We evaluated preventive cardiology education in United States cardiology fellowship programs and their adherence to Core Cardiovascular Training Symposium training guidelines, which recommend 1 month of training, faculty with expertise, and clinical experience in cardiac rehabilitation, lipid disorder management, and diabetes management as a part of the prevention curricula. We sent an anonymous survey to United States cardiology program directors and their chief fellow. The survey assessed the program curricula, rotation structure, faculty expertise, obstacles, and recommended improvements. The results revealed that 24% of surveyed programs met the Core Cardiovascular Training Symposium guidelines with a dedicated 1-month rotation in preventive cardiology, 24% had no formalized training in preventive cardiology, and 30% had no faculty with expertise in preventive cardiology, which correlated with fewer rotations in prevention than those with specialized faculty (p = 0.009). Fellows rotated though the following experiences (% of programs): cardiac rehabilitation, 71%; lipid management, 37%; hypertension, 15%; diabetes, 7%; weight management/obesity, 6%; cardiac nutrition, 6%; and smoking cessation, 5%. The program directors cited “lack of time” as the greatest obstacle to providing preventive cardiology training and the chief fellows reported “lack of a developed curriculum” (p = 0.01). The most recommended improvement was for the American College of Cardiology to develop a web-based curriculum/module. In conclusion, most surveyed United States cardiology training programs currently do not adhere to basic preventive cardiovascular medicine Core Cardiovascular Training Symposium recommendations. Additional attention to developing curricular content and structure, including the creation of an American College of Cardiology on-line knowledge module might improve fellowship training in preventive cardiology.
In January 2008, the American College of Cardiology Foundation (ACCF), American Heart Association, and American College of Physicians published the Revised Guidelines for Training in Adult Cardiovascular Medicine: Core Cardiology Training Symposium III (COCATS). Several specific recommendations were made for preventive cardiology training: the length should be ≥1 month (or the equivalent spread out over 3 months); should include attendance in a cardiac rehabilitation program, a lipid disorders clinic, and a diabetes mellitus clinic; and there should be adequate topic-area expert faculty. In addition, the Accreditation Council on Graduate Medical Education (ACGME) requires cardiology fellows to have instruction and clinical experience in a number of specific prevention-related topics. More recently, the ACCF outlined 17 areas of competency and training as a standard curriculum for prevention. The current adherence to these guidelines is unknown, and previous studies have suggested that the amount of prevention training delivered in the curriculum is low. In addition, formal opportunities for advanced training in preventive cardiology appear to be uncommon. Thus, we undertook a national survey to discover the current status of preventive cardiology training for United States cardiology fellows.
Methods
In late 2010, we sent an anonymous and voluntary survey to all United States cardiology program directors (PDs, n = 182) and asked that the survey also be forwarded to their chief fellows (CFs). PDs are faculty-level cardiologists who supervise the fellowship programs. The CF is typically a senior cardiology fellow given some administrative responsibility. The survey was distributed through the American College of Cardiology PDs’ electronic mail list. Two reminder notices followed the original electronic mail at approximately 1-week intervals. The institutional review board at Henry Ford Hospital reviewed and approved the survey. No incentive was given for participation, and no penalty resulted for nonparticipation.
The survey questions are listed in the Appendix. The responses were collected using an on-line survey engine, SurveyMonkey (available at: http://www.surveymonkey.com ). Key clinical faculty was defined per the ACGME definition of spending ≥10 hours each week in fellowship training. Preventive cardiology faculty was defined as those with advanced expertise in preventive cardiology beyond a general cardiologist’s scope of practice. The responses were entered into a database for analysis. Some continuous variable questions were given categorical answers to facilitate ease of survey completion. The Fisher exact, Mann-Whitney signed rank, Mann-Whitney-Wilcoxon signed rank, and Friedman tests were used to compare the categorical and averaged data, using SAS, version 2.2 (SAS Institute, Cary, North Carolina). A 2-sided p value of <0.05 was considered significant. Congruent responses from the CFs and PDs were combined as a single reply. Discordant answers between the CFs and PDs were reported separately.
Results
Of the 182 PDs and 182 CFs, 43 and 56 completed the survey, respectively, representing 24% of the PDs and 31% of the CFs. The exact proportion of the 182 fellowship programs represented in this survey was unknown because the overlap between a CF and PD from the same institution answering the survey could not be ascertained. Of the 36 participants who voluntarily identified their program, only 2 sets (2%) of surveys were from paired PDs and CFs at the same institution. Thus, this survey represented ≥31% but not >53% of cardiology programs, comparable to previous studies of similar design and topic.
The average number of fellows per program was 15 ± 7. The average number of key clinical faculty was 21 ± 11. The number of key clinical faculty with expertise in an area of preventive cardiology was 2 ± 2 per fellowship. Of the 44 PDs, 13 (30%) reported not having a faculty member with any special expertise in prevention. CFs were excluded from this analysis because 16 (25%) of the 65 CFs were uncertain whether their faculty had special prevention expertise. A correlation was found between the number of fellows and faculty size (r = 0.59, p <0.0001) but not between the number of fellows and the number of faculty with preventive cardiology expertise (r = 0.16, p = 0.13).
Of the programs, 24% met the COCATS recommended rotation structure: 20% reported a 1-month dedicated rotation and 4% had a 1-day/week rotation within a 3-month period. Other programs reported a suboptimal training structure: 24% had no rotation in preventive cardiology and 52% reported providing prevention experience in some other type of format or length. The rotation components are shown in Figure 1 , and the lecture content is listed in Table 1 .
| Lecture topic | PD Response (n = 43) | CF Response (n = 56) | p Value |
|---|---|---|---|
| Thrombosis management | 42 (98%) | 51 (91%) | 0.229 |
| Pathophysiology of atherosclerosis | 42 (98%) | 49 (88%) | 0.133 |
| Cardiovascular pharmacology | 42 (98%) | 42 (75%) | 0.002 ⁎ |
| Epidemiology of cardiovascular disease and risk factors | 40 (93%) | 45 (80%) | 0.087 |
| Hypertension management | 40 (93%) | 45 (80%) | 0.087 |
| Dyslipidemia management | 39 (91%) | 52 (93%) | 0.725 |
| Subclinical atherosclerosis imaging † | 38 (88%) | 48 (86%) | 0.771 |
| Cardiac rehabilitation/exercise physiology | 38 (88%) | 40 (71%) | 0.049 ⁎ |
| Diabetes and metabolic syndrome | 37 (86%) | 41 (73%) | 0.143 |
| Emerging atherosclerosis risk factors | 35 (81%) | 34 (61%) | 0.030 ⁎ |
| Family history and genetic assessment of atherosclerosis | 28 (65%) | 27 (48%) | 0.106 |
| Smoking cessation | 21 (49%) | 21 (38%) | 0.307 |
| Obesity/weight management | 20 (47%) | 24 (43%) | 0.839 |
| Cardiac nutrition | 19 (44%) | 15 (27%) | 0.089 |
| Chronic disease management | 17 (40%) | 20 (36%) | 0.834 |
| Patient adherence and compliance | 17 (40%) | 20 (36%) | 0.834 |
| Depression/anxiety in cardiac patients | 17 (40%) | 20 (36%) | 0.834 |
| Average number of responses | 12.4 ± 3.2 | 10.6 ± 4.1 | 0.027 ⁎ |
† Including ankle brachial index, coronary artery calcium, and carotid intimal media thickness.
The presence or absence of faculty with prevention expertise was predictive of the number of prevention experiences and lectures. Fellowships with no preventive faculty (n = 20) had 1.2 ± 0.9 rotation experiences versus fellowships with any preventive faculty (≥1, n = 64), with 2.3 ± 1.6 experiences (p = 0.009). Furthermore, the average number of lectures showed a trend toward significance, with 11.5 ± 3.3 lecture topics versus 9.7 ± 4.1 in fellowships with preventive faculty versus no preventive faculty, respectively (p = 0.06).
The most common obstacles and suggested improvements in preventive cardiology training are listed in Table 2 .
| Variable | PDs | CFs | p Value |
|---|---|---|---|
| Obstacles ⁎ | |||
| Lack of time/too many competing priorities | 1.9 ± 1.1 (n = 37) | 2.6 ± 1.1 (n = 44) | 0.010 † |
| Lack of developed curriculum | 2.4 ± 1.1 (n = 36) | 1.9 ± 1.1 (n = 42) | 0.055 |
| Lack of faculty expertise | 2.8 ± 1.0 (n = 38) | 2.8 ± 1.0 (n = 43) | 0.833 |
| Lack of interest among fellows | 3.0 ± 1.0 (n = 37) | 2.8 ± 1.0 (n = 42) | 0.451 |
| Row mean scores differ p value | 0.003 † | 0.004 † | |
| Suggested improvements ‡ | |||
| American College of Cardiology developed web-based curriculum | 1.6 ± 1.0 (n = 35) | 2.5 ± 1.3 (n = 43) | 0.002 † |
| American College of Cardiology Self-Assessment Program preventive cardiology question book | 2.5 ± 1.1 (n = 36) | 3.2 ± 1.4 (n = 42) | 0.035 † |
| More lectures/formal instruction | 3.1 ± 1.0 (n = 36) | 2.7 ± 1.3 (n = 43) | 0.123 |
| Faculty development | 3.3 ± 1.0 (n = 35) | 2.9 ± 1.3 (n = 43) | 0.157 |
| Identifying centers of excellence | 4.5 ± 0.9 (n = 36) | 3.7 ± 1.4 (n = 42) | 0.020 † |
| Row mean scores differ p value | <0.001 † | 0.008 † |
⁎ Sum ranked score on 4-point scale, with 1 greatest priority.
‡ Sum ranked score on 5-point scale, with 1 greatest priority.
Cardiology fellows were formally evaluated in preventive cardiology in 18% of the programs. The method of evaluation was written examination (50%), clinical evaluation exercise/objective structured clinical examination (39%), chart review (22%), and oral examination (5%). The respondents were allowed to choose >1 method of evaluation; thus, some fellows were likely evaluated through >1 method.
Advanced training in preventive cardiology was reported by 10 PDs and 12 CFs stating that ≥1 general cardiology fellow met the COCATS level II or III training requirements in prevention during the past 3 years. Eleven programs reported having a 1- or 2-year nonaccredited advanced training program in prevention. However, only 4 of these subspecialty programs trained participants every year (a total of 5 positions). Of the 11 programs, 1 was clinically oriented, 4 were mixed research/clinical, and 6 were predominantly research oriented, based on self-report. As a group, these positions were generally held by a 50:50 mixture of cardiology and internal medicine graduates.
A dominant theme emerged among the free-response questions. Of the 14 responses received, 5 comments focused on the low financial reimbursement for preventive cardiology with such comments as, “Fellows, faculty, and hospitals have interest proportionate to the remuneration,” and “…there are few procedures, and salaries are low for cognitive clinics.” Two comments suggested that prevention is something that should be “acquired during internal medicine training” and should “predominantly be … aimed at primary care fields.”
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
