application for accreditation of an area of focused

ADULT CARDIAC ELECTROPHYSIOLOGY 1 2012

APPLICATION FOR ACCREDITATION OF AN AREA OF FOCUSED COMPETENCE PROGRAM IN

ADULT CARDIAC ELECTROPHYSIOLOGY This questionnaire is to provide the Royal College with a complete description of the AFC program. The completed questionnaire must be signed by the AFC director and submitted to the office of the Assistant or Associate Dean for Postgraduate Medical Education for the approval of the Faculty Postgraduate Medical Education Committee. Please submit completed applications by e-mail to: [email protected] University University of Toronto

Date of Application

January 2016

Name of AFC Director

Krishnakumar Nair

University Appointment of AFC Director

Assistant Professor of Medicine (Cardiology)

Department(s) Responsible for AFC Program Department of Medicine / Division of Cardiology

Name of Department Head (or equivalent)

Dr. Paul Dorian

Program Internet Address (if applicable)

The following information MUST BE INCLUDED with the application. Appendix A –Supporting Documentation including: Appendix A.1 - Covering letter indicating that the Faculty has approved and supports this program Appendix A.2 - Covering letters from the Chief Executive Officer of each of the participating institutions indicating support for the program Appendix B - Terms of Reference for the AFC program committee (if applicable) Appendix C – Research support in the form of operating grants Appendix D - Peer-reviewed publications of faculty members Appendix E - Objectives for the educational experiences (Standard C3.1; C3.2) Appendix F - Signed agreements of affiliation (if required) Appendix G - Curriculum of the program Additional Appendices Appendix H – Evaluation Tools Appendix I – Other Scholarly Activity

mailto:[email protected]


STANDARD C1: ADMINISTRATIVE STRUCTURE

"There must be an appropriate administrative structure for each AFC program."

1. AFC Director a) Provide the specialty qualifications of the AFC director. (Standard C1.1.1)

MBBS (1995), MD and Diplomate of National Board (DNB, India) in Internal Medicine (1995-1998), Doctor of Medicine and Diplomate of National Board(DNB, India) in Cardiology (2000-2002), Post-doctoral fellowship in Interventional Cardiology/ Cardiac Electrophysiology (India, 2003-2004), 2 year clinical fellowship in Cardiac Electrophysiology (2007-09) University of Toronto 2 year clinical research fellowship in Cardiac Electrophysiology (2009-11)(Heart & Stroke Foundation of Canada) IBHRE CCDS (International Board of Heart Rhythm Examiners Certified Cardiac Device Specialist) IBHRE CCEP (International Board of Heart Rhythm Examiners Certified Cardiac Electrophysiology Physician) More than 5 years in Cardiac Electrophysiology Practice In Canada

b) Describe the resources (time and support) that will be available to the AFC director to administer the

AFC program. (Standard C1.1.3)

The Cardiac Electrophysiology Fellowship programs at each of the three hospitals is financially supported by the respective Departments of Medicine. The AFC Director has 0.05 FTE of protected time to fulfill the responsibilities of the program. The AFC Director is responsible for the overall program and also acts as the Site Director for the trainees at the University Health Network (UHN) location. The Program Administrator dedicates approximately 0.1 FTE to the program. Both have office space at the UHN, electronic and communications resources required to operate the program adequately. The program director is supported in his role by an AFC Site Director at St Michael’s Hospital (SMH) and Sunnybrook Health Science Centre (SHSC). The Site Directors manage local issues at each of their respective sites. Advice and support are readily available from the PGME Office at University of Toronto and program faculty located at three sites. The site directors have administrative support and have 0.1 FTE protected time. The program has 19 full-time cardiac electrophysiologists; 10 cardiac electrophysiologists at the UHN; 6 at the SMH and 3 at the SHSC.

2. AFC Program Committee

a) Briefly describe how the AFC program committee functions OR attach a copy of the Terms of

Reference of the AFC program committee as Appendix B. (Standard C1.3)

Please see Appendix B for Terms of Reference for the AFC Program Committee. b) Committee membership (underline the name of the Chair of the Committee) (Standard C1.2; C1.2.1)

Name Major Responsibility within the Program

Krishnakumar Nair

AFC Director, Site Director, University Health Network (UHN)

Dr Iqwal Mangat AFC Site Director, Director, Arrhythmia Service, St Michaels Hospital (SMH)


Name Major Responsibility within the Program

Ilan Lashevsky AFC Site Director, Sunnybrook Health Sciences Centre (SHSC)

Paul Dorian Director of the Division of Cardiology, University of Toronto

Eric Yu Director, Postgraduate Training Program in Adult Cardiology University of Toronto

Elected AFC trainee from each site (UHN, SMH, SHSC)

Represent trainees at AFC Program Committee The elected fellows from the University Health Network, the St. Michael’s Hospital and the Sunnybrook Hospital are Dr. Andreu Porta-Sanchez, Dr. Mehrdad Golian and Dr. Ayelet Shauer respectively.

c) How will AFC trainees be chosen to be members of the AFC program committee? (Standard C1.2.1) Three AFC trainee site representatives will be elected annually for a one year term by the trainees at their site and will attend all meetings of the AFC Program Committee.

3. AFC Selection Process

a) Describe the process that will be used to select candidates into the AFC program. (Standard C1.3.3) Applications are available to prospective candidates from the University of Toronto Fellowship website http://www.lmp.utoronto.ca/postgraduate/fellowship-training-programs. The AFC Committee oversees the selection process, ensuring that approved policies are followed. The selection of candidates is performed by each site. This process reflects the challenge to current funding sources for trainees. Specifically, the lack of a central provincial governmental funding agency (as exists with all accredited Cardiology Residency Programs in the province) to support trainee positions in Cardiac Electrophysiology transfers the responsibility, and burden of funding salaries, to individual sites. Accordingly, each individual site within our program supports their own Cardiac Electrophysiology trainee salaries through a variety of site-specific individual sources (including support from the respective Departments of Medicine/ Divisions of Cardiology and dedicated Cardiac Electrophysiology funds). The AFC Committee appoints a Selection Subcommittee at each site; membership includes the Site Director, one or more faculty members and an AFC trainee. The Selection Subcommittee at the UHN include Dr. Krishnakumar Nair, Professor Kumar Nanthakumar (the Director of Cardiac Electrophysiology at UHN), Professor Louis Harris (former fellowship program director), Professor Eugene Downar (former fellowship program director) and Dr. Andreu Porta-Sanchez (fellow trainee). The Selection Subcommittee at SMH include Dr. Iqwal Mangat (Site Director), Dr. Paul Angaran (Site Faculty), Dr. Paul Dorian (Cardiology Division Director and Site Faculty), Dr. Victoria Korley (Site Faculty) and Dr. Mehrdad Golian (fellow trainee). The Selection Subcommittee at SBH include Dr Ilan Lashevsky (Site Director), Dr. Eugene Crystal (Site Faculty) and Dr. Ayelet Shauer (fellow trainee). Each file is reviewed by all of the members of the Selection Subcommittee. Reviewers use a standard form for the review, with scoring for specified criteria, including quality of personal letter, letters of reference, scholarly activity, academic excellence, interest in electrophysiology, work-life balance, unexplained gaps in training and experience in electrophysiology. Candidates are invited for an interview, providing they have met the requirements, with good supporting letters, and there are no serious “red flags” found on file review. The reviewers recommend the applicants to be offered interviews. Candidates selected and interviewed by the Site Selection Subcommittees will be discussed at the central AFC Committee meeting.

http://www.lmp.utoronto.ca/postgraduate/fellowship-training-programs

ADULT CARDIAC ELECTROPHYSIOLOGY 4 2012 This will allow the AFC Committee oversight to ensure the site-specific applicants meet eligibility requirements and to coordinate the number of applicants who are offered admission. A standard set of CanMEDS-based questions is used for each interview. A standard scoring key is used which results in a score for each candidate from each interviewer, independently. Following the interview process, all interviewers meet to create a final ranking. The process for creating the ranking requires each interviewer to independently create a total score for each candidate, the totals for all candidates and all interviewers are summed up to create the preliminary ranking. Consensus is then achieved by discussing the interviews to ensure the final ranking reflects the experience of the interviewers. Screening and selection criteria have been outlined and include:

1. Prospective AFC candidates must be Royal College certified or eligible for Royal College examinations in cardiology or its equivalent. Internationally educated applicants will require documentation of equivalency.

2. Applicants will apply to a specific site for entrance into the program. Applications will include a CV, personal statement for intent of training and 3 reference letters.

3. Sites will select the candidates they wish to advance to the AFC Committee for interview. 4. Applicants will be offered a standardized interview, either in person, telephone or using Skype.

b) What is the anticipated number of AFC trainees that are expected to be admitted to the program on a

yearly basis?

At the UHN – 2-3/yr SMH – 1-2/yr SHSC – 1/yr

4. AFC Trainee Assessment (Standard C1.3.4)

a) Describe the role of the AFC program committee in the review of trainee assessment and decisions about completion of training.

The Site Director completes a detailed review of each trainee’s file and presents a summary report of trainee progress at the quarterly AFC Committee meetings and at completion of training. The file review includes ITERS, Competency Portfolio, feedback from physicians involved in mentoring fellows, Multisource Feedback, evaluation of presentations, and any other evaluation data collected regarding the performance of the AFC trainee. Following one year of experience in the program, the AFC Committee will review the documented evaluation data of the trainees to determine if the required competencies have been attained to allow recommendation for completion of the two-year program. The promotion decision is based on performance in all components of the Training Program’s evaluation system. Review will be based upon:

1) Evaluation by AFC Site Directors 2) Competency Portfolio

The Site Director provides each trainee with a formal review in a face-to-face meeting and in writing every six months to address their overall progress. Trainees are welcome to discuss their progress on an individual basis with the Site Director at any time between the formal reviews. Please also see Appendix B: Terms of Reference for a description of AFC Program Committee’s role in Trainee Evaluation.

ADULT CARDIAC ELECTROPHYSIOLOGY 5 2012 b) Describe briefly the appeals process for decisions regarding trainee assessments including how

trainees are informed of the process.

The AFC appeals process will follow the principles and recommended process of the University of Toronto Governing Council Policy on Academic Appeals. The PGME appeals process is described on the PGME website and the annual Postgraduate Medical Education Information Booklet. Trainees are informed of the appeals process directly when presented with a performance concern or failure to be promoted to the next level. Trainees may appeal the decision on evaluation to an Appeals Committee which will include Eric Yu, Director, Postgraduate Training Program in Adult Cardiology, University of Toronto, in addition to two other staff electrophysiologists from another teaching institute. Trainees opting to launch an appeal will do so in writing. Their notice will describe the nature and grounds of their appeal and will provide the Appeals Committee with any relevant documents in support of their appeal. Trainees have the right to a hearing before the committee to present their evidence and arguments. The process will ensure confidentiality of the disclosed information. If a trainee’s performance exhibits significant deficiencies and there are concerns regarding progress towards achieving the fellowship goals and objectives through the standard AFC program, the AFC committee will propose a remediation plan in accordance with the University of Toronto PGME Guidelines for Educational Responsibility in a Clinical Fellowship.

5. Ongoing Review of the AFC Program

a) Describe the process that will be used to review the educational environment of the AFC program.

(Standard C1.3.6)

AFC Program Committee will formally review the educational environment and all of its components annually. Review will include evaluation across three sites:

1. formal rounds 2. opportunities for case load and case mix 3. opportunities for procedural experience 4. feedback from trainees 5. fellow participation in National and International forums 6. faculty participation in Canadian Heart Rhythm Society Educational Committee

The Site Director will carefully examine the case mix and logbook of each trainee every four months to ensure adequate opportunity to gain competency in each of the Competency Training Requirements (CTR) domains.

b) Describe the process including the role of trainees that will be used to assess and provide feedback to

the teachers participating in the AFC program. (Standard C1.3.7)

The Faculty’s on-line system for registration and evaluation is known as “Postgraduate Web Evaluation and Registration System (POWER)”. Trainees have the ability to evaluate all teachers using the University of Toronto POWER Web evaluation system. Trainees have the choice over how many and which teachers they will evaluate on a given rotation. The evaluations are stored on the central POWER site. Teachers have access to summary aggregate reports for prior years once a minimum of three evaluations are complete. Departmental education leads and rotation coordinators have a higher level of access that allows review of individual evaluations for individual teachers in real time. An ‘alert’ system is built into POWER so that identified individuals are alerted whenever a teacher or


rotation receives a score below a minimum threshold. These are investigated in real time to ensure no threat to resident well-being and educational integrity are present and appropriate action is taken. The PGME office provides a ‘report card’ each year to the program detailing the completion rates for teacher evaluation forms and comparators including year-over-year change and PGME benchmarks. Finally, an annual report is produced by the PGME office that outlines average teaching and rotations scores for each rotation across all hospitals, again comparing sites and year over year change.

Written feedback will be obtained from trainees at completion of the fellowship. 6. Environment of Inquiry and Scholarship (Standard C1.4) a) Attach as Appendix C, the research support in the form of operating grants of faculty members in the

Area of Focused Competence during the PAST TWELVE MONTHS. Include the annual dollar amounts and the source of research funds.

ATTACHED AS APPENDIX C b) Attach as Appendix D, the peer-reviewed publications of faculty members in the Area of Focused

Competence during the PAST TWELVE MONTHS. ATTACHED AS APPENDIX D c) Describe the role of AFC trainees in scholarly activities. Scholarly activity is an area of emphasis in the AFC program. Electrophysiology (EP) Rounds: Each AFC trainee will attend and participate in hospital based EP rounds. Each fellow will present to EP staff and allied health at least 4 times per academic year. EP rounds are 1-hour sessions during accredited rounds, during which fellows receive presentation feedback using the department of medicine standardized presentation review tool. There are three rounds per week at UHN and SHSC and one round per week at SMH. Case-based Electrogram Procedure Review: Each fellow is responsible for leading 8 to 12 case based discussions per academic year for electrogram review of procedures done in the EP lab and patients seen in the device clinic. These discussions are led by a fellow and mentored by 2 to 3 attending faculty. Sessions are 1 to 1.5 hours in length and occur on a weekly basis. Scholarly Project: Each trainee will complete a scholarly project with the objective to learn how to create, disseminate, apply, and translate medical knowledge. The fellows are responsible for coming up with a research project with the help of an attending physician, who acts as a mentor. Generally, the project will be focused on mechanisms of atrial fibrillation and ventricular arrhythmia, novel predictors of sudden cardiac death, novel techniques in catheter ablation or in another area of interest as verified with the AFC committee. Off-service time will be protected for the academic project on a longitudinal basis over the two-year program. Trainees will receive support at all sites from attending faculty that has expertise in research design and methodology, established records in publication of cardiac electrophysiology research with access to multiple ongoing research projects, and opportunities to develop new research ideas. Day to day emphasis of CanMEDS Scholar role: As scholars demonstrate a lifelong commitment to reflective learning as well as creation, dissemination, application, and translation of medical knowledge, scholarship will be emphasized in day-to-day clinical practice. Trainees will be engaged in making evidence informed clinical decisions and applying reflective learning. Trainees will be expected to identify relevant evidence, evaluate it using specific criteria and apply it in their practice. Trainees will continually evaluate the process and outcomes of their daily work sharing, comparing their work with that of their faculty and other trainees, and actively seeking feedback in the interest of quality and safety. Second year fellows will have opportunities to share their advanced knowledge and expertise

ADULT CARDIAC ELECTROPHYSIOLOGY 7 2012 with first year fellows.


STANDARD C2: RESOURCES

“There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all trainees in the AFC program to achieve the educational objectives and receive full training as defined by the AFC requirements.”

1. Teaching Faculty (Standard C2.1)

List the members of the teaching faculty who have a major role in this AFC program, including members from other departments. UNIVERSITY HEALTH NETWORK

Name Specialty and AFC-specific Qualifications

Role in the Program

E DOWNAR FRCPC, Electrophysiology Fellowship Faculty

D CAMERON FRCPC, Electrophysiology Fellowship Faculty

L HARRIS FRCPC, Electrophysiology Fellowship Faculty

D ING FRCPC, Electrophysiology Fellowship Faculty

V CHAUHAN FRCPC, Electrophysiology Fellowship Faculty

K NANTHAKUMAR FRCPC, Electrophysiology Fellowship Director, Electrophysiology

K NAIR MBBS, MD, DM, MNAMS, Electrophysiology Fellowship, IBHRE Certified Cardiac Device Specialist, IBHRE Certified Cardiac Electrophysiology Physician

AFC Director

A HA FRCPC, Electrophysiology Fellowship Faculty

D SPEARS FRCPC, Electrophysiology Fellowship Faculty

M Gollob FRCPC, Electrophysiology Fellowship Faculty

ST. MICHAEL'S HOSPITAL


Role in the Program

P DORIAN MD FRCPC, Electrophysiology Fellowship

Divisional Director Cardiology U Of Toronto

I MANGAT MD FRCPC, Electrophysiology Fellowship

Site Director-SMH

K AHMAD MD FRCPC, Electrophysiology Fellowship

Faculty

V KORLEY MD FRCPC, Electrophysiology Fellowship

Faculty

A PINTER MD, Electrophysiology Fellowship Faculty



Role in the Program

P ANGARAN MD FRCPC, Electrophysiology Fellowship

Faculty

SUNNYBROOK HEALTH SCIENCE CENTRE


Role in the Program

E CRYSTAL MD, Electrophysiology Fellowship Faculty I LASHEVSKY MD, Electrophysiology Fellowship Site Director-SHSC S SINGH MD, FRCPC, Electrophysiology

Fellowship Faculty

2. What is the anticipated number of AFC trainees that are expected to be admitted to the program on a yearly basis?

At the UHN – 2-3/yr, SMH – 1-2/yr, SHSC – 1/yr

Is there an accredited residency program in adult Cardiology? YES x NO UHN 1/2014-

12/2014 AND 1/2015 -12/2015

St. Michaels Hospital 1/2015-12/2015

SHSC 01/2015-12/2015

Totals

Number of EP laboratories:

1 EP lab 2 Implant Rooms

1 EP Lab 1 Implant Room

1 EP Lab 1 Implant Room

3 EP labs 4 Implant Rooms

Number of EP studies per year: 652 310 373 Number of Ablations per year 511 281 165 Number of SVT ablations per year:

262 169 150

Number of AF ablations per year: 120 75 53 Number of VT ablations per year: 86 6-10 30 Number of advanced mapping systems per year:

249 112 289

Number of pacemaker implantations per year:

2014-451 2015-527

New: 153 Change: 72

384

Number of ICD implantations per year:

2014-351 2015-358

New:148 Change: 84

148

Number of CRT implantations per year:

2014-122(15-CRT-P,107 CRT-D) 2015-138(13-CRT-P,125 CRT-D)

52 90

Number of lead extractions per year:

2014-70 2015-56

0 1

ADULT CARDIAC ELECTROPHYSIOLOGY 10 2012 UHN 1/2014-

12/2014 AND 1/2015 -12/2015

St. Michaels Hospital 1/2015-12/2015

SHSC 01/2015-12/2015

Totals

Number of Implantable Loop Recorders per year:

2014-15 2015-25

30 23

Number of Outpatient Arrhythmia Consultations per year:

> 250 >250 >250

Number of Inpatient Arrhythmia consultations per year:

>250 >250 > 250

Number of potentially Inherited Arrhythmia Syndrome consultations per year:

>100 50-100 70

Number of Syncope consultations per year:

>200 > 200 > 200

Number of emergency consultations per year:

>100 > 100 > 100

Who is the primary person responsible for radiation safety?

1. Dr. Lawrence White, MD is the Radiation Protection Officer (RPO) for the University Health Network.

2. Dr. Lyne Noel de Tilly, MD is the Radiation Protection Officer (RPO) at St. Michael’s Hospital 3. Dr. Vevien Braga, MD is the Radiation Protection Officer (RPO) the Sunnybrook Health Science

Centre. 3. Summary of Adequacy of Resources

Comment on the adequacy of the resources in the overall AFC program. In particular, comment as to whether the facilities are sufficient to provide adequate teaching and experience for trainees in this program. The AFC program has sufficient resources to meet the training objectives for trainees over their two year training period: Teaching Faculty: The program is supported by nineteen faculty members who have completed additional training in cardiac electrophysiology. All faculty members are highly active clinically, academically productive, and offer the required expertise to provide training, supervision, and assessment of all competencies at each site. Number and Variety of Patients: The program has adequate numbers of patients and procedures to provide the full breadth of patient management experience. While procedural volumes exceeded the suggested Royal College requirements for accreditation in most areas there are three procedures that need to be managed: Number of EP studies / year and Number of SVT and AF ablations / year. All sites are teaching hospitals that will facilitate broad learning experiences relating to aspects of age, ethnicity, gender and culture. Facilities: Across the three sites the electrophysiology facilities include 3 EP labs, 4 procedure rooms for device implantation and 2 operating rooms equipped to perform simple and complex ablations; pacemaker, defibrillator and resynchronization device implants and space for inpatient, outpatient and ER consultation.

ADULT CARDIAC ELECTROPHYSIOLOGY 11 2012 Pacemaker/ICD clinic operates at all three sites and follows several thousand pacemaker and ICD patients

• Outpatient Arrhythmia Clinic daily • Inherited Arrhythmia Clinic weekly • Inpatient arrhythmia consultation service sees 10-15 patients/day

EP labs are equipped with

• Fluoroscopic facilities at all three sites are pulsed fluoroscopy and low radiation. • Zero gravity system available to reduce operator fatigue and improve radiation protection. • One EP lab has state of the art Magnetic Navigation system (Stereotaxis). • EP labs at all three sites have 3D electroanatomic mapping capability (CARTO and NAV-X)


STANDARD C3: EDUCATIONAL PROGRAM

“There must be a defined educational program that includes clinical, academic and scholarly content relative to the AFC discipline. The program must be designed to ensure that each AFC trainee is able to achieve all the competencies as outlined in the AFC-specific Training Requirements.”

1. Goals & Objectives (Standard C3.1; C3.2)

Attach as Appendix E, a copy of the objectives for the educational experiences of this program. The document should indicate how each objective will be achieved.

a) How will the trainees and faculty be provided with the objectives: The central AFC Committee has developed the objectives for the clinical educational experiences that are delivered at each site. At the onset of the program AFC trainees will be provided with the Royal College of Physicians and Surgeon’s Competency Portfolio for Trainees and the AFC program Goals and Objectives for all clinical experiences. Clinical experiences include 1.Electrophysiology Laboratory, 2. Device Implantation Laboratory and Device Clinic 3. CRT implantation 4. Consultation Inpatient Wards and Clinic and 5. Scholarly Activity / Research. Rotation-specific objectives will be circulated yearly. Annually, faculty will receive a package identical to the trainee and the Competency Portfolio for Educators. At their site orientation, trainees will receive the program policy on trainee safety related to travel, patient encounters and educational activities. In addition to our program safety policy, trainees are oriented to the document “University of Toronto, Faculty of Medicine, Postgraduate Medical Education Postgraduate Trainee Health and Safety Guidelines, January 2013”. The Guidelines are available on the PGME website. These Guidelines apply to all Trainees. Radiation safety is taught as a topic in the curriculum.

The University, hospitals and affiliated teaching sites are accountable for the environmental, occupational, and personal health and safety of their employees; in addition, all teaching sites must meet the requirements of the PARO-CAHO collective agreement. Trainees must adhere to the relevant health and safety policies.

b) How often will these objectives be reviewed by the AFC Program Committee: The AFC Program Committee will review the objectives of the education program annually. Input from supervisors, teachers and trainees will be included. The AFC Committee will make decisions about change to ensure consistency of the educational experience across three sites, facilitate competency outcomes desired by the program, and add objectives as new techniques and new diagnostic and management techniques evolve.

c) Describe the process for reviewing objectives. Data is gathered annually through POWER, for formal curriculum and facilities, through the clinical experience and teacher evaluations. Also the program may host ‘town hall’ discussions to review objectives and build consensus, adding and incorporating new developments, and deleting obsolete objectives.

ADULT CARDIAC ELECTROPHYSIOLOGY 13 2012 2. Educational Experiences (Standard C3.3)

a) Describe the mandatory educational experiences required in this program, including the duration and

location of the experiences.

The training program is a 2 year period during which there will be ample opportunity to engage in all of the mandatory educational experiences. The mandatory educational experiences will not be seen as individual “rotations”, but rather as clinical experiences that in their total will provide adequate opportunity to achieve all educational objectives. The fellows will rotate weekly through different facets of the electrophysiology environment, and will also have longitudinal research time. Trainees will maintain a Competency Portfolio, verified regularly by the Site Coordinator. For instance, interaction with a patient referred to undergo to an ablation procedure may include all of consultation, interpretation of complex ECG, performance of an EP study, performance of the procedure itself, and presentation at rounds. Fellows will not necessarily spend equal time in each of the clinical locations as defined below. Decisions related to the duration of the clinical experience will be competency based. The weekly rotation schedule is flexible and over the two year fellowship can be managed to ensure all AFC fellows achieve the required competencies and procedural volumes. The following educational experiences will be considered mandatory for the trainee and should be adequate to attain all of the relevant competencies: 1. Experiences in the Electrophysiology (EP) Laboratory performing diagnostic EP studies, ablation procedures for SVT, atrial flutter and atrial fibrillation, ablation procedures for VT, transseptal and retrograde aortic access to LA and LV chambers, and electroanatomic mapping procedures. 2. Experiences in the Device Implantation Laboratory performing implantation of single and dual chamber pacemakers, implantation and testing of ICD devices, implantation and testing of CRT devices, pulse generator changes, pocket revisions, and lead extractions that do not require specialized extraction sheaths. 3. Experiences in the Outpatient Clinic involving consultation and follow-up of patients with SVT, atrial fibrillation, atrial flutter, ventricular arrhythmias, syncope, and inherited arrhythmia syndromes. 4. Experiences in the Device Clinic involving interrogation, interpretation and programming of implantable loop recorders, pacemakers, ICD’s and CRT devices. 5. Consultation and management of arrhythmias in patients resuscitated from cardiac arrest and arrhythmias in the postoperative setting. 6. Experience in ECG interpretation of complex arrhythmias. 7. Experience teaching more junior house staff issues related to arrhythmia interpretation and management. 8. Experiences at rounds and journal club involving scholarly interpretation of arrhythmia-related literature. 9. Experience in postulating and refining a research question and in data analysis of a research project.


b) Describe the elective opportunities available in this program.

Electives are not a component of the Program. The longitudinal Scholarly project presents an opportunity for the trainee to collaborate with affiliated faculty from another program site. Further elective experience may be supported upon request in such areas as: 1. lead extraction using laser assisted extraction techniques, 2. interpretation of genetic testing results in the genetics laboratory, 3. visitation to other EP labs to become familiar technologies used in other laboratories, and 4. access to research at all 3 sites.

3. Affiliations Will the AFC program require any mandatory affiliations? YES NO If yes, attach as Appendix F, a copy of the signed agreement. 4. Increasing Professional Responsibility and Supervision of AFC Trainees (Standard C3.5)

Describe how the program will ensure that all trainees are provided with appropriate supervision and increasing professional responsibility. Trainees are competent cardiologists when they enter the program. Initially all clinical activities of the trainees are under direct supervision of an attending staff/faculty member. Trainees never work in the facility without a faculty member present in the department. Within each new clinical experience trainees are initially asked to observe the practice of experienced clinicians then are assigned patients of their own to manage under supervision. Trainees will be scheduled to perform more complex procedures in the second year of training. As the trainee progresses through the program, the trainee’s performance is monitored by the supervising staff in all clinical areas. When, in the opinion of the supervising staff, the fellow has reached an acceptable level of competence, the trainee will be granted increasing responsibilities as detailed below. Second year trainees supervise first years whenever they overlap.

Diagnostic Review (Electrophysiology Lab, ECG) Initially, all cases undergo second review by the supervising staff. With demonstrated competence, trainees are given independence for investigation of the cases with ancillary testing, progressing to independent reporting of cases. The option of consultation with the supervising staff is available to the trainee, at their discretion, once independent reporting is achieved. Consultations: An observation role is first employed, followed by introduction of consultation under direct supervision by staff Cardiac Electrophysiologists. As competency is acquired, the trainee is given responsibility of conducting the on-site consultation under indirect supervision. Eventually the trainee achieves complete independence as competence is mastered, with the supervisor in attendance at the discretion of the trainee. Device Implantation Laboratory Technical skills will be monitored by supervising staff and concerns and progress reported to the program committee. Mentorship will be ongoing in all aspects of training by the supervising physician and by the Program Director and Program Committee. Although all procedural and consultative activities will be supervised it is expected that the trainee will be able to perform these functions with increasing responsibility over time. In addition, trainees will be scheduled to perform more complex procedures in the second year of training. For instance, once adequate technical proficiency has been obtained in performing SVT ablations and left atrial and ventricular access, the trainee will be scheduled to perform more complex ablations such as atrial fibrillation (left atrial) and ischemic VT (left ventricular) ablations.

ADULT CARDIAC ELECTROPHYSIOLOGY 15 2012 Ambulatory Clinics (Arrhythmia and Device) Initially the trainee begins in an observation role. The trainee is then given increasing responsibility of conducting the patient clinical history taking and examination, and assisting the attending electrophysiologists with follow-up. Once mastery is demonstrated, the trainee is given responsibility for the entire patient encounter. First year trainees review their cases briefly with the preceptor before the patient leaves the clinic. As the trainees skills develop these reviews may occur at the end of the clinic for most patients, and only while the patient is present for more challenging cases. All chart notes are reviewed by faculty for the first several months. A chart review teaching session is carried out at intervals, with discussion focused on an in-depth review of a clinical topic, patient–centred care, evidence-based care, ethics, and medical-legal issues. Ultimately the trainee achieves complete independence, with the supervisors available as needed.

5. Academic Program (Standard C3.4) Attach, as Appendix G, the planned curriculum for the program. Indicate the teaching format for each element of the curriculum. a) Describe how the curriculum is established. The central AFC Program Committee has developed and will oversee a centralized curriculum that would then be delivered at all sites. The AFC Committee establishes and reviews the overall program curriculum, based on the competency training requirements outlined in the Royal College of Physicians and Surgeons of Canada Adult Cardiac Electrophysiology 2013 documents and faculty member expertise. Published curricula such as the “International Board of Heart Rhythm Examiners Certification Examination for Competency in Adult Cardiac Electrophysiology for the Physician Exam Content Outline, 2010" and other scholarly publications will be referenced. The curriculum will be designed to support trainees to function as a competent specialist diplomate in Adult Cardiac Electrophysiology, capable of an enhanced practice in this area of focused competence, within the scope of Cardiology. The curriculum undergoes continuous monitoring and refinement based upon feedback obtained from both faculty and trainees. Please see Appendix E: Objectives for the educational experiences and Appendix G: Curriculum of the program. In addition to separate academic rounds that are organized at the three sites, web rounds are organized on a monthly basis where fellows from all three sites attend. In addition, joint academic rounds are organized once in 3 months at each site in turn. Fellows and staff present at these rounds.

b) How will trainees be ensured of protected time to attend academic sessions? (Standard C3.4) Academic sessions will be scheduled at the beginning and at the end of the workday. Trainees will be ensured protected time to attend these sessions.

6. CanMEDS Specific Teaching Describe the teaching methods for the relevant CanMEDS competencies as described in the AFC Competency Training Requirements for Adult Cardiac Electrophysiology.

CANMEDS COMPETENCIES

TEACHING METHODS

Medical Expert

• Didactic lectures • Interactive teaching rounds • Bedside teaching • Feedback during consultations • Hands-on teaching in the Electrophysiology Lab for laboratory procedures • Review of complications


CANMEDS COMPETENCIES

TEACHING METHODS

Communicator • Supervised interactions with patients before and after invasive procedures, including consent taking

• Formative and summative feedback is given regularly by staff to trainees regarding their consultation/discharge letters to referring physicians, Electrophysiology Study Reports and Implant procedure reports.

Collaborator • Trainees participate in the performance of electrophysiology study with attending staff, who teach trainees to understand and support the roles of allied health professionals (nurse, EP technologist) in the EP lab and device clinics

• Trainees work closely with health care professionals whose patients require specialized arrhythmia care (including, but not limited to heart failure specialists, cardiac surgeons, geneticists, and genetic counselors)

Leader • Trainees perform systematic reviews of morbidity and mortality as related to arrhythmia patients.

• Trainees implement processes to ensure personal practice improvement. • Staff teach trainees to use cost-efficient practices in EP lab procedures • Taught to function as a Junior attending in the inpatient and outpatient

management of patients with arrhythmias Health Advocate • Trainees are instructed to identify the determinants of health of the

populations they serve, including barriers to access to care and resources, particularly those specialized resources required in cardiac electrophysiology.

• At the individual trainee level, trainees are taught how to prioritize professional duties when faced with multiple patients and problems, and ensure the diagnostic tests performed are the most appropriate considering the benefit and risk.

• Taught through supervised hands on interaction with patients on the wards trainees: identify the health needs of an individual arrhythmia patient, identify issues related to end of life care, and identify vulnerable or marginalized populations within those served and respond appropriately.

Scholar • Use Competency Portfolio to assist with self-monitoring of career development and competency gaps

• Taught to recognize knowledge gaps regarding patient problems by faculty and are coached to develop strategies to fill gaps in knowledge through reading and consulting other members of the healthcare team.

• Complete a scholarly project with the guidance of a mentor • Teach Junior Trainees contributing knowledge learned to patient care. • Faculty model continued learning about new and evolving technologies in

the field of cardiac electrophysiology and understand how to adapt these innovations to current clinical care.

Professional • Taught to set priorities and manage time to balance activities through discussion with Site Director every six months

• Taught to identify and appropriately respond to specialty-specific biomedical ethics arising in patient care through participating in discussions at M&M and ethics rounds and discussion around specific cases

ADULT CARDIAC ELECTROPHYSIOLOGY 17 2012 7. Scholarly Activity a) Is research or scholarly activity mandatory? YES X NO What time will be provided to allow trainees to participate? Each trainee will complete a scholarly project with the objective to learn how to create, disseminate, apply and translate medical knowledge. The fellows are responsible for coming up with a research project with the help of an attending physician who acts as a mentor. Generally the project will be focused on mechanisms of atrial fibrillation and ventricular arrhythmia, novel predictors of sudden cardiac death, novel techniques in catheter ablation or in another area of interest as verified with the AFC committee. Off-service time will be protected for the academic project on a longitudinal basis over the two year program. Trainees will receive support at all sites from attending faculty that has expertise in research design and methodology, established records in publication of cardiac electrophysiology research with access to multiple ongoing research projects, and opportunities to develop new research ideas. Research days are scheduled in the monthly schedule. In general each trainee has approximately half a day per week scheduled as research. At times of higher intensity work more may be scheduled as needed. The mentor and the trainee will meet on a regular basis (at least monthly) in order to monitor progress. Where a need for additional blocks of research time is identified the schedule will be adjusted as needed.

b) What support will be available to trainees?

Supervision Funding Material support including infrastructure Other, please describe: Mentorship with an established investigator.


STANDARD C4: COMPETENCY BASED ASSESSMENT OF TRAINEE PERFORMANCE

"There must be mechanisms in place to ensure the systematic collection and interpretation of assessment data on each trainee enrolled in the AFC program."

1. Trainee Assessment

a) Describe the assessment processes (written, oral and other) that will be used in this program to

assure satisfactory mastery of core knowledge. Include a description of who will perform the assessment and how it will be related to the goals and objectives of the AFC program. (Standard C4.1)

The assessment process will be conducted by the Site Director, electrophysiology staff, AFC Director and the AFC Program Committee. Repeated formative and summative feedback will be provided throughout the program to the fellows, by all electrophysiology staff, to enhance their understanding of fundamental concepts in electrophysiology. All consultations done by the fellows will be critiqued and discussed and their mastery of core knowledge will be assessed. There will be regular documented review of progress, performance and deficiencies with the AFC Director and AFC Program Committee. Regular review will include documented face-to-face meetings with the trainee and AFC Director. This will include a review of the Competency Portfolio and logbook, with entries signed off by faculty, with comments and feedback regarding strengths/weaknesses and areas requiring improvement. ITERs have been developed using the goals and objectives of the program. An assessment form has been created rounds presentations. An assessment form has been created for consultations, EP lab and implant rooms and device clinic encounters. In addition, a form for 360 degree evaluation has been included. Medical Expert In-Training Evaluation Report (ITER), Direct observation of procedures for technical competency (Validated logbook/portfolio) Direct observation in clinical settings for consultation role Written examinations (biannual) Oral examination: will be documented Written reflections on complications encountered OR power-point presentation on M&M rounds. Communicator ITERs Direct observation of clinic and lab based activities (Validated logbook/portfolio) Faculty review of consultation letters, electrophysiology reports, implant procedure reports and other clinical documentation Multi-source feedback from health care professionals Collaborator ITERs Direct observation of clinic and lab based activities (Validated logbook/portfolio) Multi-source feedback Leader/Manager ITER documenting active participation in use of lab equipment, including programmed stimulation. Direct observation of clinic and lab based activities Multi-source feedback Health Advocate ITERs Direct observation of clinic and lab based activities Multi-source feedback


Scholar ITERs Scholarly activity such as submission of an abstract or manuscript OR research proposal or grant application OR progress report of a research project. Assessment of teaching of junior house staff and allied health in informal and formal settings. Assessment of presentation of one critically appraised article on arrhythmia to Journal Club Assessment of scholarly presentations using standardized tool Professional ITERs Multi-source feedback Direct observation of clinic and lab based activities Documented attendance and participation at dedicated rounds

b) How will the program ensure that feedback is regularly provided to the trainees? Indicate how often

the AFC director will meet with each trainee. (Standard C4.1.1)

Each trainee will meet formally with the Site Director every 6 months to assess feedback. Trainees will receive feedback daily following EP lab cases, out-patient and in-patient consultations and device implantations and sessions in device follow-up clinic.

c) How and by whom will the “Competency Portfolio for the Diploma” be completed for onward

submission to the Royal College? (Standard C4.2)

The components of the Competency Portfolio will be completed by the fellow and will be signed off by the attending EP staff. The entire portfolio will be reviewed every six months by the Site Director with input from the Program Committee. When the trainee has completed the portfolio, the AFC Director and the Postgraduate Dean will attest that the trainee has satisfactorily completed all the required competencies outlined in the discipline-specific Competency Training Requirements (CTR) through signing the form titled Confirmation of Competencies Acquired (CCA). The form will accompany the portfolio and supporting documentation at the time of submission to the Credentials Unit at the Royal College of Physicians and Surgeons of Canada.

SUMMARY

1. Summarize the strengths of the proposed AFC program.

The University of Toronto has the resources, faculty and patients to offer a comprehensive AFC program in cardiac electrophysiology.

1. All three sites are fully equipped with interventional and non-interventional laboratories.(C2) 2. The program’s faculty have a diversity of experience as scientists, investigators and teachers and

a high level of accomplishment in the clinical and research domains to help trainees achieve their clinical and research goals and reach their career aspirations.(C2)

3. The patients cover the entire spectrum of electrophysiology (C2)

2. Summarize any difficulties you anticipate in the initial period of offering the program.

Developing the AFC committee, cross-site relationships and processes (C1) While the University of Toronto has well established training programs for cardiac electrophysiologists, with all required resources in place, historically the training has been offered

application for accreditation of an area of focused

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