Introduction
Cardiovascular disease is the number one killer in developed countries. The need for
well-trained specialists is obvious due to the societal impact of the disease. Training
of cadres of future cardiovascular specialists is a daunting task. The ever-changing
technological landscape and fast growing literature make it even more challenging.
Time and effort invested into training such a specialist should pay off to society
in improved quality of life and longevity. We would like to discuss the training of
those who have just graduated from medical school and would be considered a “quality
final product” about 2025.
Candidate selection
In our opinion, in order to be a good cardiologist, one has to develop a broad medical
knowledge base first. Thus, prior sound internal medicine training is essential. As
cardiovascular disease is a major subspecialty of internal medicine and its fellowship
training is considered the most sought after in many countries, a good candidate base
exists for the selection of future cardiologists. The importance of appropriate selection
of an individual for training as a cardiovascular specialist cannot be underestimated.
This is where success (or lack thereof) starts and can end.
The US National Resident Matching Program (NRMP, a private, non-profit organization
established in 1952) and its derivative, the Medical Specialties Matching Program
(MSMP), provide a platform for competitive distribution of spots for postgraduate
training of physicians. It is arguably the largest, single, universal, countrywide,
most comprehensive and fair system of obtaining specialty training positions. The
NRMP uses a mathematical algorithm to place applicants into training positions. The
algorithm is based on applicants submitting their preferences (known as the rank order
lists). The programs submit their candidate preference lists. Thorough examination
of programs by candidates and vice versa, including candidate visits with formal interviews,
occurs. No applicant could obtain a better outcome than the one produced by the algorithm.
Research on the algorithm was the basis for awarding the 2012 Nobel Prize in Economic
Sciences.
The match algorithm works in the best interests of the candidate, but also ensures
that the coveted programs get quality candidates. It allows applicants and program
directors to consider each other without pressure, creating an impartial venue for
matching applicants’ and program directors’ preferences, and establishes a uniform
date for appointments to programs, as well as ensuring that the applicants meet requirements
for further training. Applications are uniform and electronic; the process is confidential
and fosters fairness. The NRMP also provides policies and specialty-specific data
for training programs and candidates. The 2015 Match was record breaking, with over
41,000 applicants competing for over 30,000 specialty training positions in 4,756
programs, including 50 subspecialties through its MSMP [1].
The more competitive a given specialty training is, the more applicants per spot;
however, applicants can apply to many programs through the match. Programs can interview
as many candidates as they deem appropriate. In our fellowship, each candidate is
interviewed by all key clinical faculty members, spends time with current fellows,
takes a tour of the facilities and is presented with the potential benefits/contract
package by our program coordinator. The rank list is prepared by a committee that
includes the fellowship faculty, Chair of the Department of Medicine, Internal Medicine
Residency Director, hospital administration, program coordinator and Dean of Graduate
Medical Education. Each candidate is openly discussed and then all key clinical faculty
members assign him/her equivalent points that are then averaged out and a rank order
list is created. Thus, the process is open and democratic, though the program director
has the right to veto (so far not exercised). Our program receives about 200 applications
per 2 spots in the first year of training. We choose about 25 to interview and rank
on the match list about 15, usually matching 2 in the top 5 of our list.
Training Quality Assurance
The Accreditation Council for Graduate Medical Education (ACGME) is a private, non-profit
organization that reviews and accredits graduate medical education (residency and
fellowship) programs, and the institutions that sponsor them, in the United States.
Established in 1981, the ACGME mission is to improve health care and population health
by assessing and advancing the quality of resident physicians’ education through accreditation.
In academic year 2013-2014, there were approximately 9,600 ACGME-accredited residency
and fellowship programs in 130 specialties and subspecialties at approximately 700
sponsoring institutions, with over 120,000 active residents and fellows.
Since 1981 the ACGME has been in charge of education quality of physicians, including
future cardiologists in the USA, with their endeavors followed elsewhere in the world.
Accreditation of a training program by the ACGME is necessary for its graduates to
be eligible for board examination in their specialty. The ACGME has standardized the
training requirements in detail and has been upgrading them regularly. Also it has
been expanding into creating specific programs for post-cardiovascular disease training
(i.e. interventional cardiology, electrophysiology). At present there are 193 accredited
cardiovascular disease fellowships in the USA and 144 interventional cardiology fellowships,
translating into about 3,000 trainees (2681 + 312 positions).
The ACGME regularly upgrades its requirements for training program accreditation,
working with specialty societies. From the cardiovascular disease standpoint, the
American College of Cardiology (ACC) provides updated guidelines for specialty training,
which usually are similar to or more stringent than ACGME ones. Then specific institutions/clinics/hospitals
that employ newly graduated and certified specialists have their own credentialing
requirements, which are usually in line with the ACGME and ACC, but can be more demanding,
too. Thus, training of a specialist needs to be conducted with a long-term plan in
mind, so that the individual is not only board exam eligible, but also can be given
privileges to practice in his/her specialty anywhere.
ACGME training general competencies are the same for all specialties. The six pillars
of training are patient care, medical knowledge, practice-based learning and improvement,
interpersonal and communication skills, professionalism, and system-based practice.
General requirements are followed by cardiology-specific, structured education, mandated,
standardized, and monitored by the ACGME in every accredited program. The number and
sort of conferences, length and content of rotations, and the training institution
clinical learning environment are specified by the ACGME. The monitoring has become
mostly electronic, with ACGME site visits regular but less frequent recently. The
institutions that conduct training are also monitored and guided by the ACGME in order
to provide an optimal learning environment for trainees. The ACGME has been active
in a Sponsoring Institution 2025 project, which will further improve the quality of
ACGME-accredited institutional sponsors of graduate medical education programs [2].
Specifics of training in cardiovascular disease
The modern cardiovascular disease specialist, whether going into the interventional
field, electrophysiology or imaging practice, needs to be exposed to a large number
of patients, studies, and procedures. The “numbers” experienced during training do
translate, in our opinion, into quality of the specialist education. These are simple,
though crude measures of the specialty training program quality as well as its graduates.
The ACGME and ACC have specific requirements for these numbers; however, the rule
of the more the better applies [3]. In our opinion, the usual numbers required by
these organizations can be comfortably doubled in a cardiology fellowship. Electronic
recording of the “volume” in training is optimal. This allows for easier tracking
of for example procedures performed by a fellow and allows for quick corrections if
need be, by the program director of a given fellow's training course.
Required rotations need to be intense, elective ones less so. Dedicated research time
is a must. Publishing and presenting abstracts at national and international cardiovascular
meetings should be required of the fellows. In our program every fellow needs to attend
and present at ACC Annual Sessions and the American Heart Association Annual Meeting.
They are required to publish a minimum of 5 manuscripts in peer-reviewed journals
during their 3-year training.
Globalization of cardiovascular medicine is reflected in the organizations from different
parts of the world writing together our practice guidelines. Modern training ideally
should involve exposure to different institutions and healthcare systems, even abroad,
in order to give an appropriate perspective and open the horizons. Visiting lecturers
and trainees from other institutions enrich the training on site. Especially in the
procedural-oriented specialty with rapid technology development that is cardiovascular
disease, trainees’ exposure to different institutions is very beneficial. As new technology
and techniques evolve, one can always learn something different at a different place.
I cannot forget a random statement made by a relatively young interventionist who
thought that he has “nothing new to learn by going elsewhere”. One cannot be more
wrong. Every trip, every conference, every patient is a learning opportunity. Especially
in early stages of a cardiovascular specialist career it is important to travel and
mingle with peers as well as masters in the specialty. This experience stays for life
and connections made then could benefit the trainee long term.
Evaluations of a fellow need to be obtained not only from clinical faculty, but also
should come from representatives of mid-level providers, medicine residents, nursing,
technicians, and medical students. Fellows should be part of the teaching service
for students and residents, optimally holding academic appointments at the medical
school associated with the training institution. Regular and objective evaluation
of fellows’ learning progress can be optimally evaluated by the annual ACC In-Training
Exam that for a fee gives the relative rank of fellows against their peers across
the country and points out areas needing improvement. The training program should
be evaluated by fellows in order to provide feedback for improvement. Our fellows
fill out ACGME-required annual surveys (anonymous), but also participate in our medical
school internal program evaluation.
In our opinion, the cardiovascular specialist of 2025 should receive comprehensive
training including all aspects of cardiology. The recent trends of narrowing the training
in fellowships and focusing on one field (for example on echocardiography) do not
serve our patients well. Thus, we promote exposure to every aspect of imaging and
invasive procedures for our fellows, with an opportunity to obtain expertise that
would give them credentials in most institutions. The trends to subspecialize early
in the career are not necessarily providing quality specialists. Moreover, in cardiovascular
disease procedures we have seen convergence of specialties with widening of the scope
of practice of cardiovascular specialists [4].
The practice of evidence-based medicine has seen a shift from specific database searches
(e.g. Medline) on a specific clinical question towards applications of guidelines
and broader practice updates. Fellows need to be taught how to exploit comprehensive
clinical decision support resources like UpToDate in addition to classical medical
literature searches [5].
Our cardiovascular fellowship program started over 3 years ago and has been built
on the above ideas. Our first graduates have already passed the cardiovascular disease
board exam, and have received board certification in nuclear cardiology, cardiac CT,
echocardiography and vascular medicine. They have published over 10 manuscripts each
and presented multiple abstracts at international meetings. Perhaps the best proof
that the above ideas work is the fact that our fellows are last ACC Annual Meeting
national champions in Fellows-In-Training Jeopardy. Team South Dakota, coming seemingly
“out of nowhere”, could compete and win with the best, well-established programs.
Conclusions
Cardiovascular specialist training is a major enterprise. Only a structured, standardized,
multiple-check system can produce a good specialist. Further training standardization,
compliance with accreditation requirements, institutional involvement and compliance
are the bases for a good training program. Trainee's heavy case load, regular evaluations
and standardized medical knowledge testing are prerequisites for success. Widening
horizons with away rotations and national/international conferences plus promoting
fluency on guidelines will further advance our trainees.