Competency-based evaluation and training are the latest watchwords from the Accreditation Council for Graduate Medical Education, now mandated in the Next Accreditation System and arriving on cardiology fellowships’ doorsteps in July 2014. We now have clinical competency committees meeting regularly to evaluate fellows’ advancement along the milestone rubric. COCATS 4—the American College of Cardiology’s 2015 Core Cardiovascular Training Statement—is the most recent revision of the document since 2008. It incorporates those competencies and milestones and announces “A New Era in Cardiovascular Training.”

The committee for the new COCATS faced the Herculean task of fitting ever more content into the standard 3-year cardiovascular fellowship, while incorporating the fundamentals of the Next Accreditation System. COCATS has maintained the previously defined levels of competence. Level 1 is “the basic training required of trainees to become competent consultants.” Level 2 encompasses the training that “enables some cardiovascular specialists to perform or interpret specific diagnostic tests and procedures.…This level of training is recognized for those areas in which an accepted instrument or benchmark, such as a qualifying exam, is available to measure specific knowledge, skills or competence.” Finally, level 3 is achieved when a fellow “acquires specialized knowledge and competencies in performing, interpreting and training others to perform specific procedures or render advanced, specialized care at a high level of skill and is defined by competency components and outcome metrics.” Published elsewhere in this issue of JASE is the report of COCATS 4 Task Force 5 on training in echocardiography. A future document is promised outlining the additional exposure and requirement for level 3 training, but this document contains some guidance, and the goal numbers of studies to be performed and interpreted has not been changed from COCATS 3.

Along with the Accreditation Council for Graduate Medical Education, COCATS moves to addressing competency by way of milestones and observable behaviors. This is a welcome move away from purely prescriptive numbers of studies and procedures to ensure competence. The change makes sense. It is intuitively obvious that completing 300 cursory transthoracic studies, without adequate supervision or feedback, would not constitute the experience necessary to meet the level 3 requirements. Certainly, faculty members are not promoted for simple time in rank but are expected to meet a set of (hopefully) well-defined criteria to advance. Thus, the procedure targets outlined in Table 2 of the document are now more guidelines than strict requirements. The outline of curricular milestones is well thought out and will be helpful to training programs.

This COCATS revision has the laudable goal of improving the competence of all cardiovascular fellows in echocardiography, because the committee recognized that “echocardiography is integral to the practice of cardiology” and that all fellows should be prepared to independently perform and interpret echocardiograms. The section on training requirements outlines this change. Previously, level 2 training was considered optional and provided only to those fellows who chose to pursue it. Now all fellows must have the opportunity to achieve level 2 competency in echocardiography. Certainly, many of us have seen less than optimal patient outcomes due to inaccurate interpretation of echocardiographic (or other imaging) studies. The goal of championing and improving quality in cardiovascular ultrasound is one of the American Society of Echocardiography’s (ASE) core missions. The ASE’s support of laboratory accreditation, via the Intersocietal Accreditation Committee Echocardiography, and individual certification via the National Board of Echocardiography (both organizations are independent of the ASE) speaks to that commitment. If training programs revise their curricula to provide more robust education in cardiac ultrasound, this will serve to advance excellent patient care and will be embraced by the ASE.

There is a danger, though, in assuming that level 2 training is adequate to interpret all manner of echocardiographic studies in all manner of patients. To be clear, “competent” is defined as the ability to do something well enough to meet a standard, while “proficient” means well-advanced abilities in a branch of knowledge. This document, which is not the final word on level 3 training, specifically mentions advanced training in transesophageal echocardiography and stress and intraoperative studies as part of level 3 training. It is also noted that level 3 training is required for qualification as laboratory directorship in large or academic laboratories and in programs in which fellows are educated. However, the document does not spell out the many scenarios in which level 2 training could not be considered sufficient to ensure excellent patient care. This includes interpretation of studies in patients with left ventricular assist devices or other mechanical assist devices, adult congenital heart disease, interventional echocardiography to support structural heart programs, use of three-dimensional imaging to interrogate valvular anatomy, and strain rate imaging to assess patients receiving chemotherapy or those with other cardiomyopathies.

In my last curmudgeonly editorial in these pages, titled “The Importance of Being Expert,” my coauthor and I reviewed a study that evaluated how to teach trained echocardiographers how to improve their measurements of dyssynchrony by tissue Doppler. Unremarkably enough, a 2-day course with 50-case hands-on training significantly improved the measurement of dyssynchrony compared with a 1-hour lecture with tips on measurements. There are few outcome data for training regimens for fellows in echocardiography. There is general consensus among echocardiography laboratory directors who train fellows that the performance of 50 transesophageal echocardiographic studies is too little to ensure proficiency. However, that number is retained in this document as the minimal number of required studies. This is concerning, as there is evidence from other fields, popularized by Malcom Gladwell in his book Outliers , that deliberate practice is necessary for mastery.

As handheld ultrasound devices find their way into every medical student’s hand, will cardiac ultrasound go the way of electrocardiography, now a bundled service done as part of a routine physical examination? In fact, electrocardiograms are more and more frequently interpreted by computer, sometimes with no expert oversight. Many years ago, during a discussion about the difficulties of developing a research career, a chair of medicine said to me, “It’s easy to be a clinical cardiologist—just sit on the bed and hold the patient’s hand.” I wonder if he would now amend his advice to “Just sit on the bed and check the parasternal short axis?” I am concerned that in the attempt to ensure that fellows are competent at everything, we are in fact guaranteeing that they are proficient in little and expert in nothing. When the situation demands it, a “quick look” or a full echocardiographic examination interpreted by a nonexpert does not constitute excellent patient care and can be dangerous. Many cardiovascular subspecialties have gone to a fourth year for their training (interventional, electrophysiology, and advanced heart failure and transplant). Certainly a fellow wishing to become level 3 certified in multiple imaging techniques requires an additional year of training. The opportunities for this additional year of imaging training remain limited. There are some centers with imaging training grants to fund an additional year beyond the 3-year fellowship. But most institutions are cutting, rather than expanding, their graduate medical education slots, and few have the resources to fund unaccredited fellowships. If echocardiography is viewed as a technique that any 3-year level 2 graduate can perform (and bill for), it will be even harder to convince institutions that advanced training in echocardiography is necessary and desirable. In addition, the path to making echocardiography or multimodality imaging a fourth-year subspecialty lies through the American Board of Internal Medicine and the American Board of Medical Specialties. This path is politically difficult, as the certification examinations for echocardiography, nuclear cardiology, and cardiac computed tomography, for example, remain outside the American Board of Internal Medicine umbrella. Given the recent storm of criticism regarding the board’s maintenance of certification process, there will be very little appetite for ceding control of these examinations to that organization.

The American College of Cardiology has left a way for a fellow to complete level 3 training in echocardiography within the 3-year general fellowship. The number of available months of training for echocardiography has been reduced by the addition of requirements in ambulatory, longitudinal, and consultative care as well as critical care cardiology and multimodality imaging. Thus, Table 2 in the COCATS document now lists 9 months as the suggested training length to achieve level 3 competence, without changing the recommended numbers of studies. It is possible for program directors, in concert with echocardiography laboratory directors, to craft individual programs that will achieve level 3 training in echocardiography within 3 years. The COCATS committee notes that this will require all elective time being devoted to echocardiography. Although the ASE has endorsed the final document and had representatives on the writing group, there were serious concerns with the initial draft of the task force’s report. The published report represents a compromise on the requirements for echocardiographic training. It should be noted that the previous American College of Cardiology Foundation 2008 training statement on multimodality imaging, developed in collaboration with the ASE and other imaging societies, endorsed the concept that months spent primarily in one modality almost certainly would provide cross-training in other imaging modalities. This concept should certainly be used in individually designed programs.

Finally, level 2–trained echocardiographers must become proficient in recognizing the limits of their competence and have a clear idea of where and when to get help. Although I welcome improvement in the echocardiographic skills of all trainees, a reduction in the number of true experts in the field will have a devastating effect on patient care, the training environment, and the field of cardiovascular imaging.