736 Cambridge Street, Brighton, MA 02135 617-789-3000
St. Elizabeth's Medical Center:Fellowship in Cardiovascular Medicine
The Fellowship in Cardiovascular Medicine at St. Elizabeth's Medical Center is an integrated, multidisciplinary program that provides a unique exposure to the state-of the art in contemporary cardiovascular training. The Program imparts the knowledge and experience necessary to allow each fellow to become a competent cardiovascular specialist, with the opportunity to obtain expertise in one or more cardiovascular subspecialties. Each fellow rotates through a series of services that provide the backbone of training and supervised experience in the evaluation and management of a wide variety of patients with acute and chronic cardiovascular conditions including coronary heart disease, congestive heart failure, arrhythmias, acute myocardial infarction and other acute ischemic syndromes, lipid disorders, hypertension, cardiomyopathy, valvular heart disease, pulmonary heart disease, peripheral vascular disease, infections and inflammatory heart disease, and adult congenital heart disease. The training and experience is at a sufficient level for the fellow to acquire the competency of a specialist in the field of Cardiovascular Medicine. In addition, fellows have the opportunity for dedicated clinical or laboratory research.
Facilities and Resources
The primary training site, St. Elizabeth’s Medical Center is a modern facility where the vast majority of the educational program is accomplished. The facility include inpatient, ambulatory care, and clinical and research laboratory resources. There are state of the art cardiac catheterization laboratories for cardiac hemodynamics, angiography, percutaneous coronary and other interventions; cardiac electrophysiology and pacing laboratories for invasive and non-invasive electrophysiologic studies and implantation of anti-arrhythmia devices; and specific laboratories that provide resources for electrocardiography, ambulatory electrocardiographic recording, exercise testing, echocardiography (including stress and transesophageal studies), and radionuclide techniques. Other hospital resources include facilities for assessment of peripheral vascular disease and pulmonary physiology. Critical care units include a cardiac care unit, medical intensive care unit and a cardiac surgery intensive care unit. There is an active cardiac surgery program at the primary training site. The patient database is computerized. Fellows have ample private space and computer work stations to access, analyze and input pertinent patient data. A well-stocked medical library that can be accessed round the clock exists at the premises. Fellows also have access to on-line journal databases at the Tufts University School of Medicine Health Sciences Library. On-call sleeping quarters are provided along with an exercise and recreational area. To obtain necessary exposure to congenital heart diseases fellows rotate with Dr. Richard R. Liberthson at the Massachusetts General Hospital.
Key Clinical Faculty
Joseph Carrozza, MD - Chief, Division of Cardiovascular Medicine;
Professor of Medicine, Tufts University School of Medicine
Lawrence Garcia, MD -Chief of Interventional Cardiology
Bernard D. Kosowsky, MD -Chief Emeritus, Division of Cardiovascular Medicine; Professor of Medicine, Tufts University School of Medicine; Medical Director, Cardiac Rehab Program
Michael Maysky, MD -Director, Nuclear Cardiology; Director, Echocardiography Laboratory; Assistant Professor of Medicine, Tufts University School of Medicine
Peter Soukas, MD - Director, Interventional Vascular Laboratory; Assistant Professor of Medicine, Tufts University School of Medicine
Michael V. Orlov, MD, PhD - Director, Cardiac Arrhythmia Research; Assistant Professor of Medicine, Tufts University School of Medicine
Shaw Natan, MD - Assistant Director of Cardiac Devices and Clinical Services; Staff, Electrophysiologist
John V. Wylie, Jr, MD FACC - Director of Cardiac Electrophysiology Laboratory; Assistant Professor of Medicine
John O. Pastore, MD - Staff Cardiologist; Associate Professor of Medicine, Tufts University School of Medicine
Lana Tsao, MD - Director Advanced Heart Failure Program; Assistant Professor of Medicine, Tufts University School of Medicine
Michael Johnstone, MD - Associate Chief of Clinical Cardiology; Assistant Professor of Medicine, Tufts University School of Medicine
Faisal Khan, MD - Staff Cardiologist/Interventional Cardiology
Paul T. Schwerdt, MD -Staff Cardiologist/Interventional Cardiology
Alan Ashare, MD - Chief, Division of Nuclear Medicine; Associate Professor of Radiology, Tufts University School of Medicine
Richard R. Liberthson, MD - Physician in Medicine and Pediatrics, Massachusetts General Hospital; Associate Professor of Pediatrics, Harvard Medical School
Prerequisites for Training:
1. Medical Education:
Applicants with one of the following qualifications are eligible:
a. Graduates of medical schools in the United States and Canada
accredited by the Liaison Committee on Medical Education (LCME).
b. Graduates of colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA).
c. Graduates of medical schools outside the United States and Canada who meet one of the following qualifications:
1. Have received a currently valid certificate from the Educational Commission for Foreign Medical Graduates prior to appointment or
2. Have a full and unrestricted license to practice medicine in a US licensing jurisdiction in which they are in training.
d. Graduates of medical schools outside the United States who have completed a Fifth Pathway program provided by an LCME-accredited medical school.
2. Postdoctoral Education and Training:To be eligible for training in cardiology at St. Elizabeth's Medical Center as a fellow in cardiovascular diseases, successful completion of at least 3 years of residency training in internal medicine at an ACGME accredited program is mandatory.
a. Ranking of applicants for fellowship from eligible applicants is performed on the basis of their preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity. St. Elizabeth's Medical Center does not discriminate with regard to sex, race, age, religion, color, national origin, disability, or veteran status.
b. Cardiovascular Fellowship Program at St. Elizabeth's Medical Center participates in the National Resident Matching Program (NRMP) for Cardiovascular Diseases for matching of ranked applicants.
Objectives of Training:
- To provide an intellectual environment for acquiring knowledge,
skills, clinical judgment, attitudes and values that are essential to
- Provision of the best possible care for each individual patient delivered in a compassionate manner.
- Development and maintenance of humanistic and ethical attributes among all physicians undergoing training in cardiology
- Active effort by faculty members to encourage trainees to cultivate an attitude of scholarship and dedication to continuing education that will remain with them throughout their professional careers.
- Active participation in and completion of one or more research projects supervised by faculty actively engaged in research. This, as well as participation in journal clubs, literature reviews and presentation in cardiology conferences is expected to inculcate a habit of critical thinking to achieve greater insight into analysis of published literature.
Duration of Training:
The rotations of the fellows in training are determined by the curriculum, not by the needs of the facility or the faculty! After successful completion of training in cardiovascular diseases, fellows are expected to serve as high-level expert consultants and procedural specialists. The core components of the training program reflect that expectation.
The 3-year training program includes a clinical core of 24 months with the following minimums:
1. Nine months in non-laboratory clinical practice activities (cardiac
consultations, coronary care unit, inpatient cardiac care, interim
coronary care unit, cardiovascular surgery, congenital heart disease,
vascular medicine, heart failure, preventive cardiology)
2. Four months in cardiac catheterization laboratory
3. Six months in non-invasive imaging (echocardiography and Doppler [minimum 3 months], noninvasive and peripheral vascular studies, nuclear cardiology [minimum 2 months, with active fellow participation in daily reading sessions for a minimum of 80 hours] and cardiac MRI)
4. Two months in electrocardiography, stress testing and ambulatory ECG monitoring.
5. Two months in arrhythmia management, anti-arrhythmia device implantation and management, and cardiac electrophysiology.
6. Continuity care ambulatory experience for at least ½ day per week throughout the 3-year training program.
These time periods are considered to be the minimal time required. The remaining year in the training includes 6 months of research and an additional 6 months for acquisition of more intensive training in specific areas of individual interest/needs. This latter period permits the trainees to obtain greater experience and supervised training in the clinical management of patients with cardiovascular disease and to obtain additional training in the performance and application of particular diagnostic and therapeutic procedures.
Appropriate vacation time as well as time for participation in professional meetings and conferences is allotted.
Specific Program Content:
A. Clinical and Laboratory Rotations:
Clinical Cardiology Service
In the Clinical Rotation, two fellows form the core of a clinical team, composed of a rounding attending cardiologist (Dr. Michael Johnstone, Dr. James P. Morgan, Dr. Bernard D. Kosowsky, Dr. John O. Pastore, Dr. Michael Maysky or Dr. Lana Tsao), residents on cardiology elective, and medical students. Daily activity involves rounding in the Coronary Care Unit, Surgical Intensive Care Unit and telemetry floors and responding to consultation from other services. Experience in procedures, which are performed with the house staff, includes pericardiocentesis, pulmonary artery catheterization, intra-aortic balloon counter pulsation, and temporary pacing. As in other clinical rotations, the fellows read hospital electrocardiograms on a daily basis, receiving feedback after the tracings are over-read by an attending cardiologist. Given the depth of clinical experience in this rotation, each fellow is able, by the end of the second year, to deal effectively with most consultations. In the third year, senior fellows periodically have the opportunity to employ their ability to formulate an effective management plan by leading rounds in the CCU under the supervision of an attending cardiologist.
Cardiac Catheterization Laboratory
In the Catheterization Laboratory, each first-year fellow receives an introduction to diagnostic catheterizations as an assistant in a high-volume, state-of-the-art laboratory performing over 1500 procedures per year under the direction of Dr. Lawrence A. Garcia with additional interventional staff including Dr. Joseph P. Carrozza, Jr, Dr. Peter Soukas and Dr. Faisal Khan. This exposure leads to increasing independence in the performance of diagnostic procedures in the second and third fellowship years, along with progressive participation in a variety of interventional procedures. By the end of the catheterization experience, each fellow has had direct experience with balloon angioplasty, stent deployment, directional and rotational atherectomy, percutaneous closure of patent foramen ovale, myocardial biopsy balloon valvuloplasty and peripheral vascular disease management and therapy. The fellows are responsible for evaluating each patient and for formulating an action plan for all diagnostic and interventional procedures in consultation with the attending cardiologist. Fellows prepare a weekly catheterization conference devoted to a relevant topic with representative clinical cases and a review of the literature.
Interventional Cardiology Training
Interventional cardiovascular training begins in the third year of the cardiovascular fellowship. This two year track will encompass the full breadth of interventional training to include but be exclusive to balloon angioplasty, coronary artery stenting, directional and rotational atherectomy as well as structural heart disease therapy such as PFO/ASD and valvular interventions. Further, given the robust Vascular Medicine program the interventional fellow will further be trained in the full breadth of vascular disease interventions such as lower extremity, extra-cranial carotid and other arterial disease lesions such as renal and subclavian. Additionally training in, venous interventions and non-invasive vascular reading will occur throughout the fellowship.
Noninvasive Cardiology and Nuclear Medicine
Each first-year fellow receives an initial exposure to echocardiography as a component of the Noninvasive Rotation. Daily responsibilities include direct participation in the performance of all exercise treadmill testing, both with and without concomitant nuclear and echo imaging. Fellows are directly involved in the performance of pharmacologic (adenosine, dipyridamole and dobutamine) stress studies. Afternoon hours are spent reading the day’s nuclear studies with Dr. Alan Ashare and Dr. Maysky, and interpreting echocardiographic studies with Drs. Maysky, Pastore, Johnstone and Morgan. Individuals desiring a license in Nuclear Medicine have ample opportunity over the course of three years to amass the required clinical, laboratory, and classroom hours. Extramural programs for formal classroom instruction are available at St. Elizabeth’s Medical Center with Dr. Ashare.
Month-long rotations in the Echocardiography Laboratory provide fellows in the second and third years an in-depth introduction to cardiac ultrasound with Drs. Maysky, Pastore, Morgan and Johnstone. Imaging modalities include transthoracic echocardiography, multi-plane transesophageal echocardiography, epicardial echocardiography, exercise stress echocardiography, and dobutamine stress echocardiography. The laboratory operates three Philips Sonos 5500 systems, representing the leading edge in imaging technology. Intra-operative interaction with cardiothoracic surgeons provides unique decision-making experience in the fast-paced environment of the operating room, most notably in the management of mitral valve repair. The rotating echocardiography fellow eads a weekly conference, presenting focused topics in echocardiography with illustrative case studies and relevant literature. The aim of this rotation is to create proficiency in the performance and interpretation of transthoracic echocardiography and to provide a firm foundation for further experience in transesophageal echocardiography. The emphasis throughout is on hemodynamic quantization and the integration of echocardiographic data with the clinical history. With more than 5500 studies per year performed by this laboratory, the acquisition of echocardiographic expertise is a realistic goal.
Cardiac Electrophysiology and Pacing Service
In the second and third years each fellow rotates through the Cardiac Electrophysiology Laboratory. Under the direction of Dr. John V. Wylie, Jr, Dr. Shaw Natan and Dr. Michael V. Orlov, the fellow rounds daily on the inpatient EP service and participates directly in the invasive and noninvasive procedures in the electrophysiology laboratory, including diagnostic electrophysiology studies, radiofrequency ablation, cardioversion, permanent pacemaker implantation, pacer-cardioverter-defibrillator implantation and follow up testing, implantable loop monitor placement and tilt-table testing. In addition, each fellow receives an abundant exposure to the outpatient management of implantable anti-arrhythmia devices in several busy clinics. Most of the fellows coming out of the program are well trained to implant permanent pacemakers and independently analyze, program and troubleshoot ICD devices after rotating through one of the busiest electrophysiology services in the New England area. Fellows with a particular interest in electrophysiology have the opportunity to focus their efforts in their third year and to apply for a fourth year as an electrophysiology fellow.
Vascular Medicine Service
The Division of Vascular Medicine at St. Elizabeth’s Medical Center has played a pioneering role in the development of various diagnostic and therapeutic approaches to patients with atherosclerotic vascular disease and is a unique and special feature of the cardiology fellowship program. Rotation on this service provides experience with the management of peripheral vascular disease in both inpatient and outpatient settings. Aspects of this service include interpretation of non invasive vascular studies and participation in diagnostic and therapeutic catheterization. St. Elizabeth's Medical Center is a regional referral center for carotid artery and renal artery angioplasty and stent implantation. In addition, the Division of Vascular Medicine here has gained national and international recognition for uniting molecular biology with interventional cardiovascular medicine in the trials of vascular endothelial growth factor (VEGF) in patients with severe peripheral vascular disease and coronary artery disease. Fellows who develop a strong interest in peripheral vascular disease have the opportunity to apply for a fourth-year fellowship position dedicated to this subspecialty.
It is expected that each fellow will become involved in the formulation and execution of a project in Cardiovascular Research. This participation may involve a continuation of research interests in progress prior to fellowship. Generally, research activity receives a special emphasis in the third fellowship year. Fellows are encouraged to submit research abstracts to national meetings. A wealth of logistical support lies within the research infrastructure at the Cardiovascular Research facilities in ACH building encompassing vascular gene therapy, therapeutic angiogenesis, and restenosis. A weekly Wednesday morning-research conference attracts individuals from around the world who have made landmark contributions in clinical and basic sciences. Every fourth Wednesday morning ongoing research protocols in cardiac electrophysiology are discussed in detail and progress of the fellows involved with research in EP section is monitored. Special research meetings are also held prior to national meetings where fellows rehearse their presentations for critique by the faculty and peers.
Each fellow is assigned a continuity care clinic ½ day a week with a designated staff member in the cardiology division at St. Elizabeth's Medical Center. Fellows see new patients whom they subsequently follow on a continuous basis during follow up appointments over the course of the 36-month fellowship. Dr. Pastore runs an extremely busy cardiology clinic at the Chelsea Soldiers' Home and the assigned fellow travels with him every Thursday afternoon for the duration of the training. Additionally fellows actively participate in the Peripheral Vascular Clinic and Pacemaker/ICD clinics.
Congenital Heart Disease
In order to provide an intensive exposure to adults and children with Congenital Heart Disease, each fellow spends one month in the second year of their training with Dr. Richard Liberthson, a world-renowned expert in this field, in his busy clinical practice at the Massachusetts General Hospital.
B. Technical and Other Skills:
The program provides sufficient experience for the fellow to acquire skill in the performance and interpretation of:
1. History and physical examination
2. Basic and advanced cardiac life support
3. Elective cardioversion
4. Bedside right heart catheterization
5. Insertion and management of temporary (transvenous and transcutaneous) pacemakers
6. Right and left heart catheterization including coronary arteriography; fellows participate in a minimum of 150 catheterizations
7. Percutaneous transluminal coronary angioplasty and other interventional procedures
8. Intra-aortic balloon counter pulsation
9. Percutaneous closure of patent foramen ovale
10. Myocardial biopsy
12. Intracardiac electrophysiologic studies
13. Programming and follow-up surveillance of permanent pacemakers and ICDs
14. Exercise stress testing; fellows perform a minimum of 50 exercise tests
15. Echocardiography; fellows must perform a minimum of 75 and interpret a minimum of 150 studies, including transesophageal studies
16. Cardiovascular rehabilitation
17. Chest X-rays
18. Minimum of 3500 electrocardiograms
19. Minimum of 150 ambulatory ECG recordings
20. Radionuclide studies of myocardial function and perfusion
C. Formal Instruction
There are various conferences over the course of the year given by St. Elizabeth’s staff and visiting professors. Attendance is mandatory and every effort is made to relieve the fellows from clinical responsibilities at the time of these lectures. Yearly schedule is created with active participation of fellows and faculty. The schedule is distributed in advance and is updated every month. These talks are designed to provide didactic teaching encompassing the following:
1. Basic science, including
a. cardiovascular anatomy
b. cardiovascular physiology
c. cardiovascular metabolism
d. molecular biology of the cardiovascular system
e. cardiovascular pharmacology, including drug metabolism, adverse effects, indications, the effects on aging, relative costs of therapy, and effects of non-cardiovascular drugs upon cardiovascular function
f. cardiovascular pathology
2. Prevention of cardiovascular disease, including
a. epidemiology and biostatistics
b. risk factors
c. lipid disorders
3. Evaluation and management of patients with
a. coronary artery disease and its manifestations and complications
e. valvular heart disease
f. pericardial disease
g. pulmonary heart disease, including pulmonary embolism
h. peripheral vascular disease
i. cerebrovascular disease
j. heart disease in pregnancy
k. adult congenital heart disease
l. cardiovascular trauma
4. Management of:
a. acute and chronic congestive heart failure
b. acute myocardial infarction and other acute ischemic syndromes
c. acute and chronic arrhythmias
d. preoperative and postoperative patients
e. cardiac transplant patients
f. geriatric patients with cardiovascular disease
5. Conference Schedule:
Mondays: 12 noon-1:15pm Clinical Cardiac Electrophysiology Conference
Tuesdays: 12 noon-1:15 pm Cardiac Imaging Conference
Wednesdays: 7-8 am Clinical Cardiac Electrophysiology Case/Research Conference; 8-9 am Medical Grand Rounds. 12 noon-1:15 Clinical Case Conference
Thursdays: 12 noon-1:15 pm Cardiac Catheterization Conference
Fridays: 12 noon-1:15 pm Journal Club/Core Curriculum Conference
Evaluation and Documentation of Competence:
At the end of each rotation supervising physician for that particular rotation performs formal evaluation of fellows. Quarterly staff meetings are held to evaluate the progress of fellows, especially focusing on whether core-curriculum requirements are being met for each fellow. Rotations and time/work distribution sometimes need to be adjusted to fulfill adherence with these requirements. Fellows are evaluated for their intellectual abilities, manual skills, attitudes, critical analysis for clinical situations, patient care, medical knowledge, practice-based learning improvement, interpersonal and communication skills, professionalism and humanistic patient care, systems based learning and improvement and overall clinical skills. There is appropriate feedback of this information to the trainee at regular intervals. The fellows meet with the chief of cardiology and/or program director at frequent intervals (no less than every 6 months) in order to discuss specific issues, in particular whether the goals and objectives of training are being met.
During these meetings areas of specialized interest are identified for each fellow. Compliance with adherence to level 1 for COCATS-2 recommendations for all areas and level 2 and 3 for fields of interest for each fellow is monitored and steps to rectify any deficiencies, if needed, are discussed with the fellow and the faculty. Fellows also periodically evaluate the faculty in an anonymous fashion and the information is provided to the staff members. Measures to correct any deficiencies are discussed at the quarterly faculty meetings for assessment of the training program.
Review of Program Performance:
The Cardiology Fellowship Training Program strives to provide an enriched environment conducive to learning, emphasize the translation of ever-increasing fund of medical literature to guide evidence-based clinical patient care and the underpinnings of practice guidelines provided by national medical societies as well as COCATS-2 recommendations. The Chief of Cardiology, Program Director and members of the full time faculty meet regularly (no less than once every 4-6 months) to review the progress of individual fellows and evaluate the program as a whole to determine how successfully the goals of the program and elements of the delineated curriculum are met. The institution’s General Medical Education Committee also oversees fulfillment of training requirements and meets on a monthly basis. A formal internal review of the program is conducted periodically.