USMLE Guide

Ernesto A. Jonas, MD, FACP, FACCFormer Chief, Div. of Cardiology, and Cardiovascular Program Training Director Nassau University Medical CenterAssociate Professor of Medicine, SUNY at Stony Brook

This outline is offered as an aid in selecting among the Cardiovascular Training Programs in the United States and asking pertinent questions during the interview.
A pre-requisite to training in cardiovascular disease is the successful completion of three years of training in Internal Medicine acceptable to the American Board of Internal Medicine (ABIM).
The continued advances in cardiovascular medicine have necessitated the increase in the years for basic (Level 1) training from one year in the late 1960صs to the current three years full-time requirement. This level of training is the minimum required for admission to the ABIM Subspecialty Board on Cardiovascular Disease.
Level 1: Basic training required of all trainees to be a competent, consulting cardiologist.
Specialized competence (Level 2) in performing or interpreting some procedures requires additional training beyond the core program with specific guidelines.
Level 2: Additional training in one or more specialized areas enabling a cardiologist to perform or interpret, or both, specific procedures at an intermediate skill level.
Advance training (Level 3) requires the acquisition of a high level of skills beyond those of the core program that enables the cardiologist to not only perform and interpret specific procedures, but also trains others in these skills.
Level 3: Advanced training in a specialized area enabling a cardiologist to perform, interpret and train others to perform and interpret specific procedures at a high skill level.
The core training should be undertaken in university or university-affiliated institutions with fully accredited residency-training program in internal medicine.
There should be adequate balance between academic endeavors and clinical service
24 months of the three year core program should include a minimum of:
8 months in nonlaboratory clinical practice:1) Cardiac consultation 2) In-patient cardiac care3) Coronary care (3 months)4) Cardiothoracic/cardiovascular surgery5) Congenital heart disease6) Heart failure/cardiac transplantation7) Preventive cardiology
4 months in the cardiac catheterization laboratory.
6 months in noninvasive imaging:1) Echocardiography and Doppler (minimum 3 months)2) Peripheral vascular studies3) Nuclear cardiology techniques (minimum 2 months)4) Nuclear magnetic resonance, computed tomography, and other techniques
2 months in electrocardiography, stress testing, ambulatory electrocardiographic monitoring
2 months in arrhythmias, permanent pacemaker management, and electrophysiology
The remaining 1 year should be dedicated to research (6 to 12 months) or research combined with focused areas of individual interest and future career goals.
Ambulatory care experience of at least _ day per week (or its equivalent) should be part of the total 3-year core exposure.
In all areas of training, there are minimal numbers of procedures or encounters recommended by guidelines. It is understood that the quality of these encounters more than the quantity is essential in molding good consultants therefore supervision, and critique by faculty are an important part of the overall training program.
Electrocardiography: 3,500
Ambulatory ECG Monitoring: 75
Exercise Testing: 50
Cardiac Catheterization and Interventional Cardiology: 100 patients exposures to include right heart catheterization (including balloon flow-directed catheters), temporary right ventricular pacemaker insertions, left heart catheterization with ventriculography and coronary angiography, pericardiocentesis.
Echocardiography: 150 studies
Nuclear Cardiology Procedures: 80 hours of active participation in daily study interpretations
Electrophysiology, Cardiac Pacing, and Arrhythmia Management: 2 months exposure in this area to include at least 10 temporary pacemaker insertions and 8 elective cardioversions
Cardiovascular research: 6 months
Congenital Heart Disease in Adults: minimum of 3 hours of formal lectures.
Preventive Cardiology: Equivalent of one month full-time cumulative training.
The program should have adequate training resources in place.
There must be inpatient and outpatient facilities with an adequate number of patients of a wide age range with a broad variety of cardiovascular disorders. Trainees must be supervised and evaluated on every rotation by qualified faculty members when seeing patients in both areas. Faculty members must carefully supervise outpatient care.
The facility must provide laboratories for cardiac catheterization, electrocardiography, exercise and pharmacologic stress testing, Doppler/echocardiography, ambulatory ECG monitoring and noninvasive peripheral vascular studies. There must be appropriate facilities for cardiac catheterization, angiography and hemodynamic assessment, with adequate numbers of patients undergoing interventional procedures, including coronary angioplasty, atherectomy, stent placement, myocardial biopsy, transvalvular balloon dilation and intraaortic balloon placement
Facilities for nuclear cardiology must be available, including ventricular function assessment, myocardial perfusion imaging and studies of myocardial viability
There must be appropriate facilities for the management of patients with arrhythmias, including electrophysiologic testing, arrhythmia ablation, signal-averaged electrocardiography and tilt-table testing as well as the previous evaluation, implantation and assessment of patients with cardiac pacemakers and implantable antiarrhythmic devices and their long-term management
Facilities and faculty for training in cardiovascular research, including various basic science modalities, are important.
There must be modem intensive cardiac care facilities.
There must be facilities for cardiac and peripheral vascular surgery and cardiovascular/cardiothoracic surgical intensive care. Close association with and participation in a cardiovascular/cardiothoracic surgical program is an essential component of the cardiovascular training program. This must include active participation in the preoperative and postoperative management of patients with cardiovascular disease. Exposure to cardiac transplantation is strongly recommended.
There must be facilities and faculty involved in the diagnosis, therapy and follow-up care of patients with congenital heart disease.
There must be appropriate facilities for the clinical and laboratory assessment of patients with systemic hypertension and peripheral vascular disease
There must be facilities for assessment of cardiopulmonary and pulmonary function, cardiovascular radiography and magnetic resonance imaging (MRI).
There must be appropriate expertise and instruction in preventive cardiology and risk factor modification, including management of lipid disorders
There must be facilities and faculty with knowledge of cardiovascular pathology.
There must be facilities, personnel and faculty with expertise in cardiac rehabilitation.
There must be other appropriate facilities and resources necessary to accomplish the training, including a comprehensive medical library, facilities for continuing medical education, experimental study design and statistics and quality assurance.
Opportunities to gain knowledge and experience in related fields of medicine should be available.
Magnetic resonance imagingFamiliarity with the cardiovascular applications and interpretations of magnetic resonance images is essential to the training of a cardiovascular fellow. This imaging modality has many existing uses and considerable potential in noninvasive diagnosis. It is recommended that, where available, the fellow devote 2 months of time to magnetic resonance imaging (MRI). To become conversant enough with this methodology to be proficient with interpretation, a 4-month experience is recommended, and to become experienced enough for development and management of an MRI laboratory, a I -year comprehensive experience is essential.

Radiology
The interpretation of cardiovascular X-ray films, with particular reference to vascular structures and special cardiovascular radiologic procedures.

Surgery
The risks and benefits of cardiothoracic and cardiovascular surgery and the rationale for the selection of candidates for surgical treatment, as well as the natural history and the preoperative and postoperative management of patients with cardiovascular disease and various comorbid conditions.

Anesthesia
Close collaboration with anesthesia colleagues in the preoperative and postoperative management of patients with cardiac disease for cardiac and noncardiac surgery, and cardiac procedures requiring anesthesia (e.g., cardioversion).

Pulmonary disease
A solid knowledge of basic pulmonary physiology in addition to the interpretation of pulmonary and cardiopulmonary function testing, blood gases, pulmonary angiography and radioactive lung scanning methods and experience with the management of patients with acute pulmonary disease.

Obstetrics
A solid knowledge of the interrelations between pregnancy and heart disease, together with experience in the clinical management of patients with heart disease who are pregnant.

Physiology
The physiology of the cardiovascular system, its response to exercise and stress and the alterations produced by disease.

Pharmacology
The pharmacology and interactions of cardiovascular drugs and drugs affecting cardiovascular function.
Pathology
Familiarity with the gross and microscopic pathology of all major forms of heart disease.

Geriatrics
Familiarity with the effects of aging on cardiovascular disease and therapeutics is important
Conferences, seminars, review of published reports and lectures with full participation of the trainee should occur at a minimum of three per week.
The trainee must be offered the opportunity to teach.
Useful Link - Guidelines for Training in Adult Cardiovascular Medicine: http://www.acc.org/clinical/training/adult.htm

Author Bio:
Ernesto A. Jonas is a Graduate of the University of Nuevo Leon, Monterrey, Mexico. He completed is residency training in Internal Medicine at the Nassau University Medical Center (NUMC), East Meadow, NY, and his cardiovascular training at St. Elizabethصs Medical Center, Boston. MA. He joined the full-time faculty of the NUMC in 1973, and served as Chief of the Division of Cardiology until 1997 when he retired. He was also the Cardiovascular Program training director.

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