Author + information
- Julie B. Damp, MD∗ (, )
- Lisa A. Mendes, MD,
- Mitchell Goldman, MD,
- Eric H. Stern, MD,
- Shouvik Chakrabarty, MD,
- Deepak Bhakta, MD,
- Salvatore Cilmi, MD,
- John McPherson, MD,
- Eric S. Williams, MD and
- Chittur A. Sivaram, MBBS
- ↵∗Department of Medicine, Vanderbilt University School of Medicine, 1215 21st Avenue South, MCE 5th Floor South Tower, Nashville, Tennessee 37232
With Accreditation Council for Graduate Medical Education core competencies (1), there was a shift from time- to competency-based training. Milestones for internal medicine (IM) residents and cardiovascular medicine (CVM) fellows have created an opportunity to rethink progression through training. The American Board of Internal Medicine (ABIM) pilot training program in IM and CVM was created to develop and implement a curriculum for early career focus in CVM through competency-based rotations in the third year of IM residency (blended year). The pilot allows early transition to research, special career-focused electives, or sub-subspecialty training within the third year of CVM.
IM candidates were carefully selected at 4 sites (Icahn School of Medicine at Mount Sinai, New York, New York; Indiana University, Indianapolis, Indiana; University of Oklahoma, Oklahoma City, Oklahoma; and Vanderbilt University, Nashville, Tennessee), including acceptance into CVM training at that site. The blended year included specific experiences (vascular medicine, cardiovascular prevention, stress testing, and echocardiography), each meeting ABIM board requirements in IM and CVM. IM and CVM Program Directors and Clinical Competence Committees provided oversight of each site’s pilot trainees. Milestones relevant to blended year rotations determined advancement. The American College of Cardiology provided oversight and support for the program, which began July 1, 2014. Annual enrollment for the program continues.
An evaluation timeline for the pilot is shown in Figure 1. Self-assessment of competency (15 skills) and faculty evaluation of competency in echocardiography (6 areas) were compared between the first 2 years of pilot trainees (cohort 1 vs. cohort 2) and between all pilot trainees (cohorts 1 and 2) and all first-year CVM traditional track trainees in 2014 and 2015. Echocardiography was selected given the uniformity of this experience across the sites. Surveys were distributed via Verint (Melville, New York). Analysis was performed using SPSS version 23 (IBM, Armonk, New York). Given the small sample set, the nonparametric Kruskal-Wallis 1-way analysis and Mann-Whitney U test were used.
In 2014 and 2015, 8 pilot trainees entered the program (87% male). Comparison of self-assessment of competency and faculty evaluation of competency in echocardiography showed no significant difference between cohorts 1 and 2. Self-assessment of competency for pilot trainees compared with first-year CVM trainees showed that pilot trainees had lower scores in ability to perform basic noninvasive cardiac testing, interpret echocardiograms, interpret ECG stress tests, and appropriately obtain informed consent (p = 0.001, p = 0.021, p = 0.018, p = 0.001, respectively), with no difference in the remaining 11 skills. Comparison of faculty evaluation of pilot trainee competency of echocardiography with that of traditional track trainees showed no significant difference.
Based on all performance feedback, all pilot trainees were deemed to be performing at or above the level of their IM and CVM peers by their respective program directors. All pilot trainees in cohorts 1 and 2 have passed the ABIM IM board examination. Cohort 1 trainees reaching their third year of CVM are using the “extra” time for earlier training in sub-subspecialty programs, augmenting clinical skills not included in standard training, and/or research.
ABIM began competency-based pilot training programs in 2011 (2), but this is the first report of a program transitioning from a core residency to a subspecialty fellowship. Initial results demonstrate that, in selected trainees, this blended third year is feasible without compromising IM competency based on ABIM IM board pass rate and clinical competency. Success for implementing such a program is dependent on commitment to the concept of innovative training pathways by all IM and CVM stakeholders. Support to administer the program is needed, as are standardized expectations and assessments across institution. Pilot trainee selection is crucial, as individual characteristics of the trainee will affect suitability for such a pathway. Limitations of such a program include availability of appropriate candidates in a given year, coverage of clinical services, funding, and the potential need for remediation pathways.
Long-range implications of this pilot are promising. The American College of Cardiology and ABIM could use this pilot to further competency-based training innovation and restructure CVM fellowship. As the ability to pay off debt and length of training affect both specialty and long-term career choice (3,4), the importance of achieving competency in a shorter time frame than the traditional training period has become important. This pilot may provide a roadmap for further investigation into how to most effectively use limited training resources in producing subspecialty physicians.
Please note: This program is supported by the American College of Cardiology Foundation. Dr. Bhakta serves as a principal investigator and received a grant from Boston Scientific study. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. The authors would like to thank Robyn Snyder, Marie Sanogo, Marcia Jackson, PhD, and Katie Berlacher, MD, for their contributions to the development, implementation, and evaluation of this program.
- 2017 American College of Cardiology Foundation
- ↵American Board of Internal Medicine. Geriatrics and Palliative Medicine Pilot Program. Available at: http://www.abim.org/program-directors-administrators/competency-based-medical-education-pilot-programs/geriatrics-palliative-medicine.aspx. Accessed April 2, 2017.