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99 Winter 2011 Cardiology Fellowship Education

Special Report Am Heart Hosp J. 2011;9(2):99106
I
n 2000, Drs Hill and Kerber, then of the University of
Iowa Fellowship Training Program, published a
manuscript exploring the state of specialty training in
cardiology both nationally and at their institution.
1
They
described a comprehensive self-evaluation of their program
and their approach to managing the many challenges faced
by academic medical centers and cardiology faculties when
training fellows. In an environment of diminishing economic
resources, more demands on faculty time, and an exponential
increase in medicines complexity, they identified eight key
areas of focus and outlined their strategy for each:
clarify the mission of the training program;
inspire fellows to consider academics;
revitalize interactions between faculty and fellows;
maximize effectiveness of didactic teaching;
optimize on-the-job training of fellows;
provide adequate orientation of incoming fellows;
take advantage of the Internet as a learning tool; and
maintain a critical mass of fellows in an era of
decreasing trainee positions.
While the pressures on academic medicine remain
relatively consistent 10 years later, the overall healthcare
landscape has undergone additional major changes
since 2000.
Within the cardiovascular medicine fellowship at The Ohio
State University Medical Center, we now find ourselves in a
similar position to that of Drs Hill and Kerber 10 years ago.
In reflecting on the state of our educational programs in
2010, we noted that it would be necessary to reiterate the
context in which cardiovascular medicine training now
exists. Plus, while still works-in-progress, our strategies
for navigating these challenges might prove instructional for
other institutions. Our review centered on four major topic
areas: revisions in cardiology training requirements issued by
the American College of Cardiology (ACC); the Accreditation
Council for Graduate Medical Education (ACGME) Outcome
Project; trainee duty hour restrictions; and the era of
performance measures and quality metrics.
Changes in Cardiology-specific
Training Requirements
The first ACC Guidelines for Training in Adult
Cardiovascular Medicine (COCATS) were published in
1995 with task forces and requirements in 10 specific areas
of cardiology.
2
Since that initial document, general
Cardiology Fellowship Education in the Era of
High-density Training, Data Tracking, and
Quality Measures
Alex J Auseon, DO
1
and Albert J Kolibash, Jr, MD
2
Background: Educating trainees during cardiology fellowship is a process in constant evolution, with program directors regularly adapting
to increasing demands and regulations as they strive to prepare graduates for practice in todays healthcare environment. Methods and
Results: In a 10-year follow-up to a previous manuscript regarding fellowship education, we reviewed the literature regarding the most
topical issues facing training programs in 2010, describing our approach at The Ohio State University. Conclusion: In the midst of
challenges posed by the increasing complexity of training requirements and documentation, work hour restrictions, and the new definitions
of quality and safety, we propose methods of curricula revision and collaboration that may serve as an example to other medical centers.
1. Associate Professor of Clinical Medicine and Director, Cardiovascular Medicine Training Program; 2. Associate Professor of Clinical Medicine and Associate
Director, Cardiovascular Medicine Training Program, Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State Medical Center
Disclosure: The authors have no conflicts of interest to declare.
Correspondence: Alex J Auseon, DO, 473 West 12th Avenue, Suite 200, Columbus, OH 43210. E: alex.auseon@osumc.edu
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100 Cardiology Fellowship Education Winter 2011
training in cardiology has become increasingly dense and
complex. Following Drs Hill and Kerbers initial review in
2000, there have been two revisions required to update
competency requirements for procedures and rotational
exposure. The 2002 COCATS 2 statement included the
formation of two new task forces, in vascular medicine and
peripheral catheter-based intervention, in addition to
cardiovascular magnetic resonance (CMR). With the
anticipated publication of the Multicenter automatic
defibrillator implantation trial II (MADIT II) that same
year,
3
a new emphasis was placed on management of
implantable cardioverter-defibrillators (ICD), as the
post-myocardial infarction indication was likely to
substantially increase the number of implanted devices.
Recommendations were also made to spend at least one of
a fellows nine required inpatient ward rotations on a
dedicated heart failure/transplant service. Vascular
medicine emerged as a new two-month core requirement,
while the length of required clinical training remained
fixed at 24 months.
A focused update was released in 2006 with an emphasis
on advanced cardiovascular imaging and electrophysiology
(EP).
4
The first task force addressing cardiovascular
computed tomography (CCT) was included, reflecting the
emergence of this technology as a valuable tool for
diagnosing obstructive coronary artery disease. Two years
later, the most recent COCATS 3 document was released,
with a new total of 13 task forces and the first mention
of a new termmultimodality imagingacknowledging
the rapid growth in modalities beyond the original
tools of electrocardiography, angiography, nuclear
cardiology, and echocardiography.
5
This concepts
importance was solidified by the subsequent publication of
the ACC Foundation Training Statement on Multimodality
Noninvasive Cardiovascular Imaging in 2008.
6
Major
revisions in the traditional siloed single-modality imaging
(nuclear cardiology, echocardiography, CMR, and CCT)
curricula familiar to most fellows-in-training were
suggested, with an emphasis on patient-centered
integration and flexibility in the number of procedures and
months required. Programs were encouraged to combine
curricula from each modality into three topicsimaging
physics, general imaging aspects, and specific
imaging applications. However, both three-year and
advanced imaging subspecialty fellowship graduates with
multimodality imaging expertise still face a fragmented
system of board certification and an uncertain path to
academic practice.
7
Overall, these changes reflect both the evolution of
technology and the complexity of medicine in general.
As such, they are clearly necessary. However, they present
challenges to many programs with fewer resources or less
infrastructure to adequately train fellows in some of the
less common areas of cardiologyCMR, CCT, peripheral
imaging and interventions, and cardiac transplantation.
Programs are encouraged to collaborate with experts at
their own or other institutions to ensure at least Level 1
exposure. The definition of a general cardiologist has also
become a moving target; with increasing requirements for
minimum comprehensive training expanding to fill more
of the 36 months of fellowship, there is less time
for elective rotations. Careful consideration has to be given
when structuring training programs to be sure that fellows
achieve adequate clinical competency in basic cardiology
in an environment where technology and mandated
procedural volumes are a constant distraction.
Our Approach to Managing this Challenge
Leveraging Expertise of Faculty and Staff
With these changes in training requirements specific to
peripheral vascular disease, ICD management, heart
transplantation, and multimodality imaging, we have had
to make several adjustments to our fellowship program.
Overall, we have the luxury of having faculty and clinical
volume that we have been able to leverage in each of these
areas. Together with their input, we have made changes
that permeate fellow education at multiple levels.
During their vascular medicine rotations, trainees interact
with fellowship-trained, board-certified practitioners,
while seeing patients and interpreting diagnostic testing
ranging from ultrasound to magnetic resonance imaging.
This is paired with a didactic curriculum that alternates
case-based and topic-orientated vascular medicine topics.
We have also worked to alter our EP rotation from
laboratory-based to a more consult-driven service, realizing
that most of our graduates will not be pursuing additional
EP training. Time in the laboratory is then more focused on
interpretation of intracardiac electrocardiograms (ECGs)
for patients who have been seen the previous day when
rounding on the floor. Trainees that indicate an advanced
interest in EP may spend additional elective time with a
heavy emphasis on laboratory-based diagnosis, therapy,
and device implantation while also learning from
pacemaker clinic staff as they focus on post-implantation
device management. We feel that this approach is more
suited to todays general cardiology practice, in contrast to
the previous paradigm which placed a high priority on the
placement of temporary pacemakers, for example.
8
The expansion of implantable devices in heart failure also
provides additional opportunities for training
9
and
education of heart failure/transplant fellows, in addition to
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101 Winter 2011 Cardiology Fellowship Education
EP fellows alone. The necessity and practicality of such
training is exemplified by some of our faculty within the
section of heart failure/transplantation who have joint
training in ICD and cardiac resynchronization
therapy-defibrillator (CRT-D) implantation and
management. Although this type of integration has been
beneficial for trainees, it simultaneously presents some
paradoxical challenges for our business model and faculty
coverage, which tend to be organized by subspecialty
silos. In regard to training in multimodality imaging, we
are again fortunate in having all four imaging modalities
managed by our division, thus making faculty with
multimodality expertise available to fellows. In previous
years, morning conferences focused on individual
modalities in isolation. As faculty members with
credentials and board certification in multiple areas of
imaging have joined the faculty, we positioned ourselves
well to make adjustments to our conference curriculum
even before the release of the 2008 ACCF Training
Statement. These adjustments resulted in more
patient-centered, integrated case presentations that allow
discussion of the various strengths and weaknesses of each
imaging method. Faculty responsibilities have also been
revised, centering those with multimodality imaging
backgrounds as primary rotators on the inpatient
cardiology service and in the imaging laboratories,
maximizing their abilities to triage imaging and educate
both faculty and fellows on the most appropriate and
efficient non-invasive testing for a specific clinical question.
We have also gone through a period of intense
self-reflection regarding our programmatic mission and
strengths. Our fellowship program has traditionally
provided strong clinical training with less of an emphasis
on producing independent investigators. This approach
has been influenced by many factors within the medical
center and department dating as far back as the late 1960s.
Since then, the size and subspecialization of our division,
fellowship structure, and number of available faculty
mentors have been continually evolving. The expertise and
varied backgrounds of our fellowship committee have
become more important than ever, as we have struggled to
manage the increasing complexity of training while
making sure fundamental skills of ECG interpretation and
physical examination remain a priority.
Changes in Graduate Medical
Education Requirements
What we measure, we tend to improve.
David C Leach, MD
Former Chief Executive Officer, Accreditation Council for
Graduate Medical Education
The ACGME, which oversees trainees in over 8,300
training programs in the USincluding nearly 3,000
general cardiology and subspecialty positions, altered
the landscape of graduate medical training with the
endorsement of release of the ACGME Outcome Project in
1999.
10
The core principle was to change the emphasis of
training programs to assessing actual educational
accomplishments versus a programs potential to educate.
The project also marked the launch of the now ubiquitous
six general competencies: patient care, medical knowledge,
professionalism, systems-based practice, practice-based
learning and improvement, and interpersonal and
communication skills. Programs were expected to be
compliant with integrating these changes by July, 2002.
Aside from the obvious time required to implement this
required reorganization, there was an additional mandate
for data acquisition and quality improvement. Program
directors were now responsible for obtaining trainee
performance evaluations from multiple sources beyond
faculty alonenurses, technologists, patients, and
themselves (in the form of self-assessments)as well as
structured assessment of clinical knowledge and
procedural competency in the form of in-training
examinations and proctored practical testing, respectively.
Demonstrable efforts to analyze these data and show
action designed to improve educational goals are now part
of each programs expected portfolio when visited by the
designated residency review committee (RRC) for a site
review. The Outcome Project was then followed by new
requirements for trainee duty hours, restricting them to
80 hours per week.
11
This change has had a massive ripple
effect, forever changing the way all inpatient call schedules
have been organized since its introduction. Further
adjustments were made after the Institute of Medicine
(IOM) released a five-year follow-up report,
12
containing
recommendations that were endorsed to a large
degree by the ACGME.
13
These both acknowledged the
burden of implementing the 2002 recommendations,
while also further restricting trainees in terms of
consecutive hours worked.
The majority of these changes in graduate medical
education have weighed most heavily on residency
programs, where inpatient call coverage and team handoffs
have become infinitely more complex. Cardiology
fellowships, most of which use an at-home call system,
have only had to manage the 80-hour work week.
Mandates stemming from the ACGME Outcome Project,
however, have had a large impact on cardiology training.
The controversy was addressed in detail by current and
former fellowship program directors at Tufts Medical
Center and Duke University Medical Center in two
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102 Cardiology Fellowship Education Winter 2011
separate commentary papers published in 2008.
14,15
Touted
positive effects included the projects guidelines which
allow for standardization among programs, multi-source
feedback (MSF), providing a more comprehensive analysis
of fellow performance, and the requirement for academic
productivity from identified key faculty. Negative effects
were dominated by demands placed on the time of
trainees and faculty. With more restricted hours, shift
coverage, and increased handoffs for interns and residents,
fellows and faculty have had to fill in the gaps in patient
care. Perhaps most important was the acknowledgment
that program directors have begun to drown in data,
where time spent acquiring and analyzing information is
time spent away from the actual work of educating
trainees. Revisions to all curricula, organization and
implementation of MSF across the program,
documentation of continuous professional development
for key faculty, and exploring methods of assessing clinical
competency beyond procedure numbers alone have
resulted in an explosion of paperwork and corresponding
time commitment, stressing the capacity of program
directors and coordinators to manage the information.
Our Approach to Managing this Challenge
Targeted, Collaborative, Data-driven
Educational Reform
Aside from the commentary pieces referenced, there are
very few data describing educational methods among
cardiology fellowship training programs. A PubMed search
using the terms cardiology fellowship and education
yields 104 articles, the vast majority of which are either
similar commentary papers or panel consensus statements
on number of months/procedures required for clinical
competence in a specific area of cardiology. None of them
describe an educational intervention studied in rigorous
fashion. The key for our fellowship program when
weathering the educational improvement mandates of the
Outcome Project has been collaboration. Our divisional
faculty and program leadership represent somewhat of a
paradox, probably similar to other academic divisions in
the UShighly skilled clinicians and nationally recognized
content experts with largely minimal training in adult
learning, curriculum development, and educational
research. Simply put, while we are in support of data
tracking and analysis to make targeted, efficient
changes to improve how we teach, we need help from
educational experts.
With the institutional license for the TurningPoint

Audience Response System (Turning Technologies,

Youngstown, OH) purchased by the medical center, our
fellowship program has full access to the hardware and
software for interactive question-and-answer activities
during conferences. We have employed this every
morning during conferences, where the first 10 minutes of
the hour have been designated for board review, with a
single ECG and multiple-choice question (MCQ) posed
by the chief fellows and answered by the core fellows.
Anecdotally, the practice of using TurningPoint has
improved conference attendance and fellow satisfaction
with board review. We also host visiting residents and
fellows during morning conferences and this provides an
anonymous forum for them to participate without concern
for being called upon in an unfamiliar environment.
When re-evaluating our ECG interpretation curriculum, it
became clear that there were several approaches to
managing the challenges posed by fellows having
to acquire two separate sets of skills: patient-centered
interpretation, which often involves subtleties and
ambiguity; and facility with the American Board of
Internal Medicine (ABIM) answer sheet used during the
board certification examination, which comprises very
straightforward coded options but is non-intuitive and
may cloud measurement of content knowledge. As the
board examination for cardiovascular disease is split
between MCQs and ECGs and is non-compensatorya
candidate can achieve a 100 % score on the MCQs and still
fail the overall examination if they fail the ECG
sectionthere is a major emphasis placed on competent
ECG interpretation skill. Because there was a lack of data to
guide our revisions, we partnered with the ACC to survey
fellowship program directors in the US about how they
taught ECG interpretation and used the ABIM answer sheet
in their curriculum. The results showed that most
programs (92 %) used the ABIM answer sheet when
teaching their fellows, but only 42 % performed formal
testing of skills.
16
The information gained from this joint
venture with the College led to our use of a proctored ECG
test using the ABIM answer sheet under timed conditions.
This is given twice annually and has been received
positively by the fellows, who note that the board
simulation conditions give them better insight
into time management during test taking. We hope to
review data on certification examination performance
after the intervention, to see if scores demonstrate
statistical improvement.
A relatively recent innovative effort launched within The
Ohio State University College of Medicine, the Center for
Education and Scholarship (CES), has also served as a
valuable resource for educators within the medical center
(http://medicine.osu.edu/faculty/ces/pages/index.aspx). Its
stated goals are to:
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103 Winter 2011 Cardiology Fellowship Education
provide consultation on all aspects of medical
education;
promote and develop skills that enhance the quality of
health sciences education:
assist in the development of outstanding teachers,
curriculum developers, program leaders, and
educational scholars;
provide guidance to medical educators in turning their
teaching activity into scholarly presentations and
products;
provide guidance for educational recognition and
rewards; and
assist in the identification and/or development of
guidelines to recognize excellence in educational
scholarship and scholarly activity.
On a yearly basis, they select participants in the Faculty
Teaching Scholars Program, an 18-month course designed
to address the professional development needs of faculty
who are committed to a significant career investment in
health sciences education. Graduates have included
clinicians from all medical disciplines as well as PhDs from
within the College of Medicine.
With the help of CES experts, we have nearly completed
an analysis of predictors of fellowship graduate board
certification examination performance when weighing
the contribution of morning conference attendance,
faculty evaluations during clinical rotations, and
in-training ECG interpretation test scores. They have
collaborated to aid in efficiently tracking and labeling data
in accordance with Institutional Review Board
certifications and have helped facilitate conversations
with psychometricians at the ABIM about how
best to proceed with proper statistical analysis. This
process has already identified additional areas for future
investigation to improve our faculty evaluations of fellow
performance to save valuable time while hopefully
providing better information. Benefits from this type of
collaboration extend beyond the relationship and
data-driven educational reform. Co-authors of anticipated
manuscripts are able to demonstrate academic
productivity that engages them in the peer-review process
while satisfying promotion criteria.
The Dawn of the Quality Improvement and
Safety Era
At the very least, quality improvement has little chance of
success in health care organizations without the
understanding, the participation, and in many cases
the leadership of individual doctors.
Donald M Berwick, MD, MPP
Former President and Chief Executive Officer of the
Institute for Healthcare Improvement
The 1999 release of the landmark IOM report To Err is
Human: Building a Safer Health System arguably launched
the current era of quality healthcare and patient safety.
In it, authors estimated that as many as 98,000 people
die in hospitals each year as the result of preventable
medical errors, resulting in total costs between $17 and $29
billion nationwide. These were considered results of faulty
systems, processes, and conditions throughout healthcare
institutions and facilities. Proposed actions included
increasing the national focus on safety, encouraging
voluntary reporting of statistics, raising performance
standards, and creating a culture of safety at the level of
healthcare delivery.
From a cardiovascular standpoint, national organizations
have recognized the need to define standards for quality
and safety, while creating data registries and templates for
medical centers and practices to participate. The ACC has
established several specific quality and safety programs:
Imaging in Focus, the Practice Innovation and Clinical
Excellence (PINNACLE) Network, Hospital to Home, the
Door-to-Balloon Alliance, and the Guidelines in Practice
programs, while the American Heart Association (AHA)
offers their series of Get With the Guidelines toolkits and
the newly established journal Circulation: Cardiovascular
Quality and Outcomes. These two entities have also joined
forces to release statements regarding performance
measures and quality metrics, data elements, and
definitions to track outcomes and performance
measures for common cardiovascular disease states.
17
It is
clear that these efforts are necessary, as the cardiology
community continues to face challenges to providing
safe, evidence-based care. A recent review of the scientific
evidence underlying the 53 guidelines issued by the
ACC/AHA from 1984 to 2008 found that only 19 % of
Class I recommendations are based on evidence from
multiple randomized trials or meta-analyses.
18
The release
of the ACC Foundations Appropriateness Criteria
documents (www.cardiosource.com) has provided a
framework for the utilization of diagnostic (transthoracic,
transesophageal, and stress echocardiography,
radionuclide imaging, CCT, and CMR) and therapeutic
(coronary revascularization) modalities, but patients are
still exposed to large amounts of radiation during
diagnosis
1921
and management.
22
Even with the
many diagnostic tools at our disposal, our clinical
triage needs improvement. Data from the National
Cardiovascular Data Registry (NCDR) reveal the low
diagnostic yield of elective coronary angiography when
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104 Cardiology Fellowship Education Winter 2011
patients are referred for suspicion of angina, with only
39.2 % of referred patients exhibiting significant
obstructive coronary disease.
23
Finally, in the subset
of patients undergoing percutaneous coronary intervention
who are at the highest risk of bleeding complications,
registry data demonstrate that only 14.4 % received
bleeding avoidance strategies such as vascular
closure devices and use of bivalirudin
24
a clear opportunity
for improvement.
Our Approach to Managing this Challenge
Teaching the Language and Concepts of
Quality Improvement and Patient Safety
As directors of cardiology training programs, we are
obligated to position our graduates for clinical/academic
practice and board eligibility. Many of us probably lack
sufficient expertise to provide sophisticated training in the
specific area of quality improvement and patient safety.
There are no clear guidelines other than the existing ACC
statements described above, and a review of publications
describing effective teaching of these concepts to trainees
shows that data are limited to medical students and
resident-level physicians.
25
As such, many fellowship
programs may have concluded, as we have, that these
efforts to educate and improve clinical outcomes are best
addressed at a department,
26
hospital, or medical center
level. Under the auspices of the University Medical Centers
Quality and Patient Safety Office, the Evidence-based
Practice Policy Group has produced practice resources for
common cardiovascular diseases (acute coronary
syndromes, heart failure, atrial fibrillation, infective
endocarditis prophylaxis). These incorporate the ACC/AHA
guidelines and ACC quality measures into a single
document, available on the hospital intranet. When
referenced by fellows on the wards or in clinics, they serve
as a quick reference for both treatment and documentation.
As a complement, fellowship leadership have partnered
with the administration of the Richard M Ross Heart
Hospital, our free-standing 150-bed facility containing all of
our diagnostic and treatment laboratories, to provide a
monthly morbidity and mortality conference focused on
quality and safety. This is a modification of the traditional
M and M structure where biopsy or post-mortem data are
used to refine diagnostic skill, focusing instead on
guideline-based decision-making and opportunities to learn
from complex clinical situations that led to suboptimal
outcomes. Fellows also receive a yearly lecture, as part of
their core curriculum, that is focused on the basic structure
and current state of the healthcare system in the US.
For those with specific interest, our Office of Graduate
Medical Education has recently created a pilot four-week
rotationa Quality Electivewhere house staff are
immersed in a combination of self-driven reading,
participation in medical center committee work, and
completion of a targeted quality improvement project
focusing on error investigation and root-cause analysis.
These are only rudimentary first steps, but the field itself is
continually evolving and the attainment of quality care
is a moving target. Most important is to provide our fellows
with the skills to become lifelong learners in their clinical
practice with quality and safety in contextto do their
work and to improve it.
27
In the coming academic year
we hope to develop a curricular framework for fellows to
undertake their own small-scale quality improvement
projects as a learning tool, probably enrolling in and
using components of the ACCs NCDRAcute Coronary
Treatment and Intervention Outcomes Network (ACTION),
Carotid Artery Revascularization and Endarterectomy
(CARE), CathPCI (diagnostic catheterizations and
percutaneous coronary interventions), ICD, Improving
Pediatric and Adult Congenital Treatment (IMPACT), and
PINNACLE (www.ncdr.com). Conversely, a parallel priority
is to educate them about the disadvantages and shortcomings
of quality/performance measures and future implications in
their practice. While well-intended, the phenomenon of pay
for performance has also been found to have unintended
negative consequences in the state of Massachusetts, as an
example. At the least, physicians are finding themselves being
relegated to lower tiers of insurance reimbursements due to an
opaque system rating their care by performance measures
and, what is most concerning, creating an environment
where physicians shy away from complex cases to avoid being
associated with poor outcomes.
28
All of these issues will continue to evolve since the passage
of the Patient Protection and Affordable Care Act in March,
2010, making familiarity with terms and concepts highly
important to graduating cardiology fellows preparing to
enter practice.
Conclusions from Our Fellowship
Training Program
Clearly, the training of future specialists in cardiology, as
with all of medicine, becomes increasingly complex with
each passing year. At The Ohio State University Medical
Center, much of our recent focus has been adapting to
increasingly complex training requirements from the ACC,
managing the demands imposed by regulations issued by
the ACGME, and providing fellows with an adequate
introduction to quality improvement and patient safety
concepts. For program leadership, fellowship committee
members, and key faculty, these efforts have been an
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105 Winter 2011 Cardiology Fellowship Education
education among themselves through collaborative efforts
and continual dialog with our Department of Internal
Medicine, Office of Graduate Medical Education, and
College of Medicine educational experts. As we have
worked to rise to these challenges within our own
program, however, there remain other, larger concerns
on the horizon.
Future Challenges and Opportunities for
Cardiovascular EducatorsMedical Education
as Translational Science
There exists a great opportunity to combine medical
education research and clinical training to improve patient
safety.
29
The use of pre-procedural checklists has already
been shown to reduce catheter-related bloodstream
infections in the medical intensive care unit setting
30
and
death and surgical complications in international
operating rooms.
31
These examples, and others like them,
were implemented by medical centers and carried out by
multidisciplinary teams of practicing physicians, nurses,
and technicians in the specific clinical settings. Checklists
tend to focus on technique and equipment, but also place
just as large an emphasis on a team-based approach to staff
communication. In fact, simple training in the use of crew
resource management techniquesrules of conduct
derived from the aviation industry which are designed to
create an environment where communication is prioritized
above positional hierarchywas recently shown to
improve surgical mortality within 74 hospitals in the
Veterans Health Administration.
32
Expanded
considerations of checklists have also included utilization
as an alternative to relying on intuition and memory in
clinical problem-solving, with the hope of reducing
diagnostic error.
33
Published data have described methods
of deliberate practicefocused, repetitive practice
with testing to ensure achievement of a mastery
standard
34
when instructing medical residents during
simulation workshops in advanced cardiac life support and
central venous catheter insertion.
29
Translated to
cardiology fellowship, there are ample opportunities
to model educational interventions to improve patient
satisfaction and sedation/anesthetic-related morbidity
during transesophageal echocardiography and reduce
fluoroscopy times, contrast volumes and complications
during cardiac catheterization. Fellows perform hundreds
of these procedures over the course of their training with
unknown variability in realtime supervision and
teaching. As such, a fellows learning edge of procedural
or medical knowledge may or may not be routinely
explored. Therefore, despite the volumes listed in
fellow logbooks, faculty preceptors and fellowship
directors mark trainee progress with a combination of
partial data and assumptions.
The Elusive Definition of Clinical Competence
The next frontier of medical education in cardiology will
probably be the redefinition of clinical competence and
support of lifelong learning. A review of studies relating
medical knowledge and healthcare quality to years in
practice suggests that physicians who have been in practice
longer may be at risk of providing lower-quality care.
35
To
address this issue during fellowship training, program
directors will have to be able to help trainees achieve
core knowledge (know what they should know), identify
knowledge gaps (knowing what they dont know)
encountered during a typical day, while providing the
framework for them to close them, and translate
published evidence into practice.
36
For fellows, the first step
toward this goal will be the upcoming ACC
In-Training Exam (ITE) in fall 2011. Written by educational
experts within the college with the collaboration of the
National Board of Medical Examiners, the ACC ITE
will be a multiple-choice format examination testing
comprehensive medical knowledge in cardiology. Results
will help program directors provide formative assessments
for each specific fellow and the program as a whole in
comparison with others. In parallel to an improved
assessment of medical knowledge, the ACC hasbegun to
explore medical simulation in partnership with the ABIM
as a potential means of testing procedural skills in
interventional cardiology.
37
Such simulators already exist
for transesophageal echocardiography and pacemaker
implantation, and may serve as methods to learn without
patient exposure to risk at some point in the future.
Whether they will reach the point of near-universal use
(they are quite expensive) during fellowship training or
become adopted as a final arbiter of procedural
competence during a board certification exercise is
certainly possible. For now, fellowship directors must
continue to adapt to dynamic requirements, seek
opportunities to collaborate, and persevere among a storm
of dataall while never forgetting to trust their gut. n
1. Hill JA, Kerber RE, Quo Vadis? How should we train cardiologists
at the turn of the century?, Circulation, 2000;102:9326.
2. Kennedy HL, Goldberger AL, Graboys TB, Hancock EW,
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