Cardiology Fellowship Training Program

M E T R O H E A LT H M E D I C A L C E N T E RC L E V E L A N D , O H I O

Contact Kara Quan, M.D., program director or Audrey Patterson, program coordinatorat (216) 778-2130 for further information.

Hello,

This brochure is provided to help answer themost important questions of the prospectiveCardiovascular Fellowship applicant.

We hope that we have succeeded in answering thefollowing questions.

What’s special about MetroHealth? 2A description of our best attributes

What is expected of me? 9A description of the various rotations and the fellow’s responsibilities

What conferences will I attend? 14A schedule and description of the conferences

With whom will I work? 15The faculty and staff pictures

How will my time be divided? 16A break down of the yearly schedule

What about Cleveland? 17Information about Cleveland and the surrounding area

MISSION STATEMENT

The MetroHealth System commits to leadership in providing outstanding health care services

which continually improve the health of the people in our community. We offer an integrated

program of services provided through a system that encompasses a partnership between

management and physicians and reflects excellence in patient care supported by superior

education and research programs. We are committed to responding to community needs,

improving the health status of our region and controlling health care costs. We hold as a core

value the provision of service to any resident of Cuyahoga County regardless of ability to pay.

THE HISTORYOF METROHEALTH

MetroHealth Medical Center was founded in

1837. Its first internship started in 1892, and in

1914, affiliation with Case Western Reserve

University began. The first research building

was completed in 1953 raising the standard of

medical care and attracting prominent scien-

tists to the hospital. Rammelkamp Center for

Education and Research Center was opened in

1992. Through many years and many advances,

it is now a 731-bed facility that stands as the

center of The MetroHealth System. Today,

MetroHealth continues to be an academic insti-

tution that is committed to excellence in patient

care, which is supported by superior education

and research programs.

What’s special about MetroHealth?

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EDUCATIONAL AFFILIATIONS

As a major teaching facility of the Case Western Reserve University School of Medicine,

several hundreds of residents and medical students receive training in 18 fields of medicine

and surgery each year. All hospital full-time staff physicians hold faculty appointments at

Case Western Reserve University and have extensive teaching responsibilities throughout

the medical school curriculum. In addition, MetroHealth has a formal educational relation-

ship with the Cleveland Clinic Foundation that includes joint sections in Emergency

Medicine, Cardiothoracic Surgery, and Neonatology. This strong relationship allows the

opportunity for fellows to perform clinical rotations in nuclear medicine, cardiac transplant,

and congenital heart disease at the Cleveland Clinic.

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Heart & Vascular CenterMetroHealth’s Heart & Vascular Center provides comprehensive cardiovascular services to individuals

throughout Northeast Ohio and is nationally recognized for its leadership in the diagnosis, treatment,

and research of cardiovascular disease.The Center’s team includes 21 cardiologists, two cardiothoracic

surgeons, and two vascular surgeons, who are supported by a staff of highly trained and skilled physi-

cian assistants, nurse practitioners, registered and licensed practical nurses, and an array of technol-

ogists.

The Heart & Vascular Center celebrates the rich diversity of its patient population and focuses on pro-

viding comprehensive care and treatment for both the patient and family. A multidisciplinary approach

to the needs of patients is what makes MetroHealth’s Heart & Vascular Center unique. Together,

physicians, nurses, technologists, and other support staff work to make the practice of medicine truly

holistic in the following three key areas:

Clinical Care: MetroHealth’s Heart & Vascular Center provides fully integrated, multidisciplinary, car-

diovascular specialty care including invasive and noninvasive cardiology as well as cardiothoracic and

vascular surgery.

Research: MetroHealth is home to the Heart & Vascular Research Center, a state-of-the-art clinical

and basic science cardiovascular research center. The research studies underway at the Heart &

Vascular Research Center are collaborative in nature and promote interaction between clinicians, clin-

ical investigators, biologists, and biomedical engineers. This collaboration ensures that new diagnos-

tic techniques, treatments, and medical discoveries transition efficiently and effectively from the lab-

oratory to the bedside. Specific areas of excellence in basic cardiovascular research include mecha-

nisms and prevention of sudden cardiac death, Long QT Syndrome, and genetic susceptibility to

heart disease, heart failure, and arrhythmias.

Education: As a campus of the Case Western Reserve University School of Medicine, MetroHealth

offers comprehensive training programs aimed at developing the next generation of cardiovascular

physicians and scientists. In addition, the Heart & Vascular Research Center has developed a unique

Cardiovascular Scholars Program to train future physician scientists by providing selected cardiology

trainees with 2-3 years of additional dedicated research experience in one of MetroHealth’s cardio-

vascular laboratories.

THE FACULTY

The faculty of the Heart & Vascular

Center is committed to the training of

cardiovascular physicians who strive

to achieve the highest standards of

academic excellence as clinicians,

educators, and physician/scientists.

Each member of the department has

a full-time academic appointment at

the Case Western Reserve University

School of Medicine.

RAKITA CARDIAC INTENSIVE CARE UNIT

The Rakita Cardiac Intensive Care Unit is a busy, high-turnover, tertiary care unit. This unit

is named for Louis Rakita, M.D., who is a pioneer in cardiovascular disease and is a former

chief of cardiology at MetroHealth. The unit is equipped with a state-of-the-art, integrated

Hewlett Packard monitoring system.

Physicians working in the 12-bed acute care unit gain experience in the acute evaluation

and treatment of patients requiring critical care monitoring, mechanical ventilation, and

intra-aortic balloon pump support. Fellows will be exposed to patients with very diverse

pathophysiology of cardiac diseases.

ECHOCARDIOGRAPHY LABORATORY

The echocardiography laboratory at MetroHealth is the only adult echocardiography lab in

Cuyahoga County to be certified by the Intersocietal Commission for the Accreditation of

Echocardiography Laboratories. The laboratory performs approximately 10,000 studies per

year, which include transthoracic and transesophageal echocardiograms and stress testing.

The digital echocardiography system allows for immediate access to echocardiographic

images at any time from many locations within the Heart & Vascular Center.

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CARDIAC CATHETERIZATION LABORATORY

The cardiac catheterization laboratories at MetroHealth are both state-of-the-art General

Electric imaging suites. One is outfitted for peripheral imaging and revascularization pro-

cedures. The other employs a unique digital detector that offers enhanced image quali-

ty and reduced radiation dosage for patients, physicians, and nursing staff. Intravascular

ultrasound and intracoronary physiologic studies are routinely used in decision making

prior to interventional procedures. The laboratory is staffed 24 hours a day for emergen-

cies, and the interventional staff is committed to direct angioplasty for all acute myocar-

dial infarctions.

ELECTROPHYSIOLOGY LABORATORY

There are seven faculty in the electrophysiology section. The electrophysiology labora-

tory encompasses both the invasive diagnostic and therapeutic procedures performed

for cardiac arrhythmias. The Siemens and General Electric imaging suites are outfitted

for ablation, intracardiac device implantation, lead extraction (Excimer laser) and intrac-

ardiac mapping (Biosense). Noninvasive electrophysiologic testing includes tilt-table

testing, Holter / event monitoring, and T-wave alternans testing.

HEART & VASCULARRESEARCH CENTER

The Heart & Vascular Research Center at

MetroHealth provides an outstanding

cross-disciplinary training environment to

develop novel insights into the mecha-

nisms, diagnosis, and a bench to bedside

approach to the treatment of cardiovas-

cular disease. Integrating outstanding

talent with state-of-the-art facilities from

both the Rammelkamp Center for

Education and Research and Case

Western Reserve University, the Heart &

Vascular Research Center strives for

excellence in cardiovascular investigation. A clinical trials committee and the General

Clinical Research Center provide guidance and support for faculty and fellows interested

in clinical trials. For further information, contact www.metrohealthresearch.org.

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Basic Science Research

The basic science research section focuses on molecular, ion channel and cellular mecha-

nisms of cardiac physiology. Novel techniques include optical mapping, as well as confocal

and fluorescent microscopy. The expression of genes that regulate cardiac electrophysiol-

ogy and hemodynamics are explored using transgenics and mutagenesis. Animal models of

heart failure, cardiac remodeling, and re-entrant arrhythmias are other ongoing research ini-

tiatives.

Clinical Research

Clinical studies initiated by Heart & Vascular Center physicians include the evaluation of

nerve stimulation to reduce arrhythmia vulnerability, genetic and epidemiological studies of

the Long QT Syndrome, T-wave alternans / heart rate variability for the prediction of sudden

death, intravascular ultrasound and fractional flow reserve in acute coronary syndromes,

mechanisms of human repolarization, minimally invasive robot-assisted cardiac surgical pro-

cedures, and the assessment of novel echocardiographic indices of various disease states.

The Heart & Vascular Center is actively involved in many multi-center clinical trials and is

proud to be the coordinating center for a national multi-center trial designed to evaluate

arrhythmia risk stratification by ECG T-wave alternans (ABCD Trial).

CARDIAC REHABILITATION

The beautifully remodeled Lifestyle, Fitness, and

Rehabilitation Center provides the facilities for

comprehensive Cardiac Rehabilitation, Pulmonary

Rehabilitation, Smoking Cessation, and the Weigh

to Wellness (physician supervised weight loss) pro-

grams.

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Fellowship TracksThe Cardiology Training Program at MetroHealth Medical Center offers three tracks thatare tailored to the future interests and needs of fellows in training.

Standard Track

This is a three-year program comprised of two clinical years and one research year, withan optional additional year for research. Most fellows place in this track. Often fellowsopt to have their research year during the second year, in order to allow them to com-plete their research project during the remainder of their fellowship.

Subspecialty Short Track

This is a four-year program comprised of two clinical years followed by two years in asubspecialty area. The fellow performs a long-term research project during the sub-specialty training years.

Cardiovascular Scholar Program

This four to five-year program begins with two to three years of basic research followedby two clinical years. This track is designed for selected fellows, who plan to havefuture careers in basic research and become academic leaders in their field.

Summary of available tracks

Year One Year Two Year Three Year Four

Standard Track Clinical Clinical Research

SubspecialtyShort Track Clinical Clinical Subspecialty Subspecialty

Clinical and Clinical andResearch Research

CardiovascularScholar Program Research Research Clinical Clinical

What are my options?

INPATIENT EXPERIENCE

The “inpatient” experience includes month-long rotations in the Rakita Cardiac

Intensive Care Unit, general cardiology consultation, and arrhythmia consultation serv-

ices. The level of responsibility increases with each of these rotations, as the fellow

advances through the fellowship program. In addition, a one-month heart failure/heart

transplantation rotation is done at the Cleveland Clinic Foundation.

General Cardiology Consultation Service

The cardiology consultation service is a busy month for the fellow, who acts as the

“point person” for both emergent and routine consultations throughout the institution.

The fellow, along with the medical residents and students, evaluates, prepares initial

plans, and devises a strategy for further management of patients. The entire team

rounds each day with the attending physician to finalize these plans. The fellow is

responsible for supervising and providing direct teaching and appropriate literature to

the medical residents and students rotating on the consultation service.

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What is expected of me?

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ARRHYTHMIA CONSULTATION SERVICE

The arrhythmia consultation service is staffed by one of the cardiac electrophysiologists. Fellows

assigned to the Arrhythmia Service assist with consultations and participate in the daily management

of patients on the service. The fellow participates in the interrogation of both pacemakers and Internal

Cardioverter-Defibrillators. He/she gains experience in interpreting Holter and event monitors and per-

forming supervised cardioversions. Lastly, fellows participate in a weekly outpatient clinic for the fol-

low-up of patients with pacemakers or Internal Cardioverter-Defibrillators.

THE RAKITA CARDIAC

INTENSIVE CARE UNIT

The fellow is an integral part of the

CICU team, acting as the primary liai-

son between the medical residents,

patients, families, and nursing staff.

After evaluation of each new admis-

sion, the fellow is responsible for for-

mulating an initial plan of care and

then refining that plan after discussion

with the cardiology attending.

The fellow rounds each weekday and Saturday with the team and has an every third day call schedule

while in the CICU. Other responsibilities include didactic lectures for the students and medical resi-

dents rotating in the cardiology department for that month.

HEART FAILURE/TRANSPLANTATION ROTATION

The Congestive Heart Failure/Cardiac Transplantation Service, based at the Cleveland

Clinic Foundation, provides a unique opportunity for the fellow to become acquainted

with the issues crucial to those patients with advanced heart failure awaiting cardiac

transplantation. Pre-heart transplantation assessment is emphasized and fellows are

exposed to both short and long-term mechanical assist devices. The fellow also follows

patients in the immediate post-transplant period and can gain an appreciation of the

special needs and long-term follow-up care that is necessary to the successful recovery

of a heart transplant patient.

CARDIOTHORACIC SURGERY AND

CARDIAC REHABILITATION EXPERIENCE

This is a combined cardiothoracic surgical and cardiac rehabilitation rotation. On the cardio-

thoracic surgical rotation, the fellow assists in the management of patients after cardiac

surgery. He/she learns to recognize and manage post-operative cardiac complications.

During this combined rotation, time is

spent in the cardiac rehabilitation pro-

gram. The fellow learns the principles of

lifestyle modification and the psychoso-

cial issues that are important in the suc-

cessful recovery of patients with heart

disease. Under the supervision of the

cardiac rehabilitation attending, the fel-

low evaluates and manages any compli-

cations that may occur during rehabilita-

tion exercise sessions.

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OUTPATIENT EXPERIENCE

Continuity Clinic

Each fellow is responsible for a core

group of patients seen during the

general cardiology continuity clinic

located in the Heart & Vascular

Center outpatient area. Clinic for the

fellow is held one half day per week

for the duration of training. The fellows

at MetroHealth provide care for

approximately 200 outpatients with a

wide range of cardiovascular prob-

lems. During a typical session, a fel-

low will see two new patients and

four to six follow-up patients. Fellows also have the opportunity to supervise and teach medical students,

who rotate through the clinic. Attending supervision is at a ratio of one or two fellows per attending physi-

cian during these sessions. While they are precepting, the attending physicians have no other clinical

responsibilities, so that they can devote their attention to their teaching responsibilities.

NUCLEAR AND PEDIATRIC CARDIOLOGY EXPERIENCE

This is a combined rotation that is spent at the Cleveland Clinic Foundation. Mornings are spent evaluating

patients along with a pediatric cardiology faculty member in the outpatient pediatric cardiology clinic at the

Cleveland Clinic Foundation. The fellow gains knowledge of congenital heart disease through participation

in daily clinics as well as the weekly pediatric cardiology conference. Afternoons are spent in the nuclear

medicine department. The fellow participates in the review and interpretation of gated blood pool scans

and nuclear stress tests under the supervision of a nuclear medicine attending physician.

RESEARCH EXPERIENCE

The fellow is expected to learn the essentials of the scientific method, including research design, statisti-

cal analysis and the presentation of research results. As part of the standard three-year fellowship track,

one month in the first year and seven months in the third year are dedicated to research. The goals are to

identify a research interest, a specific hypothesis, and mentor early in the program. The fellow is expect-

ed to complete an organized project and present the results of that research as a manuscript in a peer-

reviewed journal by the end of fellowship.

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LABORATORY EXPERIENCE

Noninvasive Laboratory

The noninvasive echocardiography rotation stresses a “hands-on,” interactive learning process.

The fellow has ample time to obtain practical experience and skill in performing and interpreting

echocardiograms and stress tests. As the skill of the fellow improves, he/she also becomes

involved in performing and interpreting transesophageal echocardiograms. The echocardiogra-

phy fellow is responsible for selection and presentation of interesting studies and a didactic

presentation on a pertinent topic at the weekly echocardiography conference.

Cardiac Catheterization Laboratory

The months spent in the Cardiac Catheterization Lab

at MetroHealth allow the fellow to become knowl-

edgeable in the many aspects of invasive cardiac

evaluation and decision-making, while focusing on

the basics of diagnostic cardiac hemodynamics and

imaging strategies. Fellows participate in all cardiac

catheterization cases of that month and have the

option to assist in interventional procedures.

Responsibilities include pre-procedural evaluation as

well as post-procedural care of patients referred for

diagnostic cardiac catheterization. The fellow, along

with an attending physician, reviews the hemody-

namic and angiographic data after each case and is

expected to dictate the catheterization report. The

fellow also prepares a weekly conference consisting

of a didactic lecture as well as presentation of inter-

esting cases.

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Tuesday 5:00 - 6:00 pm

Heart & Vascular Center

Grand RoundsThis conference allows time for the entire department to assem-ble for presentations of current issues and new research in thefield of cardiovascular medicine. It is presented by a combinationof national speakers and local faculty.

The visiting professor program is a vital component of the learn-ing experience of the fellows. Nationally recognized academicleaders of the field spend a day interacting with attendings,reviewing interesting cases with the fellows and faculty, and giv-ing a didactic session. Approximately 20% of grand rounds arepart of the visiting professor program.

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What conferences will I attend?

Monday 7:00 - 8:00 am

Core CurriculumThis is a didactic conference covering all of the major topics

in the field of cardiovascular medicine and is presented by a

faculty member of the Heart & Vascular Center.

Monday 5:00 - 6:00 pm

Chief/Program Director RoundsThese bimonthly meetings are for “fellows only” time withthe chief and program director. Topics include selecting aresearch project, finding a research mentor, reviewingunknown cases, and discussing future plans.

Journal ClubDuring journal club, current or classical research articles arepresented by one of the fellows. Time is available in eachsession for lively discussion between the faculty preceptor,fellows, and local experts in the chosen topic.

ECG ConferenceThis bimonthly conference presented by one of the Heart &Vascular faculty focuses on the review of basic topics in elec-trocardiogram interpretation and review of interesting electro-cardiograms.

Wednesday 7:00 - 8:00 am

Electrophysiology ConferenceThis interactive conference emphasizes the evaluation andmanagement of complex arrhythmia cases. It is an oppor-tunity for fellows to gain knowledge in the interpretation ofintracardiac electrograms. It is presented by an electrophys-iology fellow and precepted by a member of the electro-physiology faculty.

Research ConferenceThis multidisciplinary conference reviews new research inthe field of cardiovascular medicine. Graduate students, fel-lows, and faculty present their ideas and review theirresearch progress during these interactive sessions.

Thursday 7:00 - 8:00 am

Cardiac Catheterization ConferenceThis is a multidisciplinary conference that includes fellows,cardiologists, and cardiothoracic surgeons. Coronaryangiograms and hemodynamic tracings are discussed. A por-tion of the time is set aside each week for the catheterizationfellow to review one of a series of topics pertaining to cardio-vascular physiology or coronary intervention.

Friday 7:00 - 8:00 am

Noninvasive ConferenceThis is an interactive conference designed to review inter-esting cases from the echocardiography laboratory with thenoninvasive attendings. The noninvasive fellow presentsthe conference, and a portion of time is set aside for the fel-low to review one of a series of topics.

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With whom will I work?

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Clinical year 1 Clinical year 2 Research year

ECHO 2 2 1

CATH 1 2 1

CONSULT 2 1 1

CCU 2 2 1

ARRHYTHMIA 1 1

CT/REHAB 1 1

HEART FAILURE/TRANSPLANT(CCF) 1

NUCLEAR CARDIOLGY(CCF) 1

PEDIATRICCARDIOLOGY(CCF) 1

RESEARCH 1 7

VACATION 1 1 1

How will my time be divided?REPRESENTATIVE STANDARD TRACK

Summary of Fellowship Time

• Sightseeing at the Rock and Roll Hall of Fame and Museum

• Watching Broadway shows at the beautifully restored Playhouse Square

• Learning while having fun at the Great Lakes Science Center andOmnimax Movie Theatre

• Enjoying an evening with the Cleveland Ballet

• Shopping and dining downtown at Tower City Center, the Galleria,the “Warehouse District” and the “Flats”

• Cheering at professional sporting events including the Browns,Indians, Cavaliers, Rockers, and the Force

• Listening to concerts at Severence Hall (the home of the world renowned Cleveland Orchestra) or Blossom Music Center, Gund Arena, andthe Convocation Center

• Hiking and biking on the “tow path trail” or in the extensiveCleveland MetroParks - part of the “Emerald Necklace”

• Spending a day with the family at nearby Six Flags and Cedar Point Amusement Parks or Dover Lake Park

• Doing all of these activities in a safe place with a very reasonablecost of living

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MetroHealth Medical Center is located 10 minutes from theheart of downtown Cleveland. While Cleveland is nationallyknown as a center for medical education and health care, fel-lows can expect to find almost everything they seek in cul-tural activities, entertainment, sports, and nightlife.

We have included a list of some of the attractions our fami-lies have enjoyed over the years:

What about Cleveland?