheterization laboratory are invited to present cases for consideration of revascularization. During this conference, a variety of issues related to the technical and clinical aspects of percutaneous and surgical revascularization are discussed in the context of patient case histories.
Rotating Conference Schedule: A series of conferences are held on a rotating basis for both the cardiology attending staff and cardiology fellows. This conference rotates between electrophysiology conference, imaging (non-invasive) conference, integrated hemodynamics, core curriculum, and research conferences. In the electrophysiology conference interesting patient case histories are discussed by the electrophysiology staff. Fellows and cardiology attending staff are exposed to the latest topics in the evaluation and management of patients with complex arrhythmias. Imaging conference involves a presentation by the non-invasive laboratory with interesting examples of electrocardiograms, echocardiograms, MRI, CT and myocardial perfusion studies that are discussed and fellows and cardiology staff alike are exposed to the latest in non-invasive technology. In the research conference, both clinical and basic science investigators in the cardiology section are invited to present an in-depth discussion of their latest research finding. This provides an opportunity for fellows and attending staff to gain exposure to the variety of research that is performed in the cardiology section and in the Whitaker Cardiovascular Institute. In consultant conferences, a senior member of the cardiology staff is invited to discuss interesting patient case histories and selected topics that involve unusual or rare findings in clinical cardiology practice.
VA Boston Healthcare System: A separate clinical case conference and catheterization conference takes place at weekly intervals at the Boston VA Medical Center. At these conferences, interesting case histories of clinical presentations or patients undergoing cardiac catheterization are discussed with fellows and attending staff. These conferences also usually involve the presentation of a variety of primary data including cardiac catheterization films and echocardiograms that are discussed within the context of patient evaluation and management.
Journal Club: A variety of journal club meetings are held monthly at the Boston Medical Center, which provides an opportunity for fellows to interact with cardiology staff in discussing recent research reports. These include a general cardiology journal club, echocardiography journal club, and advanced cardiac imaging journal club. These reports can be either clinical or scientific in nature and often involve important new discoveries that impact on the practice of clinical cardiology. A weekly Journal Club, which focuses on recent research that is of clinical relevance, is held at the Boston VA Medical Center.
Each fellow is given an electronic evaluation by the staff supervisor after each rotation, and feedback is given by the staff to the fellow. The performance of all the fellows is discussed at a joint staff meeting two times a year. Fellows are also evaluated by selected members of the nursing staff in certain monthly rotations, as well as their fellow colleagues at the end of the year. All evaluations are completed in the hospital standard interface, New Innovations.
The fellows are also given the opportunity to write evaluations of the staff and all laboratory experiences at the end of the year, and at the end of each rotation.
Research Training in Cardiovascular Diseases
The Fellowship in Cardiovascular Diseases at Boston University Chobanian & Avedisian School of Medicineis somewhat unique in that fellows participating in this program have access to research opportunities at the level of clinical trials, basic cardiology research, and basic science research. Clinical and basic science opportunities in cardiovascular research are available at both the Boston Medical Center and at the VA Boston Healthcare System. In addition, through the close association of Boston Medical Center with Boston University Chobanian & Avedisian School of Medicine, cardiology fellows are also offered the opportunity to participate in research at the Whitaker Cardiovascular Institute, a research institute at the Boston University Medical Campus that includes principal investigators involved in basic science research in cardiovascular disease. Fellows are expected to participate in a research or academic project (original research, clinical case presentation, review, etc.) during their 3 year fellowship. There is ample time during the 3rd year to achieve this objective, as well as additional time possible for fellows interested in an academic research career. Additional training for fellow research is also possible through the various funding mechanisms available to cardiology faculty.
** Fellows may also supplement their clinical experience with research training in statistical methods and clinical investigative techniques. The Boston University Chobanian & Avedisian School of Medicine CREST Program (Clinical Research Training) is available to interested Fellows in Cardiovascular Medicine and terminates in Masters of Arts in Clinical Investigation from the BU School of Public Health.
Fellows may elect to organize their clinical training in the following pathways:
- Standard Track
We expect that most fellowship candidates will be drawn to the standard track. In this three-year program,two years are devoted to scheduled rotations with a third year available to pursue level II training in areas of sub-specialization such as echocardiography, cardiac MRI, nuclear imaging, or invasive cardiology. Cardiology fellows may chose a third year devoted to directed basic science or clinical research with an optional fourth year that can be supported by a host of NIH-sponsored mechanism including an NIH-sponsored Basic Science Training Grant in existence at BU for more than 30 years.
- Research Track
Each year we have one to two cardiology fellows enter the research track component of our fellowship program. Typically, these individuals either have prior research experience or a strong commitment to independent research as a major career goal. Research track participants will spend one to two years in research training under the supervision of a mentor with an established record of research training and cardiovascular investigation at the highest level. Participants in the research track may pursue either basic or patient-oriented research as part of this experience. After this research experience, research track participants enter the 24 months of core clinical training designed to provide board eligibility and level I training in all disciplines of cardiovascular medicine.