Author + information
- Daniela R. Crousillat, MDa,∗ (, )
- Brieze R. Keeley, MDb,
- Mary K. Buss, MD, MPHc,
- Hui Zheng, PhDd,
- Donna M. Polk, MD, MPHe and
- Kristen G. Schaefer, MDf
- aDepartment of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
- bDepartment of Medicine, Division of Hospital Medicine, Section of Hospice and Palliative Medicine, University of California-San Francisco, San Francisco, California
- cDepartment of Medicine, Section of Palliative Care, Division of General Medicine and Primary Care and Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- dBiostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
- eDepartment of Medicine, Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
- fDepartment of Medicine, Division of Palliative Medicine, Brigham and Women’s Hospital, Department of Psychosocial Oncology and Palliative Care, Division of Adult Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Daniela R. Crousillat, 55 Fruit Street, Yaw 5B, Boston, Massachusetts 02114.
Advanced heart disease (AHD) represents a significant health burden worldwide. Due to an aging population and improved treatments for AHD, cardiologists will increasingly care for patients toward the end of life (EOL). Despite growing evidence that the integration of palliative care (PC) for patients with AHD significantly improves quality of life (1,2), <10% of patients with AHD receive these services, and most do so only at EOL (3).
The American Heart Association has endorsed integration of PC into the early care of all patients with AHD (4), yet no explicit recommendations exist to guide the content and quality of PC education for cardiology trainees. Because of the limited availability of specialty PC providers (5), the development, standardization, and dissemination of primary palliative competencies for general cardiologists is paramount to ensure access to PC for all patients with AHD (6).
Little is known about how well cardiology fellowships teach trainees PC skills. We defined essential PC competencies for cardiology trainees abstracted from published national cardiology training and clinical guidelines, and conducted a cross-sectional national survey of cardiology fellows and faculty to assess the current quantity and quality of PC education for cardiology trainees. Our survey assessed education provided in essential PC competencies as defined by the American College of Cardiology’s (ACC) 2015 Core Cardiovascular Training Statement (COCATS) 4 (7) and published national society practice guidelines (4,8–11).
Defining Essential Primary PC Competencies
To define essential PC competencies for cardiology trainees, we conducted a systematic search for PC content in the COCATS 4 (7) training document and in select published national society practice guideline documents (4,8–11). We searched the entire COCATS 4 document for key words (e.g., prognostication, communication, EOL, pain) from previously defined PC competencies for medical trainees. Competencies that were not PC (e.g., management of acute chest pain) were excluded and the remaining competencies were sorted into 5 previously defined PC domains (12). We then systematically reviewed published national society practice guidelines (4,8–11) pertinent to AHD and adapted a list of additional PC competencies that were not represented in COCATS (Table 1). We designed our electronic surveys to assess the quantity and quality of teaching in these PC competencies.
We surveyed fellows and faculty from 18 academic cardiology fellowship programs active in the ACC education and cardiovascular training committees. We conducted the survey between March 1, 2016 and May 1, 2016. Of the 241 surveys distributed, 47 fellows (39%) and 31 faculty (26%) responded. Most training programs were uniformly represented by survey participants. Most respondents were male (71% fellows, 83% faculty), which was consistent with current trends in cardiology training (13), and fellow respondents were more ethnically diverse than faculty.
PC Training Is Important to Cardiologists
More than 96% of fellows and faculty surveyed agreed that PC training is important for cardiologists (Figure 1). Among fellows, we found no significant relationship between this perspective and the type of career (basic science, clinical research, academic or community medicine) they intended to pursue (p = 0.73). Faculty and fellows reported a preference to lead goals of care (GOC) conversations, as opposed to relying on consultants to do so; however, they also reported feeling inadequately trained to do so (Figure 1). These observations highlight cardiologists’ widespread interest in developing PC skills and suggest that additional training is needed to develop expertise in this arena.
Cardiologists Lack Important Training in PC Skills
Despite how frequently cardiologists encounter patients with PC needs, there is a paucity of high-quality PC education for cardiologists in training. Among survey respondents, <10% of fellows and no faculty reported required or elective training in PC during cardiology fellowship. Collaboration between cardiologists and PC providers, however, is increasingly common. Among faculty, 62% reported minimal exposure to PC education, and only 31% cited clinical collaboration with a PC specialty service during their own fellowship training. By contrast, 71% of fellows reported clinical collaboration with PC specialists during fellowship.
Despite the absence of standardized PC education, cardiology fellows reported frequently encountering clinical scenarios that require PC skills. A total of 46% of fellows reported that they discussed transitioning GOC from curative to palliative with patients on >20 occasions during the first year of fellowship, but noted that they did so with little supervision or feedback from faculty. Compared to GOC conversations, fellows performing coronary angiograms received significantly more observation (p < 0.01) and feedback (p < 0.01).
Fellows also reported receiving significantly less formal teaching on GOC conversations, an essential PC competency, than on both common and rare general cardiology topics (p = 0.05) (Figure 2). Although most fellows reported a small amount of teaching on GOC conversations, nearly 10% reported receiving no teaching on the subject at all. Survey results also highlighted a significant discordance in the quality of teaching on these topics. Fellows reported significantly higher quality teaching on management of common cardiac conditions (e.g., ventricular tachycardia, cardiogenic shock) compared with frequently encountered PC issues among patients with AHD (e.g., discussions regarding implantable cardioverter defibrillator deactivation, management of refractory dyspnea) (4.31 ± 0.79 vs. 3.56 ± 1.04 on a scale of 1 to 5, where 1 = poor quality and 5 = excellent quality; p < 0.0001). There are several possible explanations for these findings, including limited PC expertise among faculty, as well as incompletely developed national guidelines for training and evaluating PC competence among cardiologists.
National Training Guidelines Play a Critical Role in Defining the Formal Education of Cardiologists
Faculty participants reported more teaching on PC topics included in the current COCATS 4 guidelines (e.g., shared decision making, determining when to refer to hospice care) compared with PC competencies widely considered essential in practice but not included in cardiology training guidelines (e.g., use of opiates to treat refractory dyspnea, criteria for discontinuation of inotropic or mechanical circulatory support) (p = 0.045). These results highlight the impact of national curricular standards on what is taught to cardiology trainees and the opportunity to incorporate additional essential PC competencies into future COCATS training guidelines.
Time to Bridge the Gap
This is the first study to evaluate the quantity and quality of PC education in U.S. cardiology fellowship programs using standards set by current national consensus training and practice guidelines. Our results demonstrate that PC skills are important to cardiologists in training and in practice, but cardiology fellowships currently offer incomplete education in essential PC competencies. These findings are consistent with several prior studies that demonstrate deficits in PC training within other subspecialty fellowships (14-17). Although this study is limited by small sample size, subjectivity of self-reported data, generalization of findings from academic cardiology programs, and the inherent challenges in assessing education quality, our findings provide a critical starting point for further investigation.
Our findings suggest the need for improved PC education in cardiology fellowship. This study shows that among crucial PC skill sets, symptom management and advance care planning are 2 of the least well represented in current cardiology training guidelines. To address these deficits, we propose the development of a task force to define standardized PC competencies for cardiology trainees and incorporate educational objectives into future guidelines (Figure 3). This will enable cardiologists to better integrate high quality symptom management and advance care planning techniques into their armamentarium of tools for treating patients with advanced AHD.
Funding was provided by the Brigham and Women’s Hospital Department of Medicine Education Innovation Grant 2015-2016. All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- Rogers J.G.,
- Patel C.B.,
- Mentz R.J.,
- et al.
- O'Donnell A.E.,
- Schaefer K.G.,
- Stevenson L.W.,
- Mehra M.R.,
- Desai A.S.
- Gelfman L.P.,
- Kalman J.,
- Goldstein N.E.
- Braun L.T.,
- Grady K.L.,
- Kutner J.S.,
- et al.
- Halperin J.L.,
- Williams E.S.,
- Fuster V.,
- et al.
- Hunt S.A.,
- Abraham W.T.,
- Chin M.H.,
- et al.
- Yancy C.W.,
- Jessup M.,
- Bozkurt B.,
- et al.
- Allen L.A.,
- Stevenson L.W.,
- Grady K.L.,
- et al.
- Lewis S.J.,
- Mehta L.S.,
- Douglas P.S.,
- et al.
- Larrieux G.,
- Wachi B.I.,
- Miura J.T.,
- et al.