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Task
Force 1: Training in Clinical Cardiology
Joseph S. Alpert, MD, FACC - Chairman
William J. Arnold, MD, FACP
Bernard R. Chaitman, MD, FACC
C. Richard Conti, MD, FACC
Gordon A. Ewy, MD, FACC
Eric L. Michelson, MD, FACC
Robert J. Myerburg, MD, FACC
The training experience in clinical cardiology
is fundamental to the development of the specialist
in cardiovascular medicine. It should provide
a broad exposure to acute and chronic cardiovascular
diseases, emphasizing accurate ambulatory and
bedside clinical diagnosis, appropriate utilization
of diagnostic studies and integration of all data
into a well communicated consultation, with sensitivity
to the unique features of each individual patient.
Active participation in research projects will
provide the trainee with further experience in
critical thinking and in evaluating the cardiology
literature. The knowledge, skills and experience
realized by this broad training are essential
to providing a solid foundation in clinical cardiovascular
medicine before focusing on more specialized areas,
which, for some, may become the dominant feature
of professional activity. Other goals should be
to provide a broad clinical background with an
emphasis not only on pathophysiology, therapeutics
and prevention, but also on the humanistic, moral
and ethical aspects of medicine. Although cardiologists
who are highly skilled in diagnostic and therapeutic
techniques are necessary, the fundamental requirement
for broad clinical insight needed by the consultant
in cardiovascular medicine should be emphasized.
General
Aspects of Training
Training
Institutions
Programs of training in cardiology must be accredited
and be offered only in university or university-affiliated
institutions that have a residency training program
in internal medicine and in cardiovascular disease,
fully accredited by the Accreditation Council
for Graduate Medical Education (ACGME) or the
American Osteopathic Association.
Prerequisites
for Training
Training in cardiology should almost always take
place after successful completion of at least
3 years of postdoctoral education and training
in internal medicine.
Objectives
of Training
The general principles enumerated in the General
and Special Requirements for Residency Education
in Internal Medicine (1) are also applicable to
training in cardiology. Cardiology training programs
must provide an intellectual environment for acquiring
the knowledge, skills, clinical judgment, attitudes
and values that are essential to cardiovascular
medicine. Fundamental to this training is the
provision of the best possible care for each individual
patient delivered in a compassionate manner. All
physicians undergoing training in cardiology must
have and maintain humanistic and ethical attributes
(1-4). The objectives of a training program in
cardiology can be achieved only when the program
leadership, supporting staff, faculty and administration
are fully committed to the educational program
and when appropriate resources and facilities
are present. Effective graduate education requires
an appropriate balance between academic endeavors
and clinical service. During training in cardiology,
faculty should encourage trainees to cultivate
an attitude of scholarship and dedication to continuing
education that will remain with them throughout
their professional careers. The development of
a scholarly attitude includes active participation
in and completion of one or more research projects
supervised by faculty actively engaged in research,
ideally followed by publication in critically
reviewed journals. These activities will provide
additional experience in critical thinking and
will help develop an attitude of scholarship and
greater insight into the problems of analyzing
and reporting data and other observations obtained
from patients.
Role
of the Specialist and Duration of Training
Training in cardiology must take into account
the role that the cardiovascular specialist is
likely to play in the health care delivery system
of the future. As a consequence of the aging of
the population, the demand for cardiovascular
care will increase. Cardiovascular specialists
will have to serve as high level expert consultants
and procedural specialists, and the training must
reflect this expanded role.
The 3-year training program should include a clinical
core of 24 months with a minimum of 1) 8 months
in nonlaboratory clinical practice activities
(cardiac consultation, inpatient cardiac care,
coronary care unit [3 months], cardiothoracic/cardiovascular
surgery, congenital heart disease, heart failure/cardiac
transplantation, preventive cardiology); 2) 4
months in the cardiac catheterization laboratory;
3) 6 months in noninvasive imaging (echocardiography
and Doppler [minimum 3 months], peripheral vascular
studies, nuclear cardiology techniques [minimum
2 months]), nuclear magnetic resonance and other
techniques (e.g., cine computed tomography); 4)
2 months (in blocks or equivalent experience)
in electrocardiography, stress testing, ambulatory
electrocardiographic (ECG) monitoring; and 5)
2 months in arrhythmias, permanent pacemaker management
and electrophysiology. A continuing ambulatory
care experience for at least a 1/2 day/week should
occur throughout the 3-year training program (fig.
1).
These time periods are considered to be the minimal
time required to learn the indications, interpretative
skills, knowledge of complications, risk/benefit
and cost/benefit of these procedures. This core
24-month training period does not qualify a trainee
as a consultant in cardiovascular disease or as
an expert in these technical procedures.
The remaining 1 year in the program should include
6 to 12 months of dedicated research or research
combined with focused areas of the individual
trainees' interests and future career goals. This
may include the acquisition of additional, more
intensive training in specific areas of cardiovascular
medicine. Trainees often require additional clinical
training during the final period of 12 months
to be qualified to function properly as consultants
in cardiovascular disease and as specialists in
cardiology. This latter period permits the trainees
to obtain greater experience and supervised training
in the clinical management of patients with cardiovascular
disease and to obtain additional training in the
performance and application of particular diagnostic
or therapeutic procedures. Trainees planning an
academic career usually need additional training.
Vacation time should also be included, as well
as time for participation in professional meetings
and conferences.
Program
Faculty
The program must be conducted under the auspices
of a program director who is highly competent
in the specialty of cardiovascular disease and
fully committed to the training of the cardiovascular
specialist. The director of the cardiology training
program must be certified by the American Board
of Internal Medicine Subspecialty Board on Cardiovascular
Disease or possess suitable equivalent qualifications.
The director is responsible for the adequacy of
the facility, including support resources for
the provision of an education of high quality.
There should be one full-time equivalent faculty
member for each 11/2 trainees in the Division
(or Section) of Cardiology to guarantee close
supervision of all trainees and to allow for the
critical evaluation of the program and the competence
of the trainees. Each rotation and laboratory
should have faculty who supervise the fellows.
It is essential that the cardiology program director
devote sufficient time and effort to the graduate
education program and related activities. Cardiology
program directors must be full-time faculty members.
The program director must have the effective support
of the institution(s) where the training takes
place so as to provide these educational attributes.
Environment
for Training in Clinical Cardiology
Interaction
With Other Disciplines
Cardiology training programs must provide an intellectual
environment for acquiring the knowledge, skills,
clinical judgment and attitudes that are essential
to the practice of cardiovascular medicine. Specialists
in cardiovascular disease must interact with generalists
as well as specialists in other areas and have
knowledge of other specialties in order to provide
excellent patient care. The ACGME requires at
least two other subspecialty training programs
and a residency in internal medicine. Thus, the
training program should enable the trainee to
interact with other disciplines through the availability
of collaborating consultants and suitable patients.
Close interaction with cardiovascular/cardiothoracic
surgery is of particular importance. The overall
program must provide advanced training to allow
the physician to acquire expertise as a specialist
and consultant in cardiology.
Relation
to Training in Internal Medicine
Cardiology training programs must provide the
opportunity for cardiology trainees to maintain
their skills in general internal medicine as well
as in those aspects of cardiology that relate
to internal medicine. Therefore, the cardiology
program must be closely related to the training
program in internal medicine, and there must be
closely delineated lines of responsibility for
the residents and staff in internal medicine and
the cardiology trainees. There should be close
working contact by the trainees with residents
and fellows in other areas, including surgery,
anesthesia, radiology, pulmonary disease, pathology,
pediatrics and neurology. When appropriate, teaching
and supervision by expert faculty in these disciplines
should occur.
Required
Training Program Resources
The program must have certain minimal resources,
including the following:
- There
must be inpatient and outpatient facilities
with an adequate number of patients of a wide
age range with a broad variety of cardiovascular
disorders. Trainees must be supervised and evaluated
on every rotation by qualified faculty members
when seeing patients in both areas. Outpatient
care must be carefully supervised by faculty
members.
- The
facility must provide laboratories for cardiac
catheterization, electrocardiography, exercise
and pharmacologic stress testing, Doppler/echocardiography,
ambulatory ECG monitoring and noninvasive peripheral
vascular studies. There must be appropriate
facilities for cardiac catheterization, angiography
and hemodynamic assessment, with adequate numbers
of patients undergoing interventional procedures,
including coronary angioplasty, atherectomy,
stent placement, myocardial biopsy, transvalvular
balloon dilation and intraaortic balloon placement
(see also Task
Forces 2 to 4).
- Facilities
for nuclear cardiology must be available, including
ventricular function assessment, myocardial
perfusion imaging and studies of myocardial
viability (see also Task
Force 5).
- There
must be appropriate facilities for the management
of patients with arrhythmias, including electrophysiologic
testing, arrhythmia ablation, signal-averaged
electrocardiography and tilt-table testing as
well as the previous evaluation, implantation
and assessment of patients with cardiac pacemakers
and implantable antiarrhythmic devices and their
long-term management (see Task
Force 6).
- Facilities
and faculty for training in cardiovascular research,
including various basic science modalities,
are important (see Task
Force 7).
- There
must be modern intensive cardiac care facilities.
- There
must be facilities for cardiac and peripheral
vascular surgery and cardiovascular/cardiothoracic
surgical intensive care. Close association with
and participation in a cardiovascular/cardiothoracic
surgical program is an essential component of
the cardiovascular training program. This must
include active participation in the preoperative
and postoperative management of patients with
cardiovascular disease. Exposure to cardiac
transplantation is strongly recommended (see
Task
Force 8).
- There
must be facilities and faculty involved in the
diagnosis, therapy and follow-up care of patients
with congenital heart disease (see Task
Force 9).
- There
must be appropriate facilities for the clinical
and laboratory assessment of patients with systemic
hypertension and peripheral vascular disease
(see Task
Force 10).
- There
must be facilities for assessment of cardiopulmonary
and pulmonary function, cardiovascular radiography
and magnetic resonance imaging (MRI).
- There
must be appropriate expertise and instruction
in preventive cardiology and risk factor modification,
including management of lipid disorders (see
Task
Force 10).
- There
must be facilities and faculty with knowledge
of cardiovascular pathology.
- There
must be facilities, personnel and faculty with
expertise in cardiac rehabilitation.
- There
must be other appropriate facilities and resources
necessary to accomplish the training, including
a comprehensive medical library, facilities
for continuing medical education, experimental
study design and statistics and quality assurance.
Training
Components
An educational clinical cardiovascular disease
training program must have the following training
objectives and characteristics and must encompass
the following areas:
- Training
in Patient
- Care
and Management
All trainees must be skilled in obtaining a history
and performing a complete cardiovascular physical
examination. All trainees must be familiar with
the role of aging and psychogenic factors in the
production of symptoms and the emotional and physical
response of patients to cardiovascular disease.
They must be familiar with the importance of preventive
and rehabilitative aspects of the management of
patients with known or potential cardiovascular
disease. The trainee should have considerable
experience acting as a consultant to other physicians
and should have direct patient care responsibility
under supervision in proportion to his or her
experience and qualifications. Extensive outpatient
training is essential.
Training
in Understanding, Diagnosis, Prevention and Treatment
of Cardiovascular Disease
The trainee must become well educated in pathogenesis,
pathology, risk factors, natural history, diagnosis
by history, physical examination and laboratory
methods, medical and surgical management, complications
and prevention of cardiovascular conditions, including
coronary artery disease, hypertension, valvular
heart disease, congenital heart disease, cardiac
arrhythmias, heart failure, cardiomyopathy, involvement
of the cardiovascular system by systemic disease,
infective endocarditis, diseases of the great
vessels and peripheral blood vessels, diseases
of the pericardium, pulmonary heart disease, the
interaction of pregnancy and cardiovascular disease,
cardiovascular complications of chronic renal
failure, traumatic heart disease and cardiac tumors.
Training
in Intensive Care
The training must include at least 3 months of
full-time experience with patients undergoing
intensive care for acute cardiovascular disorders
and acute coronary care. Exposure to and an understanding
of the indications, risks and benefits of cardiac
surgery, coronary angioplasty and the various
phases of cardiac rehabilitation must be included.
Training
in Ambulatory, Outpatient and Follow-Up Care
Continued responsibility for outpatient cardiovascular
patient management and consultations must occupy
at least 1/2 day/week for 36 months or an equivalent
period. Ambulatory continuity clinic is essential
for the duration of training. There should be
exposure to a wide age span of patients from adolescence
through old age with a spectrum of cardiovascular
diagnoses, including postoperative patients, patients
with congenital heart disease and patients for
evaluation and management related to pregnancy.
Additional ambulatory experience in specialty
clinics or hospital-based settings is desirable
and may include participation in same-day diagnostic
or therapeutic procedures.
Training
in Electrocardiography
All cardiovascular trainees must be skilled in
the interpretation of ECGs. There must be appropriate
review and audit and evaluation of their skills.
All cardiology trainees must be skilled in the
performance and interpretation of exercise ECG
tests and ambulatory and signal-averaged ECGs,
as described in Task
Force 2.
Training
in the Cardiac Catheterization Laboratory
There must be direct experience under supervision
in a general adult cardiac catheterization laboratory
that performs both right and left heart catheterizations.
This initial experience in the cardiac catheterization
laboratory must emphasize the fundamentals of
cardiovascular physiology as it relates to clinical
disease, the analysis of hemodynamic records and
the interpretation of angiographic images. Such
an experience must also emphasize the problems
in interpretation and analysis of such data and
the importance of quality. All fellows must have
adequate training in the principles of radiation
safety. The amount of training in the mechanical
skills of cardiac catheterization is addressed
by Task
Force 3. The acquisition of advanced procedural
skills is not the primary purpose of the initial
exposure of the trainee to the cardiac catheterization
laboratory. All trainees must understand indications,
risks and benefits of interventional therapeutic
procedures, as described in Task
Force 3.
Training
in Echocardiography
All trainees must participate in the performance
of echocardiography and Doppler echocardiography,
including a minimum of 3 months of training. All
trainees must understand the indications, risks
and benefits of transesophageal and stress echocardiography,
as well as the principles of evolving techniques
such as intravascular ultrasound. Those trainees
wishing to perform these latter techniques or
to direct an echocardiography laboratory must
have additional training, as described in Task
Force 4.
Training
in Nuclear Cardiology
All trainees should know the general principles,
indications, risks and benefits of nuclear cardiovascular
procedures, such as radionuclide ventriculography
and myocardial perfusion and viability assessment.
All trainees must receive basic training in radiation
safety. Those trainees wishing to perform these
tests must have additional training, as described
in Task
Force 5.
Training
in Other Advanced Imaging Techniques
All trainees should be aware of major evolving
advanced imaging techniques, such as MRI and cine
computed tomography (cine-CT).
Training
in Cardiac Arrhythmia Device Management
All trainees must understand the diagnosis and
management of cardiac arrhythmias. Trainees should
know the indications for cardiac arrhythmia devices
and the principles of management and follow-up
of patients with implanted pacemakers and antiarrhythmic
devices, as described in Task
Force 6. Participation in implantation is
desirable.
Training
in Electrophysiology
All trainees must be skilled in the selection
of patients for specialized electrophysiologic
studies, including arrhythmia ablation. Those
wishing to perform these procedures should receive
additional training, as described in Task
Force 6.
Training
in Cardiovascular Research
All trainees should participate actively in research
activities. Trainees who anticipate a career in
academic cardiology should have additional specialized
training, as described in Task
Force 7. All trainees should understand clinical
trial design and biostatistics.
Training
in Heart Failure and Heart Transplantation
All trainees must understand the diagnosis and
management of patients with heart failure and
of cardiac transplant recipients, as described
in Task
Force 8.
Training
in Congenital Heart Disease in the Adult
All trainees must understand the diagnosis and
management of adult patients with and without
surgical repair of congenital heart disease, as
described in Task
Force 9.
Training
in Peripheral Vascular Disease
The trainee must develop sound knowledge of the
clinical features and treatment of peripheral
vascular disease, demonstrate competency in obtaining
the history and in performing the physical examination
of the arterial and venous systems and should
become proficient in selecting and interpreting
peripheral angiography, noninvasive imaging, Doppler
vascular studies and impedance plethysmography
(see Task
Force 10).
Training
in Related Sciences
The training program should provide an opportunity
for continuing education in basic sciences, including
those aspects of anatomy, physiology, pharmacology,
pathology, genetics, biophysics and biochemistry
that are pertinent to cardiology, particularly
vascular biology, thrombosis and molecular biology.
The availability of educational programs in biostatistics,
computer sciences and biophysics is highly desirable.
It is essential for trainees to acquire a thorough
understanding of the normal physiology of the
circulatory system, including the adaptation of
the cardiovascular system to exercise, stress,
pregnancy, aging and renal and pulmonary abnormalities,
and the interpretation of tests of renal and pulmonary
function. Training in medical economics, health
care systems delivery, clinical decision making,
preventive medicine and health care outcomes should
also be available.
Training
in Related Fields of Medicine
The trainee must gain knowledge and experience
in a number of related areas of medicine, including
the following:
Magnetic
resonance imaging
Familiarity with the cardiovascular applications
and interpretations of magnetic resonance images
is essential to the training of a cardiovascular
fellow. This imaging modality has many existing
uses and considerable potential in noninvasive
diagnosis. It is recommended that, where available,
the fellow devote 2 months of time to magnetic
resonance imaging (MRI). To become conversant
enough with this methodology to be proficient
with interpretation, a 4-month experience is recommended,
and to become experienced enough for development
and management of an MRI laboratory, a 1-year
comprehensive experience is essential.
Radiology
The interpretation of cardiovascular X-ray films,
with particular reference to vascular structures
and special cardiovascular radiologic procedures.
Surgery
The risks and benefits of cardiothoracic and
cardiovascular surgery and the rationale for
the selection of candidates for surgical treatment,
as well as the natural history and the preoperative
and postoperative management of patients with
cardiovascular disease and various comorbid
conditions.
Anesthesia
Close collaboration with anesthesia colleagues
in the preoperative and postoperative management
of patients with cardiac disease for cardiac
and noncardiac surgery, and cardiac procedures
requiring anesthesia (e.g., cardioversion).
Pulmonary
disease
A solid knowledge of basic pulmonary physiology
in addition to the interpretation of pulmonary
and cardiopulmonary function testing, blood
gases, pulmonary angiography and radioactive
lung scanning methods and experience with the
management of patients with acute pulmonary
disease.
Obstetrics
A solid knowledge of the interrelations between
pregnancy and heart disease, together with experience
in the clinical management of patients with
heart disease who are pregnant.
Physiology
The physiology of the cardiovascular system,
its response to exercise and stress and the
alterations produced by disease.
Pharmacology
The pharmacology and interactions of cardiovascular
drugs and drugs affecting cardiovascular function.
Pathology
Familiarity with the gross and microscopic pathology
of all major forms of heart disease.
Geriatrics
Familiarity with the effects of aging on cardiovascular
disease and therapeutics is important.
Training
Through Conferences, Seminars, Review of Published
Reports and Lectures
There must be regularly scheduled cardiology conferences
(e.g., three per week), seminars and review of
published data. The participation of the trainees
in the planning and production of these conferences
is expected. Attendance at medical grand rounds
and multidisciplinary conferences is highly desirable,
particularly conferences closely related to cardiovascular
disease, such as conferences on surgery, radiology
and pathology. Visiting professors should provide
stimulation and at least informal evaluation and
feedback to trainees and faculty.
Teaching
and Educational Experience
The trainee must participate directly in the teaching
of cardiology and become familiar with the fundamental
principles of education, including skills in organization
of conferences, lectures and teaching materials.
The teaching experience, often by weekly or more
frequent core content conferences, must attempt
to collate basic biomedical information with the
clinical aspects of cardiology, including integration
of clinical management principles. Trainees must
be familiar with modern concepts of education
and effective communication. They must be responsible
for teaching and supervising residents in internal
medicine as well as medical students, other cardiology
trainees and allied health personnel and for working
collaboratively with other health care professionals.
They must have regularly scheduled experiences
in teaching and must be encouraged to attend and
participate in national cardiology meetings. Trainees
must learn to prepare successfully through self-study
and participation in continuing education, using
various media, for certification, recertification
and credentialing.
Special
Procedural Areas
In specific procedural areas of cardiology, minimal
training is appropriate for physicians who do
not plan to achieve additional qualifications
in a given field. Conversely, those physicians
who wish to become qualified in specialized areas
require additional training, as specified by the
individual task forces.
Evaluation
and Documentation of Competence
The evaluation of trainees for both clinical and
specialized technical skills must be carefully
documented. Cardiology program directors must
establish procedures for the regular evaluation
of the clinical competence of the cardiology trainees.
This evaluation must include intellectual abilities,
manual skills, attitudes and interpersonal relations
as well as specific tasks of patient management,
clinical skills (including decision-making skills)
and the critical analysis of clinical situations.
There must be provision for appropriate feedback
of this information to the trainee at regular
intervals. Records must be maintained of all evaluations
and of the number and type of all laboratory procedures
performed by each trainee. Examinations (e.g.,
Adult Clinical Cardiology Self-Assessment Program
[ACCSAP]) at the end of each year of training
or each specialized area are strongly encouraged.
References
- General
Special Requirements for Residency Education
in Internal Medicine. Specialty Requirements
for Residency Education in Cardiovascular Disease.
Graduate Medical Education Directory, 1994-1995.
Chicago: American Medical Association 1994:45-58.
- American
Board of Internal Medicine. Evaluation of humanistic
qualities of the internist. Subcommittee on
Evaluation of Humanistic Qualities in the Internist.
Ann Intern Med 1983;99:720-4.
- Ad
Hoc Committee on Medical Ethics, American College
of Physicians. American College of Physicians
ethics manual. Part I: history of medical ethics,
the physician and the patient, the physician's
relationship to other physicians, the physician
and society. Ann Intern Med 1984;101:129-37.
- Ad
Hoc Committee on Medical Ethics, American College
of Physicians. American College of Physicians
ethics manual. Part II: research, other ethical
issues. Recommended reading. Ann Intern Med
1984;101:263-74.
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