Training and Testing Mismatch in CVD: Spotlight on the ABIM CVD Examination

April 20, 2016 | Ankur Kalra, MD & Ronnie Ramadan, MD

The American Board of Internal Medicine (ABIM), and its standardized testing for certification and recertification in cardiovascular disease, has been in the news lately, unfortunately for the wrong reasons. Cardiologists nationwide have voiced concerns over the relevance, sanctity and validity of the certification process and maintenance of certification (MOC), forcing the ABIM to revisit its policies and strategies, and hopefully partner with peers nationwide to bring about reforms that are pivotal for both its relevance in the current era, and its sustenance.

As recent diplomates of the ABIM in Cardiovascular Disease, we share the concerns that our seniors and peers have raised nationwide. The importance of understanding cardiovascular physiology, pharmacology, and pathophysiology cannot be underestimated. In fact, what differentiates an astute clinical cardiologist from other physician colleagues across the spectrum of sub-specialties in medicine is the strong foundation of cardiovascular mechanics and physiology that is applied at the bedside for taking care of the critically-ill patients.

However, cardiovascular physiological and pharmacological principles should not predominate standardized testing for certification of clinical cardiologists. Modern cardiology has become complex with significant advancement of sub-specialties within cardiovascular medicine, e.g., interventional cardiology, structural heart disease, electrophysiology and arrhythmias, advanced cardiovascular imaging, advanced heart failure and transplant cardiology, and preventive cardiology. Upon successful completion of a three-year general cardiovascular disease fellowship program, the graduating cardiologist is expected to be comfortable in managing patients with a myriad of complex cardiovascular co-morbidities and evaluating them on a longitudinal basis to establish robust clinical follow-up and physician-patient relationship.

The vision of the ABIM is to garner confidence in and embellish the physician-patient relationship by certifying the physician as an individual who has demonstrated competence in the diagnosis and management of cardiovascular diseases. Therefore, maintaining its focus on credentialing physicians in all aspects of cardiovascular medicine, questions in the standardized computer-based examination should be based on topics and clinical conundrums that are commonly encountered in the everyday practice of general cardiology in clinics, wards and coronary care units. For example, it is more important to know about indications for anticoagulation in mitral stenosis in a patient with a prior history of transient ischemic attack or a cerebrovascular accident for stroke prevention, even in the presence of normal sinus rhythm (or lack of objective evidence for paroxysmal atrial fibrillation), compared to deciphering a pressure-volume loop in severe mitral regurgitation. Similarly, it is more important to know about indications for implantable cardiac defibrillator placement post-acute myocardial infarction, or hypertrophic cardiomyopathy and arrhythmogenic right ventricular dysplasia compared to questions focusing on myoglobin heavy chain or plakoglobin genetic mutations in these respective cardiomyopathies.

The ABIM cardiovascular disease certification is a quality metric through which competence in clinical cardiology is adjudicated, and employers and sub-specialty program directors base their recruitment decisions on fellows' performance in the examination. The examination should be geared toward testing concepts that reflect complexities cardiologists encounter in their daily clinical practice and should not merely be a forum where trivia- or fact-based knowledge is tested.

We have the following suggestions to help better streamline the certification process for graduating fellows:

1. ABIM should collaborate with the ACC for streamlining content that is being tested.

As aforementioned, questions must maintain their relevance to the practice of cardiovascular medicine in the 21st-century. While it is important to understand the mechanisms of action of drugs and pathophysiological concepts behind cardiovascular adaptations to disease states, it is crucial to be up-to-date and tested on management of complex coronary and peripheral vascular disease, valvular heart disease, heart failure and transplant, and arrhythmias. Demonstrating competence in decision-making and in evidence-based management of patients with these issues takes precedence over the former. The College, through its educational initiatives in the form of continuing medical education series, webinars, various scientific sessions, and the lifelong learning competencies, has done a terrific job in investing in education of cardiologists, and ABIM should collaborate with leaders within the College to streamline content for board certification and recertification.

2. ABIM should reach out to cardiologists in clinical practice to peer-review content that merits testing.

As cardiologists and physicians invested in taking care of our patients to the best of our capabilities, we are ingrained with the concept of "primum non nocere," i.e. "first, do no harm." For us, that translates into learning state-of-the-art evidence-based knowledge and technologies that will help our patients. Cardiologists in practice should be surveyed for topics they think are of immense importance and should be on the certification examination for fellows to demonstrate competence in, prior to receiving the coveted certification. The examination should be able to enhance competence and reinforce learning that will help augment the practice of evidence-based medicine for our patients, and the ABIM has to partner with physicians in practice for delivering peer-reviewed content that establishes congruence with what physicians encounter in their daily practices.

3. Fellowship programs need to also focus on vascular medicine.

We are trained to be experts in cardio"vascular" diseases, not cardiology alone. Talking to peers across the country who recently took the ABIM examination for certification in cardiovascular disease, fellowship programs in general continue to lack a robust vascular medicine experience for fellows and a formal didactic curriculum to comprehensively understand and review vascular disorders (peripheral arterial and venous diseases, interpretation of ultrasound studies, medical and interventional management therapies) for clinical practice and board questions. The ABIM was spot-on here in testing content based on commonly encountered topics in vascular medicine in clinical practice and encouraged the test takers to read and get up-to-date information on current guidelines in the diagnosis and management of peripheral arterial and venous disease states. The ABIM should emulate this effort in other content areas as well.

For more information on MOC, visit

This article was authored by Ankur Kalra, MD, and Ronnie Ramadan, MD, clinical and research fellows in the division of interventional cardiology at Beth Israel Deaconess Medical Center, and clinical fellows in medicine at Harvard Medical School in Boston, Massachusetts.