American College of Cardiology

PROCEEDINGS OF THE 30TH BETHESDA CONFERENCE. THE FUTURE OF ACADEMIC CARDIOLOGY. BETHESDA, MARYLAND, OCTOBER 26-27, 1998.
JACC Vol. 33, No. 5, April 1999:1091-1135

30th Bethesda Conference:
The Future of Academic Cardiology*

Task Force 3: Teaching

Gabriel Gregoratos, MD, FACC, Co-Chair, Alan B. Miller, MD, FACC, Co-Chair

COMPARING TEACHING IN 1998 AND 1978

The leadership view. To obtain information regarding teaching in academic cardiology, a questionnaire was developed and distributed to the cardiology division chiefs at the Association of Professors of Cardiology annual meeting in March 1998. A similar questionnaire was distributed to the cardiology program directors at their annual meeting. Respondents were asked to rate these answers from 1 (strongly disagree) to 5 (strongly agree). The questions were:

1. Teaching is strongly emphasized at my institution.
2. Teaching is rewarded at my institution.
3. The time I have allocated to teaching is unchanged from 5 years ago.
4. Teaching is more important than the clinical responsibilities for my faculty.
5. Medical students, residents and cardiology fellows completing training in June 1998 are better trained than their counterparts 5 years ago.
6. I would be interested in having my faculty participate in a course in faculty development to improve teaching skills.

Program directors were asked essentially identical questions (see Tables 1 and 2 for results).

There were some interesting differences between the two groups. The division chiefs believed that time available for teaching had changed over the last five years and that clinical responsibilities outweighed teaching responsibilities, whereas the program directors were split on these two answers. The program directors felt that the recent graduates were better trained than their counterparts five years ago, but the division chiefs were split. Both groups believed teaching was emphasized at their institution but was unrewarded, and both groups were interested in faculty development.

A similar questionnaire was mailed to the deans of 143 medical schools in the U.S. and Canada. There were 30 responses. The questions and responses are tabulated in Table 3. The following main points by the responders are particularly relevant:

1. Cardiology teaching today is more technical and less clinical/bedside.
2. Cardiology teaching has been de-emphasized as primary care training has been emphasized.
3. There was a wide variance of opinion as to whether these changes were for the better or worse.
4. Almost as many responders indicated that cardiology teaching today is deficient as indicated it had improved compared with 1978. An equal number of responses were noncommittal.
5. Again there was a large variance among responders with regard to whether teaching was appropriately rewarded. Almost an equal number indicated that teaching was/was not emphasized in their institution. The consensus was that teachers were rewarded in a manner that was difficult to identify and quantify.
6. Some responders admitted to having no hard data to support their answers.
7. The majority indicated that faculty development programs were in force in their institutions.

Similar responses were obtained from a survey of those attending this Bethesda Conference (Table 4).

The view of the teachers. The learning process has changed in the past decade as less time is spent at the bedside and on core knowledge base acquisition. Although there are wide institutional differences, as a result of expansion of the core curriculum, cardiology material has been de-emphasized in some medical schools, and involvement of cardiology educators in the core teaching setting may not be as prominent. At the postgraduate level the case management approach de-emphasizes the physical examination and history taking at its worst, and at its best, assumes that knowledge of history taking and bedside examination skills are present (7,8). Wide-ranging discussions generated by a mixture of medical students and interns and residents are often lost because the groups are divided, medical students in one group and house staff in another. In some institutions, the small group (two to four students) physical diagnosis sections have disappeared.

There have been lengthy discussions about the low scores achieved on questions testing knowledge about physical findings on the Cardiovascular Board examinations. The candidates themselves often argue that it is more cost-efficient (and accurate) to order a cardiac echo than to spend time with bedside maneuvers to discriminate a murmur. The American Board of Internal Medicine emphasizes physical findings by requiring the trainee to be observed taking a history and performing a physical examination, as well as by providing a number of questions about physical examination findings on the Cardiovascular Boards. Despite this emphasis by the American Board of Internal Medicine, it appears that some training directors do not emphasize clinical skills sufficiently. Naturally, clinical skills include more than a physical examination, and extend to accurate and thorough history taking as well. There are other important clinical skills in areas emphasized by the American Board of Internal Medicine (9) that are frequently neglected because of the emphasis on technological teaching.

The creation of post-training period examinations, often called certifying or proficiency examinations, by groups that are not part of the "official" educational process or certification mechanism is a new development. For example, the North American Society of Pacing and Electrophysiology offers a proficiency examination in pacing called the NASPEXAM. The American Society of Echocardiography provides an examination in echocardiography. The American Society of Nuclear Cardiology offers an examination in their specialty. Most of these societies are careful not to call this examination a "certification" examination, to avoid the legal ramifications. In addition, although not the thrust of this report, several of these groups offer examinations for technicians as well.

Recognizing the desire of clinicians to have such certification, the American Board of Internal Medicine has created the Institute of Clinical Evaluation (10). This is a body now separate from the American Board of Internal Medicine (and therefore separate from the American Board of Medical Specialties and its rules and restrictions) that will offer certification in a variety of "niches." The Institute of Clinical Evaluation has purchased the American College of Cardiology electrocardiography examination and will administer it in 1999. In addition, the Institute of Clinical Evaluation is working with multiple organizations and is considering certificates in several other areas.

Teaching ability is perceived by many faculty to be variable. Inadequate teaching does occur and is difficult to document in the absence of standard evaluation techniques. Moreover, objective teaching evaluations are difficult to obtain. Student and house staff evaluations may not be true indicators of a teacher's effectiveness; and faculty are rarely called upon to evaluate their colleagues' teaching effectiveness. Educational research for the development of standardized evaluation techniques is necessary.

Objective data to support the views noted above by teaching faculty are not available. To the contrary, available data from the American Board of Internal Medicine cardiovascular subspecialty examination (Table 5) indicate that the mean scores achieved by candidates have improved modestly between 1989 and 1997. It is not clear, however, whether this improvement in scores is related to changes in content and changes in the level of difficulty of the certifying examination and may have been influenced by the increase in training program requirements from two to three years.