CLINICAL RESEARCH: CARDIAC MAGNETIC RESONANCE IMAGING
Training cardiovascular fellows in cardiovascular magnetic resonance and vascular imaging
Current status following the core cardiovascular training symposium (COCATS-2) guidelines
Allen J. Taylor, MD*,*,
James E. Udelson, MD ,
Valentin Fuster, MD, PhD American College of Cardiology Foundation's Cardiovascular Imaging Committee and the Cardiovascular Training Directors Committee
* Cardiology Service, Walter Reed Army Medical Center, Washington, DC, USA
Division of Cardiology, Tufts-New England Medical Center, Boston, Massachusetts, USA
Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York, USA
Manuscript received July 9, 2003;
revised manuscript received October 7, 2003,
accepted October 13, 2003.
* Reprint requests and correspondence: Dr. Allen J. Taylor, LTC MC USA, Program Director, Cardiovascular Medicine, Cardiology Service, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Building 2, Room 4A, Washington, DC 20307-5001, USA.
allen.taylor{at}na.amedd.army.mil
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Abstract
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OBJECTIVES: This survey study sought to characterize the current training environment in cardiovascular magnetic resonance (CMR) and vascular imaging and to quantify the magnitude of any gaps between current training practice and the recommendations of the Core Cardiovascular Training Symposium (COCATS-2) guidelines.
BACKGROUND: The COCATS-2 guidelines published in 2002 newly included specific educational components of CMR and vascular imaging. An understanding of the current capabilities of training programs to meet these guidelines could produce efforts to improve training opportunities.
METHODS: We surveyed all accredited adult cardiovascular training programs by using a 21-question, multiple-response survey. Data were collected on center and program characteristics, clinical activities, control of clinical activities, and needs and attitudes. Parallel data were collected for nuclear cardiology capabilities as a "base case."
RESULTS: Only 13% of training programs reported "ownership" of CMR equipment, compared with 48% for nuclear equipment (p = 0.001). Dedicated fellow rotations in nuclear imaging are nearly universally present, whereas vascular (64%) and CMR imaging (29%) lag behind. A majority of programs do not use formal educational curricula for CMR and vascular imaging. Among centers with CMR training capabilities, the breadth of training opportunities is typically very limited, with most having only aortic imaging as their sole capability, except in predominately large training centers. The greatest need expressed by programs was educational assistance in the form of written and lecture curriculum materials.
CONCLUSIONS: A substantial gap exists between the current training environment in CMR and vascular imaging and the recommendations of COCATS-2. Sharing training opportunities between centers is encouraged, particularly for smaller training programs, in order to capitalize on limited equipment, personnel, and curriculum resources.
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Abbreviations and Acronyms
| | ACCF | = American College of Cardiology Foundation | | CMR | = cardiovascular magnetic resonance | | COCATS | = Core Cardiovascular Training Symposium |
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The current guidelines for the educational structure and content of fellowship training in adult cardiovascular medicine, also known as the Core Cardiovascular Training Symposium (COCATS-2), were published in April 2002 (1). Two major changes for level 1 (minimum required) training included the incorporation of training in cardiovascular magnetic resonance (CMR) imaging and a specific component of vascular imaging. Specifically, COCATS-2 indicated that for CMR imaging, cardiovascular fellows must obtain one month of minimum exposure (either dedicated or in the aggregate), including the recommendation that fellows must "actively participate in CMR study interpretation," which "may include studies from an established teaching file." Didactic education must include lectures on basic aspects of CMR imaging, with parallel reading material. Recommendations for vascular medicine include two months of exposure, either dedicated or in aggregate, including "instruction in the noninvasive laboratory" for exposure to vascular imaging.
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Rationale for training survey in CMR and vascular imaging
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Several significant impediments are present to the incorporation of new technologies into cardiovascular fellowship training. Hospital systems and their departments may defer investments until a new technology is relatively mature, demonstrating a need to balance needs and wants with the current financial realities. Also, the capabilities of new technologies often overlap with existing capabilities, placing them in a competitive relationship for the delivery of clinical care. With the expansion of older technologies into cardiovascular indications (for example, the development of CMR), cardiovascular medicine departments are typically not in control of the necessary equipment and lack experienced supporting personnel. Thus, new collaborative relationships must be forged to complete the training mission. Lastly, time is required to develop formal and informal curricula. The relevance and magnitude of these various issues is unknown.
Based on these uncertainties, we sought to characterize the current training environment in CMR and vascular imaging and to quantify the magnitude of any gaps between current training practice and the recommendations of COCATS-2.
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Methods
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All adult cardiovascular training programs accredited by the American College of Graduate Medical Education were invited to complete a 21-question, multiple-response survey. The survey was developed by the Cardiovascular Imaging Committee of the American College of Cardiology Foundation (ACCF) and collected parallel data for both CMR and vascular imaging in the following five areas: 1) center characteristics; 2) training characteristics; 3) clinical activities; 4) control of clinical activities; and 5) needs and attitudes. Parallel data were collected for nuclear cardiology capabilities as a "base case" in order to provide a reference for comparison. The survey was developed in November 2002 and completed by training program directors between November 15, 2002, and January 6, 2003. Data are presented in descriptive format. For selected responses, statistical comparisons are presented for illustrative purposes only. No primary hypothesis testing was prespecified.
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Survey results
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The survey was sent to 183 training programs, of which 96 (52%) responded. This response rate is higher than typically seen for most member surveys conducted by the ACCF. Of respondents, the mean program size (number of fellows) was 13 (median 12, range 2 to 40). Overall, the program directors rated the importance of incorporating new technologies within their programs as high. On a Likert scale of 1 "not important at all" to 7 "extremely important," the importance of nuclear imaging was rated 5.7 ± 1.3, which was statistically significantly higher than that of CMR (4.9 ± 1.4, p = 0.02) and vascular (5.2 ± 1.2, p = 0.001) imaging. Other results from the survey are shown in Table 1. In general, a gradient existed for most measures with responses for vascular imaging intermediate between nuclear and CMR imaging.
Ownership of CMR hardware is a major infrastructural hurdle for training programs. Only 13% of training programs reported "ownership" of CMR hardware, compared with 48% for nuclear equipment (p = 0.001). Currently, dedicated fellow rotations in nuclear imaging are nearly universally present, whereas vascular (64%) and CMR imaging (29%) lag behind. Educational curricula are in need of development. Programs were roughly evenly divided between those having no, formal (defined as written, content-based, periodically recurring), and informal curricula.
Among centers with CMR training capabilities, the breadth of training opportunities is typically very limited. Most programs have aortic imaging as their sole capability. Fewer programs have other CMR imaging functions available, and there was a significant linear relationship between program size and CMR capabilities (Fig. 1). In comparison, vascular imaging capabilities are better developed, with the exception of newer modalities such as coronary computed tomography and brachial reactivity testing (Fig. 2).
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Figure 1 (A) The proportion of adult cardiovascular training programs (among 96 programs responding to the survey) performing cardiovascular magnetic resonance (MR) imaging for selected indications. (Note: Five programs noted offering a 7th "miscellaneous" modality.) (B) The relationship between program size (number of adult cardiovascular fellows) and the number of cardiovascular magnetic resonance (CMR) imaging indications (correlation coefficient [Rsq, or R2] calculated without a constant).
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Figure 2 The proportion of adult cardiovascular training programs (among 96 programs responding to the survey) performing vascular imaging for selected indications. CT = computed tomography; IMT = intima-media thickness; US = ultrasound.
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At the current time, both clinical and training activities for nuclear, CMR, and vascular imaging in training centers are very much a shared function (Table 2). However, trends do exist, with CMR clinical and training activities primarily controlled by radiology providers and few programs indicating shared functions between departments.
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Table 2 Services Controlling Activities in Nuclear, CMR, and Vascular Imaging as Noted by 96 Training Programs Responding to the Survey
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Programs were asked to prioritize five possible modes of assistance that could be provided by the ACCF. The rank ordering of these, according to the proportion of programs that rated the response as either their first or second priority, is shown in Table 3. Educational assistance in the form of written and lecture curriculum materials was the highest priority among training programs.
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Discussion
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The opinions of nearly 100 training programs in cardiovascular medicine on the current status of training in CMR and vascular imaging are represented in this survey. Training in these disciplines is clearly considered to be important. Despite this, penetrance of such training into educational programs is low at the current time, with CMR imaging lagging significantly behind vascular imaging. For CMR, fewer than one in three cardiovascular fellowship training programs have dedicated rotations and formal educational curricula. Among the available training opportunities, coverage of different CMR methodologies is sparse, with most centers capable of aortic imaging only.
There are several obvious impediments to increasing the training opportunities in these areas. Principal among these is the lack of an infrastructure for training. The deficiencies extend from hardware (only 13% of cardiovascular divisions own CMR hardware), limitations in the number of trained personnel in these modalities, faculty time to support new, expanded training missions, and underdeveloped curricula. There are also limitations on time within a temporally fixed fellowship training program to incorporate new rotations.
Time and attention to the identified deficiencies are obvious, but necessary, ingredients toward all training programs fully satisfying the training guidelines provided by the COCATS-2. Considerable commitments of financial and personnel resources are also required. Maturation of CMR methodologies and greater penetrance and acceptance of the techniques into clinical practice are essential stepping-stones to success. The greatest threat to being "left behind" is to smaller programs, for which the greatest gap between current training capabilities and COCATS-2 exist. Until the aforementioned conditions are met, training programs are encouraged to establish partnerships for training, taking full advantage of local and regional centers and trained personnel to broaden the training opportunities for fellows. Collaborative relationships between clinical departments (e.g., radiology and cardiology) will be crucial to the success of these efforts.
Educational issues deserve special mention. The current state of limited curricula can be overcome through shared resources, including a focus on basic educational goals at meetings. Centers and individuals with expertise should be called on to assist in the development of common program materials, including the development of web-based curricula as a "virtual faculty." Such case-based training is consistent with the goals set forth by the COCATS-2 and is most crucial for small programs. These goals are best served by direct and open cooperation through various professional societies and stakeholders, including the ACCF (including subcommittees such as the Cardiovascular Imaging Committee and the newly established Working Group on CMR) and the Society for Cardiovascular Magnetic Resonance.
This survey demonstrates an intuitive but importantly quantitative baseline evaluation of the current status of fellowship training in CMR and vascular imaging. Re-examination of these issues in the coming years will allow measurement of the success of training programs in fulfilling the educational objectives of the COCATS-2.
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Footnotes
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The opinions or assertions herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.
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References
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- Beller GA, Bonow RO, Fuster V. ACC revised recommendations for training in adult cardiovascular medicine: Core cardiology training ii (cocats-2) (revision of the 1995 cocats training statement). J Am Coll Cardiol. 2002;39:1242–1246[Free Full Text]
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Abstract
Rationale for training survey...