ACCF TRAINING STATEMENT: TASK FORCE
Task Force 1: Training in Clinical Cardiology
Kenneth L. Baughman, MD, FACC, Chair,
F. Daniel Duffy, MD, MACP, (American Board of Internal Medicine Representative),
Kim A. Eagle, MD, FACC,
David P. Faxon, MD, FACC, (Accreditation Council for Graduate Medical Education Representative),
L. David Hillis, MD, FACC and
Richard A. Lange, MD, FACC
Key Words: ACCF Training Statement • COCATS 3 • clinical cardiology • training requirements
The training experience in clinical cardiology is fundamental to the development of the specialist in cardiovascular medicine. It should provide a broad exposure to acute and chronic cardiovascular diseases, emphasizing accurate ambulatory and bedside clinical diagnosis, appropriate use of diagnostic studies, and integration of all data into a well-communicated consultation, with sensitivity to the unique features of each individual patient. Active participation in research projects will provide the trainee with further experience in critical thinking and in evaluating the cardiology literature. The knowledge, skills, and experience realized by this broad training are essential to providing a solid foundation in clinical cardiovascular medicine before trainees focus on more specialized areas, which, for some, may become the dominant feature of professional activity. Other goals should be to provide a broad clinical background with an emphasis not only on pathophysiology, therapeutics, and prevention but also on the humanistic, moral, and ethical aspects of medicine. Although high levels of skills in diagnostic and therapeutic techniques are essential, the fundamental requirement for broad clinical insight needed by the consultant in cardiovascular medicine should be emphasized.
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General Aspects of Training
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Training Institutions.
Programs of training in cardiology must be accredited and offered only in university or university-affiliated institutions that have a residency training program in internal medicine and in cardiovascular disease. The program should be fully accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association.
Prerequisites for Training.
Training in cardiology should almost always occur after successful completion of postdoctoral education and training in internal medicine. One exception relates to medical residents on the American Board of Internal Medicine (ABIM) Research Pathway, which entails 2 years of internal medicine training followed by 2 years of clinical training in a subspecialty and 3 years of research training which includes an additional 10% clinical training (www.abim.org).
Objectives of Training.
The general principles enumerated in the institutional and program requirements for residency education in internal medicine (1–4) are also applicable to training in cardiology. (See the World Wide Web site www.acgme.org for ongoing updates of program requirements.) Cardiology training programs must provide an intellectual environment for acquiring the knowledge, skills, clinical judgment, attitudes, and values that are essential to cardiovascular medicine consistent with the 6 core competencies delineated by the ACGME (medical knowledge, patient care, interpersonal and communication skills, professionalism, practice and learning, and improvement and systems-based practice). Fundamental to this training is the provision of the best possible care for each individual patient delivered in a compassionate manner. All physicians undergoing training in cardiology must have and maintain humanistic and ethical attributes (1–7). The objectives of a training program in cardiology can be achieved only when the program leadership, supporting staff, faculty, and administration are fully committed to the educational program and when appropriate resources and facilities are present. Effective graduate education requires an appropriate balance between academic endeavors and clinical service. During training in cardiology, faculty should encourage trainees to cultivate an attitude of scholarship and dedication to continuing education that will remain with them throughout their professional careers. The development of a scholarly attitude includes active participation in and completion of 1 or more research projects supervised by faculty actively engaged in research, ideally followed by publication in critically reviewed journals. These activities will provide additional experience in critical thinking and will help develop an attitude of scholarship and greater insight into the problems of analyzing and reporting data and other observations obtained from patients. Critical thinking is also developed in such educational activities as journal clubs, literature reviews, use of the Internet for self-directed learning, and the presentation of talks in seminars or conferences.
Role of the Specialist and Duration of Training.
Training in cardiology must take into account the role that the cardiovascular specialist is likely to play in the health care delivery system of the future. As a consequence of the aging of the population, the demand for cardiovascular care will increase. Cardiovascular specialists will have to serve as expert consultants and procedural specialists, and the training must reflect this expanded role.
The rotations of fellows in training for cardiovascular disease must be determined by the curriculum that is needed to permit fellows to develop requisite competencies, not by the needs of the training facility or the training program faculty. The 3-year training program should include a clinical core of 24 months with the following minimums: 1) 9 months in nonlaboratory clinical practice activities (e.g., cardiac consultation, inpatient cardiac care, intermediate acute care unit, chest pain unit, coronary care unit, cardiothoracic/cardiovascular surgery, congenital heart disease, heart failure/cardiac transplantation, preventive cardiovascular medicine, cardiac rehabilitation, and vascular medicine); 2) 4 months in the cardiac catheterization laboratory; 3) 7 months in noninvasive imaging (echocardiography and Doppler [minimum 3 months], noninvasive and peripheral vascular studies, and nuclear cardiology techniques [minimum 2 months]) and cardiovascular magnetic resonance and other techniques (e.g., electron beam or fast helical computed tomography); 4) 2 months (in blocks or equivalent experience) in electrocardiography, stress testing, and ambulatory electrocardiographic monitoring; and 5) 2 months in arrhythmia management, permanent pacemaker and implantable cardioverter-defibrillator management, and electrophysiology; 2 months in the recognition and management of patients with peripheral vascular disease. A continuing ambulatory care experience should be provided for at least one-half day per week throughout the 3-year training program (Fig. 1). Trainees who elect to extend their fellowship training to 4 years by performing 1 additional year of research may receive 1 month only of credit for clinical consultation training by extending their ambulatory care experience for one-half day per week for at least 48 weeks during that year. No other clinical curricular activities may be performed during this time, and a maximum of 1 month of credit is allowed regardless of duration of continuity outpatient clinical experience during research years. An option for fellows undertaking 2 years of research training is to conduct a continuity clinic every other week for the 2-year period. This would be equivalent to having a weekly clinic for 1 of the 2 research years. If a fellow moves to another institution for a year of research training as part of a 3-year fellowship program, a comparable outpatient clinic experience can be undertaken at the second institution.
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Figure 1 COCATS 3-Year Cardiovascular Fellowship Level 1 Exposure
This represents outpatient exposure at one-half day per week. Electrocardiogram, ambulatory electrocardiogram, and exercise testing may be fulfilled in 24 to 36 months. *Includes echocardiography, nuclear cardiology, cardiovascular magnetic resonance, and cardiovascular computed tomography.  May include cardiac failure and preventive cardiovascular medicine.
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These time periods are considered to be the minimal time required to learn the indications, interpretative skills, knowledge of complications, risk/benefit, and cost/benefit of these procedures. This core 24-month training period does not qualify a trainee as a consultant in cardiovascular disease or as an expert in these technical procedures. Expertise in interventional cardiology, electrophysiology, heart failure/transplantation, and cardiovascular research require additional training beyond the standard 36-month fellowship.
The remaining year in the program should include dedicated research. In addition, trainees should be exposed to a curriculum throughout fellowship training that includes biostatistics, epidemiology, design and conduct of research trials, and a critical review of the medical literature. The remaining months of training may include the acquisition of more intensive training in specific areas of cardiovascular medicine or continued research. Trainees often require additional clinical training to be qualified to function properly as consultants in cardiovascular disease and as specialists in cardiology. This latter period permits the trainees to obtain greater experience and supervised training in the clinical management of patients with cardiovascular disease and to obtain additional training in the performance and application of particular diagnostic or therapeutic procedures. Trainees planning an academic career usually need additional research training (see Appendix 1). Vacation time, as well as time for participation in professional meetings and conferences, will be allotted in a manner compatible with institutional policy. Vacation time will be taken proportionately during the clinical core and research elective experience.
Program Faculty.
The program must be conducted under the auspices of a program director who is highly competent in the specialty of cardiovascular disease and fully committed to the training of the cardiovascular specialist. The program director must have experience as a faculty member in an active and accredited cardiology residency program. The director of the cardiology training program must be certified by the ABIM Subspecialty Board on Cardiovascular Disease or possess appropriate educational qualifications. The director should participate in scholarly activity (e.g., peer-reviewed publications, grants, and review articles). The director is responsible for ensuring the adequacy of the training facility, including support resources for the provision of an education of high quality.
There should be 1 full-time program faculty member for every 1.5 trainees in the division (or section) of cardiology to guarantee close supervision of all trainees and to allow for critical evaluation of the program and the competence of the trainees. Each rotation and laboratory should have faculty members who supervise the fellows. It is essential that the cardiology program director devote sufficient time and effort to the graduate education program and related activities. Cardiology program directors must be full-time faculty members. The program director must have the effective support of the institution(s) where the training takes place to provide these educational attributes.
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Environment for Training in Clinical Cardiology
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Interaction With Other Disciplines.
Cardiology training programs must provide an intellectual environment for acquiring the knowledge, skills, clinical judgment, and attitudes that are essential to the practice of cardiovascular medicine. Specialists in cardiovascular disease must interact with generalists and specialists in other areas and have knowledge of other specialties to provide excellent patient care. The ACGME requires at least 2 other subspecialty training programs in internal medicine and a residency in internal medicine in order to enable the cardiovascular disease trainee to collaborate with other disciplines by providing consultations and participating in co-management of suitable patients. Close interaction with cardiovascular/cardiothoracic surgery is of particular importance. The overall program must provide advanced training to allow the physician to acquire expertise as a specialist and consultant in cardiology.
Relation to Training in Internal Medicine.
Cardiology training programs must provide the opportunity for cardiology trainees to maintain their skills in general internal medicine and in those aspects of cardiology that relate to internal medicine. Therefore, the cardiology program must be closely related to the training program in internal medicine, and there must be carefully delineated lines of responsibility for the residents and staff in internal medicine and the cardiology trainees. Trainees should maintain close working contact with residents and fellows in other areas, including surgery, critical care medicine, anesthesia, radiology, pulmonary disease, pathology, pediatrics, and neurology. When appropriate, expert faculty in these disciplines should teach and supervise the trainees.
Required Training Program Resources.
The program must have certain minimal resources, including the following: - 1 There must be inpatient and outpatient facilities with an adequate number of patients of a wide age range with a broad variety of cardiovascular disorders. Trainees must be supervised and evaluated on every rotation by qualified faculty members when they see patients in both areas. Outpatient care must be carefully supervised by faculty members.
- 2 The facility must provide laboratories for cardiac catheterization, electrocardiography, exercise and pharmacologic stress testing, Doppler/echocardiography, ambulatory ECG monitoring, and noninvasive peripheral vascular studies. There must be appropriate facilities for cardiac catheterization, angiography, and hemodynamic assessment, with adequate numbers of patients undergoing percutaneous interventional procedures (i.e., coronary angioplasty or stent placement), myocardial biopsy, and intra-aortic balloon placement (see the Task Force 2, 3, and 4 reports).
- 3 Facilities for nuclear cardiology must be available, including ventricular function assessment, myocardial perfusion imaging, and studies of myocardial viability (see the Task Force 5 report).
- 4 There must be appropriate facilities for the management of patients with arrhythmias, including electrophysiologic testing, arrhythmia ablation, and signal-averaged electrocardiogram (ECG) and tilt-table testing, as well as the previous evaluation, implantation, and assessment of patients with cardiac pacemakers and implantable antiarrhythmic devices and their long-term management (see the Task Force 6 report).
- 5 Facilities and faculty for training in cardiovascular research, including various basic science, clinical science, and population science modalities, are important (see the Task Force 7 report).
- 6 Modern intensive cardiac care facilities must be available.
- 7 Facilities for cardiac and peripheral vascular surgery and cardiovascular/cardiothoracic surgical intensive care must be provided at the primary site of training. Close association with and participation in a cardiovascular/cardiothoracic surgical program is an essential component of the cardiovascular training program. This must include active participation in the pre- and post-operative management of patients with cardiovascular disease. Exposure to cardiac transplantation is strongly recommended (see the Task Force 8 report).
- 8 Facilities and faculty must be involved in the diagnosis, therapy, and follow-up care of patients with congenital heart disease (see the Task Force 9 report).
- 9 There must be appropriate facilities for the clinical and laboratory assessment of patients with systemic hypertension and peripheral vascular disease (see the Task Force 10 and 11 reports).
- 10 Facilities for assessment of cardiopulmonary and pulmonary function, cardiovascular radiography, and magnetic resonance imaging and computed tomography must be available (see the Task Force 12 report).
- 11 Appropriate expertise and instruction in preventive cardiovascular medicine and risk-factor modification, including management of lipid disorders, must be provided (see the Task Force 10 report).
- 12 There must be facilities for and faculty with knowledge of cardiovascular pathology.
- 13 There must be facilities for and personnel and faculty with expertise in cardiac rehabilitation.
- 14 Other appropriate facilities and resources necessary to accomplish the training must be provided, including a comprehensive medical library, facilities for continuing medical education, and a curriculum that includes experimental study design, statistics, and quality assurance.
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Training Components
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An educational clinical cardiovascular disease training program must have the following training objectives and characteristics and must encompass the following areas.
Training in Patient Care and Management.
In addition to the core clinical skills of internal medicine, all cardiology trainees must be skilled in obtaining a history and performing a complete cardiovascular physical examination. All trainees must be familiar with the role of aging and psychogenic factors in the production of symptoms and the emotional and physical responses of patients to cardiovascular disease. They must be familiar with the importance of preventive care and rehabilitative aspects of the management of patients with known or potential cardiovascular disease. The trainee should have considerable experience acting as a consultant to other physicians and should have direct, supervised patient care responsibility in proportion to his or her experience and qualifications. Extensive outpatient training is essential for learning the long-term course of patients with chronic cardiovascular disease.
Training in Understanding, Diagnosis, Prevention, and Treatment of Cardiovascular Disease.
The trainee must become well educated in pathogenesis, pathology, risk factors, natural history, diagnosis by history, physical examination and laboratory methods, medical and surgical management, complications, and prevention of cardiovascular conditions including coronary artery disease, hypertension, hyperlipidemia, valvular heart disease, congenital heart disease, cardiac arrhythmias, heart failure, cardiomyopathy, involvement of the cardiovascular system by systemic disease, infective endocarditis, diseases of the great vessels and peripheral blood vessels, diseases of the pericardium, pulmonary heart disease, the interaction of pregnancy and cardiovascular disease, cardiovascular complications of chronic renal failure, traumatic heart disease, and cardiac tumors and cardiovascular changes associated with advancing age. Cardiology trainees must develop an understanding of the various roles of collaboration, co-management, and consultation in the system-based care of patients with complex comorbidity and cardiovascular disease.
Training in Intensive Care.
The training must include at least 3 months of full-time experience with patients undergoing intensive care for acute cardiovascular disorders and coronary care. This exposure should include (but is not limited to) management of acute coronary syndromes, ST-elevation myocardial infarction, cardiogenic shock, acute decompensated congestive heart failure, symptomatic arrhythmias, hypertensive crisis, infective endocarditis, aortic dissection, pericardial tamponade, and pulmonary embolism. Appropriate use of hemodynamic monitoring; intra-aortic balloon counterpulsation; and thrombolytic, percutaneous, and surgical therapy should be emphasized. In addition, because of the additional medical comorbidities that acutely ill cardiovascular patients manifest, trainees should gain additional expertise with airway and ventilator management, use of renal replacement therapy, and treatment of sepsis and other infectious complications.
Training in Ambulatory, Outpatient, and Follow-Up Care.
Continued responsibility for principal care, co-management with primary care physicians, and consultation outpatient cardiovascular patient management must occupy at least one-half day per week for 36 months. An ambulatory continuity clinic is essential for the duration of training. There should be exposure to a wide age range of patients, from adolescence through old age, with a spectrum of cardiovascular diagnoses, including post-operative patients, patients with congenital heart disease, and patients for evaluation and management related to pregnancy. Additional ambulatory experience in specialty clinics or hospital-based settings is desirable and may include participation in same-day diagnostic or therapeutic procedures.
Training in Electrocardiography.
All cardiovascular trainees must be skilled in the interpretation of ECGs. There must be appropriate review, audit, and evaluation of their skills. All cardiology trainees must be skilled in the performance and interpretation of exercise ECG tests and ambulatory and signal-averaged ECGs, as described in the Task Force 2 report.
Training in the Cardiac Catheterization Laboratory.
The trainee must have direct, supervised experience in a general adult cardiac catheterization laboratory that performs catheterizations of both the right and left sides of the heart. This initial experience in the cardiac catheterization laboratory must emphasize the fundamentals of cardiovascular physiology as it relates to clinical disease, the analysis of hemodynamic records, and the interpretation of angiographic images. Such an experience must also emphasize the problems in interpretation and analysis of such data and the importance of quality. All fellows must have adequate training in the principles of radiation safety. The amount of training in the mechanical skills of cardiac catheterization that is necessary is addressed in the Task Force 3 report. The acquisition of advanced procedural skills is not the primary purpose of the initial exposure of the trainee to the cardiac catheterization laboratory. All trainees must understand indications, risks, and benefits of interventional therapeutic procedures, as described by the Task Force 3 report.
Training in Echocardiography.
All trainees must participate in the performance of echocardiography and Doppler echocardiography and must understand the indications, risks, and benefits of transesophageal and stress echocardiography, as well as the principles of evolving techniques, such as intravascular ultrasound. Those trainees who wish to perform these latter techniques or to direct an echocardiography laboratory must have additional training, as described in the Task Force 4 report. The duration of exposure or number of procedures to achieve levels of training are outlined in the Task Force 4 report.
Training in Nuclear Cardiology.
All trainees should know the general principles, indications, risks, and benefits of nuclear cardiovascular procedures, such as radionuclide ventriculography and myocardial perfusion and viability assessment. All trainees must receive basic training in radiation safety. Trainees need a minimum of 2 months of training; those who wish to practice nuclear cardiology must have additional training, as described in the Task Force 5 report.
Training in Other Advanced Imaging Techniques.
All trainees should be aware of and preferably directly exposed to major evolving advanced imaging techniques.
Training in Cardiac Arrhythmia Device Management.
All trainees must understand the diagnosis and management of cardiac arrhythmias. Trainees should know the indications for cardiac arrhythmia devices and the principles of management and follow-up of patients with implanted pacemakers and antiarrhythmic devices, as described in the Task Force 6 report. Participation in implantation is desirable.
Training in Electrophysiology.
All trainees must be skilled in the selection of patients for specialized electrophysiologic studies, including arrhythmia ablation. Those who wish to perform these procedures should receive additional training, as described in the Task Force 6 report.
Training in Cardiovascular Research.
All trainees should participate actively in research activities. Trainees who anticipate a career in academic cardiology should have additional specialized training, as described in the Task Force 7 report. All trainees should understand clinical study design, biostatistics, and how to critically read and interpret the cardiovascular literature.
Training in Heart Failure and Heart Transplantation.
All trainees must understand the diagnosis and management of patients with heart failure and that of cardiac transplant recipients, as described in the Task Force 8 report.
Training in Congenital Heart Disease in the Adult.
All trainees must understand the diagnosis and management of adult patients with and without surgical repair of congenital heart disease, as described in the Task Force 9 report. Trainees must participate in the transition of care of patients from pediatric to adult cardiologists.
Training in Preventive Cardiovascular Medicine.
All trainees should know the principles of preventive cardiovascular medicine, including vascular biology, genetics, epidemiology, biostatistics, clinical trials, outcomes research, clinical pharmacology, behavior change, and multidisciplinary care as described in the Task Force 10 report. Specific knowledge in the areas of hypertension, dyslipidemia, thrombosis, smoking cessation, cardiac rehabilitation, exercise physiology, nutrition, psychosocial issues, metabolic disorders, gender and racial issues, and aging is essential. Ideally, training should be undertaken in a 1-month (or longer) rotation. Those who will focus their clinical practice in preventive cardiovascular medicine should develop expertise in counseling for behavior change.
Training in Vascular Medicine.
The trainee must develop sound knowledge of the clinical features and treatment of vascular disease, demonstrate competence in obtaining the history and performing the physical examination of the arterial and venous systems, and become knowledgeable in the interpretation and selection of patients for noninvasive vascular tests and peripheral angiograms.
Training in Magnetic Resonance Imaging.
Familiarity with the cardiovascular applications and interpretations of magnetic resonance images is essential to the training of a cardiovascular fellow. This imaging modality has many existing uses and considerable potential in noninvasive diagnosis. The fellow should supplement this experience with exposure to cardiovascular magnetic resonance (CMR) studies throughout the clinical training program. Those who wish to interpret CMR studies or who desire advanced training must have additional training as designated in the Task Force 12 report.
Training in Computed Tomography.
Computed tomography (CT) is a rapidly evolving technique to evaluate cardiovascular anatomy and function. Clinical applications include noncontrast CT for coronary calcification, contrast CT to assess coronary anatomy and left ventricular function, and hybrid procedures combining CT with other noninvasive techniques. By the end of fellowship the trainee should be expected to have participated in 50 mentored interpretations to achieve Level 1 competency. See the Task Force 13 report for details.
Training in Related Sciences.
The training program should provide an opportunity for continuing education in basic sciences, including those aspects of anatomy, physiology, pharmacology, pathology, genetics, biophysics, and biochemistry that are pertinent to cardiology, particularly vascular biology, thrombosis, and molecular biology. It is essential for trainees to acquire a thorough understanding of the normal physiology of the circulatory system, including the adaptation of the cardiovascular system to exercise, stress, pregnancy, aging, and renal and pulmonary abnormalities, and trainees must be able to reliably interpret tests of renal and pulmonary function. Learning in pharmacology should recognize dietary, renal, and hepatic function as well as geriatric influence on drug therapy. Complementary medicine as it affects traditional cardiovascular therapy should be included in the curriculum. The availability of educational programs in biostatistics, computer sciences, and biophysics is highly desirable. Training in medical economics, health care systems delivery, clinical decision making, preventive medicine, and health care outcomes should also be available.
Training in Related Fields of Medicine.
The trainee must gain knowledge and experience in a number of related areas of medicine, including the following: - 1 Radiology: the interpretation of cardiovascular X-ray films, with particular reference to vascular structures and special cardiovascular radiologic procedures.
- 2 Surgery: the risks and benefits of cardiothoracic and cardiovascular surgery and the rationale for the selection of candidates for surgical treatment, as well as the natural history and the pre- and post-operative management of patients with cardiovascular disease and various co-morbid conditions.
- 3 Anesthesia: close collaboration with anesthesia colleagues in the pre- and post-operative management of patients with cardiac disease for cardiac and noncardiac surgery, as well as cardiac procedures that require anesthesia (e.g., cardioversion).
- 4 Pulmonary disease: a solid knowledge of basic pulmonary physiology in addition to the interpretation of pulmonary and cardiopulmonary function testing, blood gases, pulmonary angiography, and radiology lung scanning methods, as well as experience with management of patients with acute pulmonary disease.
- 5 Obstetrics: a solid knowledge of the inter-relations between pregnancy and heart disease, together with experience in the clinical management of patients with heart disease who are pregnant, and safety of cardiovascular drug use in pregnancy.
- 6 Physiology: the physiology of the cardiovascular system, its response to exercise and stress, and the alterations produced by aging and disease.
- 7 Pharmacology: the pharmacology and interactions of cardiovascular drugs and drugs that affect cardiovascular function.
- 8 Pathology: familiarity with the gross and microscopic pathology of all major forms of heart disease.
- 9 Geriatrics: familiarity with the effects of aging on cardiovascular disease and therapy.
Training Through Conferences, Seminars, Review of Published Reports, and Lectures.
There must be regularly scheduled cardiology conferences, seminars, and reviews of published data. The participation of trainees in the planning and production of these conferences is expected. Attendance at medical grand rounds and multidisciplinary conferences is highly desirable, particularly at conferences closely related to cardiovascular disease, such as conferences on surgery, radiology, and pathology. Visiting professors should provide stimulation and at least informal evaluation and feedback to trainees and faculty.
Teaching and Educational Experience.
The trainee must participate directly in the teaching of cardiology to peers, internal medicine residents, and to referring physicians and become familiar with the fundamental principles of education, including skills in organization of conferences, lectures, and teaching materials. The teaching experience, often through weekly or more frequent core content conferences, must attempt to integrate basic biomedical information with the clinical aspects of cardiology, including integration of clinical management principles. Trainees must be familiar with modern concepts of education and effective communication. They must be responsible for teaching residents in internal medicine, as well as medical students, cardiology trainees, and allied health personnel, and for working collaboratively with other health care professionals. They must have regularly scheduled experiences in teaching and must be encouraged to attend and participate in national cardiology meetings. Trainees must learn to prepare successfully, through self-study and participation in continuing education using various media, for certification, recertification, and credentialing.
Special Procedural Areas.
In specific procedural areas of cardiology, minimal training is appropriate for physicians who do not plan to achieve additional qualifications in a given field. Conversely, those physicians who wish to become qualified in specialized areas require additional training, as specified by the individual task forces. Trainees should log all appropriate procedures.
Evaluation and Documentation of Competence.
The evaluation of trainees for both clinical and specialized technical skills must be documented carefully. Cardiology program directors must establish procedures for the regular evaluation of the clinical competence of cardiology trainees. This evaluation must include intellectual abilities, manual skills, attitudes, and interpersonal relations, as well as specific tasks of patient management, clinical skills (including decision-making skills), and the critical analysis of clinical situations. There must be provision for appropriate feedback of this information to the trainee at regular intervals. Records must be maintained of all evaluations and of the number and type of all laboratory procedures performed by each trainee. The use of examinations (e.g., the Adult Clinical Cardiology Self-Assessment Program [ACCSAP]) at the end of each year of training or upon completion of each specialized area of training is strongly encouraged.
Attainment of core competences (medical knowledge, patient care, interpersonal and communication skills, professionalism, practice and learning and in applying the principles of quality measurement and improvement in their practice) must be documented. They should measure their clinical performance and participate in practice-based learning collaboratives, apply root-cause analysis to sentinel errors, develop improvement plans, and participate in the quality improvement activities of the institution.
This is a revision of the 2002 document that was written by Kenneth L. Baughman, MD, FACC—Chair; Charles L. Curry, MD, FACC; David C. Leach, MD (American Council for Graduate Medical Education Representative); Prediman K. Shah, MD, FACC; and Laura F. Wexler, MD, FACC (American Board of Internal Medicine Representative).
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Appendix 1
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Appendix 2
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Author Relationships With Industry—ACCF 2008 Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training (COCATS 3)—Task Force 1: Training in Clinical Cardiology
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Appendix 3
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Peer Reviewer Relationships With Industry—ACCF 2008 Recommendations for Training in Adult Cardiovascular Medicine Core Cardiology Training (COCATS 3)—Task Force 1: Training in Clinical Cardiology
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References
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1. Accreditation Council for Graduate Medical Education Internal medicine, program requirements for residency education in internal medicinehttp://www.acgme.org/acWebsite/RRC_140/140_prIndex.aspAccessed February 2, 2002.2. Accreditation Council for Graduate Medical Education Policies and procedures for subspecialties, policies and procedures for residency education in the subspecialties of internal medicinehttp://www.acgme.org/acWebsite/RRC_140/140_prIndex.aspAccessed February 2, 2002. 3. Accreditation Council for Graduate Medical Education Cardiovascular disease, program requirements for residency education in cardiovascular diseasehttp://www.acgme.org/acWebsite/RRC_140/140_prIndex.aspAccessed February 2, 2002. 4. Accreditation Council for Graduate Medical Education Subspecialties, program requirements for residency education in the subspecialties of internal medicinehttp://www.acgme.org/acWebsite/RRC_140/140_prIndex.aspAccessed February 2, 2002. 5. Benson JA, Blank LL, Frenkel EP, et al. Evaluation of humanistic qualities in the internist Ann Intern Med 1983;99:720-724.[Abstract/Free Full Text] 6. Ad Hoc Committee on Medical EthicsAmerican College of Physicians American College of Physicians Ethics Manual: part I: history of medical ethics, the physician and the patient, the physician’s relationship to other physicians, the physician and society Ann Intern Med 1984;101:129-137.[Abstract/Free Full Text] 7. Ad Hoc Committee on Medical EthicsAmerican College of Physicians American College of Physicians Ethics Manual: part II: research, other ethical issues: recommended reading Ann Intern Med 1984;101:263-274.[Abstract/Free Full Text]
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General Aspects of Training
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