VIEWPOINT
Determination of Professional Competency in a Rapidly Changing Environment
Samuel Wann, MD, MACC*
Department of Cardiovascular Medicine, The Wisconsin Hospital, Milwaukee, Wisconsin.
Manuscript received May 26, 2005;
revised manuscript received July 7, 2005,
accepted July 26, 2005.
* Reprint requests and correspondence: Dr. Samuel Wann, Department of Cardiovascular Medicine, The Wisconsin Heart Hospital, 10000 Bluemound Road, Milwaukee, Wisconsin 53226. (Email: samuelwann{at}whvc.org).
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Abstract
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The recently published American College of Cardiology/American Heart Association/American College of Physicians Clinical Competency Statement for cardiac computed tomography/cardiac magnetic resonance (CCT/CMR) will be of great value to hospital medical staff organizations that grant privileges in the exciting new fields of CCT/CMR. More evidence is needed to document the number of hours of continuing medical education (CME) and minimum case loads required to maintain competence. This ongoing experience should be integrated into comprehensive imaging and clinical education, including vascular imaging as well as cardiac. Mandating hours of CME and minimum case loads does not, by itself, assure quality. Assessment of competency should employ measurable performance standards, identify areas needing improvement, and emphasize continuous quality improvement principles.
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Abbreviations and Acronyms
| | ACC = American College of Cardiology | | ACP = American College of Physicians | | AHA = American Heart Association | | CCT = cardiac computed tomography | | CME = continuing medical education | | CMR = cardiac magnetic resonance |
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Following a tradition of periodically developing objective criteria by which hospital medical staff organizations and others may judge professional competence to deliver certain specific, highly specialized cardiac services, the American College of Cardiology (ACC) Foundation/American Heart Association (AHA)/American College of Physicians (ACP) Task Force on Clinical Competence reports its recommendations for imaging with cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) in a current issue of the Journal of the American College of Cardiology (1). Deliberations such as these are essential to the maintenance of our professional independence, because society grants us the privilege of self-regulation, conditional on our responsible assurance that we possess the knowledge, training, and skills necessary to properly serve the public (2). The definition of clinical competence in a swiftly evolving field like CCT/CMR is especially difficult. The authors of this report are to be congratulated for their timely and conscientious deliberations and for sharing their thoughtful expert opinions with us. Clinicians are understandably excited by these technologic advances and eager to add these skills to their repertoire. Guidance in granting privileges for physicians to provide CCT/CMR services is needed. These guidelines will be widely used.
Existing evidence to support routine use of CCT/CMR in widespread cardiology practice is limited. The results of many scientific studies of CCT/CMR will be forthcoming in the next few months and years, and the definition of good clinical practice and competence must evolve with this new evidence. Thus, the writing group not only defined the training and experience they felt are currently necessary to begin to provide CCT/CMR services on the basis of available scientific literature and their collective expert experience, they also recommended from 20 to 40 h of continuing medical education (CME) credits and a minimum annual caseload in CCT/CMR to assure that competent practitioners stay current with these fast-paced developments.
Recommendations of the kind made in this report regarding hours of CME and minimum numbers of cases performed over time are logical, traditional, and widely used; however, there is little, if any, evidence to support conventional CME as a means of assuring competence or improving the quality of medical practice (3–6). Nevertheless, cardiologists providing noninvasive imaging services are mandated by various hospital staff organizations, state licensing boards, and accrediting bodies in echocardiography, nuclear cardiology, and vascular ultrasound to acquire dozens of CME hours each year, a large and increasing financial and time burden on practitioners. These requirements, together with the time and expense of board re-certification, are approaching the saturation point for some cardiologists.
Cardiologists, clearly, do hunger for knowledge in exciting new fields such as CCT/CMR, as evidenced by overflow crowds at recent ACC CME courses in Washington, DC, and San Francisco, California. This hunger must be reconciled with limitations on the time taken away from clinical practice and other important obligations, including family responsibilities and the desire for healthy, balanced lifestyles, which include recreation and other activities outside medicine. Researchers and educators also hunger for a forum to present their work, just as educational institutions and industry need access to potential clients to maintain their businesses. We must balance these factors with hard evidence supporting a requirement for a discrete number of hours of CME and the fact that there are only so many hours in a day. Although it makes sense that one must regularly perform a minimum number of procedures to maintain competence, few data exist to relate the number of imaging procedures performed to the competence of interpretation or, perhaps more importantly, to patient outcome. Interestingly, the intensity of diagnostic testing has, in fact, been related to increasing volume of invasive cardiac procedures (7–8), a fact that has not escaped the attention of third-party payers and entrepreneurs alike.
Suggestions for minimal hours of CME and case volume made by the ACC/AHA/ACP CCT/CMR writing group to document competence in CCT and CMR do not fully embrace the existence of an overlapping knowledge base and skill set needed for these procedures, nor do the recommendations cover vascular imaging by either modality. While CCT and CMR have many unique attributes, and interpretation of vascular images clearly requires specific skills, as do interpretation of ultrasound and nuclear images, I believe we cardiologists are on the wrong track to keep each imaging modality in separate silos.
There is clear technical and clinical crossover between CCT and CMR, between cardiac and vascular imaging, and with cardiovascular ultrasound, nuclear imaging, and catheter angiography. Dr. George Beller, former ACC President, and others have suggested a change in graduate medical education of cardiology fellows to coordinate and consolidate training in cardiovascular imaging, creating a separate training track for imaging specialists, similar to tracks for interventionalists and electrophysiologists. Perhaps similar principles should guide CME for cardiologists already in practice. We cannot just continue to pile on unique CME and case-load requirements every time a new imaging modality comes along.
Perhaps we cardiologists should emulate the stance taken by the American College of Radiology (ACR) of requiring general, rather than modality-specific, CME and recognize that our imaging knowledge and experience in one modality has great value when using another modality and that our clinical patient focus is best served when we concentrate on addressing patient imaging needs, regardless of the modality employed. Our professional organizations, which require CME to document competency and also provide CME programs, need to constantly tailor these requirements to the volume of truly new, clinically relevant knowledge produced and document a relationship between CME and actual clinical quality improvement. We must transform our specialty to acknowledge our changing environment (9).
This month, the ACR published (10) its recommendations for radiologists providing CCT and CMR services. There are many similarities but also some significant differences between the ACR recommendations and those of the ACC/AHA/ACP Task Force. To assure quality service to our patients, avoid confusion, and preserve the autonomy of the medical profession, cardiologists and radiologists and others providing medical imaging services must come together to reconcile differing definitions of competence. Clearly, we have much to learn from one another, and our patients stand to benefit greatly if we work together in CCT and CMR. Public turf battles between medical specialists harm everyone involved, including patients, and should be avoided to honor our mutual professional commitments to put our patients’ interests before our own.
One important area that was addressed neither in the ACC/AHA/ACP report nor in the ACR recommendations is interpretation of non-cardiac findings on cardiac CCT and CMR examinations. Cardiac computed tomography is particularly controversial, not only because potentially harmful ionizing radiation is employed but also because raw CT imaging data is somewhat generic and includes diagnostic information about the lungs, mediastinum, and upper abdomen as well as the heart.
Although random screening CT examinations are eschewed by most physicians, it still seems prudent to report on all abnormalities detectable on a given CT examination, even if detection of these abnormalities was not the primary reason for ordering the test. Cardiologists might be capable of triaging CCT examinations for the presence or absence of significant non-cardiac abnormalities such as lung nodules or mediastinal adenopathy, but it seems clear that patients’ interests will be best served when cardiologists and radiologists maintain a close working relationship.
I am heartened by my observations from the trenches that cardiologists and radiologists do work well together when caring for individual patients, do respect one another professionally in the workplace, and do adapt, sometimes reluctantly, to the reality that their relative roles in the delivery of modern health care are changing. We members must insist that our professional organizations, including the ACC and ACR, curb all acrimony and rapacity and work together at a national level to resolve turf issues, keeping excellence of patient care our primary focus.
As these competency guidelines are being issued, the social contract between physicians and the public is being challenged (6,11,12). Large variations in clinical practice, easily demonstrable gaps between physicians’ knowledge base and its clinical application, and continually rising costs have all led to a shift in competency evaluation. Rather than conventional reliance on physicians’ cognitive knowledge and an "assumption of quality," our health care system now relies increasingly on performance measurement, quality improvement, and objective assessment of the appropriateness of care delivered.
Our contract with the public now includes insurers, purchasers, non-physician health care providers, patients, and consumers in general. Rigorous selection and training of physicians and their devotion to ethical and responsible patient care might not, by themselves, result in the trust, control, and autonomy that physicians desire (13). We are now required to constantly prove our competence by our behavior, and our behavior is being monitored closely by those outside our profession.
In addition to providing consensus documents to assist in defining minimum levels of professional competency, the ACC has many other comprehensive initiatives to help cardiologists function more effectively in this new environment. The ACC task forces are developing objective criteria to measure our performance and to define standards of appropriate care. The ACC actively supports laboratory accreditation programs that rely heavily on quality improvement principles. The ACC is constantly revamping its educational programs to foster measurable improvements in the quality of care and has just launched an all new Cardiosource program of targeted, electronic CME, to be provided free as a membership service. Less emphasis is being placed on simply counting the number of hours spent in lectures or listing the raw number of procedures performed, with more effort put into developing practical, interactive, point-of-service educational interventions on the basis of meaningful assessment of educational needs, with a feedback loop to improved performance.
Competent cardiologists must function within a complex health care system, working with many other physicians and health care providers to adequately serve patients. Isolated determination of a single cardiologist’s competence might have been enough in times past. More is expected of today’s cardiologist.
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Footnotes
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As a Member of the American College of Cardiology Board of Trustees, Dr. Wann reviewed and voted to approve the ACCF/AHA/ACP CCT/CMR Competency Statement. He was not a member of the Writing Committee. The viewpoint expressed in this paper is Dr. Wann’s alone and not that of the American College of Cardiology or any other organization.
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References
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