Curriculum

The curriculum of the Cardiac Electrophysiology Fellowship is comprised of several parts, including Inpatient Electrophysiology Service, Electrophysiology Laboratory, Longitudinal Clinic and Clinical Cardiac Electrophysiology Research.

I. General objectives

The trainee in Clinical Cardiac Electrophysiology (CCEP) should acquire broad knowledge in all aspects of arrhythmology, including but not limited to bradyarrhythmias, tachyarrhythmias, syncope, noninvasive and invasive diagnostic electrophysiology, and interventional electrophysiology including catheter ablation and device implantation. The trainee should have sufficient knowledge of basic electrophysiology to understand current theories of the mechanisms of cardiac dysrhythmias and the rationale for both pharmacologic and nonpharmacologic therapy.

The CCEP curriculum is organized around the 6 core competencies of the Accreditation Council for Graduate Medical Education (ACGME), introduced in 2001. These are:

1. Patient care that is compassionate, appropriate, and effective for the treatment of health problems.
2. Medical knowledge about established and evolving disciplines relevant to healthcare, and application of this knowledge to patient care.
3. Practice-based learning and improvement that involves the investigation and evaluation of healthcare delivery, the appraisal and assimilation of scientific evidence, and improvement in patient care.
4. Interpersonal and communication skills that result in effective collaboration and exchange of information with patients, families, and other health professionals.
5. Professionalism, as manifested through a commitment to carrying out professional responsibilities in an ethical manner, with sensitivity to patients of diverse backgrounds.
6. Systems-based practice, as manifested by actions that demonstrate an awareness of the organization of our healthcare system, and an ability to call effectively on multidisciplinary resources to provide optimal patient care.

This curriculum is consistent with the Heart Rhythm Society policy statement on the CCEP Fellowship Curriculum that was updated in 2011 (Link, MS et al. HRS policy statement: Clinical Cardiac Electrophysiology Fellowship Curriculum: update 2011. Heart Rhythm 2011; 8:1340-1356).

This curriculum is evaluated by fellows and faculty every 6 months.

II. Inpatient electrophysiology service

A. Overall educational goals

The inpatient CCEP service is the venue for consultative inpatient electrophysiology and hospital-based care of patients on the Electrophysiology Service. Standard and high-resolution ECGs, several types of ambulatory ECG recordings, pacemaker and implantable cardioverter-defibrillator (ICD) interrogation/programming, and evaluation of remote pacemaker and ICD tracings are covered as part of this rotation.

B. Summary of rotation

The CCEP fellow will spend about 25% of their time on the inpatient CCEP service, generally a week at a time excepting the day the fellow is in the ambulatory clinic.

The patients on the Electrophysiology Service include patients admitted after same day admit electrophysiologic procedures, patients admitted through the emergency department, or patients transferred directly from outside hospitals. Fellows are also responsible for performing inpatient CCEP consults. The fellow’s responsibilities include, but are not limited to, performing histories and physicals on admissions or consults, appropriate documentation in the electronic medical record, communication with patient families, coordination of consultations or procedures, and managing the discharge process including the discharge summary on selected patients. Later in the training experience, the CCEP fellow will assume responsibility for running the service, including assisting the associate providers, with backup from the attending electrophysiologist.

The inpatient rotation is led by an attending electrophysiologist, and the team also includes associate providers (physician assistants and nurse practitioners) as well as general cardiology fellows rotating through CCEP. The CCEP fellow has a mentoring and teaching role with regard to more junior general cardiology fellows.

The CCEP fellow generally takes call 1 weeknight a week and 1 weekend a month, which can be taken from home.

C. Teaching methods

1. One-on-one faculty supervision of the fellow’s initial patient assessments and longitudinal care of inpatients on the CCEP service and patients with electrophysiology issues on other services.
2. Walk rounds, with the fellows, associate providers, and electrophysiology attending physician to include bedside teaching and instruction about managing electrophysiology issues.
3. Conferences, including a weekly core curriculum conference, a weekly patient care conference, a monthly journal club (on average), and a monthly research conference (on average). Fellows participate in planning and conducting these dedicated CCEP conferences. There is 1 dedicated CCEP conference weekly; some of the journal clubs and research conferences are in the context of general cardiology conferences including cardiology grand rounds.

D. Educational resources

1. The fellow will have access to standard textbooks of electrophysiology, including Zipes and Jalife’s Cardiac Electrophysiology: From Cell to Bedside, Josephson’s Clinical Cardiac Electrophysiology, Ellenbogen et al.’s Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy, and Huang and Woods Catheter Ablation of Cardiac Arrhythmias. In addition, the at Dartmouth Hitchcock Medical Center electronic medical record includes links to online textbooks like Up-To-Date, as well as online access to MD Consult, and online searching of the whole medical literature. There is also a medical library on site.
2.  

E. Evaluation

Fellows are evaluated based on a global assessment tool completed every 3 months by the faculty and 360-degree evaluations completed by administrative assistants and hospital nurses.

F. Educational goals by competency

1. Patient care

   • Demonstrate competence in the evaluation and management of: inpatients with supraventricular tachycardias including atrial fibrillation; patients requiring acute or chronic anticoagulation; inpatients with ventricular tachyarrhythmias including congenital and acquired long QT syndrome; and inpatients with syncope.
   • Demonstrate competence in prevention of tachyarrhythmias, including primary prevention of sudden death.
   • Demonstrate optimal care of patients before and after an electrophysiologic procedure.
   • Demonstrate optimal care in the monitoring of patients with temporary and permanent pacemakers of all types and ICDs of all types. This skill set includes device interrogation and programming.
   • Demonstrate competence in testing that is relevant to arrhythmia diagnosis and treatment. This includes demonstrating competence in the interpretation of in-hospital continuous electrocardiographic recordings (telemetry).
   • Role model for other members of the healthcare team (general cardiology fellows, associate providers) gathering subtle and reliable information from the patient, and identifying disease presentations that deviate from common patterns and that require complex decision making.

2. Medical knowledge

   • Demonstrate knowledge of the scientific method of problem-solving and evidence-based decision-making.
   • Demonstrate competence in understanding the indications for and complications from invasive electrophysiologic procedures. This includes demonstrating competence in obtaining informed consent from patients undergoing these procedures.
   • Demonstrate knowledge of basic electrophysiology that is relevant to clinical practice, including but not limited to determinants of the normal cardiac rhythm (ionic currents), determinants of normal conduction, mechanisms of tachyarrhythmias and various modulators such as autonomic tone and ischemia, and the cellular electrophysiologic effects of various classes of antiarrhythmic drugs.
   • Demonstrate knowledge of epidemiology and genetic basis for various dysrhythmia syndromes.
   • Demonstrate knowledge of the various antiplatelet agents and anticoagulants and their role in the management of the CCEP patient.
   • Demonstrate knowledge of basic pharmacokinetics and pharmacodynamics.
   • Demonstrate knowledge of the engineering aspects of pulse generator design, and the engineering aspects of electrical sensing and stimulation relevant to implantable cardiac rhythm devices.
   • Demonstrate knowledge of pathophysiology and differential diagnosis for the various types of SVT, polymorphic VT, and monomorphic VT.
   • Understand the test characteristics (for example predictive value) of advanced electrocardiographic methods of risk stratification.
   • Demonstrate knowledge on how to interpret the results of noninvasive and invasive tests in the CCEP patient, such as Holter monitoring, signal-averaged electrocardiography, exercise treadmill testing for arrhythmia evaluation, invasive electrophysiologic testing, and remote monitoring of implantable cardiac devices.

3. Practice-based learning and improvement

   • Develop skills and habits to systemically analyze one’s own clinical practice using quality improvement methods, and implement changes with the goal of practice improvement.
   • Develop skills to locate and appraise evidence from scientific studies relevant to one’s patients’ health problems.
   • Demonstrate a leadership role in the education of all members of the healthcare team.

4. Interpersonal and communication skills

   • Demonstrate interpersonal and communication skills that result in effective collaboration and information exchange with patients, their families, and other members of the healthcare team.
   • Role model effective communication with other caregivers during transitions of care.
   • Demonstrate sensitivity to patient differences that may affect communication, including race, culture, gender, sexual orientation, socioeconomic status, educational level, and religious beliefs.
   • Demonstrate team leadership skills.
   • Demonstrate how to engage patients in shared-decision making.
   • Demonstrate effective communication with patients or families who are angry, frustrated, or in disagreement with the plan of care.

5. Professionalism

   • Demonstrate a commitment to carrying out professional responsibilities at a high level of excellence and in an ethical manner.
   • Demonstrate the importance of avoiding conflicts of interest.
   • Demonstrate a commitment to lifelong learning.
   • Demonstrate a nonjudgmental, caring demeanor toward patients at all times.
   • Demonstrate respect and consideration for all members of the healthcare team.
   • Serve as a professional role model for general cardiology fellows and associate providers on the healthcare team.

6. Systems-based practice

   • Understand the multidisciplinary resources required to prepare patients and their families for care after hospital discharge, including transfer to a skilled nursing facility, home management of disease, and end-of-life care.
   • Recognize barriers to optimal patient care, such as the patient’s ability to afford medication, and potential ways to overcome these barriers.
   • Apply evidence-based, cost-conscious strategies to the management of the CCEP patient.
   • Demonstrate how to manage the team by coordinating the activities of associate providers and technicians on the electrophysiology team.

III. Electrophysiology laboratory

A. Overall educational goals

This learning experience develops competency in diagnostic testing for syncope (invasive electrophysiologic testing and tilt testing), invasive electrophysiology testing to assess risk of sudden death, and interventional electrophysiology (catheter ablation and device implantation).

B. Summary of rotation

The CCEP fellow spends about half of their time in the Electrophysiology Laboratory, generally about a week at a time.

At least half the patients are admitted the same day for elective electrophysiologic procedures; the rest of the patients are inpatients that are added to the schedule.

Fellows are responsible for the pre-procedure history and physical, including obtaining informed consent; performing as much of the procedure as they are capable under direct supervision of an electrophysiology faculty member; and sharing in the post-procedure documentation including the procedure note, communication with the patient’s family, post-procedure orders, and completion of quality-assurance or registry forms.

C. Teaching methods

1. The fellow is directly supervised by the electrophysiology faculty member, for all critical aspects of the procedure. Over time, as the fellow progresses and attains autonomy, they perform more and more of the procedure until the faculty electrophysiologist mainly assists the fellow in a supportive role. Both the cognitive and technical aspects of invasive electrophysiologic procedures are discussed in a tutorial fashion on a daily basis.
2. See Inpatient Electrophysiology Service, II. C. 3.

D. Educational resources

1. See Inpatient Electrophysiology Service, II. D.

E. Evaluation

The fellow is evaluated with a global instrument every 3 months, a portion of which is devoted to this rotation. In addition, direct observation forms are filled out periodically for the major categories of invasive procedures (diagnostic electrophysiology study, pacemaker implantation, ICD implantation, right atrial ablation, left atrial ablation, etc.). A 360-degree evaluation is filled out frequently by an electrophysiology laboratory nurse.

F. Educational goals by competency

1. Patient care

   • Demonstrate competence in the performance of invasive electrophysiologic testing for syncope, sudden death risk stratification, differential diagnosis of SVT, and differential diagnosis of wide-complex tachycardias. Each fellow must perform a minimum of 150 invasive electrophysiology studies, half of which should involve patients with SVT.
   • Demonstrate competence in electrode catheter positioning in all cardiac chambers and the coronary sinus, incorporating 3-D mapping and intracardiac ultrasound where appropriate.
   • Demonstrate competence in catheter ablation procedures, including post-diagnostic testing. Each fellow must perform a minimum of 75 ablation procedures including left atrial ablation for atrial fibrillation.
   • Demonstrate competence in device implantation, including a minimum of 25 ICD implantations, 30 ICD/pacemaker revisions or replacements, 25 dual-chamber pacemaker implantations, and 25 CRT implantations.
   • Demonstrate competence in electrophysiologic evaluations of implantable devices, such as noninvasive programmed stimulation for arrhythmia induction through the device and defibrillation threshold testing. Each fellow must perform a minimum of 25.
   • Demonstrate competence in various mapping techniques, such as activation sequence mapping and entrainment mapping.
   • Demonstrate competence in the assessment of patients with autonomically-mediated syncope and related disorders like POTS syndrome, including conducting head-up tilt testing.

2. Medical knowledge

   • Demonstrate understanding of recording techniques, including amplifiers, filters, and signal processors.
   • Demonstrate understanding of programmed electrical stimulation techniques to determine conduction times and refractory periods, and to initiate and terminate tachyarrhythmias.
   • Demonstrate understanding of radiation of physics, and safety related to the use of x-ray imaging equipment.
   • Demonstrate understanding of the biophysics of catheter ablation including factors affecting lesion formation, covering a variety of modalities (solid electrode, irrigated electrode, cryoablation).
   • Demonstrate understanding of sterile operating room techniques, multiple techniques for vascular access, and creating pockets for pulse generators.
   • Demonstrate understanding of how to troubleshoot implantable device malfunction with external programmers.
   • Demonstrate understanding of the CMS and American College of Cardiology indications for implanted pacemakers and defibrillators.
   • Demonstrate understanding of the differences in pathophysiology and similarities in treatment for neurocardiogenic syncope, orthostatic hypotension, and POTS syndrome.
   • Demonstrate understanding of the value of diagnostic tests for the assessment of syncope, including tilt table tests, ambulatory ECG monitoring, and electrophysiologic testing.

3. Practice-based learning and improvement

   • Develop skills and habits to systemically analyze one's practice using quality improvement methods, and implement changes with the goal of practice improvement.
   • Participate in the QA processes of the Electrophysiology Laboratory, namely the Northern New England Electrophysiology Registry and the National Cardiovascular Disease ICD Registry.
   • Develop skills to locate, appraise, and assimilate evidence from scientific studies related to optimally performing electrophysiology procedures.

4. Interpersonal and communication skills

   • Demonstrate interpersonal and communication skills that result in collaboration and effective exchange of information with patients, their families, and health professionals.
   • Demonstrate a thorough understanding of the informed consent process, including the pros and cons of alternatives to invasive electrophysiologic procedures.
   • Demonstrate a thorough understanding of the approach to patients with a do not resuscitate status in the electrophysiology laboratory.
   • Demonstrate sensitivity to patient differences that may affect communication, including race, culture, gender, sexual orientation, socioeconomic status, educational level, and religious beliefs.
   • Demonstrate effective communication skills with patients and families who are angry or frustrated, or in disagreement with the plan of care.
   • Demonstrate how to engage patients in shared-decision making.
   • Role model effective communication with other caregivers during transitions of care.

5. Professionalism

   • Demonstrate a commitment to carrying out professional responsibilities at a high level of excellence and in an ethical manner.
   • Understand the importance of avoiding conflicts of interest, including those conflicts with commercial vendors who interface with physicians in the electrophysiology laboratory.
   • Demonstrate a commitment to lifelong learning.
   • Demonstrate high regard and respect for all members of the healthcare team.

6. Systems-based practice

   • Demonstrate an understanding of how the healthcare system is organized, and the ability to call on multidisciplinary resources to provide optimal care for one’s patients.
   • Recognize barriers to optimal patient care, such as the patient’s ability to afford medication, and potential ways to overcome these barriers.
   • Demonstrate incorporation of cost-awareness principles into the performance of electrophysiologic procedures.

IV. Longitudinal clinic

A. Overall educational goals

Longitudinal clinic is an outpatient clinic serving as the venue for learning how to care for patients with chronic electrophysiology issues, such as monitoring antiarrhythmic drug therapy, assessing implanted device function, and management of patients post electrophysiology procedures. In addition, the fellow will see new consultations and be involved in pre-electrophysiology procedure assessment and planning.

B. The summary of rotation

The CCEP fellow will spend about 10% of their time in longitudinal clinic, generally one-half day weekly. This clinic consists of patients with chronic electrophysiologic issues, such as syncope of unclear etiology, symptomatic ectopy, bradyarrhythmias, tachyarrhythmias, and patients who have undergone electrophysiology procedures including device implantation. The fellow’s responsibilities include, but are not limited to, performing histories and physicals, appropriate documentation in the electronic medical record, communication with patients’ families, coordination of consultations, and pre-procedure planning for patients that need electrophysiology procedures. A faculty electrophysiologist is assigned to be in clinic to review and see patients in conjunction with the CCEP fellow.

C. Teaching methods

1. One-on-one supervision of the fellow’s new patient assessments and longitudinal care of the electrophysiology patient. This includes direct review with the faculty electrophysiologist of standard and high-resolution ECGs, ambulatory ECG recordings, and in-office pacemaker and ICD interrogation and programming.
2. Conferences (see Inpatient Electrophysiology Service, II.C.3.).

E. Evaluation

The fellows are evaluated with a global instrument every three months, a portion of which is pertinent to this rotation. In addition, direct observation forms are filled out periodically for this outpatient longitudinal clinic. In addition, a 360-degree evaluation is filled out by patients, administrative assistants, and clinic nurses.

F. Educational goals by competency

1. Patient care

   • Demonstrate competence in the evaluation and management of outpatients with supraventricular tachycardias including atrial fibrillation; patients requiring acute or chronic anticoagulation; ventricular tachyarrhythmias including congenital and acquired long QT syndrome; and patients with syncope.
   • Demonstrate competence in prevention of tachyarrhythmias, including primary prevention of sudden death.
   • Demonstrate care of patients before and after an electrophysiology procedure.
   • Demonstrate care in monitoring of patients with permanent pacemakers of all types and ICDs of all types. This skill set includes device interrogation and programming.
   • Demonstrate competence in testing that is relevant to arrhythmia diagnosis and treatment.

2. Medical knowledge

   • Demonstrate knowledge of the scientific method of problem solving and evidence-based decision making.
   • Demonstrate competence in understanding the indications for and complications from invasive electrophysiologic procedures. This includes demonstrating competence in obtaining informed consent on patients undergoing these procedures.
   • Demonstrate knowledge of basic electrophysiology that is relevant to clinical practice, including but not limited to determinants of the normal cardiac rhythm (ionic currents), determinants of normal conduction, mechanisms of tachyarrhythmias and various modulators such as autonomic tone and ischemia, and the cellular electrophysiologic effects of various classes of antiarrhythmic drugs.
   • Demonstrate knowledge of the epidemiology and genetic basis for various dysrhythmia syndromes.
   • Demonstrate knowledge of the various antiplatelet agents and anticoagulants and their role in the management of the CCEP patient.
   • Demonstrate knowledge of basic pharmacokinetics and pharmacodynamics.
   • Demonstrate knowledge of the engineering aspects of pulse generator design, and the engineering aspects of electrical sensing and stimulation relevant to implantable cardiac rhythm devices.
   • Demonstrate knowledge of the pathophysiology and differential diagnosis for the various types of SVT, polymorphic VT, and monomorphic VT.
   • Understand the test characteristics (for example predictive value) of advanced electrocardiographic methods of risk stratification.
   • Demonstrate knowledge on how to interpret the results of noninvasive and invasive tests in the CCEP patient, such as Holter monitoring, signal-averaged electrocardiography, exercise treadmill testing for arrhythmia evaluation, invasive electrophysiologic testing, and remote monitoring of implantable cardiac devices.

3. Practice-based learning and improvement

   • Develop skills and habits to systemically analyze one’s own clinical practice using quality improvement methods, and implement changes with the goal of practice improvement.
   • Develop skills to locate and appraise evidence from scientific studies relevant to one’s patients’ health problems.
   • Demonstrate a leadership role in the education of all members of the healthcare team.

4. Interpersonal and communication skills

   • Demonstrate interpersonal and communication skills that result in effective collaboration and information exchange with patients, their families, and other members of the healthcare team.
   • Role model effective communication with other caregivers during transitions of care.
   • Demonstrate sensitivity to patient differences that may affect communication, including race, culture, gender, sexual orientation, socioeconomic status, educational level, and religious beliefs.
   • Demonstrate how to engage patients in shared-decision making.
   • Demonstrate effective communication with patients or families who are angry, frustrated, or in disagreement with the plan of care.

5. Professionalism

   • Demonstrate a commitment to carrying out professional responsibilities at a high level of excellence and in an ethical manner.
   • Demonstrate the importance of avoiding conflicts of interest.
   • Demonstrate a commitment to lifelong learning.
   • Demonstrate a nonjudgmental, caring demeanor toward patients at all times.
   • Demonstrate respect and consideration for all members of the healthcare team.

6. Systems-based practice

   • Demonstrate an understanding of how the healthcare system is organized, and the ability to call on multidisciplinary resources to provide optimal care for one’s patients.
   • Recognize barriers to optimal patient care, such as the patient’s ability to afford medication, and potential ways to overcome these barriers.
   • Demonstrate incorporation of cost-awareness principles into the longitudinal care of the electrophysiology patient.

V. Clinical cardiac electrophysiology research

A. Overall education goals

Trainees in CCEP should understand the design and interpretation of research studies, and the responsible use of informed consent to protect human subjects. They should be able to critically assess the medical literature with regard to new therapies and techniques. A meaningful research experience, tailored to the needs of the individual trainee, is required. Even for trainees headed for a career in clinical practice, a research exposure is important, as this scholarly activity will make the practitioner of CCEP critically aware of how the scientific basis of the field is advanced.

B. Summary of rotation

The CCEP fellow will spend about 10% of their time doing electrophysiology research, generally one-half a day weekly at a time though additional block research time is feasible depending on the needs of the individual trainee.

All electrophysiology faculty participate, to a greater or lesser degree, in clinical research with the overall director of CCEP (Dr. Kevin Kwaku) fulfilling the role as Director of Electrophysiologic Research. There are other potential research mentors within the section of Cardiology and Radiology, specifically with regard to medical imaging that is pertinent to the practice of CCEP (echocardiography including 3-D echo and various methods to assess ventricular dyssynchrony, cardiac MRI, and cardiac computerized tomography). There are other potential research mentors affiliated with the Dartmouth Institute for Health Policy and Clinical Practice which includes researchers skilled in outcomes research, decision analysis, cost-efficacy analysis, and other modalities. There are also bench researchers who may mentor the fellow in more basic forms of electrophysiology research.

It is expected that the trainee will have at least 1 manuscript suitable for publication by the end of training.

C. Teaching methods

1. The trainee will have at least 1 faculty member to individually supervise and mentor their research, in a tutorial fashion.
2. There will be periodic CCEP research conferences, and a subset of the Cardiology Grand Rounds speakers will present new research pertinent to CCEP.

D. Education resources

1. The fellows will develop an electronic teaching file, with the assistance of the faculty, so they will have ready reference to seminal journal articles.
2. The Department of Medicine has a series of didactic lectures that cover research methodology, including study design, basic statistics and FDA requirements for informed consent and the protection of human subjects.

E. Evaluation

Fellows are evaluated during the course of the tutorial process, which is tailored in part to the research interests of the trainee. The trainee is also evaluated based on the quality of the required manuscript, which should be suitable for publication by the end of training.

F. Educational goals by competency

1. Medical knowledge

   • Demonstrate knowledge of the scientific method of problem-solving.
   • Demonstrate knowledge of the design of various types of research studies.
   • Demonstrate competence in the interpretation of research studies, including basic statistics (confidence intervals, tests of statistical significance, linear correlation, multivariate analysis, metanalysis, and decision analysis).
   • Demonstrate understanding of the FDA requirements for informed consent and for the protection of human subjects

2. Interpersonal and communication skills

   • Demonstrate sensitivity to patient differences that may affect communication pertinent to participating in a clinical research study, including race, culture, gender, sexual orientation, socioeconomic status, educational level, and religious beliefs.
   • Demonstrate interpersonal and communication skills that result in effective collaboration and information exchange with other members of the research team.
   • Demonstrate how to engage patients in the informed consent process for participating in a clinical trial.

3. Professionalism

   • Demonstrate a commitment to performing CCEP research at the highest level of excellence and in an ethical manner.
   • Demonstrate the importance of avoiding conflicts of interest.
   • Demonstrate respect and consideration for all members of the research team.
   • Demonstrate a commitment to lifelong learning.