Author + information
- Valentin Fuster, MD, PhD, FACC, Chair,
- John W. Hirshfeld Jr, MD, FACC, Co-Chair,
- Alan S. Brown, MD, FACC,
- Bruce H. Brundage, MD, MACC,
- W.Bruce Fye, MD, MA, MACC,
- Richard P. Lewis, MD, MACC,
- Ira S. Nash, MD, FACC,
- Michael H. Sketch Jr, MD, FACC and
- George W. Vetrovec, MD, FACC
The two main objectives of Working Group 8 were: 1) to present detailed definitions of the various “types” of cardiovascular specialists, and 2) to offer a new model for training general clinical cardiologists. It is important to establish common definitions of cardiology's recognized and emerging subspecialties. This standardized nomenclature will be of value to a wide range of individuals and organizations. Now is the time to develop and pilot a more focused and shorter training path for physicians whose career goal is to be a general clinical cardiologist. In response to the ongoing expansion of knowledge, technology, and techniques that define cardiology, the period of training required to become a board-certified cardiovascular specialist or subspecialist has lengthened. Meanwhile, the time devoted to preliminary training in general internal medicine has remained constant (three years). The growing shortage of cardiologists presents an opportunity for our nation's academic centers and regulatory bodies to become partners in the development of innovative alternatives to the traditional model of internal medicine and cardiology training.
A comprehensive system for classifying cardiologists
A more comprehensive system for classifying the various types of cardiovascular specialists active today will be of value: 1) to medical students, internal medicine residents, and cardiology trainees as they contemplate career options, 2) to institutions and organizations as they consider the spectrum of services they provide and the educational programs they sponsor, and 3) to various public and private organizations and agencies concerned with a wide range of socioeconomic aspects of cardiology. A standardized nomenclature for classifying the different types of cardiovascular specialists will also be very helpful for enhancing workforce projections because each type of cardiovascular specialist is likely to have a different supply/demand ratio depending on a variety of factors.
As cardiology evolved as a specialty during the second half of the 20th century, several distinct subspecialties emerged—mainly as a result of scientific advances and a series of technological and procedural innovations relevant to patient care. For example, the term invasive cardiologistappeared after the introduction of cardiac catheterization in the 1940s. Today, several different types of cardiologists provide specific services to patients and to other types of cardiologists, but there is no uniform system of classifying them for the purpose of surveys, workforce assessments, and a range of other purposes (Table 1).
For our purpose we chose to limit this classification to individuals who share one credential: they are board certified in cardiology. We recognize that much of the acute and chronic care provided to patients with cardiovascular disease is delivered by general internists, family physicians, and other providers, depending on the context. The working group also thought it would be more helpful to develop comprehensive descriptions of each type of cardiologist rather than brief, incomplete ones. It is important to acknowledge that many cardiologists actually blend two or more of these types in practice, and this trend is likely to continue. The boundaries are not fixed, although trends in certification and reimbursement are leading to more distinct rules regarding what training, experience, and credentials are required to provide certain types of care or perform and interpret some procedures. Several of the subspecialties that we define below require a “critical mass” of patients and specialized facilities and support staff. For this reason, many of them practice in academic institutions, referral centers, or in large single-specialty or multispecialty group practices.
The General Clinical Cardiologistfocuses on the diagnosis, medical management, and prevention of cardiovascular disease. He or she will be actively involved in the long-term care of patients with known cardiovascular disease. These cardiologists may limit their practice to outpatients or may combine office work with inpatient practice. General clinical cardiologists are frequently asked to see the patients in consultation by primary care physicians, other medical specialists, and surgeons. A general clinical cardiologist is skilled at selecting appropriate medications for the treatment of the broad spectrum of cardiovascular conditions. Most general clinical cardiologists will interpret electrocardiograms, Holter monitors, and exercise stress tests. Depending on the interests and training of the individual clinical cardiologist and the needs of their practice or institution he or she might interpret transthoracic echocardiograms and/or standard nuclear cardiology procedures, care for patients admitted to the coronary care unit, and perform diagnostic cardiac catheterization and coronary angiography. A general clinical cardiologist will not be trained or expected to perform interventional procedures or interpret more complex diagnostic tests such as cardiac MRI studies.
The Interventional Cardiologistperforms high-technological invasive therapeutic procedures such as percutaneous coronary intervention (PCI) for the treatment of acute coronary syndromes and non-acute coronary heart disease, balloon dilatation of the mitral valve, and percutaneous device closure of a patent foramen ovale. Depending on training and local need, an interventional cardiologist may perform percutaneous angioplasty on non-coronary vessels such as the carotid, renal, or femoral arteries. The scope of interventional practice continues to expand as new devices are invented and new techniques are developed. Interventional cardiologists should have special knowledge of how to use drugs that improve the outcome of PCI such as glycoprotein IIb/IIIa platelet receptor antagonists. He or she should also be familiar with how to incorporate the results of newer imaging modalities that assess viability (such as positron emission tomography [PET] scanning) into their decision-making process.
The Electrophysiologistfocuses his or her practice on the diagnosis and management of patients with cardiac arrhythmias. The electrophysiologist's armamentarium has grown substantially in the past two decades and continues to evolve rapidly. These specialists employ sophisticated invasive, high-technology procedures to characterize and treat cardiac arrhythmias. Pacemakers, invented in the late 1950s, are now very complex devices that require a sophisticated understanding of their capabilities and appropriate use. Although other types of cardiologists implant pacemakers, it is likely that these procedures will gravitate to electrophysiologists in many contexts. The electrophysiologist is skilled at performing catheter-based ablation procedures and implanting antiarrhythmia devices such as dual chamber pacemakers and cardioverter-defibrillators. He or she also has a sophisticated knowledge of antiarrhythmic drugs.
The Echocardiologistor Echocardiographerwill have level 2 or 3 training as defined by the American Society of Echocardiography and the ACC. He or she performs and/or interprets the entire spectrum of echocardiography techniques including comprehensive quantitative transthoracic echo-Doppler, stress echocardiography, and transesophageal echocardiography. In addition, some echocardiographers (depending on their interests and local needs) perform intraoperative echo and may be involved in evolving techniques such as intravascular ultrasound, three-dimensional echocardiography, and myocardial contrast echocardiography.
The Nuclear Cardiologistwill have training as defined by the American Society of Nuclear Cardiology and the ACC. He or she is trained to interpret all standard nuclear cardiology studies such as myocardial perfusion imaging, radionuclide angiography, and myocardial viability studies. He or she is skilled at helping other cardiologists and non-cardiologists decide which nuclear cardiology techniques are likely to provide the most useful information in a specific clinical situation. In an increasing number of institutions, nuclear cardiologists also interpret PET studies to evaluate myocardial viability.
The Computed Tomography/Magnetic Resonance Imaging Cardiologistfocuses on using state-of-the-art computed tomography (CT) and magnetic resonance (MR) techniques to aid in the noninvasive diagnosis and clinical management of cardiovascular disease. He or she will have significant advanced training in these techniques beyond the basic exposure available in many cardiology training programs today. Cardiac CT and MR are powerful tools that provide anatomic and physiological information that may complement other forms of cardiac imaging such as echocardiography and nuclear cardiology studies. Although in many institutions cardiac CT and MR studies are performed and interpreted by radiologists, there is a significant trend toward active collaboration between cardiologists and radiologists. In a growing number of settings, cardiology groups have purchased this equipment.
The Heart Failure and Transplant Cardiologisthas special training and expertise in the treatment of patients with advanced or refractory heart failure. Most patients with compensated heart failure are followed mainly by general clinical cardiologists and/or primary care physicians. The heart failure cardiologist has sophisticated knowledge of state-of-the-art pharmacological treatments and device therapies for patients with severe or decompensated heart failure. He or she will be familiar with the indications for cardiac transplantation and left ventricular assist device implantation and will have expert knowledge about the various pharmacological approaches for treatment of heart failure. These cardiologists will also be involved in the ongoing care of patients with significant heart failure, usually in conjunction with other physicians.
The Adult Congenital Cardiologisthas special training and expertise in congenital heart disease, especially as it exists in patients over the age of 18. He or she will have detailed understanding of the anatomy and physiology of the entire spectrum of treated and untreated congenital heart disease. Depending on their training, interests, and local need, the adult congenital cardiologist may limit his or her practice to non-invasive diagnosis and medical treatment. The adult congenital cardiologist may, however, perform a variety of invasive diagnostic and interventional therapeutic techniques.
The Preventive Cardiologistis a general clinical cardiologist with special interest and training in the primary and secondary prevention of cardiovascular disease. All types of cardiologists must know the basics of preventive cardiology and recommend appropriate therapy for patients they see in consultation or follow long term. The preventive cardiologist possesses a more detailed understanding of the interplay of known and emerging risk factors and will have expertise in treating patients with challenging lipid disorders. As knowledge about the complex pathophysiology of (and synergy between) various risk factors grows, it is important to have specialists who help to translate this growing scientific knowledge base into clinical practice. The preventive cardiologist will have a sophisticated understanding of vascular biology, clinical genetics, cardiovascular epidemiology, clinical pharmacology, and clinical trials that focus on prevention. In addition, he or she may coordinate multidisciplinary teams that focus on smoking cessation, cardiac rehabilitation, nutritional counseling, and other approaches to reducing cardiovascular risk.
The Vascular Medicine Specialisthas specialized training in the diagnosis and management of non-coronary vascular disease. This physician is involved in the management of patients with all aspects of vascular disease, including cerebrovascular, upper and lower extremity arterial, aortic, mesenteric, and renal artery disorders; venous thromboembolic disease (both acute and chronic); lymphatic disorders; vasculitis; hypercoagulable states; environmental and occupational vascular disorders. This specialist has expertise in vascular laboratory diagnostic testing. Vascular medicine specialists evaluate patients on both an outpatient and inpatient basis, and are involved in the long-term management of these patients. Physicians who obtain COCATS-II Level 3 training may also perform peripheral endovascular interventional procedures.
The Cardiovascular Investigatoris a cardiologist who devotes significant effort to one or more types of research (e.g., basic, clinical, and population-based) dealing with the cardiovascular system. History makes it abundantly clear that advances in the care of patients with cardiovascular disease have resulted from discoveries made in many disciplines—some quite remote from cardiology. Our definition excludes PhD scientists and other non-physicians who perform cardiovascular research because we are focusing on physicians whose career path included training in general clinical cardiology.
A new short-track model for training general clinical cardiologists
Background to the proposal
As outlined in the introduction to this Bethesda Conference report, the U.S. is facing a growing shortage of cardiologists. Of the various types of cardiologists described above, the evolving supply–demand mismatch is likely to be greatest for general clinical cardiologists. The ACC Cardiology Workforce Study 2002 of senior cardiology fellows revealed that a majority of current trainees hope to devote most of their time to one of cardiology's subspecialties (e.g., interventional cardiology or electrophysiology). Only 13% hoped to practice mainly general clinical cardiology (Fig. 1).
The need to train more general clinical cardiologists was emphasized in 1994 (1), and this goal was reemphasized recently by Willis Hurst (2). Based on demographic trends and our success at reducing the mortality from acute coronary syndromes, the number of Americans with chronic cardiovascular disease will increase significantly during the first quarter of the 21st century and beyond (3). Although the demand for high-technology diagnostic and therapeutic procedures continues to grow, going forward the greatest unmet need will likely be for sophisticated long-term outpatient care of adults with various types of chronic cardiovascular disease. This would be a major practice focus of the general clinical cardiologist—the type of cardiologist who is already in short supply. As discussed in the introduction to this report and by Working Group 5, patients with cardiovascular disease benefit from team care that coordinates and blends the skills of primary care physicians, specialists, subspecialists, and non-physician clinicians. The general clinical cardiologist should be a key member of this team in many clinical situations.
The notion that we need to train more general clinical cardiologists has widespread support. The fact that we have not succeeded in this goal reflects a combination of factors including the current length and structure of U.S. cardiology training. Today, as discussed by Working Group 1, there are not enough ACGME-approved and funded training slots to meet the growing demand for cardiovascular specialists, especially general clinical cardiologists who do not perform high-technology procedures (2,4,5). We believe our short-track model will help satisfy society's growing need for this important type of cardiologist. The model is a modified version of a 1997 proposal to create a hybrid “Generalist/Cardiovascular Specialist” (5).
Short-track model for training general clinical cardiologists
We propose that a five-year “short track” internal medicine–cardiology training program be developed and piloted for physicians whose career goal is to be a general clinical cardiologist. We defined the likely scope of practice for a general clinical cardiologist in the first section of our report, but there are many possible variations that reflect individual interests and local needs. The first two years of the program would consist of core training in internal medicine as defined by the ACP, the ABIM, and other entities that influence the content of general internal medicine training. The middle year of this five-year program would be devoted to clinical cardiovascular medicine. The focus of this year would be on the non-procedural aspects of cardiology with emphasis on primary and secondary prevention and the medical management of patients with cardiovascular disease (6). It might include, for example, elective rotations in endocrinology (reflecting the importance of diabetes as a cardiovascular risk factor), clinical pharmacology, peripheral vascular disease, or research. We believe it is important, however, to allow trainees and internal medicine and cardiology program directors to customize this middle year of cardiovascular medicine to reflect the interests of the trainee and to take advantage of the strengths of the institution. The final two years of the “short track” internal medicine-clinical cardiology training program would consist of traditional clinical cardiology fellowship training as outlined in COCATS II (7).
The product of this short-track model would be a general clinical cardiologist who is eligible for ABIM certification in internal medicine and cardiovascular disease. The scope of practice of most of the individuals completing this new model would fit the definition of the general clinical cardiologist proposed in this report. We anticipate that individuals completing this program will find opportunities both in academic medicine and in private practice because the general clinical cardiologist is the ideal physician to bridge the growing gap between primary care physicians and cardiology subspecialists—most of whom prefer to focus their practice on a specific type of problem (e.g., heart failure) or certain procedures (e.g., interventional cardiology).
Attracting applicants to a short-track general clinical cardiologist model
A five-year training program of core general internal medicine (2 years)–cardiovascular medicine (1 year)–general clinical cardiology (2 years) would replace the current six-year general internal medicine (3 years) cardiology training (3 years) program. This short-track option would be designed to train general clinical cardiologists and would likely attract a large number of qualified candidates. The ACC workforce survey of cardiology training program directors documented that there are many more qualified applicants for cardiology fellowships than there are ACGME-approved and funded positions. This short-track model might be especially attractive to female medical students and internal medical residents who are interested in general clinical cardiology but who do not want to delay their entry into practice for six or seven years after they receive their medical degree. This five-year short-track model would be an attractive option for any physician seeking an outpatient cardiology practice that focuses on noninvasive diagnosis, preventive cardiology, and expert long-term expert management of patients with cardiovascular diseases.
The intent of the short-track model we propose is clear, and individuals applying for these positions should have a sincere desire to practice general clinical cardiology. Understandably, some trainees will change their minds as they progress through the five-year program. Some may wish to extend their cardiology training by one or more years in order to become qualified to practice and be certified in a cardiology subspecialty. Meanwhile, some first-year cardiology trainees enrolled in a standard three- or four-year cardiology fellowship may decide to apply for the short-track. These options should exist, but if applicants for the short-track have a clear understanding of the intent, content, and consequences of the model and are selected carefully, shifts in or out of the five-year model should be infrequent.
In general, if innovations in graduate medical education are to succeed there must be a perceived benefit that justifies change and a critical mass of support to implement the proposed modifications. Although the model we propose has a clear purpose that would help meet a growing societal need, it will require the active support of several national organizations, including the ACGME, RRC, ABIM, ACP, and ACC, among others. Ideally, representatives of these bodies could be selected and meet soon with internal medicine and cardiology training directors from a few institutions willing to consider piloting a short-track program. The goal would be to develop a detailed model that could be piloted in a few selected academic medical centers within three years. As the details are worked out it will be important to establish criteria that will be used to evaluate whether this short-track model is achieving predetermined goals.
Theoretically, implementation of a short-track model should result in some cost saving for participating academic institutions, because general clinical cardiologists trained in this way would complete their postgraduate training in five rather than six years. Assuming a pilot institution receives the same amount of GME funding it might be possible to reallocate some of these funds to increase the total number of cardiologists they train. Moreover, philanthropic foundations might be interested in sponsoring one or more of these pilots because they represent an excellent opportunity to introduce innovations in graduate medical education and health care delivery that address a growing societal need for more general clinical cardiologists.
It is important to consider what impact a five-year program to train general clinical cardiologists might have on the traditional approach to training cardiovascular specialists. Because we believe there is a national need for more cardiologists, the model we propose does not recommend a commensurate decrease in the output of subspecialty cardiologists (whose training will last six or seven years following medical school graduation). In addition to being board eligible in internal medicine and cardiology (as would the five-year trainees), these cardiology subspecialists would also be eligible to take the ABIM examinations for added qualification in interventional cardiology or electrophysiology or similar examinations that have been (or will likely be) developed to acknowledge advanced training in other cardiology subspecialties.
Finally, this model should not undermine the research mission of academic medical centers. Indeed, it might actually enhance the research opportunities for trainees who have a sincere interest in this vital activity. Although the third year of cardiology training was originally envisioned as a means to expose all cardiology trainees to research, the growth of diagnostic and therapeutic procedures and the demand for additional elective time has already eroded the time most trainees devote to research.
In summary, we believe that now is the time to design and pilot a new training path for physicians that want to practice general clinical cardiology. Because they can fill a growing void between primary care physicians and cardiology subspecialists, it is likely that these individuals will find ample opportunities in private practice, academic medical centers, and other contexts. The dramatic and rapid growth of the hospitalist model of inpatient care in recent years demonstrates how innovations in health care delivery that meet the needs of physicians, patients, and institutions can succeed in a short period of time. We believe that a short-track program can be developed that will produce a cadre of cardiovascular specialists who are experts in general clinical cardiology.
- American College of Cardiology Foundation
Working Group 8 References
- Gunnar R.M.,
- Williams R.G.
- Hurst J.W.
- Foot D.K.,
- Lewis R.P.,
- Pearson T.A.,
- Beller G.A.
- Fye W.B.
- Merz C.N.,
- Mensah G.A.,
- Fuster V.,
- Greenland P.,
- Thompson P.D.
- ↵Beller GA, Bonow RO, Fuster V. ACC revised recommendations for training in adult cardiovascular medicine core cardiology training II (COCATS 2). American College of Cardiology web site. Available at: http://www.acc.org/clinical/training/cocats2.pdf. Accessed October 25, 2003