September 29, 2016 | Peter Flueckiger, MD
Education

Multimodality cardiovascular imaging technologies continue to develop and have an increasing role in assessment, diagnosis and management of cardiovascular disease. The combination of echocardiography and cardiac computed tomography for aortic valve stenosis and transcatheter aortic valve replacement (TAVR), multiple methods of assessing myocardial viability, and the myriad of stress testing options to evaluate coronary artery disease are just a few examples of integrative imaging and distinct choices clinicians make. Because of these clinical challenges and situations, it may be time to re-evaluate imaging training for the general cardiology fellow.

1. Removing the "silos:"
   Historically, cardiovascular imaging within fellowship training programs has been taught within a “silo” mentality, as fellows rotate between cardiology mainstays of echocardiography, nuclear imaging, and potentially cardiac MRI and cardiac CT. Reinforcing this approach, the Core Cardiology Training Symposium’s (better known as COCATS) requirements delineate training based on cumulative duration of training and total number of cases interpreted. Additionally, didactic conferences are often based on modality, for example echo conference, nuclear conference, etc.  While it’s clear that certain measures need to be defined for competency in any given imaging modality, additional integrative training may provide a great depth of experience in moving between different imaging tests.  For example, integrative training may start with didactic conferences based on disease pathology (for instance, myocardial viability) rather than imaging modality, thus focusing on the comparative utility of different imaging tests based on clinical presentation.
   
   Even fellows not pursuing an imaging or non-invasive cardiology career will face clinical situations necessitating a choice of the optimal imaging test. Providing meaningful competencies in specific imaging modalities, while bringing an integrative imaging approach to cardiovascular disease assessment and treatment remains a challenge in cardiovascular training programs. Changing the “silo” mentality may be a step in this direction.
2. Right test, right time, right patient:
   The choice of cardiovascular imaging is often dictated by a provider’s comfort, knowledge and/or confidence in a specific imaging modality. As previously described within cardiovascular imaging and other medical specialties, the stewardship of medical resources often falls on the clinician. An important skill that must be developed during training is answering the clinical question with the most appropriate cardiovascular imaging test. No matter one’s opinion on appropriate use criteria (AUC) and bundled reimbursements, a greater emphasis is being placed on these concepts, and this is particularly true in cardiovascular imaging. The ACC has been integrally involved in this movement with the “Choosing Wisely Campaign,” launched by the American Board of Internal Medicine (ABIM) in 2012, and the development of the FOCUS app to support clinicians in appropriate ordering cardiovascular imaging tests for SPECT MPI, PET, stress echo, and CTA. Furthermore, COCATS 4: Training in Multimodality Imaging specifically states the “appropriate use of technologies is essential for the competent practice of clinical cardiology.” With these recommendations and increasing emphasis on health care costs, integrative training and consultation with a multimodality imager can ensure a clinical question is answered in the most efficient and effective way with the “right test, at the right time, for the right patient.”
3. A heart team approach:
   As we have seen with TAVR, the development of the comprehensive heart team has been integral in the management of complex cardiovascular pathology to improve efficiency, patient care, and clinical outcomes. It is reasonable to translate this “heart team” approach to cardiovascular imaging. While all cardiology providers are not expected to be adept in multiple imaging modalities, the goal of general cardiology fellowship should be to ensure trainees are able to recognize advantages and limitations across multiple imaging modalities. When further expertise is need, consultation with experts in two or more imaging modalities may ensure that the patient is sent for the most appropriate test. Collaboration between interventional, electrophysiology, and non-invasive cardiologist is key to this idea.

Reframing the training paradigm of cardiovascular imaging may better prepare future trainees, even those not pursuing a cardiovascular imaging career, to succeed in the this evolving field within constraints of fellowship training, appropriate use criteria, and reimbursement models. While the above are just a few examples of to approach this topic, more work is needed to identify the best paths forward.

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This article is authored by Peter Flueckiger, MD, a Fellow in Training at Wake Forest Baptist Medical Center in Winston-Salem, NC.

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