SAUDI DIPLOMA IN · 1 day ago · 4 SAUDI DIPLOMA IN ADULT ECHOCARDIOGRAPHY TABLE OF CONTENTS 1. Introduction 2. Context of practice 3. Goal and Responsibility of curriculum implementation

SAUDI DIPLOMA IN

ADULT ECHOCARDIOGRAPHY

SAUDI DIPLOMA IN ADULT ECHOCARDIOGRAPHY 1

Saudi Commission for Health Specialties (SCFHS)

The Scientific Council for Health Rehabilitation

Adult Echocardiography Scientific Committee

Curriculum of Saudi Diploma in Adult Echocardiography

(SDAE)

CONTRIBUTORS

Prepared by Institute/Affiliation

Dr. Hashem Abu Tariah KSAU-HS

Bader AlDuqsi KAU

Mai Alharthi KAU

Ahmad Almoosa NGH

Doha Alhashmi PNU

2 SAUDI DIPLOMA IN ADULT ECHOCARDIOGRAPHY

COPYRIGHTS AND AMENDMENTS

All rights reserved. © 2020 Saudi Commission for Health Specialties.

This material may not be reproduced, displayed, modified, or distributed without prior written

permission of the copyright holder.

No other use is permitted without prior written permission of the Saudi Commission for Health

Specialties.

For permission, contact the Saudi Commission for Health Specialties, Riyadh, Kingdom of

Saudi Arabia.

Any amendment to this document shall be approved by the Specialty Scientific Council and the

Executive Council of the Commission and shall be considered effective from the date of

updating the electronic version of this curriculum published on the Commission website unless

different implementation date has been mentioned.

P.O. Box: 94656

Postal Code: 11614

Contact Center: 920019393

Website: www.scfhs.org.sa


Preparation

Curriculum Scientific Group

Dr. Mohammad AlGhamdi; MD, Consultant Cardiologist, Ministry of National Guard Health Affairs, Riyadh

Dr. Saeed AlAhmari; MD. Consultant Cardiologist, Prince Sultan Military Medical City, Riyadh

Dr. Faisal Dalak; MD, Consultant Cardiologist, King Fahad Medical City, Riyadh

Supervision

Curriculum Specialists

Associate Prof. Zubair Amin

Dr. Sami Al Shammari

Reviewed by

Dr.Ali Al Assiri

Dr. Mazen Al Qasmi

Approved by Director of Training

Dr. Sami Abdulrahman Al Haider


TABLE OF CONTENTS

1. Introduction

2. Context of practice

3. Goal and Responsibility of curriculum implementation

4. Clinical practice

5. Policies and Procedures

6. Vacations, holidays, and on-call duties

7. Admission requirements

8. General program objectives

9. Program structure

10. Training requirements

11. Learning opportunities in Echocardiography:

a. Structure of the educational program

b. Core specialty topics (Areas of learning & learning objectives)

c. Core specialty topics (Knowledge & Skills)

d. Ethics and Professionalism Program

e. Types of cases the fellow should be exposed to

f. Courses, Workshops, and other activities for continuing education

g. Educational activities

12. Teaching and learning activities linked to CanMEDS roles

13. Suggested References

14. Assessment

15. Certification

16. Evaluation form



1. INTRODUCTION

Foreword:

The Saudi Commission for Health Specialties (SCFHS) has recently adopted CanMEDS as a standard framework for training in all medical specialties. CanMEDS has the

advantage of providing trainees with the necessary skills to become highly professional in their respective fields of expertise. CanMEDS competency framework provides a good balance between medical knowledge, clinical skills, scholarly activities, communication skills, inter-

personal and inter-professional collaborations, managerial skills, and patient advocacy skills which aim to produce a generation of holistic medical professionals. The mandate for writing this “Adult Saudi Echocardiography Fellowship” training program curriculum comes in line with

the continuous efforts of the SCFHS to establish high quality and well-structured national training programs. The current existing local echocardiography training programs vary widely across structure and training requirements and are often based on individual institutional agreements with the SCFHS.

The aim of this curriculum is to standardize the structure, requirements, syllabus, and the assessment format of the Adult Echocardiography Fellowship training program in Saudi Arabia and replace all existing individual institutional programs with a unified national curriculum which

aims to ensure high quality and consistent training outcomes among all local training centers. The writing committee members are experts in the field of adult echocardiography and were nominated by the Adult Cardiology Fellowship Scientific Board and the Adult Echocardiography Fellowship Training Committee Board in the SCFHS.

The implementation of this curriculum is expected to provide trainees with appropriate exposure to all adult echocardiography modalities and their basic and advanced clinical applications, covering the theoretical knowledge and psychomotor skills that would guarantee

them with the highest level of professional competencies. In order to achieve the best outcome of this curriculum, a full dedication of the trainees is required during the training period. It is also expected that the trainees will undertake the required training rotations and have an

appropriate level of exposure to the spectrum of echocardiography modalities and to their respective clinical applications.

As this is the first national curriculum of its kind in the field, this effort may be subject to human faults and shortcomings which can be amended in future versions. Additionally, this curriculum

will require periodic updates and revisions in order to accommodate medical and/or technical advances that are expected to emerge in the rapidly progressing field of echocardiography.


2. CONTEXT OF PRACTICE

Echocardiography is a non-invasive, ultrasound-based cardiac imaging diagnostic tool that is used to visualize anatomical cardiac structures, evaluate cardiac pathological

processes, and assess the cardiac hemodynamic state. Echocardiography technology has evolved over the past six decades to become the most frequently performed specialized

cardiac imaging modality in clinical practice. The origin of the echocardiogram goes back to 1953 when Dr. Inge Edler (cardiologist) and Carl Hellmuth Hertz (physicist) worked together to

produce the first A-mode, then M-mode image of the beating heart. The equipment used to produce this primitive M-mode was called a “reflectoscope,” and it paved the road to what was known as “Ultrasound Cardiography,” which was eventually renamed by Dr. Harvey

Feigenbaum as “Echocardiography.” The development of echocardiography continued to progress very rapidly from the M-mode to 2-D images, then to Doppler applications, and more recently, to 3-D visualizations and myocardial strain imaging.

The current technology of echocardiography can produce high quality 2-D and 3-D images and

can also provide accurate Doppler-based hemodynamic assessments. Advanced echocardiography modalities and applications are being introduced to the clinical practice in a rapid way. Echocardiography is well-known for its high safety profile, wide range of applicability

in clinical practice, and its reliability in formulating a specific diagnosis which is necessary for providing an appropriate treatment plan. Echocardiography has replaced most of the invasive diagnostic procedures for the assessment of structural and functional heart diseases. Despite

the numerous advantages of echocardiography and its ease in clinical practice, it carries the limitation of being operator and observer-dependent, which may compromise patient care. These limitations are avoidable via continuous echo lab quality management and through implementation of well-structured echocardiography and echo technology training programs.

In Saudi Arabia, echocardiography was introduced to clinical practice in the late 1970s and continued to evolve and expand very rapidly. Currently, over twenty governmental cardiac centers and several tertiary-care medical cities throughout the Kingdom provide specialized

and advanced cardiac care, which cannot be run without the support of echocardiography services. In addition, hundreds of general hospitals and several private hospitals in the Kingdom are providing secondary-level cardiac care including echocardiography as an

essential diagnostic modality in their daily practice. Medical professionals in the Kingdom are continuously adopting state-of-the art technologies and embracing up-to-date knowledge in all fields of medicine, including echocardiography.

Clinical indications for performing echocardiographic examinations of the heart are not limited

to patients with known cardiac diseases but may also include, among others, patients with suspected cardiac involvement in many systemic diseases and thromboembolic events, trauma victims, routine surveillance for cardio-toxicity of certain medications, and preoperative risk

assessment. High-volume cardiac centers may easily exceed 10,000 adult echocardiographic studies per year, which would typically require a team of several echo-cardiologists working simultaneously at different clinical areas to cover different procedures and other on-call duties.

The current and projected shortage of well-trained echo-cardiologists in Saudi Arabia is significantly high and will continue to increase in proportion to the population growth and health care facility expansions.


Commonly practiced echocardiographic modalities include transthoracic echocardiogram (TTE) and trans-esophageal echocardiogram (TEE). Each echocardiographic modality has several

clinical applications such as stress-echocardiograms, contrast-echocardiograms, 3-D echocardiograms, intraoperative echocardiograms, and interventional echocardiograms. Understanding the necessary theoretical, technical, and interpretation skills of all echo

modalities and their numerous clinical applications would require highly focused and specialized training that cannot be achieved during the general cardiology fellowship training program. To achieve a high level of subspecialty training in the field of echocardiography,

further training and exposure to the echocardiography procedures and clinical applications through a well-structured and highly dedicated program is required. Such a program should cover the theoretical knowledge of basic sciences and the practical skills for analyzing echocardiographic images and for formulating appropriate clinically oriented reports.

The number of academically credentialed and professionally qualified echo-cardiologists in Saudi Arabia is significantly low compared to the existing and projected demand. The vast majority of certified Saudi echo-cardiologists have received their subspecialty training and

qualifications abroad through government run scholarship projects. In various general hospitals and cardiac centers, echocardiography services are run by non-credentialed individuals who lack the sufficient training requirements and the adequate practical experience needed for echocardiography which may lead to a compromise in patient care.

In view of the expanding medical services in Saudi Arabia and the high demand for qualified echo-cardiologists, it becomes necessity to establish a national Saudi Adult Echocardiography Fellowship Program in accordance with the Saudi Adult Cardiology Board and/or an equivalent qualification under the auspices of the SCFHS.

The concept of having a structured local echocardiography training program has evolved over the past several years into multiple separate individual institutional programs in mutual agreement with the SCFHS. As of today, the SCFHS has approved six centers to provide a

one-year full-time training course in echocardiography. Prince Sultan Cardiac Center (PSCC) was the first training center to get SCFHS approval in 2013, followed by King Faisal Specialist Hospital (KFSH) in 2015, then King AbdulAziz Cardiac Center (KACC), Ministry of National

Guard in Riyadh in 2016, followed by King Faisal Cardiac Center (KFCC) Ministry of National Guard in Jeddah in 2017, and finally, Saud AlBabtain Cardiac Center in Dammam and Dhahran Military Medical Complex in 2018. At the level of SCFHS, the vision for establishing a

national echocardiography subspecialty training program under a unified curriculum started with the establishment of the Echocardiography Training Program Scientific Committee, which was initially under the umbrella of the Adult Cardiology Scientific Board, and later became an independent scientific board.

Some of the local echocardiography labs have international accreditation, which reflects on the high-quality clinical services and the optimal academic environment provided by these labs and signifies their capability in providing good-quality training in echocardiography.

Echocardiography is a well-recognized professional subspecialty that is represented, in most of

the developed countries, by well-established professional organizations. In Saudi Arabia, echocardiography, as a well-established professional subspecialty, has evolved over the past 15 years from an Echocardiography Working Group that was established in 2002 under the

umbrella of the Saudi Heart Association (SHA) to become the “Saudi Arabian Society of Echocardiography” (SASE) in January of 2017. SASE is still under the umbrella of SHA and is


affiliated with the American Society of Echocardiography (ASE) and the European Association of Cardio-vascular Imaging (EACVI). SASE aims to promote excellence in standards of clinical practice and training in the field of echocardiography in Saudi Arabia.


4. CLINICAL PRACTICE Echocardiography is an essential diagnostic tool in cardiovascular medicine that guides health

care providers in appropriate patient management. The main role of an echocardiography fellow during this training period is to differentiate appropriate requisitions from inappropriate requisitions, enhance hands-on skills in TTE and TEE, and optimize interpretation and

communication skills related to echocardiographic findings. Strong background knowledge in science and good clinical skills are essential for formulating an accurate and clinically meaningful echocardiography report. Apart from being fully dedicated to daily echo-lab services, the

echocardiography fellow is expected to actively participate in patient care either directly through performing echocardiography procedures or indirectly through interpreting study findings and communicating the results to the appropriate health care providers. Participating in

multidisciplinary case discussions as a member of the heart team is a good opportunity for the fellow to enhance his/her decision-making skills.

Differences between existing and proposed curriculum:

Currently, each training center has its own independent training manual based mostly on the

published American Heart Association/ American College of Cardiology (AHA/ACC) echocardiography training recommendations. The aim here is to establish a unified and structured national echocardiography training curriculum that is based on the CanMEDS

competency framework. The ultimate goal of this work is to establish a standard national echocardiography training curriculum that will generate consistency in the objectives, structure, contents, and outcomes among the various training centers in the Kingdom. Implementation of

this high standard curriculum will ensure the graduation of highly qualified echo-cardiologists who can safely perform and reliably interpret the different forms of echocardiographic studies, while maintaining a high level of standards in all other professional aspects.

This curriculum is run over the course of one-year and will require full dedication and

commitment to the training requirements. Trainees are expected to have achieved level-II echocardiography knowledge and skills during their Adult Cardiology Fellowship training programs. They are expected to refine their pre-existing skills and gradually progress towards

obtaining advanced skills in transesophageal echocardiography (TEE) and other specialized echocardiographic applications. Trainees are required to commit themselves to high level of independent, self-directed studies, and to practice hands-on and interpretation skills under

direct supervision. Other CanMEDS competencies, including communication skills, professional attitudes, scholarly activities, patient advocacy, managerial skills and collaboration are an essential part of the training and should be incorporated into daily clinical practice and reflected on during trainees’ periodic evaluations.

Continuous assessment of the trainees will be conducted periodically. Assessment tools will include periodic CanMEDS-based evaluations, case-based discussions, and direct observations. A logbook of all performed and interpreted procedures will represent an essential

component of the assessment. The final examination will consist of a theoretical MCQ-based test and OSCE stations of image interpretation as outlined in the exam blueprint shown in Appendix A. Research activity should be clearly stated and documented by the program director in a separate letter.


5. POLICIES AND PROCEDURES

The curriculum represents the means and materials outlining learning objectives with which trainees and trainers will interact with for the purpose of achieving the identified

educational outcomes. The Saudi Commission for Health Specialties (SCFHS) has a full set of “General Bylaws” and “Executive Policies” (published on the official SCFHS website) that regulate all processes related to training. General bylaws of training,

assessment, and accreditation as well as executive policies on the admission, registration, continuous assessment and promotion, examination, trainees’ representation and support, duty hours, and leaves are examples of regulations that need

to be applied. Trainees, trainers, and supervisors need to apply this curriculum in compliance with the most updated bylaws and policies which can be accessed online (via the official SCFHS website).


6. LEAVE ENTITLEMENT AND ON-CALL DUTIES The fellow is entitled to a total of four weeks annual leave time during the course of

the training period, in addition to one of the Eid Holidays and the national day. Any additional days of absence from the program (long sick leave, maternity leave, etc..) shall be compensated for before the release of the certificate. On-call duty after

working hours and on weekends shall be in the range of 5-7 duties per month. All on-call echo procedures and study interpretations completed by fellows should be supervised and/or reviewed by the echo consultant on duty as soon as clinically

indicated. Fellows are expected to carry on with a normal work day following an on-call duty day.


8. GENERAL PROGRAM OBJECTIVES

Candidates are expected to gain advanced knowledge and high technical competencies in:

Cardiac anatomy and physiology, including fetal circulation and normal cardiovascular embryologic development.

Understanding the basic ultrasound physics and instrumentation of different echocardiographic imaging modalities and applications.

2-D echocardiographic features and Doppler findings of various acquired and adult congenital heart diseases.

The appropriate clinical applications of echocardiography, including strengths, limitations, and safety precautions of different echo modalities and applications.

Performing and interpreting complete transthoracic echocardiographic studies.

Performing and interpreting trans-esophageal echocardiographic studies.

Decision making in the operating room based on intraoperative trans-esophageal

echocardiograms.

Decision making in the cardiac catheterization and electrophysiology labs utilizing peri-

procedural trans-esophageal echocardiograms.

Supervising and interpreting stress echocardiographic studies.

Appropriate the utilization and interpretation of contrast echocardiographic applications.

Principles of Tissue Doppler, myocardial strain, and 3-D echocardiography imaging.


9. PROGRAM STRUCTURE 1- Admission requirements:

In alliance with the SCFHS general training policy, and without contradiction to any of the

SCFHS training rules and regulations, the following requirements must be fulfilled by the candidate in order to be enrolled in the Adult Echocardiography Fellowship training program:

Admission requirements

MBBS from a recognized university.

Saudi Board in Internal Medicine or an equivalent qualification.

Saudi Fellowship in Adult Cardiology or SCFHS-approved equivalent.

Completion of level-II echocardiography training requirements, which include performing 150 TTE studies and interpreting 300 additional TTE cases during a cumulative training duration of six months or more, that is usually obtained during the cardiology fellowship

program.

Full-time dedication to the training program.

Licensed to practice medicine in Saudi Arabia.

A written approval of the sponsoring organization for a full-time one-year training period.

Signed declaration of acceptance and adherence to the rules and regulations of the

SCFHS and the Training Program.

Passing the admission interview.

Three recent letters of recommendation (within the last three months preceding the submission date) from consultants with whom the candidate has recently worked with.

Registration as a trainee at the SCFHS.

Training shall be conducted only in institutions that are accredited by the SCFHS for echocardiography training.

Valid BLS and ACLS certification.

2- Program duration:

The total training period will last for 12 consecutive Gregorian months and includes four weeks of annual vacation and one Eid Holiday off.


3- Program rotations:

The trainee will rotate through outpatient and inpatient echo labs and all related clinical areas where training objectives can be fulfilled. Due to the overlapping nature of echocardiographic

procedures which usually run in parallel, it will be impractical to dedicate a specific rotation for each modality/application and therefore, rotations are distributed through the year according to the major theme of interest during each rotation. The trainee will practice several procedures

during each rotation with major emphasis on procedure in each rotation. The rotation themes are shown in the table below.

The trainee will be evaluated at the end of each rotation according to the CanMEDS-based competency checklist shown in Appendix B, which also includes the expected number of

hands-on procedures and study interpretations required by the trainee at the end of each rotation. To ensure adequate exposure to all echo modalities in a stepwise manner, the trainee is recommended to follow the proposed training rotation plan shown in the table below:


Table of proposed thematic rotations

Theme of

Rotation

Rotation Schedule

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Outpatient

echo lab

60% TTE

20% TEE 20% Others

Inpatient echo

services

40% TTE 40% TEE

20% Others

Inpatient

echo + Intra-op. TEE

20% TTE 60% TEE 20% Others

Inpatient echo +

Cath lab. TEE

20% TTE

60% TEE 20% Others

Outpatient TTE

+ others

40% TTE 40% TEE

20% Others

Research Longitudinal activity

TTE: Transthoracic Echocardiography. TEE: Transesophageal Echocardiography. TTE and TEE skills include hands-on practice and study interpretation (reporting). Others include: contrast studies, myocardial strain imaging, stress-echocardiography and adult CHD.


10. TRAINING REQUIREMENTS

The trainee is expected to fulfil all training requirements listed in the table below:

Echo modality/application Requirements

Transthoracic echocardiogram, including ACHD

Perform a minimum of 150 full studies

Interpret a minimum of 500 additional studies Interpret a minimum of 50 additional ACHD cases

Routine Trans-Esophageal

Echocardiogram (TEE) + 3DE

Basic Observe and perform a minimum of 25 esophageal intubations

Advanced Perform and interpret a minimum of 50 full TEE studies

Intra-operative TEE + 3DE

Basic Observe and participate in 25 studies

Advanced Perform a minimum of 50 studies

Special echo procedures

Participate in performing and interpreting 25 stress echo studies (VHD + IHD) Observe and interpret a minimum of 25 bubble and 25

contrast studies Observe and interpret a minimum of 25 myocardial strain imaging studies

Leave A total of four weeks in addition to the national day and

one of the official Eid Holidays.


Types and number of cases the fellow should be exposed to during his/her training

period:

Minimum number of cases that the trainee should be exposed to:

Disease/procedure category In six months In one year

Valvular heart disease (including prosthetic valves and endocarditis)

75 150

Coronary artery disease and its complications 75 150

Cardiomyopathies 75 150

Adult congenital heart disease 30 50

Diseases of the aorta 15 30

Pericardial diseases 15 30

Masses, tumors, and source of embolism 15 30

Contrast + bubble study echocardiography 30 50

Intra- Op TEE 20 50

Stress echocardiography 15 25

Strain echocardiography 15 25

Transcatheter aortic valve implantation (TAVI) 10 15

Left atrial appendage closure devices 2 5

Mitral clip 2 5

Atrial septal defect closure 2 5

Percutaneous closure of the paravalvular leak 1 2


Learning and Competencies

1.1 CanMEDS competencies

This curriculum applies principles of competency–based medical education. CanMEDS represents a globally accepted framework outlining competency roles. The “CanMEDS 2015 framework” has been adopted in this section. Please refer to Appendix C for a detailed

description of CanMEDS. Upon completion of echocardiography training, the trainee will have acquired the following competencies and will function effectively as a:

11. Medical expert

Definition: As medical experts, echo-cardiologists integrate all of the CanMEDS roles, applying

medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical expert is the central physician role in the CanMEDS framework.

Key Enabling Competencies: Echo-cardiologists can 1) Function effectively as consultants, integrating all of the Saudi Board’s roles to provide

optimal, ethical, and patient-centered medical care

Perform consultations pertaining to the echocardiographic applications which may include the presentation of well-documented assessments and recommendations in written and/or verbal form, in response to a request from another health care

professional, Demonstrate the use of all of the Saudi Board’s competencies which are relevant

to echocardiography,

Identify and appropriately respond to relevant ethical issues arising in patient care, in relation to echocardiographic services,

Demonstrate the ability to prioritize professional duties when confronted with

multiple patients and problems during routine echo lab workflow, Demonstrate compassionate and patient-centered care while providing echo-

related services,

Recognize and adhere to the ethical dimensions of medical decision-making in the echo lab.

2) Perform appropriate targeted assessments of cardiac patients, relevant to the echo

specialty to

Effectively identify and explore echo-related issues to be addressed during a patient encounter, including the patient’s context and preferences.

Obtain patient history that is relevant, concise, and accurate

Perform focused physical examinations that are relevant and accurate for the purposes of prevention, health promotion, diagnosis, and/or management.

Select medically appropriate echocardiographic investigative methods in a resource-effective and ethical manner.

Demonstrate effective clinical problem-solving and judgment in regards to addressing patient problems, including echocardiographic interpretation and integrating information to generate differential diagnoses and management plans.

3) Use of echocardiography (TTE/TEE) effectively to


Ensure that appropriate informed consent is obtained in the echo-lab as per

standard policies and procedures. Implement management plants in collaboration with patients and their families

based on the echo findings.

Demonstrate appropriate and timely application of preventive and therapeutic interventions relevant to the diagnosis.

4) Demonstrate proficient and appropriate use of echocardiographic procedural and interpretational skills to Demonstrate the effective, appropriate, and timely interpretation and application of

the results of the following diagnostic and therapeutic procedures: Echocardiography (M-mode, 2D, and Doppler) Transesophageal echocardiography

Stress echocardiography

5) Seek appropriate consultation from other health professionals while recognizing the

limits of their expertise to Demonstrate an awareness of their own limitations in regards to expertise in other

fields of medicine.

Demonstrate the ability to conduct effective, appropriate, and timely consultation with other health professionals, as needed, in order to provide optimal patient care.

Arrange appropriate follow-up echocardiographic studies for patients, as deemed

necessary.

12. Communicator

Definition: As communicators, echo-cardiologists effectively facilitate the doctor-patient and interprofessional relationship and the dynamic exchanges that occur before, during, and after the medical encounter.

Key Enabling Competencies: Echo cardiologists can:

1) Develop rapport, trust, and ethical therapeutic relationships with patients and their

families to Recognize that being a good communicator is a core clinical skill for physicians,

and that effective physician-patient communication can foster patient satisfaction,

physician satisfaction, adherence to treatment practices, and improved clinical outcomes.

Establish positive therapeutic relationships with patients and their families that are

characterized by understanding, trust, respect, honesty, and empathy. Respect patient confidentiality, privacy, and autonomy. Listen effectively.

Show an awareness of, and be responsive to, nonverbal cues. Effectively facilitate structured clinical encounters.

2) Accurately obtain and synthesize relevant information from, as well as the perspectives of, patients and their families, colleagues, and other professionals to Gather information on patients’ diseases and sufferings including their beliefs,

concerns, expectations, and illness experiences. Obtain and synthesize relevant information from other sources, such as patients’

families, caregivers, and other professionals.


3) Convey relevant information and explanations accurately to patients and their families, colleagues, and other professionals to

Deliver information to patients and their families, colleagues, and other professionals in a humane manner and in such a way that it is understandable and encourages discussion and participation in decision-making.

4) Develop a common understanding on issues, problems, and plans with patients, their

families, and other professionals in order to develop a shared plan of care

From a patient encounter, identify and explore problems that must be effectively addressed by considering the patient’s context, responses, concerns, and preferences.

Respect diversity and difference including, but not limited to, the impact of gender, religion, and cultural beliefs on decision-making and the ability to comply with a therapeutic program.

Encourage discussion, questions, and interaction during encounters with patients. Engage patients, families, and relevant health professionals in shared decision-

making in order to develop a plan of care.

Address effectively challenging communication issues, such as obtaining informed consent, delivering bad news, and addressing anger, confusion, and misunderstanding.

5) Convey effective oral and written information concerning a medical encounter to

Maintain clear, accurate, and appropriate records (e.g., written or electronic) of

clinical encounters and plans. Present verbal reports of clinical encounters and plans. Present medical information to the public or media concerning cardiology-related

medical issues.

13. Collaborator

Definition: As collaborators, Echo-cardiologists effectively work within a health care team to achieve optimal levels of patient care. Key Enabling Competencies: Echo-cardiologists can

1) Participate effectively and appropriately in an interprofessional healthcare team Describe the specialist’s roles and responsibilities to other professionals Describe the roles and responsibilities of other professionals within the health care

team Recognize and respect the diversity of roles, responsibilities, and competences of

other professionals in relation to their own

Work with others to assess, plan, provide, and integrate care for individual patients (or groups of patients)

Work with others to assess, plan, provide, and review other tasks, such as

research problems, educational work, program reviews, and/or administrative responsibilities

Participate in interprofessional team meetings

Enter into interdependent relationships with other professions for the provision of quality care

Describe the principles of team dynamics

Respect team ethics, including confidentiality, resource allocation, and professionalism


Demonstrate leadership, as appropriate, when operating as a member of a healthcare team

2) Work effectively with other health professionals to prevent, negotiate, and resolve

interprofessional conflict

Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team

Work with other professionals to prevent conflicts

Employ collaborative negotiations to resolve conflicts Respect differences and address other professionals’ misunderstandings and

limitations

Recognize one’s own differences, misunderstandings, and limitations, which may contribute to interprofessional tension

Reflect on the functions of an interprofessional team

14. Manager

Definition: As managers, echo-cardiologists are integral participants in healthcare organizations

and in organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system.

Key Enabling Competencies: Echo-cardiologists can: 1) Participate in activities that contribute to the effectiveness of their health care

organizations and systems

Work collaboratively with others within their organization Participate in systemic quality process evaluations and improvements, such as

patient-safety initiatives

Describe the structure and function of the health care system with regards to its relevance to cardiology, including the various roles of physicians

Describe the advantages and disadvantages of cardiac care in a variety of settings,

including hospitals, ambulatory care clinics, offices, homecare, and chronic care and rehabilitation facilities

Describe the principles of health care financing in regard to its relation to

cardiology, including physician remuneration, budgeting, and organizational funding

2) Manage their practice and career effectively Set priorities and manage time so that they can effectively balance patient care,

practice requirements, outside activities, and their personal lives

Manage a cardiology practice, including finances and human resources Implement processes to ensure personal practice improvement Appropriately employ information technology for patient care

3) Appropriately allocate finite cardiac care resources

Recognize the importance of the just allocation of health care resources, balancing

effectiveness, efficiency, and access with optimal patient care Apply evidence and management processes for cost-appropriate care

4) Serve administration and leadership roles, as appropriate Chair or participate effectively in committees and meetings Lead or implement changes in health care

Plan relevant elements of health care delivery (e.g., work schedules)


15. Health advocate

Definition: As health advocates, Echo-cardiologists use their expertise and influence responsibly to advance the health and well-being of individual patients, communities, and populations.

Key Enabling Competencies: Echo-cardiologists can:

1) Respond to individual patient health needs and issues as part of patient care

Identify the health needs of an individual patient Identify opportunities to carry out advocacy, health promotion, and disease

prevention with individuals to whom they provide care to

2) Respond to the health needs of the communities that they serve

Describe the communities that their practice serves

Identify opportunities for advocacy, health promotion, and disease prevention in communities that are at risk for cardiovascular disease and its complications

Apply knowledge of primary and secondary prevention for cardiovascular disease

Appreciate the possibility of competing interests existing between the communities they serve and other populations

3) Identify the determinants of health for the populations that they serve Identify the biologic, psychosocial, environmental, and economic determinants of

the health of the population they serve, including barriers to access of care and

resources Utilize this information in a management and prevention plan, and ensure access

to appropriate health and social services when managing the health of individual

patients Identify vulnerable and/or marginalized populations within those served and

respond appropriately

4) Promote the health of individual patients, communities, and populations

Describe an approach to implementing a change in the health of the population

they serve Describe how public policy impacts the cardiovascular health of the populations

served

Identify points of influence in the healthcare system Describe the ethical and professional issues inherent in health advocacy, including

altruism, social justice, autonomy, integrity, and idealism

Appreciate the possibility that, in their role as health advocates for a patient or community, conflicts may arise with individuals operating as managers or gatekeepers

Describe the role of the medical professional in collectively advocating for health and patient safety

16. Scholar Definition: As scholars, Echo-cardiologists demonstrate a lifelong commitment to reflective learning, as well as to the creation, dissemination, application, and translation of medical

knowledge. Key Enabling Competencies: Echo-cardiologists can:

1) Maintain and enhance professional activities through the practice of ongoing learning


Describe the principles required for maintaining competency

Describe the principles and strategies needed to implement a personal-knowledge-management system

Recognize and reflect on learning issues that arise in practice

Conduct a personal practice audit Pose appropriate learning questions Access and interpret relevant evidence

Integrate new learning into practice Evaluate the impact of changes made in regards to practice Document learning processes

2) Critically evaluate medical information and its sources, and apply this appropriately to

practice decisions

Describe the principles of critical appraisal Critically appraise retrieved evidence to address a clinical question Integrate conclusions of critical appraisals into clinical care

3) Facilitate the learning of patients, families, students, residents, other health

professionals, the public, and others

Describe principles of learning that are relevant to medical education Collaboratively identify the learning needs and desired learning outcomes of others Select effective teaching strategies and content that can facilitate learning

Effectively deliver lectures or presentations Assess and reflect on teaching encounters Provide effective feedback

Describe the principles of ethics with respect to teaching

4) Contribute to the development, dissemination, and translation of new knowledge and

practices Describe the principles of research and scholarly inquiry Describe the principles of research ethics

Pose scholarly questions Conduct a systematic search for evidence Select and apply appropriate methods to address questions

Disseminate the findings of studies through presentations and/or publications

17. Professional

Definition: As professionals, Echo-cardiologists are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behavior.

Key Enabling Competencies: Echo-cardiologists can:

1) Demonstrate commitment to their patients, profession, and society through ethical

practice Exhibit appropriate professional behaviors in practice, including honesty, integrity,

commitment, compassion, respect, and altruism

Understand the nature of professional interpersonal relationships and

boundaries with patients, co-workers, and students


Demonstrate a commitment to delivering the highest quality of care and maintaining competences

Recognize and appropriately respond to ethical issues encountered in practice Manage conflicts of interest Recognize the principles and limits of patient confidentiality as defined by

professional practice standards and the law Maintain appropriate relations with patients

2) Demonstrate a commitment to their patients, profession, and society through participation in profession-led regulation Demonstrate knowledge and understanding of the professional, legal, and ethical

codes of practice Fulfill the regulatory and legal obligations required by current practice Demonstrate accountability to professional regulatory bodies

Recognize and respond to unprofessional behaviors in practice Participate in peer reviews

3) Demonstrate commitment to physician health and sustainable practice Balance personal and professional priorities to ensure personal health and

sustainable practice

Strive to heighten personal and professional awareness and insight Recognize other professionals in need and respond appropriately


11. Learning opportunities in echocardiography

Echocardiography is a highly competitive subspecialty in the field of cardiology. To master the needed echocardiographic skills, the trainee is required to have knowledge in basic and clinical sciences and to undergo an extended period of experience and practice.

In the Echo lab, the echocardiography fellow should learn the practical skills for image acquisition and perform the appropriate measurements that are necessary to make an accurate diagnosis and propose an appropriate treatment plan.

Echo-lab based learning opportunities cover different aspects of echocardiography that may help the fellow to gain greater insight into the diagnosis and management of acute and chronic cardiovascular conditions. The time that the fellow spends in the Echo-lab is one of the best

opportunities to gain workplace education, wherein a senior supervisor observes and guides the fellow during hands-on and interpretation sessions. The learning opportunities in echocardiography are vast and the fellow should be keen, enthusiastic, and proactive towards

learning and acquiring the required skills.

a. Structure of the educational program

18. Basic sciences This part can be taught in the form of courses, seminars, lectures, workshops, and laboratory experience. Trainees should acquire the appropriate background knowledge in basic and

fundamental disciplines related to echocardiogram, such as embryology, anatomy, physiology, pathology, physics, and biostatistics.

The fellow is required to: 1) Master embryology and anatomy of the cardiovascular system 2) Understand the details of cardiovascular and cardiopulmonary pathophysiology

3) Understand the basics of ultrasound beam formation and applications 4) Learn about the basic and advanced instrumentation needed for echocardiography 5) Master competency in acquisition and interpretation of echo images

6) Apply the basics of patient safety and infection control in the echo lab 7) Have adequate knowledge and skills of conducting research projects

b. Core specialty topics (Areas of learning & learning objectives)

AREA OF LEARNING

LEARNING OBJECTIVES

1. Ultrasound

physics and instrumentation

Fellows should have the ability to:

a. Basic physics of ultrasound

i. Describe sound and ultrasound wave production and propagation ii. Describe the basic ultrasound wave parameters and acoustic variables iii. Discuss the ultrasound-tissue interaction and its potential bio-effects iv. Identify different forms of ultrasound artefacts

b. Doppler

principles

i. Discuss the basic principles of fluid dynamics ii. Discuss the Doppler effect and its medical applications

iii. Describe the methods of Doppler measurement and display iv. Describe Doppler acquisition, Doppler artifacts, and image optimization

c. Ultrasound

instrumentation

i. Describe types and characteristics of commonly used ultrasound

transducers


ii. Describe the forms, advantages, and limitations of different display modes

iii. Describe the basic principles of image acquisition and optimization iv. Discuss the physics of ultrasound contrast agents

2.

Echocardiography modalities


a. Transthoracic echocardiography (TTE)

i. Identify standard transthoracic echo windows ii. Properly apply and manipulate the transducer iii. Obtain standard transthoracic echo views

iv. Interpret normal and abnormal image findings

b. Trans-esophageal

echocardiography (TEE)

i. Perform the standard patient preparation before the procedure ii. Properly introduce and position the TEE probe into the appropriate level

iii. Describe the standard trans-esophageal and trans-gastric echo views iv. Acquire and interpret normal and abnormal TEE findings

c. 3D echocardiography

i. Describe the concept and instrumentation for the 3D applications

ii. Describe advantages and limitations of the 3D echocardiography iii. Describe the modes of image acquisition in 3D echocardiography iv. Demonstrate adequate image processing and interpretation of the 3D

echocardiography

d. Doppler echocardiography

i. Describe the differences between pulsed wave and continuous wave Doppler imaging

ii. Apply the appropriate probe position and orientation to obtain the proper Doppler signal iii. Apply the appropriate machine settings and probe position for color

and tissue Doppler iv. Describe quantitative and qualitative interpretations of all Doppler modalities

e. Intraoperative

and interventional TEE

i. List common surgical and interventional procedures where TEE is required ii. Describe the pre and post procedure echo data

iii. Perform the appropriate pre and post procedure views and measurements iv. Develop an effective communication system with the primary operator

f. Stress echocardiography

i. Describe the available forms of stress strategies and their advantages and limitations

ii. Discuss the role of echocardiography in the assessment of myocardial ischemia and viability iii. Discuss the role of echocardiography in the assessment of valvular

heart disease iv. Describe protocols and expected findings for different forms of stress echocardiography

g. Strain

echocardiography

i. Describe normal and abnormal myocardial mechanics ii. Discuss the available modes of myocardial deformation imaging iii. Discuss the concept of Doppler-based and tracking-based myocardial

deformation iv. Describe the clinical applications and interpretations of myocardial deformation imaging


3. Clinical applications of

echocardiography


a. Role of echocardiography in assessment of

valvular heart disease (VHD)

i. Identify the etiology and hemodynamic effect of VHD based on the echo assessment

ii. Perform standard echo images and measurements using necessary echo modalities iii. Appropriately interpret TTE, TEE, 3DE, and stress echocardiographic

studies of VHD iv. Propose the appropriate management plan based on the echocardiographic findings

b. Role of echocardiography in the diagnosis of

cardiomyopathies

i. Choose the appropriate echo modality and perform adequate echocardiographic assessments

ii. Identify the echocardiographic characteristics of left and right ventricular cardiomyopathies iii. Assess the severity and hemodynamic impact of each individual case

of cardiomyopathy iv. Propose the appropriate management plan based on the echocardiographic findings

c. Role of echocardiography in chamber

quantification and ventricular function

assessment

i. Perform the standard echo images and Doppler assessments of the LV and RV function ii. Perform qualitative and quantitative LV and RV systolic and diastolic

assessments iii. Differentiate between global and regional LV wall motion abnormalities iv. Perform and interpret left and right atrial volume measurements

d. Role of echocardiography in coronary artery

disease

i. Identify regional wall motion abnormalities with varying degrees of severity

ii. Assess the hemodynamic impact of myocardial ischemia/infarction on the LV and RV iii. Identify cardiac complications of acute and chronic myocardial

infarction iv. Apply the appropriate echo modality as indicated for each case scenario

e. Role of

echocardiography in assessing cardiac masses

i. Identify normal cardiac structures that may mimic pathological cardiac masses ii. Describe the echocardiographic features of each form of cardiac

masses iii. Assess the hemodynamic effect and the risk of embolism of intracardiac masses

iv. Apply the appropriate echo modality and propose the appropriate mode of treatment

f. Role of echocardiography in pericardial

diseases

i. Describe the echocardiographic features of acute and chronic

pericardial diseases ii. Differentiate constrictive pericarditis from restrictive cardiomyopathy iii. Identify echocardiographic findings of cardiac tamponade

iv. Propose the appropriate management plan and assist in performing pericardiocentesis

g. Role of echocardiography

i. Describe the standard TTE and TEE views of the aorta ii. Identify pathologies of acute aortic syndromes


in assessing diseases of aorta

iii. Describe chronic pathological changes of the aorta iv. Propose the appropriate management plan

h. Role of echocardiography

in adult congenital heart diseases

i. List common adult congenital heart diseases and repaired childhood congenital heart diseases ii. Describe flow direction and hemodynamic impact of intracardiac shuts

iii. Assess the function of surgical shunts and conduits following surgical repair iv. Propose suitability for device versus surgical repair based on the echo

findings

i. Role of echocardiography in assessment of

prosthetic heart valves (PHV)

i. Identify the echocardiographic characteristics for different forms of cardiac valves prosthesis

ii. Discuss the advantages and limitations of different echo modalities in regards to PHV assessment iii. Differentiate between normal and abnormal hemodynamic parameters

during PHV assessment iv. Use the appropriate echo modality as needed and propose the appropriate management plan

j. Role of

echocardiography in the diagnosis of infective

endocarditis

i List common underlying cardiac structural heart diseases with predisposition to endocarditis ii. Differentiate infective from non-infective endocarditis based on echo

and clinical criteria iii. Describe the echocardiographic findings of infective endocarditis and its cardiac complications

iv. Use the appropriate echo modality and propose the appropriate treatment plan

k. Role of echocardiography in the evaluation

of pulmonary circulation

i. Describe the standard views and normal appearances of pulmonary

arteries ii. Identify the main pulmonary artery and its branch abnormalities iii. Estimate systolic, diastolic, and mean pulmonary artery pressure based

on Doppler assessment iv. Identify possible underlying causes and hemodynamic consequences of pulmonary hypertension


c. Core specialty topics (Knowledge & Skills)

1. Ultrasound physics and instrumentation:

a. Physics of ultrasound

Fellows should be able to:

KNOWLEDGE SKILLS

• Define period, frequency, amplitude, power, intensity,

wavelength, and velocity of ultrasounds • Discuss absorption, reflection, attenuation, and acoustic

impedance • Discuss the concept of sound beam formation, propagation,

beam shape, diameter, divergence, focal depth, focus, and resolution

• Describe the concept of tissue harmonics and the use of contrast agents

• Appreciate variations between ultrasound penetration in different human tissues

• Apply ultrasound beam focus, width, lateral resolution, and axial

resolution • Demonstrate the effect of pulse repetition, output power, dynamic

range, and compression on image quality

• Recognize and troubleshoot ultrasound limitations and artifacts

b. Doppler principles


KNOWLEDGE SKILLS

Discuss the law of conservation of mass, conservation of energy,

and conservation of momentum

Discuss the concept of the Doppler effect, the Doppler shift, and

the Nyquist limit

• Apply pulsed wave and continuous wave Doppler assessments

• Optimize the quality and accuracy of Doppler applications

• Interpret normal and abnormal Doppler signals and flow patterns

• Perform Doppler-derived hemodynamic calculations


Describe the principles and applications of Bernoulli and Continuity Equations

Explain the role of the tissue Doppler in myocardial function

assessment

c. Ultrasound instrumentation


KNOWLEDGE SKILLS

• Describe the types, designs, components, piezoelectric effects, and functions of ultrasound transducers

• Describe the hardware and software components of ultrasound

machine and the DICOM compatibility • Identify ultrasound machine knobology and control panels and

describe their appropriate use • Describe the bioeffects and safety issues of ultrasound

instrumentations and their related applications

• Demonstrate appropriate image mode display and contrast resolution • Select the appropriate transducer type and apply proper transducer

position and orientation

• Appropriately use machine controls to optimize image quality • Integrate 2D images, M-mode, Doppler color flow, and spectral

Doppler within the same study

2. Echocardiography modalities

a. Transthoracic echocardiography (TTE)


KNOWLEDGE SKILLS

• List the appropriate indications and anticipated limitations of TTE

in clinical settings • Describe TTE windows including standard and off-axis views for

each window

• Describe the appropriate patient preparation and transducer orientation for each TTE view

• Identify the window, view, and echo modality of each image in the

TTE study • Interpret the normal and abnormal findings of TTE images

• Obtain standard 2D, M-mode, color Doppler, and spectral Doppler

TTE assessment • Perform and acquire a high quality, full TTE study


• Identify the anatomical cardiac structures and the physiologic cardiac cycle events in TTE views

b. Trans-esophageal echocardiography (TEE)


KNOWLEDGE SKILLS

• List the appropriate clinical indications, advantages, limitations,

and contraindications of TEE • Discuss the appropriate safety precautions, patient preparation,

and sedation protocol for TEE • Describe the technique for performing TEE and standard TEE

windows and views • Propose the appropriate TEE window and views for visualization

of each cardiac structure

• Perform the appropriate preprocedural check list, physical

assessment, and sedation plan • Introduce the TEE probe and ensure continuous patient monitoring

with adequate safety precautions • Manipulate the TEE probe position and orientation to adjust the angle

appropriately • Interpret normal and abnormal TEE view findings

c. 3D Echocardiography (3DE)


KNOWLEDGE SKILLS

• Describe the advantages and limitations of TTE and TEE 3DE

imaging • Describe technical principles for 3DE acquisition, display, and

processing • Discuss established and potential clinical applications for TTE

and TEE 3DE • List common 3DE artifacts and propose methods for improving

3DE image quality

• Choose the appropriate 3D modality for different clinical settings

• Acquire and optimize 3DE images in TTE and TEE

• Appropriately use the on-line and off-line 3DE image processing system

• Interpret 3DE images for different cardiac structures


d. Doppler echocardiography


KNOWLEDGE SKILLS

• Describe normal intracardiac Doppler flow patterns • Identify Doppler flow pattern abnormalities

• Describe hemodynamic principles of normal and abnormal

Doppler flow patterns • Relate the Doppler flow abnormality to its underlying structural

abnormality

• Interpret normal and abnormal Doppler flow pattern • Obtain accurate Doppler measurements of left and right inflow,

outflow, and hepatic and pulmonary veins

• Apply simple and advanced Doppler-derived hemodynamic calculations

• Apply the Bernoulli equation, continuity equation, and shunt

calculations

e. Intraoperative and interventional TEE


KNOWLEDGE SKILLS

• List indications, contraindications, advantages, and limitations of

intraoperative and procedural TEE • Describe the role of intraoperative and procedural TEE in

decision making • List potential surgical and interventional procedure-related

outcomes that can be detected and fixed based on echo findings

• List common surgical and catheter-based interventions that would require pre-, intra-, and post-procedure TEE surveillance

and guidance

• Apply standard patient preparation and ensure adequate safety

precautions • Communicate and collaborate effectively with the operating team in

the cardiac OR and cardiac cath lab • Obtain informative pre- and post-procedural TEE views and

measurements

• Accurately interpret normal and abnormal TEE findings, before and after the procedure

f. Stress echocardiography



KNOWLEDGE SKILLS

• Discuss the principles of physical and pharmacological stress procedures

• Describe advantages and limitations of each stress and imaging

modality • Describe standard stress- and Dobutamine-echocardiography

protocols • Discuss the role of stress-echocardiography in ischemic and

structural heart disease assessment

• Perform adequate preprocedural assessments • Ensure adequate patient safety precautions and obtain informed

consent

• Differentiate normal from abnormal myocardial response to stressors • Interpret hemodynamic response to stressors in various forms of

structural heart disease

g. Strain echocardiography


KNOWLEDGE SKILLS

• Describe myocardial structural design and normal systolic and

diastolic mechanics

• Discuss the concept of myocardial deformation, strain, and strain rate

• Discuss the principles of longitudinal, radial, circumferential, and

global strain • Discuss the clinical applications of myocardial deformation

imaging • Realize the technical aspects of strain imaging and tracking-

based deformation assessment

• Apply different modalities of myocardial deformation imaging

• Appropriately apply strain imaging studies in clinical practice

• Interpret normal and abnormal strain imaging values


3. Clinical applications of echocardiography

a. Role of echocardiography in valvular heart disease (VHD) assessment


KNOWLEDGE SKILLS

• Describe echocardiographic features for each form of valvular

heart disease • Discuss echocardiographic criteria for the severity scale of each

valvular stenosis • Discuss echocardiographic criteria for severity scale of each

valvular regurgitation • Identify valvular vegetations and masses

• Obtain adequate 2-D views for each heart valve

• Perform adequate Doppler assessments of each heart valve

• Accurately interpret valvular heart disease etiology and severity • Propose the appropriate subsequent assessment method and/or

management step

b. Role of echocardiography in the diagnosis of cardiomyopathies


KNOWLEDGE SKILLS

• Classify echocardiographic forms of cardiomyopathy

• Describe the echocardiographic features for each form of

cardiomyopathy • Discuss the echocardiographic criteria for severity of each type of

cardiomyopathy • Discuss the role of echocardiography in screening and follow up

of cardiomyopathy

• Interpret the echocardiographic features and severity of dilated

cardiomyopathy

• Interpret the echocardiographic features and hemodynamic effects of hypertrophic cardiomyopathy

• Interpret the echocardiographic features and hemodynamic effects of restrictive cardiomyopathy

• Interpret the echocardiographic findings of other forms of

cardiomyopathy

c. Role of echocardiography in chamber quantification and ventricular function assessment



KNOWLEDGE SKILLS

• Discuss the diagnostic and prognostic role of atrial and

ventricular size and function assessment • Describe standard views and the cardiac cycle phase of each

chamber quantification • Discuss limitations and pitfalls for each chamber quantification

assessment method • Relate chamber quantification findings to their underlying

structural abnormalities

• Perform standard 2-D, M-mode, and TDI chamber quantification

assessment • Interpret systolic and diastolic ventricular assessment parameters

• Interpret atrial size/volume assessment and causes of abnormal

findings • Perform and interpret echocardiographic assessments of the aorta,

pulmonary artery, and vena cava

d. Role of echocardiography in coronary artery disease


KNOWLEDGE SKILLS

• Describe the echocardiographic findings of acute myocardial

ischemia and myocardial infarction • Describe echocardiographic findings of prior myocardial

infarction and ischemic cardiomyopathy • Discuss mechanical complications of acute myocardial infarction

and their echocardiographic features • Discuss the echo and Doppler hemodynamic manifestations of

acute and chronic ischemic heart disease

• Correctly interpret echocardiographic findings of acute

ischemia/myocardial infarction • Identify echocardiographic findings of post MI mechanical

complications • Identify echocardiographic findings of chronic ischemic

cardiomyopathy • Interpret stress echocardiography for ischemia detection and viability

assessments

e. Role of echocardiography in assessing cardiac masses



KNOWLEDGE SKILLS

• Discuss classification and common categories of intracardiac

masses • Describe the echocardiographic features of neoplastic and non-

neoplastic cardiac masses • Discuss the frequency and clinical presentation of common

neoplastic cardiac masses in adults • Discuss the role of TEE in the assessment of cardiac masses

• Interpret the echocardiographic findings for different forms of cardiac

masses • Propose the most likely diagnosis of cardiac masses according to

echocardiographic features • Interpret TEE views and findings, pertaining to cardiac masses

• Propose the appropriate management plan for different forms of

cardiac masses

f. Role of echocardiography in pericardial diseases


KNOWLEDGE SKILLS

• List common forms of congenital and acquired pericardial

diseases • Discuss the pathophysiology of cardiac tamponade and

pericardial constriction

• Describe echocardiographic manifestations of cardiac tamponade and pericardial constriction

• Correlate echocardiographic findings with clinical manifestations

of cardiac compression syndromes

• Obtain standard views and adequate hemodynamic assessments of

pericardial effusion • Perform adequate hemodynamic assessments of suspected

pericardial constriction

• Interpret echocardiographic findings of cardiac tamponade and pericardial constriction and propose the appropriate management

plan • Assist in echocardiographic-guided pericardiocentesis

g. Role of echocardiography in assessing diseases of aorta


KNOWLEDGE SKILLS

• Describe echocardiographic findings of congenital, acquired, and

genetic diseases of the aorta

• Interpret the echocardiographic findings of Marfan’s syndrome and

other forms of aortic aneurysms


• Describe clinical manifestations and echocardiographic features of acute aortic syndromes

• Describe the echocardiographic findings of aortic aneurysms and chronic atherothrombotic diseases of the aorta

• Discuss the role and limitations of TEE in the diagnosis and

management of diseases of the aorta

• Interpret the echocardiographic findings of acute aortic dissection and intramural hematoma

• Interpret the echocardiographic findings of atherothrombotic diseases and aortic plaque ulcerations

• Perform and interpret TEE views of aortic pathologies

h. Role of echocardiography in adult congenital heart diseases


KNOWLEDGE SKILLS

• List common adult congenital heart diseases and describe their

clinical presentations • Describe echocardiographic findings of TGA, PDA, and aortic

coarctation • Discuss the types and echocardiographic features of ASD, VSD,

and APVD

• Describe the echocardiographic findings of TOF, DORV, and congenital valvular heart diseases

• Perform and interpret echocardiographic studies of suspected ACHD

using a segmental approach • Identify echocardiographic features for different forms of adult

congenital heart diseases • Assess severity and hemodynamic effects for each type of adult

congenital heart diseases

• Propose the appropriate management step for each case of adult congenital heart disease

i. Role of echocardiography in the assessment of prosthetic heart valves (PHV)


KNOWLEDGE SKILLS

• Classify and list different types of prosthetic heart valves and

replacement techniques • List advantages and limitations of each form of prosthetic valves

and replacement procedures • Discuss short- and long-term prosthetic valve complications and

their echocardiographic manifestations

• Perform TTE and TEE to obtain appropriate views and hemodynamic

assessments for prosthetic valves • Identify different forms and positions of prosthetic valves

• Interpret TTE and TEE findings for normal and abnormal prosthetic

valve function


• Discuss pitfalls and limitations of TTE and TEE in relation to prosthetic valve type and position

• Propose the appropriate management step that needs to be taken for faulty prosthetic valves

j. Role of echocardiography in the diagnosis of infective endocarditis


KNOWLEDGE SKILLS

• Define infective endocarditis and list its clinical manifestations

and differential diagnosis • List common cardiac and non-cardiac complications for infective

endocarditis • Discuss the diagnostic criteria and describe common

echocardiographic findings for infective endocarditis

• Discuss the role of TEE in the diagnosis of infective endocarditis

• Identify vegetation and other echocardiographic findings of

endocarditis • Differentiate pathological vegetation from normal intracardiac

structures • Appropriately propose, perform, and interpret TEE for non-diagnostic

TTE study

• Incorporate echo findings into the treatment plan proposal

k. Role of echocardiography in the evaluation of pulmonary circulation


KNOWLEDGE SKILLS

• Describe normal anatomy and physiology of pulmonary circulation

• Discuss classification and common causes of chronic pulmonary

hypertension • Describe echocardiographic findings of acute and chronic core

pulmonale • Discuss causes and echocardiographic features of pulmonary

artery aneurysm

• Perform TTE that includes pulmonary artery anatomy and pressure assessment

• Interpret TTE findings of acute pulmonary embolism and chronic

pulmonary hypertension • Estimate pulmonary artery pressure using different Doppler

parameters • Propose, perform, and interpret TEE whenever it is indicated, as part

of the pulmonary hypertension assessment



d. Ethics and Professionalism Program

Ethical practice and professional conduct are of paramount importance to physicians of all specialties including echo fellows. Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician. It requires

establishing and maintaining standards of competence and integrity and providing authoritative guidance to society concerning matters of health. The doctrine and responsibilities of medical professionalism should be understood by both the profession and society. Fundamental to this

contract is public trust in physicians, which is dependent on the integrity of both physicians and the profession.

Adherence to professionalism is currently promoted at various levels of the Medical field. As part of the Competency-Based Educational Objectives, echocardiography fellows are expected to develop professionalism manifested by a commitment to carrying out professional

responsibilities with adherence to ethical principles. Program directors have an important responsibility and role in advancing ethical conduct among trainees in practice and in addressing the concerns about newly emerging ethical challenges.

f. Courses, workshops, and other continuing education activities

1.6.1 Mandatory

Valid BLS and ACLS certification

Valid moderate sedation course

Minimum of two local echocardiography courses and/or workshops

Attendance at annual scientific meeting of the Saudi Heart Association

1.6.2 Optional

Active membership in the Saudi Heart Association (SHA)

Active membership in the Saudi Arabian Society of Echocardiography (SASE)

Attendance at ASE or EACVI annual conference

Attendance at annual AHA, ACC, or ESC meetings

g. Educational activities


12. Teaching and learning activities linked to CanMEDS roles

ACTIVITY OBJECTIVES

CanMEDS

COMPETENCIES

Case

presentation

To develop appropriate presentation

skills

To exchange knowledge with other

colleagues

To gain expert opinion from senior staff

To gain appropriate decision-making

skills

Manager,

Medical expert,

Professional

Scholar

Morbidity and

mortality

To identify areas of potential

improvement in regards to patient care

To learn how to avoid future events

based on previous incidents

To demonstrate professional integrity

and patient advocacy

Professional

Manager,

Medical expert

Grand rounds To increase medical knowledge and

skills in the field of interest

To learn about the latest advances in

the field of interest

To discuss controversial topics in the

field of interest

Medical expert,

Professional

Journal clubs To promote continuing professional

development

To remain up to date with evidence-

based knowledge

To disseminate information and debate

good practice

Medical expert,

Scholar,

Health advocate

19. Self-directed learning:

20. Due to the small number of candidates in this program and the short

overall training period, no dedicated academic half-day release is required. Instead, Self-Directed Learning (SDL) is encouraged.

SDL refers to a learning experience that is planned and organized by the fellow. SDL is used to

advance learning in a particular topic/area or to meet a personal learning objective. Fellows should be encouraged to:

1) Engage in a variety of SDL activities


1) Perform activities relating to higher levels of learning 2) Collaborate with others or work in teams to achieve a common goal

Rules

1) The fellow must document the SDL he/she conducted.

2) The mentor or supervisor will review SDL activities during the supervisory meeting and shall evaluate the level of achievement and the score on the portfolio-evaluation sheet accordingly.

1.1.1.1 Examples of SDL activities

1) Standard textbook reading 2) Review article reading 3) Practice guidelines (review and summarization)

4) Journal clubs 5) Searching the Internet for the answer to a certain clinical question (PICO) 6) Attendance at accredited conferences/courses

7) Case presentation 8) Small-group activities 9) Practical Evidence Applied in Real Life Situations (PEARLS)

10) Teaching other fellows, residents, and/or medical students 11) Quality improvement/patient-safety activity 12) Participating in research or departmental projects

13) Performing a literature review on a certain topic 14) Writing a research proposal, abstract, and/or manuscript


13 Suggested References

Suggested references: 1) Textbook of Clinical Echocardiography, Catherine M. Otto, 5th Edition. 2) Feigenbaum’s Echocardiography, William F. Armstrong, 7th Edition.

Additional references:

1) ASE’S Comprehensive Echocardiography, Roberto M. Lang, 2nd Edition.

2) Handbook of Echo-Doppler Interpretation, 2nd Edition, Edmund K., Elizabeth M, Gary P.

3) The Normal Examination and Echocardiographic Measurements. 3rd Edition

Bonita Anderson. 4) Echocardiography Board Review: 500 Multiple Choice Questions with

Discussion, by: Ramdas G. Pai & Padmini Varadarajan. First published:3 March

2014 5) Congenital Heart Defects, Simplified; Ken Heiden and Linda Wilson, Second

Edition, 2017

6) Sonography Principles & Instrumentation: A Comprehensive Review, Kristen Solis.

Web resources: 1- https://en.wikipedia.org/wik,i/Doppler_echocardiography 2- http://www.echopedia.org/index.php?title=Main_Page

3- http://www.echocardiology.org/ 4- http://www.echocardiographer.org/index.html 5- https://www.123sonography.com/

https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Pai+MD+FACC+FRCP+Edin%2C+Ramdas+G

https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Varadarajan+MD+FACC%2C+Padmini

https://www.amazon.com/s/ref=dp_byline_sr_book_4?ie=UTF8&text=Ken+Heiden&search-alias=books&field-author=Ken+Heiden&sort=relevancerank

https://www.amazon.com/s/ref=dp_byline_sr_book_5?ie=UTF8&text=Linda+Wilson&search-alias=books&field-author=Linda+Wilson&sort=relevancerank

https://en.wikipedia.org/wiki/Doppler_echocardiography

http://www.echopedia.org/index.php?title=Main_Page

http://www.echocardiology.org/

http://www.echocardiographer.org/index.html

https://www.123sonography.com/


14 Assessment 1.1.2 Continuous formative evaluation

This type of evaluation helps trainees to identify their strengths and weaknesses and allows them to target specific areas; furthermore, it helps faculty members recognize areas where fellows may be struggling and to address such problems immediately. In order to fulfil the

CanMEDS competencies based on the end-of-rotation evaluation, fellows’ performance will be evaluated jointly by relevant staff members who will evaluate the candidate regarding the following competencies:

Trainee’s performance (knowledge, skills, interpretation, critical thinking, and clinical

judgment) during daily work. Performance and participation in academic activities will be continuously monitored by the supervising staff.

Performance during 10-20 minutes of direct observation of the trainee–patient interaction. Trainees are encouraged to perform at least one assessment per clinical rotation, preferably near the end of the rotation. (See direct observation of practical

skills [DOPS] Appendix D).

Trainee’s performance of diagnostic procedural skills. The provision of timely and

specific feedback from trainer to the trainee following each procedure is mandatory.

The CanMEDS-based competencies end-of-rotation evaluation form (Appendix B)

must be completed with the signatures of at least two consultants within two weeks from the end of each rotation. The program director shall discuss evaluations with fellows as necessary. The evaluation form shall be submitted to the SCFHS Regional

Training Supervisory Committee within four weeks of the end of the rotation.

Academic and clinical assignments should be documented in a logbook on an annual basis as outlined under the training requirements above.

Evaluations are based on trainee’s level of accomplishment in regards to the minimum requirements for the procedures and clinical skills, as determined by the program.

No Formative assessment Tools Domain

1 Case-based discussions (CBD) Knowledge

2 Average score for ITERS (end-of-rotation evaluation reports) shown in appendices A-D

Attitude

3 DOPS Skills

4 Research activity Skills

5 Logbook Skills


1.1.3 Training completionA final in-training evaluation report (FITER) is prepared for each fellow at

the end of the academic year. Based on the training bylaws and executive policy (please refer to www.scfhs.org) trainees will be granted the “Certification of Training-Completion” once the following criteria are fulfilled:

a. Successful completion of all training rotations.

b. Completion of training requirements as outlined by the scientific committee of specialty (e.g. logbook, research, others).

c. Clearance from SCFHS training affairs that ensure compliance with

tuitions payment. The “Certification of Training-Completion” will be issued and approved by the scientific committee or its equivalent according to SCFHS policies.

Final Sub-Specialty Examinations

The final specialty examination is the summative assessment component that grants trainees the specialty certification. It has two elements:

a) Final written exam: in order to be eligible for this exam, trainees are required to have the “Certification of Training-Completion.”

Written MCQ format with single best answer (120 MCQs/2.5 hours).

b) Final practical exam: trainees will be required to pass the final written exam in order to be eligible to sit for the final clinical/practical exam.

Practical, OSPE format, that consists of six stations of recorded echocardiographic

studies.

Each station includes three echo studies and is evaluated by a panel of two

examiners.

The cases are a mix of different cardiac pathologies with various findings that cover:

o Transthoracic echocardiography o Transesophageal echocardiography

o Perioperative and periprocedural echocardiography o Stress and contrast echocardiography

For each case there will be three standard questions and three preset answers.

In general, questions are formatted as follows:

1) What are the echocardiographic findings? 2) What is the diagnosis based on the echo findings? 3) What is the recommended management plan?

http://www.scfhs.org/


Appendix A

Assessment item blueprint

(both MCQs and OSCE)

To be attached


Appendix B

Saudi Fellowship for the Adult Echocardiography Rotation Evaluation form

1st quarter □ 2nd quarter □ 3rd quarter □ 4th quarter □

Fellow’s Name: ………………………………………………………………………… SCFHS trainee’s number: ……………………………………….…….…

Training Center: ….…………….……………………………………………...……… Rotation period: ……….……….……... to …………...………...…....

CanMEDS-based competencies

Meeting Expectations 1= worst & 5= best

1 2 3 4 5 NA

Medical expert

General

Described the cardiovascular anatomy and physiology

Described fetal circulation and heart embryonic development

Discussed the CV disease pathophysiology and hemodynamic abnormalities

Physics, instrumentation, and TTE

Demonstrated understanding of principles for ultrasound physics and Doppler effect

Demonstrated understanding of echo machine instrumentation and applications

Knows the indications, strengths, and limitations of transthoracic echocardiograms

Described standard TTE windows, transducer orientation, and technical steps of TTE

Transesophageal Echocardiogram (TEE)


Knows the indications, contraindications, strengths and limitations of trans-esophageal echocardiogram

Knows infection control measures and electrical safety issues related to the use of TEE

Understands sedative and analgesic agents, including their actions, side effects, and potential risks

Intraoperative and procedural TEE

Knows the spectrum of surgical palliation and surgical repair for CHD and its manifestations on the adult echocardiogram

Knows of commonly performed cardiac surgical procedures in the adult population

Knows about the types of prosthetic valves, artificial grafts, and other synthetic materials

Understands the concept of cardiopulmonary bypass machine, cross clamp, and cardioplegia

Knows the spectrum of catheter-based interventions for CHD and its manifestations in the adult echocardiogram

Special procedures

Knows the indications and limitations of exercise echocardiography

Knows the different types of pharmacologic stress agents, including their advantages and side effects

Described the concept and clinical applications of strain and strain rate

Discussed the properties, indications, contraindications, limitations, and advantages of ultrasound contrast agents

Research

Describes the appropriate applications of research methodology in the field of cardiovascular medicine

Initiated or participated in a clinical or basic science research project

Critically appraised the literature and appropriately applied them into clinical practice

Adopted evidence-based practices and recommendations in day-to-day patient care

Stayed updated with the most recent literature in the medical field of interest

Provided better patient care, based on the most recent scientific knowledge

Hands-on practical skills

Transthoracic Echocardiogram (TTE)

Mastered machine controls and adjust 2D, M-mode, and Doppler settings appropriately

Mastered practical skills for performing full transthoracic echocardiographic studies

Knows of image optimization skills and common ultrasound artifacts

Transesophageal Echocardiogram (TEE)

Mastered practical skills of performing systematic trans-esophageal echocardiogram


Applied infection control measures and standard safety precautions during trans-esophageal echocardiogram

Applied pre-procedural check list, check availability, and readiness of all equipment

Performed real time 3D echocardiography and Q-lab post-processing

Applied epicardial echocardiography approach appropriately

Interpretation skills

Recognized the 2-D and Doppler features of structural and hemodynamic cardiac abnormalities

Demonstrated confidence in systematic interpretation of transthoracic echocardiogram

Applied basic Doppler equations used in echocardiography during interpretation

Built confidence in systematic interpretation of trans-esophageal echocardiogram

Showed confidence in systematic interpretation of stress echocardiogram

Demonstrated ability to interpret bubble and contrast studies

Distinguished between adequate and inadequate echocardiographic data

Communicator

Obtained adequate and relevant history from patients and families

Built professional and effective communication skills with seniors, colleagues, and paramedical staff

Developed a good patient relationship during the examination with appropriate attention to comfort and

privacy

Interpreted, from the requisition, the relevant questions to be answered by the echocardiographic

examination

Developed a systematic approach in reporting relevant echocardiographic findings

Communicated the results of the examination to the patient when appropriate, as well as to the referring

physician

Obtained informed consent for TEE and stress test

Prepared and submitted a complete research proposal

Wrote an interim research report and reply to research related queries

Communicated effectively with co-investigators and other research-related personnel

Presented an oral or poster abstract at peer reviewed scientific meetings and during research activities

Prepared a manuscript for submission to a peer-reviewed journal

Prepared and obtained a written consent form from participants when applicable

Provided expert opinion in the field of the research project


Collaborator

Applied collaborative teamwork concepts with the echo lab staff at all levels and at all times of patient care

Collaborated effectively with consultants and other team members

Cooperated with colleagues and other allied health care professionals in providing the appropriate echo service to the patient

Showed proactivity in offering help and support

Contributed effectively to other interdisciplinary team activities

Collaborated with the concerned units to perform bedside studies if needed

Coordinated on procedure scheduling and resources

Collaborated with co-investigators, coordinators, and study subjects

Collaborated with the IRB and ethics committees in relation to feedback and suggestions

Worked effectively as a team member in collaboration with other disciplines during all steps of the research project

Manager

Utilized the echo lab time, equipment, and facilities in an efficient manner

Respected and adhered to the laboratory schedule and the patients’ need for a timely examination

Understood the indications, contraindications, and appropriateness of echo studies

Maintained a good balance between patient care, learning needs, and social activities

Utilized information technology to optimize patient care, life-long learning, and other activities

Timely reporting of urgent studies and studies of critical findings

Worked as a team leader in the research field when chosen to be a principle investigator (PI)

Managed the grant budget in an efficient and cost-effective way

Utilized facility, equipment, and human resources effectively

Managed study steps and accomplished tasks in a timely manner

Maintained a fair balance between research activities, clinical duties, educational activities, and personal

commitments

Health advocate

Described the role of echocardiography in detecting and monitoring cardiovascular disease

Utilized echocardiographic data to encourage healthy life-style practices and to avoid unhealthy practices


Used echocardiographic data for patient education and health promotion

Promoted early echocardiographic detection of familial heart diseases through family screening

Ensured patient safety during transesophageal echocardiogram

Used echocardiographic data for patient education and health promotion

Provided adequate education to study candidates about the research activity

Applied research strategies that worked in the best interest of patients

Ensured participants safety and delivery of all medical and ethical rights

Contributed effectively to improve individual and public health

Scholar

Realized and acknowledged personal limitations in knowledge and technical skills

Critically evaluated the literature on topics related to echocardiography

Assisted in teaching junior staff the theoretical and technical skills of echocardiography

Implemented and monitored a personal continuing education strategy

Contributed to the development of new knowledge via participating in research activities

Prepared educational echo activities that are presented in grand round and journal club

Built a bank of educational echo cases for teaching purposes

Discussed different types of study designs and research methodologies

Chose an appropriate study design for different forms of research questions

Conducted literature searches and critically appraisals for relevant articles

Prepared and submitted abstracts and manuscripts for presentations and publications

Participated in data analysis and write up of the discussion and conclusion part of the study

Professional

Punctuality and commitment in conducting tasks and duties

Interacted with patients coming to the echo lab with integrity, honesty, and compassion

Practices echocardiography in a manner that is ethically consistent with the obligations of a physician

Worked with other physicians and allied healthcare professionals in an appropriate and professional manner

Exhibits appropriate personal and interpersonal professional behaviors

Maintains appropriate boundaries in work and learning situations


Respects senior cardiologists as mentors and role models

Conducts research in accordance to standards of research ethics and professional code of conduct

Keeps in touch with the research mentor/supervisor to gain professional skills for conducting research

Exhibits appropriate personal and interpersonal professional behaviors

Utilizes information technology and computer skills to optimize research productivity and lifelong learning

Number of procedures 1st quarter 2nd quarter 3rd quarter 4th quarter

Expected

Performed

Expected

Performed

Expected

Performed

Expected

Performed

Hands-on TTE studies 50 30 30 40

TTE case interpretation 150 150 150 150

ACHD cases interpreted 15 15 10 10

TEE studies performed 10 15 15 10

TEE studies interpreted 20 40 40 20

Intraoperative TEE 5 5 10 10

Cath/EP lab procedural TEE 5 5 10 10

Stress echo studies 5 5 5 10

Strain imaging studies 5 5 5 10

Contrast imaging studies 10 5 5 5

Bubble studies 10 5 5 5

Overall performance

Total score:

Total score %: [(total score) / (number of applicable items x 5)] x 100 =

Comments


.…………….………………………………………………………………………………………………………………………………………………………

……………………….……

.…………….……………………………………………………………………………………………………………………………………………………………………………….……

.…………….………………………………………………………………………………………………………………………………………………………

……………………….……

Evaluators

Evaluator 1………….…………………………………………………….…… Signature: ….……………………………….…… Date: …...…...…….…. Evaluator 2.…………….………………………………………………………. Signature: ….……………………...….………… Date: …...…...….…....

Evaluator 3.…………….……………………………………………………… Signature: ….…………………………………… Date: …...…...……...…

Approvals


(I certify that I have read all parts of this evaluation report and that I have discussed it with the evaluators)

Fellow

name:.…………….……………………………………………………….…………………………………………………………………………………………

Signature:.…………….……………………………………………………….…… Date:.…………….……………………………………………………….……

Program

director:.…………….……………………………………………………….…………………………………………………………………………………………

Signature:.…………….……………………………………………………….…… Date:.…………….……………………………………………………….……


Appendix C

CanMEDS Competency Framework

(To be attached)


Appendix D

Saudi Fellowship for the Adult Echocardiography

Direct Observation of Procedural Skills (DOPS) Rating Form

Fellow’s Name: ………………………………………………………………………… SCFHS trainee’s number: …………………………………………………

Training Center: ….…………….……………………………………………...……… Rotation period: ……….……….……... to …………...………...…....

Procedure observed

Observed by Date

Signature of observer

Description Satisfactory Unsatisfactory Comment

Understood the indications for the procedure and clinical alternatives

Explained plans and potential risks to the patient clearly and in an understandable

manner

Good understanding of the theoretical background, including anatomy,

physiology, and imaging of the procedure


Advanced preparation for the procedure

Communicated the procedural plan to relevant staff

Explained procedure to the patient and obtained valid informed consent

Aware of risks for cross infection and demonstrated an effective aseptic technique during the procedure

Procedure success or failure was understood in the current setting

Coped well with unexpected problems

Demonstrated awareness through constant monitoring and maintained focus

Demonstrated correct procedural sequence with confidence and minimal hesitation

Skillfully handled patient and tissues in a gentle fashion

Maintained accurate and legible records including descriptions of problems and/or difficulties

Issued clear post procedural instructions to the patient and/or staff

Sought to work to the highest professional standards at all times

ASSESSMENT

Overall practice was: satisfactory unsatisfactory


Areas of good practice:

Areas requiring improvement:

Further learning and experience should focus on the following:

Documents

SAUDI DIPLOMA IN · 1 day ago · 4 SAUDI DIPLOMA IN ADULT ECHOCARDIOGRAPHY TABLE OF CONTENTS 1. Introduction 2. Context of practice 3. Goal and Responsibility of curriculum implementation