Author + information
- Christopher M. Kramer, MD, FACC, Chair,
- W. Gregory Hundley, MD, FACC,
- Raymond Y. Kwong, MD, MPH,
- Matthew W. Martinez, MD, FACC,
- Subha V. Raman, MD, FACC∗ and
- R. Parker Ward, MD, FACC
- ACC Training Statement
- cardiovascular imaging
- cardiovascular magnetic resonance
- steady-state free precession
1.1 Document Development Process
1.1.1 Writing Committee Organization
The Writing Committee was selected to represent the American College of Cardiology (ACC) and the Society for Cardiovascular Magnetic Resonance (SCMR) and included a cardiovascular training program director, a cardiovascular magnetic resonance (CMR) training program director, early-career experts, highly experienced specialists representing both the academic and community-based practice settings, and physicians experienced in defining and applying training standards according to the 6 general competency domains promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) and endorsed by the American Board of Internal Medicine (ABIM). The ACC determined that relationships with industry or other entities were not relevant to the creation of this general cardiovascular training statement. Employment and affiliation details for authors and peer reviewers are provided in Appendixes 1 and 2, respectively, along with disclosure reporting categories. Comprehensive disclosure information for all authors, including relationships with industry and other entities, is available as an online supplement to this document.
1.1.2 Document Development and Approval
The Writing Committee developed the document, approved it for review by individuals selected by the ACC and SCMR, and then addressed the reviewers’ comments. The document was revised and posted for public comment from December 20, 2014, to January 6, 2015. Authors addressed these additional comments from the public to complete the document. The final document was approved by the Task Force, COCATS Steering Committee, and ACC Competency Management Committee; ratified by the ACC Board of Trustees in March, 2015; and endorsed by the SCMR. This document is considered current until the ACC Competency Management Committee revises or withdraws it.
1.2 Background and Scope
The Task Force was charged with updating previously published standards for training fellows in clinical cardiology enrolled in ACGME–accredited fellowships (1) on the basis of: 1) changes in the field since 2008; and 2) the evolving framework of competency-based medical education described by the ACGME Outcomes Project and the 6 general competencies endorsed by ACGME and ABMS. The updating effort was also convened as part of a broader effort to establish consistent training criteria across all aspects of cardiology. The background and overarching principles governing fellowship training are provided in the COCATS 4 Introduction, and readers should become familiar with this foundation before considering the details of training in a subdiscipline like CMR. The Steering Committee and Task Force recognize that implementation of these changes in training requirements will occur incrementally.
CMR, one of the newest cardiovascular imaging modalities, often provides useful and unique information with which all cardiologists should be conversant. Accordingly, all standard 3-year cardiovascular trainees should receive training that would provide at least a basic understanding of the methods and utility of CMR in the practice of cardiology. To provide fellows with different levels of interest in CMR with such an understanding, training in CMR should be provided at 3 levels—basic, specialized, and advanced, as described in the following text.
For most areas of adult cardiovascular medicine, 3 levels of training are delineated:
▪ Level I training is the basic training required of all trainees to become competent consultant cardiologists and must be accomplished during a standard 3-year training program in cardiology.
▪ Level II training refers to the additional training in 1 or more areas that enables some cardiologists to perform or interpret specific procedures or render more specialized care for specific patients and conditions. This level of training is recognized for those areas in which an accepted instrument or benchmark, such as a qualifying examination, is available to measure specific knowledge, skills, or competence. Level II training in selected areas may be achieved by some trainees during the standard 3-year cardiovascular fellowship, depending on the trainees’ career goals and use of elective rotations. It is anticipated that during a standard 3-year cardiovascular fellowship training program, sufficient time will be available to receive Level II training in a specific subspecialty. In the case of CMR, Level II training is required for individuals who wish to perform and interpret CMR examinations as part of their practice of cardiovascular medicine.
▪ Level III training requires additional training and experience beyond the standard 3-year cardiovascular fellowship to acquire specialized knowledge and competencies in performing, interpreting, and training others to perform specific procedures or render advanced specialized care at a high level of skill. In the case of CMR, Level III training would enable the trainee to direct a CMR laboratory or train others in CMR. As for other noninvasive imaging modalities, Level III training in CMR requires training in multimodality imaging (see COCATS 4 Task Force 4 report). Level III training is described here only in broad terms to provide context for trainees. The additional exposure and requirements for Level III training will be addressed in a subsequent, separately published Advanced Training Statement.
The number of cases, procedures, and experiences recommended is based on published guidelines, competency statements (2), and the opinions of the members of the writing group. It is assumed that training is directed by appropriately trained mentors in an ACGME–accredited program and that satisfactory completion of training is documented by the program director. The number and types of encounters and the duration of training required for trainees are summarized in Section 4.
2 General Standards
Three organizations—the ACC, the American College of Radiology, and the SCMR—have addressed training requirements for CMR (2–4). The recommendations address faculty, facility requirements, emerging technologies, and practice. We strongly recommend that candidates for certification in cardiovascular diseases, as well as those seeking certification of subspecialty qualification in CMR, review the specific requirements of other organizations.
Cardiovascular fellowship programs should satisfy the requirements regarding facilities and faculty for training in CMR. Eligibility for supplemental subspecialty CMR examination training requires that training take place in a cardiovascular disease program accredited by the ACGME. The intensity of training and required resources vary according to the levels of certification desired.
An examination of core competency in CMR is currently under development by the CMR Exam Board in collaboration with SCMR. This group is under agreement to develop the examination with the Council for Certification in Cardiovascular Imaging, which comprises the former certification boards for nuclear cardiology and computed tomography. Thus, examinations for 3 of the 4 imaging modalities will be housed within the same organization.
CMR training faculty should include specialists who are skilled in CMR image acquisition, interpretation, and reporting and are knowledgeable about the risks to the patient and medical personnel associated with magnetic resonance procedures. There should be at least 1 key clinical CMR faculty member with Level II or (preferably) Level III certification in CMR. Occasionally, a Level II– or III–trained CMR mentor will not be available in the institution housing the standard 3-year fellowship program but will be available at a nearby nonacademic medical center accredited for CMR by an organization such as the Intersocietal Accreditation Commission for Magnetic Resonance Imaging. Under these circumstances, it is acceptable to provide all levels of CMR training at such a medical center.
This training should generally be acquired through an ACGME–approved cardiovascular or radiology program with expertise in CMR and under the aegis of a Level II– or (preferably) a Level III–qualified mentor in a laboratory accredited by an organization such as the Intersocietal Accreditation Commission for Magnetic Resonance Imaging. Facilities should be adequate to ensure a safe and effective environment for the performance of diagnostic CMR procedures.
CMR laboratories require not only the magnet, but also specialized equipment for the safe monitoring and performance of diagnostic procedures, particularly stress testing. This magnetic resonance safe equipment may include monitoring and recording systems, power injectors for administering contrast, and systems to provide inhalational as well as intravenous medications.
2.4 Ancillary Support
Ancillary support should be available to perform the CMR procedures, including individuals trained in general anesthesia for those centers performing procedures under high levels of sedation.
3 Training Components
3.1 Didactic Program
Lectures and self-study in CMR: Didactic training consists of lectures on the basic aspects of CMR and parallel reading material comprising selected articles, digital training programs, or CMR text. The lectures and reading should provide the fellow with a basic understanding of CMR imaging techniques (Table 1) and applications (Table 2). Specificity, sensitivity, diagnostic accuracy, utility in assessing prognosis, costs, appropriate use criteria, artifacts, indications, contraindications, and pitfalls must be included for each cardiovascular diagnostic subset. Such information could be effectively transmitted within a weekly noninvasive or clinical teaching conference during which CMR data are presented. Mentored interpretation of CMR studies should be coupled with comparison and integration of CMR results with other relevant clinical, imaging, and laboratory test results.
Additional training should include an understanding of: 1) sources of artifacts, including motion, arrhythmias, and metal objects; 2) the safety of implanted devices (e.g., pacemakers, automatic implantable cardioverter-defibrillators), external ferromagnetic devices, and gadolinium-based contrast agents (for a summary of safety issues in CMR, see www.mrisafety.com); 3) basic post-processing approaches and analyses; 4) noncardiac incidental findings and an approach to their recognition; and 5) appropriate use criteria as they relate to CMR.
Trainees should receive didactic lectures from CMR faculty and/or physicists on the basic physics of magnetic resonance in general and physics that relate to CMR and to patients with cardiovascular disease in particular. The content should include the materials noted in Table 3. These lectures may be web-based, if available.
3.2 Clinical Experience
Level I training should include exposure to the methods and applications of CMR for a period of not less than 1 month or its equivalent when integrated with other training activities. During the 1 month of training, the trainee should actively participate in daily CMR study interpretation under the direction of CMR faculty. Studies should incorporate the range of techniques and procedures listed in Tables 1 and 2, including exposure to a minimum of 25 cases, some of which may come from an established CMR teaching file.
3.3 Hands-On Experience
Hands-on experience is not necessary for Level I training but is an integral part of Level II training, as discussed in the previous text. The trainee should take an active role in planning and implementing protocol decision making.
4 Summary of Training Requirements
4.1 Development and Evaluation of Core Competencies
Training and requirements for CMR address the 6 general competencies promulgated by the ACGME/ABMS and endorsed by the ABIM. These competency domains are: medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism. The ACC has used this structure to define and depict the components of the core clinical competencies for cardiology. The curricular milestones for each competency and domain also provide a developmental roadmap for fellows as they progress through various levels of training and serve as an underpinning for the ACGME/American Board of Internal Medicine reporting milestones. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs. Additionally, it has developed tools to assist physicians in assessing, enhancing, and documenting these competencies.
Table 4 delineates each of the 6 competency domains as well as their associated curricular milestones for training in CMR. The milestones are categorized as Level I, II, or III training (as previously defined in this document) and indicate the stage of fellowship training (12, 24, or 36 months, and additional time points) by which the typical cardiovascular disease trainee should achieve the designated level. Given that programs may vary with respect to the sequence of clinical experiences provided to trainees, the milestones at which various competencies are reached may also vary. Level I competencies may be achieved at earlier or later time points. Acquisition of Level II skills requires additional training that can usually be obtained during elective time in the standard 3-year cardiovascular fellowship, whereas Level III skills require an additional period of training in a dedicated CMR program beyond the cardiovascular fellowship. The table also describes examples of evaluation tools suitable for assessing competence in each domain.
4.2 Number of Cases and Duration of Training
Although the training duration and numbers of procedures stated previously are typically required to obtain competency, there must also be a demonstration of achievement of the competencies as assessed by the outcomes evaluation measures.
4.2.1 Level I Training Requirements
Level I training should be required of all 3-year cardiovascular fellows and includes exposure to the methods and the applications of CMR (Tables 1 and 2) for a period of not less than 1 month or its equivalent when integrated with other training activities. This experience should provide basic background knowledge in CMR sufficient for the practice of adult cardiology and appropriate referral for CMR evaluation and for report interpretation, but not for the practice of or independent clinical interpretation of CMR. It is expected that trainees will be exposed to at least 25 mentored cases. As a practical matter, many fellowship programs in cardiovascular medicine may not be able to fulfill CMR training requirements. In these instances, fellows should be encouraged to obtain experience in an alternate program with appropriate training and accreditation in the performance of CMR studies.
4.2.2 Level II Training Requirements
Level II is for trainees who wish to practice the clinical subspecialty of CMR, including independent interpretation of CMR studies. Level II trainees must have at least 3 months of dedicated CMR training (where 1 month is defined as 4 weeks and 1 week is defined as 35 hours), including familiarity with the CMR techniques and applications listed in Tables 1 and 2, respectively. In addition to Level I requirements, the Level II trainee should have a clear understanding of CMR physics and how it relates to image acquisition, sequence building, and troubleshooting through formal CMR physics lectures when possible. These lectures should include the topics listed in Table 3 and may be web-based, if this is available.
During the 3 or more months of experience necessary to develop Level II competence, trainees should actively participate in daily CMR study interpretation under the direction of Level II or (preferably) Level III CMR faculty. In addition to Level I requirements, the trainee should interpret at least 150 CMR examinations during this training period, including 50 for which the trainee is present during the scanning procedure, directs the imaging acquisition, and serves as the primary interpreter. Up to 50 of the 100 examinations for which the trainee is not the primary interpreter can be derived from established teaching files, journals and/or textbooks, or electronic/online courses. Careful documentation of all case material and the details of the way in which the case was derived are essential. For all studies in which other cardiac imaging data are available, such information should be correlated with CMR data. Rather than seeking a certain number of case experiences, trainees should seek competency in performing and managing CMR.
4.2.3 Training in Multiple Imaging Modalities
The cardiovascular medicine specialist is increasingly expected to provide expertise in 2 or more of the noninvasive cardiovascular imaging techniques. It is understandable, then, that trainees will desire the opportunity to gain exposure to multiple imaging modalities during their fellowship experience. To the degree possible, the training program should strive to meet these needs by offering a “multimodality” imaging experience (see COCATS 4 Task Force 4 report). This might include an appreciation for each technique’s uses and indications, strengths and limitations, safety issues, and relevant guidelines and appropriate use criteria, when available.
4.2.4 Level III Training Requirements
Level III training enables a physician to direct an academic CMR section, independent CMR facility, or CMR clinic. This individual would be responsible for quality control, training technologists, and mentoring other physicians in training. In addition to the requirements for Level I and II training, Level III training requires training devoted to CMR beyond the standard 3-year cardiovascular fellowship and training in at least 1 other imaging modality, because Level III training in any noninvasive modality requires training in more than 1 noninvasive imaging modality. Level III trainees in CMR should be involved in the acquisition and interpretation of imaging examinations and demonstrate the ability to over-read CMR studies independently. Level III training should include participation in research, teaching, and the administrative aspects of laboratory operations, including data management, report generation and distribution, quality improvement, accreditation, and understanding of evolving multimodality imaging technologies.
5 Evaluation of Competency
Evaluation tools in CMR include direct observation by instructors, in-training examinations, case logbooks, conference and case presentations, multisource evaluations, trainee portfolios, simulation, and reflection and self-assessment. Acquisition and interpretive skills should be evaluated in every trainee. Interaction with other physicians, patients, and laboratory support staff; initiative; reliability; decisions or actions that result in clinical error; and the ability to make appropriate decisions independently and follow up appropriately should be considered in these assessments. Trainees should maintain records of participation and advancement in the form of a Health Insurance Portability and Accountability Act (HIPAA)–compliant electronic database or logbook that meets ACGME reporting standards and summarizes pertinent clinical information (e.g., number of cases, diversity of referral sources, testing modalities, diagnoses, and findings). The use of CMR should be aligned with both clinical need and appropriate use criteria. Trainees should be prepared to explain why a given CMR test is better suited to the clinical question than is another imaging option. Fellows should document clinical correlation with the other imaging, hemodynamic, invasive laboratory, surgical pathology, and outcomes data to enhance their understanding of the diagnostic utility and value of various studies. Finally, experiences in CMR should be assessed against measures of quality with regard to test selection, performance, interpretation, and reporting in the interest of appreciating the potential adverse consequences of suboptimal testing (5–7).
The ACC, American Heart Association, and SCMR have formulated a clinical competence statement on the performance, interpretation, and reporting of CMR studies, as well as an expert consensus document (2,8). Program directors and trainees are encouraged to incorporate these resources in the course of training.
Under the aegis of the program director and director of each imaging laboratory, facility, or program, the faculty should record and verify each trainee’s experiences, assess performance, and document satisfactory achievement. The program director is responsible for confirming experience and competence and reviewing the overall progress of individual trainees with the Clinical Competency Committee to ensure achievement of selected training milestones and identify areas in which additional focused training may be required.
Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 8: Training in Cardiovascular Magnetic Resonance Imaging
|Committee Member||Employment||Consultant||Speakers Bureau||Ownership/Partnership/Principal||Personal Research||Institutional/Organizational or Other Financial Benefit||Expert Witness|
|Christopher M. Kramer (Chair)||University of Virginia Health System—Ruth C. Heede Professor of Cardiology, Professor of Radiology||None||None||None||None||None||None|
|W. Gregory Hundley||Wake Forest University School of Medicine—Professor, Internal Medicine (Cardiology) and Radiology||None||None||None||None||None||None|
|Raymond Y. K. Kwong||Brigham & Women's Hospital Medicine, Cardiovascular Division—Instructor of Medicine||None||None||None||None||None||None|
|Matthew W. Martinez||Lehigh Valley Health Network—Associate Professor of Medicine||None||None||None||None||None||None|
|Subha V. Raman||Ohio State University—Professor of Internal Medicine, Biomedical Informatics, and Radiology||None||None||None||None||None||None|
|R. Parker Ward||University of Chicago Medicine—Professor of Medicine||None||None||None||None||None||None|
For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees.
ACC = American College of Cardiology.
Appendix 3 Abbreviation List
ABIM = American Board of Internal Medicine
ABMS = American Board of Medical Specialties
ACC = American College of Cardiology
ACGME = Accreditation Council for Graduate Medical Education
CMR = cardiovascular magnetic resonance
COCATS = Core Cardiovascular Training Statement
HIPAA = Health Insurance Portability and Accountability Act
SCMR = Society for Cardiovascular Magnetic Resonance
↵∗ Society for Cardiovascular Magnetic Resonance Representative.
Endorsed by the Society for Cardiovascular Magnetic Resonance
The American College of Cardiology requests that this document be cited as follows: Kramer CM, Hundley WG, Kwong RY, Martinez MW, Raman SV, Ward RP. COCATS 4 task force 8: training in cardiovascular magnetic resonance imaging. J Am Coll Cardiol 2015;65:1822–31.
- American College of Cardiology Foundation
- Pohost G.M.,
- Kim R.J.,
- Kramer C.M.,
- et al.
- Budoff M.J.,
- Cohen M.C.,
- Garcia M.J.,
- et al.
- Schulz-Menger J.,
- Bluemke D.A.,
- Bremerich J.,
- et al.
- Hundley W.G.,
- Bluemke D.A.,
- Finn J.P.,
- et al.
- 1 Introduction
- 2 General Standards
- 3 Training Components
- 4 Summary of Training Requirements
- 5 Evaluation of Competency
- Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 8: Training in Cardiovascular Magnetic Resonance Imaging
- Appendix 2 Peer Reviewer Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 8: Training in Cardiovascular Magnetic Resonance Imaging
- Appendix 3 Abbreviation List