Author + information
- Published online January 8, 2018.
- Cynthia M. Tracy, MD, FACC, Chair, Writing Committee,
- George H. Crossley, MD, FACC, FHRS, Vice Chair, Writing Committee,
- T. Jared Bunch, MD, FACC, Writing Committee Member,
- Grant V. Chow, MD, FACC, Writing Committee Member,
- Amy Leiserowitz, RN, CCDS, FHRS, Writing Committee Member∗,
- Julia H. Indik, MD, PhD, FACC, FAHA, FHRS, Writing Committee Member,
- Fred Kusumoto, MD, FACC, FHRS, Writing Committee Member,
- Lisa A. Mendes, MD, FACC, Writing Committee Member,
- Thomas M. Munger, MD, FACC, Writing Committee Member,
- Srinivas Murali, MD, FACC, Writing Committee Member,
- Kristen K. Patton, MD, FACC, FHRS, Writing Committee Member,
- Andrea M. Russo, MD, FACC, FHRS, Writing Committee Member,
- Melvin Scheinman, MD, FACC, FHRS, Writing Committee Member,
- John A. Schoenhard, MD, PhD, FACC, Writing Committee Member and
- Jeffrey R. Winterfield, MD, FHRS, Writing Committee Member∗
- ACC/HRS Competency Statement
- cardiac arrhythmias
- cardiac electrophysiology
- cardiac electrophysiology testing
- cardiac resynchronization therapy
- catheter ablation
- clinical competency
- implantable defibrillators
- lead extraction
- lifelong learning
- maintenance of competence
ACC Competency Management Committee
Eric S. Williams, MD, MACC, Chair
Jonathan L. Halperin, MD, FACC, Co-Chair
Jesse E. Adams III, MD, FACC
James A. Arrighi, MD, FACC
Eric H. Awtry, MD, FACC†
Eric R. Bates, MD, FACC†
John E. Brush, Jr, MD, FACC
Lori Daniels, MD, MAS, FACC†
Ali Denktas, MD, FACC
Susan Fernandes, LPD, PA-C
Rosario Freeman, MD, MS, FACC
Sadiya S. Khan, MD†
Kyle Klarich, MD, FACC
Joseph E. Marine, MD, FACC
John A. McPherson, MD, FACC
Lisa A. Mendes, MD, FACC
Khusrow Niazi, MBBS, FACC
Thomas Ryan, MD, FACC
Chittur A. Sivaram, MBBS, FACC†
Michael A. Solomon, MD, FACC
Robert L. Spicer, MD, FACC
Marty Tam, MD
Andrew Wang, MD, FACC, FAHA
Howard H. Weitz, MD, FACC, MACP
Table of Contents
1. Introduction 233
1.1. Document Development Process 233
1.1.1. Writing Committee Organization 233
1.1.2. Document Development and Approval 233
1.2. Background and Scope 234
1.2.1. CCEP Lifelong Learning Competencies 234
18.104.22.168. Distinction Between Competencies Expected of All CCEP Specialists and Those Required Based on the Focus of Practice 234
1.2.2. Research and Scholarly Activity 235
2. Clinical Competencies 235
3. Leadership and Administrative Competencies 245
4. Maintenance of Competence and Assessment Tools 245
Author Relationships With Industry and Other Entities (Relevant) 247
Peer Reviewer Information 249
Abbreviation List 250
Since publication of its first Core Cardiovascular Training Statement (COCATS) in 1995, the American College of Cardiology (ACC) has defined the knowledge, experiences, skills, and behaviors expected of clinical cardiologists. Subsequent revisions have moved toward competency (outcomes)-based training based on the 6-domain competency structure promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties, and endorsed by the American Board of Internal Medicine (ABIM). The 6 domains include: medical knowledge, patient care and procedural skills, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills. The ACC has taken a similar approach to describe the aligned general cardiology lifelong learning competencies that practicing cardiologists are expected to maintain. Many hospital systems now use the 6-domain structure as part of medical staff privileging, peer review, and professional competence assessments.
Whereas COCATS focuses on general clinical cardiology, ACC Advanced Training Statements define selected competencies beyond those expected of all cardiologists and that require training beyond a standard 3-year cardiovascular disease fellowship. This includes those disciplines for which there is an ABIM added-qualification designation, such as clinical cardiac electrophysiology (CCEP). The Advanced Training Statements describe key experiences and outcomes necessary to maintain or expand competencies during practice, and these are supplemented by additional lifelong learning statements that address the commitment to sustaining and enriching competency over the span of a career.
The ACC Competency Management Committee oversees the development and periodic revision of the cardiovascular training and competency statements. A key feature of competency-based training and performance is an outcome-based evaluation system. Although specific areas of training may require a minimum number of procedures or duration of training to ensure adequate exposure to the range of clinical disorders and effectively evaluate the trainee, the objective assessment of proficiency and outcomes demonstrates the achievement of competency. Evaluation tools include examinations, direct observation, procedure logbooks, simulation, conference presentations, and multisource (360°) evaluations, among others. For practicing physicians, these tools also include professional society registry or hospital quality data, peer-review processes, and patient satisfaction surveys.
The recommendations in the ACC cardiovascular training statements are based on available evidence and, where evidence is lacking, reflect expert opinion. All documents undergo a rigorous process of peer review and public comment. Recommendations are intended to guide the assessment of competence of cardiovascular care providers beginning independent practice, as well as those undergoing periodic review to ensure that competence is maintained.
The Advanced Training Statement on CCEP addresses the added competencies required of sub-subspecialists who focus on diagnosis and management of patients with cardiac arrhythmias and conduction disturbances at a high level of skill. The document complements the basic training in cardiac electrophysiology required of all trainees during the standard 3-year cardiovascular fellowship. The training requirements and clinical competencies designated in the Advanced Training Statement focus on the core competencies reasonably expected of all clinical cardiac electrophysiologists and identify aspects that go beyond the core expectations. These additional competencies may be achieved by some clinical cardiac electrophysiologists either during formal fellowship training or through subsequent training experiences. It should be emphasized that physicians with advanced training and experience in CCEP should maintain a strong foundation in the competencies expected of all clinical cardiologists designated in the Lifelong Learning Statement for General Clinical Cardiologists, including but not limited to the knowledge and skills applicable to cardiologists whose careers focus on CCEP.
This Lifelong Learning Statement complements the Advanced Training Statement on CCEP by focusing on the competencies expected of practicing cardiac electrophysiologists throughout their careers. It also recognizes those competencies that exceed standard expectations and may be achieved and maintained by some cardiac electrophysiologists based on their specific training and practice focus. This document provides examples of appropriate measures for assessing competence in the context of lifelong learning.
The work of the writing committee was supported exclusively by the ACC without commercial support. Writing committee members volunteered their time to this effort. Conference calls of the writing committee were confidential and attended only by committee members. To avoid actual, potential, or perceived conflict of interest arising as a result of relationships with industry (RWI) or other entities of members of the writing committee or peer reviewers of the document, each individual was required to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort. The ACC Competency Management Committee reviewed these disclosures to identify products (marketed or under development) pertinent to the document topic. Based on this information, the writing committee was selected to ensure that the Chair and a majority of members have no relevant RWI. Authors with relevant RWI were not permitted to draft initial text or vote on recommendations or curricular requirements to which their RWI might apply. RWI was reviewed at the start of all meetings and conference calls and updated as changes occurred. Relevant RWI for authors is disclosed in Appendix 1. To ensure transparency, comprehensive RWI for authors, including RWI not pertinent to this document, is posted online. Peer reviewers, along with their employment information and affiliation in the review process, are shown in Appendix 2. There are no RWI restrictions for participation in peer review, in the interest of encouraging comments from a variety of constituencies to ensure that broad viewpoints inform final document content. Reviewers are required, however, to disclose all healthcare-related RWI and other entities, and their disclosure information is posted online. Disclosure information for the ACC Competency Management Committee is also available online, as is the ACC disclosure policy for document development.
Eric S. Williams, MD, MACC
Chair, ACC Competency Management Committee
Jonathan L. Halperin, MD, FACC
Co-Chair, ACC Competency Management Committee
1.1 Document Development Process
1.1.1 Writing Committee Organization
The writing committee consisted of 15 members across the United States representing the ACC and the Heart Rhythm Society (HRS), identified because they fit into ≥1 of the following roles/categories: cardiovascular training program directors; CCEP training program directors; early-career through mid- and later-career specialists; general cardiologists; CCEP specialists representing both the academic and community-based practice settings as well as small, medium, and large institutions; specialists directing CCEP laboratories; specialists in all aspects of CCEP, including catheter ablation, device management, antiarrhythmic drug therapy, lead extraction, and left atrial appendage management; members working with ABIM and the ACGME; physicians experienced in defining and applying training standards according to the 6 general competency domains promulgated by the ACGME and the American Board of Medical Specialties and endorsed by the ABIM; and nurses specializing in cardiac implantable electronic devices. The writing committee met the College’s disclosure requirements for RWI as described in the Preamble.
1.1.2 Document Development and Approval
The writing committee convened by conference call and e-mail to finalize the document outline, develop the initial draft, revise the draft based on committee feedback, and ultimately approve the document for external peer review.
The document was reviewed by 5 official representatives from the ACC and HRS, as well as by 29 additional content reviewers (Appendix 2). The document was simultaneously posted for public comment from July 21, 2017 to August 7, 2017. A total of 235 comments were submitted on the document. Comments were reviewed and addressed by the writing committee. A member of the ACC Competency Management Committee served as lead reviewer to ensure a fair and balanced peer review resolution process. Both the writing committee and the ACC Competency Management Committee approved the final document to be sent for organizational approval. The governing bodies of the ACC and HRS approved the document for publication. This document is considered current until the ACC Competency Management Committee revises or withdraws it from publication.
1.2 Background and Scope
In 2010, the ACC began an ambitious initiative to delineate: 1) the core clinical competencies essential for trainees to attain during a 3-year cardiovascular fellowship (COCATS 4) (1); and 2) the aligned competencies that patients and accrediting bodies can reasonably expect clinical cardiologists in practice to acquire, maintain, or enhance through lifelong learning throughout their career (2,3). Key features of this outcomes-based curriculum include the 6-domain structure promulgated by the ACGME and the American Board of Medical Specialties, and endorsed by the ABIM. The cardiovascular competencies provide a structure for the ACC learning pathways and underpin all ACC educational activities.
The lifelong learning competencies for general cardiologists were published in 2016 and incorporated the new curricular competency format aligned with the COCATS 4 training milestones (3). Although the COCATS 4 and lifelong learning competencies are similar, they are not identical, reflecting the impact of practice focus and patterns on expectations of competency. Similarly, an advanced training statement on CCEP was published in 2015 (4) and this document now represents the corresponding lifelong learning competencies for CCEP specialists in practice. The aggregated lifelong learning competencies collectively underlie the Entrustable Professional Activities that patients and the public can reasonably expect all competent clinical cardiologists, including subspecialists, to be able to perform (Table 1). This 2017 document represents the first lifelong learning competencies specific to a subspecialty of cardiovascular medicine.
1.2.1 CCEP Lifelong Learning Competencies
The lifelong learning competencies for CCEP are organized using the 6 domains promulgated by ACGME/American Board of Medical Specialties and endorsed by the ABIM (Table 2). Section 2 focuses on clinical competencies, encompassing both the medical knowledge and the patient care and procedural skills competencies related to CCEP identified in Table 3, as well as the professional behavior competencies that pertain to CCEP, describing competencies for systems-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism. Section 3 of the document focuses on leadership and administrative competencies that pertain to CCEP specialists.
22.214.171.124 Distinction Between Competencies Expected of All CCEP Specialists and Those Required Based on the Focus of Practice
Table 3 distinguishes competency components expected of all CCEP specialists (left column) from those expected of selected CCEP specialists based on background, specialized knowledge, skills, experience, and practice focus (right column). This distinction is particularly relevant to the patient care competencies, which may require clinicians to obtain certain skills and experience beyond the traditional CCEP training period to be considered competent for independent practice. This distinction recognizes the breadth of experiences and practice styles in electrophysiology. Some physicians may specialize in a particular aspect of electrophysiology such as genetic arrhythmias or atrial fibrillation ablation. Others may adopt a less-invasive practice as they enter or continue throughout their career.
1.2.2 Research and Scholarly Activity
The topic areas in Table 3 define the core clinical competencies for practicing CCEP specialists. Scholarly activity and clinical research are also important in lifelong learning and professional competency. All physicians should have the skills to assess new research findings and appropriately incorporate new diagnostic and treatment modalities in patient care. In addition, physicians should utilize a scholarly approach to evaluate evidence, address clinical questions, and enhance outcomes through literature review, including at the point of care. They should use a systematic approach to critically appraise high-quality evidence from a variety of sources to apply a patient-centered approach to optimizing care and outcomes across all settings. Physicians should maintain and enhance knowledge through regular reading of peer-reviewed journals and other sources of reliable information, and through attending scientific meetings and professional congresses. Referral of patients for participation in well-designed clinical trials is encouraged for both academic and nonacademic cardiologists.
2 Clinical Competencies
3 Leadership and Administrative Competencies
In addition to clinical competency, CCEP specialists are expected to function effectively as leaders in allied efforts to ensure high-quality care and promote individual and population health. Some of these activities and attributes fall outside the realm of clinical knowledge and skill and instead involve administrative roles in clinical practice, hospitals, health systems, professional societies, or other organizations. Specific competencies expected of all general cardiologists and cardiovascular specialists including those whose careers involve greater involvement in administrative, managerial, or advocacy positions are delineated in Table 24 of the 2016 ACC Lifelong Learning Competencies for General Cardiologists (3).
4 Maintenance of Competence and Assessment Tools
Continuing practice of CCEP requires ongoing maintenance of competency beyond original training. The requirements for training as a specialist in CCEP are delineated in the 2015 Advanced Training Statement on CCEP, including the specific competencies required to achieve competence as well as recommendations for minimum procedural volume to demonstrate competence in CCEP (4). As practitioners continue in their careers beyond initial training, it is recognized that many practice opportunities and challenges will exist. As such, prescribing specific numerical requirements to any particular procedure is problematic, as patterns of practice vary from individual to individual as well as during the lifelong practice of CCEP. However, the CCEP specialist should be familiar with the literature that has related improved outcomes with specific procedural volume and, where appropriate, use these data to guide assessment of procedural skills (6–15).
In addition, there are a number of ways that CCEP specialists can maintain competency and expand lifelong learning in the course of practice and assess their own professional needs for education and performance improvement. Objective evaluation of competence in the practice setting can be challenging, but can be achieved through a number of assessment tools and learning resources that are available for this purpose and applicable to all CCEP specialists. These include:
▪ Demonstrate successful completion of a dedicated CCEP training program.
▪ Obtain ABIM certification following completion of CCEP training.
▪ Maintain certification with participation in a Maintenance of Certification process.
▪ Participate in ongoing Continuing Medical Education programs.
▪ Participate in Quality of Care Measures in hospital databases and national registries (e.g., ACC’s National Cardiovascular Data Registry) including procedure-specific registries where they apply.
▪ Experts in particular aspects of CCEP (e.g., device implantation or atrial fibrillation ablation) should perform an adequate annual volume to maintain skills and, where possible, provide their results for open scrutiny in the appropriate national databases.
▪ For new technologies and procedures, obtain adequate training through coursework, proctoring, and simulation laboratories.
Importantly, there is a growing subspecialization career focus within CCEP, in which some highly skilled practitioners limit the scope of their clinical activity to pacemaker and defibrillator implantation and follow-up, whereas others focus their efforts on complex ablation and device-related procedures. Thus, although maintenance of some CCEP competencies is an expectation for all clinical cardiac electrophysiologists, the maintenance of select CCEP competencies and the evaluation tools to assess them can be career focused.
Presidents and Staff
American College of Cardiology
Mary Norine Walsh, MD, FACC, President
Shalom Jacobovitz, Chief Executive Officer
William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publications
Dawn R. Phoubandith, MSW, Director, Competency Management
Kimberly Kooi, MHA, Education Design Associate
Shira Klapper, Publications Manager, Science, Education, Quality, and Publications
Heart Rhythm Society
George F. Van Hare, III, MD, FHRS, FACC, CCDS, CEPS-PC, President
James H. Youngblood, Chief Executive Officer
Thomas Getchius, Manager, Clinical Documents
We are grateful for the contributions of Melanie Gura, who served as a member of the Writing Committee from September 2016 to January 2017.
Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—2017 ACC/HRS Lifelong Learning Statement for Clinical Cardiac Electrophysiology Specialists
Appendix 2 Peer Reviewer Information—2017 ACC/HRS Lifelong Learning Statement for Clinical Cardiac Electrophysiology Specialists
Appendix 3 Abbreviation List
ABIM = American Board of Internal Medicine
ACC = American College of Cardiology
ACGME = Accreditation Council for Graduate Medical Education
CCEP = clinical cardiac electrophysiology
COCATS = Core Cardiovascular Training Statement
HRS = Heart Rhythm Society
RWI = relationships with industry
↵∗ Official representative of the Heart Rhythm Society.
↵† Former Competency Management Committee member; member during this writing effort.
The document was approved by the American College of Cardiology Lifelong Learning Oversight Committee in November 2017 and by the Heart Rhythm Society in October 2017. For the purpose of transparency, disclosure information for the Lifelong Learning Oversight Committee, the approval body of the convening organization of this document, is available at: http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/clinical-document-approval.
The American College of Cardiology requests that this document be cited as follows: Tracy CM, Crossley GH, Bunch TJ, Chow GV, Leiserowitz A, Indik JH, Kusumoto F, Mendes LA, Munger TM, Murali S, Patton KK, Russo AM, Scheinman M, Schoenhard JA, Winterfield JR. 2017 ACC/HRS lifelong learning statement for clinical cardiac electrophysiology specialists: a report of the ACC Competency Management Committee. J Am Coll Cardiol 2018;71:231–50.
This article has been copublished in HeartRhythm.
Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and Heart Rhythm Society (www.hrsonline.org). For copies of this document, please contact the Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail .
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (https://www.elsevier.com/about/our-business/policies/copyright/permissions).
- 2018 American College of Cardiology Foundation and Heart Rhythm Society
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- ACC Competency Management Committee
- Table of Contents
- 1 Introduction
- 2 Clinical Competencies
- 3 Leadership and Administrative Competencies
- 4 Maintenance of Competence and Assessment Tools
- Presidents and Staff
- Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—2017 ACC/HRS Lifelong Learning Statement for Clinical Cardiac Electrophysiology Specialists
- Appendix 2 Peer Reviewer Information—2017 ACC/HRS Lifelong Learning Statement for Clinical Cardiac Electrophysiology Specialists
- Appendix 3 Abbreviation List