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
FACTORS
AFFECTING TEACHING
Because
of the previously mentioned time constraints, the attending
physician who is focused upon specific aspects of patient
care must assume knowledge on the part of the house
staff/trainee to expedite rounding on patients and not
have to provide "remedial cardiology." On
the other hand, there is no question that one can teach
at the same time as one does clinical care, provided
that the house staff/trainee is following along; the
pace is necessarily rapid and the experience therefore
may be suboptimal. However, it should not be assumed
that seeing patients is somehow a different activity
from teaching about them during the encounter (rather
than later, in a conference room).
Reduction
of inpatient base is not necessarily a drawback. The
cardiologist is the only practitioner to whom the clinic/hospitalist
dichotomy does not apply, because the cardiologist is
apt in each area. Indeed the cardiologist must follow
the patient from hospital to clinic and back to follow
the natural history of disease and results of therapy.
Cardiologists
have become progressively specialized and divided into
groups such as the electrophysiologist, echocardiographer,
interventionalist and so forth. Unless a patient with
a particular problem in the area of expertise of the
subspecialist is presented on rounds, the attending
physician's teaching information base may be limited.
The emphasis on technology over basic clinical skills
is widespread. Teaching is left not uncommonly to technology-based
cardiologists; each emphasizes his/her own discipline
to the detriment of general knowledge acquisition and
with resulting transmission of various biases. For example,
the interventionalist promotes primary angioplasty over
thrombolysis, the echocardiographer promotes stress
echo over other forms of stress imaging. This type of
teaching lacks balance and supports the concept that
the cardiologist is a technician. Protocols which do
not allow the faculty or trainees the opportunity to
formulate or alter diagnostic or treatment algorithms
are probably detrimental. It is difficult to know whether
management by protocol has really impacted the academic
center.
The
role of the cardiology fellow in teaching is not well
defined. Certainly service needs have reduced the available
teaching time for fellows as well as faculty. All fellows
are not equally skilled in teaching. Therefore, fellowship
programs should foster teaching skills, as these skills
will be important regardless of the fellow's subsequent
role in formal academic medicine or practice. There
is a role for "Fellows Conferences" with house
staff and medical student teams that occur on a regular
basis. Fellows could provide some of the core knowledge
that may otherwise not be provided (such as the physiology
of heart failure) or could serve as a resource for providing,
for example, up-to-date clinical trials material. Just
as research time is protected, this fellow educator
time would have to be protected.
The
academic reward for teaching continues to be difficult
to assess despite acknowledgment of its value (11).
Objective measurements of teaching effectiveness are
difficult to obtain due to the lack of adequate standards
for teaching evaluations. Educational research in this
area is limited, and more is needed.
Financial
support of faculty with major teaching time commitments
is a problem. Specific budgets to support teaching have
not been developed in many institutions (despite the
fact that teaching is a major raison d'être of
medical schools). This has limited the capability of
divisions of cardiology, departments of medicine and
pediatrics and schools of medicine to support teaching
activity. Therefore, many clinician-educators are required
to spend more and more time in patient-related activities
to "cover their salary."
The
financial cost of education in the 21st century must
be clearly defined (12).
State support of medical school graduate education needs
to improve. Postgraduate (specialty and subspecialty)
educational costs must be borne by all health care payers
and not Medicare alone. Institutional support of postgraduate
education (trainees' salaries and faculty support) must
be standardized, as these trainees provide valuable
services to their institutions and will be a valuable
resource to the community. To pursue these changes,
the academic cardiology unit must develop accurate cost-accounting
methods for its teaching activities.
Training
programs which do not have a strong commitment to education
as opposed to service should be eliminated. The Residency
Review Committee must be increasingly stringent in this
activity and be supported by the medical community.
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