Author + information
- Valentin Fuster, MD, PhD, MACC, Co-Chair,
- Jonathan L. Halperin, MD, FACC, Co-Chair,
- Eric S. Williams, MD, MACC, Co-Chair,
- Nancy R. Cho, MD, FACC,
- William F. Iobst, MD∗,
- Debabrata Mukherjee, MD, FACC and
- Prashant Vaishnava, MD
- ACC Training Statement
- ambulatory care
- clinical competence
- consultative care
- fellowship training
- longitudinal care
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 included a cardiovascular training program director; a member of the ACC Competency Management Committee; a cardiologist early in his career; specialists representing both the academic and community-based practice settings; as well as physicians, including a staff physician from the American Board on Internal Medicine (ABIM), 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 ABIM. The ACC determined that relationships with industry or other entities were not relevant to the creation of this general cardiology training statement. Employment and affiliation information for authors and peer reviewers is 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 representing the ABIM, and addressed the comments. The document was revised and posted for public comment from December 20, 2014, to January 6, 2015. Authors addressed additional comments to complete the document. A member of the ACC Competency Management Committee served as lead reviewer. The final document was approved by the Task Force, COCATS Steering Committee, and ACC Competency Management Committee and was ratified by the ACC Board of Trustees in March 2015. 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 general clinical cardiology enrolled in ACGME–accredited fellowships (1) on the basis of the following factors: 1) changes that have occurred in the field since 2008 and as part of a broader effort to establish consistent training criteria across all aspects of cardiology; and 2) the evolving framework of competency-based medical education described by the ACGME Outcomes Project and the 6 general competencies endorsed by the ACGME and ABMS. This document does not provide specific guidelines for training in advanced cardiovascular subspecialty areas but, where appropriate, identifies opportunities to obtain advanced training.
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 ambulatory, consultative, and longitudinal cardiovascular care. The Steering Committee and Task Force recognize that implementation of these changes in training requirements will occur incrementally over time.
For most areas of adult cardiovascular medicine, 3 levels of training are delineated:
▪ Level I training, the basic training required of trainees to become competent consultant cardiologists, is required of all fellows in cardiology and can be accomplished during a standard 3-year training program in general cardiology.
▪ Level II training refers to the additional training in 1 or more areas that enables some cardiologists to perform or interpret specific diagnostic tests and 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 general cardiology fellowship, depending on the trainees’ career goals and use of elective rotations.
▪ Level III training requires additional experience beyond the general cardiology fellowship to acquire specialized knowledge and competencies in performing, interpreting, and training others to perform specific procedures and rendering advanced, specialized care at a high level of skill. Level III training typically requires training beyond the standard 3-year general cardiology fellowship.
Most cardiac care occurs in the ambulatory setting. Although hospital-based care is increasingly directed at patients who are acutely ill or are undergoing invasive procedures, the importance of training and competence in the longitudinal care of ambulatory patients, including in disease prevention and management, has been increasingly emphasized. Anticipating reallocation of health resources toward ambulatory care, an expanded commitment to training in outpatient care for all cardiology trainees is required, regardless of a trainee’s field of interest or subspecialization. Training in ambulatory, consultative, and longitudinal care is a bedrock of cardiovascular fellowship upon which all subspecialized, advanced, and procedure-oriented training is based. Accordingly, a single level of training is delineated for this aspect of cardiology fellowship, with the expectation that the principles delineated in this report should pervade all other aspects of cardiovascular training. The approximate numbers of cases, procedures, and experiences recommended are based on published guidelines, competency statements, and the opinions of the members of the writing group. Training should be directed by appropriately prepared mentors in an ACGME-accredited program, and satisfactory completion of training must be documented by the program director on the recommendation of a competency committee. The variety and types of encounters and the scope of training required by the typical fellow are summarized in Section 4.
Training to become a general or specialized physician should prepare the trainee to provide high-quality care, which the Institute of Medicine defines as effective, efficient, equitable, safe, timely, and patient-centered (2). The specific training necessary to become a competent cardiovascular specialist should address prevention of adverse events such as myocardial infarction, stroke, or premature death from disease of the heart or blood vessels. Training should facilitate cardiovascular health and foster well-being across the lifespan, healthy aging, and event- and intervention-free survival. Hence, a key attribute of this aspect of training is the establishment of relationships with patients that span several years.
Experience in ambulatory, consultative, and longitudinal care should incorporate 3 general approaches: 1) acquisition of key skills through practical exposure and clinical practice; 2) participation in consultative cardiology; and 3) a formal curriculum that emphasizes the pathophysiological mechanisms and core knowledge of cardiovascular diseases. Cardiologists should embrace novel and evolving areas such as clinical applications of genetics, mechanical cardiac assist devices, remote monitoring, and transplantation and immunotherapy; become facile in managing or comanaging patients with congenital heart disease, pulmonary hypertension, age-related disorders, and dementia; and apply preventive strategies that promote health and longevity.
As a highly trained medical subspecialist, the modern cardiologist must serve as an effective member of the professional healthcare team. In many cases, the cardiologist will assume the role of team leader. At other times, the delivery of high-quality, patient-centered care will require that the cardiologist defer to the expertise of other members of the team. Negotiating these multiple roles requires skill as a communicator, competence with emerging technology, and effective collaboration with all healthcare professionals. On an interpersonal level, the cardiologist must acknowledge mistakes when they occur, learn from them and redirect a course of action to optimize outcomes, engender trust by exhibiting benevolence, avoid or divulge material conflicts, and motivate and inspire patients and colleagues. A lifelong commitment to mastery and maintenance of these skills and to learning is essential to both providing high-quality, patient-centric, ambulatory, consultative, and longitudinal care and assuming a leadership role in directing cardiovascular patient management.
2 General Standards
In published guidelines for ambulatory, consultative, and longitudinal cardiovascular care that are organized around individual disease states or cardiovascular procedures, the ACC and American Heart Association have promulgated congruent recommendations that address faculty, facility requirements, emerging technologies, and practice. We also recommend strongly that candidates for certification in cardiovascular diseases review the specific requirements of the ABIM.
Faculty should include specialists who are able to provide integrated assessment of cardiovascular risk and are knowledgeable and skilled in the principles of bedside clinical examination; differential diagnosis; electrocardiography; chest x-ray; echocardiography; stress testing; ambulatory rhythm and electrophysiological monitoring; cardiovascular development and aging; hypertension evaluation and management; dyslipidemia; abnormalities of glucose metabolism; congenital and valvular heart disease; evaluation, staging, and management of cardiac failure; cardiac arrhythmia diagnosis and management; and clinical applications of genetics and cardiovascular pharmacology. Faculty must also have a thorough understanding of the attitudes and proficiencies required of trainees to ensure acquisition of the additional ACGME/ABMS general competencies of systems-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism as they pertain to the delivery of cardiovascular care. A minimum of 2 key clinical faculty members, including the program director, must be board-certified in cardiovascular disease or possess equivalent qualifications based on training in a similar environment for a similar length of time, and they must have expertise in the requisite skills and at least 5 years of clinical experience beyond fellowship training. Programs must also maintain at least a 1:1.5 ratio of qualified faculty to enrolled trainees.
Facilities should be sufficient to ensure an environment suitable for safe and effective ambulatory patient care and include a patient reception area; clean, orderly, private examination rooms with sinks; examination gowns; gloves; sphygmomanometers; ophthalmoscopes and related equipment; consultation rooms with seating for the physician, patient, and at least 1 additional person such as a member of the patient’s family, which can be used for or in addition to a place for case review and discussion between the trainee and faculty preceptor; and workstations with computer terminals for access to the Internet and medical records. In addition, there should be accessible facilities for outpatient laboratory evaluations, including blood specimen collection for transmittal to a certified clinical laboratory and the standard and specialized equipment for performing the routine diagnostic procedures delineated in Section 2.3. The facility should be capable of accommodating common cardiovascular emergencies either onsite or at a nearby institutional facility to which a patient in distress can be readily transported under direct and continuous physician or nursing supervision.
Clinic or ambulatory care facilities require equipment for measuring blood pressure and transcutaneous oxygen saturation and for electrocardiography, with access to chest x-ray, echocardiography, ambulatory cardiac rhythm monitoring, and exercise stress testing. An electronic or paper-based medical record system must be available that meets federal data security requirements yet that can be accessed by authorized caregivers at all times for the purposes of both data entry and retrieval at—but not limited to—the point of care.
2.4 Ancillary Support
Ancillary support should be available to facilitate appointment scheduling and follow-up; manage clinical and financial records; retrieve laboratory and other clinical reports; enable telephone communications between patients and providers (e-mailing optional); provide clean, prepared examining and consultation rooms; and properly contain, control, and remove medical waste.
3 Training Components
3.1 Didactic Program
Didactic instruction may take place in a variety of formats, including but not limited to lectures, conferences, journal clubs, grand rounds, clinical case presentations, and patient safety or quality improvement conferences. A formal curriculum should include, in addition to the evaluation and management of patients across the full spectrum of cardiovascular diseases, relevant noncardiovascular disease topics commonly complicated by cardiovascular disease to which the trainee might otherwise have been less exposed. Among the topics to consider are acute and chronic pulmonary disease; sleep-disordered breathing; malignancies and the cardiovascular effects of cancer chemotherapy; hematologic disorders including thrombophilia; diabetes mellitus; kidney disease; acute and chronic dialysis; intracranial and extracranial cerebrovascular disease; and stroke.
3.2 Clinical Experience
Rotation on cardiology consultation services is an essential component of training in clinical cardiology. The training required to achieve this Level I competency requires firsthand experiences as a consultant in both the inpatient and outpatient settings. It is important that the cardiology consultation service expose the trainee to a broad array of patients with disease of varied acuity and a range of comorbidities. During the required rotations on the consultation service, trainees should conduct several initial patient evaluations daily in addition to providing follow-up care after the initial consultation. Often, transition of care between inpatient and outpatient settings is an important component of care. In addition to the inpatient consultation experience, trainees should obtain robust clinical experiences in an outpatient setting that promotes continuity of patient care over the course of the fellowship. Current recommendations include that fellows should be responsible, on average, for 4 to 8 patients per half-day session. In each clinical setting, trainees should gain hands-on experience under the supervision of a faculty mentor or preceptor in a fashion that emphasizes patient-centered education in all aspects of cardiovascular management. It is important that, in these experiences, the trainee assume the role of a consultant responsible for communication with the patient, family members, referring physicians, pharmacists, nurses, and other healthcare personnel.
3.3 Teaching Others
An important aspect of subspecialty training is the ability to educate trainees, such as medical students, residents, or fellows in other fields, on such topics as the cardiovascular physical examination, pharmacology, electrocardiography, and cardiac imaging, at a level commensurate with their training and experience. This applies to peer-to-peer education through topic reviews, journal clubs, clinical case presentations, quality assurance programs, and preparation of case reports for publication. The objectives include enhancement of communication skills, consolidation of knowledge in core topic areas, development of enduring educational materials (e.g., syllabi, lecture slides, or web-based tools), and nurturing a commitment to lifelong learning and maintenance of competency.
4 Summary of Training Requirements
4.1 Development and Evaluation of Core Competencies
Training and requirements in cardiovascular disease 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/ABIM reporting milestones. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs. Additionally, the ACC has developed tools to assist physicians in assessing, enhancing, and documenting these competencies.
Table 1 delineates each of the 6 competency domains as well as the associated curricular milestones for training in ambulatory, consultative, and longitudinal cardiovascular care. The milestones indicate the stage of fellowship training (12, 24, or 36 months, and additional time points) by which the typical cardiovascular 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 vary as well. Level I competencies may be achieved at earlier or later time points. The table also describes examples of evaluation tools suitable for assessment of competence in each domain. It is also important to emphasize that although the table delineates key competency components for ambulatory, consultative, and longitudinal care, it is not comprehensive. Additional competency components required of a consultant cardiologist (Level I) are described in the other COCATS 4 Task Force reports.
4.2 Duration and Structure of Training
The specific competencies for training are delineated in Table 1. Continuity of longitudinal patient care is fundamental to training in ambulatory and consultative cardiovascular care. Hence, although it is expected that all trainees will engage in this activity for no less than 1 half-day weekly for at least 40 weeks of each year of training during the general 3-year cardiovascular fellowship, attendance in weekly clinic sessions alone is not sufficient to satisfy this training requirement. Longitudinal care implies not only continuity in the ambulatory setting, but also a commitment to: 1) following patients in the event of hospitalization; 2) telephone contacts or other communication with and about the patient; 3) interactions with family members, collaborating physicians, and other members of the healthcare team; and 4) general availability to address whatever cardiovascular or related issues or conditions might arise in the course of long-term clinical management.
4.2.1 Acquisition of Key Skills
The ultimate goal of fellowship training is the integration of a sound foundation of knowledge and understanding of cardiac systems and the roles of testing and technology, on the one hand, with the ability to manage difficult and challenging situations, on the other hand. These goals require the effective integration of the ACGME 6 general competencies into the delivery of safe and effective patient care. The cardiologist must accept responsibility; identify, acknowledge, and overcome gaps in knowledge; maintain flexibility and adjust direction; think creatively; keep an open mind; incorporate humanism; and employ discipline and organization to follow through with plans, motivate patients, and inspire others on the healthcare team. Although the ambulatory care or outpatient setting represents an ideal environment for initial acquisition of these skills through teaching, mentoring, and example, mastery cannot be achieved without years of experience and a commitment to lifelong learning.
22.214.171.124 Medical Knowledge, Clinical Decision-Making, and Skills in Transitional Care
The ambulatory patient often presents less obvious evidence of disease than the hospitalized patient. Therefore, outpatient training is directed at acquiring knowledge, enhancing judgment, and sharpening skills in effectively transitioning patient care.
126.96.36.199.1 Medical Knowledge and Clinical Evaluation
The trainee should routinely question why the patient has developed a given condition or problem and address the underlying etiology to guide diagnostic testing and treatment.
1. The cardiologist must be alert to life-threatening conditions that cannot be overlooked, while also recognizing the most likely causes of symptoms or asymptomatic conditions and maintaining awareness of rare possible causes. He/she should learn to distinguish urgent situations from those that can be addressed more methodically.
2. It is valuable to understand the controversies and/or complexities that surround the evaluation or management of particular cardiovascular diseases or conditions, including comorbidities; the influences of genetics and aging; variations in drug metabolism and interactions; the impact of renal or hepatic dysfunction; fluid balance; and the patient’s lifestyle and the influence of diet, exercise, alcohol, or recreational or illicit drugs. It is also essential to understand the roles of stress, anxiety, and depression in exacerbating hypertension, chest pain, cardiac arrhythmias, heart failure, and other conditions.
3. In formulating and executing an effective clinical management plan, the trainee should understand the cumulative burden of multiorgan dysfunction. Rarely does a physician encounter a purely cardiac patient. As the population ages, a panoply of conditions converge, and an appreciation of the interplay between individual patient characteristics and the natural history of disease enables the clinician to anticipate outcomes and complications, which is key to successful management. The cardiologist must balance emerging concepts and traditional strategies. Reliance on secondhand data should be avoided in favor of direct interaction with and examination of the patient, as well as direct review of prior testing data from both within and outside of one’s own facility to enable comprehensive and insightful evaluation of a given problem in the context of the individual.
188.8.131.52.2 Clinical Decision-Making
Although clinical judgment is acquired through experience over time, strategies facilitating the development of clinical judgment can be taught and honed. Specific clinical examples (patient-specific teachable moments) help convey the art of medicine. Here, the timing of tests, procedures, or interventions is vital, matching the intensity of action to the level of risk and severity of the condition. An example is to prefer initiation or adjustment of 1 drug at a time in nonurgent situations and proceed in logical sequence, rather than changing multiple aspects of a regimen concurrently. Clinical decision-making regarding testing and/or therapeutic decisions should also consider the balance of risk and benefit for the individual patient. In applying management recommendations from resources such as clinical practice guidelines, cardiovascular trainees must take into account the needs of special populations and appreciate the impact of comorbidities, particularly in older patients with cardiovascular disease who typically have multiple concurrent medical conditions that influence outcomes.
184.108.40.206.3 Effective Translation of Clinical Information
It is not sufficient to perform only an initial consultation and outline recommendations; specific instructions should be individualized and written down. Follow-up at timely intervals to assess and measure responses and outcomes on the basis of symptoms, functional status, weight, blood pressure, and heart rate form the foundation for gauging clinical progress. The clinical problem, plan, rationale, potential risks or adverse effects, and specific directions given to the patient require careful documentation. Systematic quality assurance requires recording and quantifying both successful and unsuccessful outcomes.
220.127.116.11 Interpersonal and Communication Skills
18.104.22.168.1 Communication Skills
An important objective of office- or clinic-based clinical training is to develop a rapport and communicate effectively with the patient; convey understanding of the clinical condition and prognosis; and deliver this information in a respectful, empathetic, and caring manner. Outpatient encounters provide opportunities to heighten a physician’s sensitivity to patient needs, values, and preferences, thus establishing the foundation for a relationship based on compassion and trust.
To develop the ability to communicate with patients across a range of cultural, ethnic, and socioeconomic backgrounds, the trainee must be sensitive to financial, cultural, and social barriers to diagnostic and treatment recommendations. Effective communication may require a qualified language translator. It also requires empathetic understanding of the emotional impact of and response to disease. Ultimately, the cardiologist must employ psychological insight to address the patient’s hopes, fears, and desires and then leverage these to promote healthy behavior. Appreciation of differences between men and women, young and old, working, retired, indigent, middle-class, wealthy, educated, informed, urban versus rural dwelling, and other demographic variables is necessary to modulate and individualize medical decision-making and discussion.
22.214.171.124.1.1 Communication With Other Providers
As a consultant to other physicians, the trainee should develop communication and practice management skills necessary to comanage patients with other providers, as noted in the following text.
126.96.36.199.1.2 Communication With Referring Physicians
Timely communication with referring physicians, referral of patients with unusual or complex conditions when appropriate, and close interaction with surgical and interventional colleagues are essential to shared, informed decision-making and successful outcomes.
188.8.131.52.2 Interpersonal Skills
Successful clinicians share a common asset: interpersonal skills. This is among the most difficult skills to teach because it is highly dependent on personality, but attending physicians can often have a more substantial educational impact in the outpatient environment than in the acute care hospital setting. The requisite skills include the ability to interpret cues from body language, including recognition of fear, anxiety, depression, and denial of illness, and to inspire, motivate, encourage, coach, and openly discuss goals of care and end-of-life issues. It is important to identify and overcome defensive or passive-aggressive attitudes and behavior. The cardiologist must enlist the support of spouses, children, and others with personal relationships to the patient as well as aides, companions, and nurses in the patient’s interest. Interactions with ancillary staff may provide helpful insight into patient care issues, including identifying and overcoming barriers to effective care (e.g., home situation, insurance coverage). Interpersonal skills are essential for meaningful professional communication with physician colleagues; fellowship training in the ambulatory setting provides a prime opportunity to develop and master these skills.
184.108.40.206 Patient Care and Procedural Skills in Transitional Care
The trainee should recognize the challenges at the interfaces between hospital admission, inpatient management, and discharge. Such challenges include the need for early outpatient follow-up in select circumstances (e.g., following hospitalization for heart failure), the need for strategies to minimize adverse outcomes and avoid or delay readmission, deployment of ancillary resources to maintain surveillance of the patient’s condition at home, and understanding indications for and components of cardiac rehabilitation and health maintenance. Similarly, in the longitudinal care of hospital inpatients, the cardiologist must ensure continuity during transitions of care to and from the intensive care unit and less acute settings and before and after invasive cardiovascular procedures or surgery.
Beyond standard communication skills, the cardiologist must be technologically proficient in the use of electronic health records and information systems and incorporate automatic reminders, callbacks, test and procedure result tracking, laboratory flow sheets, and surveillance to ensure timely scheduling of interventions and surveillance. Trainees must also know and adhere to the requirements and precautions regarding the confidentiality of medical information.
220.127.116.11.1 Remote Communication Tools
The appropriate use of electronic communication and cost-effective use of technology, such as remote monitoring with ambulatory telemetry, point-of-care international normalized ratio systems for patient self-testing, and downloading readouts from implanted cardiac arrhythmia devices, is essential.
18.104.22.168.2 Remote Interaction Systems
Real-time interaction with emergency care facilities, clinics, other physicians, rehabilitation centers, and ancillary caregivers by telephone, fax, or electronic record messaging avoids redundancy of care, reduces the risk of error, and helps control cost. Examples are avoiding adverse drug interactions through access to lists of concurrent medications and unnecessarily repeating tests or procedures through access to prior results.
22.214.171.124.3 Access to Internet Data
Within the context of the patient’s condition, information that is widely accessible on the Internet may provide valuable insight, but caution is needed to avoid incorporating misinformation and inferences. Information must be validated through searches of primary sources, trustworthy textbooks, or recommendations from evidence-based practice guidelines. The trainee should become familiar with the array of electronic medical record systems and information technology resources that facilitate systems-based practice.
126.96.36.199 Practice-Based Learning
188.8.131.52.1 Adherence to Accepted Algorithms
Disease-specific algorithms for clinical decision-making and patient management provide foundations for individualizing delivery of care for patients with cardiac conditions. Integration of personnel and electronic systems for organized follow-through based on target endpoints should emphasize the collaborative management of patients undergoing cardiac surgery or invasive procedures and an integrated approach to team-based patient care.
184.108.40.206.2 Appropriate Use Criteria
The trainee should incorporate relevant appropriate use criteria into decision making in the ambulatory setting. Outpatient training should offer a venue in which to practice evidence- and guideline-based care.
220.127.116.11.3 Performance Measures and Practice Improvement
The clinical trainee should gain exposure to his/her relevant, individual performance metrics through periodic reviews, including systematic updating and re-evaluation of patient charts as a means of performance assessment. Trainees should also identify opportunities for focused improvement; establish a pattern of enhancing competency; and ensure continuous quality improvement. These activities should be conducted at least twice annually throughout the fellowship as integral to the ambulatory care experience and be subject to both self-assessment and review by faculty mentors, including verbal feedback to the trainee and reporting to the Clinical Competency Committee and program director.
18.104.22.168.1 Advocacy and Mindset
The trainee should develop the mindset of being the patient’s advocate to engender confidence and mutual trust and optimize clinical outcomes. That being said, while maintaining empathy, the trainee should retain sufficient detachment to ensure objectivity, avoid bias, and sustain equanimity. Among the most important features of such a mindset approach are the following:
1. Training in patient-centered care, emphasizing shared decision-making and patient autonomy and eschewing conflicts of interest. Thus, when ordering a test or recommending a course of action, the cardiologist should clearly convey what is in the best interest of the patient. Furthermore, accepting part of the burden of worry and responsibility for the patient in difficult times—and a readiness to credit the patient, family, or caregivers when the outcome is successful—catalyzes trust.
2. Having the equanimity to avoid distress, frustration, or resentment when confronted with noncompliance while managing limited time and multiple obligations.
3. Developing the ability to challenge assumptions, open one’s thinking, and seek additional opinions. Acceptance of one’s limitations is important in the evolution of a fully-developed physician and can both enhance overall patient care and help prevent physician burnout and cynicism.
22.214.171.124.2 Ability to Delegate
The ability to delegate appropriately to trusted ancillary staff, other physicians, nurses, dieticians, physical therapists, and other healthcare professionals is critical to ensure that sufficient time is available to meet responsibilities to many patients. Micromanaging too many details can lead to exhaustion and increase rather than reduce the risk of error.
126.96.36.199.3 Management Plan
The trainee should be able to formulate a specific plan and present options to the patient, family, and referring physician. He/she should discuss risks and potential adverse outcomes of medications or other interventions or, conversely, the risks of foregoing actions, tests, or treatments in relation to outcome. Furthermore, the cardiology fellow must acquire skills in communicating unfortunate information when there are no remaining options, while conveying hope and open availability for discussion.
4.2.2 Cardiovascular Subspecialty Clinics
Opportunities should be provided to expose trainees to a range of ambulatory patients across a spectrum of cardiovascular diseases and conditions. This may involve a variety of mechanisms depending on the specialty, such as joining senior clinician tutors or attending clinics as a primary cardiovascular physician under the direction of faculty. Exposure to as many of the following specialty experiences as possible is recommended: 1) hospital-based general cardiology clinic; 2) general cardiology in the office of a senior clinician; 3) an obstetrical clinic visited by pregnant patients with heart disease, optimally in the context of an interdisciplinary approach to high-risk pregnancy; 4) a geriatric clinic visited by elderly patients with heart disease, optimally in an interdisciplinary geriatric practice; and 5) prevention and rehabilitation programs or clinics visited by patients with dyslipidemia, diabetes, hypertension, obesity, or other risk factors in both primary and secondary prevention situations. In addition, exposure to patients with pulmonary hypertension, sleep-disordered breathing, advanced heart failure, peripheral vascular diseases, complex arrhythmias, and implanted pacemakers and defibrillators, and to adult patients with congenital heart disease or genetic disorders should occur both in general clinical cardiology practice and, when possible, through participation in organized subspecialty practices or clinics under the direction of Level III–trained specialists in these fields. The overarching objective of these specialized ambulatory care experiences is to expose the trainee to the range of services available in these tertiary care settings and enhance his/her ability to generate timely referrals when indicated, interact appropriately with experts in the care of their own patients, and enhance the overall quality of cardiovascular care available to the population.
4.3 Competency in the Care of Patients With Specific Cardiovascular Conditions
Together, the COCATS 4 Task Force reports form the core curriculum in cardiovascular medicine and describe a wide range of clinical experiences during which general cardiology trainees are expected to achieve competencies in evaluating and managing patients with, or at risk of developing, acute and chronic cardiovascular disorders, in both hospital and outpatient settings. There are several other key areas of cardiology that are not individually addressed in COCATS 4 via specific Task Force reports. These include stable ischemic heart disease, acute coronary syndromes, valvular heart disease, and pericardial disease. The curricular competency components and milestones for these topics are summarized in Tables 2 to 5⇓⇓⇓. Training in many of these areas is carried out in consultative, ambulatory, or longitudinal care experiences. For other topics, such as cardiac tumors, trauma, inflammatory and infectious diseases of the heart, and the evaluation and management of patients with known or suspected cardiovascular disease undergoing cardiac or noncardiac surgery, selected aspects are included in the competency tables of the relevant COCATS 4 Task Force reports.
5 Evaluation of Competency
Evaluation tools in clinical cardiology include direct observation by instructors, in-training examinations, case logbooks, conference and case presentations, multisource evaluations, trainee portfolios, simulation, and reflection and self-assessment. Case management, judgment, interpretive, and bedside skills must be evaluated in every trainee. Quality of care and follow-up; reliability; judgment, decisions, or actions that result in complications; interaction with other physicians, patients, and laboratory support staff; initiative; and the ability to make appropriate decisions independently should be considered. 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, diagnoses, disease severity, outcomes, and disposition). The faculty, under the aegis of the program director, 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 1: Training in Ambulatory, Consultative, and Longitudinal Cardiovascular Care
|Committee Member||Employment||Consultant||Speakers Bureau||Ownership/Partnership/Principal||Personal Research||Institutional/Organizational or Other Financial Benefit||Expert Witness|
|Valentin Fuster (Co-Chair)||Icahn School of Medicine at Mount Sinai, Zena and Michael A. Wiener Cardiovascular Institute—Director||None||None||None||None||None||None|
|Jonathan L. Halperin (Co-Chair)||Icahn School of Medicine at Mount Sinai—Professor of Medicine||None||None||None||None||None||None|
|Eric S. Williams (Co-Chair)||Indiana University School of Medicine—Professor (Cardiology) and Associate Dean; Indiana University Health—Cardiology Service Line Leader||None||None||None||None||None||None|
|Nancy R. Cho||Cardiology and Medicine Associates—Cardiologist||None||None||None||None||None||None|
|William F. Iobst||The Commonwealth Medical College—Vice President, Academic and Clinical Affairs, Vice Dean; Former employment during writing effort: American Board of Internal Medicine—Vice President, Academic Affairs||None||None||None||None||None||None|
|Debabrata Mukherjee||Texas Tech University Health Sciences Center—Chief, Cardiovascular Medicine||None||None||None||None||None||None|
|Prashant Vaishnava||The Icahn School of Medicine at Mount Sinai, Mount Sinai Heart—Director, Quality Assurance; Assistant 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 2 Peer Reviewer Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 1: Training in Ambulatory, Consultative, and Longitudinal Cardiovascular Care
|Name||Employment||Representation||Consultant||Speakers Bureau||Ownership/Partnership/Principal||Personal Research||Institutional/Organizational or Other Financial Benefit||Expert Witness|
|Richard Kovacs||Indiana University, Krannert Institute of Cardiology—Q.E. and Sally Russell Professor of Cardiology||Official Reviewer, ACC Board of Trustees||None||None||None||None||None||None|
|Dhanunjaya Lakkireddy||Kansas University Cardiovascular Research Institute||Official Reviewer, ACC Board of Governors||None||None||None||None||None||None|
|Howard Weitz||Thomas Jefferson University Hospital—Director, Division of Cardiology; Sidney Kimmel Medical College at Thomas Jefferson University—Professor of Medicine||Official Reviewer, Competency Management Committee Lead Reviewer||None||None||None||None||None||None|
|Furman McDonald||American Board of Internal Medicine—Vice President Graduate Medical Education, Department of Academic Affairs and Professor, Medicine||Organizational Reviewer, ABIM||None||None||None||None||None||None|
|Kiran Musunuru||Brigham and Women’s Hospital, Harvard University||Organizational Reviewer, AHA||None||None||None||None||None||None|
|Kenneth Ellenbogen||VCU Medical Center—Director, Clinical Electrophysiology Laboratory||Content Reviewer, Cardiology Training and Workforce Committee||None||None||None||None||None||None|
|Michael Emery||Greenville Health System||Content Reviewer, Sports and Exercise Cardiology Section Leadership Council||None||None||None||None||None||None|
|Rosario Freeman||University of Washington—Director, Cardiology Fellowship Programs; Medical Director, Noninvasive Diagnostic Services; Associate Professor of Medicine||Content Reviewer, Competency Management Committee||None||None||None||None||None||None|
|Brian D. Hoit||University Hospitals Case Medical Center||Content Reviewer, Cardiology Training and Workforce Committee||None||None||None||None||None||None|
|Larry Jacobs||Lehigh Valley Health Network, Division of Cardiology; University of South Florida—Professor, Cardiology||Content Reviewer, Cardiology Training and Workforce Committee||None||None||None||None||None||None|
|Andrew Kates||Washington University School of Medicine||Content Reviewer, Academic Research Council||None||None||None||None||None||None|
|Chittur A. Sivaram||University of Oklahoma—Vice Chief, Cardiovascular Section||Content Reviewer, Competency Management Committee||None||None||None||None||None||None|
|David Vorchheimer||Montefiore-Einstein Center for Heart & Vascular Care—Director, Clinical Cardiology; Professor, Clinical Medicine||Content Reviewer, Individual||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 peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. 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.
ABIM = American Board of Internal Medicine; ACC = American College of Cardiology; AHA = American Heart Association; VCU = Virginia Commonwealth University.
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
COCATS = Core Cardiovascular Training Statement
HIPAA = Health Insurance Portability and Accountability Act
↵∗ American Board of Internal Medicine Representative.
The American College of Cardiology requests that this document be cited as follows: Fuster V, Halperin JL, Williams ES, Cho NR, Iobst WF, Mukherjee D, Vaishnava P. COCATS 4 task force 1: training in ambulatory, consultative, and longitudinal cardiovascular care. J Am Coll Cardiol 2015;65:1734–53.
- American College of Cardiology Foundation
- Baughman K.L.,
- Duffy F.D.,
- Eagle K.A.,
- Faxon D.P.,
- Hillis L.D.,
- Lange R.A.
- ↵Institute of Medicine (U.S.) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press (U.S.); 2001. Available at: http://www.ncbi.nlm.nih.gov/books/NBK222274/. Accessed March 26, 2015.
- 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 1: Training in Ambulatory, Consultative, and Longitudinal Cardiovascular Care
- Appendix 2 Peer Reviewer Relationships With Industry and Other Entities (Relevant)—COCATS 4 Task Force 1: Training in Ambulatory, Consultative, and Longitudinal Cardiovascular Care
- Appendix 3 Abbreviation List