Postgraduate Cardiology Education of Basic Clinical Skills and Patient Management

Eric S. Williams
Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN

In the United States, general clinical cardiology training requires a 3-year fellowship program, after the completion of a 3-year program in internal medicine. In the US, there are currently 173 programs and about 2,100 trainees (about 300 trainees in each year of the program). Completion of this 6-year program allows the physician to become a consultant cardiologist and to be certified in cardiovascular disease by the American Board of Internal Medicine.

Many graduates obtain added qualifications by participating in additional subspecialty training. In the US, there are 78 electrophysiology programs and 110 interventional cardiology programs, both lasting 1 year. Other areas for additional training include research, echocardiography, heart failure and transplantation, nuclear medicine, and CT/MR.

Training program requirements

Accreditation and certification play a role in the content, structure, and operation of cardiology training programs. The Accreditation Council of Graduate Medical Education (ACGME) is a private organization that certifies all of the programs for residency training in the US. The cardiovascular section of the American Board of Internal Medicine (ABIM) certifies the graduates of the residency programs. To be a board certified graduate, the physician has to satisfactorily complete the training in an ACGME-approved program and passing the ABIM certification examination.

The education resources and education environment, in addition to the program content, is of interest to the directors of the training programs, the ACGME, and the ABIM. Increasingly in the US, there has been a focus on some of the education environmental issues, such as the balance of the service activities versus the education activities of the trainees, to ensure they spend their time in clinical activities that have demonstrable educational merit. Duty hours and work rules must be humanistic, to ensure there is adequate time off and duty hours do not impair quality of care delivered. Professionalism and humanism are increasingly emphasized, as well as a robust system of evaluation and feedback for the trainees throughout the course of their program. Education resources include a broad patient base, faculty size, and facilities.

Cardiology training program curriculum

The curriculum is to some extent influenced by the ACGME, which sets the minimum requirements, by the ABIM cardiovascular (CV) section, which sets the skills needed to pass the certification test, and by the professional medical societies. COCATS-II is a vehicle by which the professional medical societies and many of the leaders in cardiology education can play a role in structuring the curriculum and the requirements of the training programs.

COCATS-II is under the auspices of the American College of Cardiology and refers to the Core Curriculum Training Symposium, which began in 1994 with COCATS-I and was then revised subsequently. COCATS provides greater detail for the training programs and provides the opportunity for the professional medical societies to comment on the different levels of training and competency required to be optimally efficient and productive. Level I training is basic training that all trainees should receive. Level II is an intermediate skill level, which would allow a person to perform or interpret specified procedures. Level III is a high skill level, which would allow a person to head a laboratory, supervise training of others, and carry out a higher degree of work.

Cardiology training curriculum

The components of the general cardiology training program include non-laboratory clinical experience (9 months minimum), catheterization laboratory (4 months minimum), non-invasive imaging (6 months minimum), electrophysiology (2 months minimum), ECG (2 months; Holter monitoring, stress testing), and research. Non-invasive imaging includes echocardiography, nuclear cardiology, MR, CT, and PET scanning. Although research was initially conceived to be about 12 months, in reality it is becoming about 6 months of scholarly activity in the third year, because of the increasing demands of the clinical curriculum and to achieve the higher level skills, such as Level II in echocardiography, nuclear cardiology, and MR. Yet, most of the programs still believe that some structured academic scholarly activity in the third year is an important part of the training and aids the overall clinical skills of the trainee. Additionally, the trainee must work one-half day per week in an ambulatory clinic in cardiology throughout the 3-year program. This is a continuous cardiology clinic that must be present throughout the program.

The non-laboratory clinical practice activities include cardiac consultations, all in-patient acute care units, post-operative cardiothoracic surgery, cardiac failure/transplantation, extra-cardiac vascular disease, and preventive cardiology and rehabilitation. The trainees are expected to cover the full range of CV disorders. These include cardiovascular disease and systemic illness, and are listed in Figure 1.

Traditional teaching model

In the US, the basic model that still is used for the 9-months of clinical training is a one-to-one relationship of the trainee with the faculty member, on various rotations in the hospital units and in the out-patient setting. Typically, the trainee is part of a team for a 1 or 2 month rotation. The team includes the attending cardiologist, the trainee, and variably may include a resident and some medical students.

Core lectures, clinical conferences, and clinical decision-making forums complement the basic teaching model. Increasingly, there is an emphasis that these forums and the basic teaching model take into account end-of-life issues, clinical ethics, geriatrics, and quality initiatives.

Multidisciplinary teams are increasing. For example, at the Krannert Multidisciplinary Heart Failure Clinic, the team includes a cardiothoracic surgeon, nurse specialist, pharmacist, social worker, dietitian, along with the attending cardiologist and the cardiology trainee All of these team members participate in the education and evaluation of the trainee. The team approach to care delivery and education is increasing.

Clinical skills, evaluation, documentation, and communication of trainee progress

Adequate documentation of the competency and progress of the trainee is required. Feedback is necessary so the trainee can improve in the areas needed additional work. The attending cardiologist evaluates the trainee every month for every rotation and provides feedback to the trainee. Additionally, the ABIM requests that progress in patient care, clinical judgment, and medical knowledge, professionalism, communication, practice-based learning, and system-based learning be systematically documented (Figure 2).

Increasingly in the US, there is a move toward more structured evaluation during the training program. This includes in-service examinations, for example for electrocardiography and echocardiography. Structured clinical skills evaluation includes simulation technology. In the so-called 360-degree evaluation, feedback is provided to the trainee by the attending cardiologist, and also the nurses and other persons in the sphere of education of the trainee.

The training program director is required for every trainee to comment on the overall clinical competence, the moral and ethical behavior, and the 6 essential components of clinical competence.

Regarding ABIM subspecialty certification, a written examination, plus the ongoing clinical evaluations by the training program director provides documentation of the clinical skill of the trainee. Additionally, the ABIM has increased the case-based and clinical judgment components of the test, now comprising a substantial portion of the written examination. In 2003, 83% of the 710 candidates who took the ABIM examination passed.

Program evaluation and challenges

In most programs there is participation by trainees on the fellowship committee, which oversees the daily operation of the program. There are anonymous evaluations of the faculty and the various rotations by the trainees. Surveys of the graduates are conducted at 2, 5, and 10 years post-graduation to obtain their comments about clinical skills and areas of the program in which they did not feel they were adequately trained or they suggest require increased emphasis.

Funding of training positions and education costs remains a challenge. This limits any increase in the size of most programs. There are also increased demands for hospital efficiency and faculty productivity, and it is possible for these demands to actually reduce the amount of time that individual faculty members may have to perform clinical education. This is a source of some concern for some educators, so that these demands do not inordinately detract from the bedside and clinical education of the trainees.

The basic cardiology skills are important because they are at the core of the identity of a consultant cardiologist. There is concern in the US about the aging of the population and thus a growing need for cardiovascular consultants in the long-term management of patients with CV disease. The need for early diagnosis of prevention and chronic disease management increases the need for clinical cardiologists. This is an area being addressed currently by some of the specialty medical societies.

The Postgraduate Education of Basic Clinical Skills and Patient Management

Tsunekazu Takashina
Japanese Educational Clinical Cardiology Society, Osaka, Japan

When approaching a new patient, the physician must remember that the patient is in the acute or chronic stage. Although there is a trend among clinicians to believe that evidence-based medicine (EBM) is the ultimate parameter for clinical judgment, many cases cannot be managed by EBM. Clinicians must look at the total patient, not just the organs and test results. To be a good clinician, one must be active with common sense, polite and warm-hearted, thoughtful and dedicated, diligent and knowledgeable, humble and always honest, and cooperative with colleagues.

The importance of bedside training of skills

The advances of diagnostic instruments using high technology in the last few decades are remarkable. However, there is a tendency for many clinicians to become too dependent on these highly sophisticated instruments, and to forget the importance of bedside clinical skills.

Based on Takashina’s pyramid of clinical skills and patient management, in the acute stage or the onset of disease requires high-level clinical skills, and in the late clinical stage low-level clinical skills are needed and the patients are difficult to manage. Diagnosis and treatment are opposite. When making the diagnosis in the early stage, it is necessary to have high-level clinical skills.

The ability to understand clinical languages is the most important step to master clinical skills and the management of patients. Clinical languages include the spoken language, the chief complaint, present illness, past history, and family history, among others. Body language includes signs and symptoms and clinical findings. Organ language is physical findings, such as heart sounds, murmur, x-rays, and other tests.

In Japan, younger physicians forget how to communicate with patients, and they need to be retrained in being polite to the patients and improving their skill in asking questions of patients. The lack of clinical skills means the person is no longer a clinician, but a technician.

The training of basic clinical skills includes understanding clinical anatomy and physiology of cardiovascular system, and a stepwise approach to patients, including performing the medical interview, completing the physical examination, and obtaining an electrocardiogram, chest X-ray, and routine laboratory tests.  Takashina and colleagues are using simulation training to teach the basic clinical skills.

In simulation training, a 30-minute pre-test is given, which includes questions about arterial pulses, cardiac impulses, auscultation, and patient management. The second step is the physical examination using a cardiac patient simulator for 3 hours. The third step is a post-test with the same questions as the pre-test (Figure 1).

The new cardiology patient simulator developed by Takashina and colleagues uses computer technology to include heart sounds, heart murmurs, pulse waves, and so forth (Figure 2). The system includes a digital-analog (D-A) board and a 4-channel amplifier. Stored in this simulator are 36 cases of heart disease and 52 different types of arrhythmia. The role of the instructor when using this new simulator is shown in Figure 3.The results obtained with this simulator training is reported in Figure 4.

The Asian Heart House was established in Osaka by the Japanese Educational Clinical Cardiology Society in January 2004 (www.jeccs.org). The Asian Heart House will play a very important role in the prevention of cardiovascular and its related diseases, in close relationship together with Heart House in the US of the ACC and European Heart House. The Asian Heart House will provide educational courses to physicians and medical personnel through seminars or extramural programs, and also provide e-learning materials on the website, available for use by anyone worldwide.

Postgraduate Cardiology Education: To Be a Certified Cardiologist

Jamie B. Conti
University of Florida, Gainesville, FL

In the United States, becoming a certified cardiologist requires a huge investment of time, including 4 years of university education, 4 years of medical school, 3 years of internal medicine training, and 3 years of training in cardiovascular (CV) diseases, for a total of 14 years of training after the age of 18.

Physicians who are awarded a certificate in CV diseases must also meet the post-doctoral training requirements, must demonstrate clinical competence in the care of patients, and must pass the certification examination in CV diseases.

Postdoctoral training requirements

Thirty-six months of graduate medical education in an ACGME-accredited fellowship program is required, beginning after completion of the 3-year medical residency. To be accredited, the program must meet specific requirements, including a minimum of 4 institutional-based faculty members including the program director, and a ratio of 1:1.5 for faculty to students in programs with more than 8 trainees enrolled.

The robust requirements for facilities and resources to be an ACGME-accredited program include laboratories for cardiac hemodynamics, coronary angiography, percutaneous coronary interventions, invasive electrophysiologic studies, electrocardiography, ambulatory electrocardiogram recording, and exercise testing; and echocardiography. Additionally, facilities for the assessment of peripheral vascular disease and pulmonary physiology, critical care units (cardiac care unit, cardiac surgery intensive care unit), and devices including implantation of pacemakers, implantable cardioverter/defibrillators and their follow-up.

Clinical competence requirements include documentation of competency in patient care (interviewing, physical examination, procedural skills), medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice.

The program director is responsible for ensuring that the trainee is competent in all of those areas. The program director has the discretion to decide whether a trainee has achieved a satisfactory rating and awards full credit. If the trainee does not achieve a satisfactory rating, then it is possible to require the trainee to repeat the year of training, whether in overall clinical competence or in moral and ethical behavior. An unsatisfactory evaluation in either of those areas would require repeating the year of fellowship.

Certification examination and recertification

The certification examination is a proctored 12-hour written examination, held over 1.5 days. There are 240 questions on the first day and the second half-day includes 4 hours of motion studies (echo, angiography, aortograms), and electrocardiogram interpretation. The examination has 2 components: multiple-choice questions and the subsection of motions studies and electrocardiograms. A passing score must be achieved in both components to become certified in CV disease. Figure 1 lists the primary content areas in the written examination and their relative proportions.

Questions are developed to try to assess whether or not the trainee can answer clinical questions and be a consultant cardiologist. Thus, most of the board questions focus on clinical scenarios. A sample question is shown in Figure 2.

Board recertification is required after 10 years in the United States. This recertification is required in the US, because of increasing public concern about the quality and consistency of physician performance. The goal of recertification is to develop a continuous and credible evaluation process that is valuable to physicians, patients, and the healthcare system in the US. The 3 components of recertification include: 1) self-evaluation, including 5 test modules, 2) a secure 1-day examination, and 3) credentialing. Ideally, the board would like the candidate to spread their recertification efforts over the 10 years. However, in reality, most physicians do this in the last 1-2 years before the testing. The self-evaluation test modules are at-home, open-book testing modules that can be done through internet-based systems. Figure 3 shows a sample question on the self-study module that can be done on the internet. The cost for recertification includes a $945 fee per module and time (each module requires about 20 hours of study).

Training using simulation technology is on the horizon. The American Board of Internal Medicine is discussing and actively working on using simulators for board certification for the actual testing.

To be a board certified cardiologist in the US, one needs an accredited CV Fellowship training program, board certification and recertification, and lifelong continuing medical education.