Heart Center

Patient population

The patient base at Boston Children's Hospital represents one of the greatest strengths of the Fellowship Training Program. It reflects the program's long history of leadership in caring for congenital and acquired heart disease in the young, and includes large local, regional, national and international referral sources.

Research opportunities

The research opportunities are diverse, combining intramural expertise in molecular genetics, cardiac morphogenesis and cellular adhesion with an exceptionally wide range of laboratory investigation occurring throughout the Boston medical community.

First-Year Clinical Rotations

The first clinical year is an intensive immersion in clinical cardiology with a focus on caring for a large number of patients in the inpatient and outpatient settings, and on learning what information is important in making clinical decisions. By the end of the first year, fellows have been exposed to each of the main sub-specialties of pediatric cardiology, and have a good sense of how cardiology is practiced at a single institution.

First-year fellows rotate through six clinical services and a night float position at approximately four-week intervals.

Two first-year fellows are on call in the hospital every night:

• one to cover the cardiac intensive care unit as his or her sole responsibility
• one as a night float to supervise cardiac medical and surgical patients on the cardiology floor, and to respond to urgent consults from other services

First-year fellows are expected to take every fourth night coverage in the ICU for approximately eight weeks and perform night float coverage for approximately eight weeks (divided time) during the year. Ample backup support is available from the second-year fellow on call, and from staff cardiologists covering the subspecialty services within the department.

Cardiac Medicine/Surgery:

The fellow leads a team of three pediatric residents in the care of cardiac medical patients on 8 East, the cardiac inpatient floor. The first-year fellow also assists the surgical team, including nurse practitioners, in the postoperative care of cardiac patients convalescing on the floor, assuming the role of consulting cardiologist and pediatrician.

The fellow runs morning rounds, manages patient care in tandem with attending cardiologists, and teaches the residents on an informal basis during the day. More formal teaching and supervision of patient care is provided by the attending cardiologist assigned each month. Additional daily teaching sessions are conducted by the cardiology faculty.

Cardiac Intensive Care:

One first-year cardiology fellow is scheduled to rotate each month on the cardiac intensive care unit. During the first year of training, therefore, each fellow will have two clinical months on the CICU. In addition, each month a second- and third-year cardiology fellow and a critical care fellow rotate through the ICU and share the call schedule. The clinical commitment is less than 80 hours/week, including call.

The fellows in the CICU are responsible for the intensive care management of the cardiac surgery, cardiac medical and select patients with cardiac disease undergoing non-cardiac surgery. Two attending intensive care staff are responsible for providing direct supervision of patient care and teaching during daily rounds. Fellows receive training in cardiac pathophysiology, intensive care management, and critical care monitoring and procedures.

Electrophysiology:

In conjunction with an electrophysiology staff physician, the first-year fellow functions as a consultant for all inpatients and selected outpatients with arrhythmias. The fellow is responsible for coordinating patient management, helping to plan and execute drug trials, esophageal electrophysiology studies, cardioversions and exercise studies, as well as review of all Holter studies. Although the second-year fellow on this service is primarily responsible for intracardiac electrophysiology studies, ablations and intraoperative procedures, the first-year fellow participates in these procedures as well.

Echocardiography:

First-year fellows are introduced to cardiac ultrasound through hands-on experience guided by the echocardiography staff, senior fellows and experienced technologists. Additionally, a comprehensive tape library and didactic sessions are provided for the fellows. The fellow is expected to take an active role in the laboratory, performing echocardiographic scanning in several half-day sessions each week to gain experience in the interpretation of anatomic, Doppler and ventricular function studies.

Catheterization Laboratory:

Three days a week are spent performing catheterizations under staff guidance. Responsibilities of the first-year fellow include: preparation of the case and review of informed consent with the patient's family the day prior to the procedure; presentation of the case at morning conference; performance of the catheterization with a staff physician; and analysis and review of the data at the end of the day. The fellow participates in two or three catheterizations per day. As the rotation progresses, the fellow learns to obtain a complete set of hemodynamic, saturation and angiographic data in a safe and expedient manner. Training in catheterization of the newborn infant and interventional procedures begins in the first year.

Night Float:

A first-year fellow is available in the hospital from 7 p.m. to 7 a.m. to assume patient care responsibilities for the cardiac medical, surgery and consult services, as well as handling referrals or questions from outside physicians. Extensive clinical backup is available from the second-year fellow on call, staff cardiologists on service and the CICU. A staff physician regularly reviews any outstanding patient management issues with the fellow.

Cardiology Clinic:

Each fellow is assigned to a weekly half-day clinic session, which is supervised by attending cardiologists. Fellows evaluate and plan the care of patients referred to the clinic for outpatient evaluation, and provide long-term continuity care for patients with more serious conditions whose care they have assumed while on their various clinical rotations.

Second-Year Clinical Rotations

The goal of the second-year is to:

• build on technical and cognitive skills to allow increasing independence
• expand the fellows' knowledge to allow a broader understanding of the controversies and challenges of the field
• most importantly, identify a specific initial career path to focus both research and clinical energies toward

To this end, the second-year is flexible in combining clinical requirements and protected time for research and study. During ICU rotations, fellows take in-house call. The remainder of the year, the fellows share "back-up" call from home on nights and weekends, acting as a resource for the first-year fellows in the hospital. The primary responsibility of this fellow is to perform night and weekend echocardiograms and catheterizations under supervision of the appropriate staff cardiologist. Scheduling of the second-year responsibilities is generally decided by the fellows themselves.

A second-year fellow or a senior clinical fellow with comparable experience is always assigned to the cardiac catheterization laboratory and the ICU. In the cardiac catheterization laboratory, the fellows take increasing responsibility for organizing the daily laboratory schedule, with a goal of performing hemodynamic cases independently and becoming more involved in interventional procedures.

In the ICU, second-year fellows perform many of the echocardiographic examinations and catheterize children as the schedule allows. There is always a second-year or more senior fellow on the consult service, providing cardiology consultation to Children's Hospital patients and infants at the affiliated neonatal units at Brigham and Women's Hospital and the Beth Israel/Deaconess Medical Center. This fellow sees all new referrals and provides continuing cardiology coverage on the floors and outpatient clinics as appropriate.

In addition, the fellow may perform echocardiograms needed by the consult service. Rounds are conducted with the supervision of a staff cardiologist.

During the second-year of training there are opportunities for advanced rotations in echocardiography, electrophysiology, cardiac transplant medicine, intensive care medicine, adult congenital heart disease, and pathology. During these rotations, the fellows assume broader responsibilities based on their interest and abilities.

Third-Year Fellowship Training

Senior fellows are largely free of clinical responsibilities, except for their own clinic patients, in order to pursue projects on a full-time basis. There are opportunities for advanced fellows to spend time in catheterization, echocardiography, electrophysiology and cardiac intensive care, depending on interest and aptitude. Two third-year fellows are selected as Chief Fellows. The administrative responsibilities include assisting with scheduling, teaching and advising of the first and second-year fellows.
 

Research Training

Experience in cardiovascular research is an essential component of fellowship training in cardiology. In addition to patient care responsibilities, fellows are expected to become involved in a clinical research project during the first year, under the guidance of a faculty member.

Such projects, either new or ongoing, are often of the chart review type, and may form the basis for a future prospective study for those fellows interested in clinical research.

Fellows should identify a clinical or basic science research mentor from among the faculty by the end of the first year. Three months of the second year, and virtually all of the third year, are dedicated to ongoing research training.

During the first half of the second year, it is expected that each fellow will, with appropriate guidance, write and submit a proposal for a research project which:

1. addresses an important question
2. applies available state-of-the-art techniques to answering that question
3. is practical within the time and other constraints of the fellowship

The project may be either basic science or clinical; clinical research will in all probability entail a prospective study. Fellowship training in the Department beyond the second year is based on finding a suitable mentor and appropriate research project(s).

Fellowship grants

The department has an institutional NIH training grant, which permits selected fellows to train in basic research laboratories throughout the Harvard Medical Area, as well as in clinical research. Fellows are encouraged to write individual grant applications, but fellowship funding does not depend on such grants being funded.

Fellows interested in higher-level training in clinical research can take part in the Program in Clinical Effectiveness at the Harvard School of Public Health or the Scholars in Clinical Science Program at Harvard Medical School.

Senior Clinical Fellowship Training

Children's Cardiology Department offers advanced clinical training in the major subspecialty disciplines of pediatric cardiology, and an increasing proportion of trainees spend one or more additional years of training as "senior clinical fellows" in subspecialty areas.

The program offers trainees a thorough introduction to the core problems and frontiers of clinical pediatric cardiology with well-developed divisions of:

This program is open to individuals who have completed much or all basic pediatric cardiology training at other institutions. In general, these trainees are funded by a sponsoring institution or grants, although some departmental resources are available.

The training varies from six months to two years, based on individual needs. Senior clinical fellowships are available in cardiac catheterization, echocardiography, MRI, electrophysiology, cardiac intensive care, and the care of adults with congenital heart disease.