The American Heart Hospital Journal
education among themselves through collaborative efforts and continual dialog with our Department of Internal Medicine, Office of Graduate Medical Education, and College of Medicine educational experts. As we have worked to rise to these challenges within our own program, however, there remain other, larger concerns on the horizon.
Future Challenges and Opportunities for Cardiovascular Educators—‘Medical Education as Translational Science’
The use of pre-procedural checklists has already been shown to reduce catheter-related bloodstream infections in the medical intensive care unit setting30
There exists a great opportunity to combine medical education research and clinical training to improve patient safety.29
and
death and surgical complications in international operating rooms.31
These examples, and others like them,
were implemented by medical centers and carried out by multidisciplinary teams of practicing physicians, nurses, and technicians in the specific clinical settings. Checklists tend to focus on technique and equipment, but also place just as large an emphasis on a team-based approach to staff communication. In fact, simple training in the use of ‘crew resource management’ techniques—rules of conduct derived from the aviation industry which are designed to create an environment where communication is prioritized above positional hierarchy—was recently shown to improve surgical mortality within 74 hospitals in the Veterans Health Administration.32
Expanded
considerations of checklists have also included utilization as an alternative to relying on intuition and memory in clinical problem-solving, with the hope of reducing diagnostic error.33
Published data have described methods
of ‘deliberate practice’—focused, repetitive practice with testing to ensure achievement of a mastery standard34
—when instructing medical residents during simulation workshops in advanced cardiac life support and central venous catheter insertion.29
Translated to
cardiology fellowship, there are ample opportunities to model educational interventions to improve patient satisfaction and sedation/anesthetic-related morbidity during transesophageal echocardiography and reduce fluoroscopy times, contrast volumes and complications during cardiac catheterization. Fellows perform hundreds of these procedures over the course of their training with
1. Hill JA, Kerber RE, Quo Vadis? How should we train cardiologists at the turn of the century?, Circulation, 2000;102:932–6.
2. Kennedy HL, Goldberger AL, Graboys TB, Hancock EW, Guidelines for training in adult cardiovascular medicine. Core cardiology training symposium (COCATS), J Am Coll Cardiol,
Winter 2011
Special Report
unknown variability in realtime supervision and teaching. As such, a fellow’s ‘learning edge’ of procedural or medical knowledge may or may not be routinely explored. Therefore, despite the volumes listed in fellow logbooks, faculty preceptors and fellowship directors mark trainee progress with a combination of partial data and assumptions.
The Elusive Definition of Clinical Competence The next frontier of medical education in cardiology will probably be the redefinition of clinical competence and support of lifelong learning. A review of studies relating medical knowledge and healthcare quality to years in practice suggests that physicians who have been in practice longer may be at risk of providing lower-quality care.35
To
address this issue during fellowship training, program directors will have to be able to help trainees achieve core knowledge (know what they should know), identify knowledge gaps (knowing what they don’t know) encountered during a typical day, while providing the framework for them to ‘close’ them, and translate published evidence into practice.36
For fellows, the first step
toward this goal will be the upcoming ACC In-Training Exam (ITE) in fall 2011. Written by educational experts within the college with the collaboration of the National Board of Medical Examiners, the ACC ITE will be a multiple-choice format examination testing comprehensive medical knowledge in cardiology. Results will help program directors provide formative assessments for each specific fellow and the program as a whole in comparison with others. In parallel to an improved assessment of medical knowledge, the ACC hasbegun to explore medical simulation in partnership with the ABIM as a potential means of testing procedural skills in interventional cardiology.37
Such simulators already exist
for transesophageal echocardiography and pacemaker implantation, and may serve as methods to learn without patient exposure to risk at some point in the future. Whether they will reach the point of near-universal use (they are quite expensive) during fellowship training or become adopted as a final arbiter of procedural competence during a board certification exercise is certainly possible. For now, fellowship directors must continue to adapt to dynamic requirements, seek opportunities to collaborate, and persevere among a storm of data—all while never forgetting to trust their gut. n
1995;25:10–3.
3. Moss AJ, Zareba W, Hall WJ, et al., Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction, N Engl J Med, 2002;346:877–83.
4. Beller GA, Bonow RO, Fuster V, ACCF 2006 Update for training in Cardiology Fellowship Education 105
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