Author + information
- Received March 16, 2016
- Revision received May 11, 2016
- Accepted May 18, 2016
- Published online September 20, 2016.
- aSection of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center
- bDepartment of Medicine and Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana
- ↵∗Reprint requests and correspondence:
Dr. Jeffrey T. Kuvin, Section Chief, Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire 03756.
Patients, hospitals, insurers, and the public rely on competent physicians. The definition and documentation of competency in cardiovascular training and practice continues to evolve. New tools, such as the American College of Cardiology’s in-training examination, restructured Core Cardiovascular Training Statement, curricular and lifelong learning competencies, and the Accreditation Council for Graduate Medical Education Milestones help define competent trainees and practitioners, and level the playing field. The American Board of Internal Medicine’s Maintenance of Certification program is undergoing critical review, and a common vision of its future form and role are not yet clear. This paper explores present-day cardiovascular competency components, assessment tools, and strategies, and identifies challenges for the future.
Competence in the medical profession refers to a person’s ability to perform a specific task, recognizing the required knowledge, skills, and attitudes needed for this ability. Until this point, the specifics of how competency is defined in cardiovascular training and practice have not been well defined.
It is imperative that cardiovascular trainees and practitioners attain and maintain a specified level of competence to provide appropriate care for patients (1). The pyramid of clinical competence created by Miller (2) focuses on building skills in a stepwise fashion to achieve competence. The foundation of the Miller pyramid is knowledge, or the ability to gather and understand information (Figure 1). The next level focuses on analytics and interpretation of data, and then the ability to demonstrate or teach information. The pinnacle of the pyramid of clinical competence is the practitioner’s ability to integrate these skills into clinical practice. Patients, hospitals, insurers, medical boards and licensing organizations, and the public expect competent physicians, and the pyramid by Miller exemplifies how competence should evolve over time.
However, how competence is achieved, measured, and maintained is not typically standardized, and in some cases, it is not clearly defined. Historically, achievement of competence in medical specialties focused on specific periods of time spent in training or practice, the number of procedures performed, and passing of largely knowledge-based examinations. Recently, the assessment and demonstration of competency have broadened and now include educational and patient outcomes, surveys, and evaluations. Today’s cardiologists practice in a complicated, specialized world, driven by robust, evidence-based information and highly advanced technology and equipment. It remains imperative that the specialists caring for patients remain competent throughout their careers in the area(s) in which they practice.
Developing and documenting one’s level of competency as a cardiovascular specialist has become increasingly complex. The Accreditation Council for Graduate Medical Education (ACGME), along with other organizations, have highlighted 6 key areas, which are known as the core competencies; these are medical knowledge, patient care, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills. Thus, competency and its assessment includes essential areas beyond medical knowledge and patient care. Graduate medical education training programs and lifelong learning have adopted the concepts related to competency-based education, with the goal of applying knowledge, providing direct and formative feedback, focusing on measurements, and holding both the teacher and learner accountable for driving the educational process (3).
This paper defines the present tools available for clinical competency assessments in cardiovascular training and practice, along with ideas for identifying and analyzing levels of competency in the future.
Assessment of Competency in Cardiovascular Training
Traditionally, assessment of cardiovascular trainee competence has relied on time-tested tools, including duration of training and required experiences, summative and formative evaluations, and numbers of supervised procedures performed. Following completion of internal medicine residency, the standard general cardiology training program consists of 3 years, 2 of which are required to be primarily clinical. The third training year, in addition to clinical experiences, may include a variety of tracks, including additional career-focused cardiology skills, research, or other nonclinical focuses. At the conclusion of their general cardiology fellowships, trainees often exhibit a broad range of competency in general cardiovascular medicine, which, of course, may change over time as their individual practice focuses evolve. Additional dedicated years of training beyond the standard 3-year program are required for sub-subspecialization in areas such as electrophysiology, interventional cardiology, advanced heart failure, adult congenital heart disease, vascular medicine, and advanced imaging. Training in basic science, or translational or clinical research often requires additional time as well.
Evaluation of performance through written and verbal feedback remains an effective tool and is essential to the growth of all trainees. Programs are required to provide a variety of competency-based summative and formative evaluations throughout training. During such evaluations, trainees receive feedback on each of the core competencies, with a focus on improvement strategies. In addition to standard evaluation surveys, assessments from peers, patients, and staff provide a 360° perspective on trainee performance, and often provide insightful and helpful comments. Direct feedback has long been accepted as a useful tool and an ongoing assessment of physician competency and will likely remain a key feedback tool for trainees.
Assessment of cardiology fellow-in-training (FIT) competence in procedural areas, such as cardiac catheterization, echocardiography, and stress testing, to name a few, has long been a major emphasis of cardiovascular training. The minimum numbers for procedural experiences have typically been set by the ACGME’s program requirements in cardiovascular medicine (4) and the Core Cardiovascular Training Statement (COCATS) (5). The latter goes beyond minimum expectations for all fellows, to also include higher levels of competency in selected areas (e.g., imaging). FITs are expected to reach or exceed the specified number of procedures during the training years. Although the most recent versions of these training documents place less emphasis on procedural numbers, focusing also on the actual demonstration of achievement of competency, benchmark levels in the procedural areas remain an important component of basic levels of competency development during training. They also serve to ensure that trainees experience a broad range of patient issues and that the faculty evaluator has observed a sufficient number of the trainee’s procedures to accurately assess competency. However, it remains imperative for FITs to understand that competency is not achieved on the basis of achieving a pre-specified number of procedures; rather, the quality of the procedures performed and patient outcomes must be monitored as well. This requires appropriate hands-on supervision, with increasing levels of responsibility and follow-up.
In-training examinations (ITEs) have long been a part of ongoing assessment of trainee medical knowledge. Recently, an annual ITE was developed by the American College of Cardiology (ACC) to assist trainees and programs about medical knowledge attained during fellowship and to identify specific knowledge gaps. The ACC’s ITE simulates the American Board of Internal Medicine (ABIM) certification examination, with multiple-choice, case-based questions incorporating a variety of still and motion multimodality images. Each ITE question is tagged to a specific competency statement and diagnosis, thereby providing the trainee feedback for incorrectly answered questions and an identification of the trainee’s knowledge gaps. The ITE is now being used in most training programs and has been shown to be an effective tool for assessing competency-based medical knowledge (6). Whether or not the ITE reflects ABIM examination pass rates remains unclear.
Until recently, understanding what core competencies trainees should know and practice during fellowship has never been fully elucidated. The ACC has developed Curricular Competencies for all areas within cardiology, with each competency addressing the 6 competency domains designated by the ACGME (7). The idea behind these Curricular Competency statements is that there should be a baseline level of understanding that each FIT exhibits, on the basis of the level of training and exposure. For example, medical knowledge of the basic principles of echocardiography is considered to be core knowledge that all FITs should have attained by the end of their first training year, whereas the understanding of complex and/or post-operative adult congenital heart disease is more appropriate at the senior training level. The Curricular Competencies now serve as a benchmark for cardiovascular training programs across the country, and allow FITs and training program directors to fully understand what is expected during fellowship. For the first time, the most recent training statement, COCATS 4, has integrated these competencies into the training document, which is clearly a major step toward defining clear training competencies across all programs.
In 2014, the ACGME implemented the Next GME Accreditation System, which was designed to respond to the changing educational needs of trainees, focusing on continuous (rather than episodic) evaluation, education quality, and innovation (8). Although many of the traditional assessment methods remain in training programs today, newer systems have been added to track and define trainee competence. One such method is the ACGME Reporting Milestones (9). Reporting Milestones have been designed as an evaluation tool to assess progressive trainee development in each of the core competency areas during the training period. On the basis of the consensus from a training program’s Clinical Competency Committee, each of the Reporting Milestones are completed and electronically transmitted to the ACGME on a semiannual basis. The Milestones provide trainees and the program with a reasonable account of competency (or lack thereof), and a trajectory over a period of time, in a variety of important domains. Milestones provide the ACGME with an opportunity to publically demonstrate, through aggregate data, the effectiveness of training programs, and these data may be helpful in establishing educational goals and curricula. Although the timing and trajectory of the Milestones may differ among trainees, the goal is to achieve the ability to practice independently (or aspirational category) in each subcompetency. There are 22 subcompetencies for cardiovascular trainees, from medical knowledge to practice-based learning and improvement. There are emerging methods aimed at linking the curricular competencies and evaluations to the ACGME Milestones. Long-term data connecting the Milestones to certification, licensure, and patient care quality are not yet available.
Finally, there is considerable renewed interest in allowing earlier career focus for trainees in cardiovascular medicine. The ABIM and ACC have developed a jointly sponsored, competency-based pilot program aimed at beginning cardiovascular training experiences (electrocardiography, vascular medicine, prevention) for selected trainees during portions of the third year of internal medicine residency (Dr. C.A. Sivaram, University of Oklahoma and American College of Cardiology, personal communication, November 2015). During this blended year, the trainee remains under the umbrella of the internal medicine training program but begins to learn some of the core areas within cardiology. The goal is to effectively and efficiently expose the trainee to some of the requirements and achieve early competency (for both internal medicine and cardiovascular disease training) without compromising the internal medicine core competencies. This could potentially free up portions of the third year of the standard cardiovascular medicine fellowship for additional experiences and skills beyond those required of all cardiovascular trainees. It is not meant to short track or establish a new type of cardiovascular specialist. The pilot program relies on competency assessment outcomes, both within internal medicine and cardiovascular disease, and has robust evaluation components, including the Milestones. It will be several years before firm conclusions can be reached, but initial experiences have been favorable.
Assessment of Competency in Cardiovascular Practice
Typically, the first, and arguably most important, assessment of medical knowledge competency upon completion of cardiology training is the ABIM certification examination. The examination is designed to test the core competencies with clinically based questions in each of the ABIM blueprint domains (arrhythmias, coronary artery disease, acute coronary syndromes, valvular disorders, congenital disorders, pericardial disease, aortic and peripheral vascular disease, hypertension and pulmonary hypertension, pharmacology, congestive heart failure, physiology, and biochemistry). In addition to the multiple-choice formatted questions, candidates are required to pass a separate portion dedicated to analysis of images and electrocardiograms. The ABIM offers certification in cardiovascular medicine and in sub-subspecialty areas, including clinical cardiac electrophysiology, interventional cardiology, advanced heart failure and transplant cardiology, and most recently, adult congenital heart disease. To achieve sub-subspecialty certification, candidates must pass the cardiovascular medicine examination.
Although ABIM certification does not confer the privilege to practice medicine, it is typically used by hospitals, organizations, insurance companies, and societies, and often by the public, as a key indicator of competency upon the completion of training. The ABIM examination has become a rite of passage for new training graduates, and a successful examination outcome is often mandated by employers. The pass rate for first-time takers of the cardiovascular certifying examination is >90%, whereas the pass rate for sub-subspecialty examinations is typically approximately 10% lower (10). In addition to ABIM examinations, numerous additional certifying examinations, often produced by specialty societies, are used as a marker of competency in a particular area. For example, the American Society of Nuclear Cardiology and the National Board of Echocardiography offer examinations in their respective imaging areas. FITs entering the clinical practice of cardiology are now faced with numerous certifying examinations, leading to issues related to cost, preparatory time, and need for recertification years later.
State licensing and hospital credentialing offices also assess competency and provide practitioners with the ability to practice medicine. These assessments depend on documentation from medical schools and training institutions regarding fulfillment of requirements, professionalism, and the implications of ongoing or past legal issues. In addition, in some cases, the Educational Commission for Foreign Medical Graduates and Office of Homeland Security must be contacted. Involvement and documentation of continuing medical education is also critical for licensure and credentialing.
Maintenance of Competency in Cardiovascular Practice
Maintaining competence in one’s field of cardiovascular practice is critical to achieving good patient care and outcomes. However, individual physicians’ practice focuses might change over time as their careers evolve. Likewise, competency requirements have evolved over the past few years and continue to be the topic of many discussions. Traditionally, maintenance of certification (MOC) has referred to the recertification process associated with the ABIM; however, the concept of maintenance of competency is broader than the ABIM. Measuring competency in practice typically requires documentation of lifelong learning activities to ensure that practitioners are appropriately staying up-to-date in the areas in which they practice. Similar to passenger expectations regarding airline pilots, patients typically believe their physicians should be held to a specific standard, including focused and relevant continuing education. Thus, competency documentation is an important ongoing metric that demands close scrutiny.
Competency attained through fellowship does not always mean that competency is maintained over time. Thus, it is important for trainees to understand that their practice of cardiology will likely evolve into a narrower focus than that during their fellowship training. For example, the trainee who becomes a practicing general cardiologist may not maintain the skillset and competencies needed to perform cardiac catheterization. Likewise, the electrophysiologist may not be able to continue to demonstrate proficiency in noninvasive imaging. However, there are basic core competencies that all clinical cardiologists must maintain throughout their practicing careers.
The ABIM MOC program has traditionally focused on a variety of continuing education methods to keep practitioners involved in lifelong learning and assessment. The ABIM established a 4-part system to include licensure and professional standing, self-evaluation of medical knowledge, a 10-year secure examination, and self-evaluation of practice performance. In 2014, the ABIM changed their MOC program by streamlining the process and focusing on continuous education, rather than episodic evaluations. The ABIM developed a new designation of “meeting MOC requirements” that refers to the completion of an MOC activity every 2 years, earning 100 MOC points every 5 years, completion of a patient safety or patient survey, and taking a secure examination every 10 years. In 2015, the ABIM decided to restructure MOC requirements by placing the practice assessment program on hold; in addition, the ABIM is now reexamining the future of the secure 10-year examination, among other items. Recently, the ABIM has approved the reversal of “double jeopardy” (the need to maintain general cardiology ABIM certification to remain certified in sub specialty areas within cardiology). The ABIM is currently working with societies, including the ACC, to further evolve, streamline, and focus the MOC process. The future of the ABIM MOC process remains unclear.
To address the needs of practicing cardiologists, the ACC has developed a set of Lifelong Learning Competencies (11). Similar to the training Curricular Competencies, the Lifelong Learning Competencies clearly define, for the first time, the competencies all practicing cardiologists should maintain, regardless of age, experiences, area of expertise, location, or practice setting. There are also specific competencies for cardiologists based on practice focus. This new set of Lifelong Competencies has been developed for all areas within cardiovascular medicine and follows along with the 6 core competencies. These statements document what it takes to remain competent in a particular area within cardiology, helps physicians to identify potential gaps, and targets personalized education activities.
The Lifelong Learning Competencies were formatted in a similar way to the COCATS 4 training competencies and provide a continuum for the cardiovascular specialist. For the first time, competency in the typical practice areas of cardiovascular medicine has been explicitly defined. There are potentially multiple sources of accountability, including the physician, the practice, the hospital, the state, the ABIM, and the profession. Cardiologists should understand that maintenance of competency in practice areas is important for themselves and their patients. The Lifelong Learning Competencies now serve as an underpinning structure for all ACC educational activities. These statements will require continued revision to keep up with the changes in the practice of cardiovascular medicine. There are also ongoing discussions focused on linking these competencies to ABIM MOC and documenting learning activities in a structured fashion with an electronic learning management tool.
Conclusions and Next Steps
Defining competency for cardiovascular specialists is necessary for the profession and is an imperative for the public. Clearly defined assessment tools and definitions are therefore needed during training and practice. There have been some recent major improvements to help define and assess cardiovascular competency, including a new structure for COCATS and the incorporation of Curricular Competencies, the institution of ACGME Milestones, ACC’s ITE, and the development of Lifelong Learning Competencies (Central Illustration). These new and robust tools to document and track individual competency accomplishments, identify knowledge gaps, and link cardiologists to appropriate education and quality improvement opportunities should enhance personalized education and ultimately improve patient care. These advances are long overdue and should improve transparency in terms of expectations for clinical cardiologists, the profession, and the public. There is a great need for evidence-based outcomes research in the area of physician competence, including an attempt to correlate physician competency assessment with patient outcomes. Faculty development in the area of competency assessment is an additional key component to this mission. There must also be further work focused on methods to recognize and act upon physician incompetence, with appropriate remediation and support plans in place.
A goal of these competency assessment tools is to provide targeted areas for lifelong learning and to help clinicians provide and ensure safe, effective care. Although it might appear to be an insurmountable amount of work, data collection, and time, the key of competency assessment is to use standardized methods of education and training. What scope of clinical competence should be demonstrated and by whom should it be certified remain key questions. The future of learning is personalized education; therefore, innovative tools are needed to allow individual clinicians to continually assess competency in a variety of areas, understand gaps in knowledge, and importantly, find ways to educate and improve.
The authors thank the staff and leadership of the American College of Cardiology for making competency assessment a priority.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- Accreditation Council for Graduate Medical Education
- Core Cardiovascular Training Statement
- in-training examination
- maintenance of certification
- Received March 16, 2016.
- Revision received May 11, 2016.
- Accepted May 18, 2016.
- American College of Cardiology Foundation
- ↵Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Cardiovascular Disease (Internal Medicine). 2016. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/141_cardiovascular_disease_int_med_2016.pdf. Accessed July 6, 2016.
- Halperin J.L.,
- Williams E.S.,
- Fuster V.,
- et al.
- Kuvin J.T.,
- Soto A.,
- Foster L.,
- et al.
- ↵American College of Cardiology. Competencies. 2016. Available at: www.acc.org/education-and-meetings/products-and-resources/competencies. Accessed July 6, 2016.
- ↵Accreditation Council for Graduate Medical Education, American Board of Internal Medicine. The Internal Medicine Milestone Project. 2015. ACGME. Available at: http://www.acgme.org/portals/0/pdfs/milestones/internalmedicinemilestones.pdf. Accessed July 6, 2016.
- ↵American Board of Internal Medicine. First-Time Taker Pass Rates – Initial Certification. Available at: http://www.abim.org/∼/media/ABIM%20Public/Files/pdf/statistics-data/certification-pass-rates.pdf. Accessed July 6, 2016.
- Williams E.S.,
- Halperin J.L.,
- Arrighi J.A.,
- et al.