- Email: [email protected]
Training Present and Future Cardiologists
Training Present and Future Cardiologists Jeffrey T. Kuvin, MD* The future of cardiology rests in the hands and minds of cardiovascular trainees and fellowship programs. Education and training is rapidly changing, and the paradigm of “see one, do one, teach one” has now been replaced by formal assessments of competency, the incorporation of practice improvement and systems-based practice, and a focus on duty hours. To keep up with the expanding knowledge and science in cardiovascular medicine, the cardiology community needs to understand new educational initiatives and formulate pathways to teach, mentor, and educate trainees to become competent cardiovascular specialists. The author highlights some of the present and future issues facing cardiovascular training. © 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;108: 1508 –1512) Over the past decade, there has been an explosion of cardiovascular science and technology. We have also witnessed unprecedented shifts in graduate medical education, notably from passive to active learning and from global to focused assessment of knowledge gaps. The paradigm of physician training is undergoing a sea change, from a “see one, do one, teach one” mentality to a comprehensive, competency-based curriculum and evaluation. Will this new education structure lead to better trained physicians and improved patient outcomes? Nobody knows, at least not yet. What is clear, however, is that change in postgraduate education is here to stay. Cardiovascular Training Today: An Overview Fellowship training in cardiology remains highly sought after, rigorous, and complex. American Board of Internal Medicine (ABIM) board eligibility in internal medicine is a requirement to commence fellowship training, and the number of cardiovascular trainees and fellowship training programs in the United States has been stable over the years. According to the 2010 National Resident Matching Program statistics, there are 169 cardiovascular training programs with 1,184 applicants for 718 available positions.1 Fellowship programs are often limited in the number of training spots, because of the availability of funding as well as key clinical faculty mentors. Typically, 2/3 of the matched applicants are graduates of American medical schools, and ⬍20% are women. Nearly all the available spots for cardiology fellowships are filled during the match; the remaining coveted positions are quickly taken after a brief postmatch scramble.
Division of Cardiology, Tufts Medical Center, Boston, Massachusetts. Manuscript received May 18, 2011; revised manuscript received and accepted June 28, 2011. Dr. Kuvin is a member of the American College of Cardiology’s Education Oversight Committee and the Cardiovascular Education Redesign Taskforce. Dr. Kuvin is the chair of the American College of Cardiology’s In-Training Examination and the Fellow-in-Training Learning Portfolio. *Corresponding author: Tel: 617-636-5846; fax: 617-636-4769. E-mail address: [email protected] (J.T. Kuvin). 0002-9149/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjcard.2011.06.075
Figure 1. Upcoming changes in the timing of the National Resident Matching Program specialty match.
Presently, applicants for fellowship, typically secondyear internal medicine residents, apply to fellowship programs via the Electronic Residency Application Service. This electronic server allows applicants to send a common application to programs with a single mouse click, thereby allowing applicants to apply to a variety of programs. Since its institution, the number of applicants per program has increased substantially. A typical internal medicine applicant has roughly 16 months from the beginning of internship to decide on a fellowship track, seek out mentors and participate in research, obtain letters of recommendation, and submit an application resulting in commencement of training ⬎1 year later. Some applicants chose to apply during their third year of internal medicine residency or beyond, which allows more time to mature in their clinical or research roles but leads to delays in beginning specialty training. Recently, on the basis of recommendations from a variety of societies and interested parties, a new scheme for specialty fellowship has been developed that delays the National Resident Matching Program specialty match until the late fall of the applicants’ final year of residency (Figure 1). This new timeline will allow trainees to gather more experience and training programs to more accurately estimate their own needs. Opposition to this change in timing of the match has raised concern over the shortened time between the match and having to potentially move to a new city, limited time to obtain medical licensure and visas, and difficulty in finding staff to interview in the late summer and fall months. Neverthewww.ajconline.org
Review/Training Present and Future Cardiologists
1509
Figure 2. Postgraduate training scheme for internal medicine and cardiology.
Figure 3. The recommendations for training in cardiovascular medicine, including stakeholders (adapted from COCATS).
less, the amended specialty National Resident Matching Program dates will begin July 2012. Fellowship in cardiovascular medicine presently encompasses 3 to 4 years of full-time training (Figure 2). Fellows participate in core training in general cardiology as well as each of the subsections within cardiology, including cardiac catheterization, imaging, electrophysiology, vascular, heart failure, research, and elective. There is now renewed interest in the possibility of blending the third year of internal medicine residency with cardiovascular training, and the ABIM is considering beginning a few pilot programs to test the concept. This would shorten total training time of internal medicine plus cardiology from 6 to 5 years. Certain issues remain, such as the recruitment of early-track fellows as well as the possible detrimental effects this might have on internal medicine training and their programs. The Accreditation Council for Graduate Medical Education (ACGME) requires 24 months of clinical training in cardiovascular medicine and 3 years of continuity clinic.2 Thereafter, trainees are ABIM board eligible for the cardiovascular medicine certification examination. In addition to the ACGME and ABIM, there are numerous stakeholders in the fellowship training process, which often leads to some confusion as to what exactly is expected from trainees and programs (Figure 3). After general cardiovascular training,
fellows may then choose to subspecialize in a variety of areas requiring further years of education and training. Many of these specialized training tracks are sanctioned by the ABIM (electrophysiology, interventional cardiology, heart failure), while others are not (advanced imaging, vascular, research). During the final stages of fellowship, trainees focus on getting jobs as cardiovascular specialists. This can be a daunting experience and is often the first job search for many. Approximately 2/3 of the present cardiology workforce is composed of general cardiologists, while the remaining 1/3 includes interventional, electrophysiology, and pediatric specialists.3 Despite the present-day contraction of the private practice of cardiology, there is still considerable need for clinical cardiologists in the United States. Because of increasing rates of cardiovascular disease in the United States with an aging population, there is increasing demand for cardiac specialists, and it is estimated that roughly twice the number of cardiac specialists will be needed by 2050. However, it will be hard, if not impossible, to meet these demands given the present financial constraints that academic centers are under regarding postgraduate training. The ever increasing cost of medical school is also an important issue to consider, and it is estimated that ⬎20% of medical students graduate with ⬎$200,000 of debt.4 Thus,
1510
The American Journal of Cardiology (www.ajconline.org)
to spend ⱖ6 years in cardiovascular training, as well as decreasing reimbursement for procedures, may be viewed as a disincentive, often pointing potential cardiologists toward different careers. Accreditation Council for Graduate Medical Education Regulations and Fellowship Training The ACGME evaluates, accredits, and oversees medical training programs in the United States, and its mission is to improve health care by “assessing and advancing the quality of resident physicians education through accreditation” and to ensure quality during the learning and training experience.5 The ACGME establishes guidelines for programs and surveys fellows and programs periodically to ensure compliance and obtain feedback. ACGME regulations, along with the ABIM, societies, local, state, and national organizations, and graduate medical education offices, provide a framework for fellowship programs and allows consistency in training (Figure 3). The present ACGME model is based on 6 broad competencies for medical training and education (Table 1), and the specialty requirements are structured along these lines. Fellows are expected to learn information, translate knowledge into clinical practice, act maturely, develop relations with staff members and patients, understand ways to evaluate and improve care, and work within an ever changing medical environment. The competencies are meant to be a framework used in all aspects of training, including written curricula and evaluations, and provide structure for training programs to standardize education. Adherence to this model and documentation is a major focus of the ongoing accreditation and review process. The ACGME provides detailed structure requirements for training programs but recommends that training programs individualize the specific needs of their own fellows and environment. Common program requirements include items such as defining the responsibilities of the participating institutions, faculty members, and fellows, assessment of resources, duty hours, and evaluations, while subspecialty requirements are more specific to training cardiologists and refer to the appropriate duration of training, procedural numbers, and specific program content. The ACGME also provides guidelines for subspecialties within cardiology, including electrophysiology and interventional cardiology, and will soon publish heart failure requirements. The ACGME requirements, along with the American College of Cardiology (ACC) Foundation Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training (COCATS),6 are generally accepted by program directors as the gold standard for training. In July 2012, updated ACGME specialty requirements for cardiovascular trainees will be implemented.5 There have been a few key changes in this document. For example, fellows are considered trainees in their “final years” of education; therefore, although duty hour restrictions remain, the new guidelines are less stringent for cardiology trainees and suggest that “specific circumstances” regarding patient care might require longer periods in the hospital. There is also more emphasis on transitions of care and patient handoffs to ensure adequate communication and patient safety.
The new guidelines will also require that programs and hospitals commit resources and activities toward electronic health records and novel educational activities, such as simulation. The updated requirements continue to emphasize a structured approach to fellowship education, including a competency-based curriculum as well as formative and summative evaluations. Participation by faculty members and fellows in systems-based practice as well as performance improvement is stressed. The ACGME provides accreditation to specialty and subspecialty training programs as well as the overseeing of institutions and departments. In addition, the ACGME provides accreditation as to how many fellows can gain ACGME-approved training at an individual site, which is largely based on the number of key clinical faculty members and the training and research environment. Typically, ACGME field crew provide on-site program reviews every 5 to 6 years, which allows an in-depth analysis of the structure of training and includes meetings with fellows, staff members, and institutional officials. In addition, annual surveys provide feedback to the ACGME and allow near continuous monitoring of programs. The Role of the Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training The first COCATS guidelines were published in 1995 with task forces and requirements in 10 specific areas of cardiology.7 Since then, additions, including magnetic resonance imaging and vascular medicine, have been written, indicative of the growth within cardiovascular medicine and the need for expanded educational offerings. This type of manifesto also helps standardize training and challenges programs to find the resources, time, and faculty members to implement meaningful learning offerings to fellows. COCATS separates training by levels, where level III training indicates the highest training level, and level I is the most basic. COCATS is heavily based on procedural numbers and months of training to assess competency and, along with the ACGME regulations, has been a helpful tool for fellows and program directors to guide training. A substantial benefit of COCATS is that it is written by cardiovascular specialists for cardiovascular trainees, and the recommendations seem appropriate for training fellows. The challenge for program directors, however, is to find a way to incorporate the ACGME and COCATS documents in a costcontained environment. In many ways, COCATS has become a blueprint of sorts for cardiovascular programs and provides a method of assessing “competency” within particular areas of cardiology. A present-day challenge, however, is the vast amount of information composed in COCATS, and the relative lack of time that fellows have to fulfill these goals. In the future, trainees and directors will need to discuss limits on establishing competency, as it is becoming obvious that fellows may not be able to be competent to practice in all areas upon graduation. Work Hours and Cardiovascular Training Duty hour restrictions for trainees in the medical field date back to the early 1980s, after the highly publicized
Review/Training Present and Future Cardiologists Table 1 Accreditation Council for Graduate Medical Education Outcomes Project and core competencies Competency
Description
Patient care
Compassionate, appropriate, effective care for the treatment of health problems and the promotion of health Established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care Commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Effective information exchange and teaming with patients, their families, and other health professionals Investigation and evaluation of patient care, appraisal and assimilation of scientific evidence, and improvements in patient care Awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value
Medical knowledge
Professionalism
Interpersonal and communication skills Practice-based learning and improvement Systems-based practice
Adapted from the ACGME Web site (http://www.acgme.org).
death of a young woman in New York City. In 2003, the ACGME passed the first set of duty-hour regulations, which was followed with further modifications by the Institute of Medicine.8 Duty hours have made a significant impact on medical training and patient care, and cardiovascular trainees have not been excluded from this paradigm. Restriction in hours worked in medicine mandates adherence to limiting the number of hours worked in a row, time off between shifts, and days off per month. Similar to airline pilots or truck drivers, there has been a significant focus on impaired decision making due to excess fatigue, and no longer is it allowable for trainees to work excess hours, whether or not patient care demands it. This has led to the restructuring of daily routines, handoffs, teaching, and on-call structure. All programs are held to duty-hour restrictions; however, programs are inherently affected differently on the basis of the need for in-hospital hours and on-call responsibilities. In cardiology, for example, many programs do not require in-house call. However, given that training in cardiology often focuses on the care of complicated, critically ill patients, fellows routinely are involved in cases for long periods. Scrutiny over hours worked in training programs has been the focus of significant controversy over the years. Although the duty-hour restrictions in place in the United States pale in comparison to those across Europe, they still pose significant challenges in the present training environment. In addition, the verdict is still out as to whether duty-hour restrictions lead to improved patient outcomes. Changes in duty hours inevitably mean changes in the workforce, not to mention educational opportunities, and this continues to remain an unfunded mandate. In addition, because of the present-day mentality that patient care is shift work, an increased number of patient handoffs may be
1511
Table 2 Newer models of education: focus on competency Traditional Education Goal of educational encounter Responsible for driving educational process Responsible for content Timing of assessment
Competency-Based Education
Acquisition of knowledge Teacher
Application of knowledge Learner
Typical assessment tool Evaluation standards
Teacher Emphasis on summative Indirect Relative to peers
Program completion
Fixed time
Student and teacher Emphasis on formative Direct Relative to objective measures Variable time
Adapted from Weinberger S, Pereira A, Iobst W, Mechaber A, Bronze M. Competency-based education and training in internal medicine. Ann Intern Med 2010;153:751–756.
complicated by poor communication, thereby increasing, not decreasing, room for error. Specialty programs, such as cardiology, are also affected by medicine intern and resident duty-hour limitations, and as is often the case, some of the work gets offloaded to fellows and attending physicians, leading to resentment and poor use of resources. Although duty-hour restrictions are controversial and complicated, they appear to be here to stay. It is also clear, however, that there needs to be greater emphasis on planning and implementation issues when mandates such as these come about. Finally, there is considerable concern that trainees will be ill prepared for the “real world,” where there are few, if any, duty-hour restrictions. Assessment of Competency in Fellowship Training At the completion of cardiovascular fellowship, trainees are expected to be competent cardiovascular consultants, able to independently care for patients. Competency encompasses knowledge, skills, behaviors, and attitudes and is a requirement for individuals to properly perform their jobs. Metrics to define competency in fellowship training include various evaluation tools used in training as well as the fulfillment of specific requirements. Until now, however, trainee competency has been typically defined on numerical metrics, primarily in the procedural areas, as well as time spent in training. Fellows learn and develop skills at different paces, and thus, there is great need for more robust tools to assess true competency. The ABIM and ACGME, along with specialty organizations, are embarking on newer methods of defining competency. Clearly, we are moving from a traditional, passive approach to learning to a more interactive, competencybased educational structure (Table 2). The Milestones Project is an example of a novel way to set minimum standards. The idea is to define concepts that a competent general cardiologist should know and then to develop specific assessment tools to evaluate. The ACC has embarked on a strategy to formulate competency statements in cardiology, on the basis of the 6 ACGME competencies and COCATS. As such, trainees can be assessed by faculty members, staff,
1512
The American Journal of Cardiology (www.ajconline.org)
and peers to see if they are reaching specific milestone competencies based on their fellowship year. If a trainee does not achieve the expected basic level of competency, then a remedial plan would be required, and proof of competency would then be required to move ahead. Ultimately, at the completion of fellowship training, competency in each area of cardiovascular training will be assessed using this, as well as other, methodologies. The ACC is developing a new tool to assess the competency of medical knowledge. The ACC In-Training Examination is designed to be an annual, secure, on-line examination administered at fellowship training sites and supported and designed by the National Board of Medical Examiners. The examination is designed to assess medical knowledge and provide feedback to fellows regarding knowledge gaps as well as help trainees and programs prepare for the ABIM certifying examination. Given that the ACGME requirements (2012) require an “objective formative assessment method,” the new In-Training Examination, due to debut in October 2011, will undoubtedly be a useful tool. Assessment of competency is critically important as fellows evolve into independent practitioners. The field of cardiology is quickly becoming too vast and complicated to assign competency solely on the basis of numbers of procedures performed. Rather, patients and the public alike demand that practicing physicians have a basic level of understanding and ability. A more formal assessment of competency is clearly needed and will hopefully help level the playing field for cardiovascular specialists. Future Directions for Fellowship Training Clearly, the future for cardiovascular trainees is bright. There is no shortage of patients with cardiovascular disease,
and there are well-validated diagnostics and therapies are available. In addition, cardiovascular research opportunities are abundant. However, there is an ever increasing amount of information to learn and absorb, and the rules and regulations for fellowship training are more stringent than ever. In addition, limited funding opportunities for fellowship training, scrutiny regarding work hours and training environments, changes in physician reimbursement, and workforce issues remain a concern for training directors and trainees. Now more than ever, fellows, program directors, faculty members, administrators, and national and international societies and organizations focused on graduate medical education need to work together to ensure a robust future for cardiovascular patient care and research. 1. National Resident Matching Program. Fellowship matches. Available at: http://www.nrmp.org/fellow/index.html. Accessed May 2011. 2. Kuvin J. ACGME initiatives improve the education of cardiology fellows. Circulation 2008;118;525–531. 3. Rodgers GP, Conti JB, Feinstein JA, Griffin BP, Kennett JD, Shah S, Walsh MN, Williams ES, Williams JL. ACC 2009 survey results and recommendations: addressing the cardiology workforce crisis. A report of the ACC Board of Trustees Workforce Task Force. J Am Coll Cardiol 2009;54:1195–1208. 4. Steinbrook R. Medical student debt—is there a limit? N Engl J Med 2008;359:2629 –2632. 5. Accreditation Council for Graduate Medical Education. Mission, vision and valves. Available at: http://www.acgme.org/acWebsite/about/ab_ mission.asp. Accessed May 2011. 6. Beller GA, Bonow RO, Fuster V. ACCF 2008 Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training (COCATS 3) (revision of the 2002 COCATS training statement). J Am Coll Cardiol 2008;51:335–338. 7. Guidelines for Training in Adult Cardiovascular Medicine. Core Cardiology Training Symposium (COCATS). J Am Coll Cardiol 1995;25: 1–34. 8. Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA 2002;288:1112–1114.
Division of Cardiology, Tufts Medical Center, Boston, Massachusetts. Manuscript received May 18, 2011; revised manuscript received and accepted June 28, 2011. Dr. Kuvin is a member of the American College of Cardiology’s Education Oversight Committee and the Cardiovascular Education Redesign Taskforce. Dr. Kuvin is the chair of the American College of Cardiology’s In-Training Examination and the Fellow-in-Training Learning Portfolio. *Corresponding author: Tel: 617-636-5846; fax: 617-636-4769. E-mail address: [email protected] (J.T. Kuvin). 0002-9149/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjcard.2011.06.075
Figure 1. Upcoming changes in the timing of the National Resident Matching Program specialty match.
Presently, applicants for fellowship, typically secondyear internal medicine residents, apply to fellowship programs via the Electronic Residency Application Service. This electronic server allows applicants to send a common application to programs with a single mouse click, thereby allowing applicants to apply to a variety of programs. Since its institution, the number of applicants per program has increased substantially. A typical internal medicine applicant has roughly 16 months from the beginning of internship to decide on a fellowship track, seek out mentors and participate in research, obtain letters of recommendation, and submit an application resulting in commencement of training ⬎1 year later. Some applicants chose to apply during their third year of internal medicine residency or beyond, which allows more time to mature in their clinical or research roles but leads to delays in beginning specialty training. Recently, on the basis of recommendations from a variety of societies and interested parties, a new scheme for specialty fellowship has been developed that delays the National Resident Matching Program specialty match until the late fall of the applicants’ final year of residency (Figure 1). This new timeline will allow trainees to gather more experience and training programs to more accurately estimate their own needs. Opposition to this change in timing of the match has raised concern over the shortened time between the match and having to potentially move to a new city, limited time to obtain medical licensure and visas, and difficulty in finding staff to interview in the late summer and fall months. Neverthewww.ajconline.org
Review/Training Present and Future Cardiologists
1509
Figure 2. Postgraduate training scheme for internal medicine and cardiology.
Figure 3. The recommendations for training in cardiovascular medicine, including stakeholders (adapted from COCATS).
less, the amended specialty National Resident Matching Program dates will begin July 2012. Fellowship in cardiovascular medicine presently encompasses 3 to 4 years of full-time training (Figure 2). Fellows participate in core training in general cardiology as well as each of the subsections within cardiology, including cardiac catheterization, imaging, electrophysiology, vascular, heart failure, research, and elective. There is now renewed interest in the possibility of blending the third year of internal medicine residency with cardiovascular training, and the ABIM is considering beginning a few pilot programs to test the concept. This would shorten total training time of internal medicine plus cardiology from 6 to 5 years. Certain issues remain, such as the recruitment of early-track fellows as well as the possible detrimental effects this might have on internal medicine training and their programs. The Accreditation Council for Graduate Medical Education (ACGME) requires 24 months of clinical training in cardiovascular medicine and 3 years of continuity clinic.2 Thereafter, trainees are ABIM board eligible for the cardiovascular medicine certification examination. In addition to the ACGME and ABIM, there are numerous stakeholders in the fellowship training process, which often leads to some confusion as to what exactly is expected from trainees and programs (Figure 3). After general cardiovascular training,
fellows may then choose to subspecialize in a variety of areas requiring further years of education and training. Many of these specialized training tracks are sanctioned by the ABIM (electrophysiology, interventional cardiology, heart failure), while others are not (advanced imaging, vascular, research). During the final stages of fellowship, trainees focus on getting jobs as cardiovascular specialists. This can be a daunting experience and is often the first job search for many. Approximately 2/3 of the present cardiology workforce is composed of general cardiologists, while the remaining 1/3 includes interventional, electrophysiology, and pediatric specialists.3 Despite the present-day contraction of the private practice of cardiology, there is still considerable need for clinical cardiologists in the United States. Because of increasing rates of cardiovascular disease in the United States with an aging population, there is increasing demand for cardiac specialists, and it is estimated that roughly twice the number of cardiac specialists will be needed by 2050. However, it will be hard, if not impossible, to meet these demands given the present financial constraints that academic centers are under regarding postgraduate training. The ever increasing cost of medical school is also an important issue to consider, and it is estimated that ⬎20% of medical students graduate with ⬎$200,000 of debt.4 Thus,
1510
The American Journal of Cardiology (www.ajconline.org)
to spend ⱖ6 years in cardiovascular training, as well as decreasing reimbursement for procedures, may be viewed as a disincentive, often pointing potential cardiologists toward different careers. Accreditation Council for Graduate Medical Education Regulations and Fellowship Training The ACGME evaluates, accredits, and oversees medical training programs in the United States, and its mission is to improve health care by “assessing and advancing the quality of resident physicians education through accreditation” and to ensure quality during the learning and training experience.5 The ACGME establishes guidelines for programs and surveys fellows and programs periodically to ensure compliance and obtain feedback. ACGME regulations, along with the ABIM, societies, local, state, and national organizations, and graduate medical education offices, provide a framework for fellowship programs and allows consistency in training (Figure 3). The present ACGME model is based on 6 broad competencies for medical training and education (Table 1), and the specialty requirements are structured along these lines. Fellows are expected to learn information, translate knowledge into clinical practice, act maturely, develop relations with staff members and patients, understand ways to evaluate and improve care, and work within an ever changing medical environment. The competencies are meant to be a framework used in all aspects of training, including written curricula and evaluations, and provide structure for training programs to standardize education. Adherence to this model and documentation is a major focus of the ongoing accreditation and review process. The ACGME provides detailed structure requirements for training programs but recommends that training programs individualize the specific needs of their own fellows and environment. Common program requirements include items such as defining the responsibilities of the participating institutions, faculty members, and fellows, assessment of resources, duty hours, and evaluations, while subspecialty requirements are more specific to training cardiologists and refer to the appropriate duration of training, procedural numbers, and specific program content. The ACGME also provides guidelines for subspecialties within cardiology, including electrophysiology and interventional cardiology, and will soon publish heart failure requirements. The ACGME requirements, along with the American College of Cardiology (ACC) Foundation Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training (COCATS),6 are generally accepted by program directors as the gold standard for training. In July 2012, updated ACGME specialty requirements for cardiovascular trainees will be implemented.5 There have been a few key changes in this document. For example, fellows are considered trainees in their “final years” of education; therefore, although duty hour restrictions remain, the new guidelines are less stringent for cardiology trainees and suggest that “specific circumstances” regarding patient care might require longer periods in the hospital. There is also more emphasis on transitions of care and patient handoffs to ensure adequate communication and patient safety.
The new guidelines will also require that programs and hospitals commit resources and activities toward electronic health records and novel educational activities, such as simulation. The updated requirements continue to emphasize a structured approach to fellowship education, including a competency-based curriculum as well as formative and summative evaluations. Participation by faculty members and fellows in systems-based practice as well as performance improvement is stressed. The ACGME provides accreditation to specialty and subspecialty training programs as well as the overseeing of institutions and departments. In addition, the ACGME provides accreditation as to how many fellows can gain ACGME-approved training at an individual site, which is largely based on the number of key clinical faculty members and the training and research environment. Typically, ACGME field crew provide on-site program reviews every 5 to 6 years, which allows an in-depth analysis of the structure of training and includes meetings with fellows, staff members, and institutional officials. In addition, annual surveys provide feedback to the ACGME and allow near continuous monitoring of programs. The Role of the Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training The first COCATS guidelines were published in 1995 with task forces and requirements in 10 specific areas of cardiology.7 Since then, additions, including magnetic resonance imaging and vascular medicine, have been written, indicative of the growth within cardiovascular medicine and the need for expanded educational offerings. This type of manifesto also helps standardize training and challenges programs to find the resources, time, and faculty members to implement meaningful learning offerings to fellows. COCATS separates training by levels, where level III training indicates the highest training level, and level I is the most basic. COCATS is heavily based on procedural numbers and months of training to assess competency and, along with the ACGME regulations, has been a helpful tool for fellows and program directors to guide training. A substantial benefit of COCATS is that it is written by cardiovascular specialists for cardiovascular trainees, and the recommendations seem appropriate for training fellows. The challenge for program directors, however, is to find a way to incorporate the ACGME and COCATS documents in a costcontained environment. In many ways, COCATS has become a blueprint of sorts for cardiovascular programs and provides a method of assessing “competency” within particular areas of cardiology. A present-day challenge, however, is the vast amount of information composed in COCATS, and the relative lack of time that fellows have to fulfill these goals. In the future, trainees and directors will need to discuss limits on establishing competency, as it is becoming obvious that fellows may not be able to be competent to practice in all areas upon graduation. Work Hours and Cardiovascular Training Duty hour restrictions for trainees in the medical field date back to the early 1980s, after the highly publicized
Review/Training Present and Future Cardiologists Table 1 Accreditation Council for Graduate Medical Education Outcomes Project and core competencies Competency
Description
Patient care
Compassionate, appropriate, effective care for the treatment of health problems and the promotion of health Established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care Commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Effective information exchange and teaming with patients, their families, and other health professionals Investigation and evaluation of patient care, appraisal and assimilation of scientific evidence, and improvements in patient care Awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value
Medical knowledge
Professionalism
Interpersonal and communication skills Practice-based learning and improvement Systems-based practice
Adapted from the ACGME Web site (http://www.acgme.org).
death of a young woman in New York City. In 2003, the ACGME passed the first set of duty-hour regulations, which was followed with further modifications by the Institute of Medicine.8 Duty hours have made a significant impact on medical training and patient care, and cardiovascular trainees have not been excluded from this paradigm. Restriction in hours worked in medicine mandates adherence to limiting the number of hours worked in a row, time off between shifts, and days off per month. Similar to airline pilots or truck drivers, there has been a significant focus on impaired decision making due to excess fatigue, and no longer is it allowable for trainees to work excess hours, whether or not patient care demands it. This has led to the restructuring of daily routines, handoffs, teaching, and on-call structure. All programs are held to duty-hour restrictions; however, programs are inherently affected differently on the basis of the need for in-hospital hours and on-call responsibilities. In cardiology, for example, many programs do not require in-house call. However, given that training in cardiology often focuses on the care of complicated, critically ill patients, fellows routinely are involved in cases for long periods. Scrutiny over hours worked in training programs has been the focus of significant controversy over the years. Although the duty-hour restrictions in place in the United States pale in comparison to those across Europe, they still pose significant challenges in the present training environment. In addition, the verdict is still out as to whether duty-hour restrictions lead to improved patient outcomes. Changes in duty hours inevitably mean changes in the workforce, not to mention educational opportunities, and this continues to remain an unfunded mandate. In addition, because of the present-day mentality that patient care is shift work, an increased number of patient handoffs may be
1511
Table 2 Newer models of education: focus on competency Traditional Education Goal of educational encounter Responsible for driving educational process Responsible for content Timing of assessment
Competency-Based Education
Acquisition of knowledge Teacher
Application of knowledge Learner
Typical assessment tool Evaluation standards
Teacher Emphasis on summative Indirect Relative to peers
Program completion
Fixed time
Student and teacher Emphasis on formative Direct Relative to objective measures Variable time
Adapted from Weinberger S, Pereira A, Iobst W, Mechaber A, Bronze M. Competency-based education and training in internal medicine. Ann Intern Med 2010;153:751–756.
complicated by poor communication, thereby increasing, not decreasing, room for error. Specialty programs, such as cardiology, are also affected by medicine intern and resident duty-hour limitations, and as is often the case, some of the work gets offloaded to fellows and attending physicians, leading to resentment and poor use of resources. Although duty-hour restrictions are controversial and complicated, they appear to be here to stay. It is also clear, however, that there needs to be greater emphasis on planning and implementation issues when mandates such as these come about. Finally, there is considerable concern that trainees will be ill prepared for the “real world,” where there are few, if any, duty-hour restrictions. Assessment of Competency in Fellowship Training At the completion of cardiovascular fellowship, trainees are expected to be competent cardiovascular consultants, able to independently care for patients. Competency encompasses knowledge, skills, behaviors, and attitudes and is a requirement for individuals to properly perform their jobs. Metrics to define competency in fellowship training include various evaluation tools used in training as well as the fulfillment of specific requirements. Until now, however, trainee competency has been typically defined on numerical metrics, primarily in the procedural areas, as well as time spent in training. Fellows learn and develop skills at different paces, and thus, there is great need for more robust tools to assess true competency. The ABIM and ACGME, along with specialty organizations, are embarking on newer methods of defining competency. Clearly, we are moving from a traditional, passive approach to learning to a more interactive, competencybased educational structure (Table 2). The Milestones Project is an example of a novel way to set minimum standards. The idea is to define concepts that a competent general cardiologist should know and then to develop specific assessment tools to evaluate. The ACC has embarked on a strategy to formulate competency statements in cardiology, on the basis of the 6 ACGME competencies and COCATS. As such, trainees can be assessed by faculty members, staff,
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The American Journal of Cardiology (www.ajconline.org)
and peers to see if they are reaching specific milestone competencies based on their fellowship year. If a trainee does not achieve the expected basic level of competency, then a remedial plan would be required, and proof of competency would then be required to move ahead. Ultimately, at the completion of fellowship training, competency in each area of cardiovascular training will be assessed using this, as well as other, methodologies. The ACC is developing a new tool to assess the competency of medical knowledge. The ACC In-Training Examination is designed to be an annual, secure, on-line examination administered at fellowship training sites and supported and designed by the National Board of Medical Examiners. The examination is designed to assess medical knowledge and provide feedback to fellows regarding knowledge gaps as well as help trainees and programs prepare for the ABIM certifying examination. Given that the ACGME requirements (2012) require an “objective formative assessment method,” the new In-Training Examination, due to debut in October 2011, will undoubtedly be a useful tool. Assessment of competency is critically important as fellows evolve into independent practitioners. The field of cardiology is quickly becoming too vast and complicated to assign competency solely on the basis of numbers of procedures performed. Rather, patients and the public alike demand that practicing physicians have a basic level of understanding and ability. A more formal assessment of competency is clearly needed and will hopefully help level the playing field for cardiovascular specialists. Future Directions for Fellowship Training Clearly, the future for cardiovascular trainees is bright. There is no shortage of patients with cardiovascular disease,
and there are well-validated diagnostics and therapies are available. In addition, cardiovascular research opportunities are abundant. However, there is an ever increasing amount of information to learn and absorb, and the rules and regulations for fellowship training are more stringent than ever. In addition, limited funding opportunities for fellowship training, scrutiny regarding work hours and training environments, changes in physician reimbursement, and workforce issues remain a concern for training directors and trainees. Now more than ever, fellows, program directors, faculty members, administrators, and national and international societies and organizations focused on graduate medical education need to work together to ensure a robust future for cardiovascular patient care and research. 1. National Resident Matching Program. Fellowship matches. Available at: http://www.nrmp.org/fellow/index.html. Accessed May 2011. 2. Kuvin J. ACGME initiatives improve the education of cardiology fellows. Circulation 2008;118;525–531. 3. Rodgers GP, Conti JB, Feinstein JA, Griffin BP, Kennett JD, Shah S, Walsh MN, Williams ES, Williams JL. ACC 2009 survey results and recommendations: addressing the cardiology workforce crisis. A report of the ACC Board of Trustees Workforce Task Force. J Am Coll Cardiol 2009;54:1195–1208. 4. Steinbrook R. Medical student debt—is there a limit? N Engl J Med 2008;359:2629 –2632. 5. Accreditation Council for Graduate Medical Education. Mission, vision and valves. Available at: http://www.acgme.org/acWebsite/about/ab_ mission.asp. Accessed May 2011. 6. Beller GA, Bonow RO, Fuster V. ACCF 2008 Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training (COCATS 3) (revision of the 2002 COCATS training statement). J Am Coll Cardiol 2008;51:335–338. 7. Guidelines for Training in Adult Cardiovascular Medicine. Core Cardiology Training Symposium (COCATS). J Am Coll Cardiol 1995;25: 1–34. 8. Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA 2002;288:1112–1114.